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3. The Tobacco Problem

Published onMar 27, 2020
3. The Tobacco Problem
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Think about this: You and your partner are the owners and operators of a struggling cartographic and statistical firm, Map-Off Ltd. You’re scraping by, barely paying the monthly mortgage installment or the bill for the kids’ hockey lessons. The hypothetical American Tobacco Consortium (ATC) offers you a highly lucrative contract. You are asked to generate a map of healthy long-term smokers over sixty-five years of age in the United States. You can use US census data as a basis for your work. In fact, they provide a link to the data. You are encouraged to find and use graphics (a bar chart, for example, or a photograph) or anything else that will make your map the best possible statement of the existence of long-lived tobacco users in the United States.

The map you produce will be used in an advertising campaign targeting tobacco-using senior citizens. You are told, informally, that if ATC likes your work, more and equally generous contracts will follow.

Do you take the contract, knowing that tobacco is a carcinogen responsible for the deaths of some but not all users, as well as the deaths of nonusers affected by secondhand smoke? Do you proudly send the map to your father if your mother died of a tobacco-related cancer?

Thinking about ethics and their underlying morals is hard stuff. As Socrates famously said in The Republic, “The argument concerns no casual topic but one’s whole manner of living.”1 And while it’s personal—what you believe, and how you choose to act—it is far more than that. “Ethics requires us to go beyond ‘I’ and ‘you’ toward a universalizeable judgment,” writes the contemporary philosopher Peter Singer, “somehow perceived from the standpoint of the impartial spectator or ideal observer.”2 The problem is that the idea of impartial spectators pronouncing on a “universalizeable judgment” is one of philosophy’s enduring great fictions. Over the centuries, its precise identification has proved to be, like complete scientific objectivity, an impossible dream. Wholly impartial spectators are phantoms we seek but can never find.

There are no ironclad tests that a thing is moral; no statistical certainty will ensure A is always ethically appropriate while B is always bad. Morality is always bounded by the mores of the society in which it is defined and the means by which its ideals are first understood and then applied in a particular context. Ethics may enforce, but cannot prove, the correctness of the underlying moral definitions—the bedrock presuppositions—on which they are based.3 This does not necessarily lead to moral anarchism or untrammeled relativism. It does, however, limit discussions of ethical alternatives from the search for universal bedrock truths (all cultures and all times) to a more limited social (and thus legal) framework.

Every culture has a small set of moral definitions used to justify laws, professional injunctions, and social codes of behavior. When stepped down to the scale of individual activities, these create the framework of a shared practical ethic. Ethical actions therefore, at least as understood here, are only as universal as the moral suppositions and resulting declarations grounding propositional if-then syllogisms. Y only follows if we accept the antecedent x. Truthfulness is defined as a moral good, for example, because without it, civility would suffer in a society dependent on honest exchanges between citizens. If social civility is important, then truthfulness is an important good. If that is accepted, then self-conscious lying must be seen as a danger to the civility and openness of society. Ethically, therefore, we should aim to promote truthfulness and condemn deceit.

Taken this way, ethics is morality’s conditional operand, the mechanism with which we evaluate actions based on a small set of broadly accepted moral presuppositions. Put another way, ethical propositions are action statements based on moral definitions reflecting the “manner of being” of good individuals in communities acting in the shared world.

Ethics is therefore from this perspective a communal thing, enacted individually within a shared morality. Its moral groundings can better be described as a set of cultural ideologies rather than as philosophic immutabilities. To call the resulting ethos ideological is not to demean it. Ideologies shape our perceptions and our judgments everywhere, in science no more or less than in philosophy.4 There is always a set of definitions, declarations, and attendant suppositions directing our focus in one direction while inhibiting thinking in another. From that ideology comes a set of conditional and unconditional values.5 Our shared truths grow from shared agreement; it is consensus that makes them powerful. The only test in the end, therefore, is whether a demonstrable consistency exists between moral declaration, ethical program, and resulting social action.

Consider the fictional tobacco company assignment that begins this chapter. Ask: Is this assignment ethically problematic? Is it morally questionable? In calling forth a graphic argument, the question becomes: why does it make us, or at least some of us, feel so queasy?

The Map

If the map of long-lived smokers (fig. 3.1) is no more than a graphic presentation of data compiled by others, then the mapmaker has no greater responsibility for its content than has the person who laid out this page for my argument. The typesetter didn’t read the whole manuscript; nor did the book’s designer. They probably didn’t read it at all. They simply took edited .docx files and transposed them into a publishable form, electronic or paper based. The designer’s job, and that of the printer, was to ensure that the result is legible and as attractive as possible, not that its argument is comprehensive and compelling.

<p><a href="#c11247_003.xhtml#fig_001a">Figure 3.1</a> “Still Smoking: After All These Years!” A potential response to the hypothetical ATC contract for a map of data on smokers over sixty-five years of age in the United States. Map by author.</p>

Figure 3.1 “Still Smoking: After All These Years!” A potential response to the hypothetical ATC contract for a map of data on smokers over sixty-five years of age in the United States. Map by author.

At Map-Off Ltd., you are not asked to critique the data on long-lived smokers, to judge its accuracy or completeness. You are not called on to consider its potential public effect on viewers. The employer, ATC, does not invite your concerns about the relation between sustained tobacco usage and various cancers. The mapmaker’s charge, like the page designer’s, is simply legible and hopefully persuasive presentation. The sole task is to transform a select set of data into a graphic argument composed of spatial (the states of the United States), illustrative (coloration, border width, etc.), and typographic (numbers and words) elements.

From this limited view, the mapmaker is simply a mindless drudge.6 The only issue is whether the map meets a professionally acknowledged, generally accepted aesthetic standard. If it does, then the employer must fulfill his or her promise of payment in exchange for a piece of work whose commercial value was agreed on in advance. To do less would be a breach of contract and thus an act of bad faith, a violation of the general ethics of responsible commercial exchange (the moral supposition that agreements must be honored).

The map that results is not a representation of reality, “the world-as-it-is,” or even a reality necessarily known to the mapmaker. Rather, the map presents as if certain and true a particular reality in a geography selected to advance the employer’s point of view. It is how he or she would like the world to be perceived. At this level, mapmaking is an ethically vacuous, thoughtless, thoroughly pedestrian, if persuasively potent, craft. Social responsibility and greater truths are off the map.

The Problem

Cartographers do not like to think of themselves as morally vacuous, ethically empty-headed people. Nor, of course, do analysts, demographers, geographers, graphic artists, statisticians, journalists, and other members of the graphic designing, number-crunching professions. Most workers in what today is sometimes called the “knowledge industry” prefer to see themselves as intellectually rigorous professionals whose skills contribute to a society that values their expertise and judgment. Like most of us, mapmakers want to be proud of the work they do, and that means proud of its public service. The idea is as old as the guild system7 and was a mainspring powering the rise of professionalism as an ideal in modern society.8

The problem is that it will be hard for most of us to be proud of “Still Smoking: After All These Years!” At issue is the message the map presents. “In every map made by a professional cartographer [and by every amateur, too],” wrote J. B. Harley, “some sort of judgment has to be made as to how to represent the world.”9 In this case, the map asserts a positive correlation between longevity and tobacco use. At the least, the map implies smoking is certainly no barrier to longevity. In “Still Smoking,” the implicit judgment is that smoking will encourage longevity, and thus health and life.

A bedrock moral presupposition defines human life as the ultimate good, as something precious. The ethical result enjoins life’s protection. The proposition behind the map is this: “If life is to be preserved (morally), and if smokers live long lives, then smoking is good for longevity. It is good for life.” That, Barthes’s semiologists would say, is what is signified by the signs embedded in the map.10 Its components (blocks of colorful states) promote a falsely positive correlation between tobacco use and the good of an extended lifespan.

The map does not lie. In its lower right-hand corner, it credits the US Centers for Disease Control for the data it deploys; and isn’t the CDC the closest thing we have to Singer’s impartial observers? That the map does not lie does not mean it tells the truth, however. While the data are official, the conclusion is not. For decades the CDC and almost every other health-related federal agency have been at pains to demonstrate the degree to which tobacco use is a causal factor in a range of cancer and cardiopulmonary fatalities.

We know with all sorts of certainty that long-term tobacco use directly or indirectly contributes to the death of thousands of people every year. Current figures suggest there are 480,000 annual deaths related to extended tobacco use in the United States, and about 47,000 in Canada.11 So the mapped association of smoking with longevity is a “false truth,”12 mendacity wrapped in a cloak of objective facticity. The map of long-lived smokers is therefore ethically problematic because it presents as factual and complete an equivalence that is unsupportable. Longevity may occur in spite of long-term tobacco use, but never because of it. The map implicitly advocates as a life-enhancing good a behavior that is injurious and perhaps life threatening. The result is not only a lie but one that violates a moral standard of life promotion and protection.

The mapmaker-as-drudge doesn’t care about any of that. He or she, in philosophical terms, is a simplistic deontologist who has followed the rules of commerce: this is the job, those are the figures, take the money and be grateful for the work. Consequently his or her engagement stops there and does not extend to the potential effect of the map campaign on readers. But for some and perhaps for many, the contract would create a conflict in which deontological rationalization conflicts consequentially with the self-image of a would-be virtuous person. Map-Off Ltd. principals know that some smokers, especially the young, may see the map as a rationale encouraging the use of tobacco products. Older addicts (and the addictive qualities of tobacco are firmly documented) may see the map as permission to continue to smoke. It is hard to be a virtue ethicist when the consequences are so harmful, whatever the rules.

Professionally the job should be completed (“I need the money!”), but socially the contract should be rejected. After all, aren’t we all charged as citizens with, if not self-consciously promoting health, then at least refusing to present as complete what we know to be a potentially injurious half-truth? Taking the contract, won’t we be at least a bit responsible for the seventeen-year-old who shows the map to his parents and says, “See, folks, I can smoke and live long, too.” It’s a mundane but practical example of Dobson’s conflict, described in chapter 2, between private needs and public responsibilities. And then there is the thorny issue of freedom of expression (who am I to censor others?) and, pragmatically, the need for Map-Off Ltd. to make enough money to pay its employees so that they can pay their bills.

We can immediately draw two conclusions from this simple but not simplistic example. The first is that the ethics of mapmaking does not reside solely in the veracity of the facts a map purports to present. Second, a map’s ethical quotient does not depend on the excellence of its design. Indeed, to the degree the map’s design is persuasive, it only makes the problem more serious, the false truth (“To live long, light up!”) more convincing. Instead, the ethics of the map—and our discomfort with it—resides in the proposition it enacts, the conclusions it is crafted to present, and the means by which our morals (MacIntyre’s virtues) are challenged (or confirmed) by the result. The map and its graph together present an idea about the world, using data that power (some would say “concretize”) a proposition in a landscape that seems “objective” and therefore “truthful.”

Representation versus Presentation

The idea that well-constructed maps are technically precise, unambiguous representations of the objective world was a broadly accepted notion until quite late in the twentieth century. This idea was implicit in the work of the doyen of post–World War II cartography, Arthur Robinson, whose Elements of Cartography was for decades and through successive editions the teaching bible of the discipline.13 Maps were to be judged on the manner in which they accurately and aesthetically ordered spatially grounded, objectively impartial data.

Robinson did not urge his students to consider the uses to be made of the maps they constructed. Nor did he advise them to question unduly the data they were asked to map. Given his history, this approach is not surprising. Robinson headed the US military department of cartography, whose members mapped Allied bombing runs in World War II. “They would come to the office,” Robinson later said of his years of military mapping, “the main office, my office, and be assigned to a cartographer. He would go over all their needs, establish what data they had and what data we had to provide.”14 Robinson’s mapmakers would use those materials to plan bombing runs for air force personnel.

The ethics of Robinson’s cartography began and ended with the resulting map’s military utility. If the bombing run he was asked to plan would destroy a church, school, or orphanage, it was not his concern. Consequently he did not agonize over the tens of thousands killed in the sorties he helped plan, or the hundreds of pilots carrying his maps who died on missions he and his team scripted. The towns destroyed were not to him the homes of civilians but dots on the target maps he and his staff constructed. For him, and then for the generations of students he taught, a cartographic ethic was in the main an ethic of moral disengagement.

That began to change by the 1990s, when a group of “critical geographers” challenged the idea of the map as a value-free objective presentation of anything.15 In 1991 J. B. Harley called for mapmakers to consider the “rightness of the social consequences of map-making,” recognizing that “every choice that goes into the making of the map has an ethical effect.”16 In 2008, Denis Wood and John Fels redefined the map as a propositional argument with an “if-then” form.17 And so attention to the predicate clause, the “if” (“if this is true,” “if this is important,” or “if this is ethical”) becomes the fulcrum on which a map’s argument might be judged. Queasiness results when mapped results violate a conditional belief in, say, health as a moral good or “truth” as more than a narrowly defined, self-serving rhetorical tool. As we will see, it is the very idea of truth as a simple, objective fact that in the end is challenged as well.

The Map as Story

The problem is not cartographic but general, arising for many people employed in today’s knowledge industries. Journalists, to take only one example, face the exact same problem. “We are chroniclers of, rather than participants in, the society around us.”18 Beyond broadly accepted social injunctions against self-conscious lying or theft (plagiarism), the rules of ethical reportage are similarly colored in “shades of grey”19 and “cannot be cast in stone,” as one Canadian journalist proudly put it.20

Consider the hypothetical case of a reporter for the Raleigh, North Carolina, News and Observer assigned to cover a press conference called by (fictitious) ATC president and well-known local philanthropist Thomas J. Crawford. Upon entering the room, reporters are given a high-resolution color copy of the Map-Off Ltd. tobacco map, “Still Smoking!,” and a printed version of Mr. Crawford’s prepared talk. The newspaper’s cigar-smoking city editor budgets the story for the front of the Metro Section to run with the Map Off Ltd. map graphic under a 36-point headline: “Long-Lived Smokers.” Perhaps the page on which it is to be printed carries an ATC product advertisement.

Here is a part of the resulting story:

“Tobacco use is not a death sentence,” Thomas J. Crawford said Thursday. The president of the American Tobacco Consortium was in town to promote a new advertising campaign focused on seniors. “While anything can be deadly in excess,” he said, most things—including tobacco—can be pleasurable and even beneficial in moderation.” After all, he continued, the human body has natural nicotine receptors, and they obviously are there for a purpose. They are … natural! Crawford urged North Carolinians to “think for yourselves … see the CDC data we’ve mapped here.”

Members of the American Cancer Agency (another made-up name) said that they, too, want Americans to think for themselves. “And when they do,” said Nikita Kwan, the ACA North Carolina director, “they’ll know tobacco is a health risk to be avoided.”

During his talk, Mr. Crawford used a laser pointer to emphasize the six-point type at the bottom of the map identifying the data source, http://apps.nccd.cdc.gov/brfss (a link no longer active), the cartographic equivalent of the journalist’s “he said” or “she said” attribution. In doing so, the ATC president assigned responsibility for the mapped data to the US Centers for Disease Control, which, as Crawford told reporters, is about as objective and unbiased a federal organization as can be found. The CDC’s findings are to be trusted.

The balancing quote from the imaginary American Cancer Agency spokesperson is supposed to make the story objective and neutral, but it does not. Indeed, it reinforces the credibility of Mr. Crawford, who first encouraged his listeners to “think for themselves” and, hey, just look at the map. The ACA official is thus transformed into a support voice urging independent thought that, on the mapped evidence and the story’s text and they together seem to embrace long-term tobacco use as an aid to longevity.

The story is “true” in a limited way—Mr. Crawford said this, and statistics on long-lived smokers can look like that—but the result is nobody’s greater truth. Mr. Crawford’s “think for yourself” invokes as a moral good autonomy and individual choice. That, in turn, echoes the call to rational philosophy and Singer’s dispassionate observation. Mr. Crawford’s “look at the data, look at the map,” neatly subverts any greater body of other public health data detailing the hazards of sustained tobacco use.

Map Stories

Every day thousands of such stories are broadcast or published. Correctly attributed quotes lead to conclusions that are questionable at best if not, upon consideration, nonsensical. During my news career, I wrote hundreds of them. A story’s limited facticity—based on the attributed quote—is what brings into being a story’s seeming value-free objectivity. From the day of their first byline until their last day on the job, reporters are instructed simply to report: question, perhaps, but do not debate. As one well-known reporter once told me, a reporter should seem to be without opinions, without a personal point of view. There are exceptions, of course, including editorial writers. But they are just that: exceptions.

It therefore should come as no surprise that maps are staple tools accompanying and buttressing news stories. The US-based Investigative Reporters and Editors (IRE), an organization to which I have long belonged, periodically hosts seminars on mapping as a way to both build and buttress news stories. Esri Press, whose parent company produces the popular computer mapping software ArcGIS, has published case studies of news maps.21 In 1999 Mark Monmonier published Maps with the News, a history of progressively accurate and ever more truthful, if sometimes limited, cartographic journalism.22 Monmonier’s book contained no discussion of ethics, or morality, or anything resembling the problems discussed here, however. Maps represented the world through the graphic presentation of data. It was as simple (or as complex) as that.

Maps often serve not simply as an illustration to a news story but as the story itself. In 2005, for example, US wire services carried a map sourced to the software mapping company ESRI (Environmental Systems Research Institute)—the parent company of Esri Press—titled “War with Insurgents Ramped Up.” It ran as a stand-alone graphic in some North American newspapers and in others as part of a broader news package.

On November 9, for example, the Reno Gazette-Journal included the map with a Los Angeles Times wire story on the Baghdad drive-by murder of the defense attorney Adel al-Zubeidi. Zubeidi had represented Iraqi vice president Taha Yassin Ramadan, then a codefendant at the trial of Saddam Hussein.23 While the Los Angeles Times copy made clear that no one knew who had killed the former vice president or why, the map linked—by means of both its text and its “epi-text,” its positioning in the newspaper with the story—the defense attorney’s murder to the then-ongoing and righteous battle by US soldiers and their allies against “insurgents.”

<p>Figure 3.2 A near facsimile of a map produced in 2005 by ESRI (or at least using ESRI materials), with content added by and distributed by US wire services. By author.</p>

Figure 3.2 A near facsimile of a map produced in 2005 by ESRI (or at least using ESRI materials), with content added by and distributed by US wire services. By author.

The original map was one of thousands generated by and for journalists during the US invasion. Many were based on, or simple reproductions of, one or another of the 35 million maps generated by and for the US military in support of its campaign in Iraq.24 Many of those maps were given to the tens of thousands of US troops (and their embedded journalists) for way finding. Thousands more were used, à la Robinson, in the planning and assessment of military sorties. Military and State Department officials used still more maps in both internal discussions and press briefings (where, I suspect, this map or at least its data originated).

On the map, its source is given as ESRI, which at that time provided map products and expertise both to the US military and to news agencies. The map was carried by the Associated Press news service and perhaps by others, as well. The map included in this book is a “near facsimile” an “almost but not quite right map” because AP refused permission for its “commercial” use here. Although ESRI was the map’s “source,” company officials said that because text may have been added to their map product (by the AP or the military; nobody knows), it could not license the map’s use here. Whoever made and then modified the ESRI map, its data almost certainly originated in a military press briefing where either the map itself or its summary data were given to reporters. The map included here has the same data and a slight but sufficiently different presentation to avoid legal stricture.25

The maps—both mine and theirs—identify locations, posted as black dots, where US troops and their allies had been killed. Those dots are linked by gray lines to explanatory text boxes. One, for example, locates US-led attacks at Husaybah, “a major way station for foreign fighters entering the country from Syria.” As in the case of the fictional Raleigh News and Observer story with its “Still Smoking!” map, we are seduced by the map’s concreteness, its apparent facticity. And certainly the map tells a small truth: US troops and their allies were killed in places identified on the map. They in turn mounted offensives against supposed insurgents in other places like Husaybah.

What would Peter Singer’s independent observer think about this? When we read the map, we see insurgents killing virtuous US troops and their allies, who in turn are defending Husaybah, a “way station” for foreign fighters. The map thus ignores the inconvenient fact that US troops were themselves foreign fighters in a country where at least some insurgents were Iraqi-born nationals who saw themselves as patriots defending their homeland against foreign invaders, the US troops. “In fact, the insurgency was made up of a complex mix of forces” who turned Iraq into a terrorist center after, and in no small part as a result of, the US invasion.26 The result is a small truth (bombs here and battles there) enfolded within a series of polemical postures.

There was nothing exceptional in this. Even the august New York Times “based their analysis of the war in Iraq on Pentagon talking points, mostly lies.”27 CNN news officials acknowledged “with some pride” seeking Pentagon approval for the hiring of a general as their principal military commentator.28 It’s hard to question a story quoting a general. They are assumed to be authoritative and knowledgeable, if not necessarily impartial. What makes the mapped argument so useful here is that its ideology is at this remove so obvious and its argument so questionable.

The Iraq map continued a long tradition of Cold War–era mapping and news writing that, while publicly proclaiming objectivity, were fashioned to present the idea of a virtuous nation defending values in a dangerously uncivil world.29 That era’s mapping, in turn, followed upon an older tradition in which maps and news stories were self-consciously fashioned to advance this or that militarily enforced, political objective.30

The resulting maps and reports were (and are), you might say, “objective propaganda,” employing carefully culled sets of data selected to promote a limited, partisan view of the world and its conflicts. In this case, the right to self-defense was the moral declarative justifying the US military’s “ramping up” its forces. The proposition was simple: if Americans are attacked by outsiders (foreigners), and if their lives are precious, they then are permitted and indeed obliged to defend themselves. Virtue therefore resides with the US troops fighting for values (democracy, for example) that the virtue ethicist would applaud. Ramping up the military response to foreign insurgents thus was presented as a morally justified, consequentially sound, ethical act.

Did the mapmaker feel queasy about the map he or she was asked to turn out? We don’t know. Probably not. In the constant press of deadlines I suspect that he or she didn’t think about it at all. Had the cartographer or perhaps a news subeditor said, “Hey, boss, this is bogus!” would he or she have been lauded or told to shut up? Again, we don’t know, although my guess, based on years of newsroom experience, is the latter. What is clear is that the map raises ethical questions that go beyond simplistic “he said, she said” truths.

Maps as Science

But, some might say, that’s just journalism. Science, on the other hand, is about objectivity, its charge Hume’s impartial accumulation of value-free facts and Plato’s imagined world of nonpersonal, more general truths.31 There at least is a bastion of impartial presentation rather than a complex and evolving negotiation between argument, bias, fact, and fancy.32 And yet scientific maps and stories can be as misleading as any produced for commerce or the news. Like all other areas of social knowledge, science is a constructed and tentative argument about a proposed reality it seeks to justify. We saw this in chapter 1 in the story of Dr. John Snow and the London cholera outbreak, and it remains true today.

Consider, for example, the two maps of waiting times for graft liver transplantation shown in figure 3.3. Both were included in a 1999 report prepared by national Institute of Medicine (NIM) scientists charged with evaluating the ethical propriety and the organizational efficiency of the US national graft organ allocation program.33 The data they used were collected by the United Network for Organ Sharing (UNOS), a nonprofit, arms-length agency created in the 1980s to supervise the US graft organ collection and distribution program under the supervision of the US Department of Health, Education, and Welfare (HEW).

<p><a href="#c11247_003.xhtml#fig_003a">Figure 3.3</a> The medical status of all patients with liver disease who will require transplants (top) compared with those in urgent need of a liver transplant (bottom). Source: Institute of Medicine, <em>Organ Procurement and Transplantation</em>, 58a.</p>

Figure 3.3 The medical status of all patients with liver disease who will require transplants (top) compared with those in urgent need of a liver transplant (bottom). Source: Institute of Medicine, Organ Procurement and Transplantation, 58a.

The maps presented state-level data on the wait times of 68,000 persons diagnosed with progressive liver disease. The first map posted a fair amount of geographic variation in the waits experienced by persons on the UNOS registry of potential recipients with chronic but not yet end-stage liver disease. The second map’s uniform yellow coloration concluded that when their disease became truly life threatening, people in every state got what they needed and, we assume, were saved.

The study was ordered because, in the 1990s, Health Education, and Welfare secretary Donna Shalala argued the necessity of reforms to correct what she described as serious geographical inequities in the UNOS system of graft organ distribution.34 If demonstrable, those inequities would have violated the enacting legislation’s promise of equal treatment for all potential organ recipients.35 That promise was based on moral ideals of “equality” and “reciprocity,” around which the service was to be ethically organized. The virtuous goal of the system was thus to ensure the equal treatment of all potential recipients.

There was a practical rationale as well as an ethical injunction. Organ transplantation depends on the free donation of organs by families of deceased persons. Presumably people would donate because they believed they or their loved ones had an equal opportunity to receive an organ if one was needed. If they believed that to be untrue, then the rationale for donation in a community of sharing would be restricted.

Hidden in both maps was a series of inequalities and, some would conclude, inequities. I discuss these more fully in chapter 8, but a brief review here makes sense. In 1999 the national organ transplant system included no transplantation centers in thirteen states. Patients in nonserved states who needed a liver (or a kidney, heart, or any other organ) were required to register at and then travel at their own expense to transplant centers in other states, where they might be required to wait for months in hopes of a graft organ becoming available.

That system imposed a number of burdens—familial, financial, and personal—potentially inhibiting the participation of patients who lacked substantial financial resources.36 Moreover, at least in some cases, those geographic inequalities and their costs presented a potential obstacle to both organ receipt and for those receiving a transplant to the postoperative care and support of patients separated from community and family support systems.

More critically, the UNOS data that report researchers studied included only patients who had been accepted as candidates for transplantation. It thus ignored the manner in which socioeconomics—a polite way of speaking about economic, racial, and social disparities—limited potential graft organ receipt.37 “Although the procurement system is national, patients’ access to it is not. Patients must generally either have health insurance that will pay for transplantation or be able to pay for it themselves.”38 Few if any of the more than 40 million citizens who in 1999 lacked health insurance could afford the cost of a transplant and its often equally expensive aftercare. “Few doubted that the barriers of socioeconomic difference were deeply embedded [but hidden] in the maps.”39

So the UNOS list of potential liver recipients hid, at least potentially, the existence of not only geographic but also socioeconomic disparities affecting a citizen’s ability to receive a lifesaving or life-extending graft organ. Legislated ideals of reciprocity and equality were violated. The poor and their families were encouraged to donate organs, but as potential recipients, many were simply … off the map.40

Race and Ethnicity

Researchers for the Institute of Medicine were firm in their insistence that “no significant effects of race or gender were observed, indicating that the system is equitable for women and minorities once listed [as potential recipients].”41 The key phrase, however, was “once listed.” The researcher thus avoided having to think about all those who never made it onto the waiting list. By focusing only on those “once listed,” report researchers were able to ignore the effect of race on income, home location, and the ability to afford health insurance on transplant eligibility.42 The real question should have been, in law and ethics, not simply the performance of the UNOS system for those “once listed” but, more importantly, the reality of those in need but not listed because of location, poverty, race, prejudice, and so on.

In an attempt to show exactly what this meant, in 2001 I produced two maps of Southern California.43 In figure 3.4, the upper map posted the Southern California counties by population. In the lower map, counties were resized to reflect only the estimated population of health-insured persons. These figures were calculated by subtracting the percentage of uninsured citizens from the total mapped population. In 1998, 35.1 percent of Hispanic Americans were uninsured, and 24.8 percent of African Americans were uninsured, compared to 15.2 percent of white Americans.44 As a result, the map of Southern Californians eligible for organ transplantation (but not, of course, donation) was changed dramatically. The equity of the system was questioned as a result.

<p><a href="#c11247_003.xhtml#fig_004a">Figure 3.4</a> Two views of Southern Californian political boundaries in 2001. The first reflects the general population, the second only the health-insured population. A lack of health insurance would result in many persons being unable to afford a graft organ transplant. Maps by author.</p>

Figure 3.4 Two views of Southern Californian political boundaries in 2001. The first reflects the general population, the second only the health-insured population. A lack of health insurance would result in many persons being unable to afford a graft organ transplant. Maps by author.

Like the map of Iraqi insurgents, the Institute of Medicine authors’ map was truthful in its presentation, but at best incomplete in the conclusions it sought to argue.45 The error resided in the assumptions that, first, all in need were admitted to the UNOS waiting list irrespective of ethnicity or income, and, second, the relation between home and hospital center locations would make no difference in patient eligibility or treatment.

Like the fictional Raleigh reporter, the transplant study researchers did not independently generate the data they mapped. Instead they used UNOS-collected data for analysis. A UNOS official might say the organization’s mandate is to provide an efficient system of graft organ retrieval and distribution and not to resolve structural inequalities in American healthcare or society. But the National Organ Transplant Act of 1984 defined transplantable organs as a national resource to be made available to all in need on an equitable basis. Equal access for all in need was enshrined in law as a moral necessity. And if equality is a moral necessity, and if there were disparities in graft organ distribution, then the system was in violation of its ethical mandate. That was what HEW Secretary Shalala argued and what UNOS officials vigorously (and successfully) disputed.

Reputation

So what? Shouldn’t the ethical weight of false or at best partial truths fall on the shoulders of those who order the map? Was it the fault of the Institute of Medicine’s cartographers and statisticians? “We took the UNOS data, and if it’s incomplete,” the mapmakers might have said, “that’s on them.” And yet wouldn’t you feel a bit queasy if these were your maps, if this was your study? What if it were your father who, laid off from his factory job, lost his health insurance and thus his chance for a necessary life-prolonging transplant? If we construct the maps (or charts, or graphs, or pictures, or stories), then we are either mindless drudges—or complicit.

Because ethics goes “beyond ‘I’ and ‘you,’” as Singer put it, this is about more than individual self-esteem or self-interest. To ask about the ethics of an act—analytic, cartographic, statistical, or any other—is to ask about our role in society, our allegiance to its ethical framework and moral values. It is about our actions or inactions as citizens in communities. As Erving Goffman put it in 1959, ethics becomes sociology in a different frame (or perhaps sociology is ethics in a different frame) when a person wants others to take seriously the persona he or she sets forth as responsible and “good.”46 When we dig through these and other examples, however, the work resembles more an anthropology of ethics rather than a sociology of morals. And as an anthropology, it is grounded in the concrete and experiential, as the next chapter attempts to demonstrate.

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