Book reviewvs 117 Clinical Ethics ARJonsen,M SieglerandWJ Winslade West Drayton, Collier Macmillan, 1982, £14. The subtitle of this book, which was first published in the United States, is 'A Practical Approach to Ethical Deci- sions in Clinical Medicine' and the authors are a philosopher, a clinician and a lawyer. The reader is given the benefit of a consensus, as it were, after the authors have discussed each problem amongst themselves. The book is crisp and short but there is an excellent bibliography and as well as a table of contents there is a 'locator' which is very helpful and there is good cross-referencing. These aids are important because instead of the more conventional arrangement of chapters by subject there are only four chapters: Indications for medical intervention; Patient preferences; Quality of life, and External factors. As the authors indi- cate in the introduction these titles are taken from philosophical literature and based on the 'Principle of beneficence behind indications for medical inter- vention, the principle of autonomy behind patient preferences and some form of Utilitarianism behind quality of life and external factors'. This grouping may seem awkward to the clinician but all the practical problems of day-to-day decisions are readily found and helpfully discussed. By 'clinical ethics' the authors mean 'the identification, analysis and resolution of moral problems that arise in the care of a particular patient'. The book, which fits readily into the pocket of a white coat, is intended primnarily for doctors, but it will also be helpful to medical students and to nurses. Although written for a readership in the United States, it is entirely relevant to the scene in other countries and the bibliography is international. The case histories are numerous, varied and succinct. The comments provoke thought and do not attempt to lay down dogmatically the appropriate course of action. The authors stress the very close links which should exist between the ethics component and the clinical care component for each patient. One ofthe authors, Siegler, has described elsewhere (Medical Ethics and Medical Education. Geneva; Council for International Organisation of Medical Sciences, CIOMS: 1981: 196-206) a model for the practice and teaching of clinical ethics. He emphasises that it is the clinician who can best understand the medical moral issues as problems within the context of the clinical situation. He goes on to describe his programme in clinical ethics which runs concurrently with a one-month attachment to the acute general medical unit. During the month the group often students meets three times a week for clinical ethics. The meetings are held in a conference room within the medical unit. They are inter-disciplinary and are led by a senior member of staff of the medical unit. A student presents the ethical aspects of a case currently in the unit and discussion follows. This arrangement emphasises the integration of ethics into clinical care. This is the approach which pervades Clinical Ethics and the reader feels he is taking part in such an interdisciplinary discussion on a great variety of day-to- day problems. A S DUNCAN Emeritus Professor ofMedical Education Uniersity ofEdinburgh A Christian Framework for Medical Ethics C Gordon Scorer London, Christian Medical Fellowship Publications, 1980, 50p. This is indeed a quart into a pint pot. In the course of a mere 14 pages Scorer mentions various themes. He discusses the power and responsibility of the doctor, which entails that medical ethics is vital, going far beyond medical etiquette. Another of his themes is the challenge to traditional ethics (which, one infers from what he writes, has been ofan individualist kind, focusing on the one-to-one doctor-patient relationship) by team work; by increasingly well informed patients who may well demand their rights; by new, profound, and sometimes insoluble ethical problems arising from new medical technologies and their cost, and by the increasing control over the doctor not only by his professional organisations but by the State. He argues that an ethical system is required which is consistent and comprehensive, but not legalistic. That is to be found in the Ten Commandments and Christ's expansion of them. A series of particular ethical problems are also mentioned - truth, confidentiality, consent, euthanasia, abortion, Artificial Insemination by a Donor (AID), and contraceptives for immature teenagers. The contribution of Christians to the medical profession is to stand for sound learning and to warn against covetousness. Love is their mainspring; and this may mean choosing between two evils. It certainly means avoiding sentimentality or moralism. Scorer was joint editor of a book in 1979 on moral-decision making in medicine, and there is clearly much ex- perience behind what he writes. Here he has attempted the impossible. If it is intended as a general survey to whet the appetite he should have indicated its limitations. For instance there is no hint of the problems which inevitably arise in the intermediate steps needed in moving from the Bible to particular contemporary decisions in the medical or any other field; nor is there any hint of problems when he urges his readers to press for 'sound legislation which will support Christian values rather than undermine them'. Here again agree- ment on details will raise problems among Christians themselves, apart from those of living in a plural society. The tone is admirably eirenic, as one would expect from one who refers four times to the thought of William Temple. RONALD PRESTON Faculty ofTheology University ofManchester Triage and Justice Gerald R Winslow Berkeley, Los Angeles & London, University of California Press, 1982, £15.00. Triage, the practice of screening patients in order to determine their priority for treatment, has long been a familiar aspect of military and emer- gency medicine. The word 'triage', according to the author of this valuable new book, first entered English with reference to the grading of agricul- tural products and later, during World War I, acquired its medical meaning. Put simply, the practice is based on what Winslow identifies as the principles of medical neediness and medical success: those who need treatment in order to survive are given priority over those who will recover without treatment and those who, even with treatment, will probably die. Triage has also been governed by what Winslow terms the principles of conservation and of immediate usefulness: lower priority, that is, may be given to patients whose survival requires resources, including time, sufficiently great to keep alive at least o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://jm e .b m j.co m / J M e d E th ics: first p u b lish e d a s 1 0 .1 1 3 6 /jm e .9 .2 .1 1 7 -b o n 1 Ju n e 1 9 8 3 . D o w n lo a d e d fro m http://jme.bmj.com/ 118 Book reviews two other candidates; while higher priority may be given to those, for ex- ample, doctors or nurses, whose treat- ment for less severe injuries will return them rapidly to usefulness. To those given low priority, and to those who care for them, the workings of triage may feel unfair, and the relevant decisions are often not taken without regret: but at this sharpest end ofmedi- cine, any lingering over the injustice of triage is a luxury. But what in one context is a luxury, in another may be a necessity. Triage and Justice has been written in the aware- ness that the principles of triage may be extended to other areas of medicine, particularly but not only during the development of expensive new tech- nologies. In an historically interesting introductory chapter, Winslow traces the development of triage in military medicine from the practice of Baron Larrey, Napoleon's chief medical officer (who insisted that casualties be tended 'entirely without regard to rank or distinction'), through the American Civil War and the two World Wars, to the more explicit categories of modern medico-military textbooks. By World War II triage principles had begun to be employed for large-scale allocation deci- sions (macroallocation) as well as in their original microallocation battlefield context: it was decided, for example, that soldiers and airmen suffering from gonorrhoea rather than battle casualties should be treated with the scarce re- source of penicillin, the justification being that of immediate usefulness to the war effort. In the post-war period, with the advent ofnew forms ofmedical technology and therapy, justification of macroallocation choices and their microallocation counterparts became more problematic: in the USA during the 1960s, for example, there was con- siderable public debate about the attempt, at the Seattle Artificial Kidney Centre, to formulate non-medical cri- teria for the selection of patients for the scarce resource of renal dialysis. In this debate, since the employment of such traditional triage principles as medical neediness, medical success and con- servation was unlikely to narrow the field sufficiently, other utilitarian principles such as those of parental role and value to society were suggested as ways of determining priorities; the principle of immediate usefulness moreover was adapted by some to justify giving priority to patients who could pay enough for it to meet the cost of others' treatment. But against these, other principles - of medical and general neediness, of queuing, of random selection, even ofsaving no one when all cannot be saved - were and have subsequently been advanced as criteria for these new triage choices. The introduction ofthese latter kinds of principle, which Winslow categorises as egalitarian, indicated that the utilitarian approach of military and emergency medicine was much less publicly accep- table in the civilian context. Away from the scene ofbattle or ofdisaster, in other words, the claims of justice became more pressing and demanded further discussion. Winslow's book is a useful contri- bution to this discussion. It identifies five utilitarian principles (medical suc- cess, immediate usefulness, conserva- tion, parental role and general social value) and five egalitarian (saving no one, medical neediness, general needi- ness, queuing and random selection) which have been argued for as criteria in triage, and considers each in relation to two hypothetical 'prismatic cases' (a future San Francisco earthquake and the development of an artificial heart) which illustrate different ways in which triage might be called for. Considera- tion of these principles is prefaced by a chapter in which Winslow argues per- suasively against the view that 'dire scarcity' ('the lack of a life-sustaining resource that cannot be further divided and remain effective') necessarily renders all forms of triage equally 'non- just': it would be unjust, for example, not to conduct triage impartially and also unjust not to use the scarce resource at all. On this latter basis, Winslow re- jects the egalitarian principle of saving no one, while acknowledging the moral weight of revulsion against having to make such choices at all. Addressing the question ofwhether the other principles can be ranked in some order of priority, Winslow makes use of John Rawls's much-discussed 'Theory of Justice' and in particular the ranking which might be adopted by Rawls's rational but self- interested social-contract makers behind their 'veil of ignorance' about their own individual life-chances. The result gives priority to the egalitarian criteria of medical neediness and queuing (in disasters such as the earth- quake) or random selection (for such benefits of medical advance as the arti- ficial heart). The priority offair equality of access to scarce life-saving resources, however, has to be limited by appli- cation of the utilitarian principles of medical success and conservation and (in disasters) by that of immediate use- fulness. The usefulness of giving priority in medical advance to wealthy candidates who can pay for others' treatment is admitted to be rational in microallocation, but its moral offen- siveness questions the whole market approach to health care. Rawls's con- tractors would seem unlikely to choose the US system, and in Winslow's view they would also reject both the utili- tarian criteria of parental role and general social value and, even if it could be applied, the egalitarian principle of general neediness. In reaching these conclusions, Winslow has some difficulty with Rawls's theory: as he admits, it is con- ceived for conditions ofmoderate rather than dire scarcity and for something closer to macroallocation than micro- allocation, in which Winslow is primarily interested; moreover it says too little about health and health care and too much about the contractors' parental role for Winslow's immediate purpose. The book might have been better had the author been less respect- ful towards the philosophical master and instead addressed his case more plainly in his own words to a more medical and general readership. But against this it must be admitted that leaving the security of Rawls's philo- sophical buttressing is a daunting prospect for the critic ofprevailing utili- tarianism, perhaps especially in a medical context; and Winslow's achievement in bringing the Theory of Justice this much nearer practical pro- blems is no mean one. Triage andJustice is to be recommended as an economical but comprehensive book which brings considerable clarity to many important aspects of the ethics of resource allo- cation in health care. KENNETH M BOYD Scottish Director Societyfor the Study ofMedical Ethics o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://jm e .b m j.co m / J M e d E th ics: first p u b lish e d a s 1 0 .1 1 3 6 /jm e .9 .2 .1 1 7 -b o n 1 Ju n e 1 9 8 3 . D o w n lo a d e d fro m http://jme.bmj.com/