Moral Thinking: Its Levels, Method and Point

In this book the authors attempt to display some moral choices faced by patients and health care professionals. The technique used is based on an extended case conference which covers the life history of a i6-year-old unmarried mother with tendencies to incest, suicide and baby battering; the upheaval in her family, and the contortions of the health care team. Seven chapters describe the crises in Angie's decline, and in discussion after each chapter the authors attempt to identify what went wrong, and how it could have been prevented. The story is told racily and entertainingly; but in the discussions the authors revert to that opaque dialect, hybridised from sociology and psychiatry, which some health care professionals adopt when talking to each other. The book suffers as a result, since a full appreciation of the complexities of the case demands more precise descriptions, the avoidance of jargon, and a good deal less rambling. Inverted commas abound, inadequately substituting for definitions: 'tender loving care', 'whole person medicine', 'detective game' (the last being used to mean the process of achieving a diagnosis, I think). Not surprisingly, (given the authors' standpoint) specialists, particularly surgeons, are assumed not to be capable of specialising in the treatment of one particular human disease and considering at the same time the health and feelings of the whole person to whom the diseased tissue belongs. In this, the book re-kindles the flames of anti-reductionism in medical training first lit by Kennedy in his Reith Lectures. When will an informed answer to this most unjust criticism appear? But having said all this, the book is penetrable, indeed readable, and many valuable messages emerge which will be useful to students, some doctors, and, of course, social workers, and anyone who relishes practical exercises in the ethics of health care. Most of the problems, true to life, arise from human failure in the attendants rather than the patient, in the poverty of the services rather than poverty in the home, and in the failure of doctors to perceive rather than the failure of patients to express. Doctor-patient interfaces are examined, and the structure of the resultant relationships is analysed constructively. Hoary old chestnuts get their deserved criticism (student-teaching ward rounds, when improperly managed, can cause havoc amongst patients when will we learn? ) and the bad habits of health visitors and psychiatrists are highlighted honestly. Happily this book does not supply too many answers, or too much advice. The appendices contain many illuminating references to case material for discussion and thought, the reader being asked to work out his own attitude to some ethical conundrums for himself. Some big problems and paradoxes are illuminated for the unaware, for instance: How can cold objectivity (necessary for good management) coexist with sympathy (necessary for good relations) in the same individual? And: When a social problem is analysed by two experts from two different standpoints the answers may be contradictory. These are home-truths formany of us, but refreshingly presented. Although little insight is given into the methodology of health administration (that would require a text-book), this little paperback makes you think, and in doing so promotes sensitivity and forward thinking, two qualities most urgently needed in the jungle of a poverty-striken welfare state.