Bulletin of the World Health Organization

Cambridge textbook of bioethics

Robert Dingwall a

This is a comprehensive and carefully designed textbook that will attract many users in the health professions. The chapters, written by a group of distinguished authors, are presented in a format that is well suited to interactive educational use. This is particularly important, given the enthusiasm of the modern medical profession for reducing everything to checklists – “tick 8 boxes out of 10 and you have made an ethical decision!” Bioethics, however, does not work in this way, although I sometimes think that part of the appeal of “principlist” approaches is that they seem capable of such a reduction. Ethics is a matter of reasoned judgement, a process that this book seeks to stimulate. Each chapter begins with a short case note describing a relevant situation. It would be easy for educators to use this as a basis for preliminary discussion and then to encourage students to work through the ethical analysis. They can review how the chapter author(s) would deal with the problem presented and compare this with their own responses. The book is divided into 10 sections and its 65 chapters present a wealth of material for “mix and match” adoption to support both generic courses on bioethics and those with particular emphases. The range of material that is covered also presents many opportunities to use the book as a practical resource to deal with presenting cases that parallel those described in the book. There is particular value in the section that deals with the religious and cultural perspective: bioethics in the northern hemisphere has often rightly been criticized for its neglect of the thoughtful consideration given to bioethical issues from sources outside a Judaeo-Christian heritage.

Given its strengths, the book also brings out some of the weaknesses of bioethics as an essentially normative discipline. The cases discussed point to ethically justifiable courses of action but do not communicate very well how these can be actually achieved. Empirical analyses of face-to-face interactions, for example, have found fundamental constraints on achieving the standards of informed consent stipulated by bioethicists. They have also shown that bad news is not necessarily best delivered in quite the direct way that bioethics tends to prefer. The chapter on torture urges doctors to report this to appropriate authorities, but presumes a state of law in which such reports will be welcomed: in many situations, doctors would simply be exposed to the same fate as the victims that they are trying to protect.

Despite the editors’ clear and commendable efforts, North American biases do creep in. The book is generally good at dealing with areas where the United States of America (USA) knows it does things differently from Europe, such as with stem cells. However, it is less good at explaining European differences to the USA, such as in the chapter on assisted conception, which does not discuss the European controversy over whether children born from donor gametes may have a right to know the identity of their genetic parents. Readers who are nurses will probably feel that the distinctive ethical voice of their profession is under-represented, although there are chapters on issues for pharmacists and for complementary healers. It is also slightly odd that there is no chapter that focuses on the extent that health professionals are ethically obliged to risk their own lives in order to treat sick people, an issue thrown into sharp relief by the experience with severe acute respiratory syndrome (SARS) in Toronto and a serious concern for those planning responses to potential health challenges such as pandemic influenza.

The book’s chapter by chapter approach leads to occasional contradictions. For example, “reproductive tourism” is seen as bad, but autonomy in seeking health care is taken as good. If, however, autonomy is generally favoured as a principle, why should there be anything wrong with free movement across international boundaries to choose a legal and regulatory regime under which to conceive and give birth? In fact, the contributors are almost all rather uncritically in favour of more regulation rather than less and they rarely acknowledge that there could be viable libertarian objections to their positions. These contradictions could, however, be valuable teaching points.

Finally, perhaps it is also time for bioethics to engage more with the historians’ work on their founding premises. It is far from clear, for example, that the Nuremberg Code deserves the importance that it is given, particularly in the light of the extensive regulation of biomedicine in Germany prior to the Second World War. The Nazi experiments on humans could equally well be seen as the result of a culture that emphasized compliance with regulation over professional deontology, which should give some pause to the contemporary enthusiasm for regulation. It is notable, too, that the recent revisionist work on the Tuskegee Syphilis Experiment is not acknowledged in the book. There is an argument that initially there was nothing wrong with the experiment, given the risk–benefit ratio for the syphilis treatments available in the early 1930s. If there was a scandal, this arose much later and today would be addressed by a clinical trial management committee that would consider whether to end a study early and make an emerging treatment generally available.

This book demonstrates the importance of bioethics to clinical practice in any reasonably developed health care system. It is respectful of cultural diversity and takes account of what may be realistically possible in resource-constrained environments. However, it is essential not to take the disciplinary project embedded within it wholly at its own valuation. The English writer Shelley once claimed that poets were the unacknowledged legislators of the world. I sometimes think that bioethicists would like to displace poets in this role but am not sure that I would really like to live in a world that was ruled by either. On the other hand, I can certainly see the point of regulative ideals that encourage reflection, but whose application is a matter of contextual judgements that place the contribution of ethics within a portfolio of relevant considerations. Singer, Viens and their team of authors have created a valuable resource to inform such judgements. ■


Affiliations

  • Institute for Science and Society, University of Nottingham, Nottingham, England.
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