Developing the knowledge and the abilities needed to apply ethical principles effectively in clinical decision making is a challenge that is underemphasized, both in medical education and in the hectic pace of clinical practice. These issues are even more difficult to address in settings in which the severity of illness increases the need for rapid decision making.

The emergency department is a place where special problems in practical medical ethics are confronted daily. The second edition of Ethics in Emergency Medicine is a useful attempt to provide practical guidance to health care professionals in the emergency care setting. The potential for ethical dilemmas in emergency medicine is exacerbated by the time frame in which decisions must be made, by the frequent lack of complete information, and by the increased incidence of impaired cognitive abilities.

In the brief introductory sections of this book, five chapters, each by a different contributor, reflect a refreshing diversity. They range from "Unique Aspects of Ethics in Emergency Medicine" and "Legal Setting of Emergency Medicine" to "An Approach to Ethical Problems in Emergency Medicine." In any attempt to deal with issues as complex as medical ethics, over-simplification is a danger.

More serious issues are raised in the section by Iverson, which outlines an approach to ethical decision making in emergency medicine. This includes several useful decision algorithms. However, Iverson attempts to give the reader three "tests" of decision processes, to be used when the patient is unable to participate and no appropriate strategy is available to delay the decision. These "tests" raise as many questions as they resolve. One example is the application of the golden rule, "Do unto others as you would have them do unto you." This may be sage advice in some interpersonal situations, but it is fraught with problems when used for health care decisions. The patient deserves our best efforts at applying a different rule. The basic "test" should be, "Do unto our patients as they would have us do unto them, if only they could speak to us." It is the patient's values and personality that should drive the decision process.

The most useful of the introductory chapters is that on the legal aspects of ethics in emergency medicine. This chapter is tightly crafted and easy to read, and it helps to establish a context for the issues discussed in practical terms.

The case study sections make up almost 90% of the book and are authored by an impressive array of persons from diverse professional backgrounds, ranging from wilderness medicine to philosophy. This diversity is certainly a strength, but it also accounts for inconsistency in the usefulness of the chapters.

In general, this work is a useful adjunct to a broader library in medical ethics for all health care professionals in emergency medicine. Future editions might expand the introductory information so that it could serve more effectively as a primary reference source.