Book Review

Medicine Unbound: The Human Body and the Limits of Medical Intervention

N Engl J Med 1994; 331:1664-1665December 15, 1994

Article

Medicine Unbound: The Human Body and the Limits of Medical Intervention
(Emerging Issues in Biomedical Policy Series.) Edited by Robert H. Blank and Andrea L. Bonnicksen. 287 pp. New York, Columbia University Press, 1994. $49.50 (cloth); $17.50 (paper). ISBN: 0-231-08148-0 (cloth)

Medicine Unbound is the third volume in the series Emerging Issues in Biomedical Policy, which examines the policy issues raised by the rapid advances in medical technology. This book is a collection of essays by ethicists, scientists, physicians, and journalists.

Part I explores the issues related to the inviolability of the human body. The essays range from attempts to define inviolability to assessments of the religious, social, and cultural differences that must be examined in framing public policy regarding medical intervention. Part II, a sensitive and thorough look at end-of-life decision making, focuses on the role of the individual in deciding what type of medical intervention is appropriate. These essays cover topics from physician-assisted suicide to the legal basis of patients' rights, case law, and legislative developments.

It is clear from the start of part I that the controversies about inviolability are not likely to be resolved. As Daniel Callahan points out in chapter 9, it is unlikely that we will see an end to efforts to manipulate human life through genetic, surgical, or other medical means. He argues that these efforts are moving in different directions without a unified goal, and he asks whether there is some level of inviolability that fixes the outer limit of our efforts to manipulate life. George Annas gives us a glimpse of this outer limit in his account of the Perfect People Project 2020. By weaving a believable and frightening tale of both actual and fictional experimentation, Annas convinces the reader that society must come to some kind of consensus on inviolability and determine its effect on decisions about medical treatment.

How does a morally pluralistic society come to such a consensus? Throughout the initial essays it is clear that different versions of inviolability are subject to different rules, based on competing moral and ethical principles. The challenge is to create public policy that reflects these different ethical considerations. Lynton Keith Caldwell argues that the force that moves public opinion is based on nonrational moral conviction. The goal is to reconcile what people want to believe and the often contradictory evidence derived from science. To accomplish this seemingly impossible task, Caldwell suggests change through education, experience, and a new definition of ethical values in religion. Public policy regarding the use of medical technology and the inviolability of the body can be developed and implemented once these changes occur. H. Tristram Engelhardt, Jr., and Kevin Wildes disagree that a pluralistic society can ever come to a consensus about inviolability. They argue that it is not possible to choose between competing beliefs when creating public policy and that decisions about medical interventions should be left to the individual, not the state.

What is the individual patient's role in medical decision making? Part II begins with an overview of the legislative attempts to empower the patient with the ability to make his or her own medical decisions, through the Patient Self-Determination Act and the use of advance directives. Robert Weir thoroughly discusses the problems and possible improvements in using advance directives to document decisions about medical treatment. But what if the patient prefers to end his or her suffering by requesting physician-assisted suicide? Timothy Quill, Christine Cassel, and Diane Meier present a convincing argument in favor of physician-assisted suicide and offer clinical criteria for making this complicated decision. Subsequent essays comment on the ethical issues that society will have to face if we take the final step toward this ultimate act of self-determination by legalizing physician-assisted suicide. From his studies of assisted suicide in the Netherlands, Carlos F. Gomez cautions us that governmental control and regulation do not always prevent abuse.

Medicine Unbound is an impressive collection of essays by well-known scholars. The authors clearly demonstrate that as advances in biomedical technology enhance our ability to manipulate life and cloud our definition of humanity, society will be forced to create policies that take diverse values and beliefs into account. As in any collection of essays, there is some repetition, but the editors have been careful to choose authors with different styles and approaches to these complicated issues.

I would not suggest that readers new to the bioethics literature tackle part I of this book. Some of the essays are cumbersome and difficult to read. I would recommend this book to anyone who is already involved in the study of bioethics and policy making. The complete bibliographies following each of the essays will prove helpful to readers researching a variety of current policy issues raised by advances in medical technology.

Anna Moretti Kavolius, R.N., J.D.
Choice in Dying, Inc., New York, NY 10014-4810