Book reviewed in this article: Life and Death: Philosophical Essays in Biomedical Ethics. By Dan W. Brock.

This book approaches ethical and legal issues in medicine from the patient's viewpoint and argues that many patients do not want the full burden of decision making that contemporary bioethics has thrust upon them.

In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life determinations, (...) the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient 's values. In order to act in the patient 's best interests, or the patient 's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient 's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient 's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician- patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)

How ought we to understand the sources and limits of the authority of family members to make health care decisions for their decisionally incapacitated relatives? This question is becoming increasingly crucial as the population ages and the power of medical technology waxes. It is also becoming increasingly contested, as faith in advance directives shows signs of waning, and the moral complexities of intimate relationship become more theoretically patent.This last point—the newly visible moral richness of intimate relationship—provides this paper with its (...) field. I am interested in probing the images of the relationship between self and other, particularly self and intimate other, that seem presupposed by some leading attempts to determine the basis for proxy decision-making authority, and what constraints it must observe. In the light of both recent work in the philosophy of mind and considerations closer to common experience, the reigning images seem too slight to support the weight of current practices and beliefs about proxy authority; supplanting them with images more faithful to our experience will have implications for our practice with proxies. (shrink)

How ought we to understand the sources and limits of the authority of family members to make health care decisions for their decisionally incapacitated relatives? This question is becoming increasingly crucial as the population ages and the power of medical technology waxes. It is also becoming increasingly contested, as faith in advance directives shows signs of waning, and the moral complexities of intimate relationship become more theoretically patent.This last point—the newly visible moral richness of intimate relationship—provides this paper with its (...) field. I am interested in probing the images of the relationship between self and other, particularly self and intimate other, that seem presupposed by some leading attempts to determine the basis for proxy decision-making authority, and what constraints it must observe. In the light of both recent work in the philosophy of mind and considerations closer to common experience, the reigning images seem too slight to support the weight of current practices and beliefs about proxy authority; supplanting them with images more faithful to our experience will have implications for our practice with proxies. (shrink)

The legal consensus that has evolved through adjudication and legislation since the Karen Quinlan case in 1976 is founded on the premise that there is a bright line between passive euthanasia and active euthanasia. Indeed, the term passive euthanasia is often eschewed in favor of less emotionally-laden terminology such as "forgoing life-sustaining treatment" or "terminating life support" so as to further sever any possible connection with active euthanasia. Legal approval has been bestowed upon passive euthanasia under certain circumstances while active (...) euthanasia is routinely condemned. This consensus was put to a test in 1990 when the United States Supreme Court ruled on the Cruzan case. However, the Court's narrow decision did not upset the consensus, and in the most significant appellate decisions handed down by state courts since Cruzan, there has been a reaffirmation-and possibly even an extension-of the consensus. Two other threats to the legal consensus about forgoing life-sustaining treatment have begun to manifest themselves: the increasing pressure for mercy killing and "futility" cases. Both of these challenge the fundamental premises on which the consensus is grounded. (shrink)

Book reviewed in this article: For the Patient's Good: The Restoration of Beneficence in Health Care. By Edmund D. Pellegrino and David C. Thomasma.

How should modern medicine's dramatic new powers to sustain life be employed? How should limited resources be used to extend and improve the quality of life? In this collection, Dan Brock, a distinguished philosopher and bioethicist and co-author of Deciding for Others (Cambridge, 1989), explores the moral issues raised by new ideals of shared decision making between physicians and patients. The book develops an ethical framework for decisions about life-sustaining treatment and euthanasia, and examines how these life and death decisions (...) are transformed in health policy when the focus shifts from what is best for a patient to what is just for all patients. Professor Brock combines acute philosophical analysis with a deep understanding of the realities of clinical health policy. This is a volume for philosophers concerned with medical ethics, health policy professionals, physicians interested in bioethics, and undergraduate courses in biomedical ethics. (shrink)

The first edition of this book was published in 1977. At that time the field of thanatology, the study of death and dying, was still reasonably new and was dominated by research done by psychiatrists and social scientists. The most notable person in the field at the time was Elisabeth Kubler-Ross, who was widely credited with having brought thanatology into public view with the 1969 publication of her book On Death and Dying. Two research centers on death and dying were (...) gaining national reputations: The Foundation of Thanatology in New York (Austin Kutscher, director), and the Center for Death Education and Research (Robert Fulton, director) at the University of Minnesota. (shrink)

How shall human suffering be conceptualized? In this succinct, deeply beautiful book, David Bakan has drawn upon recent biological and psychiatric research, as well as biblical sources, in an effort to understand the very condition of human mortality. Bakan has neither aspired to the abstraction of theological statements nor descended to a purely reductionist position. He states, "I do not know what divinity is there outside the compass of man's humanity". He is convinced, however, that human suffering is a paradox: (...) for consciousness is a precondition for suffering as well as its management; and bodily disorder, despite the traditional claims for immortality, is biologically inherent in human growth. (shrink)

Fifteen original essays open up a novel area of inquiry: the distinctively ethical dimensions of women's experiences of and in aging. Contributors distinguished in the fields of feminist ethics and the ethics of aging explore assumptions, experiences, practices, and public policies that affect women's well-being and dignity in later life. The book brings to the study of women's aging a reflective dimension missing from the empirical work that has predominated to date. Ethical studies of aging have so far failed to (...) emphasize gender. And feminist ethics has neglected older women, even when emphasizing other dimensions of 'difference.' Finally work on aging in all fields has focused on the elderly, while this volume sees aging as an extended process of negotiating personal and social change. (shrink)

Sigmund Freud, the founder of psychoanalysis, declared that religion is a universal obsessional neurosis in his famous work of 1927, The Future of an Illusion. This work provoked immediate controversy and has continued to be an important reference for anyone interested in the intersection of philosophy, psychology, religion, and culture. Included in this volume is Oskar Pfister's critical engagement with Freud's views on religion. Pfister, a Swiss pastor and lay analyst, defends mature religion from Freud's "scientism." Freud's and Pfister's texts (...) have been updated in Gregory C. Richter's translations from the original German. (shrink)

C. S. Lewis sets out to disentangle this knotty issue but wisely adds that in the end no intellectual solution can dispense with the necessity for patience and ...

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance (...) directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike. (shrink)