Clinical Ethics in Anesthesiology: A Case-Based Textbook

Abstract

Overall, the style and content of this book are good. It is interesting and easy to read and is aimed at clinicians, assuming an interest but not necessarily expertise in clinical ethics. However, it has a major flaw for UK and European readers; it is largely an American text and couched therefore in American law and society values. The book is divided into six sections of between four and 14 chapters each. The sections are: 1, Consent and refusal; 2, End of life issues; 3, Pain management; 4, Research and publication; 5, Practice issues; and 6, Anaesthesiologists, the state and society. Most chapters begin with a case, many presumably historic and real, then continues with dissection and exploration of the ethical issues and concludes with case resolution. This style is engaging and each chapter is short, the subject matter being comprehensively covered by the 49 separate chapters. Editorially, there is consistency in the standard and content of the chapters, despite most being written by separate authors. The problem for the publishers of this book is that law, ethics, and societal norms cannot be entirely separated from each other. There are efforts in a number of chapters to make the text applicable to Europe and the USA, but this is of limited success (and accuracy) and not consistent across the chapters. This becomes of major importance if it is considered that this text might be used to educate about UK law and ethics. It is not suitable as such a tool. In particular, the chapters discussing consent, end of life decisions, and decision-making by surrogates are difficult to reconcile to UK practice. The Mental Capacity Act has laid out very clearly the UK approach and law on these issues (I would recommend obtaining a full copy; it is surprisingly user-friendly). The American system puts more emphasis than we do on autonomy and surrogate decision-making is an established norm. Chapter 4 on surrogate decision-making is particularly problematic explaining the US hierarchy of next of kin permitted to make life and death decisions for their relative, irrespective of advanced directives. An example given is a family considering the financial implications to them as grounds for deciding whether intensive care management is continued for their elderly mother. I think it is reasonable to assume that in the UK (thanks to the National Health Service), we would find this reasoning rather abhorrent. The insurance and self-paying health system in the USA impacts on a number of the arguments presented and the table summarizing UK practice with regard to patients without capacity is wrong. Some of the difficulties rise from terminology. The term capacity in America is used to describe physical function and their term for ‘capacity’ is competence. This is nicely explained in Chapter 1 by the main editor who elects to use the terms interchangeably, but unfortunately this is not always continued in the subsequent chapters. The term surrogacy is also difficult. We do not use the term at all, preferring to consider the role of the ‘next of kin’ as a source of informed opinion about the patient without capacity and leaving the legal choices to appointed individuals with powers of lasting attorney within specific situations. This is not understood clearly by the authors and anyone using this text as a source of ethical guidance could be misguided in terms of the law. Throughout the text, the interrelationship between clinical decision-making and the cost of therapies along with what insurance companies will, or will not, cover is raised. It is clear we are fortunate that although we have to consider resource issues, we rarely adjust our clinical decision for individual patients on cost alone. Where the law and ethics are not so entwined, the book is a pleasure to read and informative. Most authors have tried to give complete rounded perspectives to their arguments and even when personal opinion is proffered, it is not unwelcome. There are chapters which are outside UK practice (e.g. communication and decision-making with native Amercians and Physician involvement in executions) which raise interesting and thought-provoking issues and in other areas (e.g. euthanasia, and cardiac death and organ donation), it is clear that clinicians in the USA are struggling with similar ethical issues as we are. This book cannot be recommended for an ethics novice in UK practice, mainly because of marked differences in law. Many potential pitfalls exist and the attempts to internationalize the discussions are not wholly successful. However, as a book describing ethical issues which may confront an anaesthetist in a wide variety of circumstances it is a good read, but the reader must have a sound knowledge of UK ethical and legal practice to avoid being misled.