Using their vast knowledge of clinical bioethics, Robert Hall, a doctor of philosophy and sociology with experience in clinical bioethics committees in both the United States and Mexico, and Eduardo Farías Trujillo, a professor of applied ethics, theology and patristic sciences, describe in this book the theoretical foundations of current bioethics as seen from clinical practice. They present various situations and their respective ethical approaches in the form of clinical cases, highlighting the diversity of issues addressed in the 31 clinical cases presented. The common axis is the so-called «ethical reflection» and its applicability within practical ethics, above theoretical knowledge or speculations on biomedical morality.

The work explains the turn and evolution of ethics in relation to clinical ethics and its employability in the various hospital committees for the resolution of ethical-moral problems, as well as the role played by patients in ethical reflection and in the deliberation of decisions.

One of the points best developed by Dr. Hall and Dr. Farías Trujillo is the pillar represented by the Catholic Church for the emergence of bioethics as an inter, trans and multidisciplinary discipline, since, as mentioned in the work, bioethics is capable of combining different types of knowledge from philosophy, theology, history and law with medicine, nursing, health policies and medical humanities (pp. 14-15) for its constant updating as promotion and protection of individual ontological dignity.

In the context of the clinical cases presented, various issues are discussed; among them is the therapeutic intemperance in patients in a terminal or critical state, or with no chance of a good quality of life. The book highlights as a source of conflict the medical perspective that is usually adopted in these cases, and the perseverance to «do one’s job», erroneously understanding «medical work» as a search to preserve life as far as possible and as permitted under the regulations stipulated by the law. For this reason, given the probability that similar situations may be repeated in clinical practice, the authors describe the enactment of laws such as the «Living Will» (Declaration of Advance Directive), as an alternative for those patients who are in a situation of illness that does not respond to curative treatment, preventing this situation, since these behaviors of preservation of life at any cost, often forget the principle of patient autonomy. The latter allows, in the use of their faculties, to decide to accept or reject a medical-surgical procedure, in the case that they or their relatives consider not to prolong life any longer. This decision must be respected not only because of its legal implications, but also as an act of respect for bioethical values, which must be complied with as part of ethically correct medical care.

Bioethical values, such as the previously mentioned autonomy, arise from the description of the Belmont Report as a theoretical formulation of principles for research ethics as well as for clinical bioethics. This principle is the predecessor of the current bioethical principles: non-maleficence, beneficence, autonomy and justice. The bioethical principle of non-maleficence stems from the Hippocratic principle of primum non nocere (above all, do no harm), establishing as a medical priority, when faced with the need for any medical technique or treatment, to prevent these from producing harm or risks even greater than the disease itself, thus seeking to maintain the physical and psychological integrity of the patient. On the contrary, the principle of beneficence, as its name indicates, seeks the patient’s welfare and that the proposed treatment is for the benefit of the patient’s health.

On the other hand, autonomy is the basic right of all individuals to make their own decisions, including the refusal or acceptance of treatment, as long as they are in full use of their mental faculties.

Finally, the principle of justice differs from the rest because of its relationship with people living in society, and its purpose is to establish an equitable distribution of health services and goods for all human beings.

However, as explained in the book, bioethical principles present a difficulty when applied in clinical practice, and that is the hierarchy among them. Indeed, it is necessary to decide which has greater weight when making decisions, even when trying to «individualize» each particular case, because sometimes it seems almost impossible to discern which principle should take precedence over another due to the complexity of the facts. For this reason, decision-making methodologies emerge as a model that facilitates the path to ethical reflection on the case. However, even though the objective of all methodologies is the same, the method and reasoning to achieve it is different. Such is the case of the casuistic, personalistic and deliberative methodologies, which make it possible to reach a moral deliberation based on a different set of rules for decision making.

In this sense, the authors state that one current is not better than another, but only different from the others. They make this clear when, at the end of the second chapter (pp. 37-39), they show two cases related to decision-making based on knowledge of different methodologies, and the difficulty in deliberating on which bioethical principle to superimpose on the others.

Firstly, situations are presented in which the patient is incapable of making a decision regarding his or her treatment on his or her own, so that deliberation regarding his or her care is left to the responsible family member and the physicians. This allows the physician to make certain decisions, without adopting a paternalistic role, which would result in biased behavior in ethical deliberation. The authors explain that the same is true for responsible guardians, so that an objective assessment should be made of the decisions of the responsible relative or guardian, and the parameters or guidelines for appointing or removing a guardian by decision of the Hospital Bioethics Committee should be considered.

In fact, when the wishes or decisions of the responsible family member are opposed to the physician’s intentions, they should be respected as long as they are in favor of the patient’s welfare or his or her previously requested wishes are respected. In the event of failure to reach an agreement in the follow-up care between both parties, the Hospital Bioethics Committee will have to intervene to reach an agreement, based on the responsibilities and functions of both the designated representative and the treating physician.

In the next chapter, the authors highlight the monitoring of institutional policies as a safety measure for ethically appropriate practices, based on empirical knowledge of similar cases that have occurred in the past. In this case, factors such as proxies, the patient’s written wishes, surrogate judgment in accordance with the patient’s known wishes and the patient’s best interests must be considered. This will enable both the Bioethics Committee and the physician to know how to handle subsequent cases that are similar, without losing the individual emphasis on each one.

A valuable contribution of the book is that, in the chapter on Informed consent and decision-making capacity (pp. 54-68), the authors state that it is not only patients who are «vulnerable» in situations of bioethical dilemmas. Medical personnel are also often exposed to the risks and complications of procedures. Thus, informed consent emerges as a tool to protect both the patient’s and the physician’s vulnerability when faced with the need for any medical intervention, whether preventive, diagnostic and/or therapeutic.

However, the authors explain the invalidity of consent in case of emergency or in situations in which the Committee can appeal to the law with the intention of saving life, as in the case of refusal of a blood transfusion in minors. However, even when the patient has agreed to receive treatment, and has even previously signed a consent form, the patient is able to withdraw or suspend the treatment received, because if the harm outweighs the benefit, continuing with the treatment is considered unethical, as it violates the bioethical principle of beneficence.

However, even when the criteria for refusal and discontinuation of treatment are well defined, the difficulty in decision making with respect to minors is mentioned, since they lack the capacity to exercise their autonomy. In this case, the parents exercise their own free will, even if it means suspending a treatment necessary for the survival of the minor.

In the chapter Privacy and confidentiality, six clinical cases are presented with the purpose of describing the criteria of confidentiality and patient rights, the importance of informed consent for the dissemination of information in situations of medical negligence, while at the same time exemplifying situations and criteria under which there are exceptions to the rule of confidentiality of the medical record in terms of clinical bioethics. An example of this is the report that must be given to the authorities in special situations. There is also the duty to inform all those persons at risk of suffering violence or any type of infection due to exposure.

The book concludes with chapters on Sexual Health and Palliative Care. Despite being completely different titles, they exemplify the relevance of an integral and interdisciplinary approach by the Hospital Bioethics Committee, which requires, as central elements in the deliberation, theoretical knowledge added to ethical reflection that considers the doctor-patient relationship, as well as the therapeutic needs and cultural principles that define the individual.

This work brings together, in a concise manner, everyday bioethical situations that health professionals may face. In this sense, it provides a panoramic view of clinical bioethics, where factors such as age, religion or personal culture of each patient are integrated in the analysis of the different clinical situations, without losing the focus of general bioethics, so that decision making is an integral, multidisciplinary and methodical axis in clinical practice based on theoretical knowledge.