BOOKS & ELECTRONIC MEDIA
Rosanna W PeelingI,1; Abha SaxenaII
ITechnical Officer, UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, World Health Organization, 1211 Geneva 27, Switzerland
IIScientist, Evidence and Information for Policy, Research Policy and Cooperation, WHO, Geneva, Switzerland
Author: John R Williams
Publisher: World Medical Association, Ferney-Voltaire, France; 2005
ISBN: 92-990028-1-9; softcover; 134 pages;
English, French and Spanish full-text versions can be downloaded free from the World Medical Association's web site: http://www.wma.net/ (copies of the English print version can be obtained by contacting the publisher)
In 1999 the Fifty-first Annual General Assembly of the World Medical Association (WMA) passed a resolution that medical ethics and human rights be included as obligatory courses in all medical school curricula. Subsequently, the WMA went through an extensive global consultation process, resulting in publication of its Medical ethics manual. The stated goal of this manual is "to fill the void of a basic, universally used curriculum for the teaching of medical ethics". This is an ambitious but worthy goal. In view of the complexity of today's multicultural and legal bounds to medical practice, burgeoning information overload, and rapid technological advances in medicine, the challenges to producing this manual were enormous. WMA has risen to these challenges well and published a book that has an attractive pocket-size format, is easy to read, and is appealing to a wide audience.
The first chapter outlines the principles of medical ethics. The next three chapters deal separately with the principal ethical issues of concern to a physician those related to the patient, society at large, and colleagues and in this way the book elegantly simplifies a very complex topic. The penultimate chapter, on the ethics of medical research, is followed by one on the responsibilities and privileges of a physician. These six chapters cover the entire range of issues relevant to medical ethics. Strengthening the teaching of medical ethics; Internet resources; WMA resources; a glossary, and several case studies are subsequently dealt with in five appendixes.
One can easily visualize a young doctor in a remote setting having to deal with a patient with a terminal illness but who refuses treatment. The doctor feels morally bound to insist on some treatment any treatment for this patient who has entrusted himself to his care. What is this young doctor to do? Does he accept the patient's request to stop treating him, or does he continue prescribing medicines knowing that they may be futile? He has no senior colleague or bioethicist with whom to discuss his dilemma. The Medical ethics manual, particularly the section on the right of self-determination, may provide him with some guidance. There will be many other such instances, in many countries, in many remote settings, where physicians will use this manual to understand better the issues of patient rights, their own responsibilities, and the role of families and others in the care of patients. It deals very comprehensively not only with traditional concepts such as confidentiality, communication, and consent but also with more topical issues: the care of HIV-positive patients; beginning-of-life issues such as assisted reproductive technologies, prenatal genetic screening and abortion; and end-of-life issues such as euthanasia and assisted suicide topics that are relevant to practising physicians worldwide.
Moral and ethical actions are often underpinned by philosophical discourses that can be quite daunting; their presence in a practical book such as this could have been a diversion. The author has deftly skirted this difficult issue by highlighting issues through the use of case studies. These case studies one per chapter have been chosen with great care, in that they could apply to a wide variety of settings and are almost universal in their relevance. However, they merely illustrate what is right or wrong. The really interesting and challenging case studies appear in Appendix E. These are examples of what today's doctors commonly and increasingly have to face in their practice but which are moral dilemmas with no clear solutions. It is disappointing that these cases are not analysed in the manual nor is information provided on where else they might be; perhaps we can look forward to a forum for their discussion on the WMA web site in the future.
In the first chapter, the author provides us with a brief insight into how individuals decide what is ethical and introduces us to rational and non-rational approaches to ethical decision-making. While the non-rational approaches of obedience, imitation, desire, intuition and habit are easy to understand, the rational approaches of deontology, consequentialism, and virtual ethics are not. Clearly the Medical ethics manual cannot go into very much detail here, a point acknowledged by the author; however, it is frustrating to be introduced to these concepts but not be told where one can find more information about them. A list of "recommended reading" at the end of each chapter would have been very helpful in this respect. For example, in the chapter on medical research, although the conflicts faced by the physician when embarking on research are well highlighted, references covering the various guidelines on the ethics of design and conduct of medical research would have been useful.
One of the challenges to developing an ethics guide with a universal appeal is that it has to transcend social, cultural and national issues. Ethical decision-making is, however, often culturally bound and occurs within the legal framework of a given country. This gives rise to some issues about some of the recommendations given in the manual. The foreword clarifies that the manual is based on WMA policies, and to that extent the advice given is non-controversial. However, in some instances WMA policy may be in conflict with legally accepted procedures in some countries. Take, for example, euthanasia. WMA's position is that euthanasia is unethical. But it is legal in several countries and tolerated in others. This situation could have been clarified in the manual. Similarly, in discussing who should make decisions on behalf of an incompetent person the manual suggests that in the case of conflict, either the senior member of the family may do so or a vote may be taken. If such a process is actually followed in certain countries, specific references should be provided; if not, this advice should not be included because many cultures and countries will have difficulties with it. Similarly, a distinction between law and ethics is made in the introductory chapter, but moral dilemmas may arise because legitimate acts may be unethical and ethical actions may in some cases be illegal (e.g., providing abortion services for a bleeding patient in countries where abortion is considered illegal).
The Medical ethics manual acknowledges the centrality of the patient in any doctorpatient relationship, and reminds the reader to put the interests of the patient before any other consideration. More than 2000 years after Hippocrates, when patient's interests are often forgotten by doctors in the pursuit of riches, fame or knowledge (not necessarily in that order), this manual is a timely reminder to PUT THE PATIENT FIRST.
In conclusion this is a very useful manual for physicians practising in any setting. Providing advice on the simpler issues, it does not pretend to answer all questions but helps to raise important ethical issues and questions, and guides physicians on how to respond to the ethical dilemmas they face in their everyday lives. It is also a useful reminder to practitioners that these dilemmas are shared with many others across the globe, and that often there are no easy answers. 
1 Correspondence to this author (email: peelingr@who.int).