Medical Ethics: A Very Short IntroductionMichael Dunn and Tony HopeOxford University Press, 2018Let me begin by saying as a long-term advocate of more conscientious, deliberate, and compelling education in the ethical aspects of medical practice, this book is a most welcome contribution.Medical Ethics, a volume in the Oxford University Press series of Very Short Introductions is compact (fits in a jacket pocket), brief (10 chapters, 122 pages), brilliant (passim), and affordable ($11.95). Hence, efficacy in several dimensions.This book, now in its second edition, is the best elementary introduction to medical ethics we have. By “best” I mean the most successful combination of clear writing, accessible analytic acuity of central concepts and issues, pedagogical design, useful guidance to more advanced material, and brevity.Other introductory works in this area are sometimes better in one or more of these categories. One that comes to mind (also recommended for more depth) is Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine by Albert R. Johnson, Mark Siegler, and William J. Linslade. However, none is as successful as a combination of all these criteria.If I were still teaching medical ethics to residents, when time efficiency is essential, I would certainly use Medical Ethics as a principal resource.The authors present a mix of philosophical insight, grounded in close study of foundational texts, and clinical observation, grounded in reflection on years of experience. The mix is at once intellectually elevating and clinically useful.The book opens with an explication of eight “tools of ethical reasoning” used by philosophers, which are then on display in consideration of a range of topics that challenge medical practitioners.These tools are: 1) Distinguishing facts from values; 2) Reasoning from principles; 3) Defining terms; 4) Elucidating concepts; 5) Case comparison; 6) Thought experiments; 7) Logic; 8) Spotting and avoiding fallacies in reasoning.While using these tools as guidelines, the authors advise it is important to remember: Ethical reasoning cannot be reduced to algorithms. Situations are complex and doing the right thing will often require flexibility. Rationality, if practiced in isolation from other virtues, can, like bureaucracy, become rigid and inhuman. Humane medicine will require in addition to rationality: wisdom, imagination, and creativity.This statement reflects the authors’ general and long-term approach to ethical problems, an approach that is a disciplined attempt to achieve clarity, rather than an opportunity to invoke a commitment to any sort of abstraction (theory, law, ideology, secular or religious tradition, and so on). Readers are encouraged to get rid of the fuzz and goo of careless thought, to achieve clarity about the issue or case at hand, before committing to a treatment plan. (As an aside—in many years of consulting with patients, their families, and attending caregivers, I found that most disagreements could be resolved simply by clarifying the language each party was using. Clarity alone often generated agreement; when it did not, at least differences were better defined and more amenable to resolution.)A variety of cases, laws concerning medical decisions, and “customs of practice,” are presented then followed by an evaluation employing all or some of the tools mentioned above, which discussion is in turn followed by an inquiry of the reader: “Would you use the explicated techniques differently, and perhaps reach a different judgment?” The approach, throughout the presentation of issues, is, again: What is the best way, all things considered, to reach a good judgment about the right thing to do? Reaching such judgment on solid, defensible grounds, all things considered, in a shared language, is the essence of applied medical ethics.The range of cases, laws, and customs considered includes, but is not limited to: assisted dying, people who don’t exist yet, inconsistencies about responses to mental illness, fair procedures for allocating medical resources, the myth of evidence-based value-free policy-making, the role of rescue according to statistics versus to known individuals, modern genetics testing and traditional confidentiality, cultural mores and consent, and the various support roles of medical ethics.The best summary of the book’s message I can offer is this: Attending to the particulars of individuals-in-context is always appropriate, if not mandatory while evaluating ethical aspects of clinical practice. After rational consideration of the kind outlined by the authors, forming different judgments in similar (but not identical) cases ought to be considered an achievement rather than an inconsistency to be avoided. The consistency to be most valued in clinical decision-making is not found in identical results, but rather in the application of rational processes, tempered with empathy and imagination. The particular elements of individual contexts matter and rational judgments will be, and ought to be affected by them.The Further Reading addendum is excellent, offering books, articles, journals, and institutions that have contributed to our—so far—only moderately successful effort in providing essential and continuing medical ethics education.
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