Woods, S.: 2007, Death’s Dominion. Ethics at the End of Life. Maidenhead: Open University Press/McGraw-Hill. 192 pages. ISBN 978-0335211616. Price: £ 19.99.

Death’s Dominion. Ethics at the End of Life has grown out of the author’s longstanding interest in death, end-of-life decisions and palliative care as a practising cancer nurse and philosopher. It is foremost a philosophical book, but based upon practical experiences. Referring to R. Dworkin’s Life’s Dominion (1993), the author emphasizes the certainty that we all will pass into death’s dominion. We therefore cannot escape from integrating death in our life as much as possible and whatsoever that might mean.

Chapter 1, ‘Ethics’, is an introduction into some ethical principles such as sanctity of life and personhood to which the author returns (and further develops) in the next chapters. Chapter 2, ‘Good life, good death’ is a conceptual approach—using “surrealistic” thought experiments—to the idea of a good death and a good life. It deals with all kinds of characteristics that might be considered as typical of a good death. However, the author rightly emphasizes that the context in which terms as a good death are used is of the utmost importance. He warns us against the danger that even an approach of a good death that some might consider “objective”, is going to be seen as a “moral prescription”.

Chapter 3, ‘Palliative care: history and values’, deals with the relationship between the modern hospice movement as it especially developed in the UK and modern palliative care. The transition from hospice to palliative care is marked by the recognition that the principles of hospice care did not require a special place, but could be applied wherever there was a need. The focus was on the principles rather than on the place; on a palliative care “philosophy”. Chapter 4, ‘Ethics in palliative care: autonomy and respect for persons’, returns the same to ethical theory as has been developed in chapter 1. It is in this chapter that the question is discussed—thereby referring to Randall and Downies’ study The Philosophy of Palliative Care (2006)—whether palliative care offers a discrete alternative “philosophy” to be distinguished from the core values of health care in general. In this context liberal and communitarian views of the good life are being dealt with. In chapter 5, ‘Respect for persons: a framework for palliative care’, Simon Woods continues his exploration of the practical and theoretical implications of some essential principles and values. The communitarian model of palliative care values is further examined. Chapter 6 is on ‘Terminal sedation’—or palliative sedation as is the author’s preferred terminology -, which he clearly distinguishes from euthanasia. Chapter 7, finally, is about ‘Assisted dying’, in particular about euthanasia and assisted suicide. Central in this chapter is a reflection on Daniel Callahan’s paper ‘When self-determination runs amok’. The author chose this paper because it “sweeps us along with the raw intuition that killing is wrong and that euthanasia as a form of killing is therefore to be condemned” (p. 145). This does not mean, however, that the author himself condemns assisted dying. In fact, he argues that the law ought to permit assisted dying restricted to the terminal phases of a serious condition and when the patient has passed through the so-called “palliative filter” and received attention of specialist palliative care.

I enjoyed reading this book very much. It is very readable and well argued using real life cases and thought experiments as well. It will probably attract medical philosophers and medical ethicists as readers rather than workers in the field of palliative care. The reader needs a certain level of philosophical interest and understanding. The book provides the reader with a short history of and an overview of the most important issues in modern palliative care. Various theoretical discussions are clearly set out, such as: the relationship between the hospice movement and modern palliative care, between palliative care and health care in general, between palliative sedation and euthanasia, and the question whether euthanasia can be part of palliative care. The author starts with exploring the existing debates and then develops his own arguments in a balanced and well-structured way. Simon Woods asks further questions where other authors stopped, for example, regarding the question whether one should not administer palliative sedation when the patient has refused continued ventilation (p. 124) or about the appropriateness of the term “assisted dying”. Finally, for me, the author was convincing in arguing “that, in contrast to liberal and consumer autonomy, palliative care philosophy is consistent with a communitarian approach” (p. 162).

Wim Dekkers

Nijmegen, The Netherlands

Benatar, D.: 2006, Better Never to Have Been: The Harm of Coming into Existence. New York: Oxford University Press. 238 pages. ISBN 978-0199296422. Price: $ 45.00.

This is in many respects a strange and disconcerting book. Its central ideas are, first, that coming into existence is always a serious harm; second, that in order to prevent harm to others we should cease having children. The author’s conclusion is that in the long run, we should seek the total extinction of humankind. The best way for achieving this goal is, according to Benatar, not directly to kill people (this option “might be thought to be bad, because it cuts lives short”), but “desisting from creating future people” (p. 197). This dark view of the human condition permeates the book from the very beginning: “Each one of us was harmed by being brought into existence. That harm is not negligible, because the quality of even the best lives is very bad –and considerably worse than most people recognize it to be. Although it is obviously too late to prevent our own existence, it is not too late to prevent the existence of future possible people” (Preface). We are here far beyond the controversy about the acceptability of “wrongful life” actions, which are based on the claim that a severely disabled child has been harmed by the mere fact of being born. Benatar argues that no matter what the health condition of the person is, the mere fact of coming into existence is always a serious harm to him or her. Therefore, we have a moral duty not to procreate, either by natural or artificial means (chapter 4) and women need an “excellent reason” not to abort their children (chapter 5).

The theoretical basis for such nihilistic views are, on the one hand, Schopenhauer’s deeply pessimistic vision of life, and on the other hand, questionable utilitarian evaluations of pleasures and pains that accompany our existence (although such evaluations are in the end not very helpful, because Benatar thinks that even the smallest quantity of pain renders our life meaningless).

In a few words, the author’s central thesis is built upon an ‘all or nothing’ fallacy, which leads him to conclude that since we cannot (and will never) completely eliminate suffering from human existence, it would be better not to exist at all. The counterintuitive nature of this idea is clear if one considers that the vast majority of people seem to think their lives have an inherent positive value, which significantly outweighs any suffering to which they are inevitably exposed. This is proven by the simple fact that most people are not attempting to kill themselves, although suicide is within reach of almost everyone.

Despite these criticisms, it should be said that the volume has the great merit of raising a very basic issue (the intrinsic value of human existence), which is usually assumed but rarely discussed in philosophical terms. Thus, it may be hoped that this book will encourage a thoughtful and rich exchange of ideas on such a fundamental question.

Roberto Andorno

Zurich, Switzerland

Tauber, A.: 2005, Patient Autonomy and Ethics of Responsibility. Cambridge, MA: MIT Press. 342 pages. ISBN 978-0262701129. Price: $ 25.00.

In his latest book Alfred Tauber, who is professor of medicine and professor of philosophy in Boston, contributes to the ongoing exploration of the nature of ethics in medical practice. In his theoretically ambitious study he reflects on historical, political, sociological, legal, feminist, philosophical and moral themes, while his overall purpose of the book remains a practical one: to reform US-American practice of medical education. The primary focus of such reform (and thus of his ethical analysis) is the self-understanding of physicians and, ultimately, of medicine as reflected in the patient-physician relationship. It is common practice that physicians limit their relationship to patients in providing them with relevant information about medical options available. Such behaviour reflects, on the one hand, a conception of medicine as an objective, value-free science that merely deals with the diagnosis of medical facts. On the other hand, such behaviour aligns with the governing principle of respecting patient’s autonomy—conceptualized as a kind of disengagement on the physician’s part. Tauber’s critic of such practice and self-understanding of medicine is twofold. Firstly, he is avowedly committed to humanistic medicine, that is a conception of medicine as a caring profession to help people who are ill. In developing such a conception of medicine he can attack the narrowly interpreted principle of autonomy that requires of physicians only to facilitate informed consent on the part of patients. Referring to an “ethics of responsibility” he demands of physicians to help patients identify and comprehend their own values and selected options, as well as to cope with anxieties and fears, live with suffering and pain and so forth. A humane medicine is patient-centred, and only by empathy on the part of physicians autonomy can truly flourish in the patient-physician-relationship. Instead of educating students to become narrow medical technicians they should learn to be humane practitioners.

In times of ongoing economization in framing our thinking about health care issues Tauber’s study is, without doubt, a substantial contribution to widening our perspectives on what medicine and health care treatment should ultimately be about. However, his argument that he develops throughout his book is missing a unifying threat and makes it sometimes hard for the reader to follow its track. This limitation of the study might be due to the fact that the book includes a selection of several publications, as Tauber acknowledges himself. Nevertheless, the book is worthwhile reading for everyone who is interested in thinking about patient’s autonomy and physician’s responsibility from a different angle, namely within a relational approach.

Susanne Brauer

Zurich, Switzerland

Turoldo, F. (ed.): 2007, La globalizzazione della bioetica. Un commento alla Dichiarazione Universale sulla Bioetica e i Diritti Umani dell’UNESCO. Padova: Fondazione Lanza / Gregoriana Libreria Editrice. 300 pages. ISBN: 88-7706-213-4. Price: € 22.

This volume presents and discusses the Universal Declaration on Bioethics and Human Rights adopted by UNESCO on October 19th, 2005. The importance of this document is mainly due to the circumstance of being the first global declaration adopted by a UN agency, such as UNESCO, that comprehensively addresses bioethical issues. Something analogous had been done by the Council of Europe in 1997, i.e. the European Convention on Human Rights in Biomedicine (the so-called Oviedo Declaration), but it had only continental relevance. The fact that it was UNESCO and not the WHO which adopted this declaration is important, since, in the view of the editor of this volume, the declaration tends to move beyond a strictly biomedical characterisation of bioethics, focusing instead on bioethics from a more general perspective.

This leads to two main reasons that are given for the reference to globalisation in the title of the book: on the one hand, it refers to the worldwide scope of the Declaration; on the other hand, it refers to the extension of bioethical concerns beyond the area of biomedicine. The first point is largely reflected in the third part of the volume, which widens our usual understanding of bioethical issues by confronting us with questions emerging in developing countries. Three papers are devoted to issues of justice and the allocation of resources in these countries, with particular reference to Asia and Africa. The clearly universalistic approach of many provisions of the Declaration justifies the first meaning of globalisation. The second point is however much more problematic. It is true that article 17 of the Declaration stresses “the role of human beings in the protection of the environment, the biosphere and biodiversity”, but there is hardly any other mention of non-human values or interests throughout the document. As a matter of fact, non human animals and their well-being are never mentioned and there can be no denying that, as polemically underlined by one contributor, the Declaration retains a thoroughly anthropocentric viewpoint. Therefore, it seems doubtful that the Declaration can contribute much to a globalised bioethics in the sense of reconciling bioethics in the Georgetown fashion (i.e. biomedical ethics) with bioethics in the original Potter’s fashion (i.e. biomedical ethics plus environmental ethics).

The first part of the volume offers a comprehensive analysis of the path that led to the adoption of the Declaration, and some indications on the main formal characteristics of the document. As many other international documents, it makes use of several complex and value-laden words (such as human dignity, justice, benefit, solidarity) without offering a definition of them: this strategy, it is commented, aims to leave room for interpretation at different local levels, thus linking ethical universalism with the respect for cultural diversity. Moreover, the Declaration is more of a political than an academic document, in that it largely reflects the preoccupations of governments having the last word on the drafts proposed by the independent experts. Finally, it has no mandatory power, nor binds the states to adopt legislation consistent with its provisions; it is a means of “soft law”, having the force of morally authoritative recommendations.

The main values affirmed by the Declaration are three: respect for human dignity, freedom and rights (art. 3 and 10), respect for autonomy (art. 5) and respect for vulnerability and personal integrity (art. 8). As noted in the editor’s introduction, the non-hierarchical relationship between these principles is mentioned; the Declaration just states that “the principles are to be understood as complementary and interrelated” (art. 26). This moral pluralism clearly allows for different orderings of the principles; the second section of the volume is in fact composed by three papers proposing three different orderings of the principles. It is clear that different substantive conclusions are derivable, if one assumes human dignity, autonomy, or respect for vulnerability as basic, with reference to matters such as voluntary active euthanasia or certain forms of medically assisted procreation. This may of course be problematic, since it leaves open perhaps too many options at a practical level. But it is of course all that can be expected from such international documents, and should not lead to underestimate the result that has been accomplished in reaching unanimity at least on the definition of a framework of values for this highly controversial field of inquiry.

Massimo Reichlin

Milan, Italy

Green, S.A., Bloch, S. (eds.): 2006, An Anthology of Psychiatric Ethics. Oxford: Oxford University Press. 498 pages. ISBN 978-0198564881. Price: $ 69.

The field of psychiatric ethics is very important in daily clinical practice as well as in public mental health. At the same time, issues in psychiatric ethics are characterized by its complexity, often related to conflicting principles such as autonomy and non-maleficence. Over the last two decades the complex issue of psychiatric ethics has more and more become an academic discourse in its own right. In 1981 the first textbook of psychiatric ethics was published. Today, this well-known textbook, edited by Sidney Bloch, Paul Chodoff and Stephen A. Greene is in its third edition and contains high quality chapters that delineate various issues of psychiatric ethics. This basic textbook, however, is limited in presenting the complexity and the range of different views in this field. The Anthology of Psychiatric Ethics, edited by the same authors, S. Greene and S. Bloch, closes this gap by a comprehensive collection of more than 75 readings in the field.

This anthology is helpful and useful for both those that have to teach in the field of mental health and those who are interested in a deeper understanding of the different issues in psychiatric ethics. The text is divided into nine core sections that include classical issues such as the therapeutic relationship or confidentiality but also comes to resource allocation as a newer and controversially discussed issue in psychiatric ethics. The first sections give a basic introduction to the standard bioethics theories and also present some classical readings such as Thomas Szaz’s “The Myth of Mental Illness”. For each section the basic premises which generally guide the following essays are introduced. A bibliography at the end of each introduction provides further reading that allows studying the topic in more detail.

Finally, even in this comprehensive anthology containing almost 500 pages in very small (!) print, the reader might miss some important issues of current psychiatric ethics. For instance, the section on research does not include a reading about multinational research, especially psychiatric research in developing countries. Secondly, the increasing patient population within psychogeriatrics is only reflected in one or two essays. Lastly, the reader might miss some readings on patient subgroups that address specific ethical issues, such as homeless patients or psychotic patients with drug addiction. Nonetheless, even with these shortcomings, I would recommend this anthology as an excellent reference and introductory work to the topic of psychiatric and mental health ethics.

Daniel Strech

Tübingen, Germany

Briody Mahowald, M.: 2007, Bioethics and Women: Across the Life Span. New York: Oxford University Press. ISBN: 9780195176179. Price: £ 23.99.

Bioethics and Women ambitiously aims to provide a comprehensive overview for clinicians of the ethical issues associated with women’s health. The book consists of an introduction to Mahowald’s philosophical approach (egalitarian, stand point theory), followed by ten chapters dealing with specific health topics, from medically assisted reproduction, to violence against women, to research issues. Each topic chapter is broken down into three to five sub-themes; each sub-theme is illustrated with a number of case studies and followed by empirical and theoretical analysis. One great value of the book lies in the numerous case studies; they are concise, evocative, believable, and varied and would provide an excellent teaching resource for educators.

Mahowald succeeds in presenting a diverse series of bioethical issues relating to women’s health. Her analysis is often sophisticated and original. However, for an introductory text for clinicians, matters are frequently made unnecessarily complicated. The philosophical introduction is thorough, but dense and lacking in signposting to help the reader navigate the issues. Mahowald defines a series of maxims in the introduction but these are then referred to simply by number in later chapters: e.g. “…[the patient’s wishes] may be overridden on the grounds of maxim 3” (p.197). She neither reminds the reader of the content of the maxim nor provides a cross reference. Consequently, the reader can only follow the ethical analysis of specific topics if they have read, and remembered, the seventy page introduction.

Yet, as a bioethicist, I found Bioethics and Women frustrating in places because of its cursory dealings with complicated and rich material. Mahowald draws intriguing conclusions, but can fail to adequately explain or justify her position. For example: on the topic of artificial insemination for single women: “Successful parenting is rarely if ever accomplished by lone individuals.” (76); on sex selection “…selection of females… is less problematic than selection of males…because the latter practice is more likely to reaffirm or reinforce the male dominance that already prevails” (p. 90); on research ethics, Mahowald concludes that a female cancer patient’s consent to use her frozen eggs for ‘research’ if she dies, can also be presumed to authorize fertilization of the eggs and implantation in another woman (p. 219).

All of these statements deserve greater development than they get. Writing a philosophically rigorous, comprehensive, introductory text for a clinical audience is undoubtedly a complex task – requiring the author to walk a fine line between simplicity and precision. Unfortunately Bioethics and Women does not consistently maintain this balance.

Angela Ballantyne

New Haven, Connecticut, USA

Pegoraro, R., Putoto, G. and Wray, E. (eds.): 2007, Hospital Based Bioethics. A European Perspective. Padova: Piccin. 178 pages. ISBN 978-88-299-1841-6. Price: € 22.

Social and scientific developments have led to profound changes in health care. This has stimulated a flourishing of academic and theoretical interest in ‘bioethics’, but the literature on the ethical issues that arise in the everyday life of health care institutions is relatively scanty. The present volume, which is the result of a project funded by the European Commission in the context of the Fifth Framework Programme, intends to provide a genuine European approach to the development of a hospital-based bioethics. It is a well conceived teaching book, with 9 chapters, covering the most important ethical aspects related to the work in hospitals.

Two introductory chapters by Eugenijus Gefenas and Marc Guerrier provide an overview on the relation between bioethics and professional codes and principles in hospital bioethics. The latter includes an interesting European alternative to principlism based on autonomy, dignity, integrity, and vulnerability. The next two chapters cover important problems in the daily life in hospitals, the allocation of resources by Giovanni Putoto, Renzo Pegoraro and Andrea Semplicini and the relationship between health professionals and patients by Franz Josef Illhardt. Chapters about the ethics of the beginning ( Søren Holm) and the end of life (Tomas Brzostek, Zbigniew Zalewski), the clinical ethics of psychiatry ( Søren Holm), hospital committees (Norbert Steinkamp), and research ethics (Josef Glasa) transfer the relevant and well-known subjects from the contemporary bioethical debates to the situation in hospitals.

Each chapter is suitably and well structured corresponding to the purpose of a teaching book, providing a short but complete overview. This includes learning objectives, key concepts, case studies, discussion questions, references for further reading, and main texts providing the main aspects of contemporary debates according to the state of the art. All main texts are well written by renowned experts from a representative range of European countries and their quality partially reaches beyond the intention of being a mere introduction to the subject. All in all, “hospital based bioethics” is a valuable and useful teaching book for ethical training courses addressed to clinicians and health care workers, but anyone who is interested in bioethics and clinical ethics will also benefit from reading it.

Hans-Jörg Ehni

Tübingen, Germany

Rehmann-Sutter, C., Bondolfi, A., Fischer, J., Leuthold, M. (eds.): 2006, Beihilfe zum Suizid in der Schweiz. Beiträge aus Ethik, Recht und Medizin. Bern: Peter Lang. 380 pages. ISBN: 978-3039108381. Price: SFr 87.00.

This volume is probably the most comprehensive and authoritative publication on assisted suicide in Switzerland ever published. It provides an interdisciplinary approach to the ethical, legal and social implications of this practice, which is allowed under Swiss law as long as it is not motivated by “selfish reasons”. The book is comprised of 29 individual contributions (21 in German and 8 in French) by well-known scholars. It is clearly structured and provides an excellent overview of the Swiss debate on this issue. It also includes an appendix with guidelines relating to assisted suicide issued by different bodies such as the Swiss Academy for Medical Sciences and the Swiss National Advisory Commission on Biomedical Ethics.

Assisted suicide occurs when one person provides another person with the means to take her or his life. This is the first thing the editors highlight in their foreword. Thus, assisted suicide has always two players: a person who desires death and another person (or organisation) who puts the means to depart this life into a suicidal person’s hand. This is therefore not a killing in the legal sense, as the suicidal person carries out the action him or herself and on his or her own responsibility.

This situation is anything but simple: can we grant people permission to die at all? What consequences does this have for the role of medicine? Can assisted suicide ever be a form of care? May we ever decide on the time and place of our own death? This anthology allows space for these questions from legal, medical, ethical and theological perspectives. The reader is given a complex picture of varied approaches, while always staying in firmly grounded in practice.

Reading this book, I was reminded of a quotation from the French philosopher Albert Camus. In 1942, as an introductory sentence in his book Le Mythe de Sisyphe, he wrote: “There is only one really serious philosophical problem: suicide. The decision on whether or not life is worth living is an answer to the fundamental question of philosophy. Everything else (…) comes later. These are games; first we must give an answer.” This is exactly what this volume is about: giving answers! Suicide is not a theoretical possibility: organisations really do offer these services. Many foreigners come to Switzerland to die. “Death tourism” is becoming established. Fundamental questions of philosophy are being given new shape in this Swiss context.

Rouven Porz

Basel, Switzerland