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John Havard, London, BMJ Publishing Group, 1999, 71 pages, £5.00.
This manual is designed to provide teaching modules on medical ethics for health care professionals in developing countries. The author acknowledges that, although there are common themes, their medical ethical dilemmas are often quite different from those which occur in developed countries and the approach needs to be somewhat less Western in orientation. Emphasis is properly given to topics such as AIDS/HIV and the status of women and children which create special local problems. Although universal principles of medical ethics are affirmed, care is taken to avoid the trap of imposing “our” views and solutions on “their” situations. As a teaching aid the manual is well constructed, starting with the enunciation of general principles, followed by comment and a series of well-conceived clinical examples, each of which embodies several different ethical problems. The manual has a tendency to mix up examples of pure bad medicine—negligence, incompetence, rudeness, lack of compassion—the sort of things that might bring doctors to the attention of the General Medical Council in this country; and examples of clear ethical dilemmas, resolution of which is seldom easy and is not necessarily a function of good or bad practice. I believe a distinction should be drawn between the two. Doctors who practise bad medicine need to be condemned or punished if the offences are serious or repeated, or given a warning or advised to retrain or to work under supervision if they are not serious or repeated. Doctors who make the “wrong” decision in an ethical dilemma may be acting in perfectly good faith and practising perfectly good medicine. The essence of an ethical dilemma is that there is usually no simple correct solution. If there were, it would cease to be an ethical dilemma and all the medical ethicists and philosophers who have made a career out of the subject could find something else to talk or write about. Each problem has to be analysed individually and the solution directed towards doing the best thing in the interests of the patient or, occasionally, of others, including the community. Perfectly sound and reputable doctors or philosophers may hold opposing and irreconcilable views. In the teaching of medical ethics this point should be emphasised. I failed to find it in the manual, but perhaps Dr Havard intended it to emerge in the case discussions.
At a personal level I was sorry to note the adherence to uncompromisingly orthodox views about some topics. Is it not time for us to reconsider our judgment that payment for participation in medical research is a bad thing? We allow people to work for money in far more hazardous occupations, for example deepsea diving, fishing and underground mining (in South Africa nearly 890 gold miners have been killed in the past two years); why not in far less risky reputable medical research? And is the possibility of carefully controlled trade in organs for transplantation so abhorrent that we cannot even discuss it? In both cases there is a risk of exploitation, but there are ways of minimising this, and there could be clear benefits to seriously impoverished people who have little opportunity to find alternative sources of money. Are we in danger here of doing just what the manual purports to avoid, namely imposing our set of values on others whose circumstances are quite different?
Apart from these admittedly idiosyncratic comments, I think this is an admirable manual. I hope that in the future Dr Havard will produce an expanded version which will include more detailed discussion of the answers to the searching questions he poses at the end of each clinical vignette.