Long-term Care Decisions: Ethical and Conceptual Dimensions

ductory text relating to education in bioethics, we might have expected a broad introduction to the kinds of issues with which teachers of ethics in medicine should be concerned and to some ways in which they might build ethics into the education of doctors, nurses and other health care workers. Grafius does give an introduction of a kind to education in biomedical ethics. For example, she gives an overview of some of the topics that might feature in a biomedical ethics education programme, though it is worth noting that most of these, other than issues of consent, hover around questions relating to death and terminal illness. She offers some guidance about the construction of such a programme and gives a step by step guide to a "process for ethical thinking and reflection" a kind of "beginner's guide to ethical decision-making". This detailed procedural guide to ethical thinking might be particularly useful for those whose experience of wrestling with the dilemmas thrown up by practice is limited, and for practitioners who feel paralysed by their inability to make ethical choices. They should, of course, beware of the possibility of falling into the trap of believing that having followed the procedure laid down, the decisions they make will necessarily be the right ones; in any event such an approach, though useful in the initial stages of developing one's ability in ethical thinking, must in my view, eventually be laid aside. Grafius has written Ethics for Everyone from a particular professional and cultural context and much of what she has to say about bioethics education for example, about its scope, when it should take place, and for whom it should be provided, is perhaps of limited interest to those who do not work in similar contexts. The book contains no index, which is always a source of some annoyance. It does, however, contain a substantial bibliographical section containing references to texts (both general and topic-specific), videos and journals dealing with medical ethics; interestingly, though some non-North American books appear, the J7ournal of Medical Ethics is omitted from the list of relevant periodicals as is the journal Bioethics, which I would consider an important international contribution to any library serving health care ethics education. Lists are also given of centres dealing in issues in bioethics; again the focus is on North American centres. This book is best regarded as a source for those who are already involved in teaching ethics to health care professionals. For example, it is a source of ideas for those who are unable to develop pedagogical tools of their own, or who want to learn some new tricks. One such idea is that of the "biomedical ethics grand round" a formal affair where topics or particular cases are presented and discussed in an organised and formal interdisciplinary setting. One possible advantage of such an approach to working on ethical problems, is that the formality of the setting might make it easier for colleagues of different disciplines and different status to negotiate solutions, if solutions there are, to particular problems. On the other hand a formal setting might help to perpetuate certain myths, including the idea that seniority and status necessarily convey moral rightness. Further to her discussion of biomedical ethics "grand rounds" Grafius offers a number of other "educational tools" designed to help participants in classes to become aware of various things mostly, but not exclusively about themselves about their attitudes to death and mortality, about the source and nature of their moral beliefs, and about their relationship to significant others. Many of the tools offered focus on aspects of death and dying and this brings me to a weakness in the book as an introduction to biomedical ethics education in general the limited range of issues that are addressed. Following on from the discussion of these exercises is a chapter about the use of role play, which includes many vignettes which are suggested as the basis for role plays of various kinds. Role play is a valuable tool which can have great power to move but, perhaps as a consequence of this, must be handled carefully. As was the case with the educational tools I have already discussed, I am not convinced that Grafius gives sufficient guidance about its use. She offers both an overview of role play and its uses and some instructions about how to go about setting role-playing situations. However, I do not think this is sufficient to allow those who might use this book as an introduction to biomedical ethics education to use the interesting scenarios she offers to good effect, and more importantly, safely. My view is that role play is used too lightly by too many people who would do well to sensitise themselves to its power. Grafius makes clear that she does not think that role play should be used in isolation, but rather as part of a broader educational experience. In my view it should only be used by those who have given considerable time to learning how it might be used, perhaps as part of a course of study in dramatherapy or psychodrama. Perhaps the most useful feature of this book is the fact that it contains some ready-made topics for discussion or, in the right hands, for exploration through action whether in a mock "grand round", through role play, or through other narrative forms. All of this material would have been much more useful if it had been accompanied by discussion of the ethical issues raised, and by more substantial discussions of the ways in which the material in particular the pot pourri of case studies and vignettes offered for role play might be used.