Case Studies in Biomedical Ethics: Decision-Making, Principles, and Cases

Robert M. Veatch, Amy M. Haddad, Dan C. English
Oxford University Press: Oxford, 2009
ISBN13: 9780195309720 (sb)
RRP:  £23.70

Reviewed by Emily Beckwith

Biomedical ethics is receiving more global interest today than ever before. Across the world, medical students are studying compulsory units on the fundamental ethical concepts at stake throughout the profession. Educators have the role of identifying and developing the most appropriate objectives, content, methods and assessment strategies to teach the subject at its highest level. Hence the need for a textbook as clear and systematic in its approach as Case Studies in Biomedical Ethics. The field is especially well served by new releases, given the rate of technological development and the ever-emerging trend of unforeseen dilemmas. The first edition of the book appeared in 1977, now revised with a more comprehensive range of case studies and an ethical model designed for medical students graduating in today’s era of biological revolution.

Focus

The book is tailored for medical students without any previous study of philosophy or ethics. Its purpose is outlined in the introduction as being to provide a collection of case studies from which to build a more comprehensive scheme for health care ethics. The authors, who have a multidisciplinary background in Philosophy, Pharmacy and Bioethics, construct a framework of questions that must be answered in a systematic bioethics system. It succeeds in providing students with a clear means of negotiating ethical resolutions, without losing respect for the enormous issues at stake in the field of ethics and the wealth of complex factors involved.

The text contains over one hundred case studies. Medical ethics is presented through ‘real-life, flesh and blood situations’ that cannot be dealt with through abstract theorising alone. The authors argue that the use of case studies is one of the most ‘provocative’ methods of studying ethics. They certainly are excellent for rousing the emotions about the importance of ethics, but there is a strong academic benefit as well. Students’ eyes are opened to the sheer complexity of any ethical situation and how moral evaluations are embedded in even the most basic actions. However, for those with prior knowledge of the field, the extensive use of case studies may become repetitive. The book will best serve an introductory course.

Structure

This is the ideal text for learning, with clearly formatted headings, summarising tables at the end of longer passages and useful alternative references at the start of each chapter. It is also suited to long-term reference use, given the detailed contents page and clearly presented case studies index. The appendix of cited documents and glossary of ethical terms are also useful in content. The text is broken into three parts, making a clear distinction between values in medicine, principles in medicine and their application to particularly difficult questions. The continued reference to ‘The Four Questions’ in ethics and the ‘Five-Step Model’ provides a clearly structured template to assist with decision-making. Though the book is not short, at over 400 pages, there are few pages without a break in the text for a heading, a commentary or a case study. It does not have the size of some of the larger 'Companions,' which makes it an accessible first step for the learner.

The Five-Step Model

The book gets off to an excellent start, with a practical Five-Step Model of what to do in an ethically complex situation. The Model aims to systematise moral decision-making that might otherwise be unconscious, intuitive and therefore inconsistent between medical professionals. It has a diagnostic tone that will resonate well with medical audiences. ‘Warning signs’ are given that should indicate to the practitioner the development of an ethical problem. The importance of gathering information is then highlighted, before a diagnosis of the moral dilemma can be made. When seeking a resolution, practitioners are guided towards considering all possible options in the light of both their probable outcomes and their commitment to the medical system of values. This opens up discussion concerning the difficulties of reconciling consequentialism with virtue ethics. The Model promotes the importance of open discussion and group consensus. The use of an ethics committee is recommended in cases of evenly weighted conflicting values.

The approach remains clear and systematic, yet there is no attempt to shirk the specific complexities presented by each case. The very first case study of the book is cited as an example of the ‘messy’ complexity that can prevent a definitive resolution. The suggestion that some cases would be referred to an ethics committee will be a welcome respite for students who feel overwhelmed by the number of variables at hand.

The Four Questions

The Four Questions in ethics, outlined in a comprehensive introduction, are offered throughout the text as a remedy for ethical paralysis. The first question concerns the source, meaning and justification of ethical claims. Here the book touches on perhaps the deepest question there is in ethics: ‘What is our moral authority?’ Touching upon it, and introducing a respectful sense of relativism, is all that is appropriate for this highly practical manual. Practitioners learn to recognise when they are making value judgments rather than statements of fact. The message is that normative judgments are involved in many everyday patient recommendations; ethics is inescapable. Case studies concerning the ethical evaluations in commonly accepted practice demonstrate this point well. The crucial outcome is to show that recognised codes of ethics cannot always be relied upon to provide definitive answers. Supplementary reading in metaethics is recommended for students who wish to explore the notion of moral authority in greater depth.

The second question asks what kind of actions can be seen as intrinsically right actions. Students are introduced to consequentialist and deontological theory. This is very well delivered, with Mill and Kant referenced clearly but without too much weight of detail. The intrinsic difficulties of the medical model are made apparent, with a focus on how to reconcile prioritising the overall good with a duty to individuals. Chapter 4 deals directly with difficulties in interpreting the Hippocratic principles of beneficence and non-maleficence. Students are invited to see the subjectivity and subsequent controversy of their application. The recent developments in performance enhancement are a case in point. How far should the health profession go to ‘benefit’ a patient?

Chapter 7, on veracity, encourages students to compare the Hippocratic consequentialist outlook that lying can bring benefit, with the stance adopted by the American Medical Association’s 1980 Code of Ethics that lying is intrinsically bad for relations between doctor and patient. This is a useful chapter to mark the shift away from paternalism in medicine. It is a classic ‘ends justifies means’ analysis that makes for a stimulating read. Chapter 9 discusses the principle of avoidance of killing. It provides legitimacy for the legalisation of Physician Assisted Suicide, drawing on the conseqentialist nature of the Hippocratic Oath and weaknesses in the argument for sanctity of life. The theoretical rigour of this chapter will challenge students who have an instinctive recoil against the practice. This is a thought-provoking and engaging series of chapters.

The third and fourth questions ask how one can apply these general principles and values to the most difficult cases, notably those recently brought through technological developments. This leads to an outline of the rules-based versus situationist debate. The text promotes a plausible middle path approach between these two extremes. Numerous very difficult ethical cases are highlighted with an extensive outline of the issues at stake. The special problem areas covered are abortion, sterilisation and contraception, genetics, birth and the biological revolution, mental health and behaviour control, confidentiality, organ transplants, health insurance, heath system planning and rationing, experimentation on human subjects, consent and the right to refuse treatment and death and dying.  

Understanding – not answers

It is noticeable that many of the case study commentaries end with a series of open questions. The individual approaches of different codes of ethics are highlighted, with no definitive answers offered. This can feel unsatisfying, but is a realistic portrayal of the varied manner in which ethical principles can assume prominence in different practices. The main intention of the book is to give students a compassionate, open-minded and informed outlook of the varied belief systems within ethics. The goal is not to provide an unrealistic, clear-cut resolution to the studies outlined. Students learn that sometimes a situation may be so difficult as to appear unsolvable. The text’s role is to provide solutions for the student faced with such a case. The importance of gathering information may be their crucial role, before the situation is passed onto an ethics committee.

A particularly useful aspect of the text is its discussion of ethics in religion. It will serve the deliberations of medical practitioners who feel their religious convictions are in conflict with their professional requirements or who find themselves in conflict with the preferences of their patients. A case study in part one referring to the Catholic attitude to abortion is one such example.

Omissions

Though this is a 2010 publication, the text does not contain discussion of some of the most recent and ethically complex technological developments in ethics. The topics of cloning, assisted reproductive technologies, gene therapy, nanotechnology and xenotransplantation are omitted. The same is true of any critical assessment of ethical committees and of the role of bioethics itself. To understand these omissions, we need only look to the book’s purpose. The emphasis is on practice in the now, dealing with the technologies that will impact students the moment they qualify. The aim is to be digestible and relevant, making the omission of some developing technologies a sensible editorial choice. Nevertheless, students wishing to focus on these specific areas are best advised to seek a larger textbook, such as Singer and Kuhse's 'Companion to Bioethics.'

As a teaching text, some useful strategies are not included. The book does not contain articles by notable philosophers in the field. Neither does it feature the study questions and practical exercises found in other textbooks. However, this does not weaken the text, given the case studies’ potential for rousing excellent classroom discussion and the insightful commentaries that follow.

Conclusion

In conclusion, Case Studies in Biomedical Ethics: Decision-Making, Principles, and Cases is an excellent teaching text. It is clear without compromising on complexity, providing students with a solid and secure platform from which to develop their ethical mindfulness. Any omissions in the text have been seen to strengthen this well-defined and well-executed intention. The use of case studies creates an engaging, true to life impression of the importance of ethics in each working day. Structuring the text by using the Five-Step Model and the Four Main Questions provides a solid framework for practical decision-making. It is highly recommended as a core text for any Introduction to Bioethics.  

• International
• Social Justice

There have been 0 replies to this Article. + Post your comment here.