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Medical Ethics and the Future of Health Care
  1. Dolores Dooley
  1. Lecturer in Philosophy & Medical Ethics, Department of Philosophy National University of Ireland Cork, Ireland

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    Edited by Kenneth Kearon and Fergus O'Ferrall, Dublin, Ireland, Columba Press, 2000, 168 pages, £7.99.

    Public lecture series do not always, unfortunately, result in a published volume of interdisciplinary, informed and well argued papers. Medical Ethics and the Future of Health Care has succeeded, however, in doing just this. A public lecture series was organised by the Adelaide Hospital Society, Dublin, Ireland in 1999 to facilitate better public understanding of complex issues in health care confronting citizens and carers. The book assumes correctly that the Republic of Ireland is now indisputably a pluralist society, discomforting to some readers who might look to the book for absolute answers and certainties. They would be disappointed because the essays show rather that it will be public debate and reasoned, imaginative approaches to decision making in health care that will replace the comforts of traditional certainties.

    Coming from the internationally recognised philosopher of principlism, James Childress, the nurse ethicist, Verena Tschudin and representatives from obstetrics and gynaecology, midwifery, legal medicine, psychiatry and psychology the essays are accessible and informative without over-simplifying complex ethical issues. Childress's essay, Bioethics on the brink of a new millennium, calls for the inclusion of imagination in the process of deliberation if we are going to achieve the discernment needed for balancing claims of individuals and claims of communities. And such balancing of individuals, professional institutions and communities is also an important component of the theses offered by the other authors. Tschudin encapsulates the wisdom of nursing philosophy in her essay, Ethics and holistic care, which maps out the conceptual connections between development of skills for self awareness, listening and ethics. These links are often ignored in bioethics writing and yet contributions from nursing philosophy allow the necessary expansion of a humane and person-centred framework for health care ethics.

    Four of the essays by Denis Cusack, (medical law) Marcus Webb (psychiatry), Patrick Hanafin (law) and Sheila Greene (psychology) home in on the question of patient autonomy and institutional policies and legislation arising in questions about involuntary treatment in psychiatric institutions, the right to die, abortion legislation, genetics and implied transformations in our understanding of “persons”. These four essays are particularly comprehensive and provocative in calling for responsible and sustained public debate as a medium for educating a wider public about the exercise of deliberative democracy in application to health care policy formation.

    Cusack's essay, Autonomy and consent, recognises the value of autonomy while remaining sceptical of the desirability of full implementation in advance directives, or patient rights to information regardless of a doctor's wish to invoke “therapeutic privilege”. Cusack wants to believe that the health care provider has a right to be “trusted” and that he or she should enjoy the privilege of self regulation. One response to Cusack is to argue that there is no natural right to be trusted and, as with leadership, trust must always be earned.

    Hanafin's essay, Legislating the right to die, is outstanding in its comprehensive perspective on the right to die and the impact of what seems an abstract right on institutional and cultural ideologies which are deeply embedded in Irish state policies, the Irish constitution and ecclesiastical traditions. The superb accuracy of Hanafin's analysis makes clear that ethics cannot be relevant if it remains aloof from cultural, social and identity contexts. In the final essay of the book the reader is reminded of C P Snow's Two Cultures and his injunction that we cannot afford a communication divide. Greene argues here that we can't leave science to the scientists but have to engage in active debate about the values that will guide our choices in the fast developing and promising area of human genetics. While not dodging a caution about a possible “slippery slope” in expanding reproductive technologies, Greene reiterates the bases for genuine citizen autonomy in the area of reproductive options: awareness and informed debate. It is refreshing to read in Greene's analysis that the problems are not in human cloning as such but in how we in society will perceive and value “clones” who might result from this reproductive process which is likely to be much closer to realisation than Greene predicts.

    This is a readable and provocative book of essays which might not challenge professional bioethicists but would be an exemplary text for any study group, lay reader or adult education centre motivated to develop the level of public debate so strongly called for in this fine book.

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