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Ethical Issues in Palliative Care—Reflections and Considerations
  1. P Kaye

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    Edited by P Webb. Hochland and Hochland, 2000, £15.95, Pp 138. ISBN 1–898507–27–9

    This book is a collection of essays by a variety of specialists with a particular interest in palliative care. It contains seven chapters by six different authors.

    The first chapter Why is the study of ethics important? is by Patricia Webb, a lecturer in palliative care with a background in nursing. She tells us that studying ethics encourages logical reasoned thinking in the face of difficult decisions such as allocation of resources, access to services, best care, clinical research, and rights to life. Webb reminds us that clinical guidelines may not be much help in the face of an ethical dilemma with no clear right or wrong answer.

    The chapter called Care versus cure by David Jeffrey, a consultant in palliative medicine and writer on medical ethics, reminds us that care is concerned as much with the subjective feelings of the patient as with the physical disease, and aims to relieve suffering and improve quality of life. He emphasises that by sharing the reality of uncertainty (with patient, family, and colleagues) we can make more realistic decisions, and that informed consent is a mechanism for sharing the power of doctors and patients.

    Giving it straight—the limits of honesty and deception by Heather Draper, a lecturer in biomedical ethics, explores the difference between truth-telling and honesty, and between honest and dishonest selective truthfulness. “There is a sense in which we are always selective with the truth”, she writes and reminds me of the saying so useful in palliative care that: “Truth like medicine can be skilfully used, respecting its potential to help and to harm”.

    The chapter on Advocacy by Patricia Webb defines advocacy as “the role of one with expertise who is invited to negotiate on behalf of another”, and is an interesting analysis of the power differences between patients and professionals. She makes the point that “patients have little power to influence the nature of care provision unless a determined effort is made to reduce their actual and perceived vulnerability”. She also emphasises, however, that skilful communication allows most patients to be directly involved in decision making. With good team care few patients need an advocate, except those few who prefer to be very passive, or who are unable to make decisions, such as those with severe learning difficulties.

    The next chapter, How informed can consent be?, by Calliope Farsides, a senior lecturer in medical ethics, makes the point that it is often useful to consider consent not primarily as a legal concept but a moral one, and one that depends on the relationship between patient and carer being a relationship of trust, reciprocity, and beneficence, with mutual recognition of their duties and obligations. She goes on to look at the differences between tacit and express consent and the problems of coercion and “sufficient information”.

    In Euthanasia—slippery slope or mercy killing, Marny Prouse, a sociologist, director of nursing at a hospice, with a BA in law and now a risk and litigation manager, has written an excellent essay on the euthanasia debate, and finally urges us “to research and practise our arguments and beliefs so that we can be comfortable and credible when moral questions about the end of life are discussed”.

    The final chapter on Teaching ethics in the practice setting by Rachel Burman, a consultant in palliative medicine, emphasises that medical ethics involves many disciplines, including behavioural sciences, law, theology, and philosophy, as well as medicine. The teaching of medical ethics is ideally done, she says, in multidisciplinary groups with sensitive and detailed discussion of real life ethical dilemmas, with both philosophers and clinicians facilitating. In the USA ethical committees are commonplace in hospitals, where there is often a resident ethicist on the staff to help with difficult clinical cases, developing policies, and education. In the UK ethical committees have been largely restricted to looking at research protocols, but the development of clinical ethical committees to act as a forum and resource for managing difficult clinical dilemmas is accelerating.

    Several of these chapters contain helpful clinical case histories, but the next edition of this useful book should contain another chapter, written by a clinical ethicist, with a collection of clinical cases and scenarios based on those discussed by ethical committees, together with a discussion of some of the key areas of debate that they raised. This would demonstrate this powerful teaching method and would also provide some relevant practical material for teams and trusts that are trying to set up their own ethical committees.

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