Book Review

Trust is Not Enough: Bringing Human Rights to Medicine

N Engl J Med 2007; 356:878-879February 22, 2007

Article

Trust is Not Enough: Bringing Human Rights to Medicine
(A New York Review Collection.) By David J. Rothman and Sheila M. Rothman. 213 pp. New York, New York Review of Books, 2006. $24.95. ISBN: 978-1-59017-140-0

Recent revelations about the complicity of doctors and other health professionals in the abuse of detainees at Abu Ghraib and Guantanamo Bay remind us of the vital role that medical personnel can play as guardians of human rights. Some physicians may consider this role to be outside the realm of the familiar, quotidian obligations to their patients, but for David and Sheila Rothman — social historians of medicine — it is an inherent part of medical professionalism. The Rothmans' view is informed as much by personal experience as by academic reflection. For the better part of two decades, the New York Review of Books has published the Rothmans' provocative reports on the state of medicine and human rights across the globe, as well as a number of their review essays. These pieces have now been collected, revised, and updated for Trust Is Not Enough.

The essays are loosely arranged around four themes that the authors describe as “commitments”: the integrity of the human body, informed consent and freedom from coercion, equity and fairness in health care, and “the most ancient principle of medical ethics — do no harm.” Readers soon discover that some medical professionals do not hold these commitments as dear as the Rothmans do. In the chapter on the international trafficking of organs, for example, we learn about a Thai transplantation surgeon who admitted the victims of car accidents to his hospital to harvest and sell their organs. (His medical license was rescinded, but he was acquitted of murder.) The authors also recount a Chinese official's offer to schedule an execution to accommodate the travel plans of an American transplantation surgeon. The American doctor sensibly declined the invitation to visit.

Other transplantation surgeons may be less concerned about the provenance of organs, arguing, according to the Rothmans, that “they are surgeons, not detectives, and, besides, their only obligation is to the patient on the operating table.” Most readers will support the authors' appeal for better monitoring and regulation of the organ trade. But not everyone will agree with their proposed solutions. The denial of training fellowships and surgical residencies to junior doctors from countries with exploitative practices is a blunt punitive instrument. Arguably, these doctors should be welcomed and required to take courses in medical ethics and professionalism in the hope that they will return home to change the system from the inside and the bottom up.

This short book cannot exhaustively explore the relationship between medicine and human rights, and it does not purport to do so. What it does provide, however, is a fascinating window on the Rothmans' travels and travails — a testament to lives lived meaningfully both within and outside the academy. Some essays are of greater relevance and interest to physicians than others. For many, the insider's view of the debate over the ethical standards for clinical trials in the developing world will eclipse the essay on the role of the historian as expert witness on research ethics in the United States in the 1940s.

Nonetheless, the Rothmans' discussion of American philosophical perspectives on health care rationing ought to be of interest to all. It is deftly followed by a previously unpublished essay on the right to health care in South Africa, which should be required reading. The authors' analysis of recent South African jurisprudence demonstrates that such a right need not exhaust the entire budget of a nation. Rather, the constitutional recognition of a right to health care is the first step in a politically negotiated, legally mediated process that can ensure access to basic health care resources in nations that are well able to provide them yet often fail to do so.

Jonathan H. Marks, M.A., B.C.L.
Pennsylvania State University, University Park, PA 16802
marks@psu.edu