Book Review: Foster C 2009: Choosing life, choosing death: the tyranny of autonomy in medical ethics and law. Oxford: Hart. 216 pp. GBP22.50; USD45.00 (PB). ISBN: 978 1 84113 929 6

Abstract

In this persuasively argued book, Charles Foster sets out to challenge the dominance of the principle of autonomy in medical ethics and law. He proposes that there exists '... an increasing tendency to view the whole of the law as simply a framework in which autonomy can be exercised' (p. 6). He adds that this is particularly the case in medical law. However, Foster's position is not for the complete abolition of autonomy in legal and ethical decision making. A more subtle line is advanced that, when making such decisions, other principles as well as autonomy should be called upon. Furthermore, Foster argues that, despite the dominance of the principle of autonomy in theory, in practice it is applied inconsistently. The principle, Foster argues, cannot deliver to its own rules.The above themes are developed over 14 chapters covering many of the major areas of medical law. Subjects discussed include abortion, consent, confidentiality, research on human participants, advance directives and organ transplantation. For each of these areas, landmark legal cases are analysed and their ethical and legal consequences considered. Foster returns regularly to two linked themes. The first is that autonomy should be balanced by the other well-established medical ethical principles of beneficence, non-maleficence and justice. The other is that this balance can be seen by understanding the implications of Article 8 of the European Convention on Human Rights (as required by the Human Rights Act 1998). Foster shows that, although Article 8(1) is recognized as promoting individual autonomy, Article 8(2) can override this in the public interest, using an ethical justification-based application on the other principles.This is certainly a useful book for people wishing to understand some of the legal background in key areas of medical law. The arguments that accompany the analysis are persuasive but there are some points to note. First, Foster states that there are four senses in which the term autonomy is used. However, he chooses not to specify which view of autonomy he is attacking. Arguing against autonomy in a general sense may not be fully convincing to the reader. For example, points advanced against forms of autonomy that promote unbridled individual choice may not be valid against forms of autonomy that honour universalizable principles. Second, the tone of the book is irreverent in parts. It makes for a lively read as Foster outlines the case against autonomy and the 'autonomists', making some satirical comments about the legal system along the way. However, this style may not appeal to everyone. Finally, the book makes no mention of any health care professionals besides doctors. The content is certainly relevant to nurses. There is common ground with other books written in this field for