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Stuart F. Spicker and H. Tristram Engelhardt, Jr. (eds.), Philosophical Dimensions o f the Neuro-Medical Sciences. Reidel, Dordrecht/Boston, 1975, vi + 274 pp., Dfl. 8 0 , - / US $29.00. This volume contains the proceedings of a 1975 symposium on topics of common interest to philosophy and neuromedicine. Contributions are arranged under six main headings. (i) Historical foundations: William Bynum discusses attempts by Gall and by Flourens to link specific mental functions to brain features. Gall tended to be a reductionist whereas Flourens worked within a Cartesian dualism (except for admitting animal souls). Arthur Benton traces the development of the view that the left and right hemispheres have asymmetrical functions, an asymmetry which he thinks is compatible with the unity of the central nervous system. Tristram Engelhardt, in a commentary, indicates how Jackson modified Gall by urging neurophysiology to construct a language free of psychological terms and to conduct inquiries within its own realm. On the asymmetry issue, Englehardt distinguishes the neurophysiological question of sensory-motor integration from the psychological question of the unity of consciousness. (ii) The value of psychosurgery: Joseph Margolisthinks that psychosurgery creates special assessment problems because of its consequences. Nevertheless he feels that a policy of moderate toleration is defensible. Jerry Fodor argues convincingly that problems connected with psychosurgery are not really theoretically distinctive. (iii) Perception and integration: Kid Pribram claims that we project brain 'representations' onto an objective wodd, where the result is veridical perception if validated by our other senses and by further knowledge. He thinks that this counts as 'direct perception'. But just why projection counts as perception in an ordinary sense, or why a validated perception counts as direct in a philosophical sense, is not made clear. Marjorie Grene opposes making perception the interpretation of a sensation and urges a more unified view, Social Indicators Research 5 (1978) 121-124. All Rights Reserved Copyright 9 1978 by D. Reidel Publishing Company, Dordrecht, Holland

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one which allows for physiological, psychological and social influences. She extends this unifying approach to the treatment of split brain cases and, like Benton, resists splitting the person involved. Hubert Dreyfus, in a commentary, charges both Pribram and Grene with creating artificial problems by retaining inner mental states. He thinks that if brain representations are not tied to mental states, then the problem of projection disappears, and if there are no minds for the split brain patient to have two of, then the problem of a unified consciousness disappears. But then equally there is no perception to be explained, and no failure of understanding to be assigned to the patient, in which case the range of acceptable problems is severely restricted. A quick accusation of Cartesianism is not enough to avoid or defuse this result. (vi) Causation: Hans Jonas argues that epiphenomenalism inconsistently implies that causes of impotent mental effects expend something without getting a return. But he fails to show that those same causes cannot also have potent physical effects. He finds epiphenomenalism self-defeating, since if it is true, it is a theory with no influence. He thinks that a form of interactionism is preferable and that it has the advantage of allowing psychosomatic illness. In his commentary, Stuart Spicker criticizes interactionism if it is embedded in a dualism or in an identity theory and urges a more phenomenological approach. (v) Pain and its concomitants: George Pitcher thinks that a lobotomy patient can be indifferent to his pain and that a masochist can even enjoy or like it (not merely endure it), but that a masochist also dislikes it. He thinks that enjoyed and indifferent pains are still unpleasant, however, in the sense that they are normally disliked. Jerome Shaffer accepts most of this, but not the existence of opposing affective responses, e.g. of both suffering and enjoyment. He thinks that we need more empirical data to see what theoretical contingencies actually obtain. David Bakan indicates that sensory pain typically involves a concern which focusses on the region bounded by one's outer skin but which can be restricted or extended (e.g. by nationalistic propaganda). This concern can produce anxiety about the best treatment and is most effectively eased by transferring responsibility to a trusted agent. Bernard Tursky describes techniques for measuring the sensitive, reactive and overall-intensity aspects of pain experiences, with a view to testing whether variations in the different aspects are less proportional than one might think. (vi) Philosophy's relevance to neuromedicine: Bynum thinks that recent anticartesian movements in philosophy should exert more influence on

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neuromedicine (e.g. to remove distinctions like 'mental vs corporeal disease'). He even surmizes that a complete physical basis is available, e.g. that a molecular copy of myself would have the same desires, intelligence, memories, etc. But why should we assume that a mere molecular copy would have any such things?? And if we simply stipulate that it does, would everything covered by the above 'etc'. be the same, notably the copy's actions 9. These are questions which do not have short answers. Samuel Greenblatt thinks that neuroscientists employ assumptions which should be examined by philosophers. Ian Lawson agrees and recommends conjoining the examination with specific case studies. Robert Veatch thinks that philosophical inquiry can also help medical practitioners deal with moral questions. Pribram thinks that we should start with the phenomenal person as a contraction and develop complementary accounts of the subsystems of, and supersystems containing, persons. He thinks that we can then eliminate certain paradoxes created by philosophical analyses (e.g. of masochism) by offering brain functional accounts. Grene concludes the volume by remarking on the complexities of the issues raised and of how much more is to be done through cooperative research. The aim of the volume is commendable, but its non-historical results are generally disappointing. Researchers working at advanced levels in either area will probably not find much useful material. There are few attempts either to sustain a posit~on in one discipline in the light of information from another or to develop a distinctive critique of something in one discipline by drawing on another. The reader finds preliminary data and pronouncements, but not the thorough working out of theories. For example, claims about perception are not carefully explained by reference to standard philosophical alternatives and yet they purport to compete with those alternatives. Private mental states are sometimes rejected, sometimes endorsed, but with little or no supporting argument. Dualism and the identity theory are sketchily criticized, with only hints at what their replacement should look like. Virtually nothing is said about the nature of human action or freedom. No attempt is made to connect the results of psychosurgery with a penetrating account of human goods. The discussions of pain are not linked to a general theory of sensations and attitudes. Even treatments of split brain cases fail to examine concepts normally used to describe those cases, e.g. 'understands what the object is', 'identifies it', 'describes it', and 'feels it in his hand'. There is reason to think that further co-operative effort will turn up

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something valuable. But to achieve this end, the contributors should generally show a better understanding of topics of lively concern in both areas and they should be obliged to present their positions in a more sustained way, using as little jargon as possible. The book does contain a useful collection of bibliographies.

University of Guelph

DOUGLAS ODEGARD

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ETHICS, SCIENCE POLICY, AND B I O M E D I C A L R E S E A R C H

Robert M. Veatch and Roy Branson (eds.),Ethics and Health Policy, Ballinger, 1976, Cambridge, Mass.

Accuracy of information: Reasonable;not an informational book. Scope: Adequate (but see below). Clarity of writing: Generally good; some philosophical jargon. Quality of charts, etc. : Not applicable. Value by comparison: Breaks new ground; not all contributions of equal merit. SUMMARY. This is an attempt to redirect the attention of medical ethicists away from older concerns with the ethics of individual practitioner-patient relationships and decisions and toward questions of social, even political, ethics. Part one focuses on fundamental ethical conflicts in health care delivery. Its three sections focus on the patient and society, justice and health care delivery, and the question of the right to health care. In this first part of Ethics and Health Policy some of the advances away from the older individfialistic medical ethics are not very pronounced. We still find contributions by the 'old faithfuls,' for instance, Paul Ramsey and Joseph Fletcher. But other contributors do take a first step toward a serious social ethic of health care-notably the editors, Branson in chapter one, 'The Scope of Bioethics: Individual and Social' (a plea for a broader definition of [bio]-medical ethics), and Veatch in chapter eight, 'What Is a "Just" Health Care Delivery?' (a survey of several social ethics views, with an attempt to outline the basics of a new social ethic of health delivery), but also Ronald M. Green in chapter seven, 'Health Care and Justice in Contract Theory Perspective' (an extension into the health field of John Rawls's Theory of Justice). Part two is entitled, 'Ethics and Allocating Scarce Medical Resources'. Its four chapters consider two issues, scarce life-saving medical resources,

SocialIndicators Research 5 (1978) 125 - 132. All Rights Reserved Copyright 9 1978 by D. ReidelPublishing Company, Dordrecht, Holland

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with an article by James F. Childress and a response by Frederic B. Westervelt; and implantable artificial hearts (a committee assessment from the National Heart and Lung Institute, and an article by Clark C. Havighurst). For the most part, nothing here is really new, this being one of the types of concern that first gave impetus to the redefinition of medical ethics. Part three contains just three chapters, sixteen on measuring economic benefits of health programs (by a medical economist, Rashi Fein, who happens to be interested in questions of equity and social justice); seventeen on community participation in health decisions (Laurelyn Veatch); and eighteen on technology assessment and genetics (LeRoy Waiters). This last chapter, a reprint of a 1972 article (one of the earlier ones reprinted in the book), is somewhat different from anything else in Ethics and Health Policy; it is an examination of the technology assessment movement and methodology, focusing on genetic research, and looks at the whole matter in the light of TA's dependence on a utilitarian moral approach, with the shortcomings implicit therein. Few of the contributions to this volume are directly relevant to social indicators research. Exceptions might include the final chapter, just mentioned, and Fein's essay on measuring economic benefits. Nonetheless, the whole question of health and social justice is important to anyone concerned with the quality of life, whether in measurable terms or not.

Ina Spiegel-R6sing and Derek de Sofia Price (eds.), Science, Technology and Society: A Cross-Disciplinary Perspective, Sage Publications, 1977, Beverly Hills, Calif., and London.

Accuracy of information: Excellent. Scope: Comprehensive (but see below). Clarity of writing: Generally good; some chapters more jargon-idled than others.

Quality of charts, etc.: Not applicable. Value by comparison: Excellent; valuable synthesis (with reservations, below). SUMMARY. One purpose of this volume is to bring together a number of scattered disciplines focusing loosely on 'science policy' into a single 'cross-

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disciplinary perspective' - a sort of superdiscipline henceforth to be unified (?) under the 'science policy studies' banner. The disciplines included range from sociology of science (survey by M.J. Mulkay) through social history (Roy MacLeod) and history of engineering and technology (Edwin Layton) to the economics of R & D (Christopher Freeman) and the psychology of science (Rudolf Fisch). There is also a catch-all chapter surveying a number of other disciplines having something to say about 'Models For the Development of Science' (Gemot B6hme), plus a chapter devoted to radical critiques of science of all sorts (Jerome Ravetz). Several other perspectives are brought together in Science, Technology and Society. These range from a general survey by one of the editors, Ina SpiegelR6sing, 'The Study of Science, Technology and Society (SSTS): Recent Trends and Future Challenges', to very specific topics, for instance, Harvey Sapolsky's 'Science, Technology and Military Policy'. There are also chapters surveying studies of science and power (Sanford Lakof0, and public policy (Dorothy Nelkin), foreign policy (Brigitte Schroeder-Gudehus), the international system (Eugene Skolnikof0, and science and developing countries (Z. Sardar and l~awud G. Rosser-Owen). Strangely, the volume makes no general statement on the place of science and technology in modem culture - and, a principal point to note here, the emphasis throughout is on the so-called 'hard sciences', technology, and engineering, with almost nothing on science policy for biomedical research.

Theodor J. Litman, The Sociology of Medicine and Health Care: A Research Bibliography, Boyd & Fraser, 1976, San Francisco.

Accuracy of information: Very good. Scope: Comprehensive (but see below). Clarity of writing: Bibliographese; some lack of clarity in table of contents, all-important for a bibliography.

Quality of charts, etc. : Not applicable. Value by comparison: Good; some other surveys of the field would be more useful for particular purposes; nothing else matches its com. prehensiveness. SUMMARY. This research bibliography for medical sociology, the sociology

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of medicine, the sociology of health care (the sprawling field has several names, depending on emphasis) is aimed primarily at researchers likely to be affiliated with the Section on Medical Sociology of the American Sociological Association, that organization's largest section. According to Litman, "The field finally attained the accoutrements of an established body of knowledge with the founding of the Journal of Health and Human Behavior [later ... and Social Behavior] in I960" (p. xix). It is, nonetheless, an exeedingly diverse and variegated field, with practitioners not only in academia but also in all sorts of medical and health institutions. Litman feels forced to apologize for omitting from his already overwhelmingly exhaustive survey "such highly interesting and related subjects as drug addiction, family planning, social gerontology, and sexual deviancy, as well as the problems of mental health and mental illness" (p. xx). What Litman does include ranges from general surveys, collections, bibliographies, and textbooks in the field (chapter one), to health services research (chapte~ thirteen). In between are included health economics; the 'healing arts" -(i.el, the sociology of the various health professions, as well as marginal practitioners), social epidemiology, health and illness behavior, the family and health care, long term care, disability and rehabilitation, hospitals, national health systems (the U.S. and other larger countries listed separately, plus under one heading 'the developing countries'), the politics of health care, and health planning. The bibliography, including nearly 10 000 references (with some duplicates or overlapping entries), is completely unselective. There are no annotations. It is not a guide to the field for the uninitiated, much less a survey from a particular perspective - something Litman explicitly eschews. It is just what the subtitle says, a research bibliography, and a very good one. These three books, masterful as are the second and third (while the first breaks interesting new ground), raise an interesting two-part question. On one hand, why is it that science policy analysts focus almost exclusively on the physical sciences and engineering, almost totally ignoring biomedical research policy? And, on the other hand, why is it that for students of health policy, whether sociologists or more recently ethicists, it almost always means health care policy and not policy for biomedical research? For science policy students, this ought to represent something of an anomaly. For those interested in social indicators research - perhaps especially the branch thereof called

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science indicators - it should present problems. For philosophers the question seems to represent a challenge and an opportunity. Let us look briefly at the three volumes under review to verify these impressions. First, consider the Spiegel-R6sing and Price Science, Technology and Society survey. Although there is a partial disclaimer about the omission of the biomedical sciences, this does not change the situation very much. The bibliographies in the volume are reasonable thorough, and the significant omission of references to biomedical research policy seems fairly accurately to represent the actual situation in the field(s). Turning next to Litman's sociology of medicine and health care bibliography, there are a number of headings under which one might expect to fred something on biomedical research policy: chapter two on health economics, or somewhere in chapters nine through twelve, ranging over hospitals and other health institutions, national health care systems, political aspects of health care, and - perhaps especially - health planning. But one searches in vain for anything substantial - almost for anything at all! Finally, the volume with which we began, Branson and Veatch's Ethics and Health Policy: While we hear there a call for a new social bioethics, this does not lead to an overly clear recognition that this means a significant move away from the old individualistic medical ethics toward more and more social even political - issues. (One of the editors, Veatch, does end his article in the volume with a discussion of national health insurance proposals and social justice; and the final article, by LeRoy Waiters, looks at genetic research and the technology assessment movement in the light of general ethical principles.) And among the most important social and political issues affecting health policy thereby missed are the all-important questions of direction for, priorities in, and public accountability with respect to the massive biomedical research complex. It seems inappropriate for this reviewer to presume to speak for the sociologists of medicine as to how they will respond to the significant failure of their discipline - at least as represented in the Litman bibliography - to deal adequately with the research component of the health establishment. Pretty much the same is true for the science policy analysts, though a philosopher is at least generally welcome in science, technology, and society circles. But as for philosophers, it does seem to make sense to say something here about how they might rise to the challenges and opportunities in the area of biomedical research policy. -

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The burden of the remaining few paragraphs here is to suggest that ethical theorists when they pursue bioethics questions (a) follow the line generally sketched out in the Branson and Veatch volume - i.e., move away from individual medical ethics more toward social justice concerns - but (b) go even further, focusing on matters of social policy, even of real-life politics. If they do so, they might well find that, in discussing social policy with respect to health, their most significant contributions may be in the area of biomedical research, rather than health care, policy. Philosophy has long been a source for policy analysts - though the contribution might be disguised by the novelty and technical ring of the expression 'policy analysis'. From Plato and Aristotle in ancient Greece to the Berkeley 'Free Speech' movement, from Machiavelli and Rousseau, Burke and Bentham, to present-day 'counter-culturists' - the influence of philosophical ideas on practical political action has been constant and profound. And this is not even to mention the most obvious cases: Marx and the Marxists; Dewey, Pragmatism and American liberalism. Still more relevant, if we move from political action to philosophy and political theory, the influences are equally direct and profound: Whether ethical theory is directly subordinated to political theory (as in Aristotle) or political schemes are thought of as really built upon a rational ethic (as in Kant and, perhaps, Plato) or whether ethical and political terms are simply thought of as so intermingled as to make it reasonable to move with facility back and forth between the two realms of discourse (as, for instance, in Alan Gewirth's Political Philosophy (1965)). In the three volumes under discussion here, there is one article - Jerome Ravetz, 'Criticisms of Science', in Science, Technology, and Society - which takes full cognizance of this tradition. Ravetz's survey, however, stays at a rather general level and makes not one reference to the small but significant number of 'critical' studies that have been made of health policy, and which include some passing comments on the possible misdirection of biomedical research policy. I am not suggesting that nothing has been done on biomedical research policy. There is, first of all, a brief discussion in Daniel Greenberg's The Politics o f Pure Science (1967). Then there are the Health/PAC volumes on health care, especially in New York City (cf. especially Barbara and John Ehrenreich, The American Health Empire, 1970). And one might also mention: Rosemaw Stevens, American Medicine and the Pablic Interest (1971); U.S. Department of H.E.W. Office of the Assistant Secretary for Health,

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Forward Plan for Health 1978-1982 (1976); and J. Comroe and R. Dripps, 'Scientific Basis for the Support of Biomedical Science', Science 192 (1976), 105-111. All I am saying is that thinking in this area could benefit from philosophical analysis. (It could benefit from more work by sociologists of science and science policy analysts as well, but that is not our concern for the moment.) This might be illustrated, briefly, by, first, suggesting the policy tensions there seem to be in the health and biomedical research area; then, second, citing an eminently respectable philosopher on the sorts of contributions to be expected from philosophical analysis on topics of this sort. It seems that the bureaucratic leveling process has masked a number of tensions in the HEW policy statement mentioned above. If we look behind that document to health debates at the public policy level which ended up getting written into the document as compromises between conflicting tendencies, one thing we might fred - even on a most superficial reading is a long-standing conflict, over national health insurance, between forces that can be loosely labeled 'Nixonian' and 'Kennedyite' - between the ideas of the authors of the various health proposals of the Nixon administration and those expressed in the long series of bills representing variations on the 'Health Security' idea introduced by Senator Edward Kennedy and colleagues. This seems to be the 'mainstream' policy debate on health, between 'liberal' advocates of an expanded bureaucratic-federal role (usually with a stronger emphasis on publicly-funded biomedical research than its opponent) and 'moderate' reliers on the private sector. A second, and deeper, tension outside the mainstream seems also to be operative. There are still stronger defenders of 'free-enterprise', profit-motivated private biomedical (especially pharmaceutical) research than the HEW moderates who wrote the Nixon proposals. On the other hand, there are a variety of left-leaning critics of contemporary medicine - and of the current direction of biomedical research - ranging from Ralph Nader's Health Research Group to the authors of the Health/PAC studies mentioned earlier. Each of these has a constituency, however small or powerless, and represents a force to be reckoned with in setting policy for the future of health and biomedical research. What can philosophers contribute to the rational resolution of the many issues involved here? The following summary, proposed by the philosopher Max Black at a recent symposium on philosophy of technology, aptly

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represents the best that might be said in this regard, and can serve as a suitable note to end on: The conception of the tasks facing philosophers interested in technology that emerges from these remarks might look somewhat as follows: (1) As conceptual analysts interested in developing adequate images of technology and its elements, philosophers of technology will try to analyze concepts actually used by technological operators - efficiency, skill, rationality (in its application to technological enterprises),automation, and the like - and such supervenient concepts as alienation, pollution, environmental damage, and 'negative externality', employed by students and critics of technology. (2) As intellectual critics, they will offer principled and reasoned proposals for improving these concepts and their verbal expression. (3) As moral critics, they will have principled and reasoned views on burning issues abortion, euthanasia, the rights of posterity, population control, biological engineering, and so on - also about general issues concerned with the control and improvement of technology. (4) Being themselves inevitably advocates of debatable moral, social and political positions, they will consider it part of their obligations as intellectuals to render their own commitments explicit and will, in this way, function as active partisans for better and more humane technologies. (Cf. Max Black, 'Axe There Any Philosophically Interesting Questions in Technology', PSA-1976, Volume II; ed. by F. Suppe and P. Asquith; Philosophy of Science Assn., 1977, East Lansing, Mich.)

Philosophy Department and Culture of Biomedicine and Science Center, University of Delaware

PAUL T. DURBIN