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A mesmerising tale
The role of autonomy in bioethics Autonomy and Trust in Bioethics Onora O’Neill. Cambridge: Cambridge University Press, 2002. Pp 213. £14.95. ISBN 0 521 89453 0. n this year’s Reith lectures in the UK, philosopher Onora O’Neill discussed the loss of public trust in governments, scientists, and institutions. She returns to the topic in her latest book Autonomy and Trust in Bioethics. We increasingly devolve responsibility for decision-making to others, but we also have an increasing responsibility for our part in society—does all this mean a loss of autonomy? O’Neill argues that the complexity of modern medicine makes it difficult for patients to be fully informed. At the same time, publichealth issues make greater inroads into individual autonomy. In the first part of the book O’Neill discusses autonomy and choice, and re-evaluates the philosophies espoused by John Stuart Mill and Immanuel Kant. The first three chapters have clear clinical relevance, but it has to be said that the chapter on why poor Kant has been so misunderstood is hard going. O’Neill goes on to explore the implications of the choices patients make,
I
especially in relation to new reproductive technologies. She asks if trusting others (who might be better informed) is relinquishing autonomy, and then suggests that patients really have no autonomy but merely a choice between treatments or between treatment and no treatment. O’Neill moves on to discuss lack of consent when harm might be done to others: issues such as HIV testing and the effect that refusing (mass) immunisation could have on others in the population. The issue of consumerism in medicine is also addressed. A chapter on reproductive technologies covers oral contraceptives, abortion, in-vitro fertilisation, cloning, and germ line treatments. Fertile ground for ethical discussion, but O’Neill is restrained and limits herself to discussing choice and liberty (autonomy). She addresses individual freedoms (with oral contraceptives and abortion) and the limitations that Mill would endorse when another party is involved (eg, a child resulting from in-vitro fertilisation).
A mesmerising tale Hidden Depths: the Story of Hypnosis Robin Waterfield. London: Pan Macmillan, 2002. Pp 464. £20.00. ISBN 0333779495. ypnotism has had a long and chequered history with trance states dating back to the ancient world, although its first systematic incarnation was in Vienna and Paris in the late 18th century under Franz Anton Mesmer. He proposed a theory of a fluid flowing from mesmerist to patient, which could rearrange a person’s internal structure like a magnet on iron filings. Waterfield’s book describes in vivid detail the development of mesmerism in France, where it was so popular that Mesmer treated whole groups of people at one sitting. When the mesmeric craze spread to England in the 1830s, it was first used
H
1992
in the London teaching hospitals, most notoriously at University College Hospital under John Elliotson. He was so dazzled by the wonders of this “new science” that he displayed his mesmeric patients, usually young working-class girls suffering from fits, to huge audiences of medical men, politicians, aristocrats, and literary men such as Dickens. The editor of The Lancet, Thomas Wakley, was a friend of Elliotson, and for months in 1837–38 the journal reported his mesmeric experiments in lurid detail until Wakley became suspicious and exposed Elliotson’s pet patients as frauds. It was a Manchester doctor, James
The issue of responsibility for others comes up again, as principled autonomy, in her discussion of genetic data; balancing an individual’s right to know about genetic disposition, and the right of close relatives to not know if they so choose. But the lengthy discussion on DNA analysis and insurance is somewhat laboured. The currently fashionable idea of audits is given an airing. The use of audits is an attempt to improve trustworthiness—especially in the aftermath of crises, such as bovine spongiform encephalopathy and genetically modified organisms—but O’Neill argues that such an approach could be counterproductive. This issue leads on to the Cassandra problem—where mistrust is overprevalent to the extent that it is unjustified—and she examines ways in which this problem can be overcome. For some, O’Neill’s book will be too hard going to warrant ploughing through for the new slants it provides. I found that it fell unsatisfactorily between being a philosophical work and a more practical guide to biomedical issues. Stuart Spencer The Lancet, London, UK
Braid, who realised that no external force was involved, renaming mesmerism as “hypnotism”, but the medical establishment had by then washed its hands of a topic too close to mysticism for a profession eager to divest itself of the taint of quackery. Despite the antagonism of doctors, mesmeric anaesthesia was just beginning to be taken seriously when, in 1846, ether was first used, causing the British surgeon Robert Liston to declare, “Gentlemen, this Yankee dodge beats mesmerism hollow!” At the end of the 19th century, the French doctors Auguste Liébeault and Hippolyte Bernheim refined Braid’s ideas on suggestion and laid the foundations of modern hypnotherapy, using it to treat physical and psychological disorders. Freud was a passionate advocate of hypnotism and Waterfield blames his abandonment of it for its marginalisation as a psychotherapeutic tool in the 20th
THE LANCET • Vol 360 • December 14, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
DISSECTING ROOM
century. Since 1960 there has been much academic interest in hypnosis, mostly revolving around the debate over whether it is a dissociative state— the “hidden observer” described by Ernest Hilgard—or whether it is merely a heightened state of suggestibility. Hypnosis is still so controversial that two major scientific journals rejected Kosslyn and Thompson’s paper on colour perception, which suggested that hypnosis alters brain activity so that a hypnotised person sees colour where
none exists (published in the American Journal of Psychiatry in August, 2001). In later sections of the book Waterfield loses his way in discussions of psychic powers, regression, memory recovery (accurately seen as a dangerous path to tread), and New Age practices. I was surprised to learn of the application of hypnotism in specialties as diverse as pain relief in cancer, burns, childbirth, nausea in chemotherapy, and tinnitus. The final chapter is a plea for hypnotism to receive the serious attention of
medical science. Waterfield calls for more evidence of its current status, such as how many health professionals are qualified in clinical hypnosis and where the dedicated hypnotherapy units are, as well as evidence of its drawbacks. Hypnosis has a colourful history and Waterfield tells a remarkable tale, but he is unlikely to make many converts. Sue Kinder School of History, Classics and Archaelogy, Birkbeck College, London WC1E 7HX, UK
A surgeon’s art
Tonks’s ability to combine medical knowledge with a sense of poetry is Henry Tonks: Art and Surgery best conveyed in the series of drawings An exhibition at The College Art Collections, The Strang Print Room, he made during World War I, while University College, London, UK, showing until March 28, 2003. attached to Harold Gillies’s plastic surgery unit in 1916–17. There Tonks natomical drawing was at one drew diagrams for planning stages of since Brown offered the post of time considered essential for operations to soldiers’ facial wounds, assistant to Tonks on his appointment both medical and art students, also recording the men before and after as Slade Professor. Tonks went on to and while many exhibitions have recovery. In letters, Tonks describes teach drawing at the Slade for 38 years, explored the role of artists illustrating these wounded men as “a chamber of from 1892 to 1930. His method of anatomy, it is rare to find much horrors” but he is, nonetheless, “quite teaching owed much to that of Brown, acknowledgment of doctors’ content to draw them as it is exceldraughtsmanship in the history of lent practice”. Elsewhere he more medical training. It is, therefore, sensitively refers to “rather fine fascinating to have this opportunity fragments”—meaning both his to review the work of Henry Tonks drawings and his subjects—com(1862–1936), whose training as a paring a wounded soldier with a surgeon indisputably informed his damaged statue of a Greek hero. work as an artist. He generally chose pastel for these In 1880, when he was 18 years drawings, in preference to the old, Tonks began medical training more commonly used watercolour, at the Royal Sussex County and in contrast with his diagrams Hospital, Brighton, moving on in pen and ink. The soft, smudgy to The London Hospital in 1881. texture of his pastels vividly He diligently pursued studies in and accurately records horrific anatomy, discovering an “absorbdisfigurements, while also proving ing passion” for documenting the sympathetic—largely via sensitive human form, and its parts, in attention to the eyes of his sitters— death. A passion that, early in to the effect on the men of their his career, sometimes extended to experiences. The opportunity to bribing a hospital postmortem view these essentially private porter to display a corpse specially records, alongside clinical photofor him, to help with his study. The graphs and case notes, brings exhibition catalogue includes an haunting insight into the history of early pencil sketch of the London World War I, while providing a Hospital Dissecting Room, dated thought-provoking overview of 1885, that shows a receding line Portrait of a wounded soldier before treatment (1917) comparative forms of record, both of trestle tables and dissected objective and subjective. paying close attention to the model and figures with bandaged legs: some The exhibition includes drawings for careful study of old master drawings, recumbent, others stood leaning over a commission of a large World War I but allied with an indepth understanding the end of the table. memorial painting, and conversation of underlying anatomy. Tonks’s clinical A year after making this drawing, pieces of Tonks’s friends. In the accuracy became increasingly augTonks became house surgeon at the memorial, Tonks concentrates on epic mented by the development of his London Hospital. 2 years later, he composition and heroism; the conversabecame a fellow of the Royal College of intuitive response to his subjects, leading tion pieces are warm, intimate studies, Surgeons, and also joined Westminster him to comment that, while “Being sometimes teetering on caricature. School of Art, where Frederick Brown steeped in anatomy” is invaluable to a Throughout, there is a sense of a comproved an influential teacher. Tonks draughtsman, “You need to be a poet plex balancing act between detachment saw that his own practical knowledge of to produce a beautiful drawing, and that and intuition: requirements, in their own anatomy could be greatly informed by no man can impart to another man.” ways, of both artist and surgeon. Tonks’s highly developed abilities in attention to Brown’s complementary Jane Wildgoose approach as an artist. Respect between both areas led him to become an c/o The Lancet, London, UK pupil and teacher was clearly mutual, important and inspiring teacher. The College Art Collections UCL EDC 2800
A
THE LANCET • Vol 360 • December 14, 2002 • www.thelancet.com
1993
For personal use. Only reproduce with permission from The Lancet Publishing Group.
I
especially in relation to new reproductive technologies. She asks if trusting others (who might be better informed) is relinquishing autonomy, and then suggests that patients really have no autonomy but merely a choice between treatments or between treatment and no treatment. O’Neill moves on to discuss lack of consent when harm might be done to others: issues such as HIV testing and the effect that refusing (mass) immunisation could have on others in the population. The issue of consumerism in medicine is also addressed. A chapter on reproductive technologies covers oral contraceptives, abortion, in-vitro fertilisation, cloning, and germ line treatments. Fertile ground for ethical discussion, but O’Neill is restrained and limits herself to discussing choice and liberty (autonomy). She addresses individual freedoms (with oral contraceptives and abortion) and the limitations that Mill would endorse when another party is involved (eg, a child resulting from in-vitro fertilisation).
A mesmerising tale Hidden Depths: the Story of Hypnosis Robin Waterfield. London: Pan Macmillan, 2002. Pp 464. £20.00. ISBN 0333779495. ypnotism has had a long and chequered history with trance states dating back to the ancient world, although its first systematic incarnation was in Vienna and Paris in the late 18th century under Franz Anton Mesmer. He proposed a theory of a fluid flowing from mesmerist to patient, which could rearrange a person’s internal structure like a magnet on iron filings. Waterfield’s book describes in vivid detail the development of mesmerism in France, where it was so popular that Mesmer treated whole groups of people at one sitting. When the mesmeric craze spread to England in the 1830s, it was first used
H
1992
in the London teaching hospitals, most notoriously at University College Hospital under John Elliotson. He was so dazzled by the wonders of this “new science” that he displayed his mesmeric patients, usually young working-class girls suffering from fits, to huge audiences of medical men, politicians, aristocrats, and literary men such as Dickens. The editor of The Lancet, Thomas Wakley, was a friend of Elliotson, and for months in 1837–38 the journal reported his mesmeric experiments in lurid detail until Wakley became suspicious and exposed Elliotson’s pet patients as frauds. It was a Manchester doctor, James
The issue of responsibility for others comes up again, as principled autonomy, in her discussion of genetic data; balancing an individual’s right to know about genetic disposition, and the right of close relatives to not know if they so choose. But the lengthy discussion on DNA analysis and insurance is somewhat laboured. The currently fashionable idea of audits is given an airing. The use of audits is an attempt to improve trustworthiness—especially in the aftermath of crises, such as bovine spongiform encephalopathy and genetically modified organisms—but O’Neill argues that such an approach could be counterproductive. This issue leads on to the Cassandra problem—where mistrust is overprevalent to the extent that it is unjustified—and she examines ways in which this problem can be overcome. For some, O’Neill’s book will be too hard going to warrant ploughing through for the new slants it provides. I found that it fell unsatisfactorily between being a philosophical work and a more practical guide to biomedical issues. Stuart Spencer The Lancet, London, UK
Braid, who realised that no external force was involved, renaming mesmerism as “hypnotism”, but the medical establishment had by then washed its hands of a topic too close to mysticism for a profession eager to divest itself of the taint of quackery. Despite the antagonism of doctors, mesmeric anaesthesia was just beginning to be taken seriously when, in 1846, ether was first used, causing the British surgeon Robert Liston to declare, “Gentlemen, this Yankee dodge beats mesmerism hollow!” At the end of the 19th century, the French doctors Auguste Liébeault and Hippolyte Bernheim refined Braid’s ideas on suggestion and laid the foundations of modern hypnotherapy, using it to treat physical and psychological disorders. Freud was a passionate advocate of hypnotism and Waterfield blames his abandonment of it for its marginalisation as a psychotherapeutic tool in the 20th
THE LANCET • Vol 360 • December 14, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
DISSECTING ROOM
century. Since 1960 there has been much academic interest in hypnosis, mostly revolving around the debate over whether it is a dissociative state— the “hidden observer” described by Ernest Hilgard—or whether it is merely a heightened state of suggestibility. Hypnosis is still so controversial that two major scientific journals rejected Kosslyn and Thompson’s paper on colour perception, which suggested that hypnosis alters brain activity so that a hypnotised person sees colour where
none exists (published in the American Journal of Psychiatry in August, 2001). In later sections of the book Waterfield loses his way in discussions of psychic powers, regression, memory recovery (accurately seen as a dangerous path to tread), and New Age practices. I was surprised to learn of the application of hypnotism in specialties as diverse as pain relief in cancer, burns, childbirth, nausea in chemotherapy, and tinnitus. The final chapter is a plea for hypnotism to receive the serious attention of
medical science. Waterfield calls for more evidence of its current status, such as how many health professionals are qualified in clinical hypnosis and where the dedicated hypnotherapy units are, as well as evidence of its drawbacks. Hypnosis has a colourful history and Waterfield tells a remarkable tale, but he is unlikely to make many converts. Sue Kinder School of History, Classics and Archaelogy, Birkbeck College, London WC1E 7HX, UK
A surgeon’s art
Tonks’s ability to combine medical knowledge with a sense of poetry is Henry Tonks: Art and Surgery best conveyed in the series of drawings An exhibition at The College Art Collections, The Strang Print Room, he made during World War I, while University College, London, UK, showing until March 28, 2003. attached to Harold Gillies’s plastic surgery unit in 1916–17. There Tonks natomical drawing was at one drew diagrams for planning stages of since Brown offered the post of time considered essential for operations to soldiers’ facial wounds, assistant to Tonks on his appointment both medical and art students, also recording the men before and after as Slade Professor. Tonks went on to and while many exhibitions have recovery. In letters, Tonks describes teach drawing at the Slade for 38 years, explored the role of artists illustrating these wounded men as “a chamber of from 1892 to 1930. His method of anatomy, it is rare to find much horrors” but he is, nonetheless, “quite teaching owed much to that of Brown, acknowledgment of doctors’ content to draw them as it is exceldraughtsmanship in the history of lent practice”. Elsewhere he more medical training. It is, therefore, sensitively refers to “rather fine fascinating to have this opportunity fragments”—meaning both his to review the work of Henry Tonks drawings and his subjects—com(1862–1936), whose training as a paring a wounded soldier with a surgeon indisputably informed his damaged statue of a Greek hero. work as an artist. He generally chose pastel for these In 1880, when he was 18 years drawings, in preference to the old, Tonks began medical training more commonly used watercolour, at the Royal Sussex County and in contrast with his diagrams Hospital, Brighton, moving on in pen and ink. The soft, smudgy to The London Hospital in 1881. texture of his pastels vividly He diligently pursued studies in and accurately records horrific anatomy, discovering an “absorbdisfigurements, while also proving ing passion” for documenting the sympathetic—largely via sensitive human form, and its parts, in attention to the eyes of his sitters— death. A passion that, early in to the effect on the men of their his career, sometimes extended to experiences. The opportunity to bribing a hospital postmortem view these essentially private porter to display a corpse specially records, alongside clinical photofor him, to help with his study. The graphs and case notes, brings exhibition catalogue includes an haunting insight into the history of early pencil sketch of the London World War I, while providing a Hospital Dissecting Room, dated thought-provoking overview of 1885, that shows a receding line Portrait of a wounded soldier before treatment (1917) comparative forms of record, both of trestle tables and dissected objective and subjective. paying close attention to the model and figures with bandaged legs: some The exhibition includes drawings for careful study of old master drawings, recumbent, others stood leaning over a commission of a large World War I but allied with an indepth understanding the end of the table. memorial painting, and conversation of underlying anatomy. Tonks’s clinical A year after making this drawing, pieces of Tonks’s friends. In the accuracy became increasingly augTonks became house surgeon at the memorial, Tonks concentrates on epic mented by the development of his London Hospital. 2 years later, he composition and heroism; the conversabecame a fellow of the Royal College of intuitive response to his subjects, leading tion pieces are warm, intimate studies, Surgeons, and also joined Westminster him to comment that, while “Being sometimes teetering on caricature. School of Art, where Frederick Brown steeped in anatomy” is invaluable to a Throughout, there is a sense of a comproved an influential teacher. Tonks draughtsman, “You need to be a poet plex balancing act between detachment saw that his own practical knowledge of to produce a beautiful drawing, and that and intuition: requirements, in their own anatomy could be greatly informed by no man can impart to another man.” ways, of both artist and surgeon. Tonks’s highly developed abilities in attention to Brown’s complementary Jane Wildgoose approach as an artist. Respect between both areas led him to become an c/o The Lancet, London, UK pupil and teacher was clearly mutual, important and inspiring teacher. The College Art Collections UCL EDC 2800
A
THE LANCET • Vol 360 • December 14, 2002 • www.thelancet.com
1993
For personal use. Only reproduce with permission from The Lancet Publishing Group.