108 Book reviews

Equal Justice
Eric Rakowski, 385 +xii pages, Oxford,
1991, Clarendon Press, £40.00.

Professor Rakowski begins his book
with a quote from Aristotle's Politics:
'All hold that justice is some kind of
equality'. His own account of an
egalitarian conception of distributive
justice in this outstanding book ranks
alongside the pioneering work recently
done in this area by writers such as John
Rawls and Ronald Dworkin.
Rakowski's answer to the question of

how scarce resources are to be shared
around he calls 'equality of fortune',
and his defence of this notion takes up
the first half of the book. Like G A
Cohen, Rakowski believes that the
essence of egalitarianism lies in evening
out the effects of 'brute' bad luck, that
is, ill fortune which is not the result of
risk incurred by the agent. Inequalities
arising from chance require a
redistribution of resources, and
'resources' here include physical and
mental capacities. Ideally, each should
start life with equally valuable
resources, subject to two caveats: there
is some presumption in favour of
allowing gifts and bequests to children;
and great sacrifices cannot be called for
from the more fortunate. Rakowski's is
not merely a 'starting-gate' theory.
Equality of fortune as a general ideal -
along with a stress on the importance of
personal autonomy - requires the
establishment of various insurance
schemes, and the details of these are
developed carefully in the book.

Theories of justice are often set in
opposition to utilitarianism, and here
Rakowski's thesis looks particularly
strong: why should someone who has
already been dealt a bad hand by fate
suffer yet more at the hands of morality
on the ground that he or she will be an
inefficient consumer of resources? Like
Rawls, Rakowski offers us a view of
'justice as fairness'.
Rakowski closes Part I of the book

with a chapter on whether transferable
organs or blood should be seen as
resources subject to redistribution. He
argues that they should be, and that in
certain circumstances compulsory
extraction of, for example, blood might
be justified. This would be unusual,
however, if his recommendation that
post mortem extractions be the norm
were adopted.

Part II of the book defends an
account of strict liability which may be
useful to those interested in medical
negligence. In particular, Rakowski's

attack on the idea that tort law is to be
understood in wealth maximising terms
is such that this view must henceforth
be consigned to the dustbin of
philosophical history.

In Part III, Rakowski returns to the
more straightforwardly medical ethical
issue of the allocation of life-saving
resources. He argues that numbers are
relevant in life-saving decisions, but not
because it is objectively better if, other
things being equal, a larger group
survives. Rather, we are each required
now to form an intention to save the
larger group in any such case, since this
is in the interest of all.
Rakowski dedicates a chapter to

considering whether particular
characteristics ofpersons, such as age or
moral character, should influence
choices between lives. His subtle
discussion concludes that only (i) large
differences in age and (ii) the
individual's responsibility for his or her
plight are relevant. He ends the book by
defending a rights-based view against,
in most circumstances, killing one
being to benefit others.

I disagree with some of Rakowski's
negative arguments, acute as they are;
but his sophisticated and humane
account of justice is among the most
powerful and persuasive I have read.
His discussions of medical ethical
questions will be the starting point for
those who address these questions in
future. This is a book that deserves to be
- and no doubt will be - taken very
seriously indeed.

ROGER CRISP,
Fellow in Philosophy,

St Anne's College, Oxford.

AIDS: an Epidemic
of Ethical Puzzles
Edited by the Hastings Center, USA,
187 pages, Dartmouth, 1991,
Gower Academic Publishing Group,
£32.50 hc.

The acquired immune deficiency
syndrome, with its undertones of
sexuality and a pervasive fear of
contagion, has been the catalyst for a
revolution in professional ethics. The
issues of patient autonomy, the conduct
of placebo control trials, the rights of
confidentiality, informed consent,
death with dignity, and the obligations
to provide care for individual health
care workers are all explored in this
recent collection of papers from the

Hastings Center.
What struck me most forcibly, on

reading this book, was the major shift in
ethical perceptions during the AIDS
epidemic. The early paternalistic
pronouncements from professional
bodies have been modified in the light
ofexperience and have lost some oftheir
lofty tone. It is helpful in the present
difficulties of the National Health
Service to recognise that in Britain there
has long been a consensus of an
entitlement to health care by all and a
less well expressed view of the
obligation of individual health-care
workers to provide such treatment.
Such a consensus does not exist in the
United States where health care is not
freely available to all and professional
bodies jealously cherish the right of
doctors to act as independent
contractors and to refuse to provide
health care. Human immunodeficiency
virus infection is slowly altering this
perception with many States enacting
anti-discriminatory legislation.
The other fascinating aspect of this

collection of papers is a thought-
provoking review of the obligations and
opportunities of researchers in the
Third World. The changes in ethics
occurring in different social and
cultural situations are clearly
expounded.
As a lay reader I am always left

vaguely disappointed that this sort of
book does not provide a few simple
rules which would guide me in day-to-
day ethical decisions. I am, however,
reassured when I discover that people
who have made the study of ethics their
lifetime's work face the same
difficulties. This book is a fascinating
historical account of the ethical
dilemmas produced by the AIDS
epidemic and makes a thought-
provoking change from the average
textbook, although it is rather
expensive at £32.

BRIAN GAZZARD,
Consultant Physician and AIDS

Co-ordinator, Westminster Hospital,
Dean Ryle Street, Horseferry Road,

London SWIP 2AP.

Family Rights:
Family Law and
Medical Advance
Edited by Elaine Sutherland and
Alexander McCall Smith, 135 pages,
Edinburgh, 1991, Edinburgh Press,
£25.00.

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