International Journal of Integrated Care, 11 February 2008 - ISSN 1568-4156
Book review
Ethics: contemporary challenges in health and social care
Edited by Audrey Leathard and Susan McLaren
Bristol: The Policy Press, 2007, pp 314,
ISBN 978 1 86134 755 8
M.J. D'Agata, MSc, Biomedical sciences ‘98, Senior officer for non profit Dutch institute for the proper use of medicine, Winner of the Dutch National Healthcare Innovation Award in 2006 and currently studying philosophy of medicine

‘Ethics are on the rise in the 21st century’ the editors state in their introduction. They describe the UK healthcare and social care primarily shaped by financial and political factors since the very beginning of the National Health Service in 1948 and the fifty years to come. One of the major drivers requesting the guidance of ethics nowadays is the increased stress on the healthcare system. Demand spirals out of control by aging populations while costly new technologies enter the market. At the same time funding is restricted, healthcare professionals are getting scarce and public expectations of the system's performance are higher then ever. Ethics are now bringing a more reflective, philosophical element into play, appearing in publications, decision-making, media coverage, corporate codes and professional guidelines.

It's covered in twenty chapters by different authors. First research, provisioning and research governance are described. The next part deals with law and management. The third deals with contemporary ethical issues from the start of life to the end, such as questions emerging from new reproduction techniques to euthanasia.

Before taking a closer look to integrated care, let's set out the basic choice of ethics along which the book is set up. A frameset of four key ethical values appears throughout the book in more or less explicit terms: Beneficence, Non-maleficence, Autonomy and Justice. As laid out in Chapter Two, ethics come in different flavors and evolve in context with their time. Ancient normative ethics describing one's duty found its countermovement in ‘people's rights’. Utilitarianism, practically invented in the UK, share with communitarianism and ‘social contracts’ a focus on collectives instead of individuals. The latter may be better served by virtue ethics, which focus on the character of the actor.

When we focus on integrated care, Chapters Six, Seven and Eight make a beautiful triplet. Chapter Six shows what happens when historically divided structures, social care and healthcare, start bridging. It gives rise to overlapping domains with different ‘historical streams of values’. Here emerges the first key question for ethics and integrated care: “How to implement consistent values in interagency relationships and interprofessional approaches?” Chapter Seven follows up accordingly dealing with interprofessional care. In the light of interprofessional and interorganizational collaboration a second question arises: “Which critical intersection values emerge from partnership working?” The frameset of values mentioned before shifts to Beneficence, Confidentiality, Accountability and Collaborative Governance. The next question is how partnerships ensure their arrangements are really in benefit of the user. Does merging really make a better service, or does it make a better survival strategy for suppliers? Chapter Eight considers the involvement of service users to reassure the arrangements are meeting the needs of the people.

As for the international aspect: I'd say content and audience of the book are confined to the UK area with some sidesteps to kin countries Australia, Canada and the United States of America. The reader must be familiar with British cases and incidents that hit the UK national news. Some phenomena are described as ‘worldwide’, but must really be read as English phenomena. Europe is simply covered by a conclusion taking one sentence with a stereotype. So much for a continent with 710 million people in 48 different countries.

The main points of view are from within the system, about the system, and for the system. When speaking of value streams bridging, they are professional value streams. And wasn't overly professional influence part of the problem in the first place? Clients, patients or people are named ‘service-users’ or ‘users’ in the book, some of the text is about how to give that undifferentiated ‘user’ some influence in the system. Completely missing are the many socio-cultural value streams merging and frictioning in our open societies. How they shape and diversify healthcare wants and needs at the client's side. There's no text at all dealing with questions around value diversity in society on the demand side, and how healthcare could embrace it.

On the whole, healthcare professionals who are trying to find clear directions and who want to make sense of modern healthcare complexities may find it a useful read. Health care suppliers will find many chapters have ‘partnership working’ as a background theme. But if you fully want to embrace the patient's point of view or a customer oriented point of view, you may find too little covered in this book.