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Drawing the Line: Life, Death, and Ethical Choices in an American Hospital.

Drawing the Line is an intelligent book for a general audience, as

distinguished from a nontechnical book for nonspecialists. In the latter sort of work an author translates his or her expert knowledge into lay language. Something is always lost in translation. Samuel Gorovitz understands that ethics is not the exclusive province of experts, that moral deliberation is decidedly democratic.

Ethical choices are made by everyone, nowhere more poignantly than in the throes of illness and in the face of death. Gorovitz believes that such choices are likely to be better--sounder, more responsible, more satisfying to those who have a stake in them--if they are thought about before they have to be made. And so he has recorded his experiences as an observer in a major teaching hospital and invited readers to reflect upon the import of what he witnessed there.

Availing himself of the device of dialogue, Gorovitz speaks alternately in two voices throughout. He reports and then thinks aloud in print about what he has seen and heard. The reader is privy to the author's observations of doctors, nurses, patients, and trainees, and one is engaged by the author speaking in his second voice, in a thoughtful consideration of the ideas and questions raised by the reportage. This makes interesting reading. It also makes you stop and think.

A nurse responsible for dialyzing an intermittently lucid AIDS patient who is near death asks rhetorically, "Are we doing anything for him or just to him?" Has he been offered dialysis because it is available (and paid for) and he has kidney disease? Or because this particular treatment will ease his dying? Assuming that this treatment is appropriate for this particular patient, does publicly funded end-stage renal disease treatment amake social sense? "We cannot conclude," Gorovitz avers, "that it is good to have any particular program on the grounds that each instance of treatment under that program can be reasonably expected to be good, considered separately. We need to make judgments on the basis of collective concerns. But that is something we do not yet know very well how to do." Moving deftly from particular situations to their public context and back again, Gorovitz illuminates vast tracts of contested terrain. The reader begins to see beyond the flat map to the topographical moral landscape of hospital care.

From the author's sketches of ongoing debates about in vitro fertilization, abortion, organ transplantation, cost containment, computers and confidentiality, and more, we get a sense of the sweep of recent developments in American hospital care and their ethical impact. Gorovitz's point of view is never obtrusive and always evident. Of DRGs he observes that they are fiscally sensible and, on balance, therapeutically defensible but have drawbacks nonetheless. For exaample, patients discharged to mend at home deprive health care providers of visible evidence of their good efforts, evidence that can "sustain them through the tougher aspects of their work." Of long-term care for the elderly Gorovitz asks, What are its purposes? Are we primarily committed to longevity? Do we mean to enhance the lives of the elderly, to provide opportunities for satisfaction in old age, irrespective of the length of a life? Are we trying to spare the young? Where does the cost of care come in? "Unless we know what aspirations are appropriate, it is impossible to evaluate our programs or our progress, or to know what changes to advocate."

Readers with an ear for irony will quickly realize that this book is titled with a twist. "Drawing the line" suggests a book of quandaries. There are some of those in these pages but mostly one finds moral dilemmas, hard situations that could be handled equally responsibly this way or that. Or this way this time and that way next time. It is not that these dilemmas are irresolvable. And it is certainly not that any decision is as good as any other. Gorovitz amply demonstrates that there are better and worse ways to resolve moral dilemmas in medicine, but his more fundamental insight is that. it doesn't matter where exactly such lines are drawn, so long as they include the clearly tolerable caes and rule out the clearly intolerable ones. Draw them anywhere, after suitable public debate, so long as they fall within the band of grey that separates black from white cases. Once we recognize that it is unnecessary to draw the line precisely, we need no longer be distressed that it is impossible to do so. There is a range within which judgment must be made, and that we can often do.

Following an infatuation with legalism, medical ethics is recovering an appreciation for the role of discretion in clinical judgment and health care politics. Drawing the Line puts Samuel Gorovitz in the vanguard of this reevaluation. This is analytically adept, commonsense philosophy, as concerned with the character of moral judgment as it is with the criteria and ends of moral action. It is also high-caliber practical philosophy, informed by ideas, deepened by experience, and attentive to practice.

Ronald Carson is Kempner Professor and director, Institute for the Medical Humanities, University of Texas Medical Branch at Galveston.
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Author:Carson, Ronald
Publication:The Hastings Center Report
Article Type:Book Review
Date:Nov 1, 1991
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