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The Cambridge Medical Ethics Workbook
  1. D Lloyd
  1. david.lloyd{at}kcl.ac.uk

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    M Parker, D Dickenson. Cambridge University Press, 2001, £29.95, xiv + pp 359. ISBN 0521788633

    Many health care undergraduate students would benefit from having a compact, comprehensive, and well organised focal text for their thinking about ethics that keeps the genuine complexities of the issues clearly in view. Some teachers find that certain well known works, such as Beauchamp and Childress’s Principles of Biomedical Ethics, are not satisfactory for this purpose, partly on account of their emphasis on specific theoretical positions that are not universally endorsed. But also the style of such “theory led” texts is not always accessible to students, who tend to prefer less abstraction and more immediate demonstrations of clinical relevance. The approach taken by Mike Parker and Donna Dickenson in this workbook is an attempt to satisfy the demands of teachers and students in all these respects.

    Parker and Dickenson see this workbook as having several potential applications: as a resource for individual reference, and as a set text for group teaching, as well as providing materials for open learning (an area in which the authors have particular expertise). On the back of this flexibility, students in health care disciplines, qualified practitioners, as well as a non-professional audience, are all included in the book’s broad intended readership. Claims about “flexibility” can sometimes mask a lack of direction or specificity. But the authors have taken pains to ensure that their book does not suffer from these faults.

    Parker and Dickenson have integrated three basic kinds of material in the production of this workbook: case studies, commentaries, and activities. The case studies are presented in three thematically linked groups. Part one covers ethical issues arising from new medical technologies; those in part two explore key features of the patient/practitioner relationship, with particular reference to the notion of vulnerability, and part three is a less well defined category of “broader issues”.

    The cases—contributed by an international roll of health care professionals—were chosen largely on account of their ordinariness. Parker and Dickenson are keen to ensure that the reader is given an adequate sense of the all pervasive nature of ethical considerations in health care. And they judge, surely correctly, that this awareness is best imparted through the examination of everyday clinical encounters. Cases that grab the headlines are no less important, but to make them the primary focus of a textbook can give students the misleading and unhelpful impression that a practitioner’s engagement with the ethical domain is an exotic rarity, rather than an integral part of health care practice.

    Although Parker and Dickenson provide some of the commentaries themselves, the model of international collaboration is followed here too. Thus, the majority of commentaries are provided by other academics in bioethics and related disciplines. The diversity in approach and emphasis illustrated by this international line up provides one way in which students can be introduced to real rather than merely theoretical differences in ethical outlook. The commentaries for the most part argue for specific positions in their interpretation of the cases, and thereby provide the point of reference for the third kind of material in the book, the activities.

    The activities are presented in short paragraphs interspersed throughout the main body of the text to encourage reflection, interpretation, and analysis at key junctures in complex lines of thought. They are designed to trigger critical engagement with the cases, and provoke the reader to challenge the arguments presented in the commentaries.

    With the exception of the commentaries they themselves contribute, Parker and Dickenson are assiduous in avoiding the temptation to join in and mount any detailed analysis of their own. There are merits in maintaining this level of neutrality. But it can leave students wondering what will serve as an adequate analysis of an ethical argument. As many teachers of ethics will recognise from their own experience, students new to this area frequently have little idea about how to set about distinguishing a good argument from a bad one. (In fact, it comes as a surprise to some students that assertions in ethics can be and need to be supported with reasons at all.) Of course, all teachers should provide their students with the tools necessary to examine arguments with critical rigour. But for students using this workbook outside any formal course structure, and for the general reader, there is no explicit account of how the evaluation of arguments in ethics is to be approached. Some detailed illustrative examples of good and bad ethical reasoning for the benefit of readers in these categories would be a welcome addition to any future edition of the book.

    Two appendices are included for teachers: a study guide and a scheme showing how the sections in the workbook relate to the UK consensus core curriculum in medical ethics. The inclusion of the latter will be a useful aid to UK teachers of ethics in medical schools who are revising existing programmes of study for their students, and for those who are devising new ones. The authors state that the workbook was written with the intention of dovetailing with the UK curriculum proposal, and although the two do not match point to point, they are in close alignment.

    The authors’ views on the nature of ethics and how that conception is best to be imparted to students are distributed principally in the introduction, in chapter nine, and in the first appendix. As Parker and Dickenson point out, textbooks and pure academic writing on medical ethics often start from a focus on action guiding principles for the health care professional. The chief reason they offer for adopting a different strategy is that of accessibility for the reader, and this is a powerful motivation for departing from a principles led, theoretical framework approach. But there is a further theme underlying the authors’s theoretical stance—a concern with the central importance of the nature of relationships in the medical context. This concern includes the adoption of a critical perspective on the distribution of power in these relationships. Some further elaboration of the theoretical underpinnings of the book would have made an interesting addition to the appendices aimed at teachers.

    The resource material that makes up the bulk of the book and the authors’s favoured interpretation of how its educational and ethical value can best be exploited may, however, be regarded as separable. The usefulness of the cases and commentaries is not dependent on the adoption of any specific pedagogical methodology or view of what ethics as a discipline consists in. Indeed, this independence is crucial to the book’s claims to flexibility.

    The bibliography and index are both comprehensive and serve their respective functions well. Among the workbook’s ancillary features the glossary is the poor relation, and might usefully be enlarged.

    All teachers of ethics in health care are likely to find something of value in this book. Some will raid it occasionally for illustrative or thematic material to use in seminar or lecture settings. Others will find that the combination of cases, activity triggers, and commentaries provide a handy template for giving structure to professional development study days for qualified practitioners. Teachers planning new undergraduate courses may well find the book’s spread of topics and their presentation offers a blueprint that can be readily adapted for their own purposes. Students will welcome the workbook’s accessibility, clarity, and comprehensive coverage of fundamental ethical issues in the health care context.

    It would be unrealistic to maintain that this book provides a complete solution for teachers of medical ethics and their students in every conceivable circumstance. But the claims about its flexibility are largely justified, and many readers in its broad intended audience will find it meets their needs.

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