Showing papers in "Journal of Medical Ethics in 1985"

Psychiatric diagnosis as an ethical problem.

Abstract: Psychiatrists diagnose mental illness in patients against a climate of opinion in which the value of diagnosis is questioned and non-medical formulations of the problems of psychiatric patients are put forward. Nevertheless the classic diagnostic terminology shows no sign of disappearing. The patients may find that a psychiatric diagnostic label is a stigma and has bad consequences. They may also object to standard methods of treatment. Given this situation the right of the patient to a full explanation of the diagnosis and the rationale of the treatment offered seems to be incontrovertible. If this information were given to patients it would, in addition, help them to make sense out of their often puzzling experiences and indicate that fellow sufferers existed.

The brain-life theory: towards a consistent biological definition of humanness.

Abstract: This paper suggests that medically the term a 'human being' should be defined by the presence of an active human brain. The brain is the only unique and irreplaceable organ in the human body, as the orchestrator of all organ systems and the seat of personality. Thus, the presence or absence of brain life truly defines the presence or absence of human life in the medical sense. When viewed in this way, human life may be seen as a continuous spectrum between the onset of brain life in utero (eight weeks gestation), until the occurrence of brain death. At any point human tissue or organ systems may be present, but without the presence of a functional human brain, these do not constitute a 'human being', at least in a medical sense. The implications of this theory for various ethical concerns such as in vitro fertilisation and abortion are discussed. This theory is the most consistent possible for the definition of a human being with no contradictions inherent. However, having a good theory of definition of a 'human being' does not necessarily solve the ethical problems discussed herein.

Ethics, advertising and the definition of a profession.

Abstract: In the climate of concern about high medical costs, the relationship between the trade and professional aspects of medical practice is receiving close scrutiny. In the United Kingdom there is talk of increasing privatisation of health services, and in the United States the Federal Trade Commission (FTC) has attempted to define medicine as a trade for the purposes of commercial regulation. The Supreme Court recently upheld the FTC charge that the American Medical Association (AMA) has been in restraint of trade because of ethical strictures against advertising. The concept of profession, as it has been analyzed in sociological, legal, philosophical, and historical perspectives, reveals the importance of an ethic of service as well as technical expertise as defining characteristics of professions. It is suggested that the medical profession should pay more attention to its service ideal at this time when doctors are widely perceived to be technically preoccupied.

Informed Consent: A Study of Decision — making in Psychiatry

Abstract: Why, it may be asked, should a book on communication between doctors and patients be reviewed in a journal of medical ethics? The answer is that good communication is necessary for competent and compassionate medical practice and it is unethical to do nothing to prevent the failures of communication that are so widespread in medical practice today. This book reports studies, mostly in general practice, which show both the need for better communication and how appropriate training can do much to achieve it. It begins with a lengthy review of the literature much of which is unfamiliar to doctors because it is to be found in books and journals which few of them read, and some of it is tough reading. One extreme example is: '. . . in the presence of question formatted conversational object one should, as part of formulating a response shift, gaze toward the direction of the interlocutor prior to the end of a response which terminates a Q-A sequence'. Little of the essay is as opaque as that, but if social psychologists are going to change doctors' attitudes they will have to learn to express themselves in simpler English. That this can be done is shown in the next essay by Michael Argyle who gives a readable account ofthe relevance of his studies of social skills to the interactions between doctors and patients and shows how doctors can be trained to improve their skills. Philip Ley provides a full review of the extensive literature, to which he has contributed so much, on how poor communication can inhibit patients' understanding and recall of what they have been told and on how such errors may be lessened. Fascinating accounts follow of the widely contrasting health beliefs that patients have, to which doctors should adjust their advice so that it is more acceptable to their patients. This concept is then extended to the barriers to understanding which arise from the contrasting cultural backgrounds of doctors and patients. Dr Paul Freeling gives a pleasing and helpful account of how the doctorpatient relationship is best handled in general practice. Anne Cartwright follows with her studies on prescriptions as a help or hindrance in a successful consultation. Dr Muir Gray discusses how best to listen to and talk with the elderly and Dr Peter Pritchard describes the value of patient participation not only in the practice groups which he has pioneered but also generally within the National Health Service. The last section, on medical education and medical practice, starts with a critical account ofhow irrelevant much conventional medical education in Britain is to the work of the general practitioner, largely because of its lack of attention to training in communication. Richard Wakeford confirms this defect from his General Medical Council survey of British medical curricula in 1977. He contrasts this with the far more extensive communication training given in schools in the USA. He attributes the British neglect both to doctors' innate conservatism and their dislike of working with people such as sociologists who dare to question medical competence. Finally there are four essays on current vocational training of GPs in which increasing attention is being given to interpersonal skills. Here gratitude is expressed for the sometimes abrasive, but always useful, contributions from behavioural scientists. Anyone concerned with problems of communicating with patients, particularly those in general practice will find it stimulating and helpful to delve into these essays. How long shall we have to wait for specialists, particularly those who teach students, to look into the defects in their own communications with patients and accept the ethical imperative of seeking remedies in constructive analyses such as those described in this book? McNair Wilson's recent Bill on Hospital Complaints Procedure, which was based on the grievous communication failures he suffered in hospital passed its three readings in the House of Commons without a dissentient voice. Perhaps this may act as one stimulus for action.

The moral significance of spontaneous abortion.

Abstract: Spontaneous abortion is rarely addressed in moral evaluations of abortion. Indeed, 'abortion' is virtually always taken to mean only induced abortion. After a brief review of medical aspects of spontaneous abortion, I attempt to articulate the moral implications of spontaneous abortion for the two poles of the abortion debate, the strong pro-abortion and the strong anti-abortion positions. I claim that spontaneous abortion has no moral relevance for strict pro-abortion positions but that the high incidence of spontaneous abortion is not (as some claim) eo ipso any sort of justification for voluntarily induced abortion. Secondly, I show that if the strict anti-abortionist position is to be taken seriously in its insistence that prenatal life has a right to be protected by virtue of its being conceived, then it seems necessary to take measures to prevent spontaneous abortion and its presumptive causes, and this as a matter of moral obligation.

Health, Disease, and Causal Explanations in Medicine

Abstract: power they deserve as professionals and to exercise it individually, collectively and in concert with other professionals to promote better and more costeffective health care for all persons, especially those who have least access to it'. The position taken in these papers is that if nurses are to act in a professional way they must have the power to enable them to do so. The nurse's role is said to be that of patient advocate within the complex organisational settings of health care. Nurses have responsibilities to patients, to the organisation and, if professional status is to be achieved and sustained, to their professional association. In trying to respond to these responsibilities, the nurse encounters ethical issues and may be faced with moral dilemmas. Thompson's paper, Conflicting Loyalties of Nurses Working in Bureaucratic Settings, addresses these ethical issues. The paper centres on the case of a mother who asks to hold her baby (after a normal delivery) and is met with some unwillingness on the part of the nurse, who wants to weigh the baby and place it in the 'warmer'. The questions Thompson raises from this everyday type of situation are 'How is it that child-bearing women have to ask if it is all right to hold their own baby?'; 'What has happened to hospitaloriented childbirth that it is forcing some couples to choose out-of-hospital care, or no care at all rather than submit their bodies and normal life experiences to the control of others doctors, midwives and nurses?'; 'Who makes hospital policies and for whose benefit are these policies made?' Thompson's main argument is that nurses should examine their daily practice, looking especially at the ethical aspects of their decisionmaking. If nurses are to 'live up to their status as professionals they must,' she argues, 'practise in an ethical manner, and this means studying ethics in order to determine what is ethical practice'. It has to be said that, as with some of the other papers in this collection, the questions make rather more interesting reading than the attempts to address them. One does not expect the impossible to be achieved in that answers are produced to ethical dilemmas, but a little more imaginative discussion would have been welcome. Exceptions to this disappointing trait are to be found in the papers by Margretta Styles and Richard Hall. In all it is a useful collection, with the emphasis laid more upon professionalism and power than ethical debate.

Plato's moral theory.

Abstract: Plato's ethics lie at the centre of his philosophy. His approach to 'how best to live' must deal with questions of what there is in the world where we live and how we talk, think or know about it. So to grasp his moral theory we need to understand how it is integrated with the enterprise as a whole. Moreover, since he was a dialectician par excellence we must discover what is his method of doing philosophy with us and how he will enveigle us into philosophical inquiry the answer to these questions may overturn our view of his moral theory. All talk of Plato must take a preliminary tilt at the windmill which of the ideas we encounter in the Platonic dialogues belong to Plato himself, and which must be attributed to his master Socrates? There is no short answer to the academic 'Socratic question'. For now, suffice it to register that there is development from the earlier works, such as the Protagoras (1), to the rich theory of the 'middle period', from the Gorgias (2) to the Symposium (3) and Republic (4). Plato's philosophy is organic, subject to growth and decay; we may look for the flower of his moral theory in the Republic, but must search for its roots in the early period. To know 'how best to live' we must know what is 'best'. In contrast to the subjectivist or the relativist, Plato supposed that evaluative qualities really belong to the object that is valued. Thus we call something 'beautiful' not because we are pleased by it, but because it genuinely has, independent of being appreciated, the quality of beauty (5). Values are natural and objective. From his early days, Plato supposes therefore that what is valuable can be calculated and assessed in a decisive way. Prima facie, I could judge whether x is more pleasant than y just as I do judge that a is bigger than b. All I need (6) is the right measuring skill then, with its help, I can

The products of conception: the social context of reproductive choices.

Abstract: This paper addresses the changing ideology regarding reproduction, an evolving American, and potentially worldwide, value system regarding children and parenthood. Children are increasingly being seen as products, and the new technology of reproduction, including the sale of reproductive material and services and especially prenatal diagnosis and selective abortion, encourage this commodification of the fetus. While the new technology does indeed offer new choices, it also creates new structures and new limitations on choice. In the contemporary American social structure, these choices are inevitably couched in terms of production and commodification, and thus do not offer individuals genuine choice or control.

Ethical dilemmas of the doctors' strike in Israel.

Abstract: In 1983, Israeli physicians who were working 65-75 hours a week to earn salaries equal to those of other health professionals mounted a strike against their government employer which lasted four months and culminated in a hunger strike, collapse of a physician-supported interim service, and limitation of care to life-threatening emergencies. Some of the ethical dilemmas faced by the strikers involved the moral and traditional Jewish religious obligations of the doctor, their commitment to socialized medicine, and the compromising of quality of care by overworked physicians. The authors argue that society also has an obligation in health care and that, in countries where society pays doctors' salaries, an independent body should set wages and working conditions.

Professions as the conscience of society.

Abstract: Ethics is no less of a science than any other. It has its roots in conflicts of interest between human beings, and in their conflicting urges to behave either selfishly or altruistically. Resolving such conflicts leads to the specification of rules of conduct, often expressed in terms of rights and duties. In the special case of professional ethics, the paramount rule of conduct is altruism in the service of a 'noble' cause, and this distinguishes true professions from other trades or occupations. If professional ethics come into conflict with national laws, the professional today can test the legitimacy of such laws by reference to internationally agreed legal standards in the field of human rights, and so help to perform the role of 'professions as the conscience of society'.

Sperm and ova as property.

Abstract: To whom do sperm and ova belong? Few tissues are produced by the human body with more waste than the germ cells. Yet dominion over the germ cells, and over the early embryo that results from their union in vitro, is behind much of the emotion that modern reproductive intervention can engender. The germ cells differ from other human tissues that can be donated or transplanted because they carry readily utilizable genetic information. Eventual expression of the germ cells' genetic potential is the legitimate concern and responsibility of their donors, although in the right circumstances the responsibility can by agreement be entrusted to institutions administering gamete or embryo donor programmes; these institutions, in turn, may need to assume responsibility for decisions if, in the case of embryo storage, the wishes of the two donors conflict. The fact of sperm and ovum ownership (and the genetic potential that goes with it) before individuals part with these tissues is beyond dispute. Some contentious issues may be clarified if this area of human dominion, namely control over genetic expression among offspring, is acknowledged to be the legitimate persisting concern of those who have produced sperm and ova after storage commences.

The teaching of medical ethics.

Abstract: Students at Newcastle are exposed to patients during their first week at medical school and attached to a family within the first month. The object is to sensitise them to patients as people rather than vehicles of disease. Medical ethics is introduced as part of the multidisciplinary Human Development, Behaviour and Ageing Course by a lecturer who shows a film which poses an ethical problem. At subsequent tutorials led by the Department of Family and Community Medicine's general practitioner lecturers the subject is discussed as ethical issues arise in the course of their work.

Taking blood from children causes no more than minimal harm.

Abstract: The ethical question of whether taking blood from normal children for research purposes is justified, is determined in part at least, by whether or not the children are harmed To try to assess the risks, the effects of venepuncture on a group of healthy subjects were studied, by means of a parental questionnaire completed approximately eighteen months after the venepuncture had taken place Ninety-two healthy children aged between 6 and 8 had a blood sample taken for non-therapeutic reasons as part of a research study Questionnaire responses reveal few negative effects, and in some cases positive effects

Baby Fae: a beastly business.

Abstract: The Baby Fae experiment has highlighted the growing trend in medicine of using animal parts in the treatment of humans. This paper raises the question of the logical and moral justification for these current practices and their proposed expansion. We argue that the Cognitive Capacity Principle establishes morally justified necessary and sufficient conditions for the use of non-human animals in medical treatments and research. Some alternative sources for medical uses are explored as well as some possible programmes for their implementation.

Embryonic life and human life.

Abstract: A new human life comes into being not when there is mere cellular life in a human embryo, but when the newly developing body organs and systems begin to function as a whole, the author argues. This is symmetrical with the dealth of an existing human life, which occurs when its organs and systems have permanently ceased to function as a whole. Thus a new human life cannot begin until the development of a functioning brain which has begun to co-ordinate and organise the activities of the body as a whole.

Medical ethics and medical practice: a social science view.

Abstract: This paper argues that two characteristics of social life impinge importantly upon medical attempts to maintain high ethical standards. The first is the tension between the role of ethics in protecting the patient and maintaining the solidarity of the profession. The second derives from the observation that the foundations of contemporary medical ethics were laid at a time of one-to-one doctor-patient relations while nowadays most doctors work in or are associated with large-scale organisations. Records cease to be the property of individual doctors, become available not only to other doctors but also to educational and social work personnel. Making records openly available to patients is suggested as the only antidote to this irreversible loss of individual practitioner control. The importance for doctors of understanding the nature of professional and bureaucratic organisations in order to deal with the hazards involved is stressed as is the responsibility of the General Medical Council to regulate medical competence as well as personal behaviour.

Quality of life--a response to K C Calman.

Abstract: There is no technical language with which to speak of patients' quality of life, there are no standard measures and no authority to validate criteria of measurement. It is well known that 'professionals' tend, often for institutional reasons, to play down or undervalue factors which are not defined by their particular expertise. It is fortunate that, despite this tendency, there is a growing interest in broadening the evaluation of medical care, but there is still a need to clarify what is at issue in considerations of quality of life. This article examines the strengths and weaknesses of one approach to assessing quality of life, and sketches out the implications for anyone concerned to establish a framework within which both medical and non-medical objectives of care can be taken into account.

Are we teaching students that patients don't matter?

Abstract: Medical students may fear that their training leeches away the caring attitudes which attracted them to medicine. Some research suggests they are right. The medical school has a duty to support and encourage their values, but the reverse may happen. Students are taught about legal consent but not ethical consent. They may see or participate in concealment of medical mistakes and learn to practise deceit. The use of unconscious females for gynaecology teaching may encourage the wrong attitudes to patients. Trainee GPs may learn that the doctors' rights are more important than those of the patient. Measuring patients' views should be included in research protocols.

Physicians' strikes--a rejoinder.

Abstract: The author, a physician, rejects a previous defence of a doctors' strike. There is little justification for strikes in general, still less for doctors' strikes, he claims. Should not doctors rather 'stand above the common herd' and set an example, he asks. Furthermore the whole idea of strikes in which a third and innocent party is deliberately punished in order to apply pressure on someone else is a 'a bizarre ethic indeed' and not to his knowledge justified under any ethical theory.

Ideology and Insanity — Essays on the Psychiatric Dehumanisation of Man

Abstract: When in the early 1960s I was studying psychology, the scientific explanation of behaviour reigned supreme; psychoanalytic theory and practice was, under the influence of H J Eysenck, debunked as invalid; it seemed but a matter of time before a combination of behaviourism, neuropsychology and neurochemistry would provide a complete account of human experience and a rational basis for the human sciences. In the mid-1980s we have much less confidence: all kinds of doubts have crept in as to limitations of scientific method and fundamental questions are being asked about the professional and social context in which this method is used in psychiatry and psychology. Much attention is now given to issues such as the rights of involuntary mental patients and the widespread use of psychotropic drugs, twenty years ago heralded as the great breakthrough in 20th century psychiatry. This change owes much to the work of Thomas Szasz. His seminal book The Myth ofMental Illness first published in 1961 qualified him as public enemy number one in the eyes of orthodox psychiatrists. Now follows the present collection of essays, all written in the 1 960s. They cover a wide range of topics: not only his favourite target, the treatment of the involuntary mental patient, but also the role of psychiatrists in schools and the status of the insanity plea in court; the status and use of classification in psychiatry and the ideology of community mental health services. He attacks once again the concept of mental illness as a label to stigmatise, segregate and control those persons who annoy or disrupt others and society; the illegitimate application of medical models to personal behaviour and distress which only properly belong to physical illness; and the failure of doctors to see symptoms as related to personal coping-strategies. He favours legal models for the relationship of doctor to patient and the contract between them; he argues strongly for the limitation of the relationship to a voluntary contract freely entered into by the patient. His ideal paradigm is of course the psychoanalytic treatment situation; indeed he advocates the splitting of the psychiatric fraternity into 'defence' and 'prosecuting' psychiatrists, the one whose contract is entirely to argue for and treat the patient who has chosen and paid him for this purpose; the other to argue for the State, relatives or community seeking to limit his liberties; the case to be heard in a legal context with rules of evidence etc. The attraction of Szasz's work, of which these essays are typical, lies in his polemical style and his ability to expose mystification in 'professional' concepts and practice, which allies him with Illich, Laing and Foucault. More than any other psychiatrist he has argued (from inside his profession) that psychiatrists should be far more scrupulous in supporting the autonomy of the patient in deciding his own destiny and defending his civil liberties. However, his propositions are not unflawed; as Ian Kennedy argues in his 1980 Reith lectures, to say that mental (as opposed to physical) illness is not a thing and therefore cannot be invoked in any causal sense for treatment or restraint is misconceived. Illness is essentially a social attribution by doctor to patient conferring certain privileges and obligations between them, for which there may or may not be 'objective' evidence in terms of physical or behavioural abnormality. There is therefore no reason why this attribution should not be applied to behavioural as well as to physical deviations. Again, his enthronement of the psychoanalytical conutract as the paradigm of the ideal treatment situation is naive because it ignores the subtle attributions and assumptions by both parties which bind them just as effectively as does a mental health order. Finally these essays are as tiresomely repetitious in their basic hostility to the activities of forensic psychiatrists as to any attempt to extend State and community mental health services. These he sees as oppressively imperialistic, imposing an arbitrary norm of individual behaviour and mental health, deviations from which are construed as 'illness', to be corrected by the men in white. I doubt whether this is their only function it is at least possible that the defects in such a system lie, not in the principle of extending help to as many of those in need as can be reached, but in the model being used by the helpers. If we are to have a service which would resurrect the meaning of distress rather than merely labelling it, mutual exploration, time and empathy are required; qualities not emphasised in the training of doctors, as is evidenced by the disillusionment of many who use the services and then turn to alternative psychological therapies and alternative medicine.

Heroin addiction, ethics and philosophy of medicine.

Abstract: This article discusses various ethical and philosophical aspects of heroin addiction. It arose as a result of the plan by the Amsterdam city council to supply free heroin to drug addicts. The objective of treatment of heroin addicts is ambivalent because what is in fact a socio-cultural problem is transformed into a medical problem. The characteristics of this treatment are made explicit through a philosophical analysis which sees the medical intervention as part of a strategy aimed at achieving social normalisation. The reason why such a social control function is practised by physicians is discussed, as well as the reason why heroin users in particular are the object of such a process. In this paper, heroin addiction is considered primarily as a cultural problem. The consequences of this for treatment and ethics form the conclusion.

Contracts to bear children.

Abstract: In the surrogate mother procreation can be divorced both from sex as well as any anticipation of child rearing. Often the risks of surrogate motherhood are presented in terms of alternative family structures and economic exploitation of women. Such possibilities must invite critical reflection in order for there to be legal reform. Of paramount importance is the child's best interest and until the full psychological is the child's best interest and until the full psychological ramifications for the child, adoptive parents and natural mother are determined then the law's role must be ambivalent. In this impasse the minority view of the Warnock Report has much to commend itself.

Rights, Killing, and Suffering: Moral Vegetarianism and Applied Ethics

Abstract: professed separation of Church and State to which Mr Justice Kirby draws attention in his foreword to the book under review. The book is a product of the Social Responsibility Commission of the Anglican Church in Australia. This review will concentrate, therefore, on the purported contributions to a Christian ethics of in vitro fertilisation and attendant practices, ignoring the chapters which outline the issues in ways now common to all such reports. It is a pity that, under this limitation, the two distinctive chapters by clinicians, WAW Walters and Gareth Jones, must be ignored. John Henley, in a chapter headed 'The Formulation of Official Policy: Principle versus Procedure,' outlines principles to be accommodated in ethical discussion. The 'policy' ofwhich he complains was that of a committee established in the State of Victoria which used the terms 'acceptable' and 'unacceptable' in its judgements without further explication. It is not clear, however, whether these judgements, however expressed, contravene Henley's principles. John Morgan assays a distinctively Anglican statement of the ethics and moral theology involved. His argument amounts to a cautious endorsement of IVF within marriage, and of the experimental use of 'spare' embryos but not of ova fertilised for use in research. His conceptual tool, borrowed from modern Roman Catholic theology, is 'proportionate reasoning', combining deontological with teleological arguments as necessary. He rejects the extremes, both those who 'leave it to God' to give them a child, or accept their infertility from Him if He does not, and those who condemn any intervention which interrupts the single process of marital union and conception. In his justification for research on cleaving embryos he relies on Anglican writers in the UK and the USA, and on Roman Catholic writers Haring and Kung in Europe. A line or two must have dropped out of his text somewhere on pp 37f, for he is too informed a scholar not to know how different were the pronouncements on contraception in the Lambeth Conferences of 1930 and 1958; here they are confused. Michael Hill attempts courageously a task too often evaded, to delineate 'a Biblical perspective' on IVF and the like. But does he succeed? He disowns text-chopping, and desiderates 'a unified and integrated biblical theology'. He looks for a 'theory of moral obligation' to set beside a utilitarian one. He wobbles on whether one exists or not, and then chooses a 'teleological theory' (set against a 'deontological theory') on the ground that it is 'more capable of use in relation to contemporary issues not envisaged in the Scriptures' and this because scripture 'is concerned with the purposes of God'. The ultimate principle (sic) thus curiously begotten is always to do that which generates or maintains love relationships with God and man. This ultimate good, obfuscated rather than clarified as an 'agaperelationship', is a psychological state. This was grounded in the family in Old Testament times, the unit of inheritance and so of the material assurance of God's blessing. Hill has to admit, on the evidence of St Paul's rhetorical championing of the Gentiles in Galatians 3: 28, that the relationship can cross genetic boundaries. But then he is betrayed by slovenly modern translations into bringing it back into the genetic family, for the purpose of putting a marital restriction on IVF. In New Testament Greek oikos does not mean 'the family' as we now know it; it means the household, which included servants and slaves as well as kin. His wish so to restrict the service of IVF is not contested; but his case will not stand on shallow exegesis like this. Similarly he brings in those who condemn the intentional destruction of human embryos as 'a form of murder'. But instead of examining this allegation by careful exegesis of his own Biblical material on 'the sanctity of life', he dodges the moral analysis by suggesting techniques to avoid the offence: he dodges the moral analysis by suggesting techniques to avoid the offence: either taking and fertilising only one ovum at a time, or, if more are taken, implanting the lot to let the poor mother take her chance of a multiple birth. Someone, some day, must tell us how not to use the Bible in medical ethics.

Child abuse and neglect: ethical issues.

Abstract: Children may be abused physically, sexually, emotionally and by omission or commission in any permutation under these headings. This is discussed in terms of the separate and overlapping responsibilities of parents, guardians, the community in which they live and the network of professional services developed to care for, protect and educate children. An attempt is made to place these issues within an ethical framework, with regard to the legislature of England and Wales. It is argued that professionals working within this field have an obligation either to keep up to date in respect of a large and growing body of research and practice knowledge or to consult 'experts' within the field when making complex and far-reaching decisions on behalf of abused children and their families. A representative, inevitably incomplete, bibliography is discussed and appended and there is brief reference to the role of expert witnesses concerning children involved in civil legal proceedings.

The Value of Life: an Introduction to Medical Ethics

Abstract: Like all John Harris's work, this survey and proposed solution of some of the central problems in medical ethics, especially life and death issues, is brilliantly argued (always) and highly controversial (sometimes). Both characteristics stem from the fact that the book proceeds with strict consistency from the plausible but by no means inevitable unexpressed premiss that the only possible source of ethical values lies in what is actually found valuable. Thus freedom from suffering is valued by all sentient creatures, whether or not they can formulate their values and desires in words; and so we are morally obliged to cause as little pain as possible to humans or animals. But life can be valued only by a person, ie by a being that is capable of being self-conscious and of knowing it has a life to value; hence we must respect the lives of human beings already born, but not of plants, animals or human fetuses. Now, ifwhat is valuable is the same as what is valued, two values will be of supreme importance, because they are necessary conditions for realising all other values. These are the life and the autonomy, ie capacity for free choice, of persons. Hence the obligation to respect their life and autonomy is overriding, and extends to those who are currently not able to exercise personhood but may be reasonably expected to do so in the future, such as children or those temporarily unconscious. Moreover, the lives of all persons are equally important, since no external criteria exist to make their importance unequal; and to kill and to allow to die are morally identical, since their moral effect is exactly the same. So any action (or inaction) which can be seen in advance to result in the death of one or more persons can be justified only if (a) those persons are themselves intentionally threatening the life or autonomy of other persons, or (b) the death of a smaller number ofpeople is necessary in order to save the lives of a larger number, or (c) the persons have autonomously decided that their lives are no longer of value to them. If this is applied to medical ethics, the following conclusions, among others, can be drawn: 1. Abortions and experiments on human embryos present no moral problem, since no person is involved. 2. The withholding of treatment and/or nourishment from severely handicapped children is morally identical to killing them: indeed, worse, since it causes them more suffering. As such, there is at least a strong presumption that it is wrong. 3. Voluntary euthanasia, freely chosen, is not wrong. 4. On the other hand, the involuntary euthanasia practised by the government, whose failure to provide adequate health care makes it morally responsible for the resulting deaths, is certainly morally wrong. 5. The failure to provide patients with adequate information to make autonomous decisions is wrong. 6. There should be a very strong presumption against overriding patients' expressed wishes, unless there is good reason to think that defects of selfcontrol, reasoning or information make them non-autonomous. 7. No sexual practice or mode of bringing children into the world can be morally wrong unless it violates the autonomy of another person or causes them undesired physical or mental suffering. 8. The value of a life is given by its importance for its possessor, not by its usefulness to others: hence the lives of the old, as long as they wish to live, are just as important morally as those of the young.

Medical negligence: who sets the standard?

Abstract: 'The law imposes the duty of care: but the standard of care is a matter of medical judgment'. So says Lord Scarman, outlining the hitherto accepted 'Bolam' standard, in his recent speech in the House of Lords decision of Sidaway v Bethlem Royal Hospital, reflecting earlier judicial dicta suggesting that it is for the medical profession rather than the courts to determine whether or not a medical practitioner has achieved the required standard of care (1). It is suggested here that this concept is bad in principle, and that the weight of judicial authority is against it.

Current arrangements for teaching medical ethics to undergraduate medical students.

Abstract: Those teachers in contact with medical students from pre-clinical days onwards will impart their ethical views by example and by precept, but such learning by 'osmosis' is insufficient. There is a knowledge base to be imparted which will enrich the understanding of ethical judgements on clinical problems seen during the undergraduate years. However, the learning process continues after qualification and in particular the doctor's capacity to make ethical clinical judgements will evolve with maturity and experience. It is essential therefore that students see their teachers willing and able to debate ethical issues at the postgraduate level.

Objections to hospital philosophers.

Abstract: Like morally sensitive hospital staff, philosophers resist routine simplification of morally complex cases. Like hospital clergy, they favour reflective and principled decision-making. Like hospital lawyers, they refine and extend the language we use to formulate and defend our complex decisions. But hospital philosophers are not redundant: they have a wider range of principles and categories and a sharper eye for self-serving presuppositions and implicit contradictions within our practices. As semi-outsiders, they are often best able to take an 'external point of view,' unburdened by routine, details, and departmental loyalties. Their clarifications can temporarily disrupt routine, but can eventually improve staff morale, hence team practice and patient welfare.

Moral Dilemmas in Medicine

Abstract: The next two sections deal with artificial insemination by donor and with the ethical situation surrounding conception in vitro. The first stresses that Artificial Insemination by Donor (AID) is here to stay, that in some couples it remains the only alternative to childlessness and that, at least for the foreseeable future, the subject will continue to attract considerable media publicity. The second section which is in fact the Galton Lecture of 1982 was delivered by Dr R G Edwards and describes his well-known work with Dr Patrick Steptoe. The issue is considered mainly in the historical vein and reviews subjects already well covered in the literature. The field of genetics dominates the remainder of the symposium. There are contributions on genetic registers, screening for carriers of recessive diseases and new developments in prenatal diagnosis. Again these areas have been more than adequately covered elsewhere and little new information is added. The reviewer must profess a preference for the final chapter dealing with the legal implications of AID, in vitro fertilisation and embryo transfer. Here, at least, there is a refreshing; albeit brief, breeze of originality and a praiseworthy attempt is made to break some new ground. This book scarcely merits a 1983 imprimatur. However, it may prove valuable to doctors, medical students and paramedical workers who in the past have not found the time to became conversant with these important areas of work. JOHN A LORAINE Senior Lecturer, Department of Community Medicine, The Usher Institute, Edinburgh