Gastmans, C. and Vanlaere, L.: 2005, Cirkels van zorg. Ethisch omgaan met ouderen (Circles of care. Dealing ethically with elderly people). Leuven: Davidsfonds, The Netherlands: Belgium Ten Have. 205 pages. ISBN 90-77942-11-4. Price: € 21,95.

With this book the authors state clearly that dealing ethically with elderly people in healthcare is not possible without the caregivers’ moral sensitivity and critical self evaluation, especially with regard to the everyday practice of care. To realize, for example, that the daily washing of an elderly person is a delicate and intimate event, can contribute to better attention to personal integrity, for instance by taking care of the person’s privacy.

The personal dignity and integrity of the elderly according to the authors are at stake. While institutional health care in Belgium and The Netherlands is confronted with an increasingly elderly population and is forced more and more to apply efficiency-based models of organisational care to lower costs, the caregivers-perspective of (giving) care seems to be alienated from these models. So much so that caregivers have reached a point where they do not recognize their original motivation to care for ‘their’ patients; the dignity of the caregiver is therefore at stake too. The basic sense of taking care of another person should be recovered as an essential need for both the elderly person and caregiver, in order to prevent further decrease of the quality of care. Therefore reflection on fundamentally relational values of elderly care is necessary.

The authors want to meet the needs of caregivers who ask for guidance in this process of ethical questioning in order to make the right moral decisions.

The second chapter discusses hygienic care and generally-spatial limitations of elderly people. The next part deals with the ethical issues of restraint in elderly care. Thorough reflection and attention for these issues give way to creative solutions and individual adjusted personal care, when the patient’s recognition of his personal identity is taken into account.

The importance of ‘having a meal’ instead of serving food is stressed in chapter 4. It sets an example for different sorts of daily activities, which can be supportive in terms of improving selfsufficiency and patients’ self-respect. If attended to in a proper way, these activities can create meaningfulness for those who take part in it.

The following chapters (4–8) of the book discuss several main ethical issues in elderly care: artificial feeding; withdrawing medical treatment for terminally ill elderly people; euthanasia and suicide. Each part offers practical references to facilitate the process of decision-making in the complexity of these matters. In their conclusions the authors repeatedly reflect on the potential role of (Christian) religion as a profound dimension that can enrich this process for the elderly patient as well as for the caregiver.

Although the title mentions ‘circles’ of care, the book criticizes less the levels of influence than one might have expected. Responsibility for wellorganised and humanity based care weighs heavily for the caregivers’ level of institutional care, as it should. ‘Circles’ on a policy — and political level however should be drawn into this field of ethically responsible actors as well. The authors could have made a stronger statement at this point.

The book surprises with its construction on the ethical basis of daily care in the first parts and the postponement of the ‘big ethical issues’ to the last. Therefore it links up to the experiences of caregivers at various levels of care practice who are not comfortable with the quality of the (humanity based) care they can provide.

Theo Kuunders Rosmalen, The Netherlands

Heinemann, T.: 2005, Klonieren beim Menschen. Analysen des Methodenspektrums und internationaler Vergleich der ethischen Bewertungskriterien (Studien zu Wissenschaft und Ethik, ed. by Lutz-Bachmann M and Sturma D, vol. 1). Berlin, New York: Walter de Gruyter. XIII, 639 pages. ISBN 978-3-11-018430-3. Price: € [D] 88.00; sFr 141.00; $ 118.80.

The issue of cloning, especially cloning-for-research, is at the top of governments’ and ethical advisory bodies’ agendas. At least since the mid- 1990s, it has been hoped that cloning techniques will be powerful tools for enhancing the treatment of dreadful diseases. Although steady improvements can be observed, multiple problems remain — not only technical but also normative ones. Thomas Heinemann’s book engages in this debate and provides a comprehensive overview of techniques and ethical arguments concerning cloning.

After a first, introductory chapter, the author explains essential scientific terms, techniques, and theories. Here, basics of embryology and cell biology — including the concept of stem cells — and cloning procedures are explained. The chapter also investigates the scientific and medical motivation and objectives of stem cell research and cloning and assesses the techniques according to the criteria of suitability and necessity.

The third chapter offers a comparative analysis of the legal and ethical debate about cloning-for-research in Germany, Great Britain, France, and the United States. Whereas there is relative consensus concerning the justification of research with somatic stem cells, cells derived from umbilical cord blood, EC-cells, and EG-cells, research with ES-cells is deeply controversial. For each of the four countries, the book illustrates the debate of the last decades and analyses the arguments that are used pro or contra cloning-for-research.

Chapter 4 is an analysis parallel to chapter 3, now concentrating on reproductive cloning. The arguments against reproductive cloning that the author extracts from the national documents of Germany, the UK, France, and the US clearly outweigh those in favour of it.

Chapter 5 finally summarizes and evaluates the different arguments that are used in the four countries. The British position of concentrating on the singularity after the fourteenth day after conception is criticized as not very plausible (p. 573); the ethical discourse in the US is criticized for being too obeying to common-morality (p. 574); the French position of combining internal factors (human dignity) with external ones (‘projet parental’) is criticized for not explaining the relative relevance of each of these factors (p. 575); the German position of protecting the embryo due to the concept of human dignity is criticized because it refers to a biological point in time that is not self-evident (p. 575). However, the author considers the German position as the most plausible and reasonable one, arguing with the precautionary principle (pp. 577 ff.).

Altogether, this volume provides a comprehensive database for tracing the discourse on cloning with its various, sometimes country-specific arguments, even if one does not come to the author’s evaluative conclusions.

Jürgen Wallner Wien, Austria

Illies, C.: 2006, Philosophische Anthropologie im biologischen Zeitalter. Zur Konvergenz von Moral und Natur. Frankfurt: Suhrkamp. 361 pages. ISBN 3518293435. Price: € 13.

In his book “Philosophical Anthropology in the Biological Age. The Convergence of Morality and Nature”, the Netherlands-based German philosopher Christian Illies attempts to conciliate insights from recent research on the topic of human nature — particularly from studies on evolution — with philosophical considerations about genuinely human normativity. This, in Illies’ opinion, is the central task of an up to date philosophical anthropology (a peculiarly German philosophical sub-discipline, introduced in the 1920s by philosophers such as H. Plessner and M. Scheler, further developed by A. Gehlen, and unfortunately neglected by Anglophone philosophy). With his theory of convergence (or consilience) between nature and morality Illies tries to show how human beings are part of both the physical and mental sphere, both living material organisms and moral beings (he calls this position “synthetic anthropology”, and distinguishes it from reductionist explanations preferring either of both spheres).

The first part of the book presents an instructive and competent discussion of the history of evolutionary thought from pre-Darwin times up to modern sociobiology and evolutionary psychology, but with a robust distance to the last. The second part (from chapter 5 on) further elaborates the author’s own thoughts. Here Illies develops a rather far-reaching thesis about “morality in a philosophical sense” (i.e. morality which is based on reason, cf. p. 166 sqq. The entire book shows a Kantian bent — which certainly is no disadvantage). On the one hand, morality can neither be founded upon nor be sufficiently explained by biology or evolutionary theory (as it profoundly depends upon reasonable beings willing to stick to reasons in their actions), nor can it be rejected as an illusion by the biological sciences. But, on the other hand, nature provides the “pre-history” (214) and any possible “frame” (236) for morality, and morality itself can be an object of evolutionary considerations. Illies thus tries to show how, within this framework and with the help of concrete “evolutionäres Umsetzungswissen”, morality may be made to be “evolutionary successful” (285). The author — admirably, but quite optimistically — deems the hope for the durable evolutionary success of morality well-founded, citing such advantages of morality as e.g. inner consistency, trans-cultural compatibility and evolutionary stability. Here Illies tries to understand evolution with regard to morality in a certain way as teleological: the convergence of nature and morality is the aim for which humankind can long. The ideal of a humanity within which nature and morality converge (315), and even a “moral culture” (334), are entertained here. It shall not be reached by biotechnological means — these would only produce “moral machines” (p. 324) — but rather by human actions based on reason. This is a daring secular story of salvation impregnated by the rosy optimism of Kantian Enlightenment. But if Illies were right and evolution were leading this way, it would not be bad. So, even if the core thesis is not completely convincing, the book makes for a very inspiring read, rich in relevant arguments and illustrative examples.

Jan-Christoph Heilinger Berlin, Germany

Mohrmann, M.E.: 2005, Attending Children. A Doctor’s Education. Washington, D.C.: Georgetown University Press. 212 pages. ISBN 1-58901-054-X. Price: $ 24.95.

Margaret Mohrmann’s book on attending children is a beautiful book of stories. Her stories are not conceived to illustrate what is already known, but to “reveal[s] something new, previously unthought or uncomprehended” (6). In Attending Children, Mohrmann draws on 30 years of paediatric practice in (American) academic medical centres to develop her conception of the “art of doctoring” (6). With an admirable veracity, the author tells the story of her own professional and personal development from her tough first years of medical residency to the more serene part-time work in paediatric primary care later in her career (when she was also pursuing a doctorate in religious ethics).

Mohrmann’s own story contains nineteen principle narratives — and, unsurprisingly, many more along the way — about the often grim fate of her young patients. These narratives are assembled to reveal what Mohrmann claims to be the three aspects of ‘attending’ children (and patients more generally): “‘to listen or pay attention to’, ‘to wait upon (as a servant), be present or accompany’, and ‘to wait for or expect’” (8). According to Mohrmann, “all these facets of ‘attending’ are essential in order that accurate medical knowledge, that other sine qua non of good doctoring, be used appropriately and well on behalf of those who come to medicine for succour” (15). At the same time, she is remarkably critical of empathy, a concept akin to her notion of ‘attending’, for its “imperialistic proclivity” and “significant potential for misuse” (156–7).

Attending Children makes for a touching and insightful read (in particular for those bioethics scholars who have never borne clinical responsibility). However, the book’s basic premises invite some questioning. Most would probably agree with Mohrmann that medicine is an art and not a science, yet her claim that ‘attending’ and accurate medical knowledge are sufficient conditions for the art of doctoring (15) is less convincing. The book is a powerful testimony that medical care should focus on the individual patient and his or her family — however, a concept of good doctoring must also account for decision-making under reasonable resource constraints; for defensible ways of contributing to medical knowledge in research; for acceptable approaches to making organs available for transplantation; and so forth. It seems that Mohrmann’s two conditions of good doctoring — explicitly formulated as being necessary and sufficient — will not do to address many of the most pressing ethical questions in today’s clinical practice.

One also wonders whether Mohrmann’s idea of good doctoring is not a (particular) idea of good living. Listening, accompanying and waiting seem important for almost any relationship, most importantly for personal relationships. Apparently, some of Mohrmann’s colleagues label her approach to clinical practice as a form of “overinvolvement” (144). This seems to indicate that not everyone in clinical practice would be willing to principally narrate his or her identity as being a physician (as Mohrmann does in her book). It is doubtful that Mohrmann’s encompassing normative concept of good doctoring is easily generalizable.

Finally, internal inconsistencies such as the parallel emphasis on “accurate medical knowledge” (15) and on allowing for “perplexing marvels” (129) or “moments of transcendence in an inexplicable healing” (124) are sometimes difficult to follow. These objections notwithstanding, Margaret Mohrmann’s work is commendable for what it primarily claims to be: a beautiful book of stories.

Annette Schulz-Baldes Zurich, Switzerland

Sahm, S.: 2006, Sterbebegleitung und Patientenverfu üng. Ärztliches Handeln an den Grenzen von Ethik und Recht. Frankfurt/New York: Campus Verlag. 265 pages. ISBN 3593381796. Price: € 32,90.

Every legal provision requires ethical thinking first, so too according to Stephan Sahm. In his book Sterbebegleitung und Patientenverfügung. Ärztliches Handeln an den Grenzen von Ethik und Recht, which could be translated as Terminal care and advance directive. Medical treatment in-between ethics and law, he puts current political discussions and legal revisions concerning end-of-life-decisions in Germany under scrutiny. Legal regulations of other European countries and the US are also mentioned, but only for the purpose of comparison. Taking a close look at German laws, convictions and guidelines, Sahm is concerned with the (ethical) legitimacy of euthanasia and the (ethical) bind of advance directives. According to Sahm, the recent decision of the German medical fraternity to abandon active euthanasia evokes a crucial problem, namely distinguishing immoderate medical end-of-life treatment from treatment that results in the patient’s death. Aiming at an ethical foundation for such a distinction, Sahm starts out with an empirical survey on wishes and preferences regarding medical end-of-life-treatment. In this survey he interviewed 100 patients with tumours, healthy persons, physicians and professional caregivers. His survey shows that with respect to end-of-life decisions, two ethical principles come into conflict: the right of the patient to self-determination (or the duty of the physician to ask for informed consent), and the medical indication for treatment (or the duty of the physician to act in the patient’s best interest). For advance directives, Sahm emphasizes, a conflict between principles of “paternalism” and “patient’s autonomy” can only arise if there is a medical indication or necessity for treatment in place, regardless of whether the patient has decreed such treatment by way of advance directive or not. This observation points to a novel and key understanding of medical indications, namely that such indications bear normative implications about what is the right thing to do and Sahm tries to solve normative-ethical issues in close relation to empirical findings in his survey. One upshot of the survey is that the interviewees refuse a strict binding character of advance directives, and wish that physicians should make medical decisions together with relatives in case the patient is incapable of making decisions on her own. Relatives are still seen as “natural proxies” of patients. Sahm draws the conclusion that proxies should occupy a central position in medical decision-making and thus should be combined with advance directives. Such a combination is, according to Sahm, useful for chronic disease, and could amount to an advanced care planning. Being diagnosed with a disease makes it easier to think about treatment preferences and end-of-life-options since Sahm’s empirical survey demonstrates that people change their mind (preferences and wishes regarding medical treatment) when they fall ill. Hence, an advance care planning is much more drawn from life than an advance directive set up by a healthy person, as Sahm concludes.

Susanne Brauer Zurich, Switzerland