THE LAW AND ETHICS OF MEDICINE
Essays on the Inviolability of Human Life
Oxford University Press, 2013
RRP £ 65.00, $US 100.00
This book is about the ethical and legal principle of the inviolability of human life, and not some theological discussion. It is divided into three parts. The first is about the history, influence and misunderstanding of the ethical principle, the second discusses aspects of the beginning of life, and the last deals with a number of issues at the end of life.
I found the first section a bit heavy-going, as though it was written for academic lawyers, who in fact are the intended audience. I skimped on the second, but the third part (comprising fully a third of the book) was hard to put down. He provides in-depth but readable reviews of the debate about the decriminalization of euthanasia in the House of Lords, the report from the Council of Europe and there are commentaries on the Pretty, Purdy and Bland cases. In the chapter dealing with the Mackay Report (House of Lords), he describes the debunking of two popular myths - that the great majority of our communities are screaming for legalisation of physician-assisted death now, and that we doctors are doing it all in secret. Keown also comes up with numerous pieces of evidence (from material supplied with the Mackay Report) that might have significantly strengthened the case against euthanasia. The evidence obtained about practices in The Netherlands includes some eye-opening quotes from Dutch doctors, such as: “It is the patient who is now responsible in the Netherlands for avoiding termination of his life; if he does not wish to be killed by his doctor then he must state it clearly orally and in writing, well in advance”…and “Due consideration should be given to the question how termination of life without explicit request can be prevented. It should be the responsibility of the patients…”
His chapter on palliative care is about not wasting time and energy on the euthanasia debate, but focusing on the legal and professional reforms “needed to help the 90% or more of dying patients who will never even vaguely desire euthanasia”, and includes pertinent discussions of whether palliative care is an ethical duty and a human right.
John Keown is well known in euthanasia circles. His previous contributions include Euthanasia Examined - An Argument Against Legalisation (1995) and Euthanasia, Ethics and Public Policy - Ethical, Clinical and Legal Perspectives (2002), both from Cambridge University Press, and Debating Euthanasia (Hart Publishing, 2011), and are all to be recommended. His attention to detail and clarity of thought are admirable, but he writes in a moderate and reasoned tone and in a manner easily understood whether you are a health care professional, lawyer, politician or just an interested member of the public. The Law and Ethics of Medicine is no exception and is recommended to anyone involved in the discussions about physician-assisted death and perhaps to those thinking about better strategies for advancing palliative care.
Review copy supplied by Allen & Unwin, Australia
Susan Wyndham, literary editor of The Sydney Morning Herald, was so disturbed by the “chaos of her grief’ after her mother died that she sought out other writers and their stories of losing their parents to reassure herself that ‘I was not alone or mad.”
Here are the stories of 14 Australian writers on the subject of surviving the deaths of their parents. The authors include Thomas Keneally (Schindler’s Ark, winner of the Booker Prize and made into the Oscar winning film, Schindler’s List) and Helen Garner (The Spare Room, a novel dealing with terminal illness). The stories are all quite different and almost without exception are well written. They all feel real. The humorous side of the dilemmas that families get them into is not lost. There are wonderful descriptions of the justifications and counter-justifications of behaviour, often long-standing, between parents and their adult children. I thoroughly enjoyed reading this book and was a bit cross when the man at the carwash made me stop halfway through one of the better stories.
This book will be helpful to anyone dealing with the death of a parent, but I think it is especially important to those of us who work in palliative care. We talk about recognizing and meeting the needs of the families, but in a distant, third-person sort of way. But these are first-person accounts of the sometimes life-long issues that consume the family members we see sitting dutifully at the bedside, and are a reminder of the complexity of the issues that exist.
Go on, buy yourself something for Christmas. I feel sure you will enjoy reading the stories and they may help you empathise and deal better with the (quite normal) baggage that family members bring to the palliative care setting.
CASE STUDIES IN PALLIATIVE AND END-OF-LIFE CARE
Margaret L Campbell (ed)
RRP $US 59.99, £ 37.99
This is a tightly edited collection of 36 or so clinical stories about palliative and end-of-life care, providing a case-based approach to learning. The case histories are divided into three sections, dealing with communication issues, pain and symptom management, and family care.
The clinical history is first outlined, following which there is a discussion regarding matters such as diagnosis and prognosis, assessment, treatment considerations, and finally a conclusion to the clinical story. Each chapter ends with a summary of take away points and there are a decent number of references. Each story has been edited to focus on a particular issue, which I think is of educational benefit, but is less likely to be of use to the practicing physician dealing with ordinary patients and their families where there always seems to be a list of issues.
Reading some of the vignettes made me realise how difficult the editor’s job must have been. The team wants a meeting with the wife of an 88-year old man with moderate dementia. Much is said about the planning and content of the meeting, but it happens spontaneously when the physician pops into the patient’s room. Assuming she is of similar age to her husband, I wondered how intimidated she might be in the presence of the physician, and how much she might really understand. Shouldn’t the meeting have been held over until she could be accompanied and supported by younger members of the family? And my heart went out to the mother who went to the hospital where her critically ill 25-year old daughter had been taken by ambulance. The social worker escorted her to the family room, where she was made to sit at a table and be introduced to the ED staff (name, title, and role in the ED), then required to provide a detailed account of what happened before the ambulance arrived, only then to be told (after what felt like a long time) that her daughter had arrested and died a few minutes after arriving at the hospital.
I’m not sure whether this book would be a useful resource or reference for practicing clinicians (as suggested on the back cover). But in the classroom, with a good teacher/facilitator and some robust discussion, it would be excellent. The brevity and focused nature of the stories are good but, as noted above, there is often more than one way of viewing a situation. Whilst this volume is part of Wiley-Blackwell’s Case Studies in Nursing series, I think reading and discussing the material would be just as beneficial to medical undergraduates as well.
A GOOD DEATH?
Law and Ethics in Practice
Lynn Hagger and Simon Woods (eds)
RRP £ 65.00, $US 124.95
This book grew out of a 2008 UK Clinical Ethics Network Conference entitled “The Value of Life, the Value of Death”. The editors, an academic lawyer and a philosopher, present a collection of ten essays written by a multidisciplinary cast, exploring some of the legal, ethical, moral, and social aspects of end-of-life care. The medical and nursing perspectives are not well-represented (or are viewed from an ivory tower), but there is a lot in this book to make you sit up and think. The chapter by Lord Justice Munby on the legal rights of terminally ill patients was a pleasure to read. Daniele Bryden asks whether the diagnosis of death, equating death of the organism with death of the person, needs to be re-defined for end-of-life planning and particularly when organ donation and retrieval are considered. John Erik Troyer explores the implications for end-of-life care of the constitutional changes wanted by the fundamentalist Christian anti-abortion Personhood groups in the USA. Would every patient have to have everything done, until they were dead? Hagger and Rehmann-Sutter advocate the need for liberalising assisted suicide in the UK along the lines of the Swiss model (which ‘reflects clear support for patient autonomy’) and provide help for anyone, regardless of the state of their medical health. Viewed as a clinician who deals with real patients, no two of whom are the same, I think it would be totally unworkable. Vincent Kirkbride discusses the escalating costs of health care in the last year of life, whether or not we should expect a right of access to expensive treatments, and the turbulent history of the National Institute for Health and Clinical Excellence (NICE) restricting the use of expensive new anticancer drugs. Wood’s chapter on palliative care and the ‘good death’ seemed more about philosophy than clinical care. There are another two chapters about end-of-life care for children and a mother’s account of the death of her daughter from Tay-Sachs disease.
Reading these essays will have no effect on your clinical skills, but it is good to be reminded of these other legal, social and philosophical views on end-of-life care. There’s plenty to think about here, although it is a little on the expensive side.
Roger Woodruff, MD (Australia)
Dr. Woodruff is a Lifetime Member of the IAHPC Board and Past Chair. His bio may be found here.
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Dr Roger Woodruff
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Heidelberg, Victoria 3084
Note: Review copies become property of IAHPC and are not returned to the author. Only palliative care related books which are previously approved will be reviewed. Due to the large number of requests, we can't provide exact dates of when books will be reviewed.