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Life and Death in Healthcare Ethics: A Short Introduction
  1. J Laing

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    H Watt. Routledge, 2000, £7.99, vii + 97pp. ISBN 0-415-21574-9

    This is a compact, nicely written book that provides a rejuvenating alternative to the utilitarian orthodoxy that dominates contemporary bioethics. There is currently a dearth of bioethical literature presenting what might be called a more traditional approach to medicine and health care. This contribution is a short and useful introduction to such an approach.

    The book announces itself as being written with “both the general reader and students and professionals in medicine, nursing, law, philosophy and related areas in mind”. Accordingly, it assumes no prior knowledge of ethics. It gives a neat introductory overview of some ethical concerns raised by reproduction, death, and dying. The issues considered include euthanasia and withdrawal of treatment, the persistent vegetative state, abortion, cloning, and in vitro fertilisation.

    By beginning the early chapters with a real-life case, Watt captures the interest of the reader. The case is introduced and discussed dispassionately. It is then employed as a springboard for a general discussion of principles often thought dry and difficult. Newcomers to the study of ethics will be pleasantly surprised.

    In the first chapter—for example, the Arthur case is introduced as a context for discussing putative distinctions between killing and letting die, and intending and foreseeing; approaches to homicide suggested by competing ethical theories are also covered. In the second chapter, the Bland case is analysed and philosophical concepts such as that of “personhood” are discussed. Watt considers the notion of life as good in itself and raises questions about the social significance of tube feeding. The Cox case, in chapter 3, elicits a discussion of concepts such as that of a worthless life, the oft-misunderstood principle of double effect, and questions of autonomy. In this chapter, Watt introduces a concept she calls “lethal bodily invasion”. Even if a Nazi doctor did not care whether his victims survived his experimentation on them, the doctor’s intention to invade their bodies in a way he knew would do them no good, but only lethal harm, would be enough to identify his course of action as grossly immoral. This is plausible enough in the context Watt suggests. In order to test her principle as outlined, however, Watt needs to examine other situations where the principle of double effect is often employed.

    The principle of double effect is often raised in the context of self defence, defence of a third party, and war. Clearly, the book is an analysis of health care ethics. A broad discussion of defensive action is well beyond its scope; however, it is profitable to analyse like cases where the principle of double effect is often summoned as a justification for deaths not intended but foreseen. If a mentally disordered man, or child for that matter, runs amok with a shotgun in a school, is a marksman not justified in shooting to maim? If the aggressor dies, is this lethal bodily invasion impermissible? Would the marksman not be regarded as remiss if he failed to act to prevent the death of the schoolchildren?

    The principle suggested by Watt also appears to necessitate the conclusion that even where two patients will die and one is threatening the life of the other unless a doctor intervenes to save one, the doctor is required to do nothing and allow both to die. Such were the circumstances of the recent UK case of the conjoined twins, “Jodie” and “Mary”. It is one thing to say that the doctor may decide not to intervene—for example, on the grounds that he wants to respect the parents’ wishes: it is quite another to say that it is entirely impermissible to perform life-saving treatment on one twin (even where the parents wish it), in the same way as it is impermissible for the Nazi doctor to use a patient as fodder for experimentation. In the conjoined twins’ case, there are relevant moral differences. The immediate aim, not merely the further end, of the doctor in performing the operation is to save the life of one of the children. The Nazi doctor, by contrast, has the saving of lives as, at best, his further end. It is worth remembering too that by Watt’s own account, sometimes omissions to act to save a patient can be wrongful. And one begins to wonder whether the requirement that a doctor refrain, on moral grounds, from treating either of the patients destined for certain imminent death is not moral reasoning gone awry.

    Chapter 3 is followed by brief explorations of the controversial topics of abortion and embryo destruction. The final chapter looks at the question of moral disagreement and conscientious objection. It is a reminder, if any be needed, of the practical nature of moral theory.

    It is the book’s simplicity that leads me to believe that it will be read eagerly by students from a range of different disciplines. The layout and typographical style make the book particularly accessible. There is a comprehensive index and bibliography. If I have a criticism, it is that the book could have been longer. However, for those who want a basic text to introduce them to life and death issues in bioethics, this is a most welcome contribution.