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10. Wennberg, J.E. (1991). Outcomes research, cost containment and the fear of health care rationing. New England Journal of Medicine 323, 1202-1204.

11. Williams, A.H. (1974). The cost-benefit approach. British Medical Bulletin 30(3), 252-256.

12. For a philosophical critique of cost-benefit reasoning see McIntyre, A. (1977). Utilitarianism and cost/benefit analysis: an essay on the relevance of moral philosophy to bureaucratic theory. In, Values in the Electric Power Industry, ed. by K. Sayre, University of Notre Dame Press, Notre Dame, Indianapolis

13. Williams, A. (1985). Economics of coronary artery bypass grafting. British Medical Journal 291, 1507.

14. Williams, A. (1985). The value of QALYS. Health and Social Services Journal 95.

15. Carr-Hill, R. (1991). Allocating resources to health care: is the QALY (quality adjusted life year) a technical solution to a political problem? International Journal of Health Services 21, 351-363.

16. Donaldson, C., Atkinson, A., Bond, J. and Wright, K. (1988). Should QALYs be programme specific? Journal of Health Economics 7, 47-57.

17. Harris, J. (1986). Rationing Life: Quality or Justice?. Paper presented to BMA Annual Scientific Meeting, Oxford, April 1986.

18. See, for example, Plant, R., Lesser, H. and Taylor- Gooby, P. (1980) Political Philosophy and Social Welfare, R.K.P., London.

19. Galtung, J. (1981). The basic needs approach. In, Human Needs, ed. by K. Lederer, Oelgeschlager, Gunn and Hain, Cambridge, Massachusetts.

20. Gewirth, A. (1982). Human Rights. Essays on Justi~cation and Application, University of Chicago Press, Chicago.

21. Doyal, L. and Gough, I. (1992). A Theory of Human Need, Macmillan, London.

22. Ramsay, M. (1992). Human Needs and The Market, Avebury, Aldershot.

23. Daniels, N. (1985). Just Health Care, Cambridge University Press, Cambridge.

24. Beauchamp, T.L. and Childress, J.F. (1979). The Principles of Biomedical Ethics, Oxford University Press, Oxford.

BOOK REVIEWS

Controlling Health Professionals: the Future of Work and Organization in the NHS Stephen Harrison and Christopher Pollitt, 1994, Open University Press, Buckingham, 176 pages, s ISBN 0-335-09643-3 (paperback).

The UK National Health Service (NHS), it almost goes without saying, has been undergoing rapid change for the past ten years. Whether 'privatisation', 'marketisation', 'commercialisation', or 'Americani- sation' is the preferred label for what we are now

witnessing, the current reforms represent an ideologically driven attempt at wholesale reform of the economy and culture of the NHS. In retrospect, health policy in Britain in the 1970s seems to have been a dull matter, consisting of little more than tinkering with the performance of a machine whose basic dimensions were axiomatic.

As well as creating considerable uncertainty for health service workers and users, the reforms have quickened debate about the purposes, organisation and funding of health services. Indeed, it sometimes seems that we are drowning in a sea of informed opinion which has many tributaries. For this reason textbooks on health policy are essential both for teachers trying to simplify issues for students, and for researchers seeking to locate their own empirical explorations in some wider intellectual universe. This useful book is one of the latest in the State of Health series edited by Chris Ham. It documents the most recent ructions in the NHS with precision and levity, but it also constantly reminds us that, for all the discontinuities of recent times, there is a longer history.

The authors focus here on the effects of the NHS reforms on the organisation of work, the status and power, of different 'professional' workers in the NHS---doctors, nurses and therapists. They begin with a discussion of the nature of professional work in the NHS, set against a background of the more general changes in public sector funding and employment in Britain. They go on to examine what they call the 'theoretical basis' of their analysis, which takes us through an explanation of the forces influencing supply and demand in health care, and the processes of rationing. One of their basic assumptions is that 'rationing of medical care is a chronic necessity', but this necessity does not determine the form the rationing takes. Reviewing the crisis over public expenditure that afflicted the British government in the early 1980s they argue that managerial control over health professionals was one approach--and probably the least damaging politically--to the problem of controlling expenditure on the NHS.

Three core chapters review different approaches to the business of controlling the behaviour of professional workers. First, they discuss direct challenges to professional power through the introduction of line management at different levels of organisation--an approach which proved markedly more successful with nurses and other professions allied to medicine than with doctors. Second, they examine attempts to incorporate health professionals into the managerial ethos by making them responsible for budgets and by unsettling their structures of collegiality. And third, they consider the way in which reforms in the wider health care environment--the separation of purchasers and providers, and the empowerment of ' consumers ' - have been employed to give managers more political leverage, and to provoke strife in the internal hierarchies of professional groups.

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The final chapter on the future of managerial work provides a nice turn to the story. Having suggested that the future of the NHS is an increasingly managed environment, they conclude that it is too simplistic to see the conflict of the future as being between managers and professionals. What we are more likely to see, they claim, are multiple cleavages both within management (between, for example, purchaser and provider managers), and within professions (between, say, general practitioners and hospital doctors).

Although these authors do not say it--at least not in these terms---this will be a truly post-modem environment of shifting alliances and uncertain identities! And while 'professionals' may retain high degrees of independence from 'managers', the price to be paid will be a return to the free-market in healing that Roy Porter and others have documented in eighteenth century England. The implications of this for the equitable distribution of health care in an economically unequal and politically punitive society are not promising.

Two aspects of the book are frustrating. First, for all their learning--lightly bome~the authors display remarkable parochialism. There is, for example, virtually no reference to the sociological analysis of professional power and knowledge. The concepts of 'de-professionalisation' and 'proletarianisation' may have their limitations when applied to the contemporary British situation, but they could help unscramble some of those paradoxes of professional power in the NHS the authors describe. Second, there is a marked absence of moral and political edge. No doubt it is inadequate simply to declare that the consequences of the NHS reforms are good or bad. But we should not allow the complexity and the speed of the changes taking place to deter us from making judgements about the consequences of rationing or what the British Medical Journal has dubbed the 'rise of Stalinism in the NHS'.

Nonetheless, this is an intelligent book, and a helpful guide to some of the more recent developments in the seemingly permanent revolution taking place in the NHS.

Gareth Williams Public Health Research and Resource Centre and Institute for Social Research University of Salford, UK

The Epidemiological Imagination Edited by John Ashton, 1994, Open University Press, Buckingham, 209 pages, s (paperback), s (hardback), ISBN 0335-19100-2 (pbk), 0-335-19101-0 (hbk)

Eleven eminent epidemiologists have each selected one of their favourite 'epidemiological classics' from the scientific literature of the past 50 or so years, and one paper of their own, to form each chapter of this book.

Each explains their choice in a brief introduction to their chapter, and the whole is rounded off by an introduction from John Ashton, together with his choice of two papers.

It sounds like a promising recipe for those who would prefer a light epidemiological snack as a change from the dense stodge which usually gets served up. And it is, to a degree.

The major part of the text consists of the 24 selected papers themselves, reproduced in as close to their original form as possible. Some of the papers are well known and widely cited and others, though equally widely cited are rarely actually read by anyone. All public health specialists have heard the story of John Snow, who is said to have curtailed an epidemic of cholera in London by the simple expedient of removing the handle of the Broad Street pump. But who has read a historical account of the events which preceded and followed this dramatic public health intervention? The extract in this volume reveals that, in reality, it took another ten years of persistent pressure on the authorities for the pump--an acknowledged danger to the public health--to be permanently dosed. Somehow the story gains in contemporary relevance with this postscript.

There are other fascinating accounts in this collection which remind us both how epidemiology has served to chart a territory which we now take for granted--such as the notion of the 'iceberg of morbidity'--and of how frequently epidemiology alone has been unable to catalyse the social change which its practitioners have so frequently urged. Papers on 'Food, health and income' (published in 1936) and the 'Social aetiology of s0_llbirths and infant deaths' (published in 1946) emphasise how we are still failing to act effectively in the light of the knowledge of half a century ago.

Yet despite such accounts, the book remains, in the best epidemiological tradition, worthy but dull. The brief comments and anecdotes of the contributors are not enough to leaven what turns out to be a fairly heavy meal after all. For the student of epidemiology it is not enough simply to serve up 'the classics' with little explanation of the methods used and alternative possible approaches. It is no more revealing than simply reading the current journals. For those coming to the subject from outside---and the title invites interest from health service managers, health promotion specialists and others---epidemiology will appear, as always, technically impenetrable and far too distant from real life.

The hint of nostalgia which runs through the text serves to reinforce the sense that this is a discipline which is distinctly uncomfortable with the modem world. There is no mention of the contemporary challenges facing epidemiology, particularly in terms of contributing to and evaluating the effectiveness of the new social movements for health promotion, such as Health For All and the Healthy Cities project, and this is all the more surprising given the international role of the editor in exactly these movements.

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Overall, the book has the feel of an opportunity taken but half missed. The historical importance of epidemiology is dearly demonsl~ated in the selected papers, yet its current relevance--to health technology evaluation, to health care management, to clinical practice and to social action for health--is left unexplored. We can only hope that The Epidemiological Imagination: Part Two is even now in preparation.

James Munro Department of Public Health University of Sheffield, UK

Taming Death By Law David Lanham, 1993, Longrnan Professional Publishing, Melbourne, 229 pages, ISBN 0-582-80071-4 (pbk).

This book, although written by a leading medico-legal academic, is written with the stated purpose of helping all those taking part in the medical treatment of the dying. The most important of these players is the dying person. Although the book is designed to help all the decision-makers, including health professionals and family members, it will be most helpful to the dying, their family and friends. Indeed the preamble suggests that one message which comes through the host of cases discussed by Professor Lanham is that the more that is known of the patient's prior wishes and values, the easier the decision and the more likely that it will reflect the patient's choice.

Professor Lanham's primary purpose is to encourage readers to talk to their friends and family about death and to consider how they would wish to be treated. (The appendix to the book takes the form of a Values Statement, developed at the University of New Mexico, Center for Health Law and Ethics, which readers are invited to complete and keep for reference at the appropriate time.) Although the book is first and foremost for lay persons and health professionals, lawyers too will find the book more than deserves a prominent place on their bookshelves.

Although many of the legislative references are to Australian, and particularly Victorian, legislation Professor Lanham provides an easily read yet sophisticated approach to the current debates about death and dying. In 180 pages he takes the reader through the controversial issues of decision-making for competent patients, those who become incompetent, and for those who may never be competent. These are issues which, within the State of Victoria, have been debated to a greater degree than in New Zealand, where the debate has not yet been opened for wide ranging discussion. Here the right of the competent patient to exercise autonomy over treatment decisions (for example as a result of the Report of the Cartwright Inquiry in 1988), has been well aired. However, there has been little public discussion, and few cases have come before the courts, about the rights or interests of incompetent patients, either in respect to treatment or in the dying process, and what the appropriate decision-making process should be.

In Auckland Area Health Board v Attorney-General (Re L) [1993] 1 NZLR 235, the High Court considered whether the doctors in the intensive care unit of Auckland Hospital would be guilty of culpable homicide under ss 151 (1) or s 164 of the Crimes Act 1961, were they to withdraw the ventilatory-support system which maintained the breathing and heartbeat of a patient with an extreme case of Guillain-Barr6 syndrome. In that case the court did not refer to any previously expressed view or possible values which Mr L might have held when he was competent to make his own decisions. (There may have been no evidence of these.) The court concluded that there was 'lawful excuse' to discontinue ventilation when there was no medical justification for continuing that form of medical assistance. Thus competence or lack of it was not an issue. In the English House of Lords decision, Airedale NHS Trust v Bland [1993] 1 All ER 821, on the other hand, the decision-making process as to whether to withdraw treatment or not from a patient in a persistent vegetative state was set in the context of the fully competent patient, and there was a clear recognition that the first principle to be considered must be patient autonomy. Professor Lanham's book was written before either of these two cases was decided. Had it been available his discussion would undoubtedly have been helpful to the courts.

Professor Lanham gives an insightful discussion of the meaning of incompetency and the role of the courts in exercising a parens patriae role. He is careful to put all possible (jurisdictional) approaches before his readers but finally he argues for the 'hybrid test' (from the New Jersey decision in Re Conroy 486 A 2d 1209 (1985) at p.1232), which allows appropriate weight to be given both to the evidence of the patient's wishes and the patient's best interests.

The book canvasses the prindples which should be applied to a person who has never been competent, and never will be (such as a severely disabled neonate). More generally it discusses the arguments for and against euthanasia, and considers the nature of personhood.

The quality of Professor Lanham's research and analyses of these difficult and complex legal and ethical issues is high. Nothing is sacrificed, yet the book is highly readable and deserves to attract a wide audience. It ought to be on every legislator and judge's shelf, as well as on those of every health professional and administrator.

Margaret A. McGregor Vennel Associate Professor of Law University of Auckland, New Zealand

Ethical Issues in Nursing Edited by Geoffrey Hunt, 1994, Routledge, London, 240 pages, s (paperback), s (hardback), ISBN 0415-08145-9 (pbk) 0-415-08144-0 (hbk)

This is an accessible book. It is written without jargon, and uses lots of interesting and illustrative stories to make its points. It claims to be the first book to take

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nursing ethics beyond 'stock moral concepts to a critical examination of the fundamental assumptions underlying the very nature of nursing'. Yet while I can see what the editor is getting at, this claim merits further examination.

In the introduction, Geoffrey Hunt (apparently the first philosopher to be employed by the National Health Service, though in what capacity is---tantalisingly--not explained) discusses nursing and the metaphysics of procedure, concluding that nursing is procedure dominated, to the exclusion of rational and ethical thought at times. I suspect that sometimes, in some places, this is true, but the weakness of Hunt's argument is that he takes no account of the context in which nurses work. He suggests that aspects of care are reduced to procedures, and that 'there is a strong general trend in nursing as a whole to keep an exaggerated quarter- masterly discipline Which runs counter to humane care'. While I am no enthusiast for protocols and procedures, I nevertheless acknowledge that in a place where nurses work in teams, with other health professionals, some system of organisafion must be designed, to prevent chaos, duplication and omission. At the same time, decisions about the minute by minute aspects of care are made by nurses and doctors at the bedside, some of whom are experts and some beginners. I respectfully submit, therefore, that the important question is: within this necessary system, can nurses be helped to function humanely, and with due regard to ethical considerations?

Later in the book Hunt writes about accountability, suggesting that nurses believe that accountability 'is all about following procedures', and writing in rather haranguing terms about nurses, nurse theorists and nursing. I am left with the impression that Hunt does not have much time for nursing, and that he does not understand much about it either. Yes, OK, nurses have been hung up on accountability, but is it helpful to berate the profession with this failing, rather than trying to move the debate further? Hunt makes it clear that he doubts whether ethical practice is possible in nursing, because nurses have so little freedom--in other words, nursing is completely dominated by the powerful biomedical, technocratic model of decision-making in today's NHS.

The research-based examples of practice, which make up the majority of this book, give fascinating accounts of life on the wards, and the dilemmas of decision-making which nurses face daily. Is there any way out of the state of being a helpless pawn, which Hunt suggests is the state of nurses, 'defined and moulded and driven by forces outside nursing .. . which nursing has never really understood or challenged'? Although Hunt views the account of practice as supporting his argument, I see in it stories of nurses who have continued to explore the moral dilemmas in which they find themselves, and looked for ways of resolution. I see much humanity in these stories, and concern to respect patients' choices.

And this is the weakness of Hunt 's book. In his search for truth in these matters he uses only one interpretation of accounts: his own. In so doing he comes up with a 'no-win' framework for nursing,

which seems to me to be an anachronism. Nursing is not static in its response to the demands of changing populations, health care development or health service organisation. It has been defined and moulded by others' demands, but a growing body of research- based knowledge, an increasing number of graduate nurses, able to synthesise knowledge, and a recognition of the importance of reflective practice, are contributing to major changes in the way that nurses face and deal with dilemmas.

It is a great pity that this book comes across so negatively for nurses and nursing. It is interesting, and offers many relevant examples of practice which will be useful for teachers, practitioners and students. However, it cannot be read as the only textbook on moral philosophy, because it does not offer explanations of theories. It provides a starting point for debate, following a grounding in ethical theory.

Hunt expresses his dismay at the inclusion of ethics as part of new nursing curricula suggesting that there is a danger that ethics will become yet another set of procedures, to which nurses will have to apply Procrustean principles, to make the problems fit. He says that the absence of theory in this book will stimulate readers to explore real situations for themselves, and through this nurses will learn to make sense of the disparities they face. While this is an important part of cognitive development for professionals, there must also be an adequate foundation of knowledge, from which to build skills of critical thinking. One reason why nurses have, in the past, failed to be critical of procedures is that they have not been given the breadth or depth of knowledge, in a training based preparation, to think for themselves, or to act with confidence.

What seems to me to be missing throughout this book is real understanding of the nature of nursing. Nursing is complex, concerned with helping, with organisation of care, with working with other people, with technical procedures, with teaching, with dealing with emergencies .. . and so on. And all of these things may be required during one day, or at the same time. In this context, dilemmas will occur, things will go wrong, and professionals will fail to get things right. Given that all of this is true, at least in my framework, how can nurses best be helped to use philosophy to inform their practice? Sadly, this book fails to take us further, but succeeds merely in telling nursing where it has gone wrong. A useful start only.

Barbara Stilwell Institute of Advanced Nursing Education London, UK

A Guide to Reproduction: Social Issues and Human Concerns Irina Pollard, Cambridge University Press, s (paperback), s (hardback), ISBN 0-521-42925-0 (pbk), 0-521-41862-3 (hbk).

The purpose of the above title, as stated in the preface, is to provide a comprehensive, interdisciplinary text on

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reproduction and related social issues for science and medical students. The book aims to increase overall awareness of human reproductive issues and to draw out their consequences across the disciplines, integrating theories and principles to create a holistic overview. This is an admirable starting point; so many text books designed for students of scientific disciplines neglect to consider the social aspects of the topics they are covering, leaving these to be dealt with by the humanities--disciplines that science students rarely come into contact with at any sustained level.

The book is divided into two sections, 'reproductive biology' and 'reproduction and social issues'. The first section covers an enormous range of topics, attempting to consider all elements of human reproduction, from the origins of sexual difference, puberty, fertility and infertility and onwards to pregnancy, childbirth and finally the menopause. While this gives the impression of a continuum, there are other topics put in for good measure. After the chapter on the testing and control of spermatogenesis, there are two chapters on sexual behaviour and sociobiology. These appear to be rather out of place and no rationale is given for their sudden inclusion or why they come at that particular point in the biological description of aspects of human reproduction. Other theories of sexual behaviour are not given the same amount of coverage, and sociobiology is not examined critically but rather taken as an undisputed theory.

This highlights a weakness of the book, the overall contents do not appear to be coherently arranged, and the second section exemplifies this lack of organisation. This section starts off with a chapter on population dynamics, considers the conservation of endangered species and then swings back to the artificial control of fertility (human). The section subsequently moves on to examine the AIDS epidemic, the effects of nutrition and exercise on the hypothalamic-pituitary-gonadal axis, nicotine, ethanol and caffeine abuse and concludes with a short chapter on ethical aspects of human reproduction. The aim of the book--to integrate theories and principles to create a holistic overview--is a worthy one but in order for such a project to be successful a more coherent structure is needed. The consideration of all these different subjects leaves the reader searching for some overall structure or argument to tie it all together and to give some rationale for the progression of the chapters.

In a book this size it is dearly impossible to do justice to both the biological and social aspects of such a vast subject as human reproduction. In this context the only realistic aim is to raise questions and provide possible avenues for future consideration. In some respects the book achieves this creditably, giving the reader further references at the end of each chapter and drawing attention to the possible ethical dilemmas that certain topics might raise. For instance, when looking

at surrogate motherhood Pollard runs through a list of possible areas of dispute and contention, such as problems over the definition of motherhood, difficulties for legislating in this area and our responsibilities to future generations. Nevertheless, often the solutions to such controversial ethical dilemmas are assumed without adequate argument and discussion. The consideration of pregnancy and HIV-positive women is peppered with statements such as, 'allowing HIV-infected mothers to breast-feed is unethical' and assumes that an HIV-positive woman would be acting unethically if she wanted to continue with a pregnancy. Statements such as these need careful argument to support them and, in a format such as this book, there is only space to raise the questions, not to advance the solutions.

The rather piecemeal approach to the non-biological aspects of human reproduction is illustrated by the final chapter, which focuses on the ethical aspects of reproduction. This chapter attempts to cover the history of the bioethics movement, ethics committees and to go through the principles of health care in nine pages. The lack of space is understandable, but there is not any justification for why the chosen subjects are included. By way of example, why choose to outline principles of health care as opposed to a brief summary of the central moral theories?

The strength of this book is that it does draw attention to the wider consequences of human reproduction and seeks to extend the traditional biological treatment to encompass the ethical and social dimensions of the subject. However, when considering the ethical aspects of any subject it is important not to gloss over crucial distinctions and make sweeping statements about what is or is not ethical. It is enough to raise questions and make links between disciplines. Unsupported ethical assumptions are dangerous in scientific thinking, and this book is sometimes guilty of making such unsubstantiated assumptions.

Lucy Frith Department of Primary Care University of Liverpool, UK

Review Editor's Note

We hope to make 'Retro Review' a regular feature of the Reviews section. 'Retro Review' will feature books or papers published in earlier years which remain of contemporary relevance and which, in the opinion of the reviewer, are worth a revisit. Potential contributors are very welcome to contact the Reviews Editor, who will also be pleased to consider commentaries on reviews already published, or ideas for Review Articles.