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Ethics: The heart of Health Care (2nd ed)
  1. Paul Wainwright
  1. School of Health Science, University of Wales, Swansea

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    David Seedhouse, Chichester, Wiley, 1998, 232 pages, £15.99.

    The second edition of Seedhouse's well-known book comes ten years after the first. Like the first, the second edition will undoubtedly be well received by many, including teachers, students and practitioners of health care. Indeed one is tempted to suggest that, if a medical or nursing student read only one ethics text in the course of his or her training, then this would be a good choice. If students and practitioners of health care management, policy-makers and civil servants could also be persuaded to read it then this would be a bonus.

    Seedhouse's style is highly personal and individual. He takes pleasure in being irreverent, provocative and controversial. This is most certainly not a textbook in the academic tradition of neutrality and impartialism. Seedhouse has a clear agenda of his own and strongly held views about the nature of health care and the place of ethics within that domain. He is self- assured and self-confident almost to the point of arrogance, writing un-selfconsciously of the “secret of the book's success”, describing the work as “genuinely philosophy applied” and “long overdue”. “Here at last,” he says, “is the beginning of a philosophy of health” and one wonders what to make of his observation that his Ethical Grid “has not yet been universally adopted”: perhaps he thinks this is only a matter of time. The book is likely to appeal more to health care students and young practitioners than would some of the more traditional texts in the area. Some readers, perhaps particularly those from a generation (or even two) before Seedhouse (we are told that he was at grammar school from 1967-74) may find some of his idiosyncrasies irritating rather than appealing. Others will welcome the humorous and un-stuffy approach (while many of us will share his fond memories of the Grafton Arms). Certainly few authors in the field will have given so personal an account of their own experiences of health care as Seedhouse gives of his recent diagnosis of and treatment for a benign tumour.

    Statistically one should note that the new edition is some 66 pages longer than the first and although the number of chapters is the same the structure of the book is slightly different. The selection of case studies in part one has been increased from 10 to 15 and in part three the main decision making device of the Ethical Grid has been joined by a preliminary device called the Rings of Uncertainty. In other respects the text is very similar, although a certain amount of re-writing has taken place, some additional material has been added and the typeface and presentation has generally been improved. The index to the second edition is far more comprehensive and this is certainly welcome.

    As a working text for students and practitioners the book has many strengths. The first section gives a strong argument for the importance of ethics in health care, well illustrated by many relevant examples. The 15 case studies that conclude this section are particularly powerful and well chosen and could form the basis for many individual or group exercises, either within formal educational programmes or more informally within a team of professionals. The second section gives a useful overview of the main issues and theoretical approaches within health care ethics, again well illustrated by contemporary examples. The critiques of the main approaches to concepts such as the person and the various ethical theories are on the whole clear, reasonable and balanced, although his attack (not present in the first edition) on the four principles approach of Beauchamp and Childress and their supporters is scathing. The third section, introducing the Rings of Uncertainty and the Ethical Grid, once again provides an invaluable basis for discussion. As with the case studies (which can be used in conjunction with the tools) this section would be a powerful tool for group work. It would be gratifying indeed to think that a multidisciplinary team or a group of students from the various health care professions might sit down together to work through some of the exercises suggested.

    The most controversial aspect of the book is its highly personal approach. Seedhouse has a clear view of the nature of health and the role of health care, which he enthusiastically promulgates throughout the book. His perspective is in many ways appealing and no doubt most of us would prefer to be treated in the way he advocates. However, it could be argued that social and political trends in many parts of the world have driven the reality of health care practice, if anything, further away from the ideal that Seedhouse proposes. One assumes for example that he would not recommend the American health care system as a preferred means of achieving his view of health care - the optimising of human potential. However, some commentators have suggested that President Clinton's attempts at health reform (and the consequent threat to vested interests) were a major factor in the process that led to his recent impeachment hearing. Similarly the policies of the Conservative administration in the UK in the decade or so prior to the last general election rested unashamedly on the principles of competition and market forces and sought to eliminate much of the social aspect of care. Seedhouse's vision may be attractive but he says little about the ways in which moral reasoning on the part of health care workers can stand against commercial forces or political conviction.

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