Carl Elliott, New York and London, Routledge, 1999, 188 pages, £12.99.

Bioethics became established as a distinct discipline in the United States in the 1960s. The paradox is that it arose in part from a general background of criticisms of biomedicine at that time, but has largely followed the traditional pattern of biomedicine in being reductionist and orientated to pragmatic problem-solving. So for some thirty years the theoretical debate within bioethics was mainly about which ethical theory, principle, or combination of principles to subscribe to; whilst in practice many came to see bioethics as a new medical subspecialty, with hospital ethicists as professional experts.

However, this mainstream development of bioethics has not gone unchallenged, and there have always been those advocating other approaches. The Centre for Philosophy and Health Care here in Swansea has been a good example of this, having consistently concerned itself with many of the issues that Elliott raises. These focus on the question of whether any systematic philosophical theorising, or precise arrangement of principles, could ever provide definitive answers to deeply troubling medical dilemmas, because of the inevitability of moral disagreement. Such dissident voices tended to be rather isolated until a decade ago, but since then have increased very significantly in numbers and in a variety of different ways, though united in challenging the earlier orthodoxy .

Elliott does not then provide anything entirely novel, but rather uses several examples to demonstrate how a range of these innovative approaches can provide a different perspective on familiar issues. He has accomplished this by selecting from and expanding on some of his own papers which were published during the 1990s. He has thus converted them into a series of essays which form the central chapters of the book. Narrative ethics and virtue ethics are the most notable approaches he adopts, but he has also added an introduction and conclusion which are explicitly informed by Wittgenstein's later philosophy, with the aim of providing coherence to the book as a whole. What he is attempting to show is that while at first sight these essays may appear to be somewhat disparate, they actually have a connecting theme. I am not sure though whether Wittgenstein's later work provides an adequate resource for this task, although its general relevance is clear.

To see why this is so it may be helpful to refer to Stephen Toulmin's work, which has been influential in the development of Elliott's thinking. Toulmin has made the bold claim that the philosophy of medicine has a special role to play, not just in medicine but also in philosophy. Now if this is to be fostered successfully I think that a greater range of ideas will be required than can be derived from Wittgenstein's work alone, and this is the programme within which Elliott's ideas would seem to fit most comfortably. However, one significant development in taking this forward is missing in Elliott's book. This concerns the current growth of interest in phenomenology and hermeneutics, particularly in relation to the philosophy of the body, which would seem to herald a fruitful engagement between the Anglo-American and Continental traditions in philosophy, broad enough to accommodate Wittgenstein, as well as the diverse range of other approaches which are now emerging, and will no doubt be added to in future.

None of this is intended to diminish the importance of Elliott's book, which both reflects as well as being an important contribution to, this ongoing debate. If work such as Elliott's gains the prominence it deserves it will signal the end of the worst features of bioethics, by demonstrating the central importance of a more reflective encounter between medicine and philosophy. The individual chapters are themselves full of imaginative observations relevant to the particular issues selected, for example organ donation and drug treatment for depression. Also it is part of Elliott's argument that too much work in philosophy is either trivial or unnecessarily technical or both, and this book is neither of these. It should be required reading both for health care professionals who have an interest in ethics, and for all those professionally engaged in bioethics and the philosophy of medicine.