Global Responsibility: in Search of a New World Ethic

detailed contractual theory of professional relationships in which the patient has definite duties as well as rights. This is not a new idea. The author quotes the American Medical Association's first code of ethics which included no less than eight positive obligations on the patient. Modern medical ethics, though, is largely doctor-centred, emphasising his or her duties of veracity, confidentiality, justice and so forth and the corresponding rights of the patient. In the author's contractual model, on the other hand, equal importance is attached to the duties of the patient many of which indeed mirror the doctor's duties and the corresponding rights of the doctor. There is also an interesting subtheme. The author is among those who have emphasised the way in which value judgements are woven into the very heart of clinical decision-making. Most doctors, notwithstanding the insights of philosophers and sociologists, still hold an essentially scientific view of medicine, believing that a large majority of clinical decisions are based on purely technical considerations. But all decisions issuing in action involve values as well as facts. And this leads directly to the contractual model, the values relevant to clinical decisions being at least as much those of the patient as the doctor. It also leads to the author's vision of the future of medicine. Recent work in the philosophy of science has shown that science itself is embedded in a complex nexus of personal and social values. In his concluding chapter the author indicates how this post-modern understanding of science could transform every aspect ofthe traditional relationship between doctor and patient. This sub-theme is important. The author claims, rightly, that his contractual model is a counter-balance to the arrogance of technological medicine. But it could be said of his book that it illustrates one of the pitfalls of bioethics the danger as Priscilla Alderson has put it, that patients will be 'recreated doubly as lay people' (1), originally by technical experts, and now by a new breed of ethical experts. The language of contract reinforces this. The author's recommendations on resuscitation orders, for example, although pithy and practical, read like a legal textbook. And in the section on patients' duties, was it really necessary to put the obligation to pay the doctor's fees in top position? The issues here are well illustrated by psychiatric ethics. Along with much of the bioethics literature, this is the one glaring gap in the book's coverage. It is there by implication, of course. But in psychiatry, above all, the evaluative element in clinical decision-making is transparent. And in psychiatry, above all, while legal safeguards on autonomy are essential, we need a return to caring, to that nurturing engagement with the patient's experience and values for which Priscilla Alderson argues. But these cavils are mainly against bioethics in general. This book is vigorous, detailed, well-argued and original. It is a timely contribution to scholarly debate on the relationship between doctor and patient.