Abstract
Bernard Lo, M.D., FACP. Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer business, 2009, 360 pages, $59.95.
Clinicians encounter ethical dilemmas in patient care nearly every day. Although some dilemmas may have commonly agreed upon solutions, others can be controversial and challenging to resolve. Resolving Ethical Dilemmas aims to provide clinicians with practical tools to approach a wide range of dilemmas and to find solutions when competing points of view appear to have equal merit. As the author wrote in his preface to the first edition, the goal of this book is to “help clinicians resolve the mundane ethical issues in patient care, as well as the dilemmas that keep them awake at night.”
Resolving Ethical Dilemmas is organized into six sections, each of which is divided into chapters that include a discussion of real-life sample cases and tables outlining the approach. The first section provides the foundation for the rest of the book by providing an overview of how to analyze a clinical dilemma and by explaining the fundamentals of clinical ethics and their importance to patient care. This section also offers an overview of formal theories in clinical ethics such as consequentialism and deontology as well as a discussion of their shortcomings. Relevant ethical guidelines and their practical applications are illustrated in detail in chapters on informed consent, the promotion of best interests, confidentiality, avoiding deception and nondisclosure, and keeping promises. This first section provides a thoughtful review of the literature and lays the foundation for a different, more flexible approach to clinical dilemmas.
The remainder of the book is divided into sections organized around ethical dilemmas or challenges. The second section on shared decision-making examines weighty topics such as futile interventions, decision-making capacity, surrogate decision-making, and persistent disagreements over care.
The third section on decisions about life-sustaining interventions comprises the most well-written and thought-provoking chapters of the book. In Chapter 15, the author demonstrates why several commonly held distinctions regarding life-sustaining interventions are confusing and not logically tenable. For instance, he addresses the controversy surrounding withdrawing versus withholding interventions by pointing out that the patient's preferences should decide the course of action rather than an artificial distinction between the “positive” or “negative” nature of an act. Included in this chapter is a helpful review of the doctrine of the double effect and some of its problems, such as the potential for allowing multiple intentions, and the apparent lack of accountability for foreseen (and not just intended) consequences. The author explores the important distinction between euthanasia and palliative sedation, as illustrated by a highly publicized case during the Hurricane Katrina disaster. There is a helpful section on emotional reactions to these challenging ethical distinctions, in which the reader is reminded that even actions that are ethically permissible can be emotionally distressing to clinicians. This section also includes chapters about life-sustaining interventions, artificial nutrition and hydration, and physician-assisted suicide. The chapter on do-not-attempt-resuscitation (DNAR) orders offers useful information on the effectiveness of cardiopulmonary resuscitation (CPR) and the justification for DNAR orders, but the section on discussing DNAR orders with patients is limited to only two pages of general suggestions, which may not be sufficient for experienced clinicians.
The next two sections examine ethical dilemmas involving the doctor–patient relationship and conflicts of interest. Topics include gifts from patients to physicians, inappropriate physician–patient relationships, bedside rationing of health care, incentives for physicians to increase services, and measures to control health care costs. Also included are chapters on disclosing errors and impaired colleagues. Finally, this section includes a discussion about ethical dilemmas that students and house staff face which is highly insightful and relevant to anyone involved in medical education.
The sixth and final section explores ethical issues pertaining to various clinical specialties such as pediatrics, surgery, obstetrics and gynecology, and psychiatry, as well as new issues in organ transplantation, genomics, public health, and cross-cultural care. While these chapters may be most relevant to clinicians in those specific fields, the principles outlined in the discussion could be useful for a broader audience. For instance, the chapter on pediatrics explains how the pediatrician's relationship with children and parents is unique, and points out that there are exceptions to parental decision-making, just as there are exceptions to patient confidentiality.
Overall Resolving Ethical Dilemmas is an approachable, well-written text. The rationale for its division into six major sections is not intuitive, but everything is outlined clearly and effectively, and the reader will have no difficulty locating a topic of interest. Each individual chapter is concise and well organized with good use of cases, tables, and summary points. The book covers a wide range of topics and provides thoughtful, clear, and well-reasoned discussions. Both novice and experienced palliative care clinicians will find that Resolving Ethical Dilemmas offers useful tools for approaching difficult ethical problems. While not promising resolutions to all cases, especially when ethical guidelines conflict, this book provides a practical framework for understanding differing perspectives in clinical ethics and determining a practical action plan that can directly impact patient care.