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Pharmaceutical Ethics
  1. F Wells
  1. Old Hadleigh, London Road, Capel St Mary, Ipswich, IP9 2JJ, UK; Frankwells36aol.com

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    Edited by S Salek, A Elgar. John Wiley & Sons, 2002, £45.00, pp 210. ISBN 0471490571

    Make no mistake, this interesting book emphatically reflects the backgrounds of its editors, as is to be expected, which are in pharmacy and in academic ethics. There is nothing wrong with that so long as we know. The stated target audience for the book are, however, those working in the clinical research of pharmaceutical products. Also it claims to cover a neglected area of medical ethics. What a pity therefore that the book pays no regard whatsoever to the report of the Faculty of Pharmaceutical Medicine on ethics in pharmaceutical medicine, first adopted and then published in 1997.1 Having said that, the editors’ preface refers to the issues which the research pharmacist may confront, as both a scientist and a member of society, and for this particular group of professionals the book will be of the greatest interest.

    Any collection of chapters or, as the editors prefer, articles, are likely to include those which are very good indeed and those which are more limited in their usefulness and appeal. Stimulation and thought provocation are the hallmarks of a valuable article, while irritation is the response to be most vigorously avoided. I must say that certain contributions within the book annoyed me. In the first category I place the chapter on the ethics of drug discovery and development process by Roger Bolton, which is sincere, accurate and up to date. Into the second category—–and they suffer more by appearing immediately after the Bolton chapter—fall the chapters on the structure and role of informed consent and on the ethical aspects of clinical trials. This last chapter is bizarre: it comprises over 100 references, strung together in a haphazard order, but omitting any reference at all to international, European or national codes of practice when to do so—for example, on advertising, would have been appropriate. Paradoxically, the chapter ostensibly devoted exclusively to promotion and advertising has no references at all.

    The opening chapter on the basis of ethics is short and disturbingly non-specific. Reference to the Declaration of Helsinki of 1983 (there have been three subsequent revisions) does not inspire confidence in the author’s grasp of the current scene in medical ethics. A treatise on deontology, unilateralism, and the views of Kant, though no doubt worthy in itself, does not fit easily into the introductory chapter. So what comes next?

    The three chapters by the two editors are outstanding. They cover the principles of patient focused ethics, ethical dilemmas in science and politics in relation to patient choice or physician choice, and ethical responsibilities in a holistic approach to the choice of pharmaceutical agents. These are all cogent philosophical articles, comprehensively comparing and contrasting different ethical approaches to the most practical use of medicines for and by patients. Would that all the chapters were as good as those of Bolton and the editors!

    Inevitably, in a “collation” (the word used by Trevor Jones in his foreword) the quality of the contributions will be mixed, and on balance, this book, best described as an anthology of ethics for pharmacists, has good, bad, and indifferent chapters. Only a chapter from the Netherlands, which is otherwise eminently sensible in orchestrating a code of ethics for pharmacists, could include the extraordinary statement that “a discussion about ethics in pharmacy shifts easily to the field of euthanasia”. No, it does not, at least not for the rest of Europe.

    A vignette suffices to cover ethical dilemmas arising over the affordability of medicines, but a succinct American article on the ethics of the economics of drug related morbidity and mortality covers the topic well and highlights society’s very low levels of awareness of the massive scale on which drug related problems occur. The ethical implications of this particular article are enormous and deserve further exploration.

    Ethical values in both treatment and research in a clinical context are exemplified in just one therapeutic area—depression and anxiety. The chapter, which is written by four authors from four Northern countries, is commendably lucid and decisive, making clear the importance, for both therapists and researchers, of clarifying and communicating their objectives to the patients involved.

    The final chapter, contributed by a distinguished pharmaceutical physician, is a political one, devoted to the ethical problems arising from government appointed bodies deciding on what drugs can or cannot be prescribed and for which drugs doctors can or cannot be reimbursed, and which drugs can or cannot be made available free of charge. The arguments used about the dangers of paternalism are sound, though I would not have been surprised to have come across the neologism “nannyism”. Governments do indeed have a right to decide which medicines are safe and effective enough to be marketed and they do have a right to decide how much they are prepared to pay for them. The author concludes, however, that no government has any moral right to decide who can and who cannot have prescribed medicines, or whether those medicine are available on a government supported health service, once having granted them marketing authorisation on the grounds of safety, quality, and efficacy. Decisions about which patients get what must be left to individual doctors and patients, the ethical validity of which cannot be challenged.

    In conclusion, this book, like the curate’s egg, is good in parts, but those good parts outweigh the weak parts. There are just a few editorial inconsistencies—for example, the references vary widely in their number and relevance from chapter to chapter, and sometimes the conclusions to a chapter appear in a shaded box and sometimes they do not. Also, the chapters from outside Anglophone countries suffer from stilted use of English; as an editor myself, I regret that the editors, who are noble users of the written English language, did not edit these contributions accordingly. In the chapter on informed consent—for example, what exactly does “the collision of two principles in a dilemma proper, which has a peculiar regimen of coping” mean? Those, though, are small points when it comes to reading a series of mostly highly interesting and challenging articles. The book is a must for pharmacists involved in research, is strongly recommended for pharmacists generally, and is of interest to all other disciplines committed to maintaining ethical standards in clinical research.

    Edited by S Salek, A Elgar. John Wiley & Sons, 2002, £45.00, pp 210. ISBN 0471490571

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