(Publicada en American Journal Of Bioethics, March/April 2005, Volume 5, Number 2: 64-6)

Cases are, in many ways, the lifeblood of bioethics (Crigger 1998, 15). Moral theory must be checked against the practical experience case studies provide, which experience may engender reasons to revise accepted moral theory or even to abandon it altogether (Devine 1988). In both law and ethics, precedent cases guide the consideration of new ones (Pence 2004), while new cases sometimes raise novel dilemmas, they challenge the capacity of legal and ethical rules to provide fair and consistent practical resolutions. Moreover, the knowledge of historical cases often provides precious information about why current practices and policies are the way that they are. This seems to be especially true in the field of biomedical research ethics. The reaction to scandals created by particular cases such as the Tuskegee Syphilis Study or the Willowbrook Hepatitis Study has shaped contemporary international standards concerning biomedical research. The same could be said about the Nuremberg Code – a foundational text in research ethics - whose emergence is not understandable without reference to the Nazi physician’s abuses in Dachau and Auschwitz. An increasing number of volumes of case studies are available for the study of applied ethics. Murphy’s book Cases Studies in Biomedical Research Ethics is the first book of this type specifically to adress reseach questions.

Murphy’s book is an exhaustive pannel of historical and fictitious cases that provides an overall view of ethical problems related to research. The breadth of cases is large enough to illustrate how ethical issues related to biomedical research are wide-ranging. Each case entails genuine moral dilemmas. Many morally relevant elements - such as moral and legal duties, interests, economic resources, cultural values, passions, policies, principles and consequences - converge and interact in different ways in each case. As Murphy points out, the motives for, the process of, and the social impact of research are, themselves, morally relevant. 

The publication of this book was partly the result of the work of a group of researchers engaged for two years in identifying key issues in research ethics. The by-product is a collection of 150 cases of biomedical research (some of them are taken from the social sciences). Each case covers one or two pages and they are arranged into 9 categories which constitute each chapter. Those chapters treat the following main key topics: Oversight and Study Design; Informed Consent; Selection of Subjects; Conflicts of Interest; Social Effects of Research; Embryos, Fetuses and Children; Genetic Research; Use of Animals, and Authorship and Publication. Each chapter is preceded by an educational introduction on the historical background of each issue that gives rise to a contextualized ethical reflection. Each case contains an introduction, a synthetic description of the case, and some suggested questions that will guide the study of each case. All the cases contain full references for further independent research. At the end of the book, the reader can find a complete case index, both alphabetically and by the following categories: aging and longevity; animal research; authorship, publication and the media; children; clinical care and research; conflicts of interest; deception; genetic research; human embryo and fetus research; informed consent; institutional review boards international aspects of research; oversight; placebos; reproductive research; research priorities; social uses of research; study design; subject selection; subjects’ rights and duties; tainted data and researchers; transplantation; vulnerable populations and women. This is helpful since many cases speak to more than one issue and therefore could belong to more than one chapter. Although the overlapping of categories may be problematic when it comes to searching for a particular case, the two alternative case indices, as well as a complete keyword index included in the book, minimize this complication. The volume also includes a glossary with definitions of key concepts in biomedical research ethics and the texts of the Nuremberg Code and the Declaration of Helsinki. 

One of the main strengths of this book is that the cases are presented in a concise, synthetic, honest, and impartial way. This helps the reader to discern in what ways the case is problematic without being tempted to adopt a particular moral judgment. Furthermore, cases are narrated in a way that stimulates the reader to discover similary themed cases. Almost all the classic historical cases of biomedical research ethics have been collected in the book; this invites the reader to learn the history of research ethics through the attractive viewpoint of anecdotes. Many of the other lesser known or even fictitious cases importantly highlight how people’s interests can be wrongly subordinated to those of science. In short, the book offers the reader the opportunity to receive a fragmentary but clear, concrete and representative view of the ethical problems related to biomedical research.

Murphy’s book is a comprehensive collection of case studies in research ethics. It is not a textbook in which a moral argument or a thesis is developed. That could represent a danger for a reader who wrongly oversimplifies and denies the complementary importance of non-case based theoretical approaches. In fact, ethical analysis requires a prior understanding of the meaning of specific concepts and moral theories. Mere analysis of cases may not always be abstract enough to identify the theoretical moral problems that could give rise to a sound moral judgment. Indeed, certain renowned bioethicists have warned against the risks and limits of casuistry as an approach to the study of bioethics (Jonsen and Toulmin 1988). Murphy, himself, is aware of this risk and so says: “[u]ltimately, it’s not the case itself, and especially not its length, but the quality of analysis that will matter most in casuistry” (Murphy 2004, 7). As a caveat for readers, it should be remembered that the study of biomedical ethics also requires familiarity with principles and other theoretical concepts that are not always self-evident from a case study. Concepts such as “exploitation” – employed, for instance, when it comes to distributing benefits and risks of research in developing countries (2004) - “non-therapeutic research” (Appelbaum 2002) or “vulnerability” (Levine et. al. 2004) form part of a specific terminology that one should understand before forming a moral judgment on any particular biomedical research case. Furthermore, case descriptions involve narrative elements which could favor a one-sided explanation of the problem. Therefore, it may be dangerous to induce a rule from mere case study. Timothy Murphy does not make this mistake since he doesn’t provide a so-called “right answer” but only describes the cases.

Three minor criticisms could be addressed, not to the book as a whole, but to certain parts. First, some sections of the book (i.e. 3.15 “Payment for Research Subjects”, 6.12 “What Counts as Disease”) do not offer narrative cases with real or fictitious protagonists, but rather descriptions of ethical problems that may arise from biomedical research. This will be a limitation for readers who are looking to cases as practical and concrete examples to illustrate, support or deny an idea. Second, the cases sometimes reflect problems which arise from a specific cultural context and that could be related to its legal conditions. In Murphy’s book, a significant number of the cases are taken from the USA. Even though international regulations exist concerning biomedical research, a foreign reader may find that some of the cases cannot be extrapolated to his or her own society. Third, many cases pose ethical questions that could be much further developed. This is understandable since it is not possible to be exhaustive in a volume of this nature, nonetheless, there are significant omissions. For example, many sections in this book treat ethical issues on Oversight and Study design. However no section raises the fundamental question concerning the theoretical and practical differences between research and therapeutic practices. Another example: Murphy studies the question of surrogacy in research in section 2.4 “Deferred consent in emergency experimentation”. It is known that proxies of incompetent patients may provide consent for research while the patient would have refused the participation (Warren 1986 , Coppolino 2001). Murphy doesn’t consider the question about how to deal with the risk of inaccurate surrogacy. A third example of lack of important study questions concern self-experimentation, an issue to which Murphy consecrates three sections. In Introduction to Chapter 3: “Selection of Subjects”, Murphy explains plainly “the principle of identification” stated in the 70’s by the moral philosopher Hans Jonas. By this principle, Jonas tried to set a way in which recruitment of research subjects would be morally acceptable. Following this principle, researchers should be the first subjects to be engaged in human experimentation, since they are the less likely to be exploited (researchers know better than others the potential consequences of the experimentation and their personal interests can be identified to the aims of the research). We can ask even though if the assumption that researchers are less likely to be damaged by biomedical research is always true. Since the times of Hans Jonas, it has been shown that researchers can be as vulnerable as, and sometimes event more vulnerable than- other populations. In fact, they have been victims of coercion from pharmacological industries who pressed them to experiment on themselves (del Cañizo). We think that Murphy could have asked a study question in this sense in order to give rise to a reflection on Jonas’ theoretical assumptions.

Overall, however, this book successfully accomplishes its main purpose - to be a text for instruction in biomedical research ethics. It’s intended audience is, first of all, composed of those students who have never entered the field of research ethics. Each case is eloquent and clear enough to spur the interest of the reader. Introductions to each chapter and the questions formulated at the end of each case can be useful to help the analysis without obviously favouring a pre-determined resolution. Secondly, and for the same reason, the book will be useful for professors of bioethics. Each case study is a kind of assignment in which student’s reflective and argumentative capacity is engaged. Finally, this book will be very useful for bioethics researchers, since it is, above all, a source of case examples and their bibliography.

(reseñado por David Rodríguez-Arias)

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