The aim of Neurosurgical Ethics in Practice: Value-based Medicine is to discuss “different ethical issues in the daily practice of the neurosurgical practitioner.” “Value-based medicine” refers to “good values and ethical approaches to problems” as a complement to skillful evidence-based medicine. The book is multi-authored and directed at neurosurgeons in practice and in training. The subject of ethics is broken down into 5 parts: an introduction to ethics, including a history, a review of ethical principles, and cross-cultural ethics; patients’ rights, including informed consent, privacy, and confidentiality; end-of-life issues; neurosurgeons’ duties, including errors, research ethics, professionalism, innovation, and neuro-ethics; and neurosurgeons and society, including conflicts of interest, priority setting, medicolegal issues, media relations, and international collaborations. At least 1 of the authors of each of the 24 chapters is a neurosurgeon. The approach is case-based: each case is followed by discussion and an attempt to extract the salient teaching points. The writing style is carefully edited for consistency and for the avoidance of unfamiliar philosophical language. The possibility of a multiplicity of answers to practical ethical dilemmas is emphasized explicitly. The organization of Neurosurgical Ethics is very effective. No previous background in ethics is assumed. Certain chapters, such as that on the history of bioethics, stand out for their clarity. The closing chapter on international neurosurgery collaborations should be broadened and made a standard part of every medical school curriculum. The inclusion of a section on conflict resolution in the discussion of brain death is extremely helpful. View largeDownload slide View largeDownload slide On the other hand, occasional errors of fact, intermittent simplifications, and a number of subtle biases weaken the discussion. The preface states, for example, that physicians and surgeons are not allowed to practice before taking the Hippocratic Oath (p. vii). Not only is that assertion factually erroneous, but also there has been considerable debate in biomedical ethics circles about whether the Hippocratic Oath is obsolete and what, if anything, a contemporary oath should include. Indeed, many schools no longer administer the Hippocratic Oath. John Rawls’ ideas about justice as fairness are oversimplified, as is the concept of virtue-based ethics. Despite the emphasis on cross-cultural ethics, there is only a superficial treatment of problems around the resolution of ethical conflicts deriving from different constructions of ethical or professional duties. An “ethically sound decision-making process” is recommended, but not adequately described (p. 90) other than to underscore the importance of hearing all sides of the case (p. 12), and being methodical and consistent. Neither necessarily leads to a satisfactory solution. Ethical relativism, especially in the cross-cultural setting (p. 33), is treated more tolerantly than usual: many ethicists would challenge this view. A discussion on disagreements between patients and physicians is tacitly paternalistic (p. 47) and seems focused primarily on ways to achieve patient compliance. It is almost tactical rather than ethical. A discussion of patients’ rights to choose the surgeon of his or her choice all but denies that prerogative. That may be a realistic consequence of functioning within a single payer or government-managed healthcare system, but from an ethical perspective, the discussion is unsatisfying. In another context, both patients and practitioners are admonished to accept compromise in order to achieve the best care. While that may be good advice in negotiation theory, it is problematic in ethics. Ethics is about ideas of right and wrong in an areteic or moral sense. Compromise is a reasonable aspiration in a practical context and may be one tool of many deployed in resolving conflict. The authors, however, advocate acceptance of ethical compromise within certain a priori “in order for the best medical care to be provided” (p. 25). That is a somewhat jarring idea which requires more depth and explanation than has been afforded here. The very good thing about this book is that it is well formatted and configured, short, approachable, readable, and systematic. On the whole, the use of intercalated cases followed by discussions works well. Perhaps because the book is multi-authored, however, perhaps because of its style and perhaps because of an attempt to be concise, it seems more suitable as a casebook supporting a didactic course in ethics than as a stand-alone text. As a casebook, it provides many opportunities for rich, multilayered, guided discussion. It could be improved even further with a better index. Neurosurgical Ethics in Practice serves to remind neurosurgeons that good care really does require attention to values and ethics. In that sense it succeeds very well. The editors have made an important contribution to the profession. It will be of interest to neurosurgeons seeking an overview of medical ethics, ethical methodology, and practical neurosurgical ethics. Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Copyright © 2018 by the Congress of Neurological Surgeons
Neurosurgery – Oxford University Press
Published: Apr 1, 2018
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