Lawrence P Ulrich,Washington, Georgetown University Press, 1999, 351 pages, £46.75.

This is an extremely readable and interesting contribution. The author takes the reader through the Patient Self-Determination Act in some depth, but doesn't make any attempt to look at its provisions in real detail. This cannot be taken as an omission, as the purpose of the book is to explore the principles underpinning the legislation and to explore its ethical content.

In that respect, this is a very interesting exercise. On one view, the Patient Self-Determination Act did very little to change the current law in the United States. The legislation is designed primarily to ensure that on entrance to any federally funded facility, patients are made aware of the facility's policy on advance directives and withholding and withdrawing treatment. Thus, the legislation does not directly tackle whether these polices are appropriate, but rather it makes a contribution to the information which all patients will have when they make a decision about which facility to enter, and also it may encourage them to take account of these policies in their participation in their own health care. Ulrich reads the legislation as making a significant contribution to the rights of patients to self determination, as well as making the informed consent process more meaningful. To an extent his views on this could be taken as aspirational rather than necessarily real. None the less, the way he reveals the capacity of the legislation to achieve these goals makes for a very interesting analysis of the ethical, social and legal background to the legislation.

In leading us to the conclusion that one ancillary, but in his view, beneficial, outcome of the legislation might be a move towards the assessment of what is a “reasonable patient”, Ulrich—in a very readable manner—explores fundamental principles of medical ethics and explains the extent to which these are met by the terms of the act. This is a very readable book, although it's tempting to suggest that it may be a little overenthusiastic in terms of what this legislation can achieve. None the less, if read by health care providers it should point them towards the rationale for the legislation and remind them of its potential importance.