- Email: [email protected]
Confessions of a medicine man: an essay in popular philosophy
Book
237
reviews
consider surgery for children with epilepsy. There is no information in this text on the necessary components of a children’s epilepsy team. It would have been helpful to have had detailed examples from well-established centres. Tuxhorn and her co-editors have produced a wide-ranging exploration of subjects related to surgery in childhood epilepsy. These subjects are of importance to physicians. The contributions are of a high standard, with many relating to recent research. It is important that surgeons who treat seizure disorders in children are aware of the wider issues involved. They, too, will find much of interest and relevance here. SHEILA J WALLACE University
Hospital
of Wales, Cardif% UK
Current management in child neurology Edited by BL Maria Blackwell Science Ltd, Oxford, UK (Tel: +44 1865 206233; Fax: +44 1865 206026; email: [email protected]) l999,387pp, E84 ISBN: 1550090704 Paediatricians and family physicians need to be able to manage the problems of neurological diseases in children. Even when patients are referred to neurologists, it is vital that they have speedy access to diagnosis and treatment in order to plan and provide routine therapy at home and to offer support and understanding to the family. Maria’s book tries to answer these needs. The book begins with a section dealing with problems of paediatric and neurological training as well as health care in child neurology. The evolution of market-based health care reforms in the USA is critically considered in the first chapter and all the epidemiological aspects of child neurological diseases as well as child neurology training among paediatricians, neurologists and the primary care practitioner have been briefly analysed in the subsequent chapters. The contents are presented as an interesting and clear synthesis of the main issues. One limitation of this section is the dependence on USA-linked considerations of the problems shared by many developed Western countries. The second part, concerning clinical presentation in the outpatient setting represents the main philosophy of the text, i.e. to give the bulk of information quickly - a sort of rapid glimpse. The choice of topics includes all the main problems
of everyday primary care practice, such as hyperactivity disorders, learning problems, epileptic and non-epileptic paroxysmal events, developmental delay, behavioural disorders and other frequent clinical problems. Usually the topics are dealt with comprehensively even though coverage of subjects is sometimes inevitably uneven. The last section of the book is concerned with the hospitalized child, i.e. with patients who need admission for brain tumours, cerebrovascular diseases, and other emergency conditions. This section does not fit in very well with the proposed aim of the book; furthermore, some topics are not dealt with as thoroughly as they deserve. It provides general practitioners with a brief idea of what happens to their patients after admission to the hospital, but its usefulness is doubtful. Within the cited limits, this text gives up-to-date information about the more usual disorders of child neurology. The book, integrated with the support of an acompanying CD-ROM, provides a precious tool for busy primary care operators to help them to deal effectively with neurological disorders. F GUZZETTA Cattedra di Neuropsichiafrica Infantile, Universita Cattolica de/ Sacra Cuore, Facolfa di Medicina e Chirurgica ‘Agostino Gemelli’, Rome, Italy
Confessions of a Medicine Man: popular philosophy AI Tauber The MIT Press, London, UK 1999,15opp, 617.50 ISBN: 0262201143
an essay in
This is an important and timely, but for me ultimately a frustrating book. I have not come across this author’s work before, but in reading this book one comes to feel one knows him well. The motivation to write this book comes from Tauber’s passionate belief that Medicine is more than medical science, the mere application in humans of pathophysiological insights from genetics, physiology, microbiology and so on. Indeed he argues cogently that it is the move to the scientific, reductionist model that has driven medicine through this century, that has led to an erosion of the therapeutic relationship between doctor and patient. This in turn has led to the widespread disenchantment with medicine and its practitioners in recent years, as evidenced by rising litigation, and a return to ‘alternative’ therapies.
Book reviews
238
Tauber takes us back to the explicit debate that took place in American medicine and medical education at the turn of the century between reductionist medical scientists, inspired by the triumphs of the rapidly burgeoning science of physiology, and the clinicians of a ‘previous era’, notably Osler and Peabody. A quote from the latter sets the stage for this book: ‘It is easy to overlook the fact that the application of the principle of science to the diagnosis and treatment of disease is only one limited aspect of medical practice . . . One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient’. Historically, of course, the reductivists gained the ascendancy, and the era of laboratory-led medicine dawned. Understanding something of Tauber’s medical career illustrates his philosophical viewpoint. Some of the most enjoyable, poignant, and indeed powerful parts of the book are the autobiographical vignettes scattered throughout the text recalling encounters with patients, other professionals and friends-who-were-patients. These are glimpses of the real lives behind the medical science, such as the friend seeking Tauber’s advice on whether to participate in a clinical trial of a thrombolytic when he sustains his myocardial infarction (he dies of intracerebral haemorrhage). These vignettes reveal the author to be a humane and perceptive man, sensitive to the human behind the pathology, and they also enable us to understand his personal path from thrusting young laboratory-based clinical scientist to Professor of Philosophy. They also help illuminate his thesis, that medicine is fundamentally an ethical pursuit, that it is about relationships before it is about biology. Paediatric neurologists, more than most, might be expected to be aware of the primacy of relationships over mere medical science. We are regularly reminded of the impotence of our detailed understandings of the pathophysiology of a patient’s condition to effect change. We understand importance to the child, the parent and family of our relationships with them. I would like, therefore, to be able to recommend this book wholeheartedly to an audience likely to be more than sympathetic to its message. Unfortunately for me, however, the book is unbalanced. For together with the development of his thesis of the primacy of relationships (in all matters, but particularly medicine) he attempts a quick resume of Western philosophical debate on the concept of ‘self’, from
Locke to Nietzsche and Wittgenstein, before finally admitting that what he wants to talk about is in a sense beyond philosophy. It is a metaphysical statement of Value, that the Other matters. The book makes two key points. Firstly it points to the inadequacy of the concept of ‘autonomy’ in steering medical ethical decisions. This is a courageous, somewhat politically incorrect thing to say (as he says, the concepts of autonomy, beneficence, non-maleficence and justice have attained ‘near-Constitutional’ status). It also happens to be something I strongly agree with. ‘Autonomy’ says Tauber, in the context of medical decision making, ‘is a conceit’. Perhaps this is particularly evident again to us in paediatric practice. His argument is primarily from a philosophical standpoint (philosophers are not sure what the Self is, so autonomy looks a suspiciously flawed basis on which to build an ethics) although this will perhaps strike front-line clinicians as a little self-indulgent: the point is it rarely works from a practical point of view. More importantly he argues for the fundamental primacy of relationships in all we do. Again from a philosophical background, he argues that Self is only meaningfully defined in terms of Other, or from a practical point of view that we define ourselves in relationship with others. Again, this is a profound point, and it is disappointing to see that when this crucial point is reached, and one is eager to see how this might begin to work out in practice, the book ends. I would have preferred to have been spared the tutorial on the history of philosophy, which is sometimes densely written with considerable technical language, and to have Tauber begin to expand on some of the implications of such an Ethic. This book contains an important message, somewhat hidden in a demanding text. It has been gratifying to find someone articulate some of my own unspoken feelings about the practice of medicine at the end of the twentieth century, and I will look out with interest for further writings by Tauber. For although he bills this as written for a general audience, I do not think this is the definitive account of his insights and beliefs. I look forward one day to reading it. ROB FORSYTH Department University
of Paediatric Neurology, of Newcastle upon Tyne, Newcastle upon Tyne, UK
237
reviews
consider surgery for children with epilepsy. There is no information in this text on the necessary components of a children’s epilepsy team. It would have been helpful to have had detailed examples from well-established centres. Tuxhorn and her co-editors have produced a wide-ranging exploration of subjects related to surgery in childhood epilepsy. These subjects are of importance to physicians. The contributions are of a high standard, with many relating to recent research. It is important that surgeons who treat seizure disorders in children are aware of the wider issues involved. They, too, will find much of interest and relevance here. SHEILA J WALLACE University
Hospital
of Wales, Cardif% UK
Current management in child neurology Edited by BL Maria Blackwell Science Ltd, Oxford, UK (Tel: +44 1865 206233; Fax: +44 1865 206026; email: [email protected]) l999,387pp, E84 ISBN: 1550090704 Paediatricians and family physicians need to be able to manage the problems of neurological diseases in children. Even when patients are referred to neurologists, it is vital that they have speedy access to diagnosis and treatment in order to plan and provide routine therapy at home and to offer support and understanding to the family. Maria’s book tries to answer these needs. The book begins with a section dealing with problems of paediatric and neurological training as well as health care in child neurology. The evolution of market-based health care reforms in the USA is critically considered in the first chapter and all the epidemiological aspects of child neurological diseases as well as child neurology training among paediatricians, neurologists and the primary care practitioner have been briefly analysed in the subsequent chapters. The contents are presented as an interesting and clear synthesis of the main issues. One limitation of this section is the dependence on USA-linked considerations of the problems shared by many developed Western countries. The second part, concerning clinical presentation in the outpatient setting represents the main philosophy of the text, i.e. to give the bulk of information quickly - a sort of rapid glimpse. The choice of topics includes all the main problems
of everyday primary care practice, such as hyperactivity disorders, learning problems, epileptic and non-epileptic paroxysmal events, developmental delay, behavioural disorders and other frequent clinical problems. Usually the topics are dealt with comprehensively even though coverage of subjects is sometimes inevitably uneven. The last section of the book is concerned with the hospitalized child, i.e. with patients who need admission for brain tumours, cerebrovascular diseases, and other emergency conditions. This section does not fit in very well with the proposed aim of the book; furthermore, some topics are not dealt with as thoroughly as they deserve. It provides general practitioners with a brief idea of what happens to their patients after admission to the hospital, but its usefulness is doubtful. Within the cited limits, this text gives up-to-date information about the more usual disorders of child neurology. The book, integrated with the support of an acompanying CD-ROM, provides a precious tool for busy primary care operators to help them to deal effectively with neurological disorders. F GUZZETTA Cattedra di Neuropsichiafrica Infantile, Universita Cattolica de/ Sacra Cuore, Facolfa di Medicina e Chirurgica ‘Agostino Gemelli’, Rome, Italy
Confessions of a Medicine Man: popular philosophy AI Tauber The MIT Press, London, UK 1999,15opp, 617.50 ISBN: 0262201143
an essay in
This is an important and timely, but for me ultimately a frustrating book. I have not come across this author’s work before, but in reading this book one comes to feel one knows him well. The motivation to write this book comes from Tauber’s passionate belief that Medicine is more than medical science, the mere application in humans of pathophysiological insights from genetics, physiology, microbiology and so on. Indeed he argues cogently that it is the move to the scientific, reductionist model that has driven medicine through this century, that has led to an erosion of the therapeutic relationship between doctor and patient. This in turn has led to the widespread disenchantment with medicine and its practitioners in recent years, as evidenced by rising litigation, and a return to ‘alternative’ therapies.
Book reviews
238
Tauber takes us back to the explicit debate that took place in American medicine and medical education at the turn of the century between reductionist medical scientists, inspired by the triumphs of the rapidly burgeoning science of physiology, and the clinicians of a ‘previous era’, notably Osler and Peabody. A quote from the latter sets the stage for this book: ‘It is easy to overlook the fact that the application of the principle of science to the diagnosis and treatment of disease is only one limited aspect of medical practice . . . One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient’. Historically, of course, the reductivists gained the ascendancy, and the era of laboratory-led medicine dawned. Understanding something of Tauber’s medical career illustrates his philosophical viewpoint. Some of the most enjoyable, poignant, and indeed powerful parts of the book are the autobiographical vignettes scattered throughout the text recalling encounters with patients, other professionals and friends-who-were-patients. These are glimpses of the real lives behind the medical science, such as the friend seeking Tauber’s advice on whether to participate in a clinical trial of a thrombolytic when he sustains his myocardial infarction (he dies of intracerebral haemorrhage). These vignettes reveal the author to be a humane and perceptive man, sensitive to the human behind the pathology, and they also enable us to understand his personal path from thrusting young laboratory-based clinical scientist to Professor of Philosophy. They also help illuminate his thesis, that medicine is fundamentally an ethical pursuit, that it is about relationships before it is about biology. Paediatric neurologists, more than most, might be expected to be aware of the primacy of relationships over mere medical science. We are regularly reminded of the impotence of our detailed understandings of the pathophysiology of a patient’s condition to effect change. We understand importance to the child, the parent and family of our relationships with them. I would like, therefore, to be able to recommend this book wholeheartedly to an audience likely to be more than sympathetic to its message. Unfortunately for me, however, the book is unbalanced. For together with the development of his thesis of the primacy of relationships (in all matters, but particularly medicine) he attempts a quick resume of Western philosophical debate on the concept of ‘self’, from
Locke to Nietzsche and Wittgenstein, before finally admitting that what he wants to talk about is in a sense beyond philosophy. It is a metaphysical statement of Value, that the Other matters. The book makes two key points. Firstly it points to the inadequacy of the concept of ‘autonomy’ in steering medical ethical decisions. This is a courageous, somewhat politically incorrect thing to say (as he says, the concepts of autonomy, beneficence, non-maleficence and justice have attained ‘near-Constitutional’ status). It also happens to be something I strongly agree with. ‘Autonomy’ says Tauber, in the context of medical decision making, ‘is a conceit’. Perhaps this is particularly evident again to us in paediatric practice. His argument is primarily from a philosophical standpoint (philosophers are not sure what the Self is, so autonomy looks a suspiciously flawed basis on which to build an ethics) although this will perhaps strike front-line clinicians as a little self-indulgent: the point is it rarely works from a practical point of view. More importantly he argues for the fundamental primacy of relationships in all we do. Again from a philosophical background, he argues that Self is only meaningfully defined in terms of Other, or from a practical point of view that we define ourselves in relationship with others. Again, this is a profound point, and it is disappointing to see that when this crucial point is reached, and one is eager to see how this might begin to work out in practice, the book ends. I would have preferred to have been spared the tutorial on the history of philosophy, which is sometimes densely written with considerable technical language, and to have Tauber begin to expand on some of the implications of such an Ethic. This book contains an important message, somewhat hidden in a demanding text. It has been gratifying to find someone articulate some of my own unspoken feelings about the practice of medicine at the end of the twentieth century, and I will look out with interest for further writings by Tauber. For although he bills this as written for a general audience, I do not think this is the definitive account of his insights and beliefs. I look forward one day to reading it. ROB FORSYTH Department University
of Paediatric Neurology, of Newcastle upon Tyne, Newcastle upon Tyne, UK