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Intensive Care: Medical Ethics and the Medical Profession.

Intensive Care: Medical Ethics and the Medical Profession. By Robert Zussman. Chicago: University of Chicago, 1992, Pp. viii + 252. $29.95.

In a remarkable study of what actually happens in intensive care units, Zussman, a sociologist at SUNY, Stony Brook, describes his experiences rounding in two ICUs between 1985 and 1989. His point of entry was observing in the medical intensive care unit of a large "outerboro" institution in New York and later at what he labels a "countryside" hospital in Massachusetts. His focus, unlike that of the others making those rounds, was not on the diagnostic and therapeutic aspects of medicine, but on medical ethics.

While ethics is normative, Z.'s work is not. He simply describes what he saw, heard and learned from the experience of daily rounds and his interaction with physicians, house staff nurses, patients, and families. He tell us how residents think, form their decisions, react to patients, the law, and their own situation. Most have no formal training in ethics. Some even reject the field as divorced from reality. They rely, instead, on some internal sense of "what I think is right and what I think is humane." The goal of their work is summed up by a Countryside resident: "All we care about in the unit is making sure somebody is alive."

The development of high technology produced many of the dilemmas we now confront in medicine: termination of treatment, allocation of scarce resources, decision making for the incompetent, etc. Z. examines these issues and finds that "medical ethics is one thing: medical practice is quite another." Decisions made in what he calls "the culture of the wards" are often different from the abstract theories of the philosophers.

Yet, as Z. documents, the emphasis on autonomy and self-determination raised by ethicists has significantly altered the practice of medicine. The once-near-total discretion of the physician in decision making is over. Patients and families are now fully involved in the process, and in the post-Cruzan era they have the right to decline medical treatments including those that are life-prolonging.

A careful observer and accurate reporter, Z. notes that patients "too sick" for the ICU receive too much preference. He attributes this to the inappropriate way we organize hospitals, to the erosion of physician authority with families, and to the reluctance of physicians ("whether from genuine ethical scruples or from fear of legal consequences") to withdraw treatment. One result of this situation is the growing resentment and even bitterness of physicians toward families who insist on doing "everything possible" for the dying patient.

It is in the legal area that Z.'s description and analysis are weak. He frequently misinterprets the law and the import of court decisions. He writes, e.g., that "Massachusetts law proscribes withdrawing (although not withholding) both hydration and feeding tubes." While a probate court had issued such a ruling in Brophy, that opinion had no precedential value and was soon overturned by the Massachusetts Supreme Judicial Court. He makes a similar error when he describes the Supreme Judicial Court's Saikewicz opinion as that of a lower court. His misreading of Quinlan and Cruzan leads to the overstatement that those opinions "are themselves testimony to the irrelevance of the courts and courts' principles to what actually happens in the course of medical treatment."

Z. concludes his study with the observation that the emphasis on individual rights threatens to become a source not of high ethical principles but of irrationalities and systematic, socially structured bias in favor of those with articulate or forceful families. He is correct. This and the other insights he provides on what we actually do in acute-care medicine makes this study an important resource for those concerned with the nation's health-care agenda.

Boston College John J. Paris, S.J.
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Author:Paris, John J.
Publication:Theological Studies
Article Type:Book Review
Date:Mar 1, 1993
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