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Resolving Ethical Dilemmas: A Guide for Clinicians
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B Lo. 373 pages. Baltimore: Williams & Wilkins; 1994. $35.00. ISBN 0-683-051385. Order phone 800-638-0672.
Why would one want to read or own a book on clinical ethics? Why this book—a guide to problems in clinical ethics? Indeed, Lo asked himself, Why write this book? His answer was arresting: to witness and to help people who, in their struggle with overwhelming problems, often become heroes.
This answer goes to the heart of what clinical ethics is about. What is it about persons grappling well with dilemmas that is so enriching, even when answers are not clear? This heightened sense of meaning is rarely experienced by the ethicist alone; indeed, the ethicist is unlikely to have it if it is unshared. It seems to be almost the same as the sense that occurs in the physician, patient, and family after a well-managed case of, say, cholecystitis. Perhaps it results from any well-handled encounter with something fundamental about life.
After all, what is a hero? Aren't heroes persons who show us what is important in life? Heroes make people feel alive in a good way, even in the face of struggling with something fearsome. Clinical ethics tries to help discover well-being by struggling with that which threatens it. Independent of concrete outcome, if the struggle is well done, the hero and those with the hero have been alive in an existential, positive way. If the struggle is poorly done, people feel deadened, shrunken. Suffering can make its subjects worthless or worthy; ethics aims toward the latter.
If Lo wrote his book to help clinicians and patients in their quest for being whole and heroic, even as health and existence are threatened, does his book offer good guidance? I think so.
In his first two sections, Lo describes what the discipline of clinical ethics is and identifies guiding structures that inform current thinking in the field. Here, he negotiates a lively debate about methods of reasoning in clinical ethics, and he takes a pragmatic position that blends principlism, some virtue ethics, and the case-by-case casuistic approach. Acknowledging also the place of law and other component disciplines in ethics, he places it all in a framework that is compatible with clinical traditions of case analysis, theory, and structured approaches. Section Three is the most detailed and concerns decisions about life-saving interventions. This emphasis on end-of-life care is a reflection both of Lo's own expertise and of current medical ethics, which dwells more on these than other issues. Section Four deals with aspects of the patient–physician relationship; Section Five with conflicts of interest; and Section Six with emerging areas in medical ethics.
It is not hard to imagine the trepidation involved in embarking on a book such as this. Will it be too theoretical or artificial to help practitioners? Will it be too narrow, or out-of-date in no time at all? Will it be superficial, or so balanced that it is no more than politically correct, or, alternatively, so positioned that it is a series of argued opinions rather than a guide to perplexing clinical situations? In the first of a crude triad of tests to see how successfully Lo struggled with these fears, I recalled the last half dozen dilemmas that had come to my attention in clinical contexts. They were all in the book—in cases and in analytic frameworks, with references and annotated bibliographies. Testing again, I recalled the most recent series of problems that seemed newer, profound, and less well addressed in the field. They were in the book, too—appropriately described as emerging areas. There was, however, one major set of omissions: reproductive, neonatal, and pediatric ethics. In one last test, I asked how much there was in the book to disagree with. There were a number of things ... just the right number, it seemed. Fewer, and the book might have been either superficial or biased; more, and it might have been unhelpful to potential readers. It was a crude set of tests, but a good (maybe even heroic) test result. Searching for guidance from this book felt a lot like a meeting with an experienced consultant in his or her own library—in both cases, the source has nothing to prove, a lot of perspective to offer, and a large knowledge base.
Who should buy this book? Members of ethics committees, those in training, and anyone in clinical practice. The only exception may be obstetricians and pediatricians, who will find little of their subject matter in this first edition. Lo and his readers should look forward to a long series of next editions that will expand the book's scope and keep it apace, guiding practitioners in this relatively new but doubtless permanent discipline of ethics in healthcare.
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