ETHICAL DILEMMAS IN NEUROLOGY: By Adam Zeman and Linda Emanuel. 2000. Sidcup: Harcourt Publishers Limited. Price £55. Pp. 219. ISBN 9-780702-022272.

Extract

This is Volume 36 in the W. B. Saunders series `Major Problems in Neurology', and has been written by a clinical neurologist from the UK and a medical ethicist from the US. There are 17 chapters by different authors: 10 from the UK, 10 from the US, and one each from New Zealand and Cuba. The content therefore largely reflects the ethical problems and attitudes of Anglo-American medicine. Each chapter heading poses a question and there follows an essay discussing the arguments, both for and against. Some authors have been so even-handed that their own view is either obscured or only becomes apparent at the end of the essay, while others show their bias early, but all are sufficiently well balanced to allow the reader to draw their own conclusions and in the process to recognize their own prejudices.

We would like to think that medical ethics have not or should not have changed over the years, but even if that were true, ethical issues feature much more prominently in everyday medical practice than they did, if only because of the change in the last half a century from a paternalistic attitude to close involvement of the patient with their management. The book starts with a discussion of the philosophical basis of medical ethics from Aristotle to the present day. The subsequent chapters are loosely divided into three sections. The first group relates to diagnosis and communication and discusses such issues as whether consent is required for an HIV test, should we offer predictive tests for fatal inherited diseases, and whether or not to confront patients with medically unexplained signs and symptoms. The two remaining essays in this section discuss whether or not to tell patients with Alzheimer's disease of the diagnosis, and a chapter on the ethics of breaking confidentiality. It is not surprising that these problems are largely resolved and certainly simplified by good rapport and communication with patients. This is summarized well by Simon Wessely in his chapter on medically unexplained signs and symptoms and his conclusion is that patients should be told, and what they are told be both accurate and pragmatic, but he also argues that in some circumstances it may be appropriate to be economical with the truth.