Book Review

Ethical Issues in Neurology

N Engl J Med 2008; 359:2737-2738December 18, 2008

Article

Ethical Issues in Neurology
Third edition. By James L. Bernat. 524 pp. Philadelphia, Lippincott Williams & Wilkins, 2008. $84.95. ISBN: 978-0-7817-9060-4

Ethical Issues in Neurology is firmly grounded in clinical practice and empirical data and is supported by conceptual and practical frameworks for action. James Bernat begins his book with theory and praxis and moves through topics that range from death and dying to specific neurologic syndromes and research ethics.

In his discussion of diagnostic disclosure, Bernat rightly presumes the value of sharing the truth, but knowledge and labels are often less than clear and definitive. For example, what prognostic and therapeutic information is provided to a person who is given a diagnosis of Alzheimer's disease? In the chapter on neurogenetics, Bernat provides a good discussion of classic mendelian inherited conditions but does not adequately address the problem of susceptibility genes such as apolipoprotein E4. There are formidable challenges to the application of this kind of susceptibility testing by clinicians; some say that genetics is the future of medicine, but so-called personalized medicine may well be depersonalizing because it reduces people to their genes. For example, apolipoprotein E4 is pleiotropic because it alters the risks for brain disease, heart disease, and other conditions. Given this Gordian complexity, it is difficult for a practicing neurologist to decide what kind of information to share with patients who make the mistake (in our view) of submitting to genetic tests.

Although we commend this book, which is a polished and contemporary presentation of clinical issues, it can be challenged in a broader context of ethics. Bernat pays homage to a principle-based form of ethics and gives little attention to types of ethical approaches other than case-based reasoning. Also largely ignored are ethical questions related to environmental health. This is an unfortunate omission because changes in patterns of disease and local ecology are likely to have a profound effect on the practice of neurology and medicine in the future.

The chapter on neuroethics illustrates the need to be more critical of medical ethical practices. The moral scope of the new field of neuroethics is, in our view, limited. It was defined narrowly by William Safire as addressing issues of right and wrong as they pertain to cognitive enhancement and was then elucidated more broadly by Michael Gazzaniga as a kind of brain-based philosophy of life. In fact, the problems in the field of neuroethics are emblematic of the problems in the entire field of bioethics. As Bernat points out, neuroethicists seem quite ahistorical in their perspectives. The nature of consciousness and the conditions that affect it are being rediscovered, with expectations that modern forms of technology will answer our questions about the relationships between mind and brain. Neuroethicists are excessively enamored of the moral dilemmas they believe to be associated with the use of unproven functional imaging technologies to read minds and the use of yet-to-be-developed cognitive enhancement drugs to improve them. Moreover, they ignore issues of public health and social justice, such as the effects of lifelong exposure to toxins on our brains. Also ignored are the ethical challenges posed by traumatic brain injuries that are incurred in warfare. To what degree should a field that is called “neuroethics” engage ethically in broader problems that impinge on the health of brains?

In sum, Bernat achieves his main objective by producing a guidebook for neurologists who are concerned with clinical ethical issues. However, his engagement in the broad social issues that are becoming increasingly important to good patient care and public health is limited.

Peter J. Whitehouse, M.D., Ph.D.
Case Western Reserve University, Cleveland, OH 44120
peter.whitehouse@case.edu

Daniel R. George, M.Sc.
Oxford University, Oxford OX1 3BW, United Kingdom