Ethics, case by case | |
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Ethics teaching is often theoretical, emphasising broad ethical principles, such as autonomy, or normative theories, such as consequentialism. Case studies are used primarily to illustrate these principles and theories. As a case-based text, Ethical choices: case studies for medical practice eschews the theoretical approach to medical ethics, arguing that ethics is “not just about philosophical and other principles, ideals and rigorous arguments, but about the very real aspects of what people do and why”. Through commentaries on 28 cases, divided into four sections (The clinical encounter, Non-clinical dimensions, Medicine’s collective obligations and The business of medicine), Ethical choices illustrates the resolution of a wide variety of dilemmas. Commentators do not argue by analogy with other cases — a finding consistent with the (potentially contestable) assertion that “ethical concerns are raised only when suggested courses of conduct deviate from the norm”. Instead, the emphasis is on the power of “stories” in ethics education, and on the importance of “using individual cases in all their complexity”. This does not mean that the suggested resolutions are complex; indeed, the majority of the commentaries follow a common pattern in which existing regulations and evidence are considered in light of broad ethical principles and duties, and the remaining uncertainty is navigated through relational, discursive and administrative processes. The implicit message seems to be that while principles and duties are useful for clarifying ethical dilemmas, it is processes, such as empathic doctor–patient or doctor–colleague conversations and development of institutional policies, that ultimately provide a resolution to ethical problems. The cases are realistic and topical (such as medical error or direct-to-consumer advertising) and the commentaries are clear, concise and multidisciplinary. Contributors include ethicists, clinicians, lawyers, administrators and public health practitioners. Many of the suggested procedures are refreshingly practical (for instance, the steps involved in negotiating end-of-life care) and conceptually interesting (such as the taxonomy of types of alternative medicine). There is a definite air of optimism in some of the suggested resolutions, implying that compassionate, contextually-sensitive communication procedures are certain to result in acquiescence, if not consensus. But processes do not always result in agreement and it is necessary at times to choose one principle over another, or to accept the necessity of making “tragic choices”. A brief introductory discussion of the theoretical underpinnings and potential drawbacks of relational and process-based ethics would thus be helpful. While the regulation discussed is specific to the United States, and some cases would need to be adapted for use in Australian medical schools, most of the cases are relevant to Australian practice. Those that are not directly relevant, such as the myriad difficulties associated with managed care, provide a timely warning of issues that may emerge locally. In its current US-specific form, Ethical choices would be most useful as a sourcebook for teachers but, if adapted to the Australian setting, could be used as a text for students and junior medical officers. Wendy L Lipworth
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