Preface

If you have just stumbled upon this book because it was, in some sense, “the smallest one on the shelf” and you thought this text could give you a brief introduction to bioethics and bioethical concepts, you were partly correct, but mostly wrong. This is a very particular book. But it is not a particularly exciting book. Bioethics is an exciting field of study, it is new, it is evolving, and as a formal discipline it is redefining how we look at the world. But it is far from established, it contains topics that are often contentious, there are perennial controversies and, there are often competing theories as scholars in different schools and traditions strive to give normative dimensions to moral theory in a manner that reflects and meets the challenges of our changing world.

There will not be much of any of that in this book.

Bioethics is growing; it is seeping into many places that we, as health care providers or health care consumers, occupy. Our health is important to us. The way our health is distributed is important to us. The way health care is delivered by our health care providers is important to us.  The issues at the beginning and end of life are, of course, of the utmost importance to us. Health care research is important, and technological innovations are important. All of these areas are changing and bioethics is playing a bigger role in these areas. And there will be much to say about all of these things in this text.

Why this book? The answer to that can probably be understood by knowing the impetus behind this text. It is my sincerest hope that this work begins to fill a significant void in bioethics literature. I am a Canadian physician, and as I began my master’s degree in bioethics in an American university, I searched for this book. Upon realizing that that search was futile, I began to write it myself. Though no one is to blame for it, we live in a world that is dominated by American bioethics and nowhere is this more acutely felt than next door to the United States. We, in fact, owe a debt of gratitude to American pioneers in the recognition and development of the field of bioethics, but for all that is written there is little of practical aid in the day to day “doing” of bioethics in Canada. There are several good Canadian bioethics texts but they deal more with the theoretical concerns and are largely selections of existing literature chosen for particular Canadian relevance. There is surprisingly little on the practical side of how to do bioethics in Canada.

So, enough about this text. Let me just say a word about you. The intended reader of this book is someone that is, or will be, working in health care or research, and someone who lives in or has an interest in Canada. It is geared toward Canadian health care providers, nurses, physicians, physiotherapists, dentists, counsellors, etc. It is also geared towards social workers, administrators, lawyers and of course ethicists that work in health care and related fields. And it is geared towards students of all of these disciplines.

How does this text fit with your vocations and your studies? Moving beyond the philosophical discussion of the nature of morality and the very existence of good and bad, right and wrong (the fascinating study of meta-ethics) and beyond the suggestions of what should be done and how we ought to behave (the equally exciting realm of normative ethics), is the not quite as exciting realm that this book occupies. It is a book about the very concrete and practical considerations of bioethics in Canada. It picks up where many bioethics texts end.

For the intended audience it goes beyond most of the texts in the field. You may have read Aristotle and Kant and Mill and you have a fairly good idea about how people break down the subject of morality and ethics. Perhaps you’ve read the papers and texts of notable bioethics theorists from Canada, America and beyond, and you now have a fairly good grasp of ethical principles and the idea of normative ethics. Likely you have seen the Code of Ethics for your particular profession. And you think you know bioethics; and you do, really, but there is still something missing.

Some examples may reveal just how big these missing pieces are. An example: you are a part of a health care team in an emergency room and you are presented with a 50 year old man severely injured after a motor vehicle accident, he’s unconscious and you and your team are doing everything to save and stabilize him but big decisions need to be made. You rightly decide that his autonomy should be respected, that you should do your best to do the most good and the least harm within a limited health care budget, and you recognize that all that moral theory and the principles and the codes have certainly got you this far…. but then what—what do these considerations look like in practice.  Decisions need to be made; decisions that have to conform to some ethical standard. One wrong move may trespass on this man’s autonomy, may do him more harm than good, and may impinge on the just delivery of care. You are a nurse that discovers he has an organ donation card… is that relevant, or more to the point, is it relevant in your province? You are a social worker that needs to track down his next of kin, who should you turn to and when do you need to consider public guardianship if he is incapable of making his own decisions?

Another example: you are a medical resident doing a rotation in a family practice office and a 14 year old girl appears and asks for contraceptive pill. Is it ok to prescribe it? Can this information be kept from her parents if she is adamant that her confidentiality and privacy be protected? What laws govern this and are they different in different provinces? She asks for STD testing. Can you keep these confidential? What about mandatory reporting of infections? How wide a net do the health agencies cast in Canada and in your region? You are a gynaecologist and a 15 year old asks to have an abortion. Can she sign a consent form? What does the law of the land and your code of ethics say about this? What are the laws regarding abortions in Canada or more importantly why are there no laws about abortion in Canada? What is the status of the fetus in Canada?

You are a family doctor discussing end of life decision making with your patient. What is the status of Advance Directives in your province? How can they be expressed? How shall you counsel your patient? If your patient asks you about physician assisted suicide, can you give an account of the Canadian public opinion, the legal opinion, and your medical association’s opinion in addition to your own opinion? This man’s wife is concerned about euthanasia. Can you reassure her with current and credible information about this issue in Canada? You are a hospital lawyer asked to weigh in on a redrafting of the hospital’s end of life care policies. What considerations must you entertain? What are the Canadian values in this area?

In Canada, the future is now—as a health care worker in the new millennium will you be prepared? You are an ethicist sitting on a Research Ethics Board and asked to review a protocol that involves stem cells. Moving beyond moral theory and what is written in American or international bioethics texts, what are the relevant guidelines in Canada? Who issues them, what is the authority that enables them, and how does the law fit into that understanding? You are a researcher and want to do work in nanotechnology or neuroethics. What has been done before in these fields in Canada, and which legal and administrative and academic institutions have jurisdiction over these topics?

These are but a few of the practical questions that this text can answer. It is not a text on moral theory or a recounting of the significant development of the moral arguments, or a reader of significant writings on the extant moral viewpoints. There are thinkers much smarter than I that have written large texts on this subject. Nor will this text furnish the reader with a detailed account of the provincial health statutes in each region or the phone numbers of the local communicable disease health authorities. But between the purely theoretical and the purely instrumental knowledge of these extremes is a very large void, and it is here in the realm of the real world—that place where we really work—where a book like this is necessary.

This text is a companion to both ends of the spectrum, not in the all-encompassing encyclopaedic sense, but in the supplementary textbook sense. It is a companion to the theoretical and conventional wisdom about right and wrong and about the way things ought to be done. It is also a companion to the nuts and bolts of health care; the drug dosages and treatment protocols, the rolodex on the social workers desk, the sub sections of the legal texts. This text stands as the bridge between these realms.  We may agree on rightness and wrongness, goodness or badness (and likely we will agree more than disagree), but agree or not on the ethics of a situation, there are practical boundaries to behaviour and guides to our professional activities that are delineated by societal mores, public opinion, political climate, fiscal constraints, codified ethics, public and institutional policy, and the letter of the law. That is largely the domain of this book.

So, while this is a very particular book, and even if it is not a particularly exciting book, it is, I feel, a particularly necessary book.

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