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Jungle law
THE LANCET
Themes and Variations: Sleep An exhibition at the National Gallery, Trafalgar Square, London. Showing until Sept 14, 1997. Admission free. leep is the fourth in the series of vulnerability, peace, dreams, and, of Sunley Room exhibitions, course, sex. Before entering the exhibition, literThemes and Variations, preary associations loom large and bold in sented by the National Gallery, the form of poetic and other references London. Each exhibition displays to sleep projected onto the walls. The together paintings of different periods onlooker is also diagrammatically and styles chosen from the Gallery’s collection so as to examine a specific theme or subject in art. In particular, the onlooker is invited to view familiar images in an unfamiliar way. There are 30 paintings from the 14th to the 19th century, almost exclusively by Italian, Dutch, and French artists. Each of six sections deals with the portrayal of the sleeping figure through the ages. Some of the visual associations of sleep are obvious and predictable: death, sloth, The Agony in the Garden (detail), attributed to Lo Spagna
S
Jungle law Health Care Law Jonathan Montgomery. Oxford: Clarendon Press. 1997. £19.99.Pp 476. ISBN 0-19-876259-3
ritish law is not just an ass . . . sometimes. Parts of it are a menagerie; occasionally it is a circus for passing fancies—such as the Dangerous Dogs Act (now amended). Parts are proliferous. Cultivated gardens vie with what the late American jurist Karl Llewellyn called the “bramble bush” of law. Add the growth of regulation in the post-war period and we have what Bernard Knight referred to in his first edition of Legal Aspects of Medical Practice in 1971 as “the ever-thickening jungle”. Thus guides with a good eye for clearing(s) and a sense of orientation are badly needed. Early explorers at the confluence of medicine and law in Britain, such as Kennedy, Skegg, and McLean, mapped what they saw as the key features: issues surrounding consent, con-
B
374
fidentiality, and medical negligence. With the exception of Finch’s Health Services Law (1981) the farther reaches of health-care regulation remained unexplored. Jonathan Montgomery, an academic lawyer with experience in the health service, has cut pathways through the jungle. He has created in the past 10 years vantage points from which to get a better sense of the legal environment, framing perspective through existing sociological insights and informed with empirical findings. In Health Care Law he explores beyond the boundaries of much medicolegal study by including a guide to the regulatory structure of health care in England and Wales. He clarifies the complexity of legislation, case-law, and quasi-law affecting the
guided through some of the principles of symbolic representation in art, for example, how to perceive a slothful person—asleep, with head in hand. The first section, “Peaceful Sleep”, has a pleasantly surprising lack of postprandial babies replete with pleasure. Instead, 17th century paintings idealise the pastoral life as an antithesis to early industrialisation, yet also moralise by depicting the herdsmen, in the nowknown position of the slothful one, asleep with head in hand. And of course, there is the association between peaceful sleep, death, and redemption: an elderly woman asleep in her chair, bible displayed, with Lenten meal of bread and fish on the table (no wine, for as we shall learn later, that symbolises something else)—on her one side, a burning fire, and on the other a painting on the wall depicting original sin. Section 2, “The Observed Sleeper” deals with conscious and unconscious displays of sex and sexuality. The female of the species doesn’t do too well in National Gallery, London
And so to sleep . . . perchance?
National Health Service. He describes and discusses with refreshing lucidity the range of areas traditionally covered in medical law texts: consent, confidentiality, complaints procedures; access to records; mental health; research; abortion; fertility; transplantation; and euthanasia. He adds original discussion of community and maternity care, rights to health care, and medicines. Montgomery not only helps the reader see large parts of the wood from the proliferating trees but also illuminates the tangle of reasoning and knotty problems that arise in areas such as consent and confidentiality for minors, selective non-treatment of babies, and withdrawal of treatment for adults. While he moves beyond the fixation in many medicolegal courses and texts on the doctor, a wider focus including nurses and midwives underplays the preponderant influence of a range of other professionals on health care, including dentists, health visitors, pharmacists, therapists, and dieticians. A number of key features in the
Vol 350 • August 2, 1997
THE LANCET
Mantegna’s version of Samson and Delilah. Here, we have an unusually diminutive Samson with graffiti carved in the nearby tree that translates, “a bad woman is threepence worse than the devil”. Reubens’ version of the same tale is, apart from anything else, a magnificent painting worth seeing in its own right, and thankfully more complex. With a mixture of triumph and tenderness, Delilah holds the sleeping (and implicitly postcoital) Samson as his hair is shorn, overseen by a blindfolded Cupid, with the Philistines waiting in the wings. In Botticelli’s Venus and Mars the power of the dressed (and therefore armoured) Venus is pretty tame and justifiable. War vanquished by Love and all that. In Reubens’ painting, however, not only is the common perception of that time—namely, that sexual intercourse invigorated the woman and exhausted the man—evident, but also insult is added to injury by Delilah’s impending betrayal. At the other end of the spectrum, there is Metsu’s woman in a drunken stupor. The symbolism here is rather crude (in all senses): man holds wine jug with suggestive spout, woman holds empty glass, bed looms large in background. Caricature, really. Redemption is found in Courbet’s interesting painting that caused moral indignation (among men) when it did the Parisian Salon circuit: it shows young ladies (allegedly prostitutes) on
development of law and health care emerge from Montgomery’s book: the increasing use of applications for judicial review of administrative decision; the swell of lay representation in complaints procedures; and the cre-
Vol 350 • August 2, 1997
the bank of the Seine, feigning sleep (deception, availability), partly dressed (invitation), and prone (defenceless, a lure). An odd choice of subject for that time, especially since contemporary women were becoming increasingly powerful economically and, at least vocally, active politically. Sections 3–6 are more predictable and mundane: “Sleep and Death: The Sleeping Christ Child”, “Negligence and Weakness”, “Sleep as Sin”, and “Dreams and Visions”. Negligence and sin could have been combined and the seemingly interminable versions of the Agony in the Garden could have been reduced to one painting to easily make the point. Overall, the choice of paintings cannot be said to lack range, style, calibre, or intrinsic interest, but the lessons of symbolism in art are at times overworked to the extent that they occasionally detract from seeing the paintings as a whole. And although there is an attempt to place the exhibition in literary perspective, more could have been done to illustrate the contemporary sociopolitical backgrounds. Despite the needs of a school-age audience, there is room to up the ante, even a little bit. Gabrielle Murphy 8–9 Long Acre, Covent Garden, London WC2E 9LH, UK.
ation of regulatory structures for professions such as osteopathy and chiropractic. New varieties of legislation, for instance to deal with medically assisted conception and embryo experimentation, have created international interest. Yet, at judicial level the UK reflects an enduring deference to clinical judgment which is at odds with pro-patient developments in other parts of the Commonwealth and the USA. There has been a surge in what Montgomery calls “quasi-law”; that body of administrative circulars, professional, and institutional guidelines, and norms that govern health care. Secondary legislation has burgeoned. Recent social and political shifts such as the move to a marketoriented health service and community care are reflected in large bodies
Books in brief A shock to the system Heat shock proteins have been implicated in various cardiovascular disorders, including ischaemia, hypertrophy, and atherosclerosis. This book provides an overview of the current understanding of heat shock proteins in the cardiovascular system and summarises the approaches to the study of these proteins in the heart. (Heat Shock Proteins and the Cardiovascular System. Edited by Anne A Knowlton. Dordrecht: Kluwer Academic Publishers. 1997. Pp 225. £85.25. ISBN 0-7923-9910-2.) A practical view Anal endosonography is a relatively straightforward technique for the investigation of disorders of the anal canal and sphincters. As this manual shows, it can be done on an outpatient basis. The book, illustrated with over 70 endosonographs, assumes no previous knowledge of the procedure, highlights various clinical features, and compares them with normal anatomy. (Handbook of Anal Endosonography. Clive I Bartram, Andrea Frudinger. Petersfield, UK: Wrightson Biomedical. 1997. Pp 79. £24.50. ISBN 1-871816-35-1.)
of legislation, executive and professional rules, and, inevitably, litigation. Health-care law is dynamic. Since Montgomery’s book was written, the National Health Service (Primary Care) Act 1997, for example, allows health authorities to end general practitioners’ monopoly of primary care provision. The European Convention on Biomedicine and Human Rights and European Union initiatives will further affect domestic law. Health Care Law maps the terrain and trends well. It is a thorough, informed, and wide-ranging presentation and commentary on most aspects of English law regarding health care and medicine. Montgomery achieves his objective of explaining the law clearly to an intended audience of lawyers, and students or practitioners of medicine and other health-care professions. The jungle seems less forbidding.
Dermot Feenan 90 Eglantine Avenue, Belfast BT9 6EU, UK
375
Themes and Variations: Sleep An exhibition at the National Gallery, Trafalgar Square, London. Showing until Sept 14, 1997. Admission free. leep is the fourth in the series of vulnerability, peace, dreams, and, of Sunley Room exhibitions, course, sex. Before entering the exhibition, literThemes and Variations, preary associations loom large and bold in sented by the National Gallery, the form of poetic and other references London. Each exhibition displays to sleep projected onto the walls. The together paintings of different periods onlooker is also diagrammatically and styles chosen from the Gallery’s collection so as to examine a specific theme or subject in art. In particular, the onlooker is invited to view familiar images in an unfamiliar way. There are 30 paintings from the 14th to the 19th century, almost exclusively by Italian, Dutch, and French artists. Each of six sections deals with the portrayal of the sleeping figure through the ages. Some of the visual associations of sleep are obvious and predictable: death, sloth, The Agony in the Garden (detail), attributed to Lo Spagna
S
Jungle law Health Care Law Jonathan Montgomery. Oxford: Clarendon Press. 1997. £19.99.Pp 476. ISBN 0-19-876259-3
ritish law is not just an ass . . . sometimes. Parts of it are a menagerie; occasionally it is a circus for passing fancies—such as the Dangerous Dogs Act (now amended). Parts are proliferous. Cultivated gardens vie with what the late American jurist Karl Llewellyn called the “bramble bush” of law. Add the growth of regulation in the post-war period and we have what Bernard Knight referred to in his first edition of Legal Aspects of Medical Practice in 1971 as “the ever-thickening jungle”. Thus guides with a good eye for clearing(s) and a sense of orientation are badly needed. Early explorers at the confluence of medicine and law in Britain, such as Kennedy, Skegg, and McLean, mapped what they saw as the key features: issues surrounding consent, con-
B
374
fidentiality, and medical negligence. With the exception of Finch’s Health Services Law (1981) the farther reaches of health-care regulation remained unexplored. Jonathan Montgomery, an academic lawyer with experience in the health service, has cut pathways through the jungle. He has created in the past 10 years vantage points from which to get a better sense of the legal environment, framing perspective through existing sociological insights and informed with empirical findings. In Health Care Law he explores beyond the boundaries of much medicolegal study by including a guide to the regulatory structure of health care in England and Wales. He clarifies the complexity of legislation, case-law, and quasi-law affecting the
guided through some of the principles of symbolic representation in art, for example, how to perceive a slothful person—asleep, with head in hand. The first section, “Peaceful Sleep”, has a pleasantly surprising lack of postprandial babies replete with pleasure. Instead, 17th century paintings idealise the pastoral life as an antithesis to early industrialisation, yet also moralise by depicting the herdsmen, in the nowknown position of the slothful one, asleep with head in hand. And of course, there is the association between peaceful sleep, death, and redemption: an elderly woman asleep in her chair, bible displayed, with Lenten meal of bread and fish on the table (no wine, for as we shall learn later, that symbolises something else)—on her one side, a burning fire, and on the other a painting on the wall depicting original sin. Section 2, “The Observed Sleeper” deals with conscious and unconscious displays of sex and sexuality. The female of the species doesn’t do too well in National Gallery, London
And so to sleep . . . perchance?
National Health Service. He describes and discusses with refreshing lucidity the range of areas traditionally covered in medical law texts: consent, confidentiality, complaints procedures; access to records; mental health; research; abortion; fertility; transplantation; and euthanasia. He adds original discussion of community and maternity care, rights to health care, and medicines. Montgomery not only helps the reader see large parts of the wood from the proliferating trees but also illuminates the tangle of reasoning and knotty problems that arise in areas such as consent and confidentiality for minors, selective non-treatment of babies, and withdrawal of treatment for adults. While he moves beyond the fixation in many medicolegal courses and texts on the doctor, a wider focus including nurses and midwives underplays the preponderant influence of a range of other professionals on health care, including dentists, health visitors, pharmacists, therapists, and dieticians. A number of key features in the
Vol 350 • August 2, 1997
THE LANCET
Mantegna’s version of Samson and Delilah. Here, we have an unusually diminutive Samson with graffiti carved in the nearby tree that translates, “a bad woman is threepence worse than the devil”. Reubens’ version of the same tale is, apart from anything else, a magnificent painting worth seeing in its own right, and thankfully more complex. With a mixture of triumph and tenderness, Delilah holds the sleeping (and implicitly postcoital) Samson as his hair is shorn, overseen by a blindfolded Cupid, with the Philistines waiting in the wings. In Botticelli’s Venus and Mars the power of the dressed (and therefore armoured) Venus is pretty tame and justifiable. War vanquished by Love and all that. In Reubens’ painting, however, not only is the common perception of that time—namely, that sexual intercourse invigorated the woman and exhausted the man—evident, but also insult is added to injury by Delilah’s impending betrayal. At the other end of the spectrum, there is Metsu’s woman in a drunken stupor. The symbolism here is rather crude (in all senses): man holds wine jug with suggestive spout, woman holds empty glass, bed looms large in background. Caricature, really. Redemption is found in Courbet’s interesting painting that caused moral indignation (among men) when it did the Parisian Salon circuit: it shows young ladies (allegedly prostitutes) on
development of law and health care emerge from Montgomery’s book: the increasing use of applications for judicial review of administrative decision; the swell of lay representation in complaints procedures; and the cre-
Vol 350 • August 2, 1997
the bank of the Seine, feigning sleep (deception, availability), partly dressed (invitation), and prone (defenceless, a lure). An odd choice of subject for that time, especially since contemporary women were becoming increasingly powerful economically and, at least vocally, active politically. Sections 3–6 are more predictable and mundane: “Sleep and Death: The Sleeping Christ Child”, “Negligence and Weakness”, “Sleep as Sin”, and “Dreams and Visions”. Negligence and sin could have been combined and the seemingly interminable versions of the Agony in the Garden could have been reduced to one painting to easily make the point. Overall, the choice of paintings cannot be said to lack range, style, calibre, or intrinsic interest, but the lessons of symbolism in art are at times overworked to the extent that they occasionally detract from seeing the paintings as a whole. And although there is an attempt to place the exhibition in literary perspective, more could have been done to illustrate the contemporary sociopolitical backgrounds. Despite the needs of a school-age audience, there is room to up the ante, even a little bit. Gabrielle Murphy 8–9 Long Acre, Covent Garden, London WC2E 9LH, UK.
ation of regulatory structures for professions such as osteopathy and chiropractic. New varieties of legislation, for instance to deal with medically assisted conception and embryo experimentation, have created international interest. Yet, at judicial level the UK reflects an enduring deference to clinical judgment which is at odds with pro-patient developments in other parts of the Commonwealth and the USA. There has been a surge in what Montgomery calls “quasi-law”; that body of administrative circulars, professional, and institutional guidelines, and norms that govern health care. Secondary legislation has burgeoned. Recent social and political shifts such as the move to a marketoriented health service and community care are reflected in large bodies
Books in brief A shock to the system Heat shock proteins have been implicated in various cardiovascular disorders, including ischaemia, hypertrophy, and atherosclerosis. This book provides an overview of the current understanding of heat shock proteins in the cardiovascular system and summarises the approaches to the study of these proteins in the heart. (Heat Shock Proteins and the Cardiovascular System. Edited by Anne A Knowlton. Dordrecht: Kluwer Academic Publishers. 1997. Pp 225. £85.25. ISBN 0-7923-9910-2.) A practical view Anal endosonography is a relatively straightforward technique for the investigation of disorders of the anal canal and sphincters. As this manual shows, it can be done on an outpatient basis. The book, illustrated with over 70 endosonographs, assumes no previous knowledge of the procedure, highlights various clinical features, and compares them with normal anatomy. (Handbook of Anal Endosonography. Clive I Bartram, Andrea Frudinger. Petersfield, UK: Wrightson Biomedical. 1997. Pp 79. £24.50. ISBN 1-871816-35-1.)
of legislation, executive and professional rules, and, inevitably, litigation. Health-care law is dynamic. Since Montgomery’s book was written, the National Health Service (Primary Care) Act 1997, for example, allows health authorities to end general practitioners’ monopoly of primary care provision. The European Convention on Biomedicine and Human Rights and European Union initiatives will further affect domestic law. Health Care Law maps the terrain and trends well. It is a thorough, informed, and wide-ranging presentation and commentary on most aspects of English law regarding health care and medicine. Montgomery achieves his objective of explaining the law clearly to an intended audience of lawyers, and students or practitioners of medicine and other health-care professions. The jungle seems less forbidding.
Dermot Feenan 90 Eglantine Avenue, Belfast BT9 6EU, UK
375