Over the past 30 years, a bioethics movement has developed in the United States, resulting in the presence of ethics committees at most hospitals. These committees take ethical decision making out of the private world of the physician and, to varying degrees, the patient, and make it a more public group process that represents diverse patient and societal values. Thus far, the validity of using group decision making to resolve ethical dilemmas has rarely been questioned. However, although the value of working as a group is self-evident for consciousness-raising and political movements, it is not obvious why such a process would improve deliberation about medical ethics, in which such issues as quality of life for patients with complex medical problems is at stake. Deciding Together is a long-needed inquiry into the value of group consensus in addressing the medical ethical dilemmas of our time.

Moreno's goal is to address the problem, stated by Arthur Caplan, that "without consensus about the foundations of the field [of bioethics] there may be a hole at the center of the enterprise." First, Moreno points out that a primary norm of the recent bioethics movement in the United States, the ideal of autonomy, is integral to the notion of group consensus. The concepts of autonomy and consensus are political constructs, rooted in liberal political philosophy, particularly the ideal of "liberal neutrality." This is the ideal that "in a liberal society, the state should endorse no particular vision of the good life, but should instead provide a space within which men and women are free to strive for their own vision (autonomy) and to associate with others who share to some extent their vision of the good life (consensus)." Yet, it is precisely the ideal of liberal neutrality that keeps a gap open at the center of bioethics.

Moreno bridges this gap by turning to John Rawl's idea of an "overlapping consensus," which builds from the idea of citizens "cooperating as free and equal persons" and the idea of a society ordered according to a conception of justice. Moreno claims that the ideals of treating persons fairly and having just institutions provide a sufficient basis for endorsing those medical ethical principles about which there is already widespread agreement: the ideals of autonomy, beneficence, nonmaleficence, and justice (Beauchamp and Childress; eds. Principles of Biomedical Ethics. Oxford Univ Pr; 1994). The challenge, he notes, is to derive guidance from the bare concept of consensus about cases that involve highly conflictual issues, such as a woman's right to an abortion. Moreno argues that in such cases, the quality of ethical reasoning is best assessed not by asking whether moral truth is achieved but by evaluating the process of deliberation itself as follows.

Ideally, consensus panels begin with shared uncertainty about what is morally best rather than with fixed ideas about what is right. Through open discussion, panel members come to change their very perception of the case at hand. Moreno makes a crucial distinction between consensus that operates at this deep level of shifting perception and the kind of compromise that often takes place in committees. Consensus, he says, strives for "true social transformation"; compromise involves making tradeoffs to get on with things. Moreno is influenced here by such philosophers as Habermas, who sees unconstrained conversation (in which persuasion is based on the power of ideas rather than of authority) as the ideal way to deliberate rationally.

Moreno goes beyond theory, turning to social science methods to make the discussions of ethics committees more rational and receptive to the power of good ideas. For example, he describes the usefulness of diagramming underlying group dynamics in "sociograms" (like family genograms) and the use of "alternative dispute resolution," a management technique, to mediate disagreements among panel members.

Moreno's book makes an important contribution to the field of bioethics. His discussion of the political philosophy underlying the notion of consensus suggests some of the inherent strengths and weaknesses of using consensus to resolve ethical dilemmas. After reading this book, chairs of ethics committee will be forced to examine more critically the representativeness of their committee membership and the openness and depth of committee discussions. At the same time, as Moreno recognizes, after the process of committee deliberation is improved, many ethical dilemmas will remain about which it will be difficult to achieve genuine consensus. For patients and providers who face troubling decisions, it will not be satisfactory to know that the ethics committee deliberated openly and deeply and could not reach a shared understanding of what was morally salient. For this reason, Moreno's work does not substitute for work that develops a unifying ethical theory or systematic method of case analysis for bioethics. Rather, Moreno contributes an emphasis on process that may enable members of ethics committees to rethink some of the substantive assumptions of the field. This group reflectiveness need not do away with the goal of providing a foundational theory to fill the hole at the center of bioethics but rather could generate, from the bottom up, new ideas for doing this theoretical work.