Book Reviews 571

fee-for-service tradition. Among other historical forces, however, this form of reimbursement has done much to reinforce the subordination of patients. By placing an economic emphasis on complex procedures and subspecialty care, fee-for-service medicine may devalue the honest communication missing in the patient-physician interactions Heymann describes.

This book personalizes the failure of physicians and the health care system to consider the full needs of patients. Through the pain and frustration of her own story, Heymann makes a persuasive argument for elevating the role of patients. One cannot read this book without agreeing with her concluding statement that "doctors are ignorant of

too many aspects of illness and patients' lives to work alone." If patients and physicians become equal partners, patients will less rarely face illness passively or be devastated by it. Heymann's experience of gaining insight from disease then may no longer be the exception.

Health Care Policy Research and Development Unit

General Internal Medicine Unit Massachusetts General Hospital Boston, MA 02114 U.S.A.

Randall S. Stafford

Weighing the Options. Criteria for Evaluating Weight- Management Programs, by the Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. National Academy Press, Washington, DC, 1995. 282 pp., U.S. $24.95 (paperback).

Weighing the Options is a report written in response to the lack of criteria available for evaluating the plethora of programs and approaches for the treatment of obesity. This report was written by a committee of scientists who are recognized leaders in the fields of obesity research and management, and edited by Paul R. Thomas of the Food and Nutrition Board. The information presented is intended to be useful for scientists, educators, health professionals, and individuals working in the area of weight loss products and services. As mentioned in the Preface, this report is not intended for the lay person, and a separate companion book is needed for this group.

The opening pages of this report provide a summary of the obesity problem in our country and introduce the "Weighing the Options" model. This model provides a framework for the evaluation of programs that will assist interested individuals in making appropriate program choices. In this summary, the authors make a strong ease for the evolution of our current definition of "successful" weight-loss programs. Sound recommendations are put forth to redefine successful weight management programs as those resulting in long-term weight loss, improvements in obesity-related comorbidities and health practices, and monitoring of adverse effects from the program. Additional public policy recommendations are made in this section, including acknowledging obesity as one of the most important nutrition-related diseases, increased support for obesity research at all levels, and aggressive actions to improve public awareness (in health care providers and the general public) of the health risks and treatment options for obesity.

Criteria for weight-loss programs established by the city of New York, the Michigan Department of Public Health, the Federal Trade Commission, and the National Institutes of H~.lth are reviewed in Chapter 1. Chapter 2 includes an informative review of the definition of obesity and its incidence and prevalence in the United States, in addition to its association with various diseases. Chapter 3 defines many weight-loss programs that are available, and these programs are classified into three main categories: do-it-yourself, non-clinical, and clinical programs. In Chapters 4-7, a detailed discussion of the criteria of the "Weighing the Options" model is provided. Chapter 8 gives examples of applying the criteria of the model to existing programs and to those individuals interested in selecting a program.

Chapter 9 is a brief overview of obesity prevention, and Chapter 10 includes recommendations for future research and policy guidelines. The appendices include samples of assessment tools used in the treatment of obesity, a report on pediatric obesity, a statement pertaining to accreditation of weight-management services, and biographies of commit- tee members contributing to this report.

Two of the many strengths of this report include the clarity of the information provided, and the use of the current research literature to support the recommendations of the committee. Some chapters include inserts summar- izing recent studies in areas of obesity research such as weight cycling and energy balance. These inserts provide unbiased, up-to-date information for the reader who may not be immersed in the obesity literature. Many pro- fessionals and consumers are still acquiring outdated or inaccurate information, and these inserts should help to dispel many obesity myths. For instance, weight cycling (or yo-yo dieting) has been associated with negative health risks. A brief review of the literature is provided on this topic, and the committee states that the evidence is not sufficient to warrant ignoring weight loss or to recommend against weight-loss efforts. Many individuals have also been informed that exercise can significantly increase resting metabolic rate (RMR); most studies indicate, however, that physical activity and fitness levels have a minimal impact on RMR.

A brief review of the associations among weight loss/weight management and race, ethnicity and socioeco- nomic status is provided. There is evidence to suggest that African-American women lose less weight when dieting, use different dieting strategies, and respond less positively to gastric surgery than Caucasian women. In addition, preva- lence of dieting increases with higher levels of education, and low socioeconomic status has been associated with poor exercise adherence and compliance. Unfortunately, this report falls to address how existing programs can be modified to improve the chances of success in these high-risk groups. Interested readers can refer to a review of guidelines for program planning and implementation in the African- American community [1] and to examples of successful programs focusing on minority populations [2, 3].

Weighing the Options is a timely and informative publication. It serves as a valuable resource manual for individuals interested in weight loss and weight management programs. The criteria outlined in the "Weighing the Options" model are realistic and appropriate guidelines that will assist practioners in providing appropriate, safe, and successful programs to consumers. These criteria will also assist consumers in selecting a program in which they can experience success.

572 Book Reviews

Department of Health Promotion Janlee Thomlmon and Kinesiology

University of North Carolina at Charlotte Charlotte, NC, 28223 U.S.A.

REFERENCES

1. Magnus M. H. Cardiovascular health among African- Americans: a review of the health status, risk reduction,

and intervention strategies. Am. J. Hlth Promot. 5, 282, 1991.

2. Kanders B. S., Ullmann-Joy P., Foreyt J. P., Heymsfield S. B., Heber D., Elashoff R. M., Ashley J. M., Reeves R. S. and Blackburn G. L. The Black American Life- style Intervention (BALI): the design of a weight loss program for working-class African-American women. J. Am. Diet. Assoc. 94, 310, 1994.

3. Graham M. C. and Pohlman R. L. Reducing cardiovas- cular disease risk factors in a minority population through exercise. Faro. Community HIth 17, 80, 1994.

AIDS: Crisis in Professional Ethics, edited by Elliot D. Cohen and Michael Davis. Temple University Press, Philadelphia, PA, 1994. 276 pp. $22.95.

AIDS: Crisis in Professional Ethics attempts to present a philosophical ethical framework for decision-making by professionals in HIV/AIDS-related situations. After the Introduction, the various chapters focus on particular professions and dilemmas which may arise within their practice and which call for an ethical component in the solution or decision. The professions represented are: physician, nurse, dentist (from the patient's perspective), early childhood educator, workplace manager, university administrator, counselor, attorney, clergy, journalist, and politician.

Many of these chapters present ethical arguments sur- rounding the presence of HIV-positive and AIDS-afflicted people in the workplace and among the clients served by professionals, arguments based on the very low risks of HIV transmission, even during medical and dental pro- cedures, when the precaution standards are properly observed. The chapters on physicians, nurses, and dentists, thus, "put to bed" the proposals of mandatory HIV testing for all health care workers (HCWs) and of banning HIV- positive HCWs.

Many readers will be uncomfortable with this book, although it purports to preach compassion for HIV-positive and AIDS-afflicted people. The hypothetical situations calling for ethical decisions by professionals cast the infected and ailing as nearly entirely middle-class, good, well- meaning people (with a couple of exceptions). Although the chapter on early childhood education lists a case of HIV transmission which may have occurred when two adult women were brawling over money and one bit the other, the decisions presented in this book largely ignore "not nice" behavior which occurs at higher frequency in the broken community of the targeted poor. Discussion centers on perceptions of risk from infected doctors, nurses, dentists, students, professors, and other well-behaved burghers.

A large subpopulation of the HIV positive and the AIDS afflicted is comprised of drug abusers. The ethical arguments surrounding this group are not covered in this book, although many professionals cope with such issues as siting of AIDS treatment clinics. The following is a real situation: An AIDS treatment clinic was opened in one of the last stable economically integrated neighborhoods in Manhattan and attracted a clientele still active in the drug scene. Open drug dealing suddenly arose right in front of the clinic. The police precinct seems to have been corrupted and ignores the blatant, persistent violation of law. Knife and gun fights occur sporadically. How does the ethical health care planner deal with this? You get no clue from the book. The risk of destabilizing the immediate area around the clinic is much, much higher than the risks of HIV trans- mission discussed in the book, as is the risk that a neighbor-

hood resident will be hurt or killed because of the uncontrolled criminal activity. The art world isn't the only scene of high HIV positivity and AIDS suffering.

Both the chapters on journalism and politicians took up the question of whether an ethical journalist should reveal the HIV status or outright AIDS of a celebrity or politician. Questions of privacy and adequate function received de- tailed attention. Does a criminal whose trial and prison term may be truncated because of AIDS-related illness also deserve the same delicacy?. We don't learn the answer to this question because the archetype celebrity chosen in the book was Arthur Ashe, a truly saintly man. A few years ago, the press had a ball with the AIDS illness and death of a high-level organized-crime figure.

The chapters on HCWs come down strongly in favor of physicians, nurses, and dentists providing care for HIV-positive and AIDS-aflficted patients. What is to be done in the context of an AIDS clinic or nursing home with patients who continue to test positive for forbidden drugs and who issue death threats which they back up with violence7 The AIDS cases of poverty areas arise from the drug/violence/compulsive promiscuity pathology nexus which stems from a punitive public policy targeting the poor. A high proportion of AIDS sufferers and HIV positive people, having been subjected in their communities to the institutionalized violence, is, not surprisingly, violent. If a doctor, nurse, or social worker is threatened with a knife, what are the ethical considerations in deciding whether to continue treating the AIDS-afflicted patient/client? The book gives no clue.

The two lonely examples of hypothetical antisocial behav- ior both involve a man who has a long-term relationship with a woman but who also engages in risky promiscuity. In one case, he is HIV positive; in the other, his HIV status is unknown. The professional in the former case is a counselor; in the latter, a lawyer. The author of the chapter on counselors, Elliot Cohen, is also one of the editors. In his example of the HIV-positive client who engages in unpro- tected sex with his fiancee, Cohen has the hypothetical counselor so solicitous of the totally selfish client as to devalue the life of the unsuspecting fiancee. Although the other example isn't quite so clear, the same devaluing of the woman's life occurs. In these examples, the authors wend a tortuous, Prufrockian argument about whether to warn the woman or even to ask a public agency to warn her. If this were a man exposed to, say, a radioisotope by the client, such timid waverings would not arise.

Between the invisibility of low socioeconomic status individuals and the devaluation of women's lives, this reviewer finds the book curiously unethical, despite the constant precious patting on its own back about "compas- sionate values".

Indeed, a major flaw in the book is the assumption of shared values and, by extension, a largely shared ethical code. This book will not convince those who do not share the underlying values and, essentially, preaches to the