Medicine and multimedia: The New Dictionary of Medical Ethics
Authors: Pamela J Taylor
Journal: BMJ (1998)

Eds Kenneth M Boyd, Roger Higgs, Anthony Pinching

A man recovering from schizophrenia told me with some pride that he had started to read a book. “Good, what are you reading?” I asked. “The dictionary,” he said. At the time I thought his choice indicative that his recovery was not complete. Now I have been asked to review, and thus presumably read, a dictionary for the BMJ. Is this a lesson in not being too ready to infer pathology in patients?

The effort to produce this particular dictionary was important. As medical care and treatment develop, so the challenges to ethical practice change too. There is a tendency to attribute much of the latter to growth in technology, but at least as great a challenge has come from an extension of the holistic approach—the multidisciplinary team.

Technology is defined in the dictionary as “The tools that extend the doctors’ skills,” but the entry has little of an ethical dimension. The reader is taken to the brink—with the use of computers to produce statistical probabilities in diagnosis or prognosis—but that there are ethical issues raised by this, such as by application of an actuarial approach to an individual, is not apparent. As forms and checklists, which diminish individualised approaches, are increasingly favoured by health authorities and may be sought in litigation, this is a live issue. Then, perhaps the greatest threat to ethical practice in terms of its confidentiality—the photocopier—is neither mentioned as a technology nor in its own right.

The multidisciplinary team, as a listed item, receives the kind of attention that seems closer to stated editorial aims, the principal entry balancing acknowledgment of some of the crucial issues—such as complexity of health care, responsibilities, and duties of care—but also cross referencing to other key factors such as confidentiality and concepts of professionalism.

So far so obvious, but one of the questions that keeps recurring in attempting to read such a book is how the balance of work was divided and, indeed, why some items were chosen at all. Some key words, such as “Animal experiments” or “Moral theory,” seem directly pertinent; many religions receive mention, and topics of special current controversy such as cloning or xenotransplantation are there. Why, however, is premenstrual tension included, especially as there is no hint of the recent but perhaps dead controversy about its use as a defence in the criminal courts? Why is terrorism as a distinct form of harm to others specifically referenced in such a dictionary? 

One of the longest sections in the book refers to my own specialty—forensic psychiatry. This is the subject about which I know most and by which, fairly or not, I am inclined to test the standard of the whole. Although this is a multi-author book, it has editors to maintain such standards. The first couple of sentences of strict definition for the topic are sound and encouraging. The rest of the entry is a mix of idiosyncratic choice of issues, misinformation, poor advice, and even misdirection. One sentence states: “Information must never be given to the police about patients under the care of a doctor.” The directive tone here is inappropriate; the form of words is meaningless, since it bypasses the core issue that it is the doctor in the traditional doctor-patient role of care and treatment who, if approached by police, has the dilemma; and the implied advice is wrong in that the situation is no different from any other in which it is necessary for the doctor to balance a primary duty of care (and confidentiality) to the patient with an occasional overriding duty to prevent serious harm to others. The task of medical ethics is not to issue orders but to clarify the issues to assist the doctor (or other health worker) to make the best, most ethical decision possible in each set of circumstances encountered.

When my patient was fully recovered I do not think he would have persisted in reading this book, but doctors certainly need a better grasp of ethical issues. As yet the book is too patchy to be taken as a source of reliable reference. If I were to recommend it, then it would be as a starting point in seminars, asking students and colleagues to discuss what they would have chosen to put in and what to leave out, to share their favourite and most hated definitions, and, perhaps most important of all, to provide improved versions of the definitions or essays if they could. It is easy to criticise, much harder to do better.