A THEORY OF MEDICAL ETHICS

Especially in recent physician writing, the principle 'first of all, do no harm' has gained great prominence,"" says Veatch--preparing to lay the Hippocratic oath out cold. The well-known obligatory oath in its longer form (benefit the patient and keep him from harm) is condemned as paternalistic and individualistic, while its truncated version poses still other problems, especially when not-harming takes precedence over benefiting. Veatch, Professor of Medical Ethics at Georgetown University's Kennedy Institute of Ethics, not only tackles the complex issues concerning the formulation of a new code of ethics for our complex, high-tech society; he uses case histories and prototypes to establish the dilemmas that currently abound for patients, doctors, and the community at large. The approach is particularly effective in his first case--a dying mother seeking a doctor's advice on the mercy killing of her malformed infant. Veatch reviews the moral issues in the light of historical and religious traditions, then reveals the socker: the woman and doctor are Japanese, heirs to a tradition that respects suicide and recognizes a particularly strong maternal-child bond that generates a loving dependency called amae--which can lead, in turn, to a parent's imposing a ""loving death"" upon a child. Returning to Western problems, Veatch then persuasively argues that codes of ""professional ethics"" drawn up within groups in society cannot assert ethical principles applicable to all. In this light, both the A.M.A. and the Hippocratic tradition are inappropriate sources for moral guidance. Similarly, utilitarianism is dissected and found wanting. Veatch opts instead for a three-fold contract or convenantal system. Some universal ethical principles governing behavior in society ought to be discovered or invented by conscientious individuals. Specific ethical principles derived therefrom should then govern a contract between physicians and society. Finally, relations between individual physicians and patients should abide by a personal covenant that allows for a variety of options. Themes of freedom and responsibility, mutual understanding and respect, autonomy and dignity, would provide the framework for the generation of principles. That a community of minds might foregather in the first place, and arrive at a consensus in the second place, seems unrealistic given the passionate pluralism prevalent today. Nevertheless, Veatch's sophisticated analysis and scholarly digging at texts make his book a valuable, largely non-doctrinaire contribution to the biomedical ethics literature.