Book Review

By Charles Weijer, M.D., Ph.D.
Bioethicist, Mount Sinai Hospital
and University of Toronto Joint Centre for Bioethics;
Assistant Professor, Department of Medicine, University of Toronto.

Ruth Ellen Bulber, Elizabeth Meyer Bobby, Harvey V. Fineberg, editors, Society’s Choices: Social and Ethical Decision Making in Biomedicine. Washington, D.C.; National Academy Press, 1995, xv + 541 pp. US $59.95; Can. $82.73.

he task of Canada’s Tri-Council Working Group on Ethics, a joint effort by MRC, SSHRC, and NSERC to produce a single code governing human subjects research, came to a close in June 1997 with the publication of the Code of Conduct for Research Involving Humans. It seems timely, therefore, to reflect upon the role of the public ethics body in our society. Society’s Choices is a thoughtful and thorough examination of a wide variety of public mechanisms for dealing with ethical issues. Ethical reflection and policy making takes place at a number of levels: local hospital ethics committees and research ethics boards, professional bodies, state or provincial initiatives and national ethics committee bodies, such as the Tri-Council Working Group. While all of these levels of discourse are discussed, the authors of Society’s Choices focus on the national level and, in particular, what we can learn from past successes (e.g., National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research) and failures (e.g., the short-lived Biomedical Ethics Advisory Committee) in the American arena. The volume bundles together the final report of the Committee (194 pages), including recommendations for future ethics bodies, with a wide array of commissioned papers (347 pages). Several of the commissioned papers are of particular interest to the research ethicist: Bradford Gray’s "Bioethics Commissions: what can we learn from past successes and failures?," Kathi Hanna’s "The Ethical, Legal, and Social Implications Program of the National Centre for Human Genome Research: a missed opportunity?" and Ronald Bayer’s "AIDS, Ethics and Activism: institutional encounters in the epidemic’s first decade."

Aficionados of the history of research ethics will find the fine-grained analysis of the output of the National Commission and the President’s Commission fascinating. Even from these two highly successful and prolific bodies, some reports were better received than others and the authors reflect upon this fact productively. The most important aspect of this book, however, is the framework developed to evaluate public ethics bodies. The authors of Society’s Choices are wise to recognize that the efforts of a national ethics body cannot be measured adequately by a simple checklist. A number of characteristics are nonetheless shared by successful committees.

• The committee must embody intellectual integrity. Documents emanating from it must be coherent and consistent (and, perhaps, comprehensive); conclusions need to be argued for convincingly; the work ought to draw from the best in the bioethics literature (i.e., it ought to be competent); and finally, recommendations ought to reflect sound ethical judgment.
• The functioning of an ethics body should be sensitive to democratic values. An effective committee will attempt to hear the views of all players. One way of accomplishing this is to ensure that committee membership is diverse. The question of allowing meetings open to the public is difficult; openness is a clear expression of commitment to democratic process, but closed meetings may allow for greater consensus building. In either case, a committee must solicit the views of affected parties during the data-gathering and policy formation process.
• A successful commission will be effective. A public ethics body is more likely to be effective if it is authoritative. Authority may derive from the sponsoring body, or it may come from democratic representation on the committee. The results of an ethics body must be communicated in accessible language and distributed broadly. CD-ROM and the Internet offer new media for the distribution of information. Finally, an effective committee will seek to achieve more specific goals as defined by their mandate, e.g., generation of legislation, education, and impact on public debate.

How does Canada’s Tri-Council Working Group on Ethics measure up? The jury is still out. Indeed, it would be premature to render judgment on the Tri-Council Working Group at this point: it is unclear, at the time of writing, whether the Tri-Council will achieve its main objective, a single code endorsed by the three Councils. Society’s Choices cannot tell us whether the Tri-Council is (or will be viewed ten years from now as) a success or a failure. The value of Society’s Choices is that it provides us with the criteria to make the assessment.

Book Review

By John R. Williams, Ph.D.
Director of Ethics, Canadian Medical Association.

L.W. Sumner and Joseph Boyle, editors, Philosophical Perspectives on Bioethics. Toronto: University of Toronto Press, 1996, vii + 299 pp., $19.95.

he thirteen essays in this collection were originally presented in a 1993-94 seminar series at the University of Toronto. The authors include American scholars Daniel Callahan, Albert Jonsen, Tom Beauchamp, Norman Daniels, Laura Purdy and Dan Brock, Canadians Earl Winkler, Laura Shanner, Christine Overall, Susan Sherwin, Kathryn Morgan and Will Kymlicka, and from the U.K., R.M. Hare.

The principal connecting thread running through the first half of the volume is a concern for methodology in bioethics. In their introduction the editors describe two fundamentally different approaches to bioethics, which they categorize as ‘top-down’ and ‘bottom-up’. The former, also known as deductivism, begins with general principles and applies them in specific cases. The ‘bottom-up’ approach, also known as inductivism, begins with cases and, having resolved them on their own merits, proceeds to postulate general principles based on these results.

Most of the authors concerned with methodology attempt to avoid both of these extremes. Even Tom Beauchamp, one of the founding fathers of ‘principlism’, is at pains to qualify the force of the principles he invokes (autonomy, beneficence, nonmaleficence and justice). Such principles are prima facie rather than absolute, he states; they admit of exceptions and they cannot be used as the sole support of specific judgments in particular cases. Conversely, Albert Jonsen, the major exponent of the form of inductivism known as casuistry, describes moral judgment as "a patterned whole into which principles, values, circumstances, and consequences must be fitted" (p.45). Principles such as ‘do not harm’ are essential in bioethics, but they must be interpreted in relation to the circumstances of particular cases. Several other methodologists in this volume, notably Winkler, Daniels, Sherwin and Brock, invoke the political philosopher John Rawls’s notion of ‘reflective equilibrium’ to explain how both principles and circumstances must be attended to in bioethics.

A second group of contributors is highly critical of conventional approaches to bioethics, whether deductive, inductive or a compromise between the two. In their view, none of these does justice to the concerns of feminism. Laura Shanner argues that bioethicists should begin with consideration of lived experiences, either their own or those revealed through the narratives and descriptions of others. Laura Purdy contrasts feminist (and allied liberationist) bioethics with biased bioethics; the former is based on the premise that "a woman’s welfare is as important as anybody else’s" while the latter "turns a blind eye to women’s needs even as it attends to the needs of others" (p.147). Christine Overall criticizes bioethics for reflecting "the hierarchism, individualism, professionalism, and separatism of medicine and [being] able to co-opt the radical potential of some progressive analyses of health care and the medical profession – including those, such as the ethics of care, that are derived from women’s experience" (p.179). Susan Sherwin outlines a feminist position on justice in health care that deals with "all measures that positively contribute to health, including measures aimed at preventing, not merely treating, illness" (p.203). And Kathyrn Morgan analyses a topic almost universally ignored by bioethicists – cosmetic surgery; she calls for a bioethical political theory to explain the expanding market for potentially harmful bodily refashioning.

The final two essays deal with the use of bioethics to solve public policy issues. Will Kymlicka, using the example of the Canadian Royal Commission on New Reproductive Technologies, argues that public policy makers should not attempt to develop a systematic approach to bioethical reflection but should simply rely on commonly accepted ethical principles and their members’ own moral values. Dan Brock takes a somewhat different approach: although an ethics commission need not adopt a systematic approach to ethical decision-making, it should "present the principal reasons and arguments that bear on and support the specific policy recommendations it makes" (p.209).

Although the individual articles in this volume are of interest, the editors could have added greatly to its value by circulating the articles among the authors and asking them to revise their texts in light of what the others wrote. Only Shanner and Morgan refer to the other contributors. Readers of Communiqué may be disappointed to find that there is virtually no mention of research ethics in the volume.

Recent Publications

Recent publications of potential interest to Communiqué readers

Bulger RE, Meyer Bobby E, Fineberg HV, eds. Society’s Choices - Social and Ethical Decision Making in Biomedicine. Washington, DC: National Academy Press, 1995, xv + 541 pp. US $59.95; Can. $82.73.

Humber JM, Almeder RF, eds. What is Disease? – Biomedical Ethics Reviews. Georgia State University, Altanta, Georgia: Humana Press, 1997, ix + 361 pp. US $49.50; Can. $68.31.

Lock S, Wells F, eds. Fraud and Misconduct in Medical Research, Second Edition. London, UK: BMJ Publishing Group, 1996, xx + 293 pp. UK £33.00; Can. $74.25.

Sumner LW, Boyle J, eds. Philosophical Perspectives on Bioethics (Toronto Studies in Philosophy). Toronto, Ontario: University of Toronto Press, 1996, 299 pp. $19.95.

Keown J, ed. Euthanasia Examined - Ethical, Clinical and Legal Perspectives. New York, NY: Cambridge University Press, 1995, 356 pp. US Hb $74.95, Pb $24.95; Can. Hb $103.43; Pb $34.43.

Zucker MB, Zucker HD, eds. Medical Futility - and the Evaluation of Life-Sustaining Interventions. New York, NY: Cambridge University Press, 1997, 192 pp. US Hb $59.95, Pb $22.95; Can. Hb $82.73, Pb $31.67.