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Reading:3 8/15/07 3:36 PM Page 18 Beyond the Hippocratic Oath: A Memoir on the Rise of Modern Medical Ethics by John B. Dossetor. 298 pp., $39.95 W ould you ever forcibly vaccinate a person? Make a 15-year-old girl undergo a heart transplant even though she didn't want it, but her entire family did? Perform a transplant on a man who had found a donor by advertising in the newspaper? These are all real situations that Dr. John Dossetor, a pioneer nephrologist in Canada and an expert in medical ethics, discusses in his fascinating book Beyond the Hippocratic Oath. As Dossetor sees it, there are four "epochs" in modern medical history: the first covers about 1760 to 1880, the second 1880 until the beginning of World War II, the third 1940 to 2000, and the fourth spanning 2000 to what he conjectures will be 2060. Over these time periods, as knowledge about disease and medical interventions have grown, people live and survive ever longer. Dossetor starts with the third epoch, which is when he attended medical school and began practice, and when medical ethics really emerged as a field. During this time, the evolution of the provision of healthcare posed some really tough, complex dilemmas—often with no right answer or no apparent right answer at the time. The fourth epoch deals with questions arising from the manipulation of genes, genomes, and molecular medicine. He divides most medical ethics questions into big-ticket and small-ticket groups. In the big-ticket category are societal questions such as allocation of limited resources (whether a large amount of resources should be spent helping a very small number of people when the rest of the populace has pressing needs, too); what constitutes life and what death when quality of life is factored in; and to what extent should patients and research subjects be educated to gain informed consent? In his view, small-ticket questions stem more from the individual health provider-patient relationship, such as how respect is shown for patients through how they are addressed or greeted, or how much care is given to the patient when the provider is under time constraints. Dossetor tells and explains the development of his framework for thinking about medical ethics through his own career as a physician working first in British obstetrics, then cardiology, then liver disease, then transitioning into nephrology and kidney transplantation in Montreal, Canada. In the 1980s, Dossetor took a sabbatical to study medical ethics and established a new program in bioethics upon his return to the University of Alberta. Underlying ethics are the perceived values shared by a society—values complicated by differing religions, cultures, sexes, and generations. Moreover, values are constantly evolving. Over the years he has struggled to ascertain and apply these values to many conundrums, such as how to handle a patient who advertised in the newspaper for and found a donor willing to give him a kidney "out of love." (The transplant 18 REGISTERED NURSE team let him accept the organ, but only after setting up a series of hurdles both the patient and donor had to jump through.) The chapters on transplantation ethics and evolving societal values are among the most intriguing. Dossetor spends some time explaining why he believes the free marketing of human kidneys is wrong, leading the reader through a discussion of individuals' autonomy—categorizing arenas in which society accepts an individual's full autonomy and in which it limits autonomy to protect others from physical harm, psychological or spiritual harm, or preserve the common good. In evaluating evolving societal values, he introduces readers to the concept of eth-memes, which are cultural ideas, attitudes, styles, or behaviors related to ethics that are passed from generation to generation. In the Western world, for example, conceptions about race, gender equality, interracial marriage, and the right to suicide have changed dramatically over the last century. "The challenge of ethics is to explain the transition from is (facts of nature or the natural properties of things) to ought (choice of action in accord with our norms or values with respect to good or bad, and right or wrong)," writes Dossetor. One useful way of gauging whether one acted ethically is to ask, "Would I be quite happy to have what I am about to do or did reported on the front page of the local newspaper?" A higher standard for evaluating something done in the past would be to ask the same question, but in the context of today's ethical perspectives. Looking forward, Dossetor would like to see medical professionals moving from the goal of "informed consent" to "comprehended choice," a higher standard that may involve a person or team of people other than a physician who knows the patient, understands his or her values, and knows the patient's medical history. He would also like to see better strategies for maintaining human dignity in the face of impersonal procedures and technologies that increasingly alienate patients from providers. Dossetor also anticipates many more developments in how end-of-life situations are handled, and the challenges of agreeing on values in a multicultural society. Dossetor opens the door to a whole host of challenging questions with which all medical professionals should consciously grapple. The book is peppered with "ethical dilemma" case studies that are fascinating to read just for themselves. The volume is narrated mostly as a memoir, so readers sometimes have to slog through sometimes tangential trips down memory lane, but it's worth it for the insights. —lucia hwang Cheap Motels and a Hot Plate: An Economist's Travelogue by Michael D. Yates. 272 pp., $15.95 C heap Motels and a Hot Plate: An Economist's Travelogue is a travel book for The Rest of Us. Not content to simply trill about the beautiful views of the Grand Canyon or the rich multicultural hustle and bustle of New York City, Michael D. Yates takes readers behind the scenes of America's favorite places. There we meet the armies of migrant workers and disenfranchised locals who keep the gears of tourism turning, and see the dirty, gritty reality of what life is like for those who live year round in Vacationland. Yates' story is a warts-and-all ode to our enormous, ostentatious, diverse, and undeniably unique nation. Observations are narrated simultaneously in both the keen voice of a labor expert and the earnest wonder of an appreciative small-town wanderer. To put everything in context, each new setting is introduced with a sweep- W W W. C A L N U R S E S . O R G J U LY | A U G U S T 2 0 0 7