Book Review: Singer & Viens (eds.), “The Cambridge Textbook of Bioethics”

Cambridge: Cambridge UP, 2009; 538+xv pp

£40, pb

A couple of months ago, Cambridge UP tried to post a cheeky advert for this book in the comments to one of the posts on this site.  I sabotaged the link, but offered to restore it in return for a freebie, which CUP asked me to review.  I’ve restored the link to the book’s webpage; but is it worth following?

Overwhelmingly, I honestly don’t know.  The first thing to notice about the Cambridge Textbook of Bioethics is that it’s published under the “Cambridge Medicine” badge, and its editors say in their introduction that the primary target audience is health professionals, but they also indicate that they think that the book would be useful as a textbook for a course in bioethics (pp 1-2).  It’s certainly true that philosophers and lawyers – and those who’ve been studying bioethics for a reasonable time – won’t find much here that they can’t find done in more depth elsewhere.  As for students: well, for advanced students, the same is likely to apply, so if the CToB is to be used as a coursebook, the course would have to be very basic indeed – and, even then, I’m not sure, for reasons to which I’ll return later.

The book is arranged into 65 chapters, each of which is, in turn, divided according to a pretty consistent template: there’s a case study or two; a brief survey of the issues in the case study; a section on ethics; a section on law; a section on policy; a section on emprical studies; a section on how one should approach dilemmas in this area; and a return to the cases.  I can see how this approach would be prima facie attractive to people who’re new to bioethics, or who’re most concerned with real-life patients.  However, I don’t think that they’d necessarily be served by it as well as they might be.

For one thing, to frame an issue with case studies does seem a bit underhand: there’s always a slight suspicion that they’re artificially constructed to be as simple as possible, but also to to lead to a particular conclusion.  This makes a nuanced analysis of the problems difficult – and also presents an unrealistically neat version of real-world decisionmaking.  More disingenuously, the conclusions have a tendency in many cases to be quite didactic: they tell the reader that the physician in this case ought to do this or that, rather than explaining why the problem is a problem to begin with.  That is to say: they give the impression that there’s clearly one right thing to do in a given situation; but this is rarely, if ever, the case: a moral dilemma arises just because there’s a number of equally good or bad options.  If the answer was easy, there’d be nothing to discuss.  A chapter that concludes with clearcut instructions, I worry, has either concocted an artifically weak case-study for itself, or hasn’t done what a textbook contribution ought.   Leave directive conclusions for journal articles and monographs: that’s where they belong.

Notwithstanding this, the conclusions presented are often so empty as to mean that only the most uninquiring reader would find them useful – and one might wonder why so unenquiring a mind would be reading an ethics book to begin with.  There’s a lot about a physician’s duty to respect decisions, to be sensitive to them, and so on – but it’s unclear what this means.  It’s taken as read that the patients do, and ought, always to have the last word; this is fashionable enough as claims go, but it ignores the fact that there’s often a defensible reason to ignore a patient’s wishes.  There’s a huge emphasis on informed consent in many of the chapters – and this just makes me wonder why it’s important to have chapters on diverse discrete areas of practice when replacing them with just one decent chapter on informed consent in abstracto would do the job much more efficiently.  In respect of embryo and foetal research, Ronald Green suggests that

each individual must determine where he or she will draw the line between benefitting from wrongful deeds and complicity in them. (p 236)

This may be true, but, were I worried about the permissibility of my involvement with a particular hESC research project, such advice would leave me no wiser at all; it’s not enought to echo Sartre’s refusal to advise his student in Existentialim and Humanism.  If I ask for help in drawing a line, I don’t want to be told that it’s up to me to draw it.  Wide and general answers are only infrequently useful.

At other times, the conclusions are baffling in their focus.  For example, in respect of the chapter on euthanasia and assisted suicide, Bernard Dickens et al do no more than to point out that both are illegal in most places, but that

[p]hysicians who believe that euthanasia and assisted suicide should be legally accepted may pursue these convictions through various legal and democratic means at their disposal. (p75)

In the absence of anything more, the implication has to be that a physician’s duty is primarily to obey the law, and that assisted dying is therefore impermissible.  But that’s just mistaken; the permissibility of x has nothing to do with its legality.  Faced with a patient in pain who wants to die, it’s simply not enough to tell doctors that they can write to their MP if they think that the law should be different.  At the very least, a textbook article should be giving and examining the arguments for and against a change, and encouraging readers to interrogate their own presuppositions.  Nor is it clear what appeals to democracy have to do here; democracies are capable of passing morally indefensible laws, and non-democracies capable of passing admirable ones.  (This chapter is unsatisfactory in other ways, too – it repeats James Rachels’ equation of passive euthanasia and letting die (p 73).  They aren’t the same.  You can let die without intending death; this is impossible for euthanasia.)

Other chapters are no less puzzling.  Baylis et al spend a good part of their chapter on maternal-foetal conflict insisting that there’s no such thing.  (Their dubious claim is that the term distracts attention from the real conflict between the woman and other adults “who believe they know how best to protect the f[o]etus” (p 97); note the slightly sneery tone here; the phrase “so-called experts” isn’t used, but it’s only a breath away.)  Indeed, they don’t even think that mothers are involved in foetal welfare cases at all:

The term maternal suggests the existence of parental obligations towards the f[o]etus, whereas the woman is yet to become a mother to the f[o]etus she is carrying. (ibid)

Really?  A gestational “mother” isn’t a mother at all?  Possible, I suppose – but controversial.

Jerome Amir Singh confronts the problems of physician involvement in torture, and his chapter is illuminating in places – but, again, suffers from a slight tendency to the vague.  There is a recognition that there’s sometimes a conflict between eschewing torture and patriotism (p 356)- but what’s left unquestioned is whether patriotism really is morally admirable, and whether the only way to be a patriot is to follow orders: even if we think that patriotism is important, we might still say that the true patriot would ignore certain commands.  Indeed, bringing patriotism and loyalty to the table seems to diminish the human aspect of the phsycian’s dilemma here.  (Perhaps lengthy discussions of the merits of patriotism ought to be kept for another book; but if they’re going to be raised here, there ougth at least to be a nod to the full complexity of the debate.)  Finally, Singh echoes Dickens et al‘s faith in the power of protest: physicians should, he writes,

consider their legal and ethical obligation to report or actively protest against such treatment to appropriate authorities. (p 356)

Again, ethics seems to be subsumed to law, and little consideration is given that it might be the law that’s mandating the torture, and that the “proper authorities” – quite who they are isn’t clarified – might be those who’re giving the orders.  A physician at Baghram or Guantanamo’s dilemma might be simply that there is noone to whom he can take his concerns, and that his income is at risk for causing trouble.  Self interested?  Yes.  But it’s not wrong to be self interested.

Having said all this, the fact that there’s a number of unsatisfactory and iffy papers isn’t an indication that the whole book is unsatisfactory: there’re some very good chapters, too.  Notable among them are David Benatar’s chapter on non-therapeutic paediatrics (although perhaps more could have been said about vaccination policy), Trudo Lemmens and Lori Luther’s on financial conflict of interest in research, and Richard Ashcroft’s contribution on epidemiological research – though one slight oddity of editing here is that while other chapters have felt the need to define such straightforward terms as “consent” (p11), none is offered here for the term “communitarian”; one might expect that any reader who needs the former explaining would certainly need the same for the latter.

There is a section towards the end of the book devoted to an examination of various religious approaches to bioethics; the editors here are clear that what they intend is something more descriptive than prescriptive, but I still approached the section with trepitation, expecting it to be rather uncritical.  However, I was pleasantly surprised to find that the chapter on JW approaches to bioethics was rather strong.  What was particularly impressive was this:

[A]n increasing number of JWs who have different views on the blood policy have become vocal.  This has raised an important moral issue of personal identity of the members of a religious organization.  Clinicians tend to treat JWs uniformly according to the policy of the [Watchtower Tract Society].  While such treatment may be respecting their uniform identity, their diverse personal identity may be ignored (p 420, emphasis mine).

The take-home message from this seems to be that we ought to be treating patients with due consideration for their personal beliefs and values – but this seems to be exactly how we should be approaching patients across the board anyway, and immediately puts into question why it’s important to spend 62 pages talking about broad religious outlooks that the adherents to a religion may or may not completely share to begin with.  (It’s also striking that this insight should come in the JW chapter: Rabbis arguing about doctrine is one thing, but we’re not nearly so used, I don’t think. to thinking of the JWs as a fractious bunch.)

Is the book a good one?  I still dont’ know.  It is, as I said, very basic; anyone who’s studied any ethics for any substantial length of time ought to be able to see its deficiencies and argumentative weaknesses.  On the other hand, those new to the field are likely to find it much more rewarding.  The problem here, though, is this: is there really any point in a textbook that aims so low?  Most of the “solutions” to the case studies are so vague that anyone smart enough to recognise that there’s a problem would also be left thinking, “Well, duh“, but with no enhanced grip on why it is that ethical problems are problematic and interesting.

In fact, I think there might be something slightly objectionable about such clear direction in a textbook: it reenforces the mistaken belief among those new to the field that there just is a right or wrong thing to do (the strength of the strong chapters, such as Ashcroft’s, is that they are much more doubting and much more ambiguous) and that ethics is univocal – and univocally basically about informed consent.

I never thought I’d say this, but reading parts of the Cambridge Textbook made me pine for Beauchamp and Childress.