The requirement to respect autonomy - The Royal New Zealand ...

BOOK REVIEWSof law and morals that is likely to appealto medical practitioners.The book’s breadth is its strength. Itcomplements the book Medical Law inNew Zealand with its more detailedacademic discussion of traditional healthcare law topics.Giving breadth to a specialist text riskssacrificing meaning for simplicity. Forexample, it is a Herculean challenge toexplain legal philosophical topics such asHohfeldian rights in a page-long sectioncalled ‘what is a right’. Hohfeld wasnever clear on the meaning of a right andhe never intended to describe ‘four distinctkinds of rights’ when he presentedhis ‘fundamental legal conceptions’.Hohfeld’s contribution to legal discoursewas significant, but for most readers adiscussion about the meaning of a healthcare or human right, while challenging,is of greater interest to a health carepractitioner than is Hohfeld’s analysis.International law is dealt with briefly.The author of that chapter states thatan international human rights treatyis not ‘enforceable’. International legalinstruments are difficult to enforce butmost would accept that there is a processwhereby international legal rules becomeintegrated into enforceable domestic law,and therefore become enforceable.The book could be criticised on the basisthat the editors do not ‘offer any generalizations,any theory or philosophy of[their] own in regard to the total subject.There is not a single page of synthesis inthe book’. This criticism was levelled atthe 1958 text mentioned above.The book is worthy of purchase for themanager and the postgraduate studentstudying for professional exams with theadvice that the topics presented in thisbook are a starting point for further study.References to quotations are with thereviewer.Publisher: Brookers, WellingtonDate of publication: 2010No. of pages: 569A Bitter Pill: How the Medical System is Failing the Elderlyby John SloanReviewed by Bruce Arroll, Professor, Department of General Practice and Primary Health Care, The University of Auckland, AucklandIcame across this book as a resultof listening to a podcast from theTherapeutics Education Collaborationin Canada (http://therapeuticseducation.org/). Dr John Sloan was interviewed byJames McCormack (a clinical pharmacist)and Mike Allen (an academic familyphysician from Alberta) on the fragileelderly. It was a fascinating series ofprogrammes. The podcasts are usuallyevidence-based but it was clear from DrSloan that the fragile elderly are never includedin randomised trials so it is an evidence-freezone. In the place of evidence,Dr Sloan provided large amounts of adviceand experience which made sense. Heapproaches every patient as a new entityand is always doing informal ‘singlepatient trials’. You can never predict theresponse of a fragile elderly patient to anytreatment. In the book he highlights thefact that we often feel better about startingmedication than stopping it, which isin some ways irrational. Most people don’tbenefit from most medication (numbersneeded to treat are usually greater thantwo and frequently greater than 30 meaning29 people don’t benefit) while all canget harmed by medication.The book and the podcast gave me acompletely new view on prescribing. I cansee that in future the skill of prescribingwill be working out what to stop and howand when in patients as they get increasinglyfragile. Dr Sloan is very frank abouthis successes and his failures and that isvery refreshing. We all learn from thesuccesses and failures of our colleagues. Itis a ‘dangerous’ occupation that we are inand, although we spend most of our timetrying to avoid harm, it inevitably occurs.There are some wonderful tips in thebook, such as the focus for the fragileelderly is comfort and function and thatwe should forget prevention of most diseasesas that is not the priority. Another isthat keeping someone at home when theyare sick is not abandonment (even if theymay die). Sending a fragile elderly personto an acute hospital can be abandonmentand we need to have informed discussionwith family members. My own experienceof sending such people to hospitalis that they end up in an acute ward, bedbound,and rapidly become less able to goback home and then end up in a rest home.They also acquire hospital infectionswhich complicates their care. Dr Sloandescribes acute hospitals as the ‘antithesisof dying’ which is often what is happeningto the fragile elderly. Knowing whoto talk with in the family is a key skillin dealing with this group of patients.Overall, this is a must read for all GPs.It is easy to read and provides a greatdeal of wisdom.Publisher: Greystone Books, D&MPublishers Vancouver/Toronto/BerkeleyDate of publication: 2009No. of pages: 256VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 349