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In his introduction to this collection of essays Christopher Cowley identifies its aims. Firstly, it aims to challenge the mainstream understanding of what the discipline of medical ethics is. Secondly, it aims to show the relevance of Continental European philosophy to medical ethics. A third point he mentions is that the book is aimed at a general reader. The essays are all clear and accessible, so this last aim is certainly achieved. It is less clear how well the book's two primary aims are achieved, however, largely because the book is fairly short (including 15 chapters and an introduction in 234 pages) and its contents uneven in terms of how far from the mainstream they venture. Considered not as a challenge but simply as a contribution to medical ethics, though, the book is a success.
Without going into detail on each chapter, it is probably worthwhile to give an overview of the book's contents, which are divided into four parts. Part one focuses on patients and their bodies. This part includes the essays by Alastair V. Campbell and Gaëlle Fiasse that I discuss in more detail below. Part two focuses on problems relating to old age, dying, and mental illness. Part three looks at autonomy and autonomous decision-making. And part four is about professional medical ethics and the law. Examples throughout tend to come from Europe, especially the United Kingdom, but not in a way that should pose any special problems for readers from other continents.
The need for a challenge to mainstream medical ethics is perhaps made clearest in the first chapter, an essay by Campbell on the idea of the body and its organs as property or commodities. This way of thinking about the body has certainly been challenged before (the work of Leon Kass comes to mind, and Campbell's essay itself is based on earlier work of his), but such challenges are not as mainstream as one might expect. Campbell begins with the case of Alder Hey Children's Hospital in Liverpool, England, where thousands of organs from bodies were removed and retained without authorization between 1988 and 1995. The families of the deceased were outraged, and indeed the discovery caused a national scandal, but some prominent medical ethicists have treated this reaction as a puzzle and as irrational and even wicked if it hinders medical science. Campbell diagnoses this kind of reaction as a symptom of Cartesian dualism (which treats the body as distinct from, and lesser than, the mind), and argues against it that we should treat patients not as dualities, nor as consumers, nor as collections of commodities, but as persons in need of help. In effect he takes the side of common sense, and it is hard to disagree, even if one might question the relevance of dualism (which long predates the commodification of the body) and the degree to which Campbell's is a non-mainstream view, even if some people within the mainstream think differently.
The case for bringing more Continental European philosophy into medical ethics is perhaps best made in Fiasse's essay. This essay is a sympathetic introduction to Paul Ricoeur's work on medical ethics, explaining his three-pronged ethics, his additional Kant-inspired morality, his emphasis on the Golden Rule, his three precepts for the medical profession, his three norms governing medical consultation, the three paradoxes he highlights in medicine, and so on. Fiasse can offer little more than a sketch of Ricoeur's views, but they come across as both rich and plausible, in a way that is likely to make readers want to investigate further.
If the collection has any weaknesses they are visible in what has been said already. Essays of about 15 pages cannot go into much depth or detail (Campbell tellingly refers the reader to two earlier works of his "for a fuller account of some of the arguments briefly outlined here," p. 235). Essays on such subjects as respecting patients' religious beliefs (D. K. Levy's contribution) and the questionable wisdom of physician-assisted suicide for people with depression (Cowley's other contribution in addition to the introduction) are well worth reading, but not quite trail-blazing. Nor is Continental philosophy as evident as one might expect from the introduction. There Cowley names Husserl, Heidegger, Merleau-Ponty, Foucault, and Ricoeur as the people he especially has in mind, but none of these thinkers is discussed more than two or three times in the whole book. The discussions in question are usually brief, often more mentions than discussions. In a book aimed at a general audience this is hardly surprising. Continental philosophy is often dismissed unfairly, and one reason for this is that it can be hard to read. Its practitioners have reasons for writing as they do, and their work is likely to be distorted by any attempt to translate it into easier terms. Ramplin and Hughes, in their first essay, use Heidegger to shed light on some of the ethical dilemmas involved in dealing with mental illness, but they have so little space in which to do so, and Heidegger's work is such difficult material to work with, that a sense of only scratching the surface, at best, is hard to avoid. Something similar could be said about Kristin Zeiler's use of Merleau-Ponty in Chapter 3.
Although it is not likely to change the face of medical ethics, the book does make valuable contributions to several debates within the field. It also brings out some of the problems with common ways of thinking about medical ethics, such as the idea that the end can justify the means, the desire to ignore as much as possible the religious beliefs of patients and medical practitioners, and the attempt to separate ethics from both legal and professional judgment, carving out areas of technical expertise where ethics supposedly does not belong. It could almost be said that the aim of the book is to bring ethics back into medical ethics. Certainly the way it points is worth exploring.
© 2012 Duncan Richter
Duncan Richter, Department of Psychology and Philosophy, Virginia Military Institute
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