Book Review

Ethics and Epidemiology

N Engl J Med 1996; 335:1773December 5, 1996

Article

Ethics and Epidemiology
Edited by Steven S. Coughlin and Tom L. Beauchamp. 312 pp. New York, Oxford University Press, 1996. $49.95. ISBN: 0-19-510242-8

Epidemiology came of age during the last half of the 20th century as a fundamental scientific discipline for the advancement of our understanding of disease. From the association between cigarette smoking and lung cancer to the link between munitions vapors and the Gulf War illness, the principles and practice of epidemiology have guided many strategies for improving the health of populations and treating disease. We have moved from the romantic days of the roving epidemiologist who trekked all over to discover the cause of an outbreak of hepatitis to the sophisticated scientist who works with huge volumes of data to discover causal links. With this maturity comes moral and ethical accountability, the subject of this book.

Ethics and Epidemiology is a collection of erudite essays that discuss the roots of the science, informed consent, study design, the study of vulnerable populations, and scientific regulation and education. Common to virtually all of these essays are the themes of respect for autonomy, beneficence, nonmaleficence, and justice. In particular, patients' rights and respect for autonomy are the seminal issues in the information age in which data bases, communication links, the Internet, and software viruses are the tools of the trade. Gone are the days when patient information was collected on a paper data sheet and then manually separated from patient identifiers before analysis. How information is handled during epidemiologic studies to ensure privacy now and in the future repeatedly receives careful consideration in these essays.

Another theme is the extensive work by national and international associations to develop guidelines for the professional conduct of epidemiologic investigations. Originating with the Nuremberg Code are the guidelines promulgated by the Declaration of Helsinki in 1964, the National Institutes of Health, the Medical Research Councils in England and Canada, the Australian Health and Medical Research Council, and similar councils in other European nations. Although each guideline is different, all strongly emphasize autonomy, obligations to the individual and community, scientific integrity, and access to information.

Most of these essays are written for epidemiologists, ethicists, and legal scholars, who will have a specific interest — scientific, moral, or legal — in each carefully and clearly reasoned discussion of a relevant topic. The chapters in the section “The Study of Vulnerable Populations” stand alone and should be of equal relevance to practicing clinicians. Ethical considerations of research involving children, the elderly, and persons infected with the human immunodeficiency virus are presented here with an eye toward what the practitioner should demand of the scientists conducting the epidemiologic research that comes to define standards of community practice.

The absence of essays that address blacks, other minorities, and women is especially bothersome because various authors in this collection mention the needs of these populations. No doubt there is a limit to the amount of material a single book can include. However, with the mounting epidemiologic evidence of subtle and not-so-subtle racial, ethnic, and sexual biases in medical practice, this topic should have received more attention in this otherwise excellent book.

Max Michael, III, M.D.
Cooper Green Hospital, Birmingham, AL 35233