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L B McCullough, J W Jones and B A Brody, New York, Oxford University Press, 1998, 396 pages, £35.00 (hb).
Many volumes have been written in recent years on medical ethics, but comparatively few have been focused especially on the ethics of surgery. Yet surgical practice offers a very sharp focus for many ethical principles. This excellent book is particularly timely because of the current re-evaluation of patients' rights and surgeons' rights, degrees of autonomy and the nature of consent. Of the 39 contributors, a majority are practising surgeons, who are having to make ethical decisions every day in their practice. This means that surgeons reading this book immediately identify with the situation and with the writers. However, ethicists without medical qualifications are integral to the book and many chapters are written by two authors, one a surgeon and one an ethicist. The huge range of ethical issues are divided up into 19 chapters of a manageable length so that the book can be used as a reference for particular situations and for this, the extensive index is particularly useful. The book is not over-burdened with references, but each chapter is well referenced independently.
Well-known subjects such as informed consent and confidentiality are covered, and the introductory chapter on principles and practice of surgical ethics is particularly valuable as it clarifies definitions and rights; but it is good to see that the authors do not duck the less defined areas of surgical practice, such as referral of patients to other physicians and the role of non-physician members of the team. The chapter on financial relationship with patients, although written from the standpoint of North American health care, outlines principles that are relevant to any health care system and, in this, the authors, quite rightly, claim that business aspects of medicine are also appropriate for ethical investigation. In many countries, it has been felt that business ethics are outside the remit of doctors, but the “market place” is impinging on our practice more and more. Of particular relevance to the British scene at present is the chapter on self regulation of surgical practice and research and it tackles such sensitive issues as “when should a surgeon retire?”.
The book is full of useful practical advice and guidance, not least when it is considering patients who are family members, friends and colleagues; the warning to be wary of “kerb-side consults” is very wise! With each chapter divided into an analysis of principles followed by clinical topics the reader can see how to apply principles in practice. So often books on ethics are either too theoretical, on the one hand, or on the other hand give practical advice without the moral basis.
This book is an important contribution to the literature of medical ethics and it can be warmly recommended - not only to surgeons.