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Mark G Kuczewski and Rosa Lynn B Pinkus, Washington DC, Georgetown University Press, 1999, 219 pages, £17.25, $23.95.
In spite of the stress on evidence and audit, clinicians still talk to each other mostly about cases, especially when there are difficulties. So when they come to consider problems in medical ethics, the focus is on case presentation too. However learned the participants, ethical analysis in medicine without cases feels like an egg without salt. Yet the oddity remains that case discussion is often done very badly; new tales are thrown in on a “me too” basis without any apparent questioning about why a second one will help when we haven't got far down the road on sorting out the first. It's not surprising therefore that some still dismiss these discussions as “mere anecdote”, or that there is a continuing critical literature (initiated in part in this journal) about the use and value of the genre itself. This ambivalence must be part of the explanation as to why, among the burgeoning of books on medical ethics, published collections of cases well analysed are still rare. This is therefore a welcome addition to the landscape.
It has many features which commend it. These are real cases, culled from the daily life of ordinary hospitals, not academic centres: so they ring bells as being important and common situations. The authors express some of the discomfort here: such cases can't always be neatly categorised, and they express a “day-to-day moral struggle”, but they do contain many of the bread and butter issues of our discipline, often articulated but still in a sense unresolved. The cases here are fleshed out with their particular difficulties, and so (although there are references to key articles), the major signposts of medical ethics seem to be of less use than is often thought in sorting out what to do. As a consequence, the authors speculate on different possible endings. There is a bibliography, readings being helpfully connected to the cases.
But of course as with insurance cover or a long term relationship it's in the details where disappointment may lurk. It's sad, for instance, given the important work published elsewhere, to find that the references are almost entirely from America. But being over-text, over-made and over here is not the main problem. To this reviewer the punches are still too flabby, the objectivity not sharp enough. It still reads too often like clinicians speaking to clinician friends. Other voices don't seem properly heard or satisfactorily amplified. Take one case, called “Caring for the indecisive patient”, as an example. This turns out to be about a patient with an ischaemic foot who after admission was found to have widespread and incurable cancer. In spite of an expressed wish for quality of life in her last days, when her ischaemia progresses she is advised to have an amputation and agrees, but then refuses several other interventions and says she wishes to die quietly. Fascinating staff responses are presented but not discussed. The husband has alcohol on his breath, and so it is assumed by nurses and social workers that “he might not have the patient's best interest at heart”. (His wife who came in with a sore foot is now near death and he's not supposed to have a drink before he comes in to see her?) The physician is concerned that “reimbursement for hospital days would be denied if no treatment was given” . . . and thinks there was a “significant risk that increased narcotics for pain would ‘do her in’”: he didn't go to the team meeting to discuss her care. We don't need to go on. There are well known attitudes represented here that, in part at least, concern the ethics committee. They worry that if they are too critical of a doctor's care that doctor might not bring future cases to the ethics committee. Understandable, and they all have to meet at PTA gatherings or on the golf course, but that doesn't surely prevent a robust analysis in a book, where issues not personalities are to the fore. To the reader, this poor woman seems shocked by the discoveries, and caught in transition, but not indecisive. She did a great deal better than Hamlet at making up her mind in difficult circumstances: her tragedy lay in what was beyond her control. This book reminds me of a comment on a close friend's essay at school on religion, the friend being a parson's child: “Could do better, seeing who you are”.