Inequalities in Health in the 1980s

Credibility and accountability are the two themes which must govern a responsive clinical ethics according to Dr Zaner, a philosopher and clinical ethicist at Vanderbilt University in Nashville, Tennessee. Zaner, the director of the Center for Clinical and Research Ethics (C-CARE) and the Ann Geddes Stahlman Professor of Medical Ethics, identifies in the preface two questions which guide this study. The first concerns the appropriate role of the philosopher in the clinical setting. A second, related question seeks to enumerate the intrinsic requirements of an ethics responsive to the moral issues occasioned by the clinical encounter. Paramount among these requirements are credibility and accountability. The ethicist must be: 1) 'clinically astute' and well-informed as to the medical and other facts pertaining to the case; and 2) held accountable for his/her recommendations concerning the case. In addition, the ethicist must understand not only the inherently moral nature of medicine, but also its complex social arrangement. With these themes in mind, Zaner examines the central clinical relationship that between doctor and patient known as the therapeutic dyad. An understanding of this relationship is necessary for an appreciation of the moral dimension of medicine. The moral resolve of medicine arises from this fundamentally asymmetrical relationship between the disadvantaged patient and the professed healer. Zaner's look at this relationship prompts a further inquiry into the human experience of illness, particularly as it is revealed through conversation between doctor and patient. The middle section ofthe book, chapters four to eight, is devoted to an historical and philosophical consideration ofmedicine's response to this physician-patient discourse. This response is governed largely by the prevailing philosophical view of illness and the human body. Although Zaner provides an interesting, if brief, survey of the history of medicine from a philosophical perspective, these chapters digress from his central theme and are far more likely to appeal to philosophers and historians ofmedicine than to the general reader. In fact, throughout the text it is unclear what audience Zaner is addressing: health care professionals, clinical ethicists or philosophers and historians of medicine. Following this digression, Zaner returns to the original challenge of developing a responsive clinical ethics. Through an extensive analysis of a particular case, Zaner stresses not simply the importance, but also the necessity, of this project. Zaner does acknowledge, however, various methodological problems posed by the clinical relationship, for example the problems of 'working with strangers' and the necessity of distancing. In his final chapter, Zaner suggests that the clinical encounter presents an occasion for arousing moral sensitivity, in the need to recognise both the moral imbalance represented by the affliction itself and the moral strength required for an appropriate affiliative response. This therapeutic dyad of trust and care constitutes the moral foundation of medicine. The role Zaner describes for the ethicist is 'to enable and empower both those who take care and those who must trust . to maintain their respective integrities, thereby to become better, morally responsive and responsible persons'. Zaner presents a thorough but highly readable study of the therapeutic dyad. Through the breadth of his approach and the range of knowledge he integrates in this enjoyable volume, Zaner succeeds in locating the clinical encounter within its moral and social context. However, his task has just begun. While he does establish the moral foundation of medicine and characterises some features of a responsive clinical ethics, Zaner also needs to specify how the ethicist can best fulfil this role of enabler and what unique skills the ethicist can offer in facilitating this clinical relationship.