BOOK REVIEW

Methods in Medical Ethics, Jeremy Sugarman and Daniel Sulmasy,editors. Georgetown University Press, Washington DC, 2001, ISBN0-87840-873-8, 314 pp.

It is a reflection of the maturation of medical ethics that it is nowpossible to write a book on its methodology. While this is partly a ‘howto’ guide to medical ethics it is also an attempt to sort out unproductivedisputes between disciplines, disputes that often do little to developmedical ethics.

The editors write the first chapter and it provides a solid framework forthinking through the material that follows. In particular, they give a veryuseful account of the interplay between ethics and empirical work. On p. 5they say, “by examining a moral question from the vantage point of severaldifferent methods, one gains a richer understanding of that moral question,and a better grasp of an answer.”

This view implies that while any one method may provide usefulinsights into a tough moral problem, none of them will be sufficient forarriving at the best answer. The more interesting and difficult question is:how many and which methods are necessary for arriving at a satisfactoryanswer to such a question? The answer here is likely to depend upon thenature of the question, as there will be some moral problems for whichsome methods are absurd. Still, it would have been interesting to hear theauthor’s view on this.

One of the important ground clearing exercises for a book of this kindis to make it clear whether the editors are primarily interested in disci-plines or methods. In doing so they borrow the OED definitions of ‘field,’‘discipline,’ and ‘method.’

. . . we define a field of inquiry as a subject matter or set of phenomena or questionsaddressed by a researcher or researchers. By contrast we define a discipline as a departmentof learning or knowledge, a community of scholars sharing common assumptions abouttraining, modes of inquiry, the kind of knowledge that is sought, and the boundaries ofthe subject matter proper to the discipline. Finally we define a method as a systematicprocedure, technique, or mode of inquiry employed in examining research questions. Wetake the view that medical ethics is a single field of inquiry of great interest to manydisciplines, not a discipline in its own right. What medical ethicists share is a common

Theoretical Medicine 23: 171–174, 2002.© 2002 Kluwer Academic Publishers. Printed in the Netherlands.

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subject matter, not a common disciplinary mode of investigating that subject. Their subjectmatter is the normative aspect of health care (p. 5).

This is a very useful set of distinctions for all people working in medicalethics but especially so for those starting to think and write about it for thefirst time. For many people about to embark on their first project in ethicsit’s often quite confusing to know what medical ethics is and how yourfirst discipline fits within it. The answer that the authors give is that thoseworking in medical ethics have common moral questions and that then it isa matter of choosing the most appropriate method in order to address them.Implicit within this view is the idea that there is something dubious aboutapproaches to medical ethics that treat it as a distinctive discipline. This isa point that may generalise to medical ethics programmes too. Presumablythey too should build upon the grounding that students have in other disci-plines rather than presenting themselves as teaching an intellectually andmethodologically autonomous subject. The authors’ willingness to take afirm line on issues such as these means that this is more than just a book onmethods in medical ethics, it also makes interesting and substantial claimsabout what it is.

Given that the project here is more ambitious than just giving a guideto methodology, it is unsurprising that on page 6 they say, “part of whatwe hope to make possible for medical ethicists is enough of a rudimentaryunderstanding of the other disciplines in the field to help facilitate a better,genuinely interdisciplinary conversation in medical ethics.”

While this is a laudable aim it does raise a question about the appropri-ateness of the title of the book. There is a tendency for those from differentdisciplines to talk past each other but this appears to have more to do withpeople not understanding other disciplines rather than them not knowingenough about the methodologies of different disciplines. If it were the casethat this book covered ‘what disciplines X, Y and Z say about medicalethics’ then it would not be such an interesting volume. While at timesthere is some tension between saying what methodologically a disciplinecan add and what a discipline says, most of the chapters stick closely tomethodology. Nonetheless, I am skeptical about whether a better under-standing of what people from other disciplines are up to will enable a betterdialogue between those working in medical ethics.

What makes many people talk past each other is not just a disagreementabout the methods that are appropriate for medical ethics but also funda-mental differences in what they take the problems of medical ethics to beas well as disagreement about some basic assumptions.

So, for example, if presented with a difficult decision about whetherchildren should be able to refuse treatment, a lawyer might think that theinteresting issue is how this fits with present legal requirements for consent

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and minors, a philosopher may focus upon the rationality and futureinterests of child, and a physician may be concerned with the best wayto ensure that children get the treatment they need. Differences in funda-mental assumptions may be even more difficult. If, considering the sameexample, some medical ethicists reject any attempt to justify an answerby referring to high order moral considerations such as autonomy, othersmay reject any answer that does not make reference to the influence thatpatriarchy has upon the decision that’s made. A better understanding ofmethodology is not going to lead to a resolution of baffling and frustratingimpasses such as these.

In the rest of the opening chapter, the authors give an interestingdiscussion of the fact/value distinction and they list a number of possiblefallacies. At page 10 they talk about empirical studies and normative ethicsand how the empirical feeds into the normative. It is this section that setsup the book for the chapters of methodology that are to follow.

Section two of the book is organised along a spectrum from moreconceptual methods of philosophy and moral theory through to the moreempirical methods of economics and medicine. The first chapter in thissection is on philosophy and it is written by De Grazia and Beauchamp.They suggest that philosophy contributes both method and theory tomedical ethics and give examples of both. There is nothing new here asit is all fairly well trodden ground but it is a useful introduction for thosenew to medical ethics.

The fourth chapter describes the contribution of religion and theologyto ethics. This chapter succeeds in sticking pretty closely to talking aboutmethods. It is also an interesting and useful insight for those who donot know much about theological approaches. Edmund Pellegrino givesan interesting discussion of professional codes in chapter five. His firstsentence says, “Until very recently, both in Eastern and Western medi-cine, codes of ethical conduct provided the only source of judgement ofgood and bad, right and wrong, professional conduct” (p. 70). At first thissounds pretty implausible, surely there was more to physicians’ thinkingin the past than merely reciting whatever code was in force at the time?This overstates the significance that such codes would have had in thatit is much more likely that physicians’ judgements about morality had asmuch to do with what their mentors did as whatever professional codeexisted at the time. This claim should probably be read as being aboutsources of moral justification for moral behaviour as the ability of codes toperform this function is what Pellegrino explores in the rest of the chapter.He attempts to show that “ethical codes still have an important place in thefield, provided their limitations are taken into account.” The key challenge

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for such codes is how they can be used in justification without turningmoral claims into arguments from authority.

I found chapter 6 a bit problematic. It aims to describe legal methodsin medical ethics but ends up giving an introduction to the relationshipbetween law and ethics and the American legal system. Later on in thechapter (p. 97) the authors talk about the advantages and weaknesses of alegal resolution to tough cases in medical ethics, which, while interesting,is not methodology. This is the clearest example of the temptation to slidefrom discussing methodology to discipline. To be fair, a book such as thismust have a chapter on the law and it may be that this is all that can be saidabout it.

Albert Jonsen’s paper on casuistry will be familiar ground for many but,as an introduction to such an important method, this is a great chapter.

I was skeptical at the start of Darrel Amundsen’s chapter on histor-ical methods as to whether it would be possible to avoid slipping into adiscussion of history. However, I was pleasantly surprised that he managedto write something that outlines the pitfalls for the historically naive andmakes suggestion about how to get started. He gives a brief history of thehistory of medicine and examines the nature of the historian’s craft.

The other chapters on method cover topics such as: qualitative methods;ethnographic methods; quantitative surveys; experimental methods; andeconomics and decision science. These are competently written introduc-tions and will be of use to those thinking about how to address a broadrange of questions. Inevitably those who want to know how to conductmedical ethics research and use one of the methodologies outlined willnot have information sufficient to proceed. They can, of course, use thisvolume as a starting point and use the cited supporting literature as well.In fact this is a challenge that exists for all of us working in medical ethics,as it is an area where many of us risk being jacks of all trades and mastersof none.

I think that this book is an important contribution to the field and Irecommend it as a useful resource for those embarking upon projectsin medical ethics. In addition to showing how different methodologiescontribute to the field, it also helps to clarify what the field is. I think thatit might be great use to post graduate students about to embark on thesiswork.

University College and Ethox JOHN MCMILLAN

University of OxfordUniversity CollegeHigh St, Oxford OX1 4BHUK