250 Book reviews

In recent years there has been an
expanding literature devoted to the
case stories of those who are ill, but
this collection of articles is unusual in
that it starts with this approach in part
one, and then considers the ethical,
social, cultural and political responses
to them, attempting to provide a link
with policy issues, in part two. This is
an ambitious and important develop-
ment which deserves far more atten-
tion than it has received so far.
The individual contributions to the

volume are generally of a high stan-
dard, and rather than attempt the
briefest sketch of each of them, I
will highlight certain issues which I
found of particular interest. In the first
chapter of part one Kay Toombs's
description of her personal experi-
ences - "Sufficient unto the day: a life
with multiple sclerosis" - was both
insightful and compelling. Two telling
quotations speak for themselves. First
that "...there is nothing intrinsically
good about chronic, progressive
multiple sclerosis. Nothing. This is
not, however, to deny that my life has
been profoundly affected in ways that
are enriching" (page 20). Second:
"Perhaps the greatest challenge of all
for the multiple sclerosis patient is to
learn to live with ongoing and perma-
nent uncertainty" (page 20).

In another chapter in part one,
"Whose story is it anyway?", Sue
Estroff analyses the ethical issues
raised in doing narrative research on
chronic illness. Estroff's own work has
been with the long-term mentally ill
and her sensitive and honest account
exposes the impossibility of deriving
ethical research practices from theo-
retical considerations alone. In par-
ticular she demonstrates the problem
of applying ethical codes primarily
developed for quantitative research on
those with acute physical illness, to
qualitative and especially narrative
research with those with chronic
mental illness. The central issue here
is that narrative research requires that
the researcher empathise and collabo-
rate with the subjects of the study,
whilst also being sufficiently distant
from them to maintain a degree of
objectivity. One ambiguity that arises
from this is that in attempting to
adopt a neutral stance the researcher
may be seen by the research subject as
the most caring person he or she has
contact with. Estroff concludes that
"the lines between friend and investi-
gator blur over time, producing
almost as many difficulties as positive
contributions to the quality of the
research" (page 91).

In the second part of the book,
which focuses on policy, John
Douard's chapter "Disability and the
persistence of the normal", is con-
cerned with the distinction that arose
in the nineteenth century between the
normal and the abnormal, both
medically and socially and the way it
can lead to two responses to disability
which tend to sustain conformity and
discipline within society rather than
solving problems of how to live
together. These are, first, giving
special rights to distinct minority
groups, so institutionalising labelling;
and, second, requiring people to
behave in such a way as to "qualify" as
normal, so that they are held respon-
sible for their own status. These
observations are important and
demonstrate the relevance of social
and historical analysis to ethical
issues, a theme which Arthur
Kleinman takes up in his chapter on
"The social course of chronic illness":
"I maintain that there is a role for
anthropology, social history, and
other social sciences in shifting the
object of inquiry to include the social
processes of everyday local worlds
which shape suffering in ways quite
distinct from the usual individual
psychological orientation of clinical
and ethical approaches taken to this
most human of conditions [that of
suffering]" (page 185).
The difficu!ty though is how to put

this process into operation and make
it relevant to social policy; the struc-
ture of the book is itself an indication
of where the problem lies. The first
part concentrates on the individual
experience of suffering, and the
second on how to harness that experi-
ence in fostering better approaches
to policy-making. However, the two
parts are largely unrelated to each
other. Only Estroff connects the direct
accounts ofher own narrative research
with ambiguities in its nature and so
points to ethical dilemmas relating to
research policy; and there is no
attempt to form a bridge between the
other chapters in the two parts of the
book.

This then is not just a collection of
interesting articles, because it raises
the question of how to bring together
illness narrative research with more
traditional historical, sociological and
anthropological approaches in such a
way as to enrich the overall analysis
and more fruitfully inform social
policy. Although the book is limited
in how far it has taken this project
forward, the distinction of many of
the contributions is in having shown

the importance of this area for the
future.

DAVID GREAVES
Centre for Philosophy and Health Care,

University of Wales,
Swansea

Justice and Health
Care: Comparative
Perspectives

Edited by Andrew Grubb and
Maxwell J Mehlman, John Wiley,
Chichester, 1995, 350 pages, £35.00.

Limited resources and rationing are
"buzz words" today in health care
across the globe. The development of
modem medical technology with its
ability to prolong life has at the same
time raised the dilemma of just who
should get the treatment? justice and
Health Care: Comparative Perspectives,
a collection of essays which, as the
title suggests, discusses particular
problems relating to health care
allocation in the light of experiences
drawn from a number of jurisdictions,
is thus a timely publication.
A number of essays concentrate on

broad questions of policy in resource
allocation. For instance, Alan
Maynard, an economist, examines
rationing - currently one of the most
hotly debated issues within the
National Health Service (NHS).
Maynard argues for the establishment
of criteria for resource alloca-
tion within the NHS, drawing upon
experiences in Oregon and elsewhere.
While overt resource allocation
decisions may prove a difficult and
uncomfortable task, some may see this
as preferable to the somewhat covert
allocation process undertaken in the
past. Physicians on both sides of the
Atlantic have taken into account a
patient's lifestyle in deciding whether
to undertake treatment. Robert
Schwartz questions this in his essay
"Life style, health status and distribu-
tive justice". For example, decisions
regarding lifestyle may not be truly
voluntary - the fact that an individual
becomes an alcoholic may relate to a
whole series of factors beyond
whether or not an individual chooses
to have a drink. In addition, he
doubts whether restriction of
resources on lifestyle criteria is justifi-
able on the basis of punishment or of
deterrence.
Many of the essays in this collec-

tion address the role of the law in

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Book reviews 251

facilitating access to health care. The
difficulties with legal recognition of
rights to health care are explored by
Dieter Giesen. Some of the themes
considered by Professor Giesen,
notably the duty to rescue, are also
taken up in Barry Furrow's essay
examining provision of care to
persons falling outside the health
insurance scheme in the USA.
Lawrence Gostin in his essay "The
Americans with Disabilities Act and
the corpus of anti-discrimination law:
a force for change in the future of
public health legislation", discusses
the extent to which public health
powers in the USA conflict with the
rights of persons with communicable
diseases and the role which can be
played by anti-discrimination legisla-
tion in the form of the Americans
with Disabilities Act. Deficiencies in
health provision and sensitivity to the
particular needs of ethnic groups in
England are considered by David
Pearl. This essay also illustrates the
existing difficulties in attempting
to use English law as a means of
obtaining access to health care
resources.
The remaining essays provide: an

examination of dimensions of justice
in the context of the operation of
the Canadian Health system, by
Carolyn Tuhoy; the use of financial
incentives in a market in organs, by
James Blumstein, and problems of
access to health care experienced by
those from the USA African-
American community, by Vernellia E
Randall.

All the essays in the collection
explore the central theme in the con-
text of a well-developed Western
health care system. It perhaps should
be borne in mind that a comparative
analysis of matters regarding justice
and health care in relation to, for
example, the Third World, would of
course, bring into focus somewhat dif-
ferent issues. While some essays draw
cross-jurisdictional comparisons the
primary focus of this collection is
American, with five out of nine of the
essays concentrating upon American
health care. The collection is thus per-
haps not truly "comparative". Never-
theless, overall J7ustice and Health Care:
Comparative Perspectives provides a
number of lively, provocative and
scholarly contributions to what is
becoming an increasingly vociferous
debate.

J V McHALE
Lecturer in Law,
Faculty of Law,

University of Manchester

Torture: Human
Rights, Medical Ethics
and the Case of Israel

Edited by Neve Gordon and
Ruchama Marton, London, Zed
Books, 1995, 206 pages, £42.50 hc,
£16.95 sc.

The book derives from a conference
on the International Struggle against
Torture and the Case of Israel, held in
Tel-Aviv in 1993, organised by the
Association of Israeli-Palestinian
Physicians for Human Rights and the
Public Committee against Torture in
Israel. It is not merely a proceedings,
but a compilation by seventeen of the
participants with diverse interests and
skills, though it does include reports
of workshops held at the end of each
section of the conference.

Considering the composition of the
population of Israel and the past
personal experiences of many of its
citizens, it might be thought that the
very idea of torture would be
anathema. However, it is a tragic fact
that the whole history of Israeli-
Palestinian relationships has been
tainted by allegations ofinhuman treat-
ment on both sides, but particularly by
Israeli soldiers and interrogators.
The book is divided into four parts.

The first, dealing with the public realm
takes the political status first, des-
cribing how harsh treatment amount-
ing to torture has not been condemned
but made legitimate by the Landau
Report. In 1987 a commission of
inquiry headed by ChiefJustice Moshe
Landau, was set up to investigate com-
plaints of ill-treatment of Palestinian
detainees. The commission, instead of
outlawing torture, authorised the
General Security Service (GSS) to use
"a moderate measure of physical
force" in the interrogation of "secur-
ity" detainees. The recommendations
became law. Though the exact
methods permitted have never been
published, the interpretation of "mod-
erate physical force" has led to the use
of such techniques as beating, hood-
ing, sleep deprivation, confining in a
cupboard-sized cell, electric shocks
and vigorous shaking. Next, the social
response to the situation is described.
There are three lines of argument
commonly used: i: To deny that tor-
ture takes place except as an occa-
sional aberration; ii: Avoiding the use
of pejorative words and substituting
phrases such as "moderate physical
pressure" or what the French in

Algiers called "special procedures";
and iii: Acknowledging its use but
justifying it by claiming that harsh
measures are necessary to bring the
emergency to a more speedy con-
clusion. Even "liberal" sections of the
community are guilty of these decep-
tions, colluding with the majority in
turning a blind eye.
The second section deals with the

involvement of health professionals in
torture. It is alleged that a doctor is in
the background behind every torturer/
interrogator. He performs a pre-
torture examination, monitors the tor-
ture process, examines and takes care
of the prisoner following the infliction
of torture and writes a medical opin-
ion or a pathology report. A form of
"Fitness for torture" used by the
Department of Interrogation asks the
doctor to certify whether there are any
medical reasons for limitations to a
stay in an isolated cell, chaining,
hooding or prolonged standing. When
the Israeli-Palestinian Physicians for
Human Rights protested to the Israeli
Medical Association (IMA) about this
form, their chairperson, Dr Miriam
Tzangen, wrote urgently to the Prime
Minister. He replied that it was simply
experimental and its use would be dis-
continued. Apart from this example,
the IMA has remained silent over
the mounting evidence of participa-
tion by doctors in interrogation by the
security services, in spite of the fact
that the terms of the Declaration
of Tokyo (to which the IMA is a
signatory) are clearly being breached.
They even failed to take any action
when one of their colleagues, a
Palestinian doctor, was detained and
ill-treated.
The workshop at the end of this

section of the conference decided on a
number of measures which could be
expected to improve the record of the
health professionals coming into con-
tact with evidence of torture. These
included better education in ethics for
students and doctors, mechanisms of
reporting offences anonymously, and
making video records of interroga-
tions.
The third brief section, which deals

with the legal struggle against torture,
begins with a history of torture in
Israel, giving examples of confessions
being extracted from Palestinian
detainees by torture as early in the
Occupation as 1968, when the very
existence of the Shabak, the interro-
gation organisation, was officially
denied though it enjoyed a symbiotic
relationship with the police, judiciary
and elements of the medical profes-

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