Cold comfort, Rae Varcoe

Medical Ethics
Alastair Campbell, Max Charlesworth, Grant Gillett and Gareth Jones
ISBN 0 19 5583507

Into the Fire
Sandra Coney
Tandem Press $24.95,
ISBN 1 877178 071

Medical Ethics is the updated edition of the 1992 Practical MedicaI Ethics. Because it is directed particularly at that very pragmatic trade, the medical profession, the omission of the word practical in this edition seems a curious contraction.

Ethicists are necessarily philosophers, with the resulting inclination to explore points of view, examine argument and define both the underpinnings and consequences of a given ethical position. Philosophers can afford to concentrate on the theoretical. Medical ethics requires an amalgam of theory and practicality, which the phrase medical ethics” only partly achieves.

The first section briefly outlines the history of professional ethics and the principles and value systems which underlie medical ethics. The theory is described in such clear, concise and accessible language that I eagerly anticipated the later sections on clinical ethics and on medicine and society.

As a clinical haematologist, I meet ethical dilemmas frequently. Not only the much publicised conundrums concerning the end of life, but also informed consent in the ill or impaired, transfusion in Jehovahs Witness minors, tissue donation from minors, potentially toxic treatment of malignant diseases in the elderly and issues of rationing within the hospital system.

This week the General Manager of the Auckland CHE has been publicly protesting about reduced funding for the next financial year. Services will have to be curtailed and in our unit or others, some people will be denied treatment. For help in examining the ethics one might apply to this rationing, I turned to the chapter on justice and health care.

While the six principles underlying distributive justice are interesting and the logical reduction of them to two practical principles – equal distribution or distribution according to need with its ferociously difficult practical problems – is understandable, I am still unclear about how to act when rationing is a reality. It is hard to argue with the principles of fairness, distribution according to need, equality of access and with the notions of defining a minimum entitlement of health care . . . to be applied without discrimination to each person in society”, but when even the authors find such an entitlement “very hard to define”, Shanker for some guidance on how to act.

Likewise, the recent furore over the actions of Pharmac in limiting the range of available funded drugs highlights some of the dilemmas of distributive justice in health. Which people or conditions warrant which drugs? Pharmac makes difficult decisions in both an economic and an ethical framework. The latter is not explicit but Pharmac must weigh moderately expensive new drugs for common conditions such as schizophrenia against new and very expensive therapy for rare conditions like Gauchers disease.

Medical Ethics notes the failure of the Core Services Committee and that the consequent practical reality of resource distribution is apolitical balancing act. The exhortation to health professionals to enter the public debate does not help me with today’s rationing, but perhaps knowing that medical philosophers cannot provide any practical guidance will offer other readers more comfort than despair.

However, there is comfort in the chapter on death, particularly when the philosophers step from their office into the ward. Dr. Kevorkian does not feature personally but the issues surrounding active and passive euthanasia here and in the Netherlands and the always troublesome notion of doctorly intent in administering potentially life-shortening drugs are constructively considered, along with the complexities of valuing individual patient autonomy in the face of powerful technologies. This chapter, with its final emphasis on patient autonomy and the humane art that is medicine”, would provide useful background reading for house physicians and others newly acquainted with caring for people with mortal illness.

Because the text is directed at health professionals and therefore assumes basic medical knowledge, the inclusion of such medical detail as the neurobiology of Alzheimers disease OI1h;;gg-@3 involved in xaliious diseases seems redundant in a text on ethics; This is particularly so when there are important omissions as, for example, in the section on ageing and dementia, which contains no discussion on the doctors ethical obligation to caregivers or exploration of their rights.

Conversely, the discussion of research ethics is broad, practical and clearly based on long involvement with research and ethics committees (which are here also described as ethical committees). Because the rights as well as the duties of researchers are highlighted along with the duties of the committee, this chapter would be useful reading for anyone introducing a project to a local ethics committee.

The ethical issues in psychiatry are such painful public knowledge at present that it is disappointing to see so little space devoted to the issues of confidentiality, compulsory treatment and the allocation of scarce resources, as well as to the ethical duties of servants of the mental health service in publicising the dilemmas which scarce resources impose on providing help for the mentally ill. Similarly, a discussion of the ethical difficulties of people finding themselves in a whistleblower situation such as Neil Pugmire’s would have made interesting reading.

Two hundred and three pages after the opening sentence, Medical Ethics is an applied branch of . . . moral philosophy”,

I am clearer about the philosophical constructs which can help in examining many of the ethical dilemmas which confront me and every other clinician. Although it comforts me to know that ethicists and philosophers are as frequently unable to offer anything other than pragmatic approaches, I look forward to the next edition in the hope that it will again be a volume of practical medical ethics.

2

Into The Fire is a collection of Sandra Coney’s columns from the Sunday Star-Times separated into three sections concerning social values, gender politics and health. Each section is prefaced by an essay. The unifying framework is the effect of New Right policies on New Zealand life, but there are diversions into the Old Right such as an amusing interpretation of Prince Charles and his tamponly ambitions, and also mourning for the Old Left, particularly its social, community and political manifestations, as well as for the era of the self-built back.

Sandra Coney’s essays have featured in the Sunday Star-Times for more than ten years, sometimes in close proximity to Frank Haden’s Contributions, much like an antiphlogistic or counterirritant. I enjoy reading and frequently react to them, but the column length limits the development of argument. The essays which comprise a third of this book overcome that limitation and put the columns in context.

The essays alone make informative, persuasive and sometimes disturbing reading. The section on health is closest to my own immediate concerns. In the past I have sometimes had different views from Sandra Coney over such topics as hormone re-placement therapy, and I have felt startled by her apparent demonisation of most of the medical profession, but I found her essay on New Zealand’s experience of health reform so well-documented and persuasively argued that it is both enlightening and frightening.

She exposes the fallacy of assuming that hospital and health services can operate like any other market when the purchasers of private health services are necessarily ill and frequently ill-informed. She clarifies the history of the health reforms and characterises them as a consequence of ideolological wilfulness rather than economic necessity, a conclusion supported by detailed background information 1 and astute analysis.

It is surprising that so few journalists have been as diligent in scrutinising the New Zealand health services as Sandra Coney, and that the politicians have until recently met with very little public opposition in enacting the reforms.

The notion that individuals can either control or predict their health care needs is clearly ludicrous, as are the premises that “only businessmen with no background in the health sector could be trusted to design a new health care system and that health competition will drive down prices – yet so few people seem to be informed about these basic premises. In detailed clear prose, Sandra Coney exposes these and other shakes foundations on which the ineffective constructions of the New Right are built.

The depressing history of the health reforms ends with the conclusion that they are relentlessly unravelling a health system that was once the envy of the world”. It is difficult to believe that Ms Coney’s next assessment of the health services will find her admiring New Right knitting.

The essays on social values and gender politics, The End of the Golden Weather and From Aprons to Power Suits“, like that on health, are lively, incisive, analytical and informative. They also describe and categorise decline.

Despite this, they are as much a call to alertness if not action, rather than an invitation to depression. There is little to amuse, but much to engage in all three of the essays, but for me the most powerful is the essay on health and the most predictable The End of the Golden Weather”. The rest of the collection is as varied as its newspaper column origin would imply, but it sits well with the essays and is at least amusing and at best thought-provoking.

In her introduction, Ms Coney notes that one of the most damaging aspects of the rise of the New Right ideology has been the sidelining of other intellectual frameworks and the stifling of debate. Into The Fire impels debate and discussion. For her diligent research, clear exposition and forceful views, I am grateful to Sandra Coney and recommend Into The Fire to those other citizens who anticipate the politics of the next two years with anxiety.

Rae Varcoe is an Auckland physician and poet.

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