Edited by Laurence B McCullough, James W Jones, and Baruch A Brody
Oxford University Press Inc,
USA; £37.50
ISBN 0 195 103475
Rating: 3/4

I started reading this book in a week that the medical profession was being pilloried because of several high profile cases of doctors passing through the disciplinary process of the General Medical Council. That week was also associated with the publication of a report by a distinguished barrister, claiming that consultant surgeons were being treated like gods.

I wrote to the Times explaining that after 30 years as a consultant surgeon I could confirm that surgeons were indeed treated like gods. We are expected to perform miracles with inadequate resources and to mate. rialise in several places at the same time because of inadequate staffing levels. Perhaps I should have added that we must also adjudicate on who should live and who should die, and other such ethical questions.

Surgical Ethics has 19 chapters, coauthored by pairs or triplets of practising surgeons and professional bioethicists. The authors admit to an explicit American orientation of the majority of the text, while acknowledging the importance of cultural and societal determinants. For example, in the chapter by Mattox and Engelhardt on moral choices in the face of surgical emergencies, they state, "The actual moral content of these assumptions can only be fleshed out in particular communities within particular societies and will under different circumstances have different expressions in law and policy." Most of the book, however, has a message which transcends geopolitical boundaries.

The chapter on research and innovation in surgery describes with perfect logic, and much wisdom, the ethical imperative for performing randomised controlled trials of any innovations in surgery. The authors describe the grey area where deviation from standard surgical protocols merges with uncontrolled experimentation, concluding that "in the long run diminishing the distinction between scientific enquiry, innovative practice and therapeutic intervention in ways that encourage critical appraisal of whatever surgeons do, seems the wisest course."

I found myself mildly irritated by the chapter on consent for surgery in non. emergency patients. This starts from the assumption that all rational adults wish to be perceived as equal partners in the decision making process for surgical intervention. The patient who does not want active involvement is given scant regard and dismissed within a short paragraph. I would have thought that it was an expression of autonomy for an adult patient who is entirely compos mentis to abrogate his responsibility in the decision making process to the surgeon.

But the most troubling section for me was the one in which Shaw and Purtilo argue for the publication of hospital and physician specific mortality rates. This is already required for consent in some US states and it might be coming to Britain. We are indeed going down this route, but at a huge cost. The general surgeon will disappear and there will be more and more specialisation. Defensive practice may in fact lead to the abandonment of very high risk patients.

So how should you read this book? I cannot believe that there will be many surgeons who will sit down with it in the evening or take it away on holiday and read it from cover to cover. It is more likely to become a resource for teachers of bioethics, who I hope will be teaching all surgical trainees.