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Classic Cases in Medical Ethics.

Classic Cases in Medical Ethics. By Gregory Pence. New York: McGrawHill, 1990. 397 pp. $22.95 cloth.

Quinlan, Cruzan, Baby Doe, Baby M, Bouvia, Barney Clark: with apologies to Wittgenstein, in bioethics it often seems that the world is indeed aU that is the case. But the role cases are thought to play in this field has been undergoing dramatic change lately. During the first decade of bioethics teaching in the 1970s, cases were mainly reference points to the court decisions that shone in the firmament of principles. In the 1980s, as "ethicists" moved into the clinic, they were often more impressed with the cases they found there than with the principles they brought with them. By the end of the decade, taking a cue from the maligned casuistic tradition, a movement led by Jonsen and Toulmin sought to make of cases a bioethical methodology in themselves.

If "principle-ism" has come under attack by an articulate minority in the theory and practice of bioethics, the teaching side has not yet been part of the struggle. I do not mean to impute any pedagogically subversive motivation to Gregory Pence in this book, but the case-based Zeitgeist is surely on the move, and in that respect his approach is timely. Unlike most of the standard texts from which one might teach bioethics, there is here no philosophical development of a "framework" followed by "applications" to "cases," within discussions of which considerations must be "balanced" if straightforward application of principles fails to yield a clear result. Instead, there are sixteen "cases" (in a very loose sense of the word), including in each chapter a historical introduction, a presentation of the case, discussion of the ethical issues, and an update. In fact, this rough pattern is merely a formality, as each chapter has much its own character.

By now, readers will have realized that this is not a "case book" with Pence as editor, but a series of stories with Pence as teller. This is one of the several reasons that Pence's title, though pleasing, is somewhat misleading. Another reason is that the stories aren't always about cases in the sense that they focus on a set of circumstances or conditions that characterize an individual, but have more to do with practices and controversies about them, such as the use of primates in research or mandatory AIDS testing. More seriously, many will feel that these are not classic cases in medical ethics so much as they are sexy cases in bioethics. Numerous pillars in the pantheon of medical ethics cases, including for instance Schloendorff v. Society of New York Hospital and Canterbury v. Spence are not even mentioned. Rather, the episodes related here are identified with the "hot" issues that have set modern bioethics apart from its ancient and more staid variant, medical ethics. They include, among others, Quinlan, Bouvia, Dutch euthanasia, Baby Louise Brown, surrogate motherhood, Baby Jane Doe, Tuskegee, Christiaan Barnard's first heart transplant, Barney Clark's artificial heart, and Baby Fae.

These are among the best true stories of our time, and Pence is by and large a good storyteller. The aesthetics of storytelling are often thought to require the teller's voice to be virtually transparent, to let the story ten itself, so to speak. Yet one also expects a book in bioethics to be critical, setting itself apart from the story. In the critical retelling of stories one side or the other must suffer. Thus at times Pence seems to want to let aU sides have their day while at other times he appears to let a distinct position emerge from the text. When his own views do emerge, they tend to be in line with the received bioethical wisdom, to wit: withdrawal of hydration and nutrition from the permanently unconscious is ethically acceptable, in vitro fertilization is a good for otherwise childless couples, Dr. Barnard abused his heart transplant patients out of his own ambition, and Dr. Bailey exercised poor judgment in attempting to transplant a baboon heart into Baby Fae.

In at least one respect this volume is a tour deforce, for Pence has assembled and mastered a wealth of detail. In spite of all the specifics I found rather few interpretations to quibble about. When he does falter, as in his erroneous description of the current law in Missouri and New York on the Cruzan issue, it is rare indeed and not grave enough to detract from the main point. At times Pence is so caught up in the tale he does not stop to help out the novice that this book appears to be geared for, as when he fails to define a semitechnical term here and there; for example, "residents" are referred to in a context that would not instantly identify them as physicians in postgraduate training.

As an introduction to bioethics, the focus on these good stories is considerably more enticing than the typical anthology of learned essays. Yet particularity also has shortcomings for didactic purposes. Without further instruction someone just starting out win have a hard time making out the conceptual connections among the cases, since Pence's analysis sticks pretty close to each state of affairs. Similarly, although numerous prominent commentators make brief appearances on stage, it is not always clear that their opinions stem from some systematic standpoint. Thus, for example, Paul Ramsey repeatedly sounds like just a crotchety conservative who was especially good at generating neologisms for rhetorical effect" (p. 82). This might be true, but it gives short shrift to the thought of one of the most important figures in the early period.

Pence's enthusiasm for his task, and his obvious empathy for a number of the human beings who were suddenly transformed from patient to cause celebre, are perhaps the most compelling features of this book. His account of the stories of Christiaan Barnard and his first heart transplant patient, Louis Washkansky, and of their developing relationship, I found especially gripping:
 Inside an oxygen tent, Washkansky
 grabbed the tent's sides to prevent
 Barnard from entering to reopen
his tracheotomy hole. Having been
on a respirator before, Louis knew
reconnection of a respirator meant
giving up speech.
Washkansky refused, saying, "No,
Barnard replied, Yes, Louis."
 Dr. Barnard put Washkansky on
 the respirator anyway. Washkansky
 would never talk again. (p. 215)

Though the subject himself was rendered voiceless, his case and those of the others described here speak volumes. Jonathan D. Moreno is professor of pediatrics and of medicine (bioethics) and director of the Division of Humanities in Medicine, SUNY Health Science Center at Brooklyn.
COPYRIGHT 1991 Hastings Center
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Copyright 1991 Gale, Cengage Learning. All rights reserved.

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Author:Moreno, Jonathan D.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Sep 1, 1991
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