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Bioethics in the ClinicReview - Bioethics in the Clinic
Hippocratic Reflections
by Grant R. Gillett
Johns Hopkins University Press, 2004
Review by Tony O'Brien RN, M. Phil.
Mar 1st 2006 (Volume 10, Issue 9)

Bioethics in the Clinic is the latest offering by New Zealand neurosurgeon and philosopher Grant Gillett, whose previous output includes the comprehensive Mind and its Discontents, as well as other more straightforwardly philosophical works. Being Grant Gillett must be a busy life; speculating about the content of the brain while stitching it up, reflecting on the structure and physiology of the philosophical problems discussed in seminars. Gillett is one of the few who can truthfully claim, unlike the pet shop owner in the Monty Python sketch: "I don't have to do this job, you know! I'm a qualified brain surgeon!" Students must have some anxiety that Gillett remembers which doctoral role he is performing.

In Bioethics in the Clinic Gillett provides a broad discussion of medical ethics, beginning with a philosophical critique of traditional ethical theory and an exploration of narrative ethics. This is followed by a range of applied ethical analysis of perennial issues such as informed consent, and uniquely contemporary issues such as stem cell technology and cloning. The book is not for the newcomer to philosophy, although it is accessible to anyone with a passing acquaintance with Wittgenstein and Aristotle. Gillett explores medical ethics from a Hippocratic perspective, drawing heavily on classical writings. He argues that an ethically motivated practitioner, left to pursue the Hippocratic ideal of service, will produce not only ethical, but clinically sound health care not because she has followed a set of rules such as those of evidence based medicine, but because the moral imperative of medicine, coupled with the naturalist tradition, will lead to the Hippocratic path. That can be a hard case to argue given the climate of distrust of professionals, neatly captured by Gillett's discussion of the National Womens' Hospital experiment in New Zealand. An historically grounded ethics would have to acknowledge, as Gillett does in discussing HIV / AIDS as a postmodern illness, that ethical frameworks are not absolutes; they must fit the times. In that sense the litigious ethics of the 1990s may have been right for that time, if not right for the present.

The first section explores philosophical ethics, including ethical principles, values, the Hippocratic tradition and truth. Gillett employs a skeptical approach, refusing to accept that medical experts occupy a position of privilege in ethical debate. Within the narrative approach, the doctor is an interpreter, rather than a detached authority; interpretation is a discursive process requiring the skill of attending. Patients are understood as presenting with 'broken stories' rather than diseased bodies. This positioning renders traditional ethics problematic. Medical experts cannot solve problems in isolation from the lives in which those problems are experienced. Having undermined the reassuring certainty provided by reducing ethics to a utilitarian balancing act, or a set of comfortable rules, Gillett explores a range of issues such as informed consent, medical heroism, and the medical gaze. He is particularly critical of institutional responses to ethical problems, arguing that audit and monitoring regimes, while a necessary protection for patients, have the potential to undermine medical practice by creating a climate of suspicion. There is something of a romantic longing for the doctor as an involved, caring fellow traveler, rather than a purveyor of scientific and sanitized cure. The science of medicine is there, but in the background, wanting to be of service, rather than confining healthcare decisions to those dictated by science. This approach is applied to Gillett's own practice as a neurosurgeon, exemplified by case in which he made a decidedly 'unscientific' intuitive decision not to operate. He argues that such decisions have to be made at times, although they cannot be accounted for by rules of evidence or logic. Later he extends this reasoning to the intuitive anxiety many people feel about cloning. There is no science to it, but Gillett urges respect for such intuitions.

The remaining two sections consider ethics at the ends of the life continuum. Gillett argues convincingly against active euthanasia, and in favour of life ending decisions to withdraw interventions such as artificial ventilation. He argues in favour of stem cell surgery, but is equivocal on the issue of cloning. The criteria for decision making, located within the narrative framework of the book, is the best possible understanding of the life story of the patient. Such an approach releases patients and clinicians from the uncertainty of narrow deontological or utilitarian reasoning (or the illusive certainty of rigid moral codes). The three appendices are a welcome addition for those who need revision of basic philosophy, or who want to know more about how Gillett interprets Wittgenstein and Aristotle.

Gillett asks searching questions, and is not content with easy answers. While arguing for narrative ethics he does not valorize that approach to the complete disregard of ethical rules or the principles of beneficence and autonomy. On many difficult issues he appeals to a right to autonomy, although contextualizes that within the patient's narrative. In providing an alternative to ethical principlism, Gillett draws heavily on postmodern theory, especially that of Foucault and Lacan. There is less acknowledgement, even for the purposes of critique, of feminist theorists such as Gilligan, or the nursing theory of ethic of care. It is true that such theory often reduces to a duty, but it also contains a narrative thread that is worth considering in any attempt to argue an alternative to traditional bioethics. There are times when Gillett struggles to contain his disdain for some of his contemporaries. Principlists like Beauchamp and Childress are dismissed rather scornfully, as is the mechanistic ethical grid of Seedhouse. Gillett owns to being a philosophical magpie, drawn to whatever idea or concept will shed light on his questions. However reading this book you get the sense that Gillett is less territorial than your average magpie. He is willing to concede that his preferred narrative approach is no more a stand alone theory than its rivals, but vigorous in defending the necessity of a narrative approach in order for principles to have meaning.

There is plenty to keep New Zealand readers engaged. Many of the illustrations are drawn from recent New Zealand experience, although the examples are always chosen to make a more general point. There are plenty of uses of Maori language too, although I would not agree with Gillett's use of tino rangatiratnga to represent 'having a story to live by'. The book is written with a good deal of humor. Philosophers frequently look for amusing illustrations to ease the way through difficult areas of argument. In this Gillett is more successful than most. Heard the one about the surgeon and the anesthetist on the airplane? I won't spoil it for you.

Bioethics in the Clinic is a clearly written, passionately argued, and a deeply felt treatise on ethics. If there is a fault it is that Gillett cannot resist the asides and qualifications that a more pedantic writer might omit. But the tone of the book is engaging, and there is a sense that Gillett is happy to sacrifice some of the niceties of style in the cause of communicating his ideas.

This book comes highly recommended to all health practitioners, and especially to those whose work brings them into contact with the margins of health care, where standard care can have major ethical implications. That includes most health practitioners. Readers will not find a set of easy answers, but they will benefit from the broad perspective offered, and perhaps feel relieved that they can share some of their ethical burden with the person who brought it to them: the patient.

 

 

2006 Tony O'Brien

 

 

Tony O'Brien RN, M.Phil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz


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