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.
Noted in Religious Studies Review
"...his probing critique of contemporary bioethics rhetoric....With provocative presention and the use of literary references, Annas invites the reader to become engaged in a conversation of vital importance to us all. He challenges the reader to critically examine how we talk about issues in health care and how to think about issues of life and death, autonomy and responsibility. Readers shall no doubt benefit from the evaluation and will emerge better prepared to participate in a democratic transfomation of a historically revered tradition."--APA Newsletters
Noted in JAMA
"I have barely displayed the richness of George Annas' observations on the ambiguities in motivations and actions that persist in current research practices. The many recommendations he makes should be of valuable assistance to those interested in reforming current rules governing research on humans....He values scholarship but he also wants it to have an impact on shaping institutions and health care policies." --Jay Katz, The Journal of Contemporary Health Law and Policy
"...an insider's account of the contradictions in US healthcare.... Annas' account of US healthcare policy as seen through the rubric of bioethics is clearly written, and rich in metaphor and literary allusions. Some Choice should be required reading for both domestic and international readers who want an unsentimental account of how US healthcare policy has been distracted by simplistic notions of choice and those who would hope to transcend choice rhetoric and view bioethics as a human-rights issue."--Lancet
"In this age of cultural and moral relativism in which there are no standards save individual choice, Annas makes an important contribution." --The New England Journal of Medicine
"...the essays are accessible and offer the general reader a sound introduction to a broad array of urgent health law and policy dilemmas." Professor Annas' book is insightful and deserves to be required reading for students and policy makers. This worthy addition to the health policy literature could be just the catalyst we need to refocus the health care inquiry and policy debate in this country.--The Journal of Legal Medicine
"The author explores the validity of choice rhetoric in medical decisionmaking, with the intent to foster increased respect for health and human rights. Topics include choice in the medical market, informed consent, experimental treatment, and genetic issues." Hastings Center Report, Nov-Dec 1998
"Annas passionately reveals the practical and fundamental theoretical problems of the health care system. His main achievement is to demonstrate that in health policy, choice often serves the role to maks the effects of previous discrimination. The book contains a lot of case studies, useful examples for teaching and further thinking." -- Judit Sandor, Medicine, Health Care and Philosophy 3: 2000
