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Practical Decision Making in Health Care Ethics: Cases and Concepts
  1. Heather Draper
  1. Centre for Biomedical Ethics, University of Birmingham

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    Raymond J Devettere, Washington DC, Georgetown University Press, 2000, 639 pages, £25.25, $35.

    My colleagues and I in Birmingham are always on the lookout for an undergraduate textbook for our medical students, which was why I agreed to review this book. By and large it is pitched at an undergraduate audience and covers many of the areas that one might expect to find in a UK undergraduate medical course (consent, making decisions for the incompetent, end-of-life issues, beginning-of-life issues, research, transplantation and medical genetics). It also has a chapter on managed care, which is less relevant to a UK audience but is interesting none the less. (The case study for the chapter on James Adams who, it is alleged, lost both his hands and feet as a result of delays caused by managed care, is a harrowing but salutary reminder of the weaknesses of telephone health care consultations and the dangers of trying to cut costs using protocols in emergency situations). Other issues (for instance, HIV and mental health) make an appearance within chapters. There are many interesting cases and the commentary on these is generally useful and structured in a way that would facilitate teaching and—perhaps more importantly these days—independent learning. For instance, in his case analysis Devettere has the subheading “situational awareness” where he lists the facts and ethical aspects of each case. This is a fine example to students of how to organise their thoughts around ethics issues and how to pick out the important points of the cases.

    There is perhaps more in the way of moral theory than we could expect (at Birmingham at any rate) undergraduate medical students to engage with—but this is perhaps a problem with our medical students rather than the book! The overview of ethics is thorough without being overly detailed. In Chapter three, for instance, Devettere includes a long section called “distinctions which can mislead” and whilst I did not agree with the way some of the distinctions were drawn—for instance is the difference between the reasonable and the unreasonable really based on whether the action is ethical or not?—the idea was a good one and overall I thought it was a useful exercise. Devettere claims to “approach health care ethics from the perspective of an ethics of the good rather than an ethics of obligation … more specifically…Aristotle's ethics of the good” (page 21). This is more obvious when he discusses theory and I found myself disappointed not to find virtue-theory-in-action more evident in the case discussions. If this had been achieved it would certainly have made the book more distinctive. This said, the text is a welcome contrast to principlism.

    The main disadvantage of this book as a textbook for UK undergraduates is that all the legal references are based on US legislation and cases. Of course, this does not mean that the references are not useful or interesting: the ethical discussion generated is applicable and it is proper that students should have an awareness of the differences in approach in different legislatures. Nevertheless, this is a significant disadvantage. Students are unlikely to buy more than one medical ethics text and I fear, therefore, that this book is unlikely to be adopted as a set text outside the USA. It is, however, worth buying for a library and certainly worth a look for teachers of medical ethics—and I do mean medical ethics, despite its title. For my colleagues and I back in Birmingham it looks like another summer revising our own course materials.

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