Walsh, James L.

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The Linacre QuarterlyVolume 60 | Number 3 Article 148-1-1993[Book Review of ] Who Lives? Who Dies? EthicalCriteria in Patient Selection, by John F. KilnerJames L. WalshFollow this and additional works at: https://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationWalsh, James L. (1993) "[Book Review of] Who Lives? Who Dies? Ethical Criteria in Patient Selection, by John F. Kilner," The LinacreQuarterly: Vol. 60 : No. 3 , Article 14.Available at: https://epublications.marquette.edu/lnq/vol60/iss3/14Callahan proposes is six levels of care; the first sets "the basic moral agenda." Together the first/our levels address those "threats to personal integrity and health that are shared by almost everyone in society"; included are preventative medicine, immunization, antibiotics and primary care medicine. Although further refinement of the specifics that Callahan places at each level is appropriate, his approach offers a much needed methodology for the discussion as we embark on further debate both in the community and in the formulation of public policy. (My own suggestion can be integrated appropriately into Callahan's level three and four.) It is especially important that Callahan appropriately identifies as most basic those forms of caring (hospice, home care, etc.) to which we now give short shrift; in contrast we allocate disproportionately high funding to his level five and six. These later levels include high tech medicine, specialized care and "individual curative needs." Callahan's challenge: as a society we must decide if it is time to assign priorities at the higher levels only when we have made available the basic levels to everyone. Callahan's distinction between curing and caring and its implication is lucid and important. Here, as elsewhere there is a new depth, warmth and an easier style than was present in Setting Limiis. There are few criticisms I can offer of this extremely important book. One weuness is the lack of emphasis on the role of entrepreneurial forces contributing to the problems in health care deli~·~.ry and its high costs. Callahan's identification of professional and societal expectations as critical factors is correct. What also is needed is an eludication and analysis of the manipulation of these expectations by the profit motivation both within and outside the medical profession. Arnold Reiman's characterization of the medical-industrial complex is as appropriate as ever and its influence ever greater. This will be one of the most important books of this decade. It should be read and discussed, not only by those in health care and ethics, but by anyone concerned about the priorities and moral values in society. The themes should be studied by all concerned with economics and public policy. It is imperative that throughout our communities that we find ways to have a meaningful dialogue about the issues that Callahan has so eloquently raised. Just as Paul Starr's The Socilll Trans/oTmlllion 0/ American Medicine was the most important book of the 1980s for an appreciation of the historical background of medicine's current pragmatic and moral dilemmas, an understanding of the content of WhoI Kind of Life will be foundational for their resolution in the 1990s and beyond. - Robert J. Barnet, M.D., MA Who Lives? Who Dies? Ethical Criteria in Patient Selection by John F. Kilner Yale University Press, New Haven, CT. $24.95. The growing necessity to make patient selection for scarce medical resources, where non-selection means death, demands ethically sound criteria for choice which receive widespread acceptance within an ethically pluralistic society. John F. Kilner's book makes a valuable contribution to the quest for such criteria. Kilner is associate professor of social and medical ethics at Asbury Theological Seminary and adjunct professor of medical ethics at the University of Kentucky. The first two chapters deal with the worldwide problem of resource scarcity, the necessity for criteria (as against formal avoidance of criteria) and how the criteria examined in the book have 94 Linacre Quarterly I ~ ... - I I I 4 .. I .. - -I I ~ - I 1 - . 'f . 1 I r -r ... . ] .... ... .... - .. -- r-,,4. - ,'" [ been identified and analyzed. Kilner then brings together for our consideration 15 criteria in present use which he has uncovered through his own original study of U.S. medical directors of kidney dialysis and kidney transplantation facilities. These are considered under four main headings, Social Criteria (social value, favored group, resources required, special responsibilities), Sociomedical Criteria (age, psychological ability, supportive environment), Medical Criteria (medical benefit, imminent death, likelihood of benefit, length of benefit, quality of benefit) and Personal Criteria (wilIingness, ability to pay, random selection). The book ends with a chapter on the use of criteria when the resources are experimental and a final chapter which summarizes conclusions thus far and then presents the author's own selection criteria proposed as both ethically sound and capable of wide acceptance. The 15 chapters dealing with the various criteria follow an identical pattern. First, the author describes the criterion and gives evidence of its use in practice. Then he presents justifications made for its employment and its weaknesses as a criterion. This is followed by a section designated "possible common ground" where the author tries to salvage from the criterion what migbt find common acceptance. The chapter ends with discussion of an illustrative case. On page 226 (chapter 19), the author says that bis analysis to this point has been more descriptive than normative. It is certainly true that he has been anxious to identify those selection criteria whicb have the greatest potential to elicit social consensus. However, all through be has been employing ethical arguments. He has shown a preference for people oriented arguments over productivity oriented ones. Productivity oriented arguments are defined as concerned with promoting the acbievement of some good such as efficiency or happiness. Person oriented arguments are concerned with respecting people per se, irrespective of the goods they produce. But Kilner has not till this point (p. 227) clearly stated his ethical commitments, and even bere he simply states that person oriented concerns should be given clear priority over productivity oriented concerns - yet without diminishing the fullest possible influence of productivity within the dictates of this priority. The reader is referred for discussion of this claim to other works of the author. This is frustrating in a book entitled "Ethical Criteria in Patient Selection", all the more so since the author recognizes that even ethical terms like responsibility and the human are variously employed in different ethical theories. It would have been more helpful had he clearly outlined and defended his ethical stance. It would be an interesting but time consuming exercise to extrapolate this from the text. The author makes a strong statement at the conclusion to his book that a story is what finally makes sense of ethical claims. For him, this is the Judeo-Christian story. The reader is left with a question at this point. Do ethics rely ultimately on religion so that consensus is reached by mistake rather than commitment to value? It is surprising also that Kilner does not discuss religious themes explicitly in the body of his text or in the presentation of his own criteria, nor does he make use of the writings of Christian ethicists. If this is the price to be paid for dialogue with secular medicine, then it is a heavy one indeed. This book is clearly written and has an easy-ta-follow pattern. Non-specialists in ethics will be able to follow the arguments easily. Granted the premises, these arguments make a great deal of sense. Hidden agendas are exposed and values slipping in under different guises are laid bare. For example, on pp. 118-120 he discusses how medical criteria can mask social value criteria. There is a delightful use made of the author's earlier study of the Akamba people of Kenya, corrective of North American ethnocentrism, with respect to scarce resource criteria. Kilner's own criteria (p. 230) are easy to understand and follow a logical sequence. No doubt, some of the author's claims will be disputed. for example, it is not clear that a people oriented criterion is being adopted if the greater number being saved is due to the further activity of the chosen patient (special-responsibilities criterion). Further, a Christian institution would have to allow its Christian intentionalities to inform Kilner's work if it is to be given approval. This notwithstanding, it is the reviewer's hope that this book will find an important place in the esssential search of sound ethical criteria for patient selection for scarce lifesaving resources. - James L. Walsh University of St. Michael's College, Toronto August, 1993 95 

[Book Review of] \u3cem\u3eWho Lives? Who Dies? Ethical Criteria in Patient Selection\u3c/em\u3e, by John F. Kilner

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[Book Review of] \u3cem\u3eWho Lives? Who Dies? Ethical Criteria in Patient Selection\u3c/em\u3e, by John F. Kilner

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