The volume illustrates how alternative policy designs may incidentally affect the degree of policy transparency—although the effects may sometimes be subtler than anticipated. In his chapter on British educational reform, Finkelstein observes that one side effect of a new standard curriculum is an increase in transparency, since central government is required to articulate curricular requirements before they can be imposed on local authorities. But Finkelstein also says that this improvement in transparency may be illusory: there is wide variation among schools in their interpretation of the centrally established curriculum (34–6). Similarly, Steven Woolf argues that Americans know “far less” about the rationing of health care than do Britons, because of the dominant role of private providers within the U.S. health care system, who may assert a proprietary interest in critical information (30). However, this position is partly rebutted by Paul Shekelle and Martin Roland, who argue that private provision may actually raise transparency. Private provision requires sophisticated information systems to manage billing and auditing functions, which incidentally serve as good sources for data to assess health care practices. In Britain’s publicly funded National Health Service, there is no need for such systems, and as a result the system “runs almost free of information. Virtually no data are routinely available on individual patient encounters.” Shekelle and Roland argue that this weakness will seriously impair efforts to establish quality improvement programs within the NHS (167–8, 172).

Woolf and fellow author Jeffrey Prottas share common ground in their views about the impact of policy designs that rely heavily on the exercise of professional discretion. Woolf argues that many decisions regarding the rationing of care within the National Health Service “remain the prerogative of the health care professions,” who need not “spell out the detailed rationale behind their recommendations” (23). Prottas observes the same approach in decision making over human organ transplantation in the United Kingdom, “[P]ublic officials endeavor to ‘delegate’ rationing responsibility as far as down the service delivery chain as possible—often to individual clinicians. In this way, decisions are made less visible, and the responsibility placed on professional caregivers. These and other techniques avoid the need to develop and defend explicit criteria for deciding who will receive care and, more importantly, who will not” (70).

In such circumstances, demands for increased transparency represent an assault on the autonomy of professionals within the health care system. (This is equally true in other sectors, such as education.) But Prottas says that U.S. experience shows that attempts to promote transparency may have limited effect. The effort required for laymen to have significant influence can be underestimated, with the result that decision-making procedures conform to the formalities of public control but continue to be dominated by professional interests: “Allocation decisions are now public and ‘transparent.’ These decisions are made in the presence of outsiders and are generally debated using terms of public discourse. Extra-legal factors, such as expertise and willingness to invest time and energy, however, have ensured that those most affected by allocation decisions—the transplant programs—continue to dominate the content of decisions” (78).

Neal Finkelstein observes in his introduction that the assumption that “transparent policies are better than those that are opaque ...remains an unproven and significant point” (1). Woolf and Prottas seem to share this reservation. Woolf suggests that a system of implicit rationing could serve “a useful social function,” by reducing the pain that would otherwise be caused to patients, clinicians, and society. Furthermore, says Woolf, more explicit methods could engender controversies about rationing decisions that would damage public trust in the profession and the health service (27–8). Similarly, Prottas argues that the essential question is whether public trust in rationing procedures is maintained. In the United States, trust seems to require transparency, while the British public seems more willing to defer to professional discretion. The British approach is said to be “neither better nor worse—merely different” (90–1). These arguments may have merit, but the presentation is brief and unsatisfying.

Elsewhere, contributors make familiar but important arguments in favor of improved public knowledge about public policy. Jim Leitzel examines the black market in firearms in the United States and the United Kingdom, and the challenges confronted by officials as they attempt to craft policy under conditions of limited knowledge. “In the absence of empirical evidence,” says Leitzel, “almost any claim concerning the outcome of a policy change is defensible” (103). Leitzel suspects that ignorance fuels a belief in the futility of regulating the illegal market, and calls for innovative research to improve our knowledge. Similarly, Thomas Judge complains about the irrational policy decisions that result from public misconceptions about the role and efficacy of emergency health care—but warns that poorly designed attempts to promote public knowledge through performance reporting may actually exacerbate problems of resource misallocation (122).

The volume also considers how transparency can be consciously employed as a component of policy design. Disclosure of information about school performance is an essential element of the British school choice scheme described by Finkelstein—although Finkelstein suggests that bureaucrats and clients may have starkly different conceptions of what information should be relevant to decisions about schooling, with the result that published information may rarely be used by parents in making choices (40, 47–50). Robin Juni says that transparency is also a distinctive characteristic of the American approach to environmental regulation, which relies on civil litigation as a tool for ensuring compliance with explicit standards. But Juni is also careful to note the high transaction costs imposed by the American approach, and suggests that there are important advantages to the relatively opaque British approach, which relies on bargaining between regulators and polluters to achieve compliance with broadly articulated goals (54–5, 64). In effect, it is an argument in favor of professional discretion, complementing the arguments made by Woolf and Prottas.

The chapters by Finkelstein and Juni help to make an important point: the disclosure of information can only be meaningful if individuals or groups are capable of acting upon that information, whether by exit (as in the case of school choice) or litigation (as in the case of environmental regulation). But these are not the only avenues that citizens may pursue. A third is accommodation—that is, decisions by citizens to adjust their behavior to suit the requirements of administrative agencies. A fourth is political action, to compel policy makers and bureaucrats to change policy. These latter routes get short shrift in this volume, although the numbing effect of opacity on the exercise of political rights is briefly noted by Lynda Edwards, who suggests that the secrecy surrounding the British expenditure budget process has disenfranchised citizens and made deficit reduction an “apolitical” issue (147). Notwithstanding this and other small deficiencies, the volume provides a useful and nuanced view of what Finkelstein calls the “question of policy transparency.”