Book Review

Ethical Issues in Neurology

N Engl J Med 1995; 333:71July 6, 1995

Article

Ethical Issues in Neurology
By James L. Bernat. 364 pp. Boston, Butterworth-Heinemann, 1994. $49.95. ISBN: 0-7506-9501-3

With the rapid spread of managed care, we have entered a critical period in which the very concept of medicine as a profession is being questioned. Faced with the increasing demands of the medical marketplace, many physicians have forgotten how and why medicine differs from other professional services. This book is a timely reminder of what a professional's ideals and behavior should be.

The book is intended for neurologists, neurosurgeons, and other physicians who treat patients with neurologic disorders, but much of it is more widely applicable. The first five chapters cover the fundamentals of ethical theory and practice, professional ethics, medicolegal concepts, and the hospital ethics committee. There are discussions of the ethical issues associated with brain death, the persistent vegetative state, profound neurological defects in neonates, profound paralysis with intact cognition, dementia, mental retardation, neurogenic diseases, and AIDS. The author also examines the concepts of physician-assisted suicide and voluntary active euthanasia, as well as the concept of medical futility.

Each of these topics is covered extensively and with the sensitivity, skill, and wisdom born of erudition and long reflection on these matters. In each case, the author gives not only the points of view of various scholars but also his own opinions. There are numerous well-chosen references, with useful annotations, and a detailed index.

The author is careful to point out the difficulties inherent in practicing medicine at a time when resources for medical care are declining. The concept of medical futility is becoming more important because of this decline. As the author notes, it is unethical to waste resources by treating patients aggressively when such efforts are futile. However, the use of the concept of futility to justify withholding treatment requires care and a thorough accounting of the possible clinical outcomes of various situations. This accounting should foster a consensus among physicians, laypeople, and elected officials about the treatment of hopelessly ill patients.

This book should be a valuable resource for any health care professional struggling with the ethical issues of daily practice.

Roderic Fabian, M.D.
University of Texas Medical Branch, Galveston, TX 77550