Ambiguous Prognosis: Disease and Narrative
One Hundred Days: My Unexpected Journey from Doctor to Patient.
David Biro.
New York: Pantheon, 2000. 291 pp. $23.00 (Hardcover).

My favorite line in David Biro's illness narrative occurs after he has been diagnosed with the rare disease that will ultimately lead to a bone-marrow transplant at Sloan-Kettering Memorial Cancer Center. Biro enjoys what many would imagine to be a perfect life. He has just completed a dermatology residency and joined his father's thriving Manhattan practice; he is happily married to a lovely and successful woman; and he is completing a novel that has good prospects for publication. But as a student of mythology, Biro knows the presence of Nemesis, the redistributor of good fortune. Thus he writes: "There is too much evil and tragedy in this world to pass through unscathed. It wouldn't be fair for only some to bear the brunt of suffering. Otherwise how would we communicate?"

Even when Biro is not offering such insights—and they occur too infrequently for me—he is an excellent guide through the horrors of transplantation. After considerable medical dispute he is diagnosed with a rare disease called paroxysmal nocturnal hemoglobinuria, a name deriving from the symptomatic presence of blood in the urine (Biro's urine remains clear, confounding diagnosis). PNH has an ambiguous prognosis. Some patients, he is told, do quite well, yet he reads that many others "succumb," a conventional medical description he suddenly finds ominous. Confronting diverse specialist opinions, Biro opts for a transplant with its hope of complete recovery. "I'm a risk-taker," he writes. "I'd rather drive aggressively and dent a fender than sit in traffic for hours on end." Here are the poles of Biro's personality: his insight that without suffering humans could not communicate, and his willingness to dent not only his own fender but also someone else's. His story takes both its fascination and its limitations from the distance between these poles—a distance Biro does not spend much time contemplating.

Most of the book is a well-written medical adventure story of ambiguous diagnosis, troubled decision over treatment, the horrendous treatment itself, and a recovery almost as ambiguous as the diagnosis. Biro's experiences lead him to reflect on how medicine is organ-ized and practiced but, on my reading, less than he might have. Biro studied classics and took a doctorate in literature at Oxford before becoming a physician; his chapter epigraphs show his considerable intellectual sophistication. But he does not substantially develop the ideas from the epigraphs when describing the phases of his illness. He introduces but does not develop interesting thoughts—for example, the nature and limits of empathy. Likewise, various plot lines never develop. At first the family's medical insurance, carried through his wife's employer, refuses to pay for the transplant; then someone says they will make a call, and the issue disappears. Similarly, Biro's participation in a Yom Kippur service early in the book suggests continuing spiritual reflections that never occur or were cut in editing.

Biro's experiences might be most usefully read by young physicians caught in the myth of their own physical invulnerability, or by those undergoing transplants similar to his. Fellow patients should be warned, however, that Biro's status as a physician leads to various acts of preferred treatment; for example, the chief resident at Sloan-Kettering is a medical school friend who promises him "the presidential suite" as his room. Such treatment can only spare Biro so much of what everyone goes through, but more than a few rough edges are smoothed by his and his family's resources.

Perhaps the most singular aspect of the book for me was the simmering conflict between Biro's family, with its effusively emotional, protective, ceaseless helping style, and his wife, who finds the family's incessant intervention suffocating. If this conflict also remains unresolved, perhaps this lack of resolution—like the final ambiguity of Biro's physical prognosis—is simply the nature of things.

Looking back on his experience with a physician's appreciation for physiology and a writer's sense of metaphor, Biro asks, "How is it possible for all the broken pieces of the puzzle to be reassembled . . . ?" He has learned that the parts can reassemble, but the puzzle remains. I hope he will continue to return to his illness in future writing and deepen the puzzle into more of a mystery.

Divorce: The Children's Burden
The Unexpected Legacy of Divorce: A 25 Year Landmark Study.
Judith S. Wallerstein, Julia M. Lewis, and Sandra Blakeslee.
New York: Hyperion, 2000. 352 pp. $24.95 (Hardcover).

Most Americans are aware that almost one in two marriages now end in divorce, yet the long-term effects of this revolutionary development in family life are less well known. Social scientists have demonstrated that children of divorce do more poorly than children from intact families on a host of social indicators. Only Judith Wallerstein, however, followed the same group of children of divorce over a span of decades, examining their inner lives as they became adults. At the twenty-five year mark, Wallerstein and coauthors Julia Lewis and Sandra Blakeslee now report that divorce affects children well into adulthood. Since at least one-quarter of adults under the age of forty-four in this country are children of divorce, this is a very significant finding indeed.

Wallerstein argues that a number of "cherished myths" about divorce persist in our culture. One myth is that if divorce makes parents happier, then children will be happier too. Yet, Wallerstein found, the very changes that can make life better for adults after a divorce—a new lover or spouse, a more demanding but fulfilling career—often make children feel worse because parents become less available to children.

Again contrary to myth, divorce is not a temporary crisis where everything will be normal after six months or a year. Wallerstein found that divorce is just the beginning of a series of upheavals that can last throughout childhood.

Still another myth is that divorce ends conflict between the parents, that after divorce the children may miss their intact family but at least the parents will no longer be fighting. But Wallerstein and her colleagues demonstrate that divorce opens up whole new realms of conflict between parents.

Wallerstein's book does not just dispel myths; it also brings new and important findings to light, and it poses significant questions for our future. After a divorce children often take up new roles in the family. Some children become caretakers, some act out, and still others become loners, essentially abandoned as parents are swept up into postdivorce lives and responsibilities. Wallerstein found that children of divorce now in their twenties or thirties often reinstalled these childhood roles in their own romantic relationships, and many struggled for years to find loving, stable marriages. Even those who were successful in love reported recurring fears that the relationship could end unexpectedly.

Wallerstein also includes an important—and rare—discussion of how vulnerable children fare. Bright, physically healthy children can be devastated by divorce, but they also have internal resources to help them adapt quickly to the many changes divorce brings. But vulnerable children, especially those with physical or mental disabilities, adapt to change very slowly, if at all. As a consequence, they suffer more and, in the case of one young man Wallerstein discusses at length, they can end up clearly heartbroken.

As the children of divorce in her study aged, Wallerstein found they were more likely to have strained relationships with their divorced parents—especially their fathers—than did adults in a comparison group who grew up in intact families. When adults feel their parents did not fulfill basic obligations to them as children, they are often less willing to help when those parents become older and dependent. Therefore, Wallerstein raises a critical question for the future. If the baby boomers who first ushered in the divorce revolution are aging—and living longer then previous generations—and if many of them have strained or nonexistent relationships with their adult children, who will care for this new cohort of dependent, disconnected older Americans?

While Wallerstein cannot answer that question, she does offer other suggestions to parents, politicians, and society. In particular, Wallerstein has much to say to family courts. She charges they have treated children in divorce cases as passive, voiceless agents. She urges the courts to seek out and listen to the child's perspective, to allow custody decisions to change as a child's needs change, and to evaluate all custody decisions one year later to see how a child is doing (something, astonishingly, the courts do not do at the present time). She also urges more data gathering. For instance, there is no tracking of how many children of divorce fly alone each year, and no one knows how these solo journeys affect children.

For years, the courts and many parents have been making decisions about divorce with strikingly little information about how divorce affects children. Thanks to Judith Wallerstein and a handful of other social scientists the question is no longer whether divorce affects children, but what we should do about it.

The Goods of Marriage
The Case for Marriage: Why Married People Are Happier, Healthier, and Better Off Financially.
Linda J. Waite and Maggie Gallagher.
New York: Doubleday, 2000. 260 pp. $24.95 (Hardcover).

Marriage is good for you. This is the message of Linda Waite and Maggie Gallagher's recent book, which has been eagerly anticipated by many in the nascent "marriage movement." Waite is a professor of sociology at the University of Chicago, where she has focused on the family, aging, and women in the work force. Gallagher is a syndicated columnist, social commentator, and director of the Marriage Program at the Institute for American Values. The marriage movement is an emerging coalition of scholars, religious leaders, and civic leaders who view strengthening marriage, reducing divorce, and curtailing unmarried pregnancy as key to building a good society, particularly for children. The health benefits of marriage are part of the arsenal that these folks, and Waite and Gallagher in their book, use to make the "case for marriage."

The thrust of Waite's statistics and Gallagher's rhetoric is that a case can be made. They debunk what they call the five myths of the postmarriage culture: (1) divorce is the best outcome for children when a marriage is unhappy; (2) the decision of adults to cohabit or remain single does not (and should not) matter to the wider society, so long as they do not have children who could be harmed by these alternative lifestyles; (3) marriage is good for men, but bad for women; (4) marriage puts women at risk for violence; and (5) marriage is a purely private matter.

Waite and Gallagher deconstruct the last of these myths first with a description of a "marriage bargain" that seems to have become unenforceable, if altogether extinct, in recent decades. Significantly, this marriage bargain—the very modern-sounding term by which the authors seem to invoke the classical marital goods of procreation, fidelity, and permanence articulated in many religious traditions—is a public as well as a private good. Society has a role in strengthening marriage, and it benefits from the social stability that these happy unions provide. Indeed, at one point the authors remark that recent attempts of gay and lesbian couples to marry demonstrate the importance of marriage as a social institution.

Marriage and family are not, however, uncontroversial topics—and this will likely not be an uncontroversial book. One area of possible controversy is the use of the language of health. Indeed, the authors strike the notes of the traditional marriage blessings of health, wealth, and happiness throughout. Nonmarried people have higher rates of mortality than the married—50 percent higher among women and 250 percent higher among men. Married surgical patients are less likely to die in the hospital than singles. Happy marriages are thought to foster higher levels of immune function. Married people have better and more frequent sex than single people. Married people are more affluent, and married men make significantly more money than bachelors. Indeed, getting married is reported to increase a man's salary by about as much as a college education. Women, too, benefit from the economies of scale in marriage (two together can live more cheaply than two apart) and from the social capital and support provided by their husbands' families, particularly in childrearing and inheritance. The authors also take care to point out the benefits of marriage to children, which are presumably a boon to parents, as well.

The somewhat dry, utilitarian tone of the argument may sound a discordant note for romantics wont to focus more on marriage's intrinsic goods than its instrumental uses. Somehow the authors never conclude that their strikingly utilitarian argument, unjoined to any language of commitment and reciprocity, also risks making marriage a selfish enterprise, if the consideration of one's own good elides consideration of marital mutuality and the good of the family. Moreover, just as the plea to "eat your vegetables because they're good for you" often falls on a child's deaf ears, the call to get or stay married for one's own good may not persuade an adult to partake of marriage as a means of achieving happiness, health, and wealth.

But then again it just might. One can quibble endlessly with rhetoric, but quibbling becomes more difficult when the rhetoric is backed up with the ample statistics that Waite and Gallagher provide. While children in high-conflict marriages may be better off after their parents' divorce, the evidence suggests that children in low-conflict marriages may do just fine. It turns out that the decision of some adults to cohabit or to give birth to children out of wedlock may have lasting negative effects, not just for the adults involved, but for the wider society; the ideals of commitment and shared sacrifice in the "marriage bargain" may devolve to the "cohabitation deal" reality of hypertrophied individualism and easy exit. The old view was that single men live a life that is "nasty, brutish, and short" while spinsters flourish; the new knowledge is that, while single men still go to an earlier grave than their married counterparts, married women apparently outrank their single sisters in both length and quality of life.

Perhaps a more contentious issue than the book's utilitarian twist is the way in which it straddles the line between describing and prescribing. For many growing up in the same Baby Bust/Generation X cohort as this reviewer, the problem is not an inability to appreciate the benefits of those marriages that make it, but the paralyzing perception that far too many marriages do not. Recent studies have shown us to be a generation with ideals of married life that may be so overly romantic and unrealistic that troubles arise when reality does not meet expectations. Growing up in the aftermath of the sexual revolution and the divorce revolution, many of us view the "marriage bargain" as a risky venture. As a result, we settle for relationships that are less than they could, and should, be. The Case for Marriage may not persuade all with its foray into a more normative realm, but its wealth of statistics accompanied by cogent argument should contribute greatly to broader social discussion of the goods—and even the health benefits—of marriage and family.

Man With a Balance on a Table
Sovereign Virtue: The Theory and Practice of Equality.
Ronald Dworkin.
Cambridge, Mass.: Harvard University Press, 2000. 511 pp. $35 (Hardcover).

Whatever else you might want to say about recent philosophical work on justice emerging from the New York area, you can hardly fault the aesthetic taste of its producers: Vermeer's extraordinary Woman Holding a Balance decorates the covers of Frances M. Kamm's Morality, Mortality (vol. 1, Oxford, 1993), the cover of the May 2000 Hastings Center Report (with lead articles on health care justice), and now Ronald Dworkin's new book too.

Using Vermeer's image as the emblem for explorations of justice is, of course, enormously inviting: a woman, possibly pregnant, certainly serene, delicately poises an empty balance over a table strewn with rare and precious things—pearls and gold jewelry. She stands under a painting of Christ judging all souls at the world's end, obscuring just that place where Saint Michael traditionally stands wielding a balance of his own. The iconographic resonances are almost too available.

Still, in some way, the art is less appropriate for Dworkin's book than it might be—less so than for Kamm's book, certainly. Kamm weighs minute moral distinctions in the finely calibrated balance of her intuitions; Dworkin's procedure is bolder, his ambition to build theory stronger, and the range of application of his views much wider. It almost seems that the background painting, the ultimately authoritative separation of all sheep from all goats at the Last Trump, coheres more closely with Sovereign Virtue.

The broad sweep of Dworkin's position is most clearly on view in his statement of the book's fundamental theme. He defends the now unpopular idea that equality is a sine qua non for political legitimacy—any state that does not treat its citizens with equal concern is unworthy of their allegiance, and in a state with striking levels of material inequality, the equal concern of the government for its citizens is gravely suspect, since those inequalities reflect decisions and actions of the government. Although he never quite comes right out with it, the implications of his view for the fundamental legitimacy of the American government seem inescapably grim.

The book's first seven chapters are devoted to the idea of equality as the sovereign virtue, first (and most superficially—a curiosity in this densely-argued book) providing basic motivation, then specifying the understanding of equality that is appropriate to the assessment of governmental institutions and practices. Dworkin argues that the pertinent kind of equality is equality of resources, not of welfare, and then turns to the problem of gauging equality of resources. This is tricky, in part because Dworkin's political philosophy is constrained by the two principles of a moral philosophy he calls "ethical individualism": it is equally important that each human life be successful rather than wasted; it is also important that each individual is specially responsible for the choices that shape the kind of life lived. The first of these principles requires social arrangements that strive to render our political and material standing insensitive to our gender, race, class, or particular skills or handicaps; the second principle requires that our social arrangements allow our lives to reflect our choices. Nothing so simple as making sure that everyone always commands an equal share of the gross domestic product will accommodate this view.

To assess whether a given political order accords with these principles, Dworkin has us imagine a situation of initial equality of resources as determined by an auction that divides lots among bidders who were originally equipped with equal amounts of currency. The auction continues to run until all the lots are distributed in such a way that no one envies anyone else's holdings. People will then start to do things with their resources that will likely result in the initial situation being disturbed—some will be more risk prone than others, some luckier, some unluckier—and the initial equality of resources will give way to some individuals controlling more resources than others. Some of the resulting inequality will reflect choice, and thus be acceptable. But some of it will reflect contingencies of fate—ill health, for example—and a legitimate political system must have mechanisms to correct for inequalities not traceable to choice. The amount of social resources appropriately made over to such mechanisms is to be determined by a hypothetical insurance market. Dworkin claims that we can roughly determine what the appropriate rate of redistributive taxation would be, as well as how much of our wealth we should set aside to fund such things as universal health care, by imagining at what levels reasonable individuals, operating from a position of initial resource equality, would insure themselves against, for example, the possibility that their constellation of talents and interests would command unacceptably low rates of income in a developed economy.

This is only the barest sketch of the book's fundamental argument. But it is not only in the scope of its theorizing that Dworkin's views seem not altogether well symbolized by the painting. Vermeer's woman holds the balance in her hand; it is not set upon the steady table before her. This image seems to better symbolize an understanding of the moral life that is in some important way pluralist—values that are the most deeply important to us can pull against one another in fundamental ways, and moral decisionmaking will require discerning judgment, rather than the skillful application of theory. But what is perhaps most philosophically striking about Dworkin is how insistently systematic his vision is. It is not merely that he builds interesting, and sometimes compelling, connections between the book's first seven chapters on theory and the later seven, which explore health care insurance, welfare reform, campaign finance reform, affirmative action, genetic engineering, and physician-assisted suicide. It is, rather, in his almost platonic argument for a kind of unity of the virtues that the deepest aspirations of his thought can be seen. Dworkin insists that, far from conflicting with each other, equality and liberty are mutually compatible and that our own hopes to live lives morally admirable on a personal level can be fulfilled only if we live in just communities (yet another grim implication of his view).

Fundamentally, however, Sovereign Virtue does manifest, in its own medium, much of what is most generally impressive about Woman Holding a Balance. Despite its dense complexity, something like Vermeer's light can be seen washing over its image of a way of life that answers to the strong desire to lead lives richly shared, yet distinctively significant.