• Open Access

Practical Decision Making in Health Care Ethics: Cases and Concepts (3ed)

By: Raymond J.Devettere , Published by Georgetown University Press , Washington DC 2010 528 pages , Paperback , ISBN: 9781589012516 , RRP US$37.50 .

Reviewed by Jennie Louise

Lecturer, Discipline of Philosophy, The University of Adelaide, South Australia

This book claims to offer a new, virtue-theoretic approach to decision making in healthcare ethics. The author emphasises what he calls prudential reasoning– we ask what we could do to live well. After outlining this approach, the book discusses various issues in healthcare ethics. In each chapter, several real-life cases are described in detail and analysed. The focus is on the United States, meaning that some discussions (e.g. of the legal context) are not relevant to a non-US readership, but the ethical issues themselves have wider significance.

The book is clearly and accessibly written. The case descriptions and the factual/historical background discussions are interesting and informative. Chapter 3, about the language of healthcare ethics, is particularly good, as are the discussions about informed consent and proxy decision making in Chapters 4 and 5. There is a useful annotated list of suggested readings at the end of every chapter (although it would have been nice to see which references were actually used in writing the chapters; there are no footnotes or other citations).

Overall, however, the book suffers from several serious flaws. The first is that the ethical theory is often confused, inaccurate and overly simplistic. For example, the author argues that his virtue-based framework is superior to the ‘ethics of obligation’ because it tells us to aim at happiness, which “is what each of us already desires anyway” (p26). But when we see that the happiness we are supposed to aim at includes the happiness of others, it is just false that this is what we all actually want (regardless of whether it does in fact contribute to our flourishing). The claim must be that if we had appropriate beliefs and reasoned properly this is what we would want. But then there is no difference between the virtue-based theory and any other moral theory, according to which what we ought to do is what we would want to do if we were fully informed and rational.

There are many instances of basic misunderstanding. For example, it is asserted that Kant's Categorical Imperative tells us to act according to maxims which “condone the behavior that we would want everyone to do” (p10). This is wrong: the test is not whether we would want everyone to follow the maxim we adopt, but whether such a maxim could be consistently universalised, that is – roughly – could I will that everyone did that without contradicting myself? Similarly, it is just erroneous to assert (p10) that deontological is synonymous with absolutist.

There are also many cases of confused or fallacious reasoning. One prominent instance is the argument in favour of abandoning the notion of ‘personhood’ in debates about, for example, abortion and euthanasia, and instead substituting the notion of “one of us”. The argument is that the criteria for personhood can be changed to suit our desired conclusion, so that the concept is not useful. It is true that there is controversy over the criteria for personhood (although it is not true that any set of criteria is as good as any other; the question is whether independent justification can be given for the proposed criteria). However, the proposed substitute concept, “one of us”, is subject to exactly the same problem: just as an opponent of abortion can insist that the embryo is a person because it is human life, so they can insist that the embryo is “one of us” because it is human life.

The major failing of the book is that the supposedly novel decision-making approach does not translate across into the analysis of cases. This is perhaps unsurprising, as it is difficult even to make sense of the question we are, according to this book, supposed to ask: namely, what each person involved can do to live well in that situation. Take a nurse wondering whether to protest the withdrawal of a feeding tube for a patient in a persistent vegetative state. To ask what she can “do to live well” in this situation is bordering on incoherent, and can only be answered by assuming that we are really asking what she ought to do.

Indeed, it turns out that the the analyses of case studies (which admittedly are sometimes sensible and insightful) usually depend on nothing more than commonsense and empathy. However, ethical decision making occurs far less often than vague handwaving. Thus, for example, the author defends the permissibility of abortion in cases of ectopic pregnancy or severely defective fetuses, but does not discuss whether he thinks abortion permissible for, say, financial reasons or in cases of rape. Similarly, he asserts that euthanasia is not permissible just because a patient does not want to “lose control”, but does not then go on to say whether he thinks euthanasia is permissible for other reasons.

When there are concrete conclusions they are usually not adequately justified and very often rest on undefended assumptions. One of these is the unexamined premise that even totally unaware human life (e.g. embryos or patients in persistent vegetative states) has significant moral value. Another is the rather idiosyncratic assertion (without elaboration or argument) that “contraceptive behavior, even natural family planning, is always a disorder, a bad feature, in sexual intimacy” (p241). And throughout there is a quite Aristotelian fondness for taking the middle ground between two opposed positions. Moderation in all things may be a good characterisation of virtue, but it is not a good way to choose an ethical position.

Overall, I would not recommend this book for those wanting to learn about the concepts and principles of healthcare ethics, although it may be a valuable source of background information on cases and issues.