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certed action should be taken against it. In the longer versions of the debate a wider variety of social, cultural and moral variables is put into the equation, in an attempt to get nearer to 'the other'. Morally speaking, however, the impression which the current literature on female circumcision leaves is one of social- normative confusion. Rather than the black- and-white antithesis of social-normative universality versus relativity which Lane and Rubinstein thought they observed in recent publications, the problem seems to be more one of social-normative explicitness versus various degrees of implicitness or undecided- ness. The latter situation is a state of affairs which one might attempt to deal with by arguing in favour of greater social-normative clarity. Not by a return to old social-normative configurations, but by making an effort to create new clear perspectives in this area. Formulating the problem this way, one might then take matters one step further than merely arguing for the creation of favourable precon- ditions for intercultural interaction, as Lane and Rubinstein did. Rather, this would amount to taking a considered, normative stance.

2. Independently of the fact that current Western public and scholarly responses to female cir- ctancision vary in normative explicitness, there remains the basic social-moral problem of 'how to approach the other'. The current bibliography on the subject of female circum- cision is still dominated by people other than the individuals most directly involved. Of course, this state of affairs is more the rule than the exception in scholarship in the humanities, but some particularly acute problems arise when social morality is at stake. Firstly, there is the issue of the legitimacy of acting as a spokesman for others. Translated to the case under discussion: what can we accept/expect from researchers going into villages as 'naive empiricists', armed with questionnaires to be answered by local people about local prac- tices? Secondly, the gap between reporter and those reported on raises tough issues with respect to the knowledge and interpretations these spokespersons advance. And finally, it puts to the test the self-proclaimed liberal

image of Western societies and their dynamics of social change [4]. In the end, is it not simply a question of one group of people forbidding another group to practise its own traditions? Or are broader shifts in patterns of social relations possible which bring 'solutions' more satisfactory for all. Commonly, partici- pants in debates such as the one about female circumcision have their preferences for one or another model of socio-cultural change. But, again, more often than not, they leave the model's basic moral tenets implicit and uncrit- icised. My preliminary conclusion, therefore, is that if the case of female circumcision rests uneasy with many of us who are not affected directly by these practices, it is because it reminds us of how far humanity is from even the beginning of new social-moral awareness, let alone creative institutional configurations based upon such understanding.

G o d e l i e v e van Heteren Catholic University of Nijmegen, The Netherlands

References and Notes

1. Briggs, L.A. (1998). Female circumcision in Nige- ria: is it not time for government intervention? Health Care Analysis 6(1), 14-23.

2. I will use the term 'female circumcision', even though the designation 'female genital mutilation' has become more prominent in Western articles on the subject.

3. Lane, S.D. and Rubinstein, R.A. (1996). Judging the other: responding to traditional female genital surgeries. Hastings Center Report 24(3), 31-40.

4. The social-moral literature on multiculturalism is rapidly growing. A recent provocative text which explicitly addresses the challenges posed to liberal society by non-liberal minorities is: Kymlicka, W. (1995). Multicultural Citizenship. A Liberal Theory Of Minority Rights, Open University Press, Oxford.

BOOK REVIEWS

Unhealthy Societies: The Afflictions of Inequality Richard Wilkinson, 1996, Roufledge, 255 pages, £13.99, ISBN 0 415 09235 3

This book brings together evidence about states of health within and between societies. It argues that

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life expectancy in developed countries is dramati- cally improved where income differences are smaller and societies are more socially cohesive. The central premise of the text is that quality of life in developed societies is now limited by social rather than material factors. In doing this, the author attempts to move us away from thinking of individual determinants of health to address the broader issue of the health of societies.

In the introduction, the author invites his readers on a 'rapid tour of the emerging picture of the interface between health and society'. The scene for this tour is fundamentally set in parts 1 and 2 of the book. In chapter 2, the author argues why our un- derstanding of health depends on social research and why it is important to look at the health of societies as opposed to individuals. He argues that focusing of differences within and between societies has meant that research has increasingly examined the relationship between the individual and society and the effects of structural factors on health--such as social position, wealth, poverty and employment or unemployment. Chapter 3 looks specifically at why life expectancy, especially at younger ages, continues to improve with each generation. In doing so the author explores past and present improvements in death rates by looking at the relationship between living standards and life expectancy over time.

Part 2 deals more specifically with health inequali- ties within societies. Wilkinson does this in two ways. Firstly, by explaining the association between equity and health, and documenting the research which shows that people lower down the social scale have death rates two to four times higher than oth- ers further up the scale. Chapter 4 explores the pos- sible reasons for this, explaining that it cannot be attributable to social mobility, genetics, health be- haviours or inequalities in access to medical care, and concluding that the explanation has to be the social and economic circumstances in which people live. Secondly, the author looks at the paradoxical finding that health is related to differences in living standards within developed societies but not to the differences between them. He concludes that what matters is relative rather than absolute income, citing evidence that countries with lower income differ- ences have lower mortality rates.

Parts 3 and 4 explore the dynamics of Wilkinson's explanation--the psychosocial pathways through which health is affected. In Part 3, chapter 6 illus- trates the relationship between income differences and health with the use of five case study societies which are notably egalitarian and have low mortality rates, among them the UK in wartime. Healthy, egal- itarian societies are characterised by a sense of social cohesion and public spiritedness. The next chapter in this section draws on the work of anthropology and social psychology to pursue the notion of social co- hesion further. It provides a historical perspective on how earlier forms of society preferred more egalitar-

ian social systems to avoid economic causes of social disharmony. In an interesting discussion, the author suggests why we may not be psychologically adapted to inequality and individualism. Lastly, this section turns to the 'symptoms of disintegration', discussing particularly inegalitarian countries and examining the effects of social disintegration conse- quent of wider income differences, and in particular looks at the social causes of death within these. Part 4 of the book discusses the pathways through which inequality and loss of social cohesion affect health. This is done through examples of the impact of psychosocial circumstances on health and particu- larly on the biological consequences of chronic stress.

Finally, Part 5 discusses the policy implications of health and quality of life being primarily dependent on distributional justice and levels of social capital. One of the interesting messages prevalent in this discussion, and elsewhere in the book, is the contin- ual reminder that health is only one of the social costs of material inequality. As Wilkinson states:

' . . . i f it was a matter of eating too many chips . . , then that in itself would not necessarily mean that the quality of life which people experi- ences was so much less good. You can be happy eating chips. But sources of social stress, poor social networks, low self esteem, high rates of depression, anxiety, insecurity, the loss of a sense of control, all have such a fundamental impact on our experience of life that it is reasonable to won- der whether the effects on the quality of life are not more important than the effects on the length of life.'

This book is a timely and important contribution. However, whilst I found the book interesting and useful, throughout I became increasingly concerned about the implications of psychologising the expla- nation which may divert attention away from the material and social to individual based responses-- an issue the author briefly mentions in the final chapter. The most powerful message from the text was the description of how social organisation can affect health and peoples' quality of life. In pursuing the consequences of social organisation in this way it would also have been helpful to consider the possi- ble negative consequences to the health of communi- ties characterised by social cohesion and public spiritedness. However, in providing this description the book offers a perspective on how we can under- stand inequalities. As a researcher in the field of health inequalities, I found this perspective useful but feel that it would be equally useful to policy- makers and other health professionals practising in this field.

Sharon Bennett Public Health Research and Resource Centre, University of Salford, UK

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168 REVIEWS

Health Care Systems--Cost Containment versus Quality Eleanor G. Feldbaum and Miriam Hughesman, 1997, Pearson Professional, London, 213 pages, £450.00, US$710, ISBN 185 334 8198

This is one of those rare books reviewers are asked to return to the publisher, because they're too expensive to be given away to critics.

Pearson, the owner of the Financial Times, pub- lished through its Financial Times Healthcare division the first review of Healthcare Systems in 1992. The 1997 edition represents the second edition of this work. Unfortunately, at £450 the price of this xe- roxed, spiral-bound review is so steep that only uni- versity libraries and health care management professionals are likely to purchase this book. It compares the cost containment efforts and the quality of health care delivery in the UK, France, Germany and the USA. The authors of this review are US- based Eleanor G. Feldbaum, a health care consultant with Logistic Management Institute, a non-profit think tank, and Miriam Hughesman, a former editor of the Financial Times Biotechnology Business News.

They suggest that the reasons for spiralling costs in virtually all Western health care delivery, systems can be found in three broad categories:

Ageing Population, Advances in Medical Technology, and System Inefficiencies.

Solidarity-based health insurance systems, as they exist in Germany, the UK and France, inevitably face problems when the life expectancy of the elderly continues to increase while the fertility rate seems to be in a terminal decline. After all, health care for the elderly is more expensive than care for the younger members of society. For instance, in 1995 in Germany the statutory funds spent DM7763 per pensioner for all health care services compared to DM3831 on citizens below the pension age (p. 10). Of course, declining birth rate results in an overall smaller workforce contributing towards the health care of increasingly longer living elderly people. Unsurpris- ingly, advances in medical technology have driven health care costs upwards. Not only are new (read: patented) drugs generally very expensive, the infor- marion age also guarantees that those affected will know about the availability of new agents or innova- tive diagnostic tools, and they will demand access.

The structure of the rest of the book is fairly straightforward, and very practical, as one would expect from a Financial Times publication. It compares the health care systems of the UK, France, Germany and the USA. Each country is analysed in turn in a separate chapter, under the following headings: De- scription of the Health System, Role of Government, Payers and Expenses, Health Industry, Cost Contain- ment Policies, Quality of Care, and Future Reform Plans. Cost containment efforts in all countries were

accompanied by attempts to measure the quality of health care delivery. In France, ANAES, a national agency for the accreditation and evaluation of hospi- tals, has been established to guarantee a minimum quality of care. It has the power to close down establishments falling below these standards. A simi- lar agency is in operation in the USA since the 1950s. More recently another agency was established with the express purpose to set quality standards for in- surance companies. Still, the report notes that 'it is not clear that the government or private sector en- forces any quality standards'. Patient rights declara- tions exist at this stage only in the USA and the UK.

By and large, the authors conclude, cost contain- ment efforts have failed, largely because of faulty premises, and nebulous and/or contradictory objec- tives. A surprising lack of studies measuring quality of health care delivery in each of the surveyed coun- tries ought to be mentioned here. In Germany, access to health care is superior to any of the other Eu- ropean countries, and to the USA. The USA is singled out for its exemplary hospital accreditation process. The authors sound a note of warning: Cost contain- ment activities can have negative effects on the quality of health care. They suggest that 'the purpose of several cost cutting reforms runs directly counter to health systems quality' (p. 203). The sad conclusion is that the cost cutters (going about the business under the euphemism of just resource allocation) seem to 'have forgotten that the health system exists to serve pa- tients, not to obstruct their use of services'.

This book provides an excellent port of reference for anyone interested in the issue of resource alloca- tion. The authors don't spend much time with the ethics of resource allocation or the philosophy of health, but everyone working in these areas would certainly greatly benefit from this study. It contains a wealth of statistical information and references for further inquiries.

Udo Schiiklenk Centre for Professional Ethics, University of Central Lancashire, UK

Should Pharmaceutical Prices be Regulated? The Strengths and Weaknesses of the British Pharma- ceutical Price Regulation Scheme lEA Health and Welfare Unit, London, 1997, 133 pages, £12.00, ISBN 0-255 36430-X, ISSN 1362-9565

This report from the lEA Health and Welfare Unit is worth reading. However, you would be hard put to justify the judgement from the selective misrepresen- tation of its contributors that passes for an accompa- nying press release, or the ideologically predictable editorial 'introduction' by David Green, the Unit's Director. Most of the contributions to this report are balanced, searching and well-substantiated; they do

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not provide an easy 'yes' or 'no' to the question in the title, nor do they unreservedly damn the regula- tory curiosity that is the British pharmaceutical pric- ing scheme. A much more complex picture emerges.

The USA apart, there are practically no industri- alised countries in which the government does not intervene in a fairly direct way to influence the level of pharmaceutical prices. Although not in itself a justification for instituting or maintaining such con- trois, this does suggest that there is something differ- ent about therapeutic drugs that invites active intervention of this kind. Essentially, it is their heal- ing properties. These provide a moral dilemma both for the companies selling drugs and governments subsidising them. This is a double-edged sword for both parties: should companies exploit the vulnera- bility of the sick and charge what the market can or cannot bear, or feel blackmailed into providing cheap medicines? Can governments use moral suasion on companies, or are they more likely to be skewered themselves in the glare of the public spotlight?

Aside from the moral dimension, there are ques- tions of safety, the integrity of information about drugs, the dynamic of innovation, and the special agency relationship of the doctor on behalf of the patient, all of which conspire to make the market for therapeutic drugs rather unusual. Indeed, a strong case can be made that these special conditions, far from requiring a compete removal of regulation in order to make the market work better, actually need different kinds of regulation. Just take two exam- pies--price competition and the integrity of informa- tion about drugs. A well-functioning market should, one imagines, exhibit competitive, clearing prices and accurate information. Yet, this is not the case for pharmaceuticals; there are serious distortions in these two important mechanisms for a well-functioning market.

For example, although there is growing evidence of competition on price, companies prefer to compete on innovation, promotion and product differentia- tion. Reference pricing--where the public subsidy gives a marginal advantage and consumer leverage to the cheaper drug--helps encourage price competi- tion. Similarly with information. This is an area where Gresham's Law applies--the exaggerated, well-orchestrated and suspect promotion of a drug too often forces out the better currency of the more restrained and accurate scientific claim. Again, the public interest requires some regulatory framework.

Because of the ideological shepherding provided by the editor in the introduction and the accompany- ing press release, these are issues that are not can- vassed. Also, the voice of the organised consumer movement is a notable absentee. Otherwise, this is a useful survey.

Peter Davis Department of Public Health, University of Auck- land, New Zealand

Morality and Health Allan M. Brandt and Paul Rozin (eds), 1997, Rout- ledge, New York, 416 pages (paperback), £15.99, ISBN 0-415-91582-1

When confronted with a solid piece of interdisci- plinary work, a book written by historians, anthro- pologists, medical sociologists, epidemiologists and lawyers, it seems a bit childish to complain that your own favourite discipline, medical ethics, was left out. Yet I take the liberty to utter this complaint, because I have seldom read a book that raised so many interesting normative questions (both explicitly and implicitly) and offered so few satisfactory answers.

Morality and Health is the result of a number of conferences held in the 1980s and 1990s. The book covers a plethora of subjects varying from health and suffering in Chinese society, to the moral debate about eating sugar in the USA before slavery was abolished, to out-of-wedlock births in general and teenage pregnancies in particular. In this review, I will follow the thread that runs most prominently through the book: the moralisation of biomedical phenomena. This thread starts with an interesting chapter on health and morality in early modem Eng- land by Keith Thomas, who shows that Elizabethan England was torn between two perspectives on dis- ease. There was the scientific (Galenic) body of knowledge on the one hand and there was the Chris- tian perspective on the other hand, which took dis- ease to be either an outright punishment by God or an ordeal to tempt one's faith (cf. the tragic saga of Job). Following the thread, we find an anthropologi- cal contribution by Richard A. Shweder and others in which Thomas's two explanations of disease are put in a broader perspective. According to Shweder et al., mankind has developed no less than seven causal ontologies of disease. Apart from the biomedical and the moral ontologies introduced by Thomas, there are the interpersonal ontology (disease is perceived to be caused by black magic, bewitchment and the like), the sociopolitical ontology (suffering is the product of oppression in one form or other), the psychological ontology (disease sprouts from frustration and un- fulfilled desires), the astrophysical ontology (disease is caused by 'malevolent arrangements of planets, moons, and stars') and a contemporary ontology in the making in which the environment (ecological factors, stress, pressure, etc.) is held responsible for illness and suffering. There seems to be a general tendency to prefer causal ontologies which leave room for some form of human control. Hence the ever growing popularity of the biomedical perspec- tive; even people who do not adhere to the biomedi- cal ontology are inclined to seek biomedical therapy when a problem occurs. The two other most popular ontologies are the moral and the interpersonal one.

These days we can witness interesting coalitions being formed between the biomedical and the moral ontology. Three chapters by anthropologist Solomon

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Katz, lawyer Lawrence Gostin and political scientist Howard M. Leichter discuss the development of a new secular morality in the US. 'Thou shalt not smoke' has become an 11th commandment for most Americans. Similar lifestyle prescriptions ('Thou shalt not drink and drive', 'Thou shalt eat a low fat diet', 'Thou shalt exercise regularly') may become equally popular. Katz describes the factors and actors which contributed to the establishment of the new secular morality. It all started with the 1964 Surgeon General report on the dangers of smoking. The Surgeon General's appeal was soon picked up by the health and fitness move- ment as well as certain patient advocacy groups. The advocates of the new health-oriented morality got a lot of media attention. Both Gostin and Leichter draw attention to the ways in which the new morality is enforced in the USA. It is both fascinating and fright- ening to read that some American employers forbid their employees to smoke, not only at work but also in their cars on their way to work or in the privacy of their own homes (Gostin, p. 349; cf. also Leichter, p. 362). Statutes have been enacted which make smokers ineligible for certain government jobs and positions (ibid.). Sometimes employees who are overweight have to pay extra insurance premiums (Leichter, p. 362). 'Failure to adopt correct lifestyle practices might lead to being turned down for an insurance policy, or a job, or admission to school' (ibid.). The dangers of sidestream smoke are exaggerated so as to be able to establish a link between the new public health moral- ity and traditional liberal principles (the government may only interfere with people's lifestyle if their behaviour causes harm to other people; hence it is of paramount importance to demonstrate that smoking really does harm others than the smokers themselves). The new morality has also been tied to Christian Puritanism, traditionally a religious movement that preached abstinence, self-control and temperance (cf. also Rozin, p. 391). By now the healthy have become the chosen, the virtuous.

Observations like these have inspired the authors of Morality and Health to ask questions such as: (1) How did Americans come to be so obsessed with their own physical well-being? Leichter thinks this may have something to do with the weakening of traditional socialising and moralising institutions: the church, neighbourhoods and the family. He also suggests that periods of national turmoil such as the 1960s are generally followed by periods in which a people becomes more inward looking. (2) How do I go about if I want to introduce other lifestyle regulations? A list of dos and don'ts is provided by Rozin in the last chapter. (Emphasise that innocent children can be victimised by the behaviour you want to rule out. Try to remain realistic. It is impossible to make people eat things that do not taste good and are not easy to prepare either.) Apart from some sound, albeit rather modest moral/legal remarks in Gostin's chapter, nor- mative evaluation is virtually absent. (I pass over one remarkable exception. Shweder et al. want us to adopt some version of karma philosophy; we should take our moral intuition that disease is a past transgression catching up with us much more seriously. In an otherwise interesting chapter, this advice struck me as utter nonsense.)

The material assembled in Morality and Health would haunt me with questions like: What should we think of this emerging lifestyle tyranny? How can we make it go away? If this can happen in a country such as the US, with a strong libertarian tradition, what will happen if the lifestyle correctness really breaks out in Western Europe, where this tradition has never had much impact?

There is little noticeable horror in this book while there is so much to be horrified by.

Margo Trappenburg Department of Political Science, Leiden University, The Netherlands

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