Anand, S., Peter, F. and Sen, A. (eds.): 2004, Public Health, Ethics, and Equity. Oxford: Oxford University Press. 336 pages. ISBN: 0-19-927636-6. Price: $99.00.

So far, issues of health equity have been discussed predominantly in terms of access to health care. These approaches, however, fail to take into account that health is influenced by a wide range of social circumstances and public policies. For example, poverty is still one of the main factors behind health inequalities within and between countries. Any comprehensive approach to health equity therefore must take into consideration the socio-economic determinants of health, including the empirical literature on social inequalities in health. The volume, edited by Sudhir Anand, Fabienne Peter and Amartya Sen, tries to examine these issues from a variety of different perspectives, including contributions from philosophers, anthropologists, economists and public-health specialists.

In the first section, Sudhir Anand and Amartya Sen discuss the concept of health equity. Anand argues that inequalities in health status are of special ethical concern because of the denial of opportunities. Socio-economic inequalities in health matter more than inter-individual inequalities in health because they derive from social rather than natural factors. Amartya Sen then provides a multidimensional framework for examining health equity.

In the second section “Health, Society, and Justice”, Michael Marmot demonstrates — based on the famous “Whitehall” studies — that health is positively correlated with socio-economic status. Norman Daniels, Bruce Kennedy and Ichiro Kawachi provide further empirical evidence from cross-national research that there is a rather steep socio-economic gradient of health inequality. Reform efforts therefore should focus on the social living conditions. Along the lines of these arguments, Fabienne Peter outlines an approach to health equity that proceeds indirectly and embeds health equity within a broader concept of social justice.

Section three is devoted to the responsibility for health and health care. According to Daniel Wikler, personal responsibility for health should only play a limited role in health policies by empowering people to improve their health-related behaviour. Based on a relational conception of justice, Thomas W. Pogge argues that responsibility for health outcomes transcends national boarders. Philippe van Parijs discusses the case of Belgium where the two main linguistic groups, the Flemish and the Walloon, disagree on the allocation of the national health-care budget.

Section four is concerned with ethical and measurement problems in health evaluations. Sudhir Anand and Kara Hanson first provide a critical review of the DALY concept as a measure of the burden of disease. Dan Brock discusses ethical issues in the use of cost effectiveness analysis for the allocation of scarce health care resources, Frances Kamm discusses different principles and arguments that determine whom we should help. John Broome finally investigates how longevity can be included in the valuation of people’s health.

The final section provides an overview of different perspectives on the evaluation of health and health equity with contributions by Amartya Sen (external and internal perspectives), Arthur Kleinman (anthropological perspective) and an ethnomedical case study by Vincenne Adams (Tibet). Altogether, this volume presents a wide spectrum of different perspectives on health equity. Hopefully, this will be a starting point for further investigations of these important ethical issues.

Georg Marckmann

Tübingen, Germany

Steinkamp, N. and Gordijn, B.: 2005, Ethik in Klinik und Pflegeeinrichtung. Ein Arbeitsbuch. 2. überarbeitete Auflage. [Ethics in Hospitals and Nursing Homes. A Manual. 2nd revised edition]. Neuwied: Luchterhand. 301 pages. ISBN: 3-472-06238-X. Price: €43.00.

In this manual the authors share their vast experience of clinical ethics consultation, both on a practical and on a theoretical level. Steinkamp is a theologian and Gordijn a philosopher, both from the Department of Ethics, Philosophy and History of Medicine at Radboud University Nijmegen Medical Centre. In the first edition from 2003 they referred to Germany as a “late nation” concerning clinical ethics. In the present edition this remark has been deleted and this is partly due to the authors’ engagement in advising hospitals and institutions in the German speaking countries and the subsequent success of their book.

After some useful introductory definitions and explanations of morals and ethics with particular respect to the context of health care institutions, the basic idea of a “model of interaction in clinical ethics” is developed. In this model the authors conclude that clinical ethics can only thrive if it is dealt with both on an institutional level and on the level of individual cases. According to this model nothing can be achieved without support from the organisation as a whole (top-down) and no noticeable changes will happen in patient-care without moral deliberations on a case to case basis (bottom-up). Therefore chapter 5 is addressed to structures, tasks and implementation of clinical ethics committees as an institutional endeavour and chapter 6 is devoted to methods of ethics consultation in the ward.

The authors focus on a combination of an ethics-committee, which is responsible for the generation of ethical guidelines for the whole institution, and the “Nijmegen Method” of individual moral case discussions, which are moderated by qualified personnel. Although this is probably the most advanced and elaborate model, it is not the only one available. For instance the model is restricted to requests from within the organisation and — at least implicitly — excludes patients and relatives from deliberations. The authors emphasise that the modalities of implementing ethics have to match the specific needs of each institution. Therefore a desideratum for the next edition would be an even more comprehensive presentation of different models of ethics consultation.

What is new in the second edition? The text has been slightly condensed and stylistically improved, the literature was updated. The title was changed and now explicitly includes ethics in nursing homes. Thus, it is surprising that this change is not reflected by additional content: only a brief amendment of less than one page specifically deals with moral challenges in nursing homes. Nevertheless, the chapters dealing with institutional ethics apply to nursing homes equally well. Summing up, this is an important and already influential bfook. It is an intelligible and well structured practical guide to everyone interested in practising ethics consultation in a health care institution.

Gerald Neitzke

Hannover, Germany