PostScript ............................................................................................. LETTER Medical commitments ceremonies I read Raanan Gillon's piece on the defence of medical commitments ceremonies with interest.1 I was, however, disturbed to see that in the declaration of a new doctor considered satisfactory at Imperial College there is no mention of age among the politically correct list of human and social characteristics that should not influence a doctor's duty of care. The omission is conspicuous in view of the abundant evidence that age discrimination is widely practised in medicine and that it has recently been proscribed in the National Service Framework for Older People. Does this mean that I must advise all my elderly patients that in any encounters with graduates of Imperial College they must insist on a second opinion? J Grimley Evans Nuffield Department of Clinical Medicine, Division of Clinical Geratology, The Radcliffe Infirmary, Oxford OX2 6HE; john.grimleyevans@geratology.oxford.ac.uk Reference 1 Gillon R. In defence of medical commitment ceremonies. Journal of Medical Ethics 2002;28:7–9. BOOK REVIEWS The Ethics of Genetics in Human Procreation Edited by H Haker, D Beyleveld. Ashgate Publishing Co, 2000, £45.00 (hb), pp 335. ISBN 0 7546 1021 7 This is a challenging book that I recommend for anyone who wishes to engage with contemporary philosophical discussions relating to assisted reproduction, pre-implantation genetic diagnosis (PGD) and embryo research. It consists of six principal papers, each accompanied by responses from two discussants. There is also, in an appendix, a summary of the discussion that followed each of these six sessions in the final symposium of the EU-funded European Network for Biomedical Ethics held in Sheffield in 1999. In addition, there is a seventh paper in which the network, funded from 1996–1999, is evaluated, and there are introductory and closing remarks to the volume by Dietmar Mieth, Professor of Social Ethics at Tübingen. In his introductory contribution, Professor Mieth asks us to consider the words that are used to describe the practices of IVF and PGD and the problems they generate. He follows Illich in problematising the word "life", tracing its use over the past two centuries in the context of our mechanistic biology and our society's possessive individualism. He argues that the terms of the "official" moral debates in this area-the terminology of bioethics as well as the terms of reference of the learned bodies and committees-have pre-empted these deliberations so that they can only lead to the fully liberal, permissive position. In the first major paper, Sheila McLean discusses the "right" to procreation. What does this amount to? When may obligations to a future child restrict or potentially infringe upon parental freedom to make specific decisions? And when can individual wishes be challenged in the interests of society-the wider community? In the responses to this paper, Anders Nordgren sets out a coherent position in which there can be limited, local, contractarian rights to fertility treatments and a limited autonomy on the use of prenatal diagnosis and decisions about selective terminations of pregnancy. Onora O'Neill applies the concept of the "good enough" parent to the realm of assisted reproduction, and asks how the new ways of becoming parents may lead to new ways of being parents. She asks us to examine the ethical issues in this area from the perspective of children born as a consequence of the new technologies. She emphasises the differences between that perspective and that of the perspectives of children who have been adopted or fostered. An increase in choice for adults may lead children to feel rejected by their genetic or gestational parents. Chosen relationships are often understood as very different from given relationships, and more easily become conditional. How may this alter parent-child relationships? Notions of autonomy, it is argued, should not be the only or central concern in regulating this area. Finally, Walter Lesch discusses the question of when parents or children can be considered "good enough" in the genetic sense. He maintains that it is legitimate for the standard of "good enough" to vary, depending upon the biological and social origin of the child. A similar format applies in the five other sections. Derek Beyleveld presents a technical argument about the status of the embryo and the fetus, starting from the ethical system of Alan Gewirth. I found this unconvincing, as did the two discussants for several reasons, but I am happy to concede that this topic is outside my area of expertise. The third paper is presented by Jean-Pierre Wils. Autonomy, it is argued, only makes sense in the context of a relationship in which the other is recognised as a(nother) moral agent. Accordingly, the difficulty in achieving this in relation to an embryo or fetus makes it difficult to treat the embryo with full respect, and technological modes of visualising the embryo or fetus can make this even more difficult. Our habits of perception pre-empt our ability to choose how to understand what we see. Wils argues for a graded recognition of (active) personhood or (passive) moral rights. In the discussions, Engels emphasises the danger of determinism and Dierickx discusses the depersonalisation that often accompanies prenatal screening programmes at the population level and the altered notion of responsibility (for the genetic health of one's children) now that nature need not simply take its course. The fourth paper, by Regine Kollek, locates the new reproductive technologies within modernity-and therefore within the paradoxical conjunction of both increased freedom and heightened accountability for one's "free" choices. The notion of risk management is crucial to this paradox, and Kollek discusses the impact this has on women's lives. The ways in which the new reproductive technologies can reinforce the emphasis on genetic identity-one's "true" family consisting of one's molecular relations-is also discussed. And Kollek echoes Mieth's criticism of bioethics as a mechanism that controls and silences opposition to the new reprotechnologies. The discussants to this paper both challenge Kollek and extend the scope of her argument. The fifth paper, by Marcus Düwell, is methodological; it considers how to justify an ethical position in this area. He outlines several of the areas of contention already discussed and proposes a framework within which to consider them. He suggests-and I disagree- that bioethical principles can define what is justified, allowed or forbidden while other considerations (of apparently lesser importance, beyond the scope of ethics) can guide other aspects of behaviour. The discussants criticise this view too, objecting to the narrow scope of applicability of this ethics and the framing of ethical responsibility as (merely) the recognition of justified interests. The final paper, by Beyleveld and Pattinson, examines the legal frameworks within which various European countries tackle IVF, PGD, cloning, and related technologies. The substantial differences are accounted for in several ways, including messy political compromise, and the nation-specific meshwork of legislation and non-legislative regulation, professional codes of practice etc-as discussed further in a commentary. The other discussant examines the specifically medical aspects of fertility treatment. This is a wide ranging volume that examines reprotechnology and reprogenetics from several, conflicting perspectives. The resulting compilation is especially valuable for bringing If you have a burning desire to respond to a paper published in JME, why not make use of our "rapid response" option? Log onto our website (www.jmedethics.com), find the paper that interests you, and send your response via email by clicking on the "eLetters" option in the box at the top right hand corner. Providing it isn't libellous or obscene, it will be posted within seven days. You can retrieve it by clicking on "read eLetters" on our homepage. The editors will decide as before whether to also publish it in a future paper issue. J Med Ethics 2002;28:329–334 329 www.jmedethics.com group.bmj.com on June 3, 2016 Published by http://jme.bmj.com/Downloaded from strands of Continental philosophy, with a heavy representation-especially from Tübingen, into dialogue with a more Anglo-Saxon bioethics. This breadth of perspective is uncommon, impressive, and very helpful. I hope that further contributions of this sort emerge from future collaborative projects in Europe. A Clarke ClarkeAJ@Cardiff.ac.uk The Concise Encyclopedia of the Ethical Assessment of New Technologies Edited by R Chadwick. Academic Press, 2001, pp 404, £53.95. ISBN 0-12166355-8 Whilst offering extensive new opportunities, technological developments also tend to pose serious challenges and difficult ethical questions. Developments in-for example, biotechnology, information technology, transport technology, and nuclear technology have for decades been the subject of intense public debate and a principal object for philosophical reflection and ethical analysis. The Concise Encyclopedia of the Ethical Assessment of New Technologies is a collection of articles, thoughtfully edited by Ruth Chadwick, which addresses a range of the ethical issues pertaining to contemporary technology. The editor's objective in this collection appears to be to describe general methodological issues in ethical analysis and to give an account of the practical application of ethical theory to issues surrounding new technologies. Some of the articles provide an outline of conceptual frameworks for ethical analysis and key ethical principles-for example, discussions of consequential and deontological perspectives, the precautionary principle, and slippery slope arguments. Other articles go beyond these methodological issues and apply ethical terminology to specific technologies such as genetics, computers, nuclear technology, and reproductive technology. The collected articles all have a standardised and easily accessible layout and are arranged in a single alphabetical list by topic. This confirms what is already suggested in the book's title, namely that the encyclopedia is a scholarly reference work. The main body of each article follows a short outline section, including a preview of headings, a glossary of essential concepts, and a brief introductory paragraph defining the debated issues and summarising the content. A short bibliography completes each article. The encyclopedia provides a detailed first introduction to a number of new technologies and the ethical issues pertaining to them. The very helpful introductory paragraphs make it easy for the reader to focus on essential themes and the glossary makes it possible to keep track of sometimes quite complex technical and philosophical issues. Most articles are easy to read and the authors succeed in giving a nuanced account of often quite controversial cases. However, the limited space available makes it difficult for the articles to be more than good and thorough introductions. An extended bibliography, consisting of suggestions for further reading, could make the encyclopedia an even better work of reference. Naturally a collection of articles on a very broad subject such as new technologies will have to depend on a cautious selection among a large number of relevant and important topics. It seems the articles for this collection have been selected with some preference for biotechnology and medical technology, and although the book to some extent also addresses the impact of other technologies it leaves the impression that ethical questions relating to bio/medical technologies are particularly numerous and significant. The distinct focus adopted in the selection of articles suggests that this is a work aimed mainly at an audience specifically interested in biotechnology and medical ethics. In sum, The Concise Encyclopedia of the Ethical Assessment of New Technologies impresses as a highly applicable reference work, particularly for readers with an interest in biotechnology, medical technology, and biomedical ethics. The book is easy to use for reference but also serves to bring attention to important new issues and emphasises the need to develop the conceptual basis for analysis as new technologies emerge. For that reason it is likely to become essential reading for ethicists, medical students, scientists, and others working with the ethical implications of technology. Acknowledgement I thank Donald Hill, John McMillan, and Michael Parker for discussion on the points made in this review. A Hasman admin@ethox.ox.ac.uk Legal and Ethical Aspects of Organ Transplantation D Price, Cambridge University Press, 2000, £45, pp 487. ISBN 0-521-65164-6 Some lawyers, even some academic lawyers, have developed the happy knack of being in the right place at the right time, without being ambulance chasers. Thus David Price, with not only a timely but a thoughtful and thought provoking examination of organ transplantation and associated questions of commerce and commodity in body parts, seems almost prescient. Did he know, when he set out to compose what has emerged as his elegant and authoritative account and critique, that bodies and body parts were about to become one of the most controversial intellectual properties for years? Price's corpus is in three parts; predictably cadaveric organ transplantation and living donors comprise the most substantial elements of his exegesis and critique. While his review largely antedates cell nucleus substitution and the potential therapeutic application of stem cell research, he recognises that this is one of a number of "alternatives" to current transplant technologies that will later require more comprehensive consideration and review. In a third, concluding section, he addresses the troubling issue of "commerce" and the troublesome one of "recipients". Throughout, his analysis and arguments are driven by the need-as he perceives and defends it-to respond to "medical globalisation". This entails setting in place an integrated, coherent, and global conception of appropriate and acceptable transplantation practice, and a similarly fashioned and dedicated form of regulation. Price attempts to stake out what for him would be a coherent and defensible position on organ transplantation that may be of global reach and appeal while yet remaining sensitive to culturally and politically diverse circumstances. As others have concluded, this is no mean task, and yet the attempt is an important and urgent one. Too often, in the absence of some agreed alternative framework for international approaches to modern scientific biomedicine the contemporary default mechanism of market regulation succeeds. Here, Price is shy neither of introducing nor courting controversy. He engages with commerce (it is "too dismissive to simply sideline at least consideration of commercial schemes"), marries doubt about the wholehearted value of intuitionism-(too long dominant in public policy consideration of transplant policy), with an appeal to relativity ("philosophical choice in a specific cultural milieu"), but would divorce the views of potential donors from those of their relatives, clearly preferring an apparently autonomyenhancing preference for doing as the former (would have) wished, to what the latter would have done. Price concludes that developed countries which do not facilitate an increase in organs available for transplantation purposes encourage the development of an alternative trade in organs. Thus, exploration of supranational responses to need and regulation are necessary to respect and protect donors, recipients, and health care professionals, while yet encouraging donation and increasing the supply of transplantable organs. One of the keys to unlocking this response is a strong slice of autonomy-so that the premortem wishes of potential donors are neither frustrated nor assumed-and another is a mild draught of commercialisation. Failing this, Price would advocate a system of mandatory choice and adherence to those choices even when they would encompass presently legally dubious practices-such as elective ventilation. This is a comprehensive and considered book on legal approaches to organ transplantation which, as far as lawyers have been concerned, has been strangely lacking as a companion to a number of excellent studies of the philosophy and ethics of the subject. But Price engages also in those ethical debates and arguments, and compared with many who have surveyed other discrete areas of modern biomedical practice has done so from a broad international perspective; there is, (as one example) more in this essay from the rich and vibrant traditions of South America than in many comparable volumes. This is a particularly welcome addition to the emergent library of international biomedical ethics and comparative law. D Morgan MorganDM1@cf.ac.uk Transplantation Ethics R M Veatch. Georgetown University Press, 2000, £46.75, pp 427. ISBN 0-87840811-8 Transplantation Ethics is a book that will be welcomed by teachers and students of medical ethics as well as health care professionals and policy makers involved in transplantation issues. The book provides a broad overview of recent and contemporary debates relating to organ transplantation, while also defending particular methods of approaching the ethical questions and using them to argue for particular policy proposals. Most of the book's chapters are based on previously published material, and while this leads to a certain amount of repetition, the overall result is coherent and highly readable. The book is divided into three parts. The first addresses the definition of death, a matter which is clearly of great importance for 330 PostScript www.jmedethics.com group.bmj.com on June 3, 2016 Published by http://jme.bmj.com/Downloaded from transplantation ethics, given the rule that vital organs may only be removed form a corpse, but on which opinions are highly divergent. Veatch reviews the debates surrounding the shift from cardiorespiratory to brain-oriented definitions of death, but argues that the currently favoured whole-brain approach is an unstable compromise, subject to the same kinds of objection that its advocates level against the traditional cardiorespiratory accounts. The whole-brain definition should therefore be abandoned in favour of a higher-brain oriented concept which acknowledges that a person is dead-and that "death behaviours" such as mourning and organ procurement are appropriate-once he or she has permanently lost the capacity for consciousness. Recognising, however, that this is not an issue where consensus can be expected, Veatch proposes a "conscience clause", according to which individuals would have the right to choose, from a range of alternatives including traditional, wholebrain, and higher-brain accounts, which definition will apply in their own case. This is an interesting idea, though one wonders whether it would not better be formulated as a right to select the conditions under which lifesaving treatment will be ceased and organ procurement initiated, independently of the determination of death. The second part of the book deals with organ procurement. Here Veatch focuses on the problem of how to increase the numbers of organs available for transplant, and considers proposals including a shift from donation to routine salvage of organs; transplantation from live donors, anencephalic infants, minors, and older persons; the use of tainted- for example, HIV positive organs, and xenografts. It is here that the underpinning moral theory becomes apparent. Veatch defends on grounds of beneficence the use of tainted organs, where this is better for the patient than no organ at all, suggesting that the reluctance of practitioners to perform such operations is understandable but misguided. For Veatch, however, the cluster of deontological principles which go under the heading of "respect for persons" has priority over the principle of beneficence, leading him to reject a policy of routine organ salvage as inconsistent with respect for autonomy. Veatch allows that sale of organs and other forms of rewarded procurement may be justified on grounds of autonomy and beneficence, and that a policy of routine salvage with provision for opting out may be justified as a last resort, but he firmly rejects the idea of "presumed consent" as an "outrageously unethical" attempt "to hold onto the consent and donation model by using the language of consent for what is really a policy of routine salvaging". A further non-consequentialist element in Veatch's moral theory is a principle of distributive justice which requires priority to be given to the interests of the worst off even if the aggregate welfare in society is thereby diminished. Veatch uses this principle to defend xenotransplantation, arguing that while the widely discussed risks of transmitting viruses from "donor" animals into the human population (including nonconsenting third parties if the infections, like HIV, prove to be transmissible between humans) may render xenografting hard to justify on consequentialist grounds, it may be justified on grounds of justice since those requiring organ transplants are among the worst off in society and are likely remain so even if infections are passed through them into the wider population. To me, however, this illustrates the implausibility of too rigid a policy of prioritising the worst off. In the worst case scenario ("another HIV epidemic or worse") thousands might be made very nearly as badly off as those whom the policy is intended to help, while the value of the transplants would be diminished; thus a large aggregate disbenefit and an increase in the numbers of the seriously disadvantaged would be the price paid for what might be a fairly marginal benefit for a small subset of that group. The same principle of justice is applied-to my mind more plausibly-in the third part of the book, which addresses the allocation of organs. Here Veatch sets out in more detail his egalitarian approach to distributive justice, and considers the moral relevance of such factors as self inflicted illness, age, and social worth, ending with a discussion of the vexed issue of "directed donation" (where an organ is donated with the proviso that it be given to a particular category of recipient-for example, a member of the same racial group as the donor). Much of the discussion in this part of the book will be of interest to those concerned with the allocation of heath care resources in general, and not just those with a particular interest in transplantation. Overall, Transplantation Ethics is a valuable contribution to its field. It is accessible to non-specialists while providing a thorough treatment of the issues and a high standard of argument. Although the book has a strong US orientation in its discussion of law and policy issues, this does not detract from its interest or relevance to readers elsewhere. J Hughes j.a.hughes@keele.ac.uk Life and Death in Healthcare Ethics: A Short Introduction 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 PostScript 331 www.jmedethics.com group.bmj.com on June 3, 2016 Published by http://jme.bmj.com/Downloaded from those who want a basic text to introduce them to life and death issues in bioethics, this is a most welcome contribution. J Laing The Medical Profession and Human Rights: Handbook for a Changing Agenda British Medical Association. Zed Books, 2001, £50.00 (hb), £18.95 (pb), pp 561. ISBN 1 85649 611 2 Doctors are to good governance what the miner's canary is to decent air: their testimony is often the first sign that something has gone seriously wrong. For someone like Wendy Orr, who was a South African district surgeon of 24 when she was forced to confront the lax attitude towards abuse of prisoners' rights in her workplace-the building in which Steve Biko had been tortured-the decision to fight a prevailing medical culture of complacency and passivity was a clear and obvious ethical dilemma. But although this well-structured, comprehensive, and clearly written handbook begins with Wendy Orr's story in her own words, its theme is that the air is more polluted, and that human rights abuses are more of a problem for practitioners, than we like to think. The effect of human rights abuses on doctors has broadened in the thirty years since the BMA first began to monitor such issues. Conversely, and more hopefully, the effect of the medical profession on human rights abuses has also deepened. Doctors and their constituent organisations around the globe are more aware of the myriad ways in which the medical profession may be called on to be complicit in rights abuses, and less likely to be complicit. For example, the Indian Forum for Medical Ethics condemned the supposedly more humane practice of asking a doctor to certify death rather than prolonging hanging, since if the victim was still alive, the doctor was in fact being required to say "Not dead yet, carry on killing". More generally, the prison physician may feel that his or her participation in capital or corporal punishment will at least make the punishment more humane; against this argument, the BMA notes dryly that "Medical participation usually brings . . . an air of propriety" (page 168). The BMA's handbook testifies to a sophisticated awareness of the ways in which the agenda for medicine and human rights has moved beyond the still important but more obvious areas, such as torture, prison medical governance, and capital punishment, and into increasingly worrisome but more convoluted areas-such as trafficking in women and children; the effect of the new genomics on weapons research; commodification of organs, and the effect of Third World debt on health as a human rights objective. This breadth of coverage is matched by breadth of participation in preparing the report. The principal authors, Ann Sommerville and Lucy Heath, have involved human rights campaigners in such countries as El Salvador, organisations such as the UK's Medical Foundation for the Victims of Torture, national medical associations (most notably in Turkey), and a very cosmopolitan human rights steering group including representatives from India, the Philippines, and South Africa. The inclusion of Third World views puts paid to the oddly patronising notion that human rights are a Western concept (which, it is implied in this common but wrong-headed account, nonWesterners are too backward to have developed for themselves.) Although I am glad to see women's rights taken seriously as human rights in this book, I have some doubts about the wisdom of concentrating women's issues largely in one chapter, comprehensive though it is (with material on violence against women, enforced sterilisation and abortion, "honour" killing, rape in wartime, and female genital mutilation). There are other ways in which women are exploited by or with the complicity of doctors-particularly in commodification of gamete donation, which will be especially worrisome in light of the need for enucleated eggs in the stem cell technologies. It was disappointing not to see much mention of the disproportionate burden that structural adjustment policies and debt payments impose on women's health in the otherwise excellent chapter on health as a human rights objective. The Medical Profession and Human Rights is nevertheless a very important book: testimony to the need for the British Medical Association to continue using its unique position at the hub of Commonwealth and other international medical professional bodies, in order to bring to public and professional attention wider ethical issues than the everyday nitty-gritty of consent and confidentiality. This is a book for dipping, rather than reading at one sitting, not least because few of us can stand the sustained grimness of much of what has to be reported. Busy practitioners might want to begin at the end, with the succinct, clear-headed and hard-hitting summary of all the book's recommendations, and work back from there to the individual topical chapters in which the recommendations first appear. I hope that teachers of medical ethics-and more broadly, anyone who has a role in training health care practitioners at any level-will make time for the chapter on teaching ethics and human rights, which, like the rest of the book, is admirably wide ranging, considered, and comprehensive. One final note, if I may: the Centre for the Study of Global Ethics is currently presenting a series of six public lectures drawn from some of the topics in this handbook-the death penalty; genomic research and weapons development; trafficking in women and children; medicine and debt; global commodification of organs and tissue, and research on Third World populations. We owe a great deal to the inspiration of this book, and hope that we can extend its audience by this public lecture series. As the introduction says of the book itself, the lectures are "dedicated to all those who struggle to protect human rights and, in particular, to doctors who take on what is often a thankless and troublesome task". D Dickenson d.l.dickenson@bham.ac.uk Principles of Biomedical Ethics, 5th edn. Beauchamp T L, Childress J F. Oxford University Press, 2001, £19.95, pp 454. ISBN 0-19-514332-9 The Principles of Biomedical Ethics by Beauchamp and Childress is a classic in the field of medical ethics. The first edition was published in 1979 and "unleashed" the four principles of respect for autonomy, non-maleficence, beneficence, and justice on the newly emerging field. These principles were argued to be mid-level principles mediating between high-level moral theory and low-level common morality, and they immediately became very popular in writings about medical ethics. Over the years Beauchamp and Childress have developed this approach and vigorously defended it against the various criticisms that have been raised. The 5th edition of this book is, as all the previous editions, well written and for the most part very persuasively argued. In some places the authors' intention of being comprehensive does, however, create problems. There are, for instance, places where opposing views are mentioned merely in order to be summarily dismissed as "morally perilous" without further argument. What is new in the 5th edition? The main theoretical novelty is that the authors now clearly state what they mean by "common morality" and that this definition has changed from previous editions where the common morality was viewed as a set of socially sanctioned norms. The common morality is now defined as " . . . the set of norms that all morally serious persons share" (page 3) and it is linked explicitly to human rights discourse. This is a major new theoretical commitment on the part of Beauchamp and Childress and saddles them with the problem of showing that there really are any norms that "all morally serious persons share". We may agree that there are norms that all morally serious persons ought to share on serious reflection and after exposure to a wide range of views and arguments, but there is quite some distance between this view and the view that Beauchamp and Childress seem to advocate. In order to get a common morality that has some content they are arguably compelled to define "morally serious person" in terms of holding norms that are to some degree congruent with "common morality", thereby introducing a problematic circularity in their analysis of common morality. The structure of the book has also been changed. The chapters on moral theory and moral justification are now the last chapters and have swapped places with the chapters on moral norms and moral character. This is presumably to make the book more accessible to health care professionals. The whole book has been comprehensively rewritten, but the core arguments in the four chapters explicating the four principles are still the same. This also means that the restrictive limits in the scope of the principles of beneficence and justice are still open to the same criticisms that were levelled against the previous editions of the book. For the person who already has the 4th edition on the bookshelf, and who is not actively using the book for teaching or study there is thus little reason to buy the 5th edition although it is very modestly priced. The underlying arguments have changed to some extent, but the conclusions are pretty much the same. S Holm soren.holm@man.ac.ut Ward ethics. Dilemmas for Medical Students and Doctors in Training Edited by T K Kushner, D C Thomasma. Cambridge University Press, 2001, £18.95, pp 265. ISBN 0-521-66452-7 Kushner and Thomasma have assembled a distinguished group of contributors who are almost all practising clinicians with an interest in medical ethics. The book is well laid out and is divided into two main parts: part one "On caring for patients" and part two "On becoming a 'team player': searching for esprit de corps and conflicts of socialization". This is a convenient way to think about medical ethics. 332 PostScript www.jmedethics.com group.bmj.com on June 3, 2016 Published by http://jme.bmj.com/Downloaded from Part one covers the ethical dilemmas of doctors caring for patients and the many practical problems that arise; this area of medical ethics is what most doctors would consider to be "true" medical ethics. Many doctors would not consider part two to be medical ethics at all, because once a person has fully undergone the process of becoming a medical professional they can lose sight of the ethics involved in professional interactions. This is not to say this area of medical ethics is not important, indeed, it is extremely important but is not often considered by doctors in their everyday practice. The medical student, however, is in a better position to evaluate the ethical problems arising in training and staff interaction because they have not yet fully undergone medical socialisation. Each of the two main parts is further subdivided into sections. The first section of part one is performing procedures. This covers informed consent; the person performing the procedures when inexperienced; blaming the patient for your own shortcomings; doctorpatient confidentiality; the newly dead and their rights, and peer and senior support in caring for patients. The format within each subsection is identical throughout the book. One to five clinical cases are briefly described that will be instantly identifiable to any medical student or doctor. Two commentaries then follow, written by different contributors. These commentaries are in general well thought out, logically argued, and pitched so that someone with little or no prior exposure to medical ethics will be able to understand them. They tend to contradict one another in parts, which is one of the books strongest attributes in that it shows medical ethics to be a subject where debate is encouraged rather than a discipline where a prescriptive set of rules holds sway. Concluding each section is a set of thought-provoking discussion questions. The two further sections of part one are: (a) problems in truth-telling, which covers issues such as admitting mistakes to patients and omitting to tell patients salient facts and (b) setting boundaries, which explores doctor-patient professional boundaries, treating patients you don't like, and the limits of a doctors compassion. The second section of the book covers all aspects of professional behaviour, including: abuse (psychological, physical, and sexual); professional communication (jargon and humour); questioning authority and the status quo; whistle blowing; alcohol and drug abuse; mistreating patients; covering up, and misrepresenting research. These issues are rarely covered in medical education and it is to be hoped that through this book their profile will be raised in mainstream medical education. The second section is as equally well written as the first and the authors communicate their ideas well. I think this book would make an excellent basis for a course in medical ethics for medical students. The course could be taught as a continuous module or a number of planned sessions throughout an academic year. Ward Ethics is also very suitable for trainee doctors, if not all doctors, and I would recommend it to anyone with the slightest interest in medical ethics. R N J Graham rnjgraham@doctors.org.uk Bioethics in social context Edited by B Hoffmaster. Temple University Press, 2001, US$69.50 (hc), $22.95 (pb), pp 230. ISBN 1-56639-845-2 Hoffmaster endeavours to enrich the dominant bioethical paradigm, based on abstract principles, with the lived experience of moral decision making. He proposes that bioethics involves not only the justifications for moral judgments, but also the understanding of the beliefs and values underpinning them. The "old" conventional bioethics, situated in "rationality and generality", is to be replaced by a new "reoriented" bioethics, situated in the untidy world of "lived human experience". In other words, context, in its widest sense, is to be integrated into the bioethical framework. The relevance of social context in moral philosophy is not new, however. As MacIntyre tells us in After Virtue: " . . . it also follows that we have not yet fully understood the claims of any moral philosophy until we have spelled out what its social embodiment would be". He reminds us that Plato and Aristotle, amongst others, undertook this project. MacIntyre, like Hoffmaster, laments the loss of social embodiment in the "narrow conception" of contemporary moral philosophy. I submit that we are now witnessing the rejection of Cartesian duality and the revival, or restoration, of an old paradigm-reintegrating the social milieu, narrative, and the emotions, in our conceptualisation of moral philosophy. Hoffmaster's second goal is to raise the profile of social science research in the field of bioethics. He argues that the distinction between descriptive and normative ethics is artificial, and that the former is unfairly devalued. Tony Hope, in an editorial in this journal two years ago, somewhat tentatively suggests that "a more systematic approach to the empirical base might lead to new issues and new perspectives" for medical ethics. He describes philosophical medical ethics as the parent of empirical medical ethics. Hoffmaster, I suspect, would disagree, and would argue that they are both equal and complementary partners. Does this book achieve these stated aims? The authors certainly do provide us with diverse perspectives, showing us how the social environment and dominant moral norms can shape moral attitudes and decisions. The related valuable work of English social scientists is notably absent-for example, Paul Atkinson's work with training doctors, and Priscilla Alderson's ethnographic studies of children and their parents in hospital. Nor does it read as a coherent, integrated account, as the chapters lack a clearly identifiable common thread. Sharon Kaufman's clinical narratives in the practice of geriatric practice provide us with a rich example of the complexity of "clinicomoral" decision making. She illustrates, with case examples, the power of the "technological imperative" in framing and constraining decisions in the care of frail and sick elderly persons-many of whom may be harmed by medical intervention. She also shows how decision making evolves, and may not even be perceived as the deliberate act of making choices, but as part of routine practice. Margaret Lock's ethnographic study in Japan sheds light on attitudes and practices towards the dead-in particular the definition of brain death and the use of the recently dead for organ donation. The resistance in Japan to equating brain death with human death is not, she believes, simply due to cultural and religious inhibitions, but is also linked to the dominant communitarian ethic, with the dying person anchored in kinship. The self is relational, and not individuated and atomised as in the West, with death viewed as an evolving process in which the family participates. Despite the lack of a significant cultural divide in attitudes towards death and afterlife, Lock proposes that there are few socially sanctioned channels in the USA-in contrast to Japan-for articulating concerns and disagreement. Sydney Halpern interprets the changing attitudes and public discourse towards human experimentation as arising from a shift in emphasis from the collective good to the protection of individual rights. Moral judgments, he argues, are mutable, and contingent upon the social and cultural environment of the time. Peter Conrad's chapter on the media, genetics, and culture demonstrates the potential for oversimplification and distortion of scientific discoveries in the lay press. He argues that genetic optimism-the naïve positivist belief that we will find the basis for human behaviour in our genes, and be able to root out antisocial behaviour by genetic manipulation-can be equated with the fallacy of the "magic bullet" in therapeutics. He concludes that geneticisation reflects the current ideology of blaming individuals, rather than deficiencies and inequities in the social system. I would argue that genetic fatalism can also absolve individuals from moral responsibility, and allow them to blame their inheritance for wrongdoing, so that they eschew reform and redemption. Beeson and Doksum, in contrast, explore how and why individuals reject genetic testing, underscoring the enduring themes of romantic love and family values. Anspach and Beeson argue that bioethics discourse has neglected the emotions, and describe in detail their role in shaping values and moral decisions in medical life, as well as the interplay between emotions and power. They describe "moral dissonance" as the conflict between emotions and morals, and how its resolution can lead to a revision of moral decisions. Health professionals need to be able to move freely between emotional engagement and detachment, so that they can embody both fairness and imaginative sympathy towards their patients. Interest in the role of the emotions in moral life has developed in many quarters: neuroscience (notably Antonio Damasio); psychology (Daniel Goleman, amongst others); cognitive science (for example, Mark Johnson), and contemporary philosophy (Peter Goldie, Alasdair MacIntyre, Martha Nussbaum, Michael Stocker, and Bernard Williams, to name a few). Modern philosophers are building on the earlier work of Aristotle. Cate McBurney's ethnographic study of clinical ethics committees provides a chastening insight into to how they can marginalise front line staff (nurses) and patients themselves. Objectivity, they argue, is two edged, for it can indicate impartiality and fairness, but also objectification and indifference. Patricia Marshall's narrative account of working as a clinical ethicist reveals the conflicts and tensions in that role- particularly the compromise of being part of the institution in which the patient is held captive. Perhaps Charles Bosk's chapter on the role and moral standing of the social scientist is the most controversial and provocative. He argues that all social science research involves duplicity, the erosion of informed consent, and the violation of confidentiality. The research subject, flattered to be the object of attention, reveals more than originally intended, but relies on the researcher to safeguard these revelations-a trust that is liable to abuse. According to Bosk, the social PostScript 333 www.jmedethics.com group.bmj.com on June 3, 2016 Published by http://jme.bmj.com/Downloaded from scientist's perspective is ironical, and debunks professional idealism. This debunking, in addition to compromised anonymity, can particularly damage high status professionals. Finally, he argues that there is role-based incompatibility between doing ethics and doing ethnography. Hoffmaster counterargues these claims, but cannot entirely remove the disquiet. On the other hand, at least some social scientists appear to demonstrate a profound respect and sympathy towards their research subjects-for example, Rayna Rapp's work with pregnant women and genetic counsellors. In conclusion, this book provides a valuable contribution to the expanding field of empirically based ethics, or "ethics in use", revealing the moral decisions people make in the real world, and how and why they make those decisions P de Zulueta p.dezulueta@ic.ac.uk Ethics Committees in Central and Eastern Europe Edited by J Glasa for the Council of Europe. IMEB Foundation and Charis a.s.: order from the Institute of Medical Ethics and Bioethics Foundation, Limbova 12, 83303 Bratislava, Slovak Republic, j.glasa@upkm.sk, 2001, US$7.00 (within Europe), US$9 (elsewhere) (includes postage), pp 266. ISBN 80-8874340-0 The growth of research ethics committees worldwide is now fairly rapid and new "markets" for research ethics are opening all the time. The market metaphor is appropriate, since a good deal of the impetus for research ethics review comes from the development of new pharmaceutical products, the globalisation of pharmaceutical research, development and marketing, and the internationalisation of regulatory standards for pharmaceutical R&D. The need for independent ethical review of research protocols by a committee drawing on a range of professional and lay expertise is established as a moral, a quality-management and a regulatory requirement in many jurisdictions, and internationally in the Declaration of Helsinki, the Council of Europe's Biomedicine Convention, and the International Committee on Harmonisation's Tripartite Guideline on Good Clinical Practice. Central and Eastern Europe have for many years been sites of pharmaceutical R&D, but this has intensified in the aftermath of the revolutions of 1989 and since that time. These revolutions and this intensification have been followed by liberalised markets in health goods and health care, the opening of the state and university sectors to public-private collaborations and private enterprise, creating a fertile context for clinical trials. In addition, the widespread official or unofficial privatisation of health care has created a new set of ethical problems for health care workers, and the beginnings of clinical ethics committees and education programmes. In many cases these beginnings this builds on foundations laid down in the 1960s and later after, but the creation of new nation states (or reinvention of old ones) and the changes in political culture, have made important differences to the scope and significance of ethical reflection on health care and biomedical research. This useful volume summarises the experience of many states in Central and Eastern Europe, together with comparative material from some Western states, including the UK, the USA, Germany, and the Netherlands. The volume includes helpful material on the role of the Council of Europe and the Biomedicine Convention, the international and national regulations defining research and clinical ethics committees, and the special local issues relevant in each of the countries. It is based on a conference held in Bratislava in late 2000 under the auspices of the Council of Europe's Demo droit Ethical Review of Biomedical Research Activity (DEBRA) programme, designed to facilitate the development of research ethics committees in Europe. In addition to the useful comparative material, a few papers describe historical factors relevant to the development of ethical review in particular countries. For example, several papers describe the changing nature of university bioethics under the various changes in government over the past 30 years, and several papers describe the changing involvement of the pharmaceutical industry in their countries-including the role of "home" companies as well as multinational firms. A few papers raise philosophical questions about research, research ethics, and research ethics review-the quality of these is good, and they raise some interesting questions which are not often discussed, for example, should ethics committees pronounce on the substantive ethics of a research programme, or only on the actual work planned in this application? For instance, research into the supposed genetic basis of homosexuality, and what the relationship is between ethical review and political culture (does review depend on some form of "pragmatic tolerance" in society and its institutions)? The strong and longstanding philosophical traditions in Central and Eastern Europe are not widely known in the West, and deserve to be better understood. Too much work in research ethics assumes that the US/UK model is the ideal to be exported. On the evidence of this volume, the potential for a more reflective research ethics lies as much in Eastern Europe as in the USA or the UK, however different the state of institutional development may be. This book will be useful to researchers planning projects in the various states in Central and Easter Europe, to scholars of research ethics and its regulations, and to those working in, or otherwise interested in, the development of health care in the region. R E Ashcroft NOTICES European Integration-Philosophy and Ethics of Health Care The XVIIth international congress of the European Society for Philosophy of Medicine and Healthcare will be held from August 21–23 2003 in Vilnius, Lithuania. Its theme is European Integration-Philosophy and Ethics of Health Care. Abstracts are invited addressing the following topics: development of medical philosophy and bioethics; institutionalisation of philosophy and ethics in health care; harmonisation of medical research regulations; human rights and health care; solidarity and health care; just health care; the gap between "academic" and "bureaucratic" bioethics; commercialisation in health care; patenting and genetics; genetic health related databases; research and personal data; use of biological materials, and (future) European guidelines in biomedical research. Abstracts, (500 words maximum) should reach the organisers on disk or by email before December 1 2002. For more information please contact: Professor Dr Henk ten Have, secretariat ESPMH, Department of Ethics, Philosophy and History of Medicine, University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands. Fax: 024–340254; from abroad: +31– 24–3540254. Email: h.tenhave@efg.kun.nl Course: Death Without Suffering An Advanced European Bioethics Course, Death Without Suffering, will be held from 31 March to 2 April in Nijmegen, the Netherlands. Specialists from various countries will discuss ethical issues to do with medically assisted death and palliative care. Subjects will include: Death, suffering and the concept of palliative care; Death and suffering: ethical perspectives; Ethical issues in pain management in hospice care, and Scientific research in palliative care. The lecturers will be: D Gracia (Spain), W Dekkers, B Gordijn, H ten Have, D Willems, and Z Zylicz (all from the Netherlands). The language of the course will be English and the price is €295. For more information please contact: N Steinkamp, University Medical Centre Nijmegen, Dept 232 Ethics, Philosophy and History of Medicine, PO Box 9101, 6500 HB Nijmegen, the Netherlands. Telephone: + 31 24 3615320; fax: + 31 24 3540254; email: n.steinkamp@efg.kun.nl Spring conference: Bioethics in a Small World From April 10 to 12 the Europäische Akademie will organise an international conference on bioethical problems connected to the globalisation process. The conference will include sessions on methodological problems-"Bioethics. A science and its application in politics"; "Culture-dependent ethics?"-as well as practical problems such as "Research Ethics", "Access to essential drugs", "Patents on biomaterials", and "GMOs and the world's nutrition problem". Speakers will include Abdallah Daar (Toronto), Weyma Lübbe (Leipzig), Edgar Morscher (Salzburg), Udo Schüklenk (Johannesburg), Carmel Shalev (Tel Hashomer), Joseph Strauss (Munich). For further information contact the scientific organisers: Richard Ashcroft (r.ashcroft@ic.ac.uk) or Felix Thiele (Felix.Thiele@DLR.de). 334 PostScript www.jmedethics.com group.bmj.com on June 3, 2016 Published by http://jme.bmj.com/Downloaded from (hb), £18.95 (pb), pp 561. ISBN 1 85649 611 2 Medical Association. Zed Books, 2001, £50.00 Handbook for a Changing Agenda: British The Medical Profession and Human Rights: D Dickenson doi: 10.1136/jme.28.5.332 2002 28: 332 J Med Ethics http://jme.bmj.com/content/28/5/332.1 Updated information and services can be found at: These include: service Email alerting box at the top right corner of the online article. Receive free email alerts when new articles cite this article. 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