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50
Book
reviews
updating,
and
that
the
way
to
do
this
was
for
distinguished
doctors
to
distil
their
accumulated
wisdom
in
personal
reflections
on
their
own
experience
of
learning,
doctoring
and
teaching.
Dr
Bulger
also
expresses
a
wish
to
provide
a
written
analogue
of
various
inspirational
encounters
in
his
own
history.
Unfortunately
even
those
who
possess
wisdom,
or
can
inspire
by
personal
example,
cannot
necessarily
transmit
that
wisdom
or
inspiration
in
writing;
it
is
all
too
easy
to
lapse
instead
into
idiosyncrasy
and
platitude.
Dr
Bulger
has
in
fact
put
together
a
very
heterogeneous
set
of
articles,
reflecting
his
conviction
that
something
is
wrong
with
US
medicine,
and
that
the
cure
is
a
reform
of
US
medical
ethics,
starting
with
the
motivation
of
individual
practitioners,
and
an
expansion
of
the
concept
of
scientific
medicine
into
more
holistic
healing.
Apart
from
reflecting
the
editor's
interests,
the
collection
has
little
coherence.
It
encompasses
many
different
styles
or
genres,
for
instance:
personal
musings
on
the
ethics
of
medicine;
the
application
of
psychiatric
theory
to
ethics;
sociological
description
of
healing
in
different
cultures;
accounts
of
key
personal
experiences
within
and
outside
medicine;
historical
studies
of
Hippocrates
and
the
Hippocratic
corpus;
reflections
on
the
ethics
of
truth-telling
in
medicine,
and
an
embarrassing
fictional
dialogue
between
Hippocrates
and
a
revered
colleague
of
the
editor,
in
which
Dr
Bulger
puts
his
own
re-writing
of
the
Hippocratic
oath
into
the
mouth
of
Hippocrates
himself.
In
Britain
at
any
rate,
few
could
find
much
to
object
to
in
Dr
Bulger's
new
oath;
its
interest
lies
in
why
it
is
felt
to
be
necessary
and
pertinent
in
the
USA
now.
But
what
is
conspicuously
lacking
in
most
of
the
essays
-
particularly
in
the
editor's
own
(seven)
contributions
-
is
any
very
clear
or
powerful
analysis,
or
even
description,
of
exactly
what
is
felt
to
be
wrong
with
US
medicine,
let
alone
evidence
for
the
analysis
or
careful
argument
for
the
proposed
cures.
Exceptions
to
this
are
the
articles
by
Drs
Relman
and
Reiser,
which
do
at
least
offer
a
coherent
story
and
an
intelligible
link
between
the
perceived
ills
(excessive
commercialism,
imperson-
ality
and
fragmentation
of
care
into
multiple
medical
and
technological
specialisms)
and
the
proposed
remedies
(greater
social
responsibility
in
and
tighter
control
by
the
medical
profession
as
a
body,
and
greater
understanding
of
the
uses
and
effects
of
new
technologies
on
care).
But
the
collection
contains
virtually
no
sustained
ethical
argument;
we
are
offered
instead
deeply
felt
but
unexciting
personal
convictions
(such
as,
for
instance,
the
belief
that
doctors
should
put
patients' interests
first,
listen
to
them,
talk
to
them,
tell
them
the
truth,
and
be
motivated
by
an
ideal
of
service).
Transmitting
wisdom
requires
something
more
than
this,
even
though
the
authors
may
well
have
good
store
of
wisdom
between
them.
However,
perhaps
the
reader
can
distil
his
or
her
own
from
the
good
thoughts
and
interesting
ideas
that
do
from
time
to
time
crop
up.
It
is
moreover
interesting
for
a
British
reader
to
find
that
just
when
private
medicine
is
being
encouraged
to
expand
in
the
UK
and
market
economics
and
entrepreneurial
verve
are
extolled
as
the
answer
to
all
social
ills,
US
doctors
are
lamenting
the
effects
of
just
these
factors
on
their
own
system
of
delivering
medical
care,
and
are
calling
for
greater
social
responsibility,
collective
thinking,
and
disinterested
service
in
the
medical
professions.
SUSAN
KHIN
ZAW
Department
of
Philosophy,
The
Open
University
Shared
concern
Video;
Society
of
Parents
Helping
in
Education,
1987.
Available
for
sale
for
£45
from
King's
Fund
Centre,
126
Albert
Street,
London
NWI
7NF
and
for
hire
from
CFL
Vision,
Chalfont
Grove,
Gerrards
Cross,
SL9
8TN
(02407
4433)
ref
UK
3965,
for
£10.50.
Cost
includes
P
&
P,
VAT
and
booklets.
Shared
concern
(subtitled
Breaking
the
news
to
parents
that
their
newborn
child
has
a
disability),
is
a
video
made
for
medical
and
health
workers
and
students
by
SOPHIE
-
Society
Of
Parents
Helping
In
Education.
SOPHIE
originates
from
a
group
of
parents
with
children
with
varying
disabilities.
Most
members
of
the
group
were
dissatisfied
with
many
of
the
services
and
wanted
to
help
to
improve
them.
They
regarded
'breaking
the
news
as
the
first
crucial
step
undertaken,
and
the
one
which
had
the
most
lasting
effect
on
our
lives,
and
on
those
of
our
children'.
Concerned
that
medical
students
had
little
training
in
this
area,
they
made
the
video.
The
strength
of
the
video
is
the
restrained
and
careful
way
in
which
it
portrays
and
discusses
many
aspects
of
breaking
sad
news
to
parents.
There
is
a
fine
balance
of
sympathy
and
respect;
sadness
does
not
become
cloying
and
a
rather
inept
doctor
is
shown
as
uncertain
rather
than
indifferent.
Scenes
of
one
family
learning
that
their
baby
has
Down's
syndrome,
are
interspersed
with
comments
from
doctors
and
from
a
well
selected
range
of
families.
The
video
is
clearly
based
on
the
experiences,
both
rewarding
and
bitter,
of
parents
and
doctors.
Anyone
looking
for
the
perfectly
correct
method
of
breaking
sad
news
will
be
disappointed
and
possibly
irritated
by
the
sequence
of
comments.
There
is
a
constant
contradiction.
One
parent
asks
for
hope,
another
for
realism.
A
mother's
criticism
of
an
unnecessarily
gloomy
prognosis
is
followed
by
another
family
slowly
coming
to
terms
with
terribly
severe
limitations:
'I'm
learning
things
now,
twenty
years
on,
that
I
should
have
known
from
day
one,'
said
the
father.
Within
this
simply
made
film
there
is
a
wealth
of
detail
to
provoke
discussion
and
to
encourage
the
viewer
towards
an
ethical
understanding
of
the
problems
of
breaking
such
news.
And
part
of
the
problem
is
that
learned
techniques
are
only of
limited
help.
The
most
important
element
is
the
quality
of
the
person
giving
the
news
and
the
care
with
which
he
or
she
responds
to
the
family
and
continues
to
offer
support
and
to
teach
acceptance.
This
close
contact
with
families
can
be
extremely
wearing
but,
as
one
mother
said,
'If
you
can't
relate
to
the
patients
because
it's
going
to
hurt
you,
then
you're
in
the
wrong
job'.
A
copy
of
the
handbook
is
meant
to
be
given
to
every
viewer.
It
is
a
useful
complement
to
the
27-minute
video,
being
a
permanent
record
full
of
definite
and
practical
information,
sources
of
help
and
further
discussion
points.
As
a
result
of
SOPHIE's
work,
many
more
parents
should
be
able
to
say
with
one
mother
in
the
film:
'I
can't
think
of
anything
more
the
hospital
could
have
done
to
make
it
easier'.
PRISCILLA
ALDERSON
14
Holyoake
Terrace,
Sevenoaks,
Kent
TNB3
IPA
The
Foetus
as
Transplant
Donor:
Scientific,
Social
and
Ethical
Perspectives
Peter
McCullagh,
215
pages,
Chichester,
John
Wiley
&
Sons,
£25,
1987
Book
reviews
51
Peter
McCullagh
aims
to
assess
the
scientific
validity
of
proposals
to
transplant
fetal
tissue.
He
believes
that
'only
if
it
is
established
that
the
new
proposal
is
scientifically
valid,
is
it
necessary
for
society
to
address
the
question
of
whether
it
is
also
ethically
acceptable'
(page
42).
With
great
care,
McCullagh
sets
out
the
history
of
fetal
research,
citing
little
known
papers
dating
back
to
1878.
He
illustrates
how
scientific
proposals
evolve
from
earlier,
sometimes
discredited,
theories,
and
how
many
scientific
theories,
far
from
being
value-
free,
are
value-laden,
causing
great
benefit
or
harm.
He
also
shows
how
once
a
theory
is
enshrined
in
a
journal,
it
can
sustain
a
credibility
long
after
it
has
been
discarded
as
useless.
Claims
that
human
fetal
tissue
as
transplant
material
is
demonstrably
superior
to
other
matter,
and
has
proven
therapeutic
value,
are
stringently
assessed
and
are
found
to
be
unfounded.
McCullagh
shows
how
scientific
reports
are
constructed
and
publicised
in
order
to
gain
social
approval
for
what
he
finds
to
be
unproductive
research.
He
advocates
far
more
critical
analysis
of
scientific
claims
before
they
are
endorsed
by
society.
Transplant
material
is
likely
to
be
taken
from
fetuses
aged
12-18
weeks
gestation.
There
is
a
detailed
section
on
the
status
of
the
fetus
at
this
stage,
on
its
aliveness
(which
is
very
different
from
its
viability),
and
on
research
showing
well-developed
physical
and
neuro-
logical
responses
to
pain
in
fetuses
of
ten
weeks'
gestation.
Fetal
tissue
for
transplantation
must
be
'harvested'
within
a
few
minutes
of
delivery.
Ideally
this
is
by
hysterectomy,
with
the
fetus
delivered
in
utero.
Drugs
which
reduce
fetal
physiological
activity
need
to
be
avoided.
The
fetus
is
therefore
in
as
alive
and
aware
a
state
as
possible
when
being
opened.
McCullagh
is
concerned
that
the
fetus
has
none
of
the
protections
offered
by
laws
and
codes
controlling
research
on
humans
and
animals,
although
it
shares
many
of
their
characteristics.
One
moral
principle
is
that
the
more
weak
and
helpless
a
sentient
subject
is,
the
more
society
is
responsible
to
defend
it
against
deliberate
harm.
McCullagh
argues
that
the
harm
of
fetal
research
is
that
it
damages
society's
moral
integrity,
reducing
our
collective
sensitivity
to
the
claims
and
needs
of
weaker
beings.
His
general
theory,
that
such
research
also
harms
the
researcher,
takes
on
specific
meaning
in
some
of
the
examples,
such
as
severed
fetal
heads
being
perfused
with
a
solution
in
order
to
measure
brain
activity.
Some
research
begins
in
utero,
and
is
therefore
likely
to
be
closely
associated
with
medical
staff
and
research
students
who
may
also
be
engaged
in
obstetric
and
neonatal
care.
Laws
about
dead
human
donors,
forbidding doctors
who
treated
the
patient
from
performing
post-
mortem
dissections,
do
not
cover
fetal
research
and
tissue
transplantation.
McCullagh's
points
need
to
be
considered
in
relation
to
women's
criticisms
of
distressingly
impersonal
treatment
of
patients
in
obstetric
and
neonatal
units.
Does
society
want
medicine,
and
medical
training,
research
and
promotion
requirements,
to
become
ever
more
highly
technical,
if
this
is
at
the
cost
of
less
compassionate
medical
care
for
patients?
Especially
if
research
continues
despite
being
shown
to
be
costly,
harmful
and
unproductive.
McCullagh
gives
a
clearly
argued
analysis,
for
example,
of
'good
coming
out
of
evil',
and
of
other
ethical
arguments
familiar
to
readers
of
this
journal.
He
shows
how
ethical
concepts
can
be
twisted
to
support
dubious
activities,
and
is
concerned
that
fallacies
about
therapeutic
use
of
fetal
material
may
lead
to
abortion
being
accepted,
even
valued,
by
society.
On
consent,
he
says
that
it
is
not
necessarily
likely
that
mothers
agreeing
to
abortion
will
either
base
their
decisions
on
the
interests
of
the
fetus,
or
be
reasonably
informed
about
the
proposed
research.
He
dismisses
McCormick's
notion
(about
research
on
children)
that
the
subjects'
consent
should
be
assumed
because
they
ought
to
fulfil
moral
obligations
to
society
by
co-operating
in
research.
McCullagh
considers
that
the
aborted
fetus
owes
no
moral
obligations
to
society,
since
it
has
been
accorded
none.
Earlier
reviews,
such
as
the
Peel
Report
of
1972,
are
criticised
as
superficial
and
often
fallacious.
McCullagh
discusses
the
shortcomings
of
present
controls
and
ends
by
recommending
alengthy,
formal,
critical
enquiry
into
fetal
research.
He
outlines
its
tasks
which
include
investigating
alternative
forms
of
research.
McCullagh's
sensible
insistence
that
ethical
discussion
must
be
based
on
clear,
detailed
understanding
of
each
scientific
proposal
raises,
I
think,
three
serious
problems.
First,
it
implies
that
research
must
actually
be
carried
out,
in
order
to
provide
detailed
scientific
knowledge,
before
we
can
decide
whether
it
is
acceptable.
Yet
many
people
would
argue
that
certain
research
is
so
harmful
in
principle,
that
it
would
be
unethical
to
collect
details
about
it
through
a
practical
study.
Second,
emphasising
scientific
details
tends
to
result
in losing
sight
of
ethical
principles
in
a
mass
of
technical
practicalities.
Thirdly,
the
non-
scientists'
contribution,
especially
of
the
women
concerned,
is
liable
to
be
lost
in
esoteric
debates
dominated
by
scientists.
This
relates
to
one
more
problem
of
this
book,
its
heavy-going
style,
which
gives
a
sense
of
a
thin
lively
book
struggling
to
get
out
of
a
rather
fat
repetitive
one.
It
would
be
unfortunate
if
the
style
prevented
Peter
McCullagh's
very
important
work
from
reaching
the
wide
audience
which
needs
his
information.
PRISCILLA
ALDERSON
14
Holyoake
Terrace,
Sevenoaks,
Kent
TN13
IPA
By
No
Extraordinary
Means
Joanne
Lynn,
272
pages,
USA,
$25,
Indiana
University
Press,
1986
It
is
no
longer
controversial
to
withhold
or
withdraw
technological
therapeutic
interventions
from
a
patient
with
no
prospect
of
recovery
once
it
is
widely
agreed
that
this
is
in
the
patient's
best
interest.
These
measures
include
ventilator
support,
cardiopulmonary
resuscitation,
blood
transfusion,
surgery
or
chemotherapy
for
advanced
cancer,
and
antibiotics
for
intercurrent
infections.
Decisions
of
this
kind
can
all
be
regarded
as
'letting
die'
-
because
when
death
comes
it
can
be
ascribed
to
pathological
developments
in
the
course
of
illness,
albeit
those
that
in
other
circumstances
might
have
been
temporarily
alleviated
by
some
medical
intervention.
Such
pathological
events
may
not,
however,
occur
for
some
time
and
even
when
various
complications
do
develop
the
lack
of
medical
intervention
does
not
always
ensure
a
rapid
release
for
the
patient.
This
is
especially
so
for
conditions
that
are
not
terminal.
These
include
various
types
of
severe
neurological
disability
such
as
the
vegetative
state
due
to
permanent
loss
of
function
in
the
cerebral
cortex,
advanced
motor
neuron
disease,
multiple
sclerosis
and
high
quadriplegia.
Patients
in
the
vegetative
state
in
particular
can
survive
for
many
years
if
nourishment
and
basic
nursing
care
are
provided.
Although
tube-
feeding
is
a
medical
measure
it
is
so
comparatively
simple
that
it
is
often
