Book Review

Standard of Care: The Law of American Bioethics

N Engl J Med 1994; 330:295-296January 27, 1994

Article

Standard of Care: The Law of American Bioethics
By George J. Annas. 291 pp. New York, Oxford University Press, 1993. $24.95. ISBN: 0-19-507247-2

During the past two decades, George Annas has ranked among this country's leading scholars of health law. He has been a prolific contributor to the literature, and his work has offered valuable guidance to bioethicists, physicians, and jurists. Standard of Care brings together Annas's best essays in a well-organized and superbly crafted book that focuses on the most compelling ethical and legal issues of our time.

The 19 chapters are grouped in three sections. The first section, entitled “The U.S. Constitution and Bioethics,” focuses on cases in which the Constitution has failed to shield the physician-patient relationship from unreasonable government intrusion. Annas has made an excellent choice in discussing Rust v. Sullivan and Washington v. Harper as illustrations of the extent to which federal and state governments may influence the physician-patient interaction with constitutional impunity.

Annas then turns to In re A.C., in which the Washington, D.C., Court of Appeals initially decided, then reversed its decision, that a terminally ill pregnant woman could be required to undergo a cesarean section to protect the interests of her presumptively viable fetus -- a decision that would have resulted in a court-ordered cesarean section. In addressing the court's initial decision, Annas states, “This cavalierly lawless and unprincipled opinion posed the question not whether the patient was competent, but whether the lawyers and judges were competent.” Such incisive commentary is representative of the analysis offered by Annas throughout this exceedingly well-written book.

The discussion of In re A.C. is followed by a chapter devoted to a careful review of U.S. Supreme Court decisions on the constitutional right to abortion, from Roe v. Wade to Planned Parenthood v. Casey. Annas's distillation of Casey is excellent, offering the reader a valuable analysis of the present state of the law in regard to this complex issue.

Brief but pointed chapters on the Baby M case and Davis v. Davis grapple with the issues of commercial surrogacy, frozen embryos, and the definition of motherhood. Annas appropriately concludes this section of the book with an evaluation of state and federal judicial pronouncements on the right to die. The Supreme Court decision in Cruzan, as well as important cases from New York and New Jersey, is considered. He urges readers to reflect on the growing importance of living wills, durable powers of attorney, and health care-surrogate legislation.

In the second section, entitled “Private Sector Bioethics,” Annas discusses such issues as the impact of AIDS on treatment obligations in the physician-patient relationship and sociopolitical considerations underlying trials of drugs for the treatment of AIDS. He then offers a comprehensive exposition of the legal and ethical issues raised in current efforts to map and sequence the nearly 3 billion base pairs of nucleotides that form the 23-chromosome human genome. This section concludes with a discussion of the landmark decision in Moore v. Regents of the University of California, which Annas uses to evaluate financial incentives in biomedical research in the light of the fiduciary nature of the physician-patient interaction.

The third section, “Public Sector Bioethics,” addresses organ donation, with an emphasis on fetal-tissue transplantation, including the use of organs from anencephalic newborns. Annas also grapples with the concept of informed consent in scientific experimentation and the role of the institutional review board. Having served as a member of an institutional review board for nearly 15 years, I could not help but underscore Annas's powerfully concise observation that “consent, even informed consent, cannot convert an otherwise unacceptable experiment into an acceptable one.”

The rationing of medical care is an essential topic in current writing on American bioethics. Annas offers a compelling discussion of the allocation of scarce resources, presented in the form of a hypothetical Supreme Court decision handed down in the year 2020. With a majority opinion, a concurring opinion, and three dissenting opinions, Minerva v. National Health Agency provides a balanced examination of the conflicting values inherent in the debate over the rationing of health care. Annas concludes the third section with a discussion of the ethical conflicts that arise in the context of treating Siamese twins -- a particularly timely topic in the light of the recent treatment of the Lakeberg twins in Philadelphia. Also timely is the discussion of assisted suicide, which focuses on the activities of Dr. Jack Kevorkian. At this writing, he is believed to have been involved in at least 18 such suicides.

Annas's case-based discussion is a particularly meaningful vehicle for studying the complex bioethical and legal issues that confront medicine and society today. There are valuable lessons here for both readers who wish to become generally familiar with these issues and for those who already have some knowledge of them. Annas's approach of revisiting important cases from the 1970s and 1980s makes it clear that there is always a new perspective to be gained from a reevaluation of case law. The book is exceptionally well annotated, reflecting extensive research. Annas's lucid and cogent discussions draw from the legal, ethical, philosophical, sociopolitical, and economic literature. His ability to blend humor and wit with incisive analysis makes the book particularly enjoyable.

Throughout the book, Annas's thoughtfulness and intellect are evident. He does not hesitate to use and even juxtapose the views of highly respected scholars in the field. Of even greater interest is the manner in which Annas draws from great works of literature in establishing a foundation for his views or supporting his analysis and commentary. The authors he cites include Albert Camus, F. Scott Fitzgerald, Gustav Flaubert, Aldous Huxley, William Shakespeare, George Bernard Shaw, Mary Shelley, Adam Smith, Alexander Solzhenitsyn, Robert Louis Stevenson, John Updike, H.G. Wells, and William Carlos Williams.

Standard of Care is a pleasure to read. Annas is both concise and thorough. He articulates his views clearly and logically, challenging the reader to squeeze each chapter for the very last drop of intellectual stimulation. For those in the field of bioethics, this book is a must.

Theodore R. LeBlang, J.D.
Southern Illinois University School of Medicine, Springfield, IL 62794