Some Choice: Law, Medicine, and the Market - Hardcover

Annas, George J.

Hardcover

ISBN 10: 0195118324 ISBN 13: 9780195118322

Publisher: Oxford University Press, 1998

Synopsis

This book is a passionate critique of the shallowness of choice rhetoric used to camouflage critical personal and public policy issues in contemporary debates in American medicine. Our public discourse on life and death, from health care to medical research, and from risky behavior to assisted suicide, is dominated by the market model of consumerism augmented by appeals to individual freedom. In fact, however, in most cases there is no real choice left for individuals to make; the important choices have been made by others, and the illusion of choice fosters complacency. Knee-jerk libertarianism leads to a superficial consumer culture and life choices valued only by their monetary value.
Some Choice uses the cases of cloning, drive-through deliveries, emergency medicine, genetic privacy, human experimentation, tobacco control, and physician-assisted suicide, among others, to suggest ways in which we can break through our vapid and superficial public discourse on life and death issues and begin to engage in a public dialogue that enriches our lives and society rather than cheapens them. George Annas is one of the most widely recognized names in current bioethics debates. His goal in this new book is to help open a national and international dialogue that sees the search for universal human rights as valuable, and international cooperation to define, protect, and promote them as central to life.

About this title

About the Author

George J. Annas, J.D., M.P.H., is the Edward R. Utley Professor of Law and Chair of the Health Law Department at the School of Public Health, Boston University. He is the author of several books, including The Nazi.

From The New England Journal of Medicine

Readers of these pages have seen sections of Some Choice before, since earlier versions of many of the book's chapters have appeared as Legal Issues in Medicine articles in the Journal. Nonetheless, George Annas has made an important contribution by reworking this material and placing it in a single, persuasive, and in many respects, countercultural framework.

The title of the book is to be read with irony, even with a touch of sarcasm. American health care and the debates surrounding it are awash in claims of the right to choose. In many ways, these claims are not only a hallmark of the American scene but also an important moral accomplishment. In most health care contexts, individual patients do have some choice. On deeper examination, however, the real choices open to patients are frequently not good ones, and certainly not what people outside the health care context would want as a choice. The choice they have is some choice: an unpalatable choice, an illusion of control, a choice that is psychologically real but made irresistible by social and cultural forces over which the individual patient has no control. One thinks of Sophie's Choice, Hobson's choice, or the existential choice that Jean-Paul Sartre held was the bedrock of human freedom: suicide. Some choice.

Annas finds such dubious choices in the areas of cloning, managed care in general and postpartum hospital discharge in particular, "therapeutic research" (especially in terminally ill patients), overly aggressive care for dying infants, soldiers as experimental subjects, the "free choice" of tobacco use, and the Sartrean choice actually offered by Jack Kevorkian and Oregon's assisted-suicide law.

In the cloning debate, for example, those who see asexual reproduction as simply another technological option for having a baby reduce the dynamic of the discussion to choice: people should have the choice to have children any way they want. Although this does create some choice for a would-be parent, it is some choice for the child who results from cloning. Annas argues that to come into being by cloning is to be robbed of one of the most fundamental characteristics of being human -- namely, to be reproduced by two human beings and not merely replicated by one. Cloning thus undermines the uniqueness of individuals. In fact, Annas describes cloning as "asexual child abuse" and would make it an international crime.

Annas is also strongly opposed to doctor-assisted suicide. The options offered by Kevorkian and the Oregon law do create some new choices. They provide patients whose dying is out of control -- or who fear it will be -- a feeling of control. The deeper issue, though, is the poor job the health care system does on behalf of dying patients: inadequate efforts to control their pain, enthusiasm for enrolling them as research subjects, and a tendency to ignore their clear wishes as the end nears. In a nutshell, we have refused to accede to the overwhelming choice of Americans to die at home, in peace, and with the ones they love. In view of these failures, doctor-assisted suicide offers another choice, but some choice it is.

Annas is especially emphatic with regard to research abuses. He considers the Nuremberg Code (formulated in 1947) the premier document of human rights in this arena. The Code enshrines voluntary, informed, competent, and understanding consent at the heart of research ethics, but it also contains nine other provisions that must be satisfied before consent is accepted from the subject. It thereby establishes a reasonable set of protections for each subject that cannot be waived by his or her choice. After this, the World Medical Association's Declaration of Helsinki (1964) was a moral retreat. It legitimized the concept of therapeutic research and thus opened the door for a wider imposition of risks on patients. The worst category of abuses under the heading of "therapeutic research" occurs with terminally ill patients, for whom the notion of potential therapy is highly attenuated. When patients in such situations have "nothing to lose" because of the desperate situation that they face, they are easily exploited by expectations of some measure of success, even when the probability and meaning of success are not articulated. Annas's view is that such patients should be disqualified from experimentation on the grounds that they cannot give genuine and informed consent.

Throughout the book, Annas links his critique of choice with an assault on individualism and the market-oriented climate that sustains it. Annas's public health viewpoint constantly points his analyses "upstream" -- that is, to the underlying social and economic realities in which the limited choice offered to patients is some choice. His critique of market values and the consequent commercialization of medicine is particularly sharp in his discussions of managed care, the pharmaceutical industry, and cigarette smoking, but it informs his views throughout. The domination of market values enshrines consumer choice in health care, to the detriment of the needs of patients, the doctor-patient relationship, and the public health of society. Some choice.

One of the most refreshing aspects of Some Choice is Annas's commitment to universal human rights. Theoretically, this allows him a platform from which to critique contemporary American medical culture. Practically, it is the basis for his call for international regulation: a ban on cloning, control of research involving human subjects, and establishment of a tribunal on doctors' ethics. In this age of cultural and moral relativism in which there are no standards save individual choice, Annas makes an important contribution by reminding us that the Nuremberg Code was grounded in an assumption of universal human rights based on natural law. These rights give moral meaning to the respect for individual choice, but at the same time provide it with boundaries. No society with decent respect for human rights can allow individual choice to undermine that respect. Annas believes that doctors and lawyers have a special moral responsibility to ensure that individuals can make choices that affirm their status as human beings and as bearers of universal human rights, even if it means limiting some of those choices.

Reviewed by Charles J. Dougherty, Ph.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

About this edition

• Publisher: Oxford University Press
• Publication date: 1998
• ISBN 10: 0195118324
• ISBN 13: 9780195118322
• Binding: Hardcover
• Edition number: 1
• Number of pages: 303