The cultural crisis of modern medicine

253

Book reviews omission to convey a sense of separateness from the realm of clinical psychology. The handbook should appeal to a wide readership. It should be especially useful to those already directly or indirectly involved in the field of health psychology, identifying as it does particularly pressing problems within the area, including those with unusual potential for meaningful research. THOMAS E. HANLON Dep~urmrnt of Pswhiutrj, L’nicusiry of Morj,/trnd School of Medicine Baltimore. MD, L’.S.A.

Bioethics and Human Rights: A Reader for Health Prw fessionals, edited by ELSIF L. BANDMAN and BERTRAM BANDMAN. Little. Brown. Boston. IJ.S.A.. 1978. 386 pp. $10.95 This is an important book. for it brings together 53 articles on a wide range of topics which are of growing concern both to those directly involved in the delivery of health care services and to those concerned in a more general way with public health and well-being. No student of contemporary social movements who has followed the public debates involving civil rights as they apply to the rights of minorittes, women. children. prisoners. etc. can avoid having to deal with arguments based on the concept of moral rights. This collection of essays. contributed by professionals and scholars m a variety of disciplines, is intended to help one to understand and evaluate these kinds of arguments. Edited by a professor of nursing and a professor of philosophy. it offers both a theoretical and a practical orientation. Concentrating on moral rights in the area of bioethics, the volume discusses these topics: the rights of future generations (the moral issues in genetic counseling), the right to life (abortion), the right to prolong or terminate life (euthanasia). the rights of children and parents in a biomedical and social setting (including treatment or nontreatment of defective newborns). the rights of the aging. of the mentally ill. of prisoners. of patients and nurses, and the general right to health care. The book begins. appropriately. with some theoretical discussions of the concepts of rrghts. But the non-philosopher who tries to follow the rather detailed nature of the many distinctions drawn and the intricacies of the arguments and counter-arguments might find this first section disappointmg and confusing. Moreover, this section belies the nature of the remainder of the book. which is ouite readable and free of professional jargon. It is important to become familiar with the relationship between rights and duties and the analysis of rights in terms of claims. which is defended in the Joel Feinberg essay. and the dlstinction between option rights and welfare rights in its historical context. as presented in the essay by Martin Golding. But the needs of the general reader would have been better met by a good clear editors’ introduction laying out the different senses of rights and giving some analysis of the ways the notion has been used or can be used in argument. There are several topics covered in this volume which are of particular interest because they are fairly new or under-represented in the literature on rights. One of these is the rights of parents and children. In an article entitled. Prdrutrlc

Ir~rerc~r~~tiot~ Odds

(IW rhr

Parent

K~IOWS Best,

Deborah Michelle Sanders presents arguments for what she calls the “minimlst positlon”. i.e. the absolute right of parents to make medical decisions for a child, with intervention from the state on11 in life-threatening situations. She bases this right on the fundamental legal right of privacy within the family. but also appeals to the pragmatic cotsideration that parents know the individual needs of a child better than the courts. Florence Lieberman, Professor of social work. gives a general statement of the plight of

children who have special needs because of their environment, such as poverty or ill or abusing parents, and gives a description of the mis-match between social services available to these children and their needs and basic rights. There is also a brief but provocative article by Adele 0. Hofman, Professor of clinical pediatrics, on the right to consent and confidentiality in adolescent health care. Another topic very much under-represented in the literature is that bf the -rights of the elderly. ‘There are three short pieces in this section of the book. The first describes a home care program as an alternative to institutionalization; the second is a plea for restoring dignity to the aged; and onlv the third. bv Harrv Moodv. addresses the ethical question of whether dr not ii is righcto allocate health care resources on the basis of age. He argues that age may be considered a relevant factor. but he does not formulate principles by which to apply it. Moody has formulated the questions in the right way, and makes it clear that much more thinking needs to be devoted to resolving the very real problems of limited resources and seemingly unlimited need. There is an interesting section in the book on the medical structure and the problem of alienation. Departing from the focus on rights, three psychiatrists, Bernard J. Bergen, Jacob J. Lindenthal and Claudewell S. Thomas, describe not only the alienation felt by a patient toward the physician on whom he is dependent, but also the alienation of the physician felt toward the institution of medicine, itself. The authors see this as causally related to the focus of modern medicine on treating diseases instead of treating patients. Four essays on the role and rights of the nurse complete this section. It is good to see more direct attention given to the ethical problems in nursing than is usually offered in bioethics discussions. The editors have opted for comprehensiveness rather than depth in this volume, with the result that many of the articles seem quite short. The book is also provincial in one sense, for of the fifty-odd contributors, only about twelve are not now or recently located in the greater New York City area. This geographical provincialism may or may not have effected a provincialism in ideas as well. Department

~raron Norton,

of Philosophy

ROsALtND EKMAN LADD

College MA,

U.S.A.

The Cultaral Crisis of Modem Medicine, Edited by JOHN EHRENREICH. Monthly Review, NY, 1978. 300 pp. 95.95 In his film Annie Hull, Woody Allen retells the punchline from a story about a disappointed restaurant customer; “Not only was the food terrible, but the portions were so small!” This gag characterizes the so-called “radical cultural critique” of modern medicine as presented by John Ehrenreich in the introduction to this volume of thirteen essays on medicine and social issues. The claim is made that not only does medicine produce net negative effects on patients, but that too many people can’t gain access to it. The author compiles a list of grievances against modern medicine-e.g. that drugs have toxic as well as beneficial effects, that atherosclerosis and cancer continue to kill at an alarming rate, that addictions and psychosomatic illnesses are poorly treated by current approaches, that patients may become dependent on their doctors, that doctors tend to prefer to treat patients who pay their bills and so on. He asserts that unlike past critics who focused on the quantity of medical care available, he is now stressing the analysis of its quality. At one point, he sums up this critique as identifying that medical interventions are not “morally neutral, essentially benign and effective” but that they are “frequently useless and., often actually physically harmful”, that doctors often proffer advice based on value judgments not scientific evidence, and that doctor-patient relationships “are not mere technical relationships but

254

Book reviews

social relationships which express and reinforce. the social relations of the larger society”, These are all valid and important observations but they hardly qualify as new radical insights. nor do the individual observations sum to produce a consistent convincing argument that American medicine’s failures are the result of its capitalist roots. This criticism applies as well to the selection of essays in the remainder of the text. Individually many reveal detrimental social uses of medical practice+.g. as an arm of imperialism, or as the source of pseudo-biologic support for sexist values-but taken together the essays do not form a coherent statement about the existence. causes, or cures of “the cultural crisis of modern medicine”. Several of the most indicting essays deal with medicine’s role in defining normal and abnormal female biologic and social functions. The quantity of misinformation promulgated by physicians on the proper way for women to conceive, bear and raise children is impressive. In particular, several of the cited gynecology textbook quotes on female sex roles made me cringe. Nonetheless, most of the offenses noted occurred in decades past. Moreover, they resulted not from the mainstream of medical interest, i.e. objective disease, but from physicians pronouncements on issues about which they have no particular expertise, or at least no scientific data. Thus, while techniques for uncomplicated childbirth, and the value of breastfeeding are highly medicalized topics, precious little scientific data informs most debates about them. In this respect, Irving Zola’s essay “Medicine as an instrument of social control” is germane. We have to be very careful to avoid “medicalization” of decisions whose major components are not medical in nature. My reading of the prevailing current medical opinion is that physicians are, in fact. becoming more limited in the scope of their normative statements, and are more likely to restrict themselves to issues where scientific evidence exists. Heightened sensitivities of medical consumers encourages this view as well. The essay I found most interesting was E. R. Brown‘s “Public health in imperialism: Earlv Rockefeller nrograms . at home and abroad”, a study of Rockefeller Foundation support of research in tropical medicine. The author develops a compelling argument that Rockefeller programs to rid tropical areas of endemic disease were aimed at making these areas more hospitable to American economic exploitation. A domestic thrust of these programs was directed at hookworm in the American South. Apparently the parasite was known as the “lazy bug” because of the torpor associated with hookworm infection and the anemia it produced. Rockefeller and his lieutenants were convinced that hookworm eradication would increase southern workers‘ lagging productivity. Similar considerations led to Rockefeller support of the new schools of public health at Johns Hopkins and Harvard. In sum then, Ehrenreich’s volume does little to identify the systematic causes of medicine’s social ills. It does provide, however, a compendium of readable analyses and polemics about specific social and political consequences of medical practice. Y

Progrum Narcard Media! School Boston. MA, tl.S.A.

Kniser

DANIEL E. SINGER

The Mechanical Baby: A Popular History of the Theory aod Practice of Child Raising, by DANIEL BEEKMAN. Denms Dobson, London. 1977. 267 pp. f6.95 Introducing his book, Daniel Beekman writes that he began with a plan to examine the notion that the youthful unrest of the 1960’s resulted from the permissive child rearing practices advocated by Benjamin Speck. Fortunately for the reader, the author in his research came upon a richer and wider field of enquiry--the historical relationship between societal events and child rearing thoughts

and practices. The result is a well written, amply documented. and thought provoking survey of child rearing literature from the 15th century to the present. Much of the book is taken up with recounting the curious things which have been thought about and, in some cases, actuaily done to infants and young children through the ages. Bagellardo, a 15th century physician, suggests bathing in a broth of boiled pig or sheepheads as a treatment for convulsions. Both Rousseau and Locke considered icy baths to be excellent for the young child’s constitution. And lest the reader assume that such odd ideas and practices were restricted to the distant past, Beckman describes the aluminium mittens, cardboard cuffs. and metal thigh spreaders which were marketed this century as aids in the control of thumb-sucking and masturbation. The entertainment value of learning how our ancestors went about or, more accurately, were advised to go about raising their children is not be to underestimated. It is intriguing to find the parent of the late Middle Ages consulting expert advice on the selection of the wetnurse just as today’s parents seek expert advice on the selection of day care. However. it would be unfortunate if this book was viewed merely as an excursion through historical curiousities because Beekman also touches upon substantive points concerning the nature of child rearing advice. One such point is that child rearing advice is always a mixture of fact and fantasy. And a topic on which factual knowledge is lacking has historically invited the child-care writer to speculate. Thus. physicians during the Middle Ages could neither explain or treat common childhood complaints. As a result, a largely fanciful list of remedies was provided for each ailment. While scientific advances have reduced the scope for speculation regarding physical aspects of childhood, the expert’s tendency to fill factual vacuums with myths could still be discerned in advice on the psychological aspects of development. Thus, Watson’s recipe for the creation of genus appears every bit as fanciful and unlikely to suceed as Bagellardo’s treatment for convulsions. Equally. one can distinguish between Speck’s advice on caring for the feverish child. which is derived from clinical experience, and his advice on disciplme. which is largely ideological in character. Beekman also illustrates how a writer’s experience with children influences his or her advice to others. Rousseau. for instance, could write at length on the child and the noble savage without the impediments of having had much contact with either children or savages. The result was a theory of child rearing at best impractical and probably rather dangerous. The author repeatedly contrasts the advice of the phiiosopher. physician, and religious writer with that of women having direct experience of child rearing. From the 17th century midwife Caterina Schraders to Melesine Trench in the early 19th century to Elinor Smith in the 1950’s women exposed daily to the developing child have provided advice which counterbalances the musings of the philosopher, the theories of the physician, and the moral arguments of the minister. As Beeckman points out. a woman is more likely to appreciate that a parent cannot apply advice and depart before its consequences become evident. The author displays an occasional tendency for overstating his historical case, as in his suggestion that the 19th century writer Holt enjoyed wide acceptance because the rigid rearing practices he advised corresponded to parents’ wish to raise automatons to fil1 factories. This book should nevertheiess interest both the scholarly audience and those parents who are wondering whether and how to digest the mass of available advice on the care and maintenance of their children. Departmrtlt

of pediatrics

Center fbr Child Drcelopment Unirrrsit~ oj’ Miami Medical School

Mailman FL,

U.S.A.

R. H. Wooasn~