George J. Annas, Worst Case Bioethics: Death, Disaster and Public Health, Oxford University Press, 2011, Paperback, 335 pp., £27.50 r.r.p.
In Worst Case Bioethics, George Annas- a respected and well-known professor in health care, human rights and bioethics at Boston University- gives a broad account of the manner in which US public health policy has been and continues to be shaped over time by national responses to doomsday or worst-case scenarios, both real and posited. In doing so he aims to illustrate the manner in which ethically questionable practices and controversial decisions have been excused politically as defences against these often sensationalised eventualities. He also frames his discussion in the context of the American public’s fear of death as a concept, and their apparent unwillingness to accept it as an inexorable eventuality. In order to fulfil his remit, Annas discusses a great variety of contemporary issues. He divides the book into three- ‘Death and Disaster’, ‘Death and the Constitution’, and ‘Disaster and Public Health’- each with a different general ethos. The first section of the book, ‘Death and Disaster’, briefly discusses American health care as a system (p.3), before moving on to more challenging ideas in chapters focussing on bioterror and its counterpart biodefence (p.17), war (p.75), and the role of medical personnel in ethically challenging practices instituted after the World Trade Centre attacks, such as ‘waterboarding’ torture (p.52) and in the force-feeding of hunger striking captives at Guantanamo Bay (p.60). ‘Death and the Constitution’ concentrates on more domestic matters, putting forward the idea that the obsession with saving life comes with moral costs, through the subjects of access to experimental medicines (p.101), doctors as executioners (p.120), late-stage abortion (p.138), and the right to death (p.143). This latter topic is examined in the light of the public and political furore which framed the Terri Schiavo case, about which Annas enters into great detail. The final section, ‘Disaster and Public Health’, constitutes a more conceptual discussion and is less exclusively US-centric. Within, the author gives his own views on such issues as recent fears regarding pandemic flu (p.219), retention of personal genetic data (p.235), and the potential for the development of genetic racism (p.251)- frequently questioning other long-held public opinions.
The spread of topics, then, is particularly vast, as is the number of cases and examples which are entered into. If we consider the concept of the publication, though, this expansiveness can only be considered a positive. In providing such a range, Annas evidences his point extremely strongly and persuasively. Regardless of a reader’s personal agreement with his conclusions, we cannot deny that every point is well researched and well reasoned. As such, Annas has undoubtedly achieved his overarching aim with the book, giving a convincing account of how such varied topics have been affected by worst-case thinking and panic. Furthermore, this wide basis of subject matter is a major strength for the book, in that readers with wildly differing fields of knowledge and areas of interest will all find sections of use and relevance. In this manner, Worst Case Bioethics can act as a useful text to link seemingly disparate areas of policy, by providing an area of thematic similarity and consequently a basis from which to consider each topic.
However, we cannot ignore that this last strength is also, in another light, one of the book’s weaknesses. While in many contexts it is useful to have this wide-ranging discussion, we might consider that for the more discerning reader there is a lack of deeper detail and discourse on any given area. Consequently, those readers interested in certain areas alone may come away disappointed by Annas’ comparative brevity. For example, the author delivers his catch-all chapter on cancer in under ten pages, whereas the Terri Schiavo case in the context of the right to refuse treatment alone (p.143-) has over twice as many dedicated to it. Though any author is not held to dedicate equal weight to their subjects, we might consider the inconstancy to be counter-productive in a piece which otherwise strives so strongly to achieve a viewpoint encompassing all of American bioethics.
The author’s personal interests, opinions and knowledge in the fields of human rights and liberties are highly evident in the book. While he covers a wide array of topics, Annas consistently writes as a gentle critic of the governing body concerned. Though this is well reasoned and certainly in keeping with the concept on which the book is based, it is worthy of note that readers will not glean any mitigating evidence or alternative perspectives on any of the scenarios highlighted. Annas is never so crass as to explicitly condemn a decision, but his displeasure can occasionally be felt and the objective reader must always bear this in mind, whether we agree with his stance or not. As discussed, the author indeed fulfills his aim to ‘illustrate and explore radical changes” (p.xi) in bioethics through the broad spectrum of cases and topics included in the book, but at no point does the book purport to be an opinion-led piece. In this manner, we might consider Annas’ personal views (notably referring to doctor’s participation in lethal injection as a breach of their ethics because they are “facilitat[ing] the commission of crimes against humanity” [p.124]) filtering through to constitute something of a failing on his behalf in the writing of the book, although it is by no means detrimental on any practical level.
A more concrete failing of Worst Case Bioethics is its lack of an adequate explanation of the why behind Annas’ conclusions. Although he provides strong and indeed compelling evidence that his postulations are indeed the case, the author never details how this link was made. While the parade of examples and subjects affected repeatedly lends him support, the reader fails to ascertain just why this situation came to pass. To many, this may not prove especially important, and indeed the argument stands perfectly well without it- the moral and ethical problems are made plain, as is the political involvement and grandstanding which allowed the problems to be ignored. For the casual reader, the reader for interest, this is more than sufficient. However, a reader looking to develop these ideas further may struggle to understand the basis of the conclusions. Furthermore, Annas fails to provide us with a solution to the problem he has identified so clearly. The book at no point set out to do so, and as such we cannot condemn it on this basis, but there is a palpable sense that something is missing. Without a suggested framework within which worst case policymaking might proceed, the book is reduced somewhat to a mere list of examples. This is not to say that it is without merit- as discussed, it fulfils its aims in totality. However, by informing us of the need to consider ethics in these scenarios Annas leads us to question just how we might mitigate the circumstances he has illustrated- and by failing to make a suggestion, he lacks any kind of satisfactory conclusion.
Worst Case Bioethics’ final and most important strength is its readability. For a publication dealing with such controversial issues as abortion, torture, terrorism, and racism, and against such a complex and specific scientific and legal background, it is highly accessible. This is due in no small part to Annas’ clear, almost personable writing style. Whilst consistently sticking to his point and never wavering, the author never lapses into the impenetrability and jargon so common in high-concept books of this nature. It is eminently possible to begin reading at one’s topic of interest, without tackling the rest of the book, and still come away with a complete picture. However, the clarity with which Annas writes will encourage further reading. His forays into literary examples and occasional pop culture references (Phillip Larkin and Jack Bauer making wry appearances) do not cheapen the gravitas of the discussion, but instead genuinely add perspective. While not to say that the piece is anything less than an accomplished academic tome, it is refreshing to read something so reflective and yet able to make such a determined point. The publication is exemplary in its writing.
George J. Annas’ Worst Case Bioethics sets out to provide evidence for and explore the idea that “worst case scenarios are almost always counterproductive as planning exercises”, and it does this in very definite, well reasoned and accountable terms. The broad spectrum of topics discussed provides identifiability for a wide range of readers, although some of the more analytically minded may find a lack of depth and of consideration for other viewpoints disappointing. Although the book cardinally lacks any solution to the problem it poses, Annas presents us with a well written and highly persuasive account of the situation he has identified in US biopolitics, which holds its point and validity despite being flavoured in places with the author’s personal opinions.
Somebody, give me a book deal!