A gloss on civilisation

Document Sample
A gloss on civilisation Powered By Docstoc
					BRITISH MEDICAL JOURNAL            2 APRIL 1977                                                                                               885

                                                                              MEDICAL PRACTICE

Spring Books

A gloss             on      civilisation?

Today's fashion is to question the value of modern medicine.                  human affairs, and lowered the divine part of humanity still
Ivan Illich's remarks on the subject are perhaps too well known,              further [than Darwin]"; or that in Britain the Labour Party's
and too strident, to deserve quotation. Much more interesting                 ideas of social relationships, "have been increasingly accepted
are the questions being asked within the medical profession,                  by the majority of the people."
especially when these come from doctors who have apparently                      One probably knows what the author is trying to say in such
succeeded in their career. Professor Rhodes's book' is of this                enigmatic sentences, but they do not stimulate our historical
type. Since he is post-graduate dean-elect at Newcastle-and                   imagination: on the contrary, they illustrate only too clearly that
former dean of Adelaide and St Thomas's-he can hardly be                      the spirit of an age cannot be captured by a rapid precis of what
regarded as an outsider to the medical world. Yet his dis-                    seem to be its more important ideas. It is a pity that a work which
passionate assessment of medicine's contribution to society puts              does not set out to be a textbook in medical history should attempt
his own profession firmly in its place. After pointing out that               such an impossible task. Its aims would surely have been much
the most significant factors in man's continued survival have been            more effectively accomplished by treating in some depth two
environmental changes rather than medical interventions, he                   critical turning points: the emergence of the scientific approach
claims that medicine "is not a necessity for Man: it is a gloss on            to medical practice, and the rise of the utilitarian analysis of
his civilisation." From this he concludes that the continued                  social problems. These (in my opinion) are the main determ-
acceptability of medicine depends on the ability of doctors to                inants of the current debate about the value of medicine.
persuade people that the somewhat expensive services they offer
are justified because they ensure an enhanced quality of life.
Nevertheless, when the humanitarian and self-sacrificing image                Contemporary ambiguity
of the profession is being overtaken by a more militant attitude
towards income and hours of work, governments and private                        The later chapters of the book are much more satisfactory in
individuals may become less and less open to persuasion.                      both style and content, as the author's critical eye turns to the
   These conclusions are reached in an interesting way, for the               ambiguous place occupied by medicine in the world today. At
types of argument used illustrate both the strengths and weak-                this point his ability to summarise salient facts comes into its
nesses of the book as a whole. The first seven chapters attempt               own, and we gain a vivid picture of the inconsistencies and
to set the practice of medicine in a historical context by surveying          paradoxes of twentieth century medicine. Obvious examples are
its development from the Greek schools of medicine to the                     the part played by medical advances in aggravating the popula-
modern humanitarian ideals which led to the welfare state. This               tion problem; the unfortunate fact that no sooner is one group
is the least successful part of the book: its scope is too vast, and          of diseases conquered than a new and less tractable group moves
the survey much too hurried, for the reader to gain anything                  in to take its place; and the evident inability of medical educators
other than a blurred image of what is a highly complex evolution              to agree among themselves about the goals of medical education.
of social attitudes and philosophical ideas. At times we stumble              This all means that no progress can be made in assessing the
upon some very strange statements-for example, "The philoso-                  true value of medicine until the conflicting assumptions about
pher Spinoza had founded his theories on monads in the                        what medicine can and should achieve in any society are brought
seventeenth century." Odd syntax apart, this sentence surely                  out into the open. Some common agreement would then become
does some disservice to Leibniz. It is even more startling to read            possible about attainable goals, and some trial solutions could
that: "Freud started the process of putting the mind back into                be put forward in relation to a carefully selected range of prob-
  The Value of Medicine by Philip Rhodes. (Pp 158; ,4-95.) Allen and Unwin.      The hard-headed, factually based arguments of this section
    1976.                                                                     of the book make it essential reading for anyone disturbed by the
886                                                                                                   BRITISH MEDICAL JOURNAL         2 APRIL 1977

increasing problems of health care which at present face all                       Thus his argument boils down to a defence of privilege-
countries. I welcome the note of realism which Professor PFhodes                based on the idea that some economic inequities are inevitable
brings to a debate so often conducted at the level of abstract                  and might as well be accepted as such. At this point the reader
moral goals, rather than at the level of the historically and socially          may remain unconvinced. No one would suggest that it is easy
verifiable. We must not suppose, however, that the arguments                    to overcome inequity, especially when this is on an international
are devoid of moral value judgments. The case which the author                  scale. But privileges which seemed historically inevitable within
is making out for the socially determined value of medicine is                  societies have been removed through the growth of humanitarian
based on the view that medical care is a luxury and not a basic                 ideals. It need not be totally idealistic to work for a similar
human right and that the aim of achieving an equitable distribu-                redistribution of social benefit between societies. If such a goal
tion of health care throughout the world is "grandiose." Perhaps                is at all possible it should not be excluded from the discussion as
these value judgments are defensible, but they are rather easily                unrealistic or grandiose. Indeed, it could be argued that when
made by a member of a society which already has a high doctor:                  medicine is used only to enhance social advantage it can lay no
patient ratio and which has achieved a reasonable degree of                     claim to moral values.
equitable access to health services. The argument would ring                       There is no contesting the fact that this is a provocative book:
truer if Professor Rhodes were seriously suggesting that those                  indeed, it contains assertions which virtually invite disagree-
deprived of modern medical care really are more fortunate. But                  ment. Presumably, then, to quarrel with the author's conclusions
his assessment of medicine's ambiguities does not extend this                   is to demonstrate the effectiveness of his writing. The important
far. He clearly expects the richer countries to benefit from their              point is that he has provoked a debate which no society can
medical services, provided they are more rationally planned.                    afford to ignore.

No golden rules

Lord Beeching, arriving to help the Irish reorganise their                      has too many gaps to become a standard reference book: only
railways, took a taxi from a Dublin station. The driver pulled up               two brief references, for instance, to the laws of libel (Americans
at a T-junction where newly installed traffic lights were at red,               are spared the unreason that British law inflicts on writers and
looked cautiously up and down the road, and then turned left.                   editors) and the section on copyright deals only with US law
   "Do you know you just drove through a red light ?" asked                     and ignores the world outside.
Beeching.                                                                          The book grew from a series of group discussions and shows
   "'Tis a matter of philosophy, sir," said the driver. "Traffic                some of the dangers of corporate creation. Lois DeBakey
lights are there to help us not to hinder us."                                  assembled a team of editorial stars but the need to accommodate
   Books about writing share one characteristic with roadside                   their range of opinion has produced far too much "on the one
furniture: designed-often laboriously-to help, they all too                     hand... on the other hand...." This neutered approach,
often hinder. Stephen Lock's book is one of the exceptions and                  hereby christened the However Syndrome, often leads to
any aspiring writer who finds it unhelpful should lay down his                  banality: "Placement of the various features in a scientific
pen and turn his hand to something less demanding like                          journal may vary considerably from one editor to another. The
quarrying granite.                                                              format, however, should remain constant over long periods
   It's sad but true that most doctors who write articles for                   unless there are compelling reasons for change."
publication don't really want to. They are compelled to join a
ridiculous published-paper chase just to get preferment (a                      Questionable dogma
decent job) or patronage (a merit award or research grant).
Small wonder they make such a mess of putting words on paper.                      Occasionally, when the text seems to rebel against the bland
Even doctors who want to write because they think they have                     consensus, the syndrome leads to highly questionable dogma.
something interesting to say feel insecure when forced to                       "Although a catchy editorial title may attract attention, the title
unsheath their fountain pens. Thorne's Better Medical Writing,'                 should above all be informative." That "above all" is difficult to
in its much improved second edition, will take the edge off their               justify. Many an editor would claim that if the title catches the
anxiety for it gives clear unstuffy answers to questions about                  eye and gets the reader to read the informative editorial beneath,
what to write, how to write, and where to publish.                              it has done its job.
   Stephen Lock, practising what he preaches, delivers the                         Gazing too long down the retrospectroscope is as dangerous
information in uncluttered prose that encourages the flow of                    for editors as it is for clinicians and the picture the book gives of
ideas from the page into the reader's mind. I read the book at                  scientific journals derives wholly from what has already appeared
one session and not once did I stub my eye on an awkward                        on the library shelves. Lois DeBakey invited the editors to unveil
construction or syntactical aberration. As a writer, I, of course,              the rules-detailed enough to include organisational and manu-
apportioned blame for the grammatical errors-only a few-and                     script flow charts-that hadmade their journals successful. Those
the one meaningless subheading to the publisher.                                rules are worth examining because they have been tested in the
   Doctors in search of practical advice will have to dig harder                hurly burly of journal production, but people seeking to create
to find it in Lois DeBakey's book,2 though medical editors will                 new journals or to improve existing ones must look beyond exis-
enjoy the chance to read how colleagues tackle thorny problems                  ting rules and try to diagnose what problems they were devised
like multiple publication and manuscript reviewing (more                        to solve.
familiar this side of the Atlantic as refereeing). Sadly this book                 A new editor with new ideas invariably finds new solutions to
                                                                                editorial problems. He defines new rules, many of which are
     Thorne's Better Medical Writing by Stephen Lock. (Pp 118; £3 50.) Pitman   remarkably like those of his colleagues but some of which are
       Medical, London, 1977.                                                   remarkably different. Above all-remember the phrase ?-he
 2   The Scientific Jrournal, ed Lois DeBakey. (Pp 129; $10-45.) St Louis,
       C V Mosby Co, 1977.                                                      tries not to live by rules alone because the quality, dare we call it

Shared By: