Book reviews 59 ethics. This range means that the collection can be read in two main ways. First, it can be read simply for factual information. In this respect, perhaps unsurprisingly, it is the con- tributions that are predominantly medicine-based and law-based that are generally the most useful. Secondly, the book can be read for clarification of the ethical issues surrounding reproductive technology. Here, the reader is immediately confronted by a catholicity of the concepts of ethics. For example, ethics refers sometimes to what appears on the agenda of a hospital ethics commit- tee (in Richard West's contribution), to a specific moral or religious stance which is commended to practitioners (in the contributions of Richard Lilford and Jack Mahoney), and sometimes to a branch of academic philosophy (in Anne Fagot-Largeault's contribution). This catholicity does of course represent the wide range of opinion in medical ethics, but in a single collec- tion it inevitably poses a problem. Despite the convenient grouping of the book according to substantive topics, the sheer range of approaches makes it difficult for the reader to identify the precise points at which different contributors would agree or disagree. The discussions go part of the way towards such an identifica- tion, but, like most conference dis- cussions, they reveal a fair amount of mutual misunderstanding between contributors. It is probably for these reasons that the most successful part of the book is where withholding neonatal care is examined first by Alexander Campbell as a paediatri- cian and, in response, by Jennifer Jackson as a philosopher. Here, and in the usefully delimited discussion that follows, genuine debate is discernible, taking the level of analysis beyond that of mere juxtaposition of diverse views. ELIZABETH KINGDOM Department of Sociology, Social Policy and Social Work Studies, University of Liverpool. Protecting the vulnerable: autonomy and consent in health care Edited by Margaret Brazier and Mary Lobjoit, 183 pages + xi, London, 1991. Routledge, £30.00 This volume in the 'Social ethics and policy' series is a collection of papers, some of which were originally given as part of a public lecture series in Manchester in 1988. The unifying theme is the ethical and legal problems of making health-care decisions in cases where patients are, or at least are thought to be, partially or completely incapable of making valid decisions for themselves. This unity at one level of course conceals enormous variety at another, since the forms which such actual or apparent incompetence can take are incredibly varied, as are the decisions which have to be taken in providing care for such patients. The ethical problems generated are equally varied. Thus the papers range over very premature babies, people with mental handicap, women undergoing sterilisation, subjects of non-therapeutic research, people with suicidal tendencies and those receiving psychotherapy, especially students. In addition to the discussions of particular types of decision, there are also more theoreti- cal papers about the nature of auto- nomy, informed consent and the right to information. The papers on particular types of case are on the whole sensible, practical and sensitive, but hardly ground- breaking. The policy recommenda- tions made are usually plainly right but there often seems to be a reluc- tance really to get to grips with the ethical complexities of a situation. For instance, Heather Draper, writing about the sterilisation of mentally handicapped women, recommends a review of the law concerning wardship and research into the attitudes of mentally disabled women towards pregnancy, labour and children - both eminently sensible suggestions. But the ethical issue in such cases - the balance to be drawn between the interests of the woman herself, those of the people who care for her and those of the potential child - is referred to but never really explored in her paper, and she comes to the conclusion that sterilisations must be 'solely in the interests of the individual concerned'. An exception to this line of criticism is Gavin Fairbairn's paper 'Suicide and justified paternalism'. Drawing both on his reflections on his own profes- sional experience and on a subtle philosophical analysis, Fairbairn succeeds in moving beyond the tired discussions of the right to suicide and gives an account of the ethics of pre- venting suicide which makes due allowance for the interests of those other than the suicider who are involved. In the course of this, he also has interesting general things to say about, for instance, paternalism: much, he says, of what passes for paternalism is really 'self-interested pseudo-paternalism because it is more concerned with protecting its perpe- trator than with caring for the welfare of the individual in question'. The more theoretical papers are variable in quality. Margaret Brazier very thoroughly examines the legal problems of treating incompetent patients, but rightly concludes that the rights of, for example, mentally handicapped people depend far more on general social attitudes to disabled people than on legal frameworks. Richard Lindley's paper on a doctor's duty to inform patients of the facts in cases of surgery comes to interesting conclusions, recommending a form of the Bolam test which takes in groups other than medical experts. Harry Lesser provides a useful discussion of the patient's right to information. Alastair Campbell's paper, however, seems simply confused. He makes great play with the notion that patients are dependent on their doctors, as they clearly are, but seems to think that that implies limits to the value of patient autonomy rather than being precisely the reason why respect for patient autonomy is needed. ERIC MATTHEWS Department of Philosophy, University ofAberdeen. Organ replacement therapy: ethics, justice, commerce First joint meeting of ESOT (European Society for Organ Transplantation) and EDTA/ERA(European Renal Association) in Munich, 11-14 December, 1990. Edited by W Land and J B Dossetor, 578 pages + xxiii, London and Berlin, 1991. Springer- Verlag, ,C78.50 The contents pages of this volume list 81 papers, five transcripts of plenary discussion sessions, and 201 contri- butors, giving some idea as to the huge input the conference it is based upon received. The articles range in kind from those which are more or less purely medical, though having 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 .1 9 .1 .5 9 -a o n 1 M a rch 1 9 9 3 . D o w n lo a d e d fro m http://jme.bmj.com/ 60 Book reviews some bearing on certain kind of moral discussion, for instance, 'Results of an Audit of Living Related Renal Allograft Donation from a Single Centre', all the way to those which are more or less entirely moral philoso- phy, though having some bearing on what one should or should not do in transplant surgery, for example, 'Is There a Universal System of Ethics, or Are Ethics Culture Specific?' There is an attempt here to cover all of the current ethical debates in transplantation medicine; the book includes papers related to living donor organ donation, to the buying and selling of organs and the growing international business in transplanta- tion, to the problems associated with cadaver explantation, and to the dif- ficulties of fair distribution of the restricted numbers of organs avail- able for transplant. At the same time, the volume gives an idea of the state of the art in transplant techniques, and some sense of where the cutting edge of this branch of medical sci- ence might be. Partial liver trans- plants, domino heart transplants, pig-person transplants, fetal tissue transplants, all have articles devoted to them in these pages. An omission, however, is any direct consideration of the current position on artificial organs. Organ Replacement Therapy, looked at as a philosophical discussion of moral issues, will inevitably leave something to be desired. The argu- ments of the lawyers, theologians, philosophers and doctors, are unavoidably underdeveloped. The first, and more significant, con- sequence of this is that fundamental assertions made by contributors sometimes escape scrutiny. For instance, in the discussion of brain death (is it tantamount to death?) all participants base their arguments on the distinction between 'person' and 'human being' and the impression given is that this is a settled fact of life. It is nothing of the sort. A second, less serious, consequence is that where other assumptions (for instance that clinicians should be involved in organ allocation decisions) are put under the microscope, and subjected to useful inspection, the discussion is shortlived and inconclusive. It is perhaps most accurate to describe this book as a panoramic snapshot (if that is not a contradic- tion in terms) of the huge and com- plex scenery of transplant medicine and ethics at a particular moment in its evolution. Most interestingly, that panorama shows distinct and, on occasion, contradictory, cultural perspectives. One instance of this is the discussion of the morality of rewarded gifting (that is, offering an organ donor something, over and above compensation, for the dona- tion of his or her organ). Into this discussion are fed views from India, Iran, and Pakistan, as well as the perhaps more familiar perspectives of Western Europe and North America. The value of Organ Replacement Therapy, then, lies not in its taking a moral idea and subjecting it to rigorous and careful philosophical scrutiny, but rather in its being a source book of differing points of view and rich examples, worth extended philosophical reflection. NEIL PICKERING Centre for the Study ofPhilosophy and Health Care, University College, Swansea. The values of psychotherapy Jeremy Holmes and Richard Lindley, ix + 256 pages, Oxford, Oxford University Press, £7.99 Inside an offputting black and white striped cover is a very solid, clear and intelligent book which argues the case for psychotherapy from the combined experience and perspectives of an analytic psychotherapist and a philos- opher. This is a useful book for those who want to know more about what distinguishes the different forms of psychotherapy (there is a clear description in the first chapter and the glossary at the end is helpful). It is also useful in dispelling many of the anti-psychotherapeutic myths and prejudices that still lurk in our culture, - providing a response to those who argue that psychotherapy 'promotes dependence', is an 'inter- minable', 'expensive' and 'elitist' form of treatment. It addresses all these issues and many more. It sees the promotion of emotional auton- omy as the core value of all psychotherapeutic treatment and from this perspective makes out a cogent case not simply for it to be made more widely available in the health service but for psychotherapy to be recognised as a necessary and integral part ofwhat the health service should provide for every citizen of a civilised democracy. In the first chapter the authors describe the task they have set them- selves in the first half of the book: 'We shall present a philosophical, ethical, technical, economic and political case for seeking a wide expansion of publicly funded psychotherapy'. First of all they pose the question 'What is psychotherapy?' and define it as 'the systematic use of a relationship between therapist and patient . . . to produce changes in cognition, feelings and behaviour'. They claim that the common ground or essential elements present in all psychotherapies are structure, space and relationship, and go on to classify the different therapies and their trainings with this in mind. I think it is in this area that the book runs into some difficulties. In order to make their case, they have to empha- sise the common ground between therapies and minimise the differ- ences. Not wanting to identify with what one might call the psychoana- lytic purism or elitism of parts of the psychoanalytic establishment, they have bent over backwards to take an eclectic and even-handed stance, implying that all forms of therapy have equal value and that the important thing is that the range and diversity is available. In effect, in many parts of the book, for example chapter 6, the book is arguing its case from the perspective and experience of analytic work so it is a little surprising that it doesn't make more explicit what is of particular value in applying psychoanalytic insight to the assessment and treat- ment of patients even if not in pure form. Is it really not of great impor- tance or significance that some train- ings do not require the trainees to undergo therapy themselves? Is the promotion of emotional autonomy of central and crucial significance to all different forms of therapy or do other values in some cases supersede this? The second chapter looks at the case against psychotherapy and ques- tions whether it is scientific and testable. It looks at arguments and counter-arguments in a coherent way and comes to the conclusion: 'It is extremely difficult to form a balanced, objective view of the scientific status of psychoanalysis and psychotherapy' and later on 'But is psychotherapy effective? This for most people is the decisive issue, rather than whether psychotherapy is strictly speaking a science, a pseudoscience, or perhaps 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 .1 9 .1 .5 9 -a o n 1 M a rch 1 9 9 3 . D o w n lo a d e d fro m http://jme.bmj.com/