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Book Reviews   |    
Matters of Life and Death: Making Moral Theory Work in Medical Ethics and the Law
Reviewed by Stuart A. Anfang, M.D.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.3.322
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by David Orentlicher; Princeton, New Jersey, Princeton University Press, 2001, 234 pages, $19.95 softcover

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In Matters of Life and Death: Making Moral Theory Work in Medical Ethics and the Law, David Orentlicher takes on an important challenge in contemporary medical ethics. He suggests that most philosophical debates about fundamental principles guiding life-and-death decisions occur at an academic distance from the real world of the bedside. He emphasizes the moral concerns involved in translating ethical principles into actual practice. Orentlicher first systematically reviews ethical paradigms for considering the moral concerns that arise in the translation of principle into practice. He then applies those methods to three contemporary controversies: the distinction between physician-assisted suicide and withdrawal of life-sustaining treatment; whether pregnant women can refuse treatment needed to preserve the health of their fetuses; and the denial of life-sustaining treatment on grounds of medical futility. Along that line of exploration he comes up with some controversial conclusions, such as a morally justified recognition of a limited right to assisted suicide for patients who are terminally ill.

Orentlicher brings considerable experience to this task. Trained as both an attorney and a physician, he directed the division of medical ethics at the American Medical Association (AMA) and staffed the AMA council on ethical and judicial affairs. With a deft style, Orentlicher interweaves clinical vignettes, case law analysis, and philosophical theory to offer pragmatic and thought-provoking insight into these difficult issues.

Although short, this is not a book for light summer reading. Orentlicher writes clearly and without much technical jargon, but considerable concentration is required in order to follow his arguments. His style reminds one of a common pedagogical technique used by lecturers: he first tells you what he is going to argue, then makes his arguments, and finally summarizes what he has by then ostensibly proven. In written form, however, this approach seems a bit redundant, and there is a way in which the true substance of the arguments gets lost in the repetition. By the end of each chapter, despite Orentlicher's reminder of what he has clearly proven in the preceding pages, the reader is left wondering whether the arguments were really that persuasive or just articulately restated several times.

From a psychiatric perspective, the book is a little disappointing. For example, one would anticipate some exploration of the assessment of decision-making capacity around a patient's selection of physician-assisted suicide. Although Orentlicher briefly acknowledges such questions—for example, in the case of impaired capacity as a result of untreated depression, are treating physicians adequately trained to assess for such issues?—he essentially skips over these concerns in physician-assisted suicide by arguing that the risks are similar for patients who ask that their life-sustaining treatment be withdrawn. Although he may be correct that the capacity issues are not particularly critical to parse the ethical distinctions between physician-assisted suicide and treatment withdrawal, from the perspective of translating principle into clinical practice, these are tremendously important issues that have engendered considerable discussion within the psychiatric literature. But Orentlicher's endnotes on this topic cite a few ten-year-old articles and leave the psychiatrist reader disappointed by his thin analysis.

Overall, however, the book does live up to its (oft-restated) goals and is a compelling discussion for readers who are interested in the intersection of clinical medicine, legal practice, and bioethics theory.

Dr. Anfang is the Western Massachusetts area medical director in the Department of Mental Health and is also affiliated with the University of Massachusetts Medical School in Worcester.

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