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Clinical Pharmacist Veterans Affairs Medical Center Erie, Pennsylvania
| Edited by H Tristram Engelhardt Jr and Mark J Cherry. Published by
Georgetown University Press, Washington, DC, 2002. ISBN 0-87840-882-7.
Paperbound, x + 331 pp. (23 x 15.5 cm), $39.95.
|
Published Online, December 30, 2002. www.theannals.com, DOI
The book is divided into 7 parts: Moral Responsibility and High Technology: An Introduction; A Moral Consensus Statement; The Challenges of Critical Care: High Technology, Rising Costs, and Guarded Promises; Moral Theological Perspectives; Moral and Public Policy Challenges; From a Different Point of View: Jewish, Orthodox, and Protestant Perspectives; and Critical Commentary. With the exception of Part II, each part is composed of several essays. Interestingly, the essays are not necessarily in agreement with each other. Authors do refer to other essays and coauthors' perspectives.
Essays are well referenced and references are relevant and up to date; substantial references to historical contributions of individuals and institutions are also included. Many of the essays have extensive notes of explanation. Using endnotes to include this information decreases the possibility of it causing distraction.
One author notes that the book is as much a text on moral theology as it is bioethics. This statement is true. The book contains extensive discussion on moral theology at the expense of bioethics. Some essays lose the focus on allocation of scarce resources while they develop extensive perspectives on moral theology, often making them difficult to read.
The essays that are clear and focused include the introductory sections and the essays that address Protestant and Jewish perspectives. Essays addressing Roman Catholic views vary in clarity and focus. Attempts to provide extensive explanation of the Roman Catholic tradition are often deeply philosophical and totally overwhelming for anyone who has no background regarding the documents referenced.
The strength of the book is that accurate descriptions of the moral perspectives on the use of intensive care unit beds according to several faith traditions are presented. Occasional clear and insightful statements lie within the essays, even those that lack focus. The Roman Catholic perspective includes natural law that can be understood by use of reason alone. The dignity of all human life and the potential for spiritual growth during times of unconsciousness are discussed. Quality of life is not a make-or-break factor in decisions. Measurement of a beneficial life is not restricted to living a long or healthy physical life on earth. There is not an obligation (nor is there an absolute prohibition) to prolong physical life with extraordinary measures, since the ultimate goal is eternal life beyond the physical. Discussions of social justice and distributive justice, as well as global perspectives, are considered.
The Orthodox perspective emphasizes that a Christian life must focus on the well-being of others more than oneself and that the ability to offer loving care to others does not end at death. The Christian community has a responsibility to care for others and to be generous toward hospitals and other organizations that provide care. The author addressing the Orthodox perspective (residing in the US) describes critical care issues as rare, partly because, as he states, the resources to provide such care are confined to urban centers. He emphasizes the need to move from a focus on the best medical care to providing the best spiritual care. Protestant theology approaches the issue from the perspective of the fallen character of the world and thereby does not require the impossible. The essay deals with unequal distribution of resources, the search for a just minimum and reasonable resignation to unfortunate circumstances. The Jewish perspective emphasizes the obligation to preserve human life. Quality of life does not play a prima facie role in decisions. The obligation to intervene is greatest when the conditions are specific, concrete, and immediate. Significant sacrifice may be required to save a life. Theoretical threat to human life does not hold the same obligation. Essays providing commentary range from almost antagonistic to summative in approach.
Another strength of the book is that scholars from various countries add a broad perspective and attempt to incorporate a plurality of values and cultures. However, this is also a weakness in that it contributes to the inordinate task that is attempted and, perhaps, to the inability to answer questions or reach conclusions. It does underscore the enormity of the issues regarding appropriate use of medical resources throughout the world.
A weakness of the book is that some of the essays on the Roman Catholic perspective, are presented in a scattered and unorganized manner. This further complicates the understanding of an extremely complex issue.
The title of the book would lead the reader to believe that some practical answers would be included and that a broad range of scarce resources would be addressed. Neither of these is true. At best, the book may provide some understanding of the views of different faith traditions as they relate to patients' healthcare decisions. Generally, it does not provide much assistance to the clinician or administrator trying to allocate or determine how to restrict resources that cannot be provided to all patients. One of the clear points from the Consensus Statement (reprinted from Christian Bioethics and acknowledged, but the specific reference is not noted) is, "Patient-centered and justice-based considerations converge to suggest that critical care services should be restricted to patients who can get medical benefit from the careful monitoring critical care provides."a However, definitions of medical benefit are not clear.
In conclusion, Allocating Scarce Medical Resources: Roman Catholic Perspectives is generally difficult to read and often unfocused. Although the cost is not financially prohibitive to the clinician, the time and effort to read and comprehend it may be. The benefit for the clinician does not equal the effort it would take to read the entire book. It is unclear who would benefit the most from reading this book. The task that was undertaken is huge and the approach diffuse, resulting in an inefficient presentation of complex material, with more discussion of philosophy and theology than practical application to the clinical setting.
Footnotes
a A literature search revealed that the reference is Christian Bioethics
2001;7:179-84. Other articles in this issue comment on the Consensus
Statement. Interestingly, the editor of the journal is H Tristam Engelhardt
Jr, 1 of the editors of this book. Other editors and contributors to the
journal are authors of essays in this book. 
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