This is a learned, even erudite text, examining several fascinating topics – life and death, assisted reproduction, privacy, confidentiality, family care among them. But nevertheless it is a book with serious deficiencies. It is not a wide ranging book on ethics in practice, nor does it have a great deal on ethical theory, although what is there is valuable. It does have a focus on professional practice, but that focus is confined to a small number of professions. Of the thirteen chapters in the book, over half are written from the viewpoint of people working with the health or social welfare professions.
There is nothing on the ethical issues in the sciences, in engineering, in animal welfare, or in aid to the poor of this world. There is only one chapter of the multitude of ethical issues in business – and that is confined to “Corruption”. There is nothing on advertising, marketing, employment practices, stakeholder theory or financial management, or on negotiation and the use of ambit claims.
That one corruption chapter also encompasses government. The all absorbing ethical issues of recent years never surface: Andrew Wilkie and the weapons of mass destruction, the children over-board affair, the accusations against Alan Kessing, found guilty, under penalty of two years in prison, of providing information to the media on the lack of safety at Australian airports. The fundamental moral issue of how much we are entitled to know – freedom of information never gets a mention.
In any case, it is not clear to this reviewer why ethical practices should be of particular concern to the professions. He has always thought that morality is a universal concern. Alexandra and Miller, however, give two reasons for this emphasis. First, the tasks for professionals (in the authors‘ “narrow sense”) are essentially moral – their aim is to help people make a better life. Second, the uncertainty arising in the course of a professional life requires some way of assessing the available options.
These arguments for concentrating on professionals are not convincing. The social issues in the seven chapters are of concern to all of us – whether plumbers, university lecturers, or tow truck drivers. Suicide or euthanasia, for instance (discussed from two viewpoints: from a person‘s right to autonomy and from that of compassion), are factors that influence all of us. Life and death are issues that are universal. This chapter concurs, incidentally, with the general public support for the right of the physician and family to withdraw life support in hopeless cases (passive euthanasia), but not to support euthanasia where an outsider actively assists. The chapter also ends with a two way bet: “even when there are overwhelmingly good reasons to adopt laws forbidding certain kinds of action, there may still be particular cases where action of that kind is morally correct”.
The approach used throughout the book is to set out up to a dozen vignettes at the beginning of each chapter, and then to analyse them. Not all are strictly ethical issues. The chapter on reproduction for instance, quotes the teachings of the Catholic Church. The authors do not appear to come down in favour of this teaching, except perhaps in the case of designer children, although their conclusion there is far from clear.
One overriding difference between this and other publications on ethics is the treatment of ethical theory. The first four chapters cover ethical theories. Existing theories, in Chapters 1 and 3 are, with the exception of Bernard Gert‘s Common Morality, not described in any depth. Utility, from J.S. Mill‘s treatise, gets a page. Kant, in his universalising principle, gets even less, although he does reappear in the Life and Death chapter (9) with a later formulation of his categorical imperative – the principle of autonomy. Gert, however, gets several pages and an apparent endorsement from the authors (with small amendments). They do note, however, that no theory will deliver an unambiguous directive.
Gert is a consequentialist, setting out five basic and five indirect harms that we should avoid. Mill‘s utilitarianism is described as a search after happiness, although Gert, in developing his harm-based focus, does quote Mill: “A person may not need the benefit of others but he always needs that they not do him hurt.” Mill in fact puts avoiding harm at the top of his list: “The moral rules which forbid mankind to hurt one another … are more vital to human well-being than any maxims.” Not harming others is also at the pinnacle of Gert‘s theories. Gert‘s ideals, which are essentially doing good, are not obligatory. The authors take exception with Gert in one respect, claiming that he argues that the ideal that we should help is obligatory only for people in special roles, for instance, that a doctor or nurse is morally obliged to give assistance at the scene of an accident. Gert in fact elevates help into a moral duty if we are the only ones there who can assist (“Common Morality” p. 50). A woman in expensive clothes is duty bound to assist a child struggling in a deep pond.
The second chapter on relativism appears oddly placed. Its conclusion that cultural relativism will not guide us to morally acceptable behaviour raises the question as to why it warrants such an early positioning. The chapter on Virtues and Vices (4) does not make the exaggerated claims of some of the proponents of Virtue Ethics; it does not even make the claim that virtue will decide for us what to do. The chapter is inconclusive, perhaps deliberately so. The last chapter in the theory section (5) explores our emotions: why we want to help, why we harm others. It is a useful reminder of the fact that the reasons why we act in an ethical or unethical way are worth some deep exploration on our part.
So what else could have been included? If we are to discuss ethical practice, even if confining ourselves to the health-related professions, we need to cover Beauchamp and Childress‘s principles of bio-ethics.
It is a near obligatory text in most schools of medicine and nursing around the world. A text on ethics should also include whistleblowing. Extensive research now shows that it is the most effective way to identify and stop wrongdoing; Toni Hoffman in Bundaberg Base Hospital and Steve Bolsin at the Bristol Royal Infirmary have shown us it is a major way to strengthen ethical practices. But whistleblowing – and the multitude of problems associated with it – gets no mention. Similarly codes of ethics, a significant preoccupation of the health industry – where again research tells us ways to make them effective – do not warrant mention. Nor does a book on ethics in practice mention the near exponential increase in ethical guidelines, anti-corruption institutions, and legislation, all part of the practice of ethics.
When the second edition comes, for there is much useful material in the book, it would perhaps be best to narrow the title, to cut back on the overly ambitious claim of the book‘s current title.