Debates about medical ethics often centre on points of acute dispute: issues at the start and end of human life, problems relating to experimental treatments and research, and various other points of discussion, debate and dissent in the medical and research communities. There is a lesser, although still significant, literature on ethical issues at the level of populations rather than individuals: inequitable distribution of healthcare resources around the world, the persistence of preventable illness in poor countries, and the global imbalance of the impact of climate change on health.

There is, however, another, even more neglected, aspect to medical ethics, which is the extent to which the actions and decisions of healthcare professionals are influenced by other factors in addition to the needs of the patient. For example, every healthcare professional is only too aware that resource limitations affect decisions and that rationing always occurs in a world where resources are finite and need is infinite. Most rationing is subtle and implicit, and occurs at multiple levels in health systems that are so complex that the rationing of resources can be virtually imperceptible and almost defies understanding.

But perhaps the most concerning ethical situation is when external forces, often the state, influence the thinking or actions of healthcare professionals to the extent that they – knowingly or unknowingly – compromise their medical ethics. These situations can be relatively clear in retrospect, but decision-making can be complex and unclear in the moment when it occurs, not least because the issues involved are usually complex, time is often limited, pressures can be substantial and healthcare professionals are only human.

With this in mind, it is essential that healthcare workers remain acutely aware of their primary commitment (to their patients) and cognizant of the external forces that can shape their thinking, influence their decisions and even lead to slippage of ethical standards. Against this background, there is a clear, pressing need for the excellent new book by Dr John Tobin, titled A Terrible Aberration: When Doctors and Health Professionals Compromise their Medical Ethics at the Bidding of the State. This book is well worth reading and reflecting on.

As the cover of the book points out, Dr Tobin ‘examines, from the standpoint of medical ethics and international humanitarian law, how the medical and associated professions can be used by state agencies to inflict harm upon individuals’. True to this mission, the book certainly does not shy away from those aspects of medicine that raise deeply uncomfortable questions about the actions of healthcare professionals: torture, corporal punishment, internal body searches, chemical castration, involuntary sterilisation, solitary confinement, the death penalty, organ harvesting, force-feeding, working in repressive state systems, state abuse of psychiatry, denial of medical treatment, and unethically facilitating state policies and actions. The list is long, and Dr Tobin explores each area with knowledge, understanding and piercing insight.

Dr Tobin is exceptionally well placed to write this book. As a consultant psychiatrist, he has worked in Ireland, the United Kingdom and Canada. He worked with the Irish military for 20 years (and held the military rank of Lt Col) and worked with the Irish police force for 17 years. He has served on United Nations’ missions to the Lebanon, Liberia and East Timor. In addition, Dr Tobin has worked in the area of human rights around the globe with Justice Rapid Response and the International Institute for Criminal Investigations. He is retired vice-president of the Irish College of Psychiatrists.

With this background, it comes as no surprise that Dr Tobin’s book is exceptionally well informed, hugely insightful and impeccably sourced and foot-noted. Most of all, though, his book is reflective and perceptive in a way that is involving, valuable and rare. Dr Tobin writes that ‘the medical profession reflects the society from which it comes. At the same time, it needs to strive to be something more. Something better’ (pp. 3–4). This is very true: medical professionals both reflect the societies in which they live and work, but must also adhere to an ethical standard that can place them in conflict with certain elements of that society and sometimes with the state itself.

Dr Tobin points out that healthcare workers who stand up for human rights are not always remembered, but their efforts are still vital:

This book makes an important contribution to our journey towards that ‘more just world’ by holding up a mirror to aspects of medicine that are challenging to confront, but must be addressed.

Dr Tobin writes that ‘it will be an ongoing battle for the medical profession to ensure that they are not acting as agents of the state instead of being agents for their patients’ (p. 262). This book is an elegant, timely reminder of the importance of this task and the need to passionately defend the core principles of medical ethics – even against the state, when necessary.