BOOK REVIEWS, NOTES AND COMMENTS
Edited by Federica Napolitani Cheyne
Introducing issues with opposing viewpoints
Lauri S Friedman and Jennifer L Skancke. Detroit, New York, San Francisco: Greenhaven Press; 2009. 136 p. ISBN: 978-0-7377-4168-1
In this book, the editors Lauri S. Friedman and Jennifer L. Skancke present a series of opposing viewpoints regarding the triggering causes of eating disorders (EDs): anorexia and bulimia. In recent years, the prevalence of EDs is rising all around the world and they represent a main health problem among adolescents, young and even adult women. In addition, all know how it is difficult to treat the EDs and that these conditions are related to a high mortality.
The chapters are organized in a way that the opposing points of view on every topic - such as the role of media in causing eating EDs, the effects of websites about EDs in triggering these conditions, etc. - are consecutive, so the readers can easily make a comparison between the two arguments. The viewpoints are well presented with tables and figures that help to catch at the glance the information in the text. Coloured windows underline the "take home" message. Social, behavioural, environmental, genetic, biological and psychological factors are considered as triggers of EDs, and the role of every and each of these issues is carefully considered.
The book presents the subject in a divulgative manner; the chapters are extracted from articles published in magazines, websites and scientific peer-reviewed journals. The format of this publication is ideal for those who are new to this subject. For those who would like to go in depth of the EDs, the book gives a useful list of further readings. In conclusion, an interesting and pleasant reading for a first glance to EDs but also a guide to go further inside this subject.
Istituto Superiore di Sanità, Rome, Italy
Issues of conscience for the twenty-first century
Ronald M Green, Aine Donovan, Steven A Jauss (Ed.). Oxford: Oxford University Press; ISBN 978-0-19-954659-6. $ 90,00.
What is "global bioethics"? Is it a new field of bioethics, one of its possible specializations or a meta-perspective on bioethical issues? First of all, does a global bioethics exist today? It is not so simple to answer to these questions, firstly because there is not a general consensus about how to define global bioethics: is it "global" in a transspecific and environment-friendly sense? Or is it "global" in an epistemological sense, that is to say global bioethics is a unified global field beyond local geo-political and cultural differences? Or is it possible to find a different meaning of global bioethics?
The present book is an in-depth examination of the meaning(s) and feasibility of a global bioethics, both from a theoretical and practical point of view.
Born from a symposium hosted at Darthmouth College 45 years after the conference on "Great Issues of Conscience in Modern Medicine" in 1960, one of the forefront meeting of Bioethics, this book is a collection of 16 papers about the most relevant issues arising from contemporary world, particularly from the management of biomedicine. Two possible meanings of global bioethics are at the background of all papers: an emerging area reflecting the urgent need to promote global health, with particular attention to the needs of developing world populations in poor health; a look beyond a particular health care and legal system. The first definition is focused on a particular matter of inquiry: how to develop a real global health; the latter is more formal, underlying the necessity "to be global" in the study of bioethical issues.
From this twofold definition at least seven broad areas of debate emerge, that constitute the framework of the book: global research ethics; biomedical/bioethical collaborations; training professional, ethical physicians; euthanasia and physician-assisted death; global bioethics and religion; public global bioethics consultation.
Thus the starting point of global bioethics is a critics of classical bioethical discourse, defined and practiced as a reflection on relationship between individual patients and their physicians or between investigators and their research subjects. Less visible are ethical issues arising at the population level, that, according to Wikler and Brock, come into focus adopting a "bird's-eye view" that focuses on population, from which new issues become visible. Therefore global bioethics is concerned not only on health care, but also on other social determinants of health, such as socio-economic standing, environmental and working conditions, social exclusion, so that its object is health as such instead of health care. A first question emerges from this definition of global bioethics: what are its borders as a specific field of research? How to distinguish it, for example, from biopolitics or sociology of medicine or economics? What is, if there is one, the epistemological specificity of global bioethics?
From the book it seems that it is a "hybrid discipline": extending itself spatially (including poor countries populations) and temporally (including future generations), it transcends disciplinary borders into demography, gerontology, genetics, economic development, relying principally on theories of justice and other political philosophy's issue, speaking of the relationship between individuals, groups and state.
Surely global bioethics is also one of the most intriguing and interesting current topics in culture, as showed by some of its key issues: society's and individual responsibility for health; health and human rights; priority setting; cost-effectiveness analysis; health measurement; health and economic development; vulnerable populations and emergency humanitarian intervention; risks and the people who bear them; environmental equity; populations and genes; protecting health, endangering civil liberties; global aging; global health equity; inequality in health within countries; social determinants of population health.
All of these issues are generally not or only partially taken into account in classical bioethical discussion, focused on physician-patient relationship and related issues. This does not mean medical and clinical bioethics is out of date, but maybe the right strategy is a complementary one between the two: global bioethics can help us to understand the social and economic determinants of health in contemporary world, while classical bioethics can help to avoid the risk of medicalization of society that global bioethics brings with itself.
Furthermore, as Eyal underlies in his paper, it is not always so easy to distinguish between the two approaches: for example, many non-population issues arise at the population level. Moreover, when does a group of patients constitute a population? And does a population require distinct methods and answers than doctor-patients relationship? Do macro-questions (e.g., social and economic determinants of health, disparity of access to health care, etc.) really affect more people than micro-questions (e.g., informed consent, end of life regulations, etc.)? If global bioethics was only a matter of extension it would be difficult to clearly define it.
As Emanuel and van Delden show in their papers, the historical development of sociology and ethics of medical care has increasingly changed the perception and meaning of health care during the XX Century. Particularly, an important characteristic of contemporary understanding of medical ethics which we can infer from their not always convergent argumentations is the shift from a deductive model (medicine does not contain adequate practical norms, but only philosophical reasoning can say what is right to do) to a "phronesis model" (ethical norms are internal to practice). In the perspective of global bioethics, this new conception of medical ethics is linked to human rights, that became the framework for the universalization and globalization of bioethics without simply promoting a lowest common denominator or the creation of a homogenized bioethics.
In this view became relevant issues like global justice, global right to health, global health equity, harm reduction research, the impact of religions on global bioethics and the role of public global bioethics consultations, all deeply investigated in the book.
For example, the discussion about harm reduction in Kass' and Iltis' papers is very topical: is it ethically acceptable to reduce, rather eliminate, harms to health for individuals or communities when it's impossible to remove the underlying causes? Or is this pragmatic and prioritizing approach a sort of compromise? Whatever is the personal answer to this question, there is no doubt about the ethical problematicity of harm reduction strategy. A relevant ethical problem connected to it is for example the accessibility: if and how health care is accessible to a subject is morally very relevant. The "pragmatic strategy" of Iltis is expressed in his justification of harm reduction, seen as the best that can be done given our real world. Yet we could ask: who decide what our world is? Is it not a matter of biopolitics a (global) bioethical discussions and mediations? Maybe our world is more a consequence than a premise of our choosing or refuting the acceptability of harm reduction strategy.
Thus to accept the ethical legitimacy of harm reduction strategy is not neutral but expresses a specific personal answer to the global bioethics' question: what is "standard of care"? Is it relative to the context or does one worldwide standard exist? This is particularly relevant for the so called "global research ethics", as emphasized by Macklin: how does the research in different countries challenge accepted norms of research? What about the gap between rich and poor countries? How is the universal right to health realized in different societies? Is a research justified if conducted in a poor country and it does not give present benefits to it? What are the ethical standards employed in and required for researches conducted in poor countries and sponsored by private industries? Has researches and/or sponsors ongoing obligations to the community when the research is concluded? For example, the Declaration of Helsinki, the National Bioethics Advisory Commission and the Nuffield Report say that successful products of research must be made available to the participants after research. The Declaration of Helsinki also says that a research can be conducted in a Country only if there is a likelihood of benefit from it for the country. Yet what a "likelihood of benefit" is? Who can decide about it? What conception of justice is involved? A distributive one? Or justice as reciprocity? From a general point of view, can we say that in the perspective of global justice the goal for promoting health merits exception from the rules that govern world trade in all other communal products? What can be stated from the international law? Probably as a great methodological tool the suggestion by Merlin is potentially fruitful: instead of a top-down approach, in which a group of experts decide what to do from a distance with the goal of producing a generalizable and universalizable instrument, a ground-up one must be taken into account. It fashions a collaborative agreement and understanding between institutions, ethics review committees and researchers. In this way groundup approach underlies the importance to develop initiatives at the local level and the crucial role of local circumstances. It also underlies the disparity in global health as the greatest ethical challenge today.
This is, we think, the most important potential usefulness of a global bioethics: not a simple generalization of particular bioethical issues, but an acknowledgement of global differences in the perspective of universal right to health. Because global bioethics is an emerging new field, how much its approach is new in the bioethical discourse, and how original it can be compared to other disciplines (especially biopolitics, sociology and economics) are big still unanswered questions, and this book is undoubtedly one of the most useful tool to unfold these tricky problems.
Biogem IRGS, Institute of Research Gaetano Salvatore,
Ariano Irpino (AV), Italy
BIOETICA ED ETICA DELLA RESPONSABILITÀ
Dai fondamenti teorici alle applicazioni pratiche
Fabrizio Turoldo. Assisi: Cittadella; 2009. ISBN13 9788830810198. 13,00.
Bioetica ed etica della responsabilità. Dai fondamenti teorici alle applicazioni pratiche is a collection of Fabrizio Turoldo's recent papers about bioethics and the ethics of responsibility. The aim of the book is to offer an ethics of responsibility which is able to provide guidance in some issues in the field of bioethics. In this way, Turoldo refers, according to Hans Jonas, to an ontological conception of the being that shows its intrinsic finalistic structure.
The author compares several etymologies of the word "responsibility". In doing this, his aim is eminently theoretical, not just philological. In describing various kinds of responsibility - linked by the common requisite of relation and intersubjectivity - he wants to emphasize the inadequacy of a solipsistic approach. Socialness is, as Aristotle underlines, the field in which the subject is naturally enclosed, indeed the relation precedes the subject. In this light, Turoldo criticises perspectives, as the one defended by Rousseau, that consider social life as the result of a contract.
This ethics of responsibility, as Turoldo remarks, refuses principialism (criticized for its technicality) but, at the same time, seeks universality which is particularly necessary in contemporary complex societies. In other words, universalism must be integrated within the context of situations and with the singularity of the agent of the moral behaviour. For this reason, Aristotelian phronesis and Kantian reflective judgments complement each other: the second one runs from the individual to the more inherent universal.
Turoldo's ethical view concerns also the public health sphere, issue that requires widening bioethical horizons. Born as ethical reflection about clinical setting and experiments carried out on human beings, this branch is here directed to topics addressing not just the individual, but the whole society. With reference to this problem, if bioethics, at its beginning, was focused on the principle of autonomy and informed consent, now the responsibility due to the society requires instead coercion (in cases like epidemic or mandatory vaccinations alike).
Multiculturalism sees Turoldo engaged to specify further his idea of responsibility: ethics of responsibility emphasizes the need to provide recognition of the other in its difference. Furthermore, the Author disputes relativism and its way to consider cultures as static and homogeneous: the risk is, indeed, to legitimise cultures that oppress their single members. Reflect to a particular culture must be focused on individuals which settle the culture and, at the same time, has to consider their weakness, fragility and vulnerability - these characteristics engrave on procedures to tell patient the truth. Clinical case studies help the Author to draw out contexts in which ethics of responsibility occur.
Turoldo deals also with the refuse of medical treatments in Italy presenting recent cases as Welby, Nuvoli and Englaro, taking into account the Italian law. According to the author, it is important to note the role of responsibility in the Italian Constitution: Article 32 offers a particularly interesting perspective with regard to the possibility of a shared social ethics and describes a dialectic - but not a contradiction - between two values: on the one hand, the care addressed to the community, on the other hand, autonomy and, consequently, the patient's right to decide when to stop a specific treatment or course of medical intervention.
Dipartimento di Filosofia e Teoria delle Scienze
Università "Ca' Foscari", Venise, Italy
PERCHÉ SI NASCE SIMILI E SI DIVENTA DIVERSI?
La duplice nascita: genetica e culturale
Giovanni F. Azzone (Ed.). Milano, Torino: Bruno Mondadori Editore; 2010. 205 p. ISBN: 8861594638. 16,00.
In a letter dated July 7 1688 to John Locke, the English empiricist philosopher author of An Essay Concerning Humane Understanding , the Irish scientist and politician William Molyneux (1656-1698) put forward a problem, which was to awaken great interest among philosophers and scientists throughout the Enlightenment and up until the present day. Molyneux, put very simply, wondered if a person born blind would gain, if cured, the ability of fully perceive and recognize objects in the external world, or if instead she would not be able to interpret this new sensory evidence. The problem has been considered a tough experiment until very recent times, when optical surgery advancements allowed blind people to regain sight, showing how intricate is the connection between the physiological machinery and its psychological counterparts, just as predicted by Molyneux some three hundred years before.
Philosophical and ethical issues, and related regulatory considerations, have increasingly permeated the debate on the complex relationship between sciences and societies, particularly with regard to biomedicine. Contemporary public health is confronted and progressively shaped by bioethical issues. Credit therefore is ought to professor Giovanni Felice ("Licio") Azzone, distinguished MD, national member of the Accademia dei Lincei and of the Istituto Veneto di Scienze, Lettere ed Arti, for choosing to face directly one of the most binding, and uncomfortable, "open questions" sitting on both scientifical and philosophical agendas: the singularity of the human species and of her abilities. Azzone exerted a remarkable cultural leadership, first at "La Sapienza" Rome University and, for almost thirty years, at Padua University Medical School. In the last years he authored a series of important essays, all very useful for readers interested in bioethical perspectives.
In the present book, such themes are critically discussed, giving a prominent role to the late Donald Davidson's (philosopher at University of California, Berkeley) analytical paradigm on the dualistic relationship between the human body and its "mental correlates" . Gathering evidence from different research fields, from neurosciences to psychobiology up to evolutionary theory, all recollected in the context of biological sciences, Azzone attempts to bond together both the scientific causal determinism, embodied by relentless positivism of Nobel laureate Jacques Monod in his Le Hazard et la Necessitè, polemical target of the first part of the essay, and the chaotic nature constituting the very heart of our, human, most distinguished characteristics: free will. In the author's opinion it is this very property of intentionality that, triggering the "great leap forward" (as biologist Jared Diamond called the apparent discontinuity in human evolution), lies at the heart of our uniqueness. We read, in fact:
"My idea is that is thanks to imprinting that living beings and humans in particular, acquire or increase their knowledge and their abilities and modify their behaviors" (p. 122-123).
In such context the classical concept of imprinting is, therefore, not considered as a fixed learning pattern, but a combinatorial mechanism thanks to which human beings are able to generate new behaviors. According to ethologist sir Patrick Bateson, imprinting embodies mechanisms and processes serving as a "rule for changing rules" within biological programs , at least in higher vertebrates. Azzone amplifies this kind of visions, underlying species-specific characteristics and rendering Homo sapiens an absolute "peculiarity" among living entities.
The whole key concept of the humans' double birth, the cultural together with the natural, the author argues, is grounded on the employment of linguistical acts and strictly depends on this extraordinary sort of imprinting, another argument against Noam Chomsky's idea of a universal grammar module hardwired in our brain. Such double nature has been present since when our ancient ancestors became able to build:
"Their history, therefore birth, growth and development of organisms are the result of processes continuously evolving, that accordingly cannot be considered as stable and not modifiable structures, but only as in fieri buildings" (p. 151).
This vision parallels the essay "The Symbolic Species" in which neuroanthropologist Terrence Deacon shows how the coevolution of language and symbolic thought, by means of natural selection, is the remarkable specificity of genus Homo .
Avoiding ancient antinomies on the mind-body problem, the author is satisfied of suggesting the idea of anomalous monism (in most literal sense of "law-less") which states that our current level of knowledge about the mind-brain behavior does not allow us to produce a predictive explanation and, therefore, we must, for now, be satisfied of just peeping at their interface (with the different techniques offered by the skyrocketing technologies of cognitive science). In such impossibility of neither considering physical properties only of our "inner life" nor taking a full dualistic stance (according to Azzone, scientifically not justifiable), we must acknowledge:
"That consciousness, as a mental property, is always a physical property of the mind-brain system (...). In order to get through the ontological dualism introduced by the materialistic distinction between body properties and mind's ones (...) the inevitable alternative is thus accepting the principle according to which the worlds of mind and consciousness are both biological in nature" (p. 140-141).
Philosopher Telmo Pievani already reasoned elsewhere about this book : we simply add that his mild critiques appear too deterministic for neuroscientific readers, daily dealing with the surprising plasticity of the nervous systems and the emerging adjustment performances of neuronal assemblies. With its compelling grasp on these dilemmas, the book touches ethical priorities in biomedicine, from vegetative states condition to informed consent in psychotic or demented patients, up to "advance directives". Members of bioethical committees may therefore gain some benefits, as well as students or lecturers committed to these entangling disciplines not yet formally embedded in universities courses.
Diego De Simone(a) and Enrico Alleva(b)
(a)Istituto di Scienze e Tecnologie della Cognizione, CNR, Rome, Italy
(b)Istituto Superiore di Sanità, Rome, Italy
1. Locke J. An essay concerning humane understanding. Oxford: Oxford University Press; 1979.
2. Davidson D. Essays on actions and events. Oxford: Oxford University Press; 2001.
3. Bateson P, Hinde R (Ed.). Growing points in ethology. Cambridge: Cambridge University Press; 1976.
4. Deacon TW. The symbolic species. New York: WW Norton & Co; 1997.
5. Pievani T. Le due nascite dell'umanità. L'Indice dei libri del mese 2010;9:29.
Lucio Sotte, Massimo Muccioli, Lucia Pippa, Margherita Piastrelloni, Piero Quaia, Emanuela Naticchi, Alfredo Vannacci. Quinto volume del Trattato di Agopuntura e Medicina Cinese, a cura di Lucio Sotte. Milano: CEA Casa Editrice Ambrosiana; 2010. 761 p. ISBN 978-88-08-18234-0. 92,00
The publication of this volume is the crowning achievement of a life-long work by Lucio Sotte, President of the Society of Chinese and Traditional Pharmacology (1992-1998), teacher and medical practitioner of Chinese acupuncture, pharmacology, massage, dietetics and medical gymnastics and director of the Italian Journal of Traditional Chinese Medicine (1990-2008). Sotte is a protagonist of the history of the introduction of Chinese pharmacology and traditional medicine in Italy. After 20 years, this volume, as part of the series of treatise on acupuncture and Chinese medicine of CEA Casa Editrice Ambrosiana, systematizes the knowledge and scientific production available on one of the most ancient, yet relevant, medicines worldwide.
Just as the other volumes of the series, this treatise on Chinese pharmacology is a text of great practical value, written by medical doctors of major clinical and teaching experience, and addressed to medical doctors willing to learn and deepen traditional Chinese medicine, for a correct integration with modern bio-medicine.
The volume is divided into three parts: the first draws the history of Chinese medicine and pharmacology; the second part, introduces the principles of Chinese pharmacology and discusses epidemiological, normative and surveillance issues of Chinese traditional phytotherapy; the third and main part of the volume presents a rich selection of the most important remedies and recipes of Chinese pharmacology for the treatment of pathologies as well as its energetic and preventive functions. The focus is on those remedies most used in China and available in our Western countries, while substances which cannot be found in our drugstores are also described.
The volume thus represents, to all intents and purposes, the major encyclopaedia on Chinese pharmacology, rich in tradition and science. Indeed for each recipe and remedy, in addition to the historical excursus and the description of its traditional Chinese usage, the active principles, their pharmacological effects, indications, precautions, contraindications and dosage are also detailed, just as in any treatise of pharmacology.
Among the merits of the volume stands out, besides the close examination of the cultural and philosophical principles, the carefulness of the terminology: for every remedy it is reported the most accredited Chinese name, the common name of the plant, the pharmaceutical name in Latin, and the botanical name and family.
To conclude, this volume is the result of years of work, study and teaching of all the authors involved and can be considered the direct offspring of the most important scientific publications in Italian for professionals and practitioners of traditional Chinese medicine available. It therefore represents the most valuable tool for clinical practice in traditional Chinese medicine in Italy.