Field of medicine: Medical ethics.

Format: Hardcover book.

Audience: The book will be most interesting and accessible to bioethicists and students of bioethics. It can be read with profit by professionals with little background in moral philosophy, but the rigorous and sustained philosophical argumentation may be slow going for some.

Purpose: To illustrate the grounding of bioethics in our common morality by making its rules, ideals, and methods of reasoning explicit and then relating them to the fundamental concepts and issues of medical ethics.

Content: The rules of our common morality serve as the basis for the book's ethical framework. These rules are based on the universal desire to avoid harm and thus proscribe behaviors (such as killing, deceiving, and causing pain) that are harmful. An exception to the rules can be justified only if an impartial, rational person can advocate that it be publicly allowed. Issues such as consent, confidentiality, paternalism, abatement of treatment, and euthanasia are discussed in light of the ethical framework that is articulated. Concepts important to these discussions, such as disease, competence, and death, are carefully analyzed.

Highlights: Competence is often defined as the ability to understand relevant information and to appreciate that the information applies to oneself. The authors define it instead as the ability to make a rational decision about a proposed treatment. This ability includes not only understanding and appreciating but also coordinating the information with one's own value and belief system. Such a definition excludes competence in any person with a mental condition that causes him or her to make irrational decisions. With this understanding of consent, the authors develop a subtle argument to justify physician paternalism and illustrate it with numerous examples.

Limitations: The book is full of careful, rigorous conceptual analyses and arguments; the prose is sometimes dense and proceeds at a philosopher's pace. This is not a criticism but a warning. Readers not used to the detailed and meticulous style of analytic philosophy may need some patience. The last chapter, which deals with terminating life-sustaining treatment, physician-assisted suicide, and active euthanasia, is disorganized and unfocused. On the last two topics, especially, the argument is imprecise and inconclusive, perhaps reflecting lack of agreement among the authors.

Context: Books on medical ethics typically begin with a chapter on ethical theory that summarizes the leading theories of western philosophical tradition, such as utilitarianism, formalism, and libertarianism, and then move to a discussion of ethical issues in medicine, leaving it to the reader to "apply" the various theories to the issues in an ad hoc manner. Gert, Culver, and Clouser are correct that this approach promotes superficiality and inconsistency. They offer a deeper and more fully integrated treatment of the subject by developing their own theory of morality and using it to illuminate and resolve particular moral issues. The book is a significant contribution to the field and deserves a studious reading.

Reviewer: Chris Hackler, PhD, University of Arkansas for Medical Sciences, Little Rock, Arkansas.