Brain, Vol. 123, No. 11, 2361,
November 2000
© 2000 Oxford University Press
Book reviews |
ETHICAL DILEMMAS IN NEUROLOGY
By Adam Zeman and Linda Emanuel. 2000. Sidcup: Harcourt Publishers Limited. Price £55. Pp. 219. ISBN 9-780702-022272.
Guy's Hospital, London, UK
This is Volume 36 in the W. B. Saunders series `Major Problems in Neurology', and has been written by a clinical neurologist from the UK and a medical ethicist from the US. There are 17 chapters by different authors: 10 from the UK, 10 from the US, and one each from New Zealand and Cuba. The content therefore largely reflects the ethical problems and attitudes of Anglo-American medicine. Each chapter heading poses a question and there follows an essay discussing the arguments, both for and against. Some authors have been so even-handed that their own view is either obscured or only becomes apparent at the end of the essay, while others show their bias early, but all are sufficiently well balanced to allow the reader to draw their own conclusions and in the process to recognize their own prejudices.
We would like to think that medical ethics have not or should not have changed over the years, but even if that were true, ethical issues feature much more prominently in everyday medical practice than they did, if only because of the change in the last half a century from a paternalistic attitude to close involvement of the patient with their management. The book starts with a discussion of the philosophical basis of medical ethics from Aristotle to the present day. The subsequent chapters are loosely divided into three sections. The first group relates to diagnosis and communication and discusses such issues as whether consent is required for an HIV test, should we offer predictive tests for fatal inherited diseases, and whether or not to confront patients with medically unexplained signs and symptoms. The two remaining essays in this section discuss whether or not to tell patients with Alzheimer's disease of the diagnosis, and a chapter on the ethics of breaking confidentiality. It is not surprising that these problems are largely resolved and certainly simplified by good rapport and communication with patients. This is summarized well by Simon Wessely in his chapter on medically unexplained signs and symptoms and his conclusion is that patients should be told, and what they are told be both accurate and pragmatic, but he also argues that in some circumstances it may be appropriate to be economical with the truth.
The second section on therapy starts with an essay on randomized controlled trials and discusses the ethical issues involved; again it is a matter of good communication. This is followed by an essay on neurosurgical practice and the ethics of performing procedures on patients that in theory seem entirely appropriate but which have not been subject to any systematic study and certainly not to a randomized control trial. Subsequent chapters include discussions on the problems of rationing expensive treatments using the example of ß-interferon, the circumstances when treatment may be enforced against the wishes of a patient when of course the law dictates the procedure, the use of embryos and animals in research, the effect of private practice on a public health service and the potentially conflicting interests of military physicians in respect of their responsibility to the military and to their patients in relationship to Gulf War syndrome.
The last section concerns ethical dilemmas in the management of the end of life, including whether or not to respect advance directives, when treatment may be withdrawn, whether it is ever ethical to expedite death, and finally, Calixto Machado responds to the question `is the concept of brain death secure?' He proposes a new standard of brain death as the irreversible loss of consciousness, but unfortunately he does not lay down the criteria with which to make this judgement and the reader is left with the existing polarization of views between death of the whole brain and death of the brain as a whole (brainstem death). Whatever view is taken, the medical profession needs absolutely reliable criteria for the diagnosis of brain death and the public will be reassured if these criteria have the strong support of the medical profession and the approval of the law. The British criteria for brainstem death satisfies these requirements.
All these issues will be familiar to practising neurologists and these essays do not present any very new or controversial ideas. They do lay out the arguments clearly and concisely, serving the useful purpose of making the reader judge their own ideas and practice against views of the authors.
Many so-called ethical problems are actually the residua of outdated practice. It is usually appropriate for the physician to introduce an ethical dilemma gently, subsequently exploring the issue in more detail according to the individual circumstances. Good communication is the key message.
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