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Biomedical technology and human rights
Book Reviews
755
complementary personal interviews, figures, or tables to balance or confront earlier finding and conjectures. The first of only two chapters is a selective review of Western literature from the classical age to the present. Here Lock attempts to trace "the invention of Menopausal Woman in Europe and North America, her reduction to the menopause, and still more recent demotion to a deficiency disease and an endocrinopathy" (p. 305). Again Lock postulates a set of conclusions or mythologies for which she finds evidence in literature written by physicians, philosophers, and biologists of earlier times to support. The final chapter draws these selections together with more cultural and historical accretions (here from modern Western women, viz. de Beauvoir, Helene Deutsch, Margaret Mead) to present menopause as a crisis of aging embued with symbolic significance (cf. Freud, Erikson et al.). Loss of estrogen and therefore loss of reproductive capacity and sexuality, according to these views, reduces women to inessential, unfeminine, sexless people. The fear of aging, in
this view is culturally embedded over time and across disciplines and is exacerbated by the idea that an estrogendeficient body is a diseased body. Lock presents this view as the prevalent view of Western culture and biology. She writes with strength to oppose the medicalization of menopause in her closing epilogue--a virtual polemic against the drug industry and the attitudes of North American gynecologists. Margaret Lock's book presents contradictory cultural and biological viewpoints of a phenomenon of growing significance: the health care for menopausal women and the politics of aging. This admittedly subjective exploration of the Eastern and Western mythologies of menopause provides a thought-provoking historical background. More objective, scientific viewpoints may move us forward into a demythologized future,
Biomedical Technology and Human Rights, by Eugene B. Brody. Published jointly by the United Nations Educational,
decisions enter, rather than humane considerations, individual wishes, and citizen's expectations: rationing, cost containment, technology by age and medical history, and, at times it appears that the biomedical standards for the use of technology often reproduce those of health insurance plans. Readers of the last chapter, 'Biomedical Technology: Towards Health for All?', particularly those using the models provided by the political economy of health and critical medical anthropology, may note the lack of a more direct critique of the goals set by the Assembly held at the World Alma Ata and the slogan "Health for all by the year 2000'. The intervening chapters take on the most difficult work of discussing issues related to the essence of human acts and decisions--birth and death. They are devoted to the targets of reproductive technology, organ and tissue transplants, genetic technology, rights of the mentally ill, and the management of death. Throughout, medical technologies and interventions, including how and why they are used, are explained in a language that can be understood by a non-specialist. They are woven into a framework which contrasts individual motives and concerns with those of the larger society (e.g. state, legal decisions and mandates, concepts of the 'social good'). This issue reaches its culmination in the treatment of the mentally ill and the 'dying', who, once having been bestowed with these labels, are usually characterized as having 'diminished capacities' and not fully responsible for their choices. Behavioural scientists will be particularly convinced of Dr Brody's expertise in placing the issues in the context of his experiences in non-western societies. The concept of cultural relativity runs throughout the book along with the legalities imposed by Western constructions of what is humane. While the west is the producer of the last word in biomedical technology, Dr Brody does not support that it should have the last word in its implementation. This conflict is never finally resolved; universal rules and global solutions legitimated by pancosmic judicial decisions are not suggested. Indeed, some chapters end rather abruptly, perhaps in the author's attempt to remain neutral, allowing the reader to ponder the multitude of facts presented and the complexities of human pain and need. However, some solutions are posed at the end of the chapter, "'Biomedical Science and the Rights of the Mentally Ill", which speaks of social support to "...redress the inequity in social power which impairs communication between helper and help-seeker", the education of clinicians so that they do not "'...depend totally upon methods of physical and pharmacological treatment", the dialogue between clinician and patient which "'...must
Scientific and Cultural Organization (UNESCO), Paris, and the Dartmouth Publishing Company Limited, England, 1993. 312 pp., $39.95. In this compendium, Eugene B. Brody consolidates more than three decades of international research and practical experience in the area of medical ethics. Having witnessed and recorded the emergence of the new medical technologies from the early 1970s in numerous publications, he brings together his knowledge and takes on the difficult task of addressing the issues of medical ethics and the advances in biomedical technology, integrating them with a global perspective on human rights. This task is not undertaken as a philosophical endeavour or a record of personal history (the latter only briefly touched upon in the Author's Foreword). It is based upon experience from ethnographic and clinical research, providing the reader with concrete facts so that the philosophical and existentialist queries can be taken up in another forum. It has a legalistic dimension as well, documenting local cases of human rights, in almost all instances by examining them from at least two sides, and placing them within an international context. That it often takes on the form of a 'shopping list' allows the reader to not become burdened with esoteric arguments. That it is, in some places filled with 'a history' of documents and decisions (either legal or human) does not detract from its use. Rather, it enhances it for those new to the field and it should serve as a handbook (with what seems to be at least 450 references) for scholars and clinicians faced with the inevitable problematique of the book's title. Chapters One and Two are inversions of each other. First health is addressed in the context of human rights, and then, human rights in the context of the culture of science and technology. In the former, Dr Brody tackles the essence of the complicated, multifacted issue: e.g. parental rights, children's rights, welfare for families under stress, and includes United Nation's Declarations (contrasting them with excerpts of reality). This chapter provokes the question of: What is 'health' if human rights are missing? In the second chapter, although phrases such as 'society and culture', 'cultural values', and 'socio-cultural change' are used generously, the concept of exactly what might be the 'culture of science and technology' is not explicitly stated. Both introductory chapters are directly tied to the last chapter, Biomedical Technology: Towards Health for All? Instead of 'all' the reader is reminded that bureaucratic
8207 Limehouse Lane Louisville, KY 40220, U.S.A.
Louise Justice Pass
756
Book Reviews
rest upon the qualities that they share in common with the rest of the human family" (p. 185). Now that this book has appeared, Dr Brody will need to append it every six months, given the rate of biomedical technology expansion (a task of which he is surely capable). This volume is essential for the libraries and repertoire of those teaching medical ethics in law and medical schools and in departments of behavioural science, international law and human justice.
ISocial Work Department Technological Educational Institution (TEl) of Athens Greece
Health Care Across the Border: The Experience of U.S. Citizens in Mexico, edited by David C. Warner and Kevin Reed. U.S.-Mexican Policy Studies Program, Policy Report No. 4. Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, 1993, 233 pp. $15 (paperback).
The setting for this study is intriguing. Pharmaceuticals and hospitalization are markedly less expensive in Mexico. The dilemma is that Medicaid and Medicare reimbursement procedures function only when beneficiaries are closer to a Mexican than a U.S. hospital when medical emergencies result. Given the lower cost of living in Mexico and the large retirement communities in Guadalajara, the northern Mexican states and borderland areas, the potential savings to the U.S. government are great, if only federal regulation could pay Mexican providers and facilities. In this regard, Part IV, "Financing Alternatives," comes closest to the policy recommendations we expect from a product of the LBJ School of Public Affairs. Readers likely to benefit most from this monograph include health-policy analysts at the federal level, U.S. corporations interested in furthering commercial ties with Mexican maquiladoras, and U.S. border states who participate in matching U.S. Federal health-care programs. This book is a good primer on understanding health-care delivery systems in both the U.S.A. and Mexico. It does a fine job of summarizing the major features of the Mexican social security institutes which, at first instance, may seem complex and unduly rigid to the non-Spanish reading U.S. citizen traveling through or living in Mexico. The uneven treatment of policy given by this book may stem from the backgrounds of the contributors: nine with B.A.s (in fields ranging from Spanish to international relations), two M.A.s, two J.D.s and one Ph.D. Although the data used in estimating the potential savings to the U.S. government are fuzzy, this reviewer expected a simple cost-benefit model that would drive home the point for reassessing federal reimbursement policies. Should U.S. policy take an incrementalist approach to this problem? Might an executive order address these concerns? Regrettably, we are not told. The book provides thick descriptions of medical costs, long-term care utilization patterns, and profiles of U.S. citizens living and seeking health care in Mexico. The data are culled from original survey research and in-depth interviews carried out by the larger research project. Despite the author's best efforts, they conclude that it is difficult to measure the flow of retirement benefits coming directly into Mexico from U.S. Social Security payments and other remittances. Clearly, the time has come to rethink U.S. financing of health care for its citizens living south of the Rio Bravo. This work will serve as an empirical contribution to that policy process.
While the powers of globalization creep into our lives through technological wizardry and innovative trade agreements, Mexicans and Americans influence each other's country the old-fashioned way: by living and traveling across the border. Policy-analyst David C. Warner and attorney Kevin Reed examine a little-studied phenomenon that is diametrically opposed to the issue of nondocumented Mexicans receiving free medical services in the U.S.A. (evidenced by the 1994 debate surrounding California's proposition 187). Instead, the authors peruse the consumption of medical care by U.S. citizens who pay for their care in Mexico. This edited work spans 204 pp., four parts, ten chapters and 28 pp. of appendices. It is a timely empirical piece that appears on the eve of the North American Free Trade Agreement and in the midst of heated U.S. social policy debate on how to curtail federal bealth-care expenditures for Medicaid, Medicare and U.S. veterans. Although no new technological innovations drive the book's inquiry into this particular dimension of globalization, new medical-care financing arrangements will be needed to meet the needs of thousands of mostly retired U.S. citizens living in sunny Mexico. Twelve contributors join the editors in reporting on a policy research project whose goal is "to examine health services in Mexico for U.S. citizens and residents and the use of U.S. services by residents of Mexico." The goal of this "largely exploratory report" is to help "analysts, policymakers, and entrepreneurs to develop residential and treatment alternatives in Mexico" (p. 1). The authors are moderately successful in attaining this objective, but this reviewer expected more clear-cut policy recommendations from the editors who shy away from forthright proposals. It is the reader who must labor through ten chapters written with uneven clarity of exposition and formats (only one has a conclusion) as well as 60-odd tables. We learn that U.S. citizens in Mexico generally find minor ambulatory care and some hospitalization acceptable, but largely return to the U.S.A. for most of their major secondary and tertiary care. Cumbersome U.S. federal regulations prohibit Medicare, Medicaid and veterans' health-care programs from reimbursing less-expensive Mexican health-care providers and facilities. The great irony, of course, is that the U.S. Federal government passes up a way to save money in these cost-conscious times. Geography matters in this case and it carries a hefty opportunity cost.
Joannes ChUu,uttkis' and Deanna J. Trakasz
2Department of Social Anthropology University of the Aegean Lesbos, Greece
Department of Urban Affairs Joseph L. Scarpeci and Planning College of Architecture and Urban Studies Virginia Tech Blacksburg, VA 24061-0113 U.S.A.
755
complementary personal interviews, figures, or tables to balance or confront earlier finding and conjectures. The first of only two chapters is a selective review of Western literature from the classical age to the present. Here Lock attempts to trace "the invention of Menopausal Woman in Europe and North America, her reduction to the menopause, and still more recent demotion to a deficiency disease and an endocrinopathy" (p. 305). Again Lock postulates a set of conclusions or mythologies for which she finds evidence in literature written by physicians, philosophers, and biologists of earlier times to support. The final chapter draws these selections together with more cultural and historical accretions (here from modern Western women, viz. de Beauvoir, Helene Deutsch, Margaret Mead) to present menopause as a crisis of aging embued with symbolic significance (cf. Freud, Erikson et al.). Loss of estrogen and therefore loss of reproductive capacity and sexuality, according to these views, reduces women to inessential, unfeminine, sexless people. The fear of aging, in
this view is culturally embedded over time and across disciplines and is exacerbated by the idea that an estrogendeficient body is a diseased body. Lock presents this view as the prevalent view of Western culture and biology. She writes with strength to oppose the medicalization of menopause in her closing epilogue--a virtual polemic against the drug industry and the attitudes of North American gynecologists. Margaret Lock's book presents contradictory cultural and biological viewpoints of a phenomenon of growing significance: the health care for menopausal women and the politics of aging. This admittedly subjective exploration of the Eastern and Western mythologies of menopause provides a thought-provoking historical background. More objective, scientific viewpoints may move us forward into a demythologized future,
Biomedical Technology and Human Rights, by Eugene B. Brody. Published jointly by the United Nations Educational,
decisions enter, rather than humane considerations, individual wishes, and citizen's expectations: rationing, cost containment, technology by age and medical history, and, at times it appears that the biomedical standards for the use of technology often reproduce those of health insurance plans. Readers of the last chapter, 'Biomedical Technology: Towards Health for All?', particularly those using the models provided by the political economy of health and critical medical anthropology, may note the lack of a more direct critique of the goals set by the Assembly held at the World Alma Ata and the slogan "Health for all by the year 2000'. The intervening chapters take on the most difficult work of discussing issues related to the essence of human acts and decisions--birth and death. They are devoted to the targets of reproductive technology, organ and tissue transplants, genetic technology, rights of the mentally ill, and the management of death. Throughout, medical technologies and interventions, including how and why they are used, are explained in a language that can be understood by a non-specialist. They are woven into a framework which contrasts individual motives and concerns with those of the larger society (e.g. state, legal decisions and mandates, concepts of the 'social good'). This issue reaches its culmination in the treatment of the mentally ill and the 'dying', who, once having been bestowed with these labels, are usually characterized as having 'diminished capacities' and not fully responsible for their choices. Behavioural scientists will be particularly convinced of Dr Brody's expertise in placing the issues in the context of his experiences in non-western societies. The concept of cultural relativity runs throughout the book along with the legalities imposed by Western constructions of what is humane. While the west is the producer of the last word in biomedical technology, Dr Brody does not support that it should have the last word in its implementation. This conflict is never finally resolved; universal rules and global solutions legitimated by pancosmic judicial decisions are not suggested. Indeed, some chapters end rather abruptly, perhaps in the author's attempt to remain neutral, allowing the reader to ponder the multitude of facts presented and the complexities of human pain and need. However, some solutions are posed at the end of the chapter, "'Biomedical Science and the Rights of the Mentally Ill", which speaks of social support to "...redress the inequity in social power which impairs communication between helper and help-seeker", the education of clinicians so that they do not "'...depend totally upon methods of physical and pharmacological treatment", the dialogue between clinician and patient which "'...must
Scientific and Cultural Organization (UNESCO), Paris, and the Dartmouth Publishing Company Limited, England, 1993. 312 pp., $39.95. In this compendium, Eugene B. Brody consolidates more than three decades of international research and practical experience in the area of medical ethics. Having witnessed and recorded the emergence of the new medical technologies from the early 1970s in numerous publications, he brings together his knowledge and takes on the difficult task of addressing the issues of medical ethics and the advances in biomedical technology, integrating them with a global perspective on human rights. This task is not undertaken as a philosophical endeavour or a record of personal history (the latter only briefly touched upon in the Author's Foreword). It is based upon experience from ethnographic and clinical research, providing the reader with concrete facts so that the philosophical and existentialist queries can be taken up in another forum. It has a legalistic dimension as well, documenting local cases of human rights, in almost all instances by examining them from at least two sides, and placing them within an international context. That it often takes on the form of a 'shopping list' allows the reader to not become burdened with esoteric arguments. That it is, in some places filled with 'a history' of documents and decisions (either legal or human) does not detract from its use. Rather, it enhances it for those new to the field and it should serve as a handbook (with what seems to be at least 450 references) for scholars and clinicians faced with the inevitable problematique of the book's title. Chapters One and Two are inversions of each other. First health is addressed in the context of human rights, and then, human rights in the context of the culture of science and technology. In the former, Dr Brody tackles the essence of the complicated, multifacted issue: e.g. parental rights, children's rights, welfare for families under stress, and includes United Nation's Declarations (contrasting them with excerpts of reality). This chapter provokes the question of: What is 'health' if human rights are missing? In the second chapter, although phrases such as 'society and culture', 'cultural values', and 'socio-cultural change' are used generously, the concept of exactly what might be the 'culture of science and technology' is not explicitly stated. Both introductory chapters are directly tied to the last chapter, Biomedical Technology: Towards Health for All? Instead of 'all' the reader is reminded that bureaucratic
8207 Limehouse Lane Louisville, KY 40220, U.S.A.
Louise Justice Pass
756
Book Reviews
rest upon the qualities that they share in common with the rest of the human family" (p. 185). Now that this book has appeared, Dr Brody will need to append it every six months, given the rate of biomedical technology expansion (a task of which he is surely capable). This volume is essential for the libraries and repertoire of those teaching medical ethics in law and medical schools and in departments of behavioural science, international law and human justice.
ISocial Work Department Technological Educational Institution (TEl) of Athens Greece
Health Care Across the Border: The Experience of U.S. Citizens in Mexico, edited by David C. Warner and Kevin Reed. U.S.-Mexican Policy Studies Program, Policy Report No. 4. Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, 1993, 233 pp. $15 (paperback).
The setting for this study is intriguing. Pharmaceuticals and hospitalization are markedly less expensive in Mexico. The dilemma is that Medicaid and Medicare reimbursement procedures function only when beneficiaries are closer to a Mexican than a U.S. hospital when medical emergencies result. Given the lower cost of living in Mexico and the large retirement communities in Guadalajara, the northern Mexican states and borderland areas, the potential savings to the U.S. government are great, if only federal regulation could pay Mexican providers and facilities. In this regard, Part IV, "Financing Alternatives," comes closest to the policy recommendations we expect from a product of the LBJ School of Public Affairs. Readers likely to benefit most from this monograph include health-policy analysts at the federal level, U.S. corporations interested in furthering commercial ties with Mexican maquiladoras, and U.S. border states who participate in matching U.S. Federal health-care programs. This book is a good primer on understanding health-care delivery systems in both the U.S.A. and Mexico. It does a fine job of summarizing the major features of the Mexican social security institutes which, at first instance, may seem complex and unduly rigid to the non-Spanish reading U.S. citizen traveling through or living in Mexico. The uneven treatment of policy given by this book may stem from the backgrounds of the contributors: nine with B.A.s (in fields ranging from Spanish to international relations), two M.A.s, two J.D.s and one Ph.D. Although the data used in estimating the potential savings to the U.S. government are fuzzy, this reviewer expected a simple cost-benefit model that would drive home the point for reassessing federal reimbursement policies. Should U.S. policy take an incrementalist approach to this problem? Might an executive order address these concerns? Regrettably, we are not told. The book provides thick descriptions of medical costs, long-term care utilization patterns, and profiles of U.S. citizens living and seeking health care in Mexico. The data are culled from original survey research and in-depth interviews carried out by the larger research project. Despite the author's best efforts, they conclude that it is difficult to measure the flow of retirement benefits coming directly into Mexico from U.S. Social Security payments and other remittances. Clearly, the time has come to rethink U.S. financing of health care for its citizens living south of the Rio Bravo. This work will serve as an empirical contribution to that policy process.
While the powers of globalization creep into our lives through technological wizardry and innovative trade agreements, Mexicans and Americans influence each other's country the old-fashioned way: by living and traveling across the border. Policy-analyst David C. Warner and attorney Kevin Reed examine a little-studied phenomenon that is diametrically opposed to the issue of nondocumented Mexicans receiving free medical services in the U.S.A. (evidenced by the 1994 debate surrounding California's proposition 187). Instead, the authors peruse the consumption of medical care by U.S. citizens who pay for their care in Mexico. This edited work spans 204 pp., four parts, ten chapters and 28 pp. of appendices. It is a timely empirical piece that appears on the eve of the North American Free Trade Agreement and in the midst of heated U.S. social policy debate on how to curtail federal bealth-care expenditures for Medicaid, Medicare and U.S. veterans. Although no new technological innovations drive the book's inquiry into this particular dimension of globalization, new medical-care financing arrangements will be needed to meet the needs of thousands of mostly retired U.S. citizens living in sunny Mexico. Twelve contributors join the editors in reporting on a policy research project whose goal is "to examine health services in Mexico for U.S. citizens and residents and the use of U.S. services by residents of Mexico." The goal of this "largely exploratory report" is to help "analysts, policymakers, and entrepreneurs to develop residential and treatment alternatives in Mexico" (p. 1). The authors are moderately successful in attaining this objective, but this reviewer expected more clear-cut policy recommendations from the editors who shy away from forthright proposals. It is the reader who must labor through ten chapters written with uneven clarity of exposition and formats (only one has a conclusion) as well as 60-odd tables. We learn that U.S. citizens in Mexico generally find minor ambulatory care and some hospitalization acceptable, but largely return to the U.S.A. for most of their major secondary and tertiary care. Cumbersome U.S. federal regulations prohibit Medicare, Medicaid and veterans' health-care programs from reimbursing less-expensive Mexican health-care providers and facilities. The great irony, of course, is that the U.S. Federal government passes up a way to save money in these cost-conscious times. Geography matters in this case and it carries a hefty opportunity cost.
Joannes ChUu,uttkis' and Deanna J. Trakasz
2Department of Social Anthropology University of the Aegean Lesbos, Greece
Department of Urban Affairs Joseph L. Scarpeci and Planning College of Architecture and Urban Studies Virginia Tech Blacksburg, VA 24061-0113 U.S.A.