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The Future of Bioethics By Howard Brody. 261 pp. New York, Oxford University Press, 2009. $49.95. ISBN 978-0-19-537794-1.

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ince the inception of bioethics as a discipline almost 40 years ago, its scholars and practitioners have devoted much of their time and attention to two sets of issues — namely, ethical quandaries posed by medical treatment, particularly end-of-life care, and the protection of human subjects in the conduct of biomedical research. The reasons for the focus of bioethics are readily apparent to any historian of medicine. The first set of issues flourished in the wake of new technologies that have enabled physicians to prolong life; the second set grew out of infamous cases of abusive “research” at home and abroad — most notably in Tuskegee, Alabama, and in Nazi Germany. In The Future of Bioethics, Howard Brody — a veteran bioethics scholar with a medical degree and a Ph.D. in philosophy — offers an articulate and compassionate plea for an expanded and enriched discipline of bioethics. Drawing on feminist scholarship, Brody accuses bioethics of “wishing to appear macho” by focusing on life-and-death decisions. He argues that bioethics has neglected other important issues — not the least of which is whether patients’ pain, anxieties, and information needs are being addressed — because they seem, by comparison, to be “housekeeping” or “women’s work.” Brody is similarly critical of the field for its neglect of the ethical implications of evidence-based medicine and physician incentives such as pay-forperformance programs. The author argues for a “patient-centered bioethics” that pays attention to these problems and maintains a strong alliance with primary care medicine. This is, he contends, “the side of medicine most concerned about talking with and listening to patients and forging long-term relationships” with them. Brody also argues that bioethicists should talk with and listen to com-

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munities (not just patients), and in an insightful chapter, he compares and critiques several models of community dialogue. More broadly, Brody calls for a revolution in “future bioethics.” He argues persuasively that “we need to understand how certain facts, issues, and questions turn invisible to us, depending on where we happen to be placed in a hierarchy of power” (italics in the original). According to Brody, “feminism teaches bioethics that it must ‘learn to see’ what the dominant power structure may be actively, even if unconsciously, discounting.” As far as inequalities between the sexes are concerned, Brody acknowledges that bioethics has been a relatively good student. It has learned that such inequalities are not resolved “merely by appeal to autonomy” and that “much of human ethical life exists outside of the sphere of rules and principles.” But, the author contends, these insights should also be applied to power disparities that arise from cultural, racial, and ethnic differences; to disparities that are experienced by people with disabilities; and to disparities that are experienced by inhabitants of the developing world. Not surprisingly, Brody’s “future bioethics” has practical as well as theoretical dimensions. He exhorts bioethicists to speak up for the powerless — or, better still, to help the powerless find ways to speak for themselves — and he concludes with a plea for more activism in bioethics. Recognizing the challenges that this vision pre­ sents, he counsels bioethicists to “act as people of thought, and think as people of action.” This provocative critique of bioethics and the accompanying prescription for the future, from one of the discipline’s most respected scholars, are welcome. Although neither the critique nor the prescription will be met with unanimous agreement, they should trigger a vociferous debate about the path that bioethics has taken and the way ahead. Brody’s discussion is also timely, given the recent proliferation of graduate programs in bioethics. Students in these programs deserve the education and mentorship they will need to

n engl j med 361;5  nejm.org  july 30, 2009

book reviews

become the next generation of multidisciplinary bioethics scholars. Taking stock of bioethics is the best way to ensure that they receive both. Jonathan H. Marks, M.A., B.C.L. Pennsylvania State University University Park, PA 16802 [email protected]

Observing Bioethics By Renée C. Fox and Judith P. Swazey. 388 pp. New York, Oxford University Press, 2008. $45. ISBN 978-0-19-536555-9.

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then, did it take them so long to publish the research? Moreover, according to the book’s appendix, their research is essentially based on 45 interviews that were performed between 1997 and 2000 with leading figures in bioethics in the United States. An oral history of U.S. bioethics would have been an expected result of these interviews, but they are not included in the book, other than as select quotations, which seem to me to be used more to illustrate relevant points that Fox and Swazey make than to serve as basic elements of the book. Fox and Swazey do provide the names and affiliations of the interview subjects, and they indicate where all this wonderful firsthand and secondary material is deposited. It is as if something happened that did not permit Fox and Swazey to bring their project to a conclusion once the research was complete. My interpretation is that this book is an answer to what Fox and Swazey call, using a phrase coined by bioethicist Daniel Callahan, the coming of “culture wars” to bioethics. They give an account of the conflict between liberals and conservatives that has characterized the first decade of 21st-century bioethics in the United States. Bearing the message of the importance of thinking socially and culturally, not only about bioethics but also within bioethics, it is as if this conflict obliged Fox and Swazey to reconsider their own involvement in the field. What could have been just a book made of parts and pieces elegantly reframed in an ethnographic style is instead a deep reflection about the future challenges of bioethics. Etienne Lepicard, M.D., Ph.D.

n this book, sociologist Renée Fox and social historian Judith Swazey give us their views on bioethics. The result is not a history of bioethics, although there are many historical insights in the book, especially about the origins of bioethics in the United States (as detailed in the five chapters in part one) and its worldwide diffusion (as discussed in the three chapters in part three). Nor is it a systematic sociological account of bioethics, even though the main theoretical chapter of the book is a plea for the importance of “Thinking Socially and Culturally in Bioethics” (chapter 6) and the last section of the book is called “Taking Stock of Bioethics in the United States.” Instead, the book is an ethnographic account of American bioethics written by two of its principal participants. This is perceptible throughout the book. The authors explain their own positions as “the team of two” in the introduction, and many of the chapters are written from the “observing participant” viewpoint of the ethnographer. Another example of this perspective is Institute for the History of Medicine at Giessen University the authors’ examination of how bioethics was 35392 Giessen, Germany received in different cultures, which spans two [email protected] fascinating chapters on the development of bioethics in France and in Pakistan. Fascinating as the book is, its purpose remains Medicating Children: ADHD an enigma. Why do a sociologist and a social and Pediatric Mental Health historian have to cross the boundaries of their disciplines and adopt a posture taken from an- By Rick Mayes, Catherine Bagwell, and Jennifer Erkulwater. 352 pp. Cambridge, MA, Harvard University Press, 2009. other field of research? Fox and Swazey were $39.95. ISBN 978-0-674-03163-0. funded by the National Science Foundation in the late 1990s to conduct this research and near edicating Children is an account of the the end of the project held a 1-day meeting of an past 100 years of the diagnosis and treatadvisory committee in September 2000 “to discuss some of the major themes and findings ment of attention deficit–hyperactivity disorder that had emerged from [their] research.” Why, (ADHD). The three authors come from different

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n engl j med 361;5  nejm.org  july 30, 2009

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book reviews

Jul 30, 2009 - veteran bioethics scholar with a medical degree and a Ph.D. in philosophy — offers an articulate ... social historian Judith Swazey give us their views on bioethics. The result is not a history of bioethics ... funded by the National Science Foundation in the late 1990s to conduct this research and near the end ...

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