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Principles of Biomedical Ethics, 4th Edition
Book Reviews
Principles of Biomedical Ethics, 4th Edition By Tom L. Beauchamp and James F. Childress New York, Oxford University Press, 1994 546 pages, ISBN 0-19-508536-1 (bc), $45.00 hardcover, $22.95 paperback
Reviewed by Carol B. Perez, MD.
A
t a recent Medical Grand Rounds pertaining to medical ethics, the presenter asked that the audience free associate to the phrase "informed consent." At the top of the list of words thus generated was "lawsuits." This is but one example of the clinical transformation and dilution of biomedical ethics-the examination of standards of right or good action in the biomedical fields-into a body of techniques for avoiding litigation. It reflects the temptation to calIon a hospital ethics committee and/or a consultationliaison psychiatrist solely to buttress one's legal position. But perhaps even more insidious is the temptation to employ vague notions of biomedical ethics as post hoc justifications for one's own political or personal agenda. For instance, the mantra "managed care is unethical" reverberates through our current discourse on health care as, essentially. a conversation stopper. Who would dare advocate for an "unethical" system? Does "unethical" mean unjust to patients or inconvenient to providers? What ethical principles were invoked to reach such a conclusion? Unfortunately, such questions remain unanswered all too often, because most of us have not had the privilege of reading a thorough, accessible, and interesting treatise such as Principles of Biomedical Ethics. Happily, Beauchamp and Childress, in this fourth edition of their standard philosophy text, assume no knowledge of philosophy. They begin with a definitional overview of ethics (Ch. I) and an exposition of the types of ethical theory (Ch. 2), which is enhanced by presentation of a difficult case and discussion of how each type of ethical theory (i.e., Utilitarianism, Kantianism. etc.) would approach that case. Next, the authors 312
expound on each of the four principles of ethics that they deem to form the foundation of ethical consideration: autonomy. nonmaleficence, beneficence, and justice (Ch. 3-6). Finally, they discuss various aspects of the professionalpatient relationship (veracity, privacy, confidentiality. fidelity) as they reflect those basic principles (Ch. 7) and conclude by addressing the expression by health professionals of virtues and ideals that transcend the mere performance of moral obligations (Ch. 8). Throughout, Beauchamp and Childress carefully delineate situations where principles override each other or at least require some form of balancing. They effectively employ numerous brief clinical vignettes as well as lengthier expositions of important legal cases, 10 of which appear in an Appendix. Consultation-liaison psychiatrists will derive particular benefit from the perspectives offered on topics including allocation of scarce resources such as organs for transplantation as well as the myriad issues surrounding treatment of HIV patients. The authors encourage examination of areas where important distinctions are often ignored clinically, such as the distinction between mere disclosure of details of a planned treatment vs. actual informed consent by the patient. Conversely, they point out areas where artificial, morally untenable distinctions are drawn, such as "withholding" vs. "withdrawing" treatment and "killing" vs. "allowing to die." Finally, they advocate honesty in the articulation of the real basis for a particular ethical decision. Accordingly, they warn that raising the standard for competency as decisions become more risky may indicate merely a manipulation of the principle of autonomy; a preferable approach in some cases might be to deem the patient able to make an autonomous choice but to decide to override that choice by invoking the principle of beneficence. Significantly, Principles ofBiomedical Ethics does not provide absolute answers, but rather a framework for thinking about these important life questions. We are reminded in the discussion of assisted suicide that an action that is deemed ethical in an individual situation might not translate into a public policy permitting or requiring PSYCHOSOMATICS
Book Reviews
such actions. We are reminded to strive for what is right in our dealings with patients, not merely what is safe, legally or otherwise. And we are gently, elegantly, and effectively prodded to the humbling realization that a "judgement can be proposed for consideration on any basis a person chooses-random selection, emotional reaction,
VOLUME 36 • NUMBER 3 • MAY - JUNE 1995
mystical intuition, etc.-but to propose is not to justify.... " (p. 105) Dr. Perez is an attending psychiatrist. Fairfax Hospital. Falls Church, VA, and instructor in psychiatry. Georgetown University School of Medicine. Washington, DC.
313
Principles of Biomedical Ethics, 4th Edition By Tom L. Beauchamp and James F. Childress New York, Oxford University Press, 1994 546 pages, ISBN 0-19-508536-1 (bc), $45.00 hardcover, $22.95 paperback
Reviewed by Carol B. Perez, MD.
A
t a recent Medical Grand Rounds pertaining to medical ethics, the presenter asked that the audience free associate to the phrase "informed consent." At the top of the list of words thus generated was "lawsuits." This is but one example of the clinical transformation and dilution of biomedical ethics-the examination of standards of right or good action in the biomedical fields-into a body of techniques for avoiding litigation. It reflects the temptation to calIon a hospital ethics committee and/or a consultationliaison psychiatrist solely to buttress one's legal position. But perhaps even more insidious is the temptation to employ vague notions of biomedical ethics as post hoc justifications for one's own political or personal agenda. For instance, the mantra "managed care is unethical" reverberates through our current discourse on health care as, essentially. a conversation stopper. Who would dare advocate for an "unethical" system? Does "unethical" mean unjust to patients or inconvenient to providers? What ethical principles were invoked to reach such a conclusion? Unfortunately, such questions remain unanswered all too often, because most of us have not had the privilege of reading a thorough, accessible, and interesting treatise such as Principles of Biomedical Ethics. Happily, Beauchamp and Childress, in this fourth edition of their standard philosophy text, assume no knowledge of philosophy. They begin with a definitional overview of ethics (Ch. I) and an exposition of the types of ethical theory (Ch. 2), which is enhanced by presentation of a difficult case and discussion of how each type of ethical theory (i.e., Utilitarianism, Kantianism. etc.) would approach that case. Next, the authors 312
expound on each of the four principles of ethics that they deem to form the foundation of ethical consideration: autonomy. nonmaleficence, beneficence, and justice (Ch. 3-6). Finally, they discuss various aspects of the professionalpatient relationship (veracity, privacy, confidentiality. fidelity) as they reflect those basic principles (Ch. 7) and conclude by addressing the expression by health professionals of virtues and ideals that transcend the mere performance of moral obligations (Ch. 8). Throughout, Beauchamp and Childress carefully delineate situations where principles override each other or at least require some form of balancing. They effectively employ numerous brief clinical vignettes as well as lengthier expositions of important legal cases, 10 of which appear in an Appendix. Consultation-liaison psychiatrists will derive particular benefit from the perspectives offered on topics including allocation of scarce resources such as organs for transplantation as well as the myriad issues surrounding treatment of HIV patients. The authors encourage examination of areas where important distinctions are often ignored clinically, such as the distinction between mere disclosure of details of a planned treatment vs. actual informed consent by the patient. Conversely, they point out areas where artificial, morally untenable distinctions are drawn, such as "withholding" vs. "withdrawing" treatment and "killing" vs. "allowing to die." Finally, they advocate honesty in the articulation of the real basis for a particular ethical decision. Accordingly, they warn that raising the standard for competency as decisions become more risky may indicate merely a manipulation of the principle of autonomy; a preferable approach in some cases might be to deem the patient able to make an autonomous choice but to decide to override that choice by invoking the principle of beneficence. Significantly, Principles ofBiomedical Ethics does not provide absolute answers, but rather a framework for thinking about these important life questions. We are reminded in the discussion of assisted suicide that an action that is deemed ethical in an individual situation might not translate into a public policy permitting or requiring PSYCHOSOMATICS
Book Reviews
such actions. We are reminded to strive for what is right in our dealings with patients, not merely what is safe, legally or otherwise. And we are gently, elegantly, and effectively prodded to the humbling realization that a "judgement can be proposed for consideration on any basis a person chooses-random selection, emotional reaction,
VOLUME 36 • NUMBER 3 • MAY - JUNE 1995
mystical intuition, etc.-but to propose is not to justify.... " (p. 105) Dr. Perez is an attending psychiatrist. Fairfax Hospital. Falls Church, VA, and instructor in psychiatry. Georgetown University School of Medicine. Washington, DC.
313