352 - Health and Human Values: A Guide to Making Your Own Decisions Human Values in Medicine and Health Care: Audio Visual Resources Biomedical-Ethical Issues: A Digest of Law and Policy Development & Who Should Decide? Paternalism in Health Care

Health and Human Values: A Guide to Making Your Own Decisions
Human Values in Medicine and Health Care: Audio Visual Resources
Biomedical-Ethical Issues: A Digest of Law and Policy Development
By Frank Harron, John Burnside, and Tom Beauchamp
New Haven, Yale University Press, 1983. 194 pp. $24.95, $6.95 paper; 86 pp. $3.95; 166 pp. $4.95,

Who Should Decide? Paternalism in Health Care
By James F. Childress
New York, Oxford, 1982. 250 pp. $24.95; $11.95 paper.

The deluge of writing on biomedical ethics has nearly reached spate proportions. When the rising tides of interest in professional ethics in general, cost containment in health care, genetic research, the treatment of defective new-borns, and artificial hearts join the continuing flow on such perennial topics as euthanasia, abortion, and informed consent, the swell mounts to flood stage. For the alert lay person as well as for the professional whose responsibilities demand staying current, keeping one's head above water gets harder by the day. Not only does the

353 - Health and Human Values: A Guide to Making Your Own Decisions Human Values in Medicine and Health Care: Audio Visual Resources Biomedical-Ethical Issues: A Digest of Law and Policy Development & Who Should Decide? Paternalism in Health Care

popularity and pertinence of the field keep the books, articles, and television programs pouring forth, but the speed of new developments in medical research and technology adds to the feelings of helplessness among those who are not constantly anchored to the bioethics data bank of their choice.

The growing dimensions of the dilemma on both the personal and the professional front make the appearance of life boats which enable both survival and the achievement of a better perspective on the flood more welcome than ever. Several recent publications endear themselves to us not just because of their high quality but because of the assistance they provide in sorting out the larger scene in biomedical ethics.

One kind of life boat is the collection of articles. Tom L. Beauchamp and LeRoy Walters have recently provided a new edition of their Contemporary Issues in Bioethics (1982). Biomedical Ethics, edited by Thomas Mappes and Jane Zembaty (1981), and Thomas Shannon's Bioethics (revised edition, 1981) are other examples of the many anthologies which guide us through the troubled waters by providing a few choice articles on each of a wide range of central issues, prefaced by introductions to the issues in focus. These boats are coveted mostly in the textbook market.

Another kind of life boat is afforded by the recently published, broad, introductory survey by Frank Harron, John Burnside, and Tom Beauchamp, Health and Human Values: A Guide to Making Your Own Decisions. It is not an anthology of articles, although each chapter concludes with short selections from relevant and contrasting pieces by leading lights in the field, and it is not a case book, although each chapter devotes considerable time to the examination of one or more cases. It also does not develop and defend a particular theoretical stance or set of practical stands on the issues since it resolutely avoids providing answers. It furnishes information, sorts out issues, asks the tough questions, lays out alternatives, and then leaves it to the reader to decide. It does not overwhelm us by dropping names and belaboring the bibliography in the text. Though up to the minute in their grasp of the literature, the writers leave a lot of the bibliographical helps for the end of the chapters and emphasize the distilling of the chief items of quandary and controversy in a concise and readable treatment.

Three companion volumes have been published also by the United Ministries in Education to enhance the usefulness of the primary guide or to provide additional resources that are useful independent of Health and Human Values. The Leader's Manual is simply an aid for persons leading study groups and academic classes using the book. The other two can stand alone. Human Values in Medicine and Health Care: AudioVisual Resources, compiled by Nadya Shmavonian, lists approximately 400 audio-visual resources with information about content, rental, and purchase. In addition to the alphabetical list, there are indexes listing items by topic and format (film, videocassette, audio-cassette, or slide/tape).

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The audio-visual guide may be snatched up quickest by the general reader, but another volume is equally valuable for those wishing a handy guide to court decisions, legislation, and policy statements by religious and professional groups. Entitled Biomedical Ethical Issues: A Digest of Law and Policy Development, it is a veritable gold mine or, if you prefer the original metaphor, a twin pontoon for the life boat to balance the audio-visual guide. Though under the general editorship of Frank Harron, the book is primarily the work of Nadya Shmavonian and George Annas. If you have ever wanted the full text of Roe v. Wade or the Hyde Amendments or the "Human Life" Amendment or summaries of other judicial decisions related to abortion or the positions of various religious bodies on the subject, and thought it was too much trouble to dig out the information, fret no more. Just get this book. What about federal guidelines on fetal research, state statutes on the Living Will, model statutes on determination of death or the donation of organs, judicial decisions pertaining to consent to therapy or experimentation, and guidelines of the National Institutes of Health and the Department of Health, Education, and Welfare on recombinant DNA research? These and a lot of other primary sources in public policy development are at your finger tips in this handbook.

Still another way to negotiate the mounting flood of literature, policy questions, and demands for personal decision is to discover a book which affords guidance by giving new meaning to traditional principles and images. Such a book takes a conflict or question or concept which has been with us for a long time and reexamines it in such a way as to illumine its meaning more clearly and to extend its applicability more broadly. To the surprise of no one who has followed his career, James Childress has made just such a contribution in his book, Who Should Decide? Paternalism in Health Care. As Georgetown University's Dr. Edmund Pellegrino contends, "The growing conflict between patient autonomy and physician authority is the central crisis in medical relationships today." By focusing on the who rather than the what of decisions in the biomedical field, Childress is able to cover much of the same waterfront that a survey of the issues covers because paternalism is germane to most dilemmas in medical ethics.

Informed consent, disclosure of information, suicide and refusal of lifesaving treatment, forms of preventive health care, and models of health care relationships are prominent topics in his treatment. As readers of Principles of Biomedical Ethics, which Childress wrote with Tom Beauchamp, would expect, the problems of paternalism are presented as potential conflicts of principle-those of beneficence and respect for persons, the approach is not a utilitarian but a deontological one in which respect for persons sets limits on what we should do for others even if we are confident that the consequences are beneficial to them. The reader is provided a rich collection of cases to illustrate the relevance and conflicts of principles.

As readers of Priorities in Biomedical Ethics by Childress would

356 - Health and Human Values: A Guide to Making Your Own Decisions Human Values in Medicine and Health Care: Audio Visual Resources Biomedical-Ethical Issues: A Digest of Law and Policy Development & Who Should Decide? Paternalism in Health Care

expect, his consideration of paternalism is not limited to the doctorpatient relationship; he also treats societal paternalism as expressed in governmental regulation and other forms of intervention into people's life-styles. What may be an unexpected bonus for those who are acquainted with Childress's past adherence to a legal (not legalistic) model with its emphasis on applying principles is his growing interest in the impact of metaphors, such as father or parent, autonomy, and war (to which medicine is often likened), and models on the roles people play in relationships touching biomedicine and the way they conceive the situations they have to assess.

Childress distinguishes more sorts of paternalism than most of us ever imagined: pure and impure, restricted and extended (which are the same as weak and strong), soft and hard, direct and indirect, active and passive. He also delineates six kinds of consent. With his characteristic precision and care, he scrutinizes the meanings of beneficence, which derives support from the religious love ethic and the Hippocratic patient-benefit tradition, and respect for persons, which he prefers to the closely-related autonomy. Autonomy is for Childress not so much an end state or goal, but a side constraint on the pursuit of goals for ourselves and others. He gives criteria for justifying a weak or limited paternalism, the limits being set by respect for persons.

As Childress puts it, "Such a principle will constrain and limit, but not subvert the principle of beneficence." Those conditions are strongly reminiscent of the criteria in traditional just war theory for waging a justifiable war. The adult in question must be incompetent to decide (thus in need of a defender). There must be a strong probability of harm unless the intervention occurs. The probable benefits of the intervention must outweigh the probable harm from nonintervention (proportionality). The means employed should not be deceptive or coercive but should be the least restrictive, least humiliating, and least insulting means available.

The most important contribution of Childress is not his provision of a periscope for bringing a range of crucial issues into focus as the waves threaten to inundate us, it is his provision of a compass to keep one's bearings in the churning waters. The other life boats put or keep us in a position to survey the immediate swell and the horizons of biomedical ethics. They do less to enable us to get or keep our bearings with reference to some traditional perspective. They make us aware of alternative approaches, but they do not equip us so fully with conceptual skills or steep us so fully in a way of sorting out the issues with a particular set of principles and metaphors. The anthologies and surveys keep us in view of the mainland in the biomedical field and perhaps even set us on it. The Childress book gives us a place to stand in making assessments. It is a life saver not so much because of the sweep of its scan as because of the depth of its probe into one particular set of issues, using one well-developed point of view. In examining Who Shall Decide? we become aware again of the importance of knowing what makes the

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decider tick as well as designating who the decider will be. Anyone who risks exposure to the careful moral reasoning of Childress will not arrive empty-headed at the sites of decision-making, and if we choose to differ we will be pressed to know the reason why.

Eric Mount, Jr.
Centre College
Danville, Kentucky