It Just Ain't Fair: The Ethics of Health Care for African Americans (Annette Dula & Sara Goering eds., Praeger 1994) About the editors and contributors, acknowledgements, bibliography, foreword by Mark Siegler, index, notes. L.C. 93-43780, ISBN 0-275-94494-8. [ 336 pp. Paper $19.95. P.O. Box 5007, Westport CT 06881-5007.]
to facilitate a dialogue among African Americans, medical ethicists and those working in African-American communities; and to help shape the development of medical ethics so that it no longer reflects the dominance and arrogance of any one group.They also attempt to redress a lack of literature on disparities in health care and the need for specialized consideration of underserved groups3 and seek to provide a basis for "reforming the traditional ethical framework that in an effort to be impartial and colorblind fails to see particular groups in their unique social contexts."4
The first part of this book discusses medical ethics within a political context; the second, disparities in access; the third, ethical responsibilities and the health profession; and the fourth, community involvement as a practical way to effect reform -- identifying a few specific programs that encourage reform within African American communities. Generally, it accuses those in health care of creating a system that, e.g., "may result in decisions by African Americans... to rely only on alternatives or home remedies instead."5 The book's premise is that too little attention is paid to differences in values and beliefs of African Americans as compared to those deemed responsible for flaws in the current dispensation of health care. For example, the Introduction recounts an experience of Dula's African American uncle who was admitted to an emergency room for treatment of chest pains.6 When his family looked at his medical records, they were upset to find him recorded as an alcohol abuser, when in fact he did not drink, and his ethnicity recorded as "Indian." Dula and Goering fulfill their promise of promoting awareness of inequitable health care treatment of African Americans in the U.S. by detailing disenfranchisement through the writings of medical professionals and ethicists. They also fulfill their goal of facilitating dialogue by filling a perceived void of scholarly works and creating an impetus for response.
It Just Ain't Fair shows, e.g., "the health experiences of real people,"7 but it inadequately develops a basis for reforming the current medical system. While it notes various local efforts, e.g., community-based organ donor education programs,8 the editors fail ultimately to delineate a way of redressing the problem at the higher levels of the system that they fault for existing inequities. To accomplish fully their goal of "providing a basis for reforming the traditional ethical framework,"9 it seems that its editors could have more coherently organized what appear to be scattered reform efforts. Anyone associated with health care should find this book illuminating. However, I failed to find a next step proposed and believe that readers looking for recommended solutions to the identified needs for unbiased care will be frustrated.
Carrie Anne Juliano*
2 At 8.
3 At 7.
4 At 4.
5 Id.
6 At 1-2.
7 At 4.
8 At 234.
9 At 4.
* Ms. Juliano received a B.S.(Biology) from Saint Anselm College. After working in molecular biology research, she is a candidate for the J.D. and Masters of Intellectual Property degrees at Franklin Pierce Law Center (FPLC).
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Lawrence J. Kaplan & Rosemarie Tong, Controlling Our Reproductive Destiny: A Technological and Philosophical Perspective (The MIT Press 1994) Appendix (basic biochemistry), illustrations, index, notes, preface, series foreword by Samuel Goldberg, tables. CIP 93-38060, ISBN 0-262-11176-4 [418 pp. Cloth $29.95. 55 Hayward St., Cambridge MA 02142.]
The authors tackle critical social concerns head on, noting that access to the best means of contraceptive and fertility enhancing technologies is limited by power and wealth; women continue to bear the burden of responsibility for contraception; and emerging embryo-saving technologies raise questions about ownership, rights and responsibilities. Moreover, ethical and social questions posed about current reproductive technologies will apply to future ones. Discussing these questions should, as the authors intend, encourage students to responsibly consider their reproductive choices. In discussing the ethical and social implications of reproductive technologies, Kaplan and Tong succeed in providing balance throughout their book. They initially describe predominant western ethical traditions, and then refer throughout to the work of ethicists in these and other traditions. Done in a dispassionate, nonjudgmental way, this provides a refreshing perspective on issues such as abortion that are so often addressed only in polarized fashion. By including perspectives that range from Roman Catholic theorists to Marxist feminists, they encourage discussion and debate. Unfortunately, however, in discussing issues such as contracted motherhood, in vitro fertilization and embryo transfer, some perspectives on these technologies are labeled as "liberal feminist" and "radical feminist." Such labeling marginalizes these views and, given the current political climate, may allow them to be too easily dismissed. Fortunately, this minimally detracts from a work that has much to offer.
Structurally, the book is well laid out. Each section, treating an area such as contraception, explains the technology, often using illustrations and diagrams, then addresses the ethical, legal and, finally, social dimensions. The authors address what is currently available, such as RU 486, Depo-Provera and Norplant and what may soon be developed, e.g., a wider range of male contraceptives. Addressing the social dimensions of contraception, they note common observations, such as that women are generally responsible for contraception and mention new developments; e.g., AIDS awareness has made more men willing to wear condoms.
The authors frequently relate developments to the bigger picture of reproductive choices. They point out that, instead of fighting over the legal rights of those engaged in contracted motherhood, society should try to provide all children with a nurturing environment. Similarly, they bridge the gap between pro-choice and pro-life advocates, suggesting that both would agree that a world where women did not have to face abortion as a choice would be preferable.
By putting discussions about reproduction in a greater context, this book provokes important debate. As Kaplan and Tong so aptly note in their introduction, technology is often developed and used before its ethical and social implications are fully understood. Students exposed to this text should be well equipped to discuss these technologies and use the questions it poses in analyzing reproductive developments well into the future.
Sophie M. Sparrow*
* Ms. Sparrow received her A.B. from Harvard/Radcliffe College and her J.D. from Harvard Law School. She is Assistant Dean for Career Services at FPLC.
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Organizations, Uncertainties, and Risk (James F. Short, Jr. & Lee Clarke eds., Westview Press 1992) Acknowledgements, contributor biographies, author and subject indices, foreword, references. ISBN: 0-8133-8562-8. [383 pp. Cloth $52.50. 500 Central Ave., Boulder CO 80301-2847.]
In the foreword, Charles Tilly begins:2
Sociology is a second-guessing science. Much of its work consists of examining how people account for their own actions, then confronting these accounts with ostensibly deeper explanations.... Some of sociology's subversive reputation results from this will to challenge people's own cherished beliefs about their behavior. ...From that alone, it is clear that this book was not prepared for sociologists only. Readers with little or no knowledge of the socio logical study of risk will find the materials presented so that they, by the end, can have a better understanding of how risk-related decisions are made. The concepts and theories, however, are discussed at a level that require close attention.
Second-guessing does not mean second-rate.
Organizations, Uncertainty, and Risk is divided into six parts, each consisting of one or more chapters. In Part One, Short provides an introduction and overview of the study of risk and sets the stage for the remainder by discussing "risk" in the context of identifying and managing risks.3 Part Two, "Decision Making Contexts and Networks of Risk," discusses two theoretical perspectives regarding risk analysis. Parts Three through Five, "Corporate Contexts of Decision Making," "Institutional Responses to Uncertainty," and "Choosing Technologies, Managing and Regulating Risks," provide empirical analyses of decision making in organizations faced with risk. Part Six, "Institutionalizing Risk," attempts to pull everything together, and the final chapter is written by Short and Lee.
Although researchers, particularly sociologists should find this book valuable -- particularly in view of its comprehensive reference section -- managers, policy makers and lawyers will also find it helpful. Indeed, several chapters are explicitly concerned with sociolegal problems.4 Because Short and Lee provide both theoretical perspectives and empirical studies, readers without extensive prior knowledge can bridge the gap between decision making practices and theories that attempt to explain processes organizations use in coping with risk and uncertainty. Chapter 4, for example, would be of special interest to in-house corporate lawyers who must advise managers on how adopting and enforcing internal manufacturing compliances rules will increase product safety and help to avoid the legal uncertainties of product liability.
Mehdi Sheikerz*
2 At ix.
3 At 13, Short details the book's organizational scheme.
4 Also, several chapters were earlier published in a special issue of Law and Policy; see at xiii.
* Mr. Sheikerz received a B.S. (Computer Science) from Virginia Polytechnic Institute and State University. Following four years as a software developer, he is a candidate for the J.D. at FPLC, with an interest in intellectual property.
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Dorothy J. Howell, Ecology for Environmental Professionals (Quorum Books 1994) Appendices, bibliographical references, figures, glossary, index, preface, tables. LC 93-5580; ISBN 0-89930-745-0 [215 pp. Cloth $59.95. 88 Post Road West, Westport, CT 06881.]
only the human organism is directly amenable to legal constraint, and then only to the extent the individual respects the law.... Other biological systems, including ecosystems... respond to intervention... according to the constraints of natural law... only dimly understood, if at all.Howell hopes to help humans manage nature by teaching environmental professionals basic ecology. Her book is organized into six parts based on her lectures at Vermont Law School.5 It teaches everything from the most basic to most complex tenets of ecology.
In part one, Howell explains science, the scientific method and the scope of ecology. She starts with the premise that everything in the environment is interconnected. An ecosystem is very efficient and holistic. Each organism has a job and must do it for the ecosystem to function.6 This is demonstrated by the Theory of Integrative Levels, which holds that:7
each level of organization within the natural sciences builds on those below in conceptual steps from pure mathematics to the planetary complex of ecosystems identified as the biosphere.Thus, mathematics is seen as expanded by physics, chemistry and biology to reach, at the highest level, ecology.
Part two covers the basic units of a typical ecosystem, habitats, communities and specific organisms, but it is difficult to isolate them.8 Ecosystems are not static; they develop and evolve.9 To determine whether an ecosystem is being polluted, an environmental professional must know its initial state.10 Although this is difficult, it is even more difficult to translate this information into law and policy.11
Part three describes how energy flows through ecological systems and materials cycle biogeochemically.12 Parts four and five discuss the last two ecosystem elements, time and biota. For example, Howell says that extinction is infrequent and difficult to predict: "the last event in a long sequence of subtle ecological and evolutionary processes acting in concert.''13 She asks what an environmental professional should do if a species must adapt, evolve or face extinction.14
Howell's last chapter lists eighteen great ideas in ecology. One problem she sees with the human perspective on environmental quality is that it focuses on human use rather than healthy environments for all species. Some Native Americans consider the effects of actions through seven generations.15 Maybe that would be a good rule for all.
Although short, Howell's book is informative, well organized and documented. It also has a glossary for those with limited technical backgrounds.
Karla Sievers McManus*
2 At 4.
3 At 49.
4 At 4.
5 At xii.
6 At 23.
7 At lO
8 At 39.
9 At 37.
10 At 49.
11 At 65.
12 At 86.
13 At 168.
14 At 170.
15 At 182.
* Ms. McManus received her B.A. (Psychology) from Cornell university. She is a candidate for the J.D. at Franklin Pierce Law Center and for the M.S.L. (Environmental) at Vermont Law School.
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Dorothy J. Howell, Scientific Literacy and Environmental Policy: The Missing Prerequisite for Sound Decision Making (Quorum Books 1992) Acknowledgements, bibliography, epilogue, index, introduction. LC 9136028; ISBN 0-89930-616-0. [181 pp. Cloth $45.00. One Madison Ave., New York, NY 10010.]
Howell's frustration with scientific illiteracy has grown through experience in the corporate world, government and academia. It is colored by her experience as a biologist, lawyer and environmental law professor-as well as a member of the public. Through Scientific Literacy..., Howell sets forth problems faced by a public "disenfranchised" by its incomprehension of scientific principles.
In her introduction, Howell defines scientific literacy as:1
the abilities to read with comprehension news items on science and to apply scientific information to personal decisions on emerging policy based in science [and] the capacity for meaningful participation in policy formulation through recognition of relevant issues with an appreciation of the underlying science and technology, including a realistic view of their limitations.In pursuit of that goal, Howell discusses the merger of the U.S. political system and the scientific community that she believes to date from the 1960's. In doing so, she describes public controversies such as those over pharmaceutical innovation and the effects of biotechnology on the environment.
Howell aptly begins each section with a relevant quotation from a scientist or philosopher, often echoing her own sentiments. Two themes resonate throughout Scientific Literacy... and speak to the consequences of technical illiteracy-public frustration with scientific uncertainty and misgiving about whether science and technology can somehow "rescue us from the consequences of stupidity, arrogance, and ecological malfeasance."2
Yet, Howell ends optimistically, finding the environmental movement to have sparked public interest in science education. She believes that this is evident in scientific literacy efforts by government, scientific institutions, law schools, the press and various volunteer programs.
Howell passionately vows to contribute to public reenfranchisement through efforts such as those represented by this book and ultimately concludes:3
We have the means to meet the promises of the scientific endeavor in the next century. We must prove wrong those who assert we lack the will.Diane M. Albert*
2 At 152 (quoting David W. Orr, Ecological Literacy: Education for the Twenty-First Century, Holistic Educ. Rev., Fall 1989, at 48, 49).
3 At 172.
* Ms. Albert received her B.A. (Biology and German) from Colby College and M.S.L. (Environmental) at Vermont Law School. After seven years as an environmental regulator and consultant, she is a candidate for the J.D. at FPLC.
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World Health Organization, Legislative Responses to Organ Transplantation (Martinus Nijhoff Publishers 1993) Bibliography. LC 92-48521; ISBN 0-7923-2147-2. [534 pp. Cloth $174.00. P.O. Box 322, 3300 AH Dordrecht, The Netherlands.]
To the extent that any piece of legislation reflects the underlying values of a given society, this compilation of statutes provides insight into the level of sophistication with which countries deal with issues such as the spread of the HIV virus, determination of death, informed consent and with whom rests the authority to consent. However, the book contains no annotations or commentary; any inferences must be drawn by the reader.
A note to the table of contents states that materials appearing in this volume were obtained through WHO's Health Legislation Unit in Geneva and indicates that it is limited by what was available to that Unit at the time of printing. The incompleteness of the collection is underscored by the absence of state statutes from within the U.S.
Legislative Responses to Organ Transplantation would not be an exciting read for most people, but it provides an important resource to anyone interested in either locating a specific piece of legislation or doing a comparative study. Many libraries will want to acquire it. However, it must be cautioned that it is remarkable for its variety of fonts and formats, expensive by U.S. standards and, as mentioned above, incomplete.
Lisah K. Carpenter*
* Ms. Carpenter received her B.S.(Nursing) from the University of Vermont, a M.A.L.S. from Dartmouth College and a J.D. from FPLC. She is the Director of the Institute for Health, Law & Ethics at FPLC.
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Community Risk Profiles: A Tool to Improve Environment and Community Health (Iddo K. Wernick ed., Rockefeller University 1995) Appendices, background paper, bibliography, case studies, notes, preface, synopsis. ISBN 0-9646419-0-9. [95 pp. No price indicated.]
The book mainly comprises a summary report, a background paper written by Dr. Wernick and two case studies suggesting possible approaches to the generation of CRPs. In the background paper, Wernick concludes:1
Would the quality of health and environmental research and the provision of public... services differ greatly if we take the "community as the patient" as the basis for approach? We believe the answer is yes.One case study by Lenny Siege discusses how community task forces in Silicon Valley reached consensus in evaluating risks against a list of criteria. However, I doubt that this approach would have helped the citizens of my town decide what to do about our landfill. It seems far too complex for ordinary citizens and may have worked in Silicon Valley only because of the extraordinary educational level of its citizens.
Another study by Theodore S. Glickman explains how geographic information system (GIS) computer programs were used to investigate whether environmental risks have been inequitably allocated to minority and low income neighborhoods in Allegheny County, Pennsylvania. It demonstrates that GIS programs have great power in generating useful information, but how does that information get to the grassroots?
The summary report describes a CRP as providing:2
information resources sensitive to local concerns and suitable for multiple and continuing uses... In particular situations, it may be used to help a community reach consensus on risk priorities. But this is not the justification for its existence. It is a more general tool for both prognosis and diagnosis.I am troubled by this. The idea of community as patient may improve the quality of thinking about health and environmental issues. However, as a community member, I want to be treated as a partner not a patient. It seems to me that any model failing to be more participatory than even the best doctor-patient relationship does not represent ideal decision making in a democracy.
Also, I am troubled by informational tools that cannot be understood by most community members -- particularly if the tools are not equally available to everyone. For example, last summer I worked for a community group attempting to monitor whether banks were redlining (discriminating against certain neighborhoods or communities). GIS software made it possible for the banks themselves to determine if they were doing so, but the software publisher would not sell to community groups because of a perceived conflict of interest.
Community Risk Profiles relates how important work is addressing the risk management needs of specific communities. But I would have preferred some attention to the gaps that separate experts and citizens. I hope that future work along these lines will focus more on the needs of grassroots members of communities than on communities as a social organism.
Bennett Mortell*
2 At 20.
* Mr. Mortell received his B.A. (History) from Trinity College and is a candidate for the J.D. at Franklin Pierce Law Center. He is active in community affairs and was a paralegal in a legal aid program for the poor for thirteen years.
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William Leiss & Christina Chociolko, Risk and Responsibility (McGill-Queens University Press 1994) ISBN 0-7735-1177-6 (cloth) 0-7735-H1194-6.(paper). Abbreviations, acknowledgements, bibliography, figures, notes, preface, tables. [405 pp. Paper $55.00; cloth $22.95. 3430 McTavish St., Montreal, Quebec, H3A 1X9 Canada.]
In supporting such a determination the authors highlight not only risks brought about by, e.g., commercial searches for better products, but also by day-to-day risks undertaken by the general population -- ones that arise, for example, in daily household chores, sports, recreation and driving automobiles.
That apportioning responsibility for risk is highly controversial is the cornerstone of this book. By examining a few health and environmental risks, e.g., electromagnetic fields, Alar (a growth regulator for food crops) and Antisapstain (a pesticide used in softwood lumber products), the authors set up a dichotomy with institutions and experts on one hand and the media and general public on the other. Such a split, they say, reflects that all parties "have a direct interest in under-assessing and under-estimating risks so as to maximize net benefits for themselves."2 This self interest is said to lead to inevitable disputes.
Much of the book is to be commended, e.g., the authors' coherent overview of risk3 and risk assessment for a reader previously unacquainted with such concepts as presented here. They offer a cool, collected objective analysis of risk-based disputes that can be desirable and helpful in a field often driven by subjective aims.
Yet, Risk and Responsibility seems to trivialize or miss issues that call for deeper analysis. At the outset, its authors state that society cannot "maintain our attained level of material well-being without engaging in [risky] activity."4 They go on to say that "failure to properly apportion responsibility for inevitable losses, and to compensate adequately those who suffer unfairly..., will result in gradually rising... support for risk-avoidance...."5 However, they seem not to appreciate that some in society already regard the initial statement as controversial and the outcome as not necessarily desirable. In the face of disparities between losses and benefits as reflected by economic, social and political realities, people appear unwilling to settle for loss compensation when gains appear to go elsewhere. Notwithstanding its useful contributions, this book's matter-of-fact approach to resolving conflicts seems to miss the heart of much risk-based controversy.
Catriona Glazebrook*
2 At 52.
3 "The exposure to the chance of loss... usually induced by some social actor to realize an incremental net benefit," at 6.
4 At 5.
5 Id.
* Ms. Glazebrook received her M.S. (Environmental Studies) from Antioch University New England Graduate School and her J.D. from Brooklyn Law School. She has practiced environmental law and is currently an environmental policy consultant.