Book Review: Who Decides? Conflicts of Rights in Health Care

The Problem of Medical Knowledge: Examining the Social Construction of Medicine P Wright & A Treacher (ed) pp 232 £12.00 Edinburgh University Press 1982 In this book sociologists, historians and psychologists, of which only two of the eleven are medically qualified, look at medical knowledge and conclude that. modern practice is not qualitatively different from that in previous centuries and that it is based on cultural and social influences. The authors attempt to use the past to shake confidence in the obvious appearance of medicine today, and the book therefore smacks of Illich, McKeown and Kennedy. It is worth looking at two of the medical problems discussed. The section on bronchial asthma (Gabbay) considers the vast array of factors that, at one time or another, have been put forward as 'the cause', and the corresponding variety of treatments: furthermore, that the death rate has not appreciably declined. Nevertheless, from the patients' point of view modern treatment has immeasurably improved the quality of life whether the disorder be attributed to the psyche, allergy, biochemistry or just plain GOK (which is often the case). Good physicians confronted with asthmatics always ask the three 1930s psychosomatic questions: 'What kind of person is this?', 'Why did he get the disease he did?' and 'Why did he get it when hedid?' Genetics (Dr Yoxon) has a major error on the first page. The controversy between Platt and Pickering was not whether hypertension was a 'dominant' or had an environmental cause, but whether it was controlled by a single gene or polygenically, and this shakes one's confidence in what follows. Genetic diseases do not include 'all the ills that flesh is heir to' but only those which obey the mendelian laws. Genetic engineering is hardly mentioned (for it could not sustain the authors' thesis) the discipline has almost no history but its impact is about to revolutionize medicine regardless of cultural background and social practices. In summary, the historical and social survey is useful, and I applaud the mention of the change in fashion between 'non-bonding' and 'bonding' but the book sadly lacks a knowledge of practical modern medicine and I cry out to be included as an author if there is another edition! CYRIL A CLARKE Director, Medical Services Study Group (London) & Nuffield Research Fellow Department of Genetics. Liverpool Who Decides? Conflicts of Rights in Health Care. Nora K Bell (ed) pp 218 £21.30 Clifton, New Jersey: Humana Press 1982 In spite of occasional lapses this is a thoroughly readable and often stimulating book. It deals with what are described as 'four selected controversial areas in health care ethics: the limits of professional autonomy, refusing/withdrawing from treatment, electing "heroic" measures, and advancing reproductive technology'. The contributors are a mixed bag of historians, lawyers, nurses, philosophers, physicians, public health professionals and theologians. Not the least merit of the book is that, in the editor's words, 'the essays presuppose only minimal acquaintance with the technical terms of the various disciplines'. Which is a relief in these days of technical jargon. The outstanding chapter is the editor's introduction, in which she summarizes the views of her contributors in a clear, concise style which is so rare in books on this subject emanating from the United States. The major criticism is that the book is based almost entirely on US experience and writings. 'Rights' might be said to be the key-word of the book, particularly the rights of patients to withdraw from, or refuse, treatment. Equally prominent are autonomy and consumerism. Here, United States practice inevitably dominates the fundamental approach, as illustrated by the report that the US courts 'have upheld the decision of prison authorities to impose kidney dialysis on "a mentally competent inmate" suffering from endstage renal disease who had refused haemodialysis'. In refreshing contrast is the little gem dropped by a philosopher: 'If you are serious about promoting health as efTectively as you can, do not go into medicine'. Unfortunately the extortionate price will preclude a wide sale on this side of the Atlantic, but it is a book that should be 'begged, borrowed or stolen'. WAR THOMsON Editorial Representative Open Section