Bruno Reynell reviews the latest popular text on medical ethics.
A 22-year-old woman is discharged from hospital following treatment for an overdose of painkillers and antidepressants. Thirty minutes later, she covers herself in lighter fluid and sets herself alight. As she is being treated for burns, a tattoo on her chest is spotted – “DNR, do not resuscitate”. The theatre team are faced with an unenviable decision. Continue their resuscitative treatment? Or respect the apparent wishes of the patient?
Though not always as extreme as the example above, Daniel Sokol’s new Tough Choices makes it abundantly clear that such thorny moral dilemmas exist far and wide both in hospitals and beyond. The book consists of a collection of short essays highlighting the importance of medical ethics, and Sokol’s wide-ranging professional experience lends his voice great authority throughout. His impressive credentials include a masters in medical history, a doctorate in medical ethics, experience working as a clinical ethicist in a variety of circumstances, and as a barrister specialising in medical law. It is evident that the cases that he has seen and the situations that he has been in allow him to approach these complicated questions in a manner both considered and empathetic. For such an approach is essential in the realm of medical ethics. In spite of the medical school impression that there are ‘clean’ answers, clinical decision-making in the real world can be surprisingly subjective, with equally experienced hospital staff often coming to different conclusions. There is a concern that medical students today perhaps fail to sufficiently appreciate this: in a memorable passage in the book, Sokol questions a student on medical ethics, to which he receives the simple reply, “I’m scientifically minded so I struggle with the fact that there’s no clear answer in ethics.”
Sokol demonstrates throughout the book that a dismissive attitude like this is far from ideal – although there may not be clear-cut answers, effort should always be made to come to a solution which is as ethically appropriate as is possible. Reading through the essays, it is impressive to see him unpick various quandaries, and you repeatedly find yourself internally nodding at the sensible approaches he takes.
Some of the subjects covered in Tough Choices are well-known for their divisiveness. Essays in the chapter entitled ‘The End of Life’, for example, offer new perspectives on famously sticky subjects such as assisted suicide and DNR orders. Another essay that springs to mind here takes as its subject medical negligence. As Sokol notes at its outset, it is a word that no doctor wants to hear, yet it is a very real prospect in today’s hospitals. It is an issue that can often appear nebulous but the essay establishes with clarity the conditions that must be met for it to occur.
Elsewhere, Sokol writes on matters that some may be less familiar with, but are interesting nonetheless. Examples run from a discussion surrounding the concept of futility, an exploration of whether it is ever acceptable to restrain a patient, to an explanation of the contradictions inherent in the British Medical Association’s calls for boxing to be banned.
The range of experiences recounted in the book gradually establish the relevance and urgency of the book. While the US healthcare system isn’t always held up as a model of excellence, Sokol comments that, when it comes to the application of medical ethics, they are far ahead of the UK. Currently, we see escalating clinical negligence litigation costs in the NHS, combined with poor morale amongst doctors and much public scrutiny resulting from high-profile cases. While clinical ethicists won’t abolish all these problems, Tough Choices makes a thought-provoking and intelligent case for their increased use.