REVIEWS Robert J. Levine, Ethics and Regulation of Clinical Research, Urban and Schwarzenberg, Baltimore Munich, 1981, 299 pp., cloth, U.S. $35. This book critically reviews the duties of biological or behavioral researchers and Institutional Review Boards (IRBs). The author is particularly well suited to this task since he is a distinguished researcher, chairman of the IRB at Yale University, editor oflRB: A Review of Human Subjects Research, former editor of Clinical Research, and staff member, later consultant, to the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. His fine, well-written book reflects his rich background of experience and the wisdom that comes from intelligent and sincere struggle to make regulations sensible enough to fit specific studies, and specific studies responsive to sensible regulations. Levine sets high standards for IRBs, arguing, quite correctly I think, that IRBs must provide and be perceived as providing a service to investigators as well as a means for pro° tecting human subjects. He urges IRBs to enhance their authority in their institutions by fair, impartial and thorough work, even if this means resisting sometimes inappropriate federal policies (227) or refusing to apply double standards depending on funding sources (229). If this book is read as widely as it deserves to be, one consequence should be to help standardize how IRBs operate. For example, after reading Levine's book, it should be very clear that investigators, in seeking IRB approval, need to be explicit about how subjects are to be selected. Levine's book is interesting as an insider's account of how the Commission arrived at its recommendations. While he does not think the Commission did a bad job, he does state that "both DHHS and Congress have missed a golden opportunity to do much better; they could have adhered much more faithfully to the Commission's recommendations" (xiii). Not surprisingly, Levine, in reviewing the rules and regulations of the Department of Health and Human Services (DHHS) and the Food and Drug Administration (FDA), often contrasts them to the Commission's recommendations. With an admirable succinctness and clarity of style, Levine reviews many important and controversial issues. These include rules and goals concerning the just selection of subjects, consent, compensation for research-induced injury, deception and the use of special subjects like children, prisoners, those institutionalized as mentally infirm, and pregnant women and fetuses. The discussion of such a broad range of issues from a legal and moral standpoint frequently precludes little more than a review of major pros and cons. After doing this quite well, Levine rather quickly closes the discussion by stating his own views. He generally compensates for what will seem to some rather speedy closure on substantive issues by suggesting further readings. (The bibliography is excellent.) In fairness to Levine, he could hardly do mucla more than this given the broad sweep of issues he considers. Predictably, the combination of the review of many issues and his strongly stated views has created a work where it is not difficult to find points that will provoke further discussion and disagreement. For example, if there is anyone left who does not know Levine has little use for the terminology 'therapeutic' and 'nontherapeutic' to describe research, they will have the issue cleared up after reading this book. Though he finds these terms unacceptable, he does not abandon the concepts underlying this distinction (whether or not the intervention is intended to, or holds out the prospect of, direct therapeutic benefit for the individual subjects; whether or not the primary intent is to do this or to gain new information). Levine is correct that it is sometimes hard to say whether a study is primarily therapeutic or nontherapeutic, because there is a corresponding difficulty about determining what the primary intent and source of risks or likely benefits may be. Since he and everyone else who writes sensibly on this topic uses these concepts, further discussion is needed to show why a verbal shift really advances matters.
TheoreticalMedicine 4 (1983) 323.
324
REVIEWS
His discussion of kinds of risks and gaining consent is generally excellent. Levine argues that the consent form is "an instrument designed to protect the interests of investigators and their institutions [and], to defend them against civil or criminal liability" (98). However, he is also concerned about whether it is written in a way that subjects are likely to understand and points out that the consent form is "most effective when viewed by investigators as an instrument designed to guide the negotiations with the prospective subject" (98). Thus, his own discussion shows that protecting the institution and investigator from liability is only one of the many functions of consent forms. Criticizing guidelines which do not permit principal investigators to delegate responsibility for gaining consent from prospective subjects, Levine points out that others might do a better job; he writes: "it seems reasonable to suppose that the more equal the negotiators are in these two categories [degree of education and social class[, the more likely there is to be comprehension . . ." between the prospective subject and the individual discussing the study and seeking consent (103). (Would Levine like to generalize this observation about education and apply it to teaching students at his home institution?) He is correct, of course, that sufficiency of presented information and comprehension by subjects are entirely different. However, he has not discussed the dangers to subjects, investigators and IRBs of delegation of the authority for gaining consent where the study is risky. (Where the risk is minimal, such delegation of consent is permissible.) There is an occasional discussion of philosophical themes, and on the whole they are not as successful as the rest of the book. For example, in the preface he writes: "While God, who no longer speaks personally to me, does not require that I argue ethics on deontological grounds, it is my judgment that sound deontological arguments merit respect. However, in the decision-making arenas to which I am accustomed, rule-utilitarianism tends to yield the most pleasing consequences" (xvi). This is a puzzling remark for several reasons. One is that deontological and teleological kinds of theories (rule-utilitarianism is one kind of teleological theory) both may, but need not have a theological dimension. In his discussion of framing guidelines for the use of prisoners participating in research, he states that a key problem was a conflict between two principles, that of respect for persons and that of justice (188). Since mutual respect is usually taken as the underpinning of a principle of justice, this seems odd. However, if one ignores what he says about principles of ethics, his meaning is clear enough. It is a conflict between allowing people who happen to be prisoners to make their own choices and the concern for not having one group, prisoners, take on a disproportionate amount of risk for the rest of society. Certainly one does not need to have two principles to generate a moral conflict. One principle, in this case justice, can generate disagreements about how to apply it. These are relatively minor points in a well written, finely researched book on a very important subject. I recommend this book to those who serve on institutional review boards, engage in biological or behavioral research or have an interest in the legal or moral choices that are involved in human research. LORETTA KOPELMAN
East Carolina University, School of Medicine, Greenville, North "Carolina 2 7834
REVIEWS
325
Bioethics and Law, edited by Michael H. Shapiro and Roy C. Spece, West Publishing Company, St. Paul, Minnesota, 1981, XLIX + 892 pages, cloth, US $23.95. In recent years, courts, attorneys, and legislators have increasingly turned their attention to a wide variety of legal and ethical issues brought about by the rapid growth of new technologies in biology and medicine. These issues, such as genetic control or mind and behavior control, all raise profound and difficult questions of theory and practice, for individuals and society. Attempts at resolving some of the problems created by these issues and others have, in many instances, resulted in court actions where the attorneys and judges have found themselves to be dangerously ignorant and ill-equipped to cope with, much less decide, the ethical and legal issues being pondered. As a way of dealing with some of these issues, new studies in bioethics are being developed in schools of science and medicine, along with the expansion of traditional law and medicine seminars in law schools to include the study of ethics. Unfortunately, most of the existing texts concentrate either on the legal analysis of the issues (the traditional case study approach) or on the ethical side of the issues, which although important, often remains isolated from practice. The failure of these texts to respond to the interrelationships and interchange of values inherent in the triad of ethics, law and medicine, greatly reduces any study to fairly rudimentary surveys of various clusters of issues in biology and medicine. In the recent past, someone wishing authorative and scholarly detail pertaining to law and bioethics would have been limited to a few sources. Topical interests were served by journal articles and analyses in law reviews; but more permanent references were in short supply. The situation has fortunately changed with the recent release of the excellent volume Bioethics and Law. Much more than its title suggests, this is a full-scale attempt by Shapiro and Spece to equip the law student and scholar (I would add also the future scientist and physician) with a comprehensive text uniquely suited for a seminar-type study of bioethics and law. Their new book might be more appropriately titled 'An Investigation of the New Biology', for it is just that. By their own definition, 'bioethics' refers primarily to a moral and legal analysis of those areas of biology where technology has been brought to bear the strongest, " . . . those biological technologies that permit a striking degree of influence over and knowledge about human characteristics and life processes". It is not their intent to pick up on those issues in medical ethics and law which spring directly from the professional-patient relationship (e.g., confidentiality, truthteUing, etc.) or the more traditional topics generally found in health care administration, delivery of health care, and law and medicine. Although acknowledging the importance of these areas of bioethics, it is the broader sense of bioethics that Shapiro and Spece wish to focus on. For it is there that the health care professionalpatient relationship is housed and surrounded by all of the modern day technologies. And it is there that the 'hard cases' arise and make their way to the courts. The large volume is both well organized and well written. It is divided into five major sections, each corresponding to an important area of legal and ethical concern in medicine and biology: the field of bioethics and law; control of mind and behavior; genetic control; reproductive control; death control; and, organ transplantation. Within these five grand sections, each chapter addresses a particularly difficult dilemma brought about by the 'new biology', one which generates serious value conflicts in law and ethics. One of the strongest features of this big book, and certainly the most unique considering the intended audience of law students, is the careful attention paid by the editors in setting the stage and sense of direction for a study in bioethics and law. Before any case study is offered for analysis, or before any ethical issue is raised for discussion and debate, Shapiro and Spece present a fairly well balanced discussion about what the new biology involves, along with a recognition of some recurrent dilemmas and paradoxes that are taking place in biology and medicine. The dilemmas selected for study relate to autonomy, distributing scarce resources, acquiring knowledge by research and experimentation, obligations to
Theoretical Medicine 4 (1983).
326
REVIEWS
future generations, bringing persons into existence with the use of new genetic and reproductive technologies, and resolving dilemmas by being unprincipled on principle' (i.e., the use of lotteries in decision-making rather than principled resolution on the merit). These dilemmas account for a major portion of the bioethical problems being debated today. Following this opening study of the new biology, a surprising chapter follows on managing the dilemmas within the context of law and morals. Here the important connection between law and morals is looked at and in particular, with those questions that can be raised concerning the place of normative ethical theory in law-making and in law-applying actions. In doing this, a brief but stimulating introduction to ethics is set out. This is an important chapter, and it breaks new ground in bringing to the law student something more than the time-worn, and often boring, case study text. It is this feature, along with the accompanying commentaries, that clearly sets the book apart from other law texts. The necessity for brevity here does not permit an equal review of the five grand sections, however, the section on death control must be mentioned because of its unusual depth and quality. This section alone justifies the use of the text. It is by far the best resource available today for the study of the many critical and complex issues surrounding death control. Covering almost 200 pages, or one-fourth of the book, the issues and cases discussed move from that of the concept of death control, through the nature of dying and death, the present and projected mechanisms of life maintenance, the decision-making dilemmas of who does and ought to decide, to finally, criminal or civil liability in death control. Each chapter focuses on a cluster of issues pertaining to the central topic and contains not only many landmark cases, but important commentaries by noted scholars from the fields of ethics and law. Not only does this chapter merit the use of the book as a text in bioethics classes as well as law, it should also prove to be an invaluable resource and guide to future work in the area of death control. Because the volume is both a study in law and ethics of difficult topics, the task of assembling suitable and relevant materials which related to both fields must have been extremely hard. While some of the sections are uneven in the quality of the literature presented, the editors have for the most part accomplished what they set out to do - to put together a solid comprehensive text combining legal and moral analyses of important concerns facing us today in biology and medicine. The strengths of this type of approach simultaneously lead to limitations. However, these are limitations not weaknesses. The volume is limited in its instructional utility insofar as the ethical picture is presented. Although the editors do pose some serious and baffling questions with each chapter, some of the literature used appears rather short on substance, suffering from too much editing. As a result, at times the literature appears disconnected, disguising where the chapter is headed, and with what issue. This limitation is minor however, and does not detract from tt~e overall importance of the book not only as a law school text, but also one that could just as easily be used in medical schools and graduate courses in medical ethics. FRANK
H. M A R S H
University of Colorado at Denver, and University of Colorado Medical School
James H. Jones, Bad Blood." The Tuskegee Syphilis Experiment, The Free Press, New York; Collier Macmillan Publishers, London, 1981, 272 + xii pp., cloth, U.S. $ 12.95. This is, at once, an engrossing and troubling book. It is engrossing in the measured pace with which the author tells the story of the Tuskegee Syphilis Experiment (conducted in Macon County, Georgia, U.S.A.). It is troubling, deeply so, in the moral dimensions of
Theoretical Medicine 4 (1983).
REVIEWS
327
the detail of this chronicle, an intricate story of subtle shifts and changes in the research protocols, goals, enconomics, bureaucratic politics, racism, and personal ambitions that together shape the history and morality of this now infamous American program of research involving human subjects. In the face of a story that can provoke only moral outrage, Jones quietly tells of the incremental mounting of an evil perpetrated by individuals who were, for the most part, decent men and women. The unspoken theme of this important book is that ethical issues in research with human subjects are significant not because researchers are sometimes people of bad will. Instead, their significance is rooted in how we should understand the normative dimensions of such basic ideas or concepts as research, experimentation, and disease, and how these normative dimensions are shaped by such factors as geography, history, and racism. In order to see why this is so, some attention to the details of Jones' study is necessary. Jones early identifies the basic theme of the book: "the need to protect society from scientific pursuits that ignore human values" (14). This need arises from the Tuskegee study because it was "the longest nontherapeutic experiment on human subjects in medical history" (91). Jones's historical approach focuses on two main factors. The first is "racial medicine", a view shaped by concepts of health and disease that were, in turn, shaped by racism. According to Jones, racial medicine came to see the incidence of venereal disease among blacks as typical, so that what in whites was a disease was taken in blacks to be (nearly) the norm. Such a view created a "powerful rationale for inactivity in the face of disease", a rationale that characterized the Tuskegee project in crucial ways. The second main historical factor was the public health movement of the early decades of our century in the United States. Three features of this movement are noted: (1) a shift away from race to class as the denominator for epidemiology; (2) concomitantly, an analysis of the environmental factors of disease; and (3) emphasis on the benefits of scientific medicine and "modern public health management" (44). At times in contradiction and at times complementary, these two forces also shape the Tuskegee story. That story properly begins with public health demonstration projects funded by the Rosenwald Fund and the U.S. Public Health Service in 1930. These were designed to study means of detecting and treating venereal disease in the rural South. Six counties in six southern states were involved. Macon County, Georgia, the site of the Tuskegee experiment, was among them. Since the project was therapeutic in nature, it was clearly designed to benefit the subjects involved. From these lofty intentions, the downward plunge did not occur all at once. Citizens were told that the public health doctors were testing people for "bad blood". This was taken to be rural argot for syphilis but, in the black community, the phrase had multiple meanings. Right from the beginning, therefore, confusion ruled and even the most minimal requirements of truthfulness to patients were not satisfied. The next step occurred when the Rosenwald Fund money dried up two years later. The physician in charge of the first project, Taliaferro Clark, realized that, with so large a population already identified, there was an ideal opportunity to continue study of syphilis in blacks - partially to determine if the natural history of the disease was different in whites than in blacks, partially to add a prospective study to existing retrospectiva studies, and partially to advance his own reputation in the research community. This experiment was to last only six months to one year (95), but it was continued beyond this period. Its true purposes, however, were obscured from the subjects, who had come to trust the "government doctors" who had worked in the first project and were reassembled to work in the second. The enticement to the subjects was a free blood test. Some were also to be given lumbar punctures, but the purposes of doing so were not explained (132). Thus, further erosions in truthfulness - and what we now call informed consent - occurred. All the men, it should be noted, were to be given treatment, though not all subjects received effective treatment. So again, the moral picture is mixed. This study and subsequent studies thus included some subjects who had been treated and some who had not, raising serious questions about the validity of any results that might be obtained. This
328
REVIEWS
shortcoming was papered over, at least twice, by the self-deceptive ruse that those who had received previous treatment had received outmoded therapy "and may still be considered untreated in the modern sense of therapy" (126). A similar self-deception was employed later, after the introduction of antibiotics (182). Another step occurred when, under a new project director, it was decided in 1933 to bring the subjects to autopsy, so that more reliable data could be gathered about the systemic effects of chronic syphilis, something the director was under a good deal of pressure to do. Again, the 'government doctors' returned to Macon County, but this time there was no plan to provide treatment. Some subjects did receive treatment from the 'government doctors', again contaminating the project. Moreover, some were given 'pink pills', aspirin. No one at the time found these practices to be ethically troublesome. Another step occurred in the offering of burial stipends to subjects' families who agreed to autopsy. For people who were impoverished this was a nigh irresistable inducement to agree. Yet another step occurred in the late '30s and early '40s, when it was decided to pick up new subjects who had not ever been treated, to try to offset the contamination problems (173). Only a small number were added, but they were never offered treatment, even when penicillin became available. Finally, a decade ago, the whistle was blown, and the project stopped. These incremental steps toward moral disaster can be understood in light of the normative dimensions of concepts like experimentation, research, and disease. The normative dimensions of the first two are complex: they involve at least the intrinsic good of seeking expanded knowledge of the natural world, the instrumental good of such knowledge, and the protection of research subjects - issues on the agenda of medical ethics since at least 1800. These three goods, however, are not mutually compatible. But, how we should strike a balance among them is a question that can be finally answered only if the third trumps the first two values or vice versa. Because it is not clear that moral values trump each other in such simplistic ways, the justification of research on human subjects raises complex and difficult moral problems. The moral problems of research, however, were apparently not a concern during most of the forty years of the Tuskegee project. One reason for this may be found in the normative dimensions of the researcher's understanding of health and disease. That is, the health and disease of the Tuskegee subjects were shaped, as conceptual matters, partly by geography (this was, after all, the rural South where chronic diseases were endured and perhaps not perceived by physicians as terribly disabling), history (the subjects had known little other than poverty and chronic illness - such conditions were 'normal'), and racism (racial medicine came to view some disease states as normal, if not typical in the black population, so there was no strong obligation to do anything about them). Applied to venereal disease, these value judgments rather straightforwardly imply indifference to the plight of the afflicted. It is no surprise, therefore, that those involved in the project found little or nothing ethically troublesome about it. But, they should have found the project ethically troublesome, we want to say. To say this, however, we have to be able to show that there are values that are wholly inappropriate to normative concepts of health and disease. Just what, then, are 'correct' and 'incorrect' concepts of health and disease? By what criteria should we make such determinations? What kind of arguments would sustain such criteria? In raising these questions (in effect) in the context of an actual case history, Jones moves the present debate about the normative dimensions of concepts of health and disease to a new and important level. L A U R E N C E B. M c C U L L O U G H
Department o f Community and Family Medicine, Georgetown University, Washington, D. C. 20007
REVIEWS
329
Arthur L. Caplan, H. Tristram Engelhardt, Jr., and James J. McCartney (eds.), Concepts of Health and Disease: Interdisciplinary Perspectives, Addison-Wesley Publishing Company, Reading, Mass., 1981, xxxi + 756 pp., Paper $29.50. What are health and disease? Is health a positive state of mental, social, and physical wellbeing as the World Health Organization claims, or is health merely the absence of disease? Are diseases definable entities (over and above a pattern of symptoms) that we have when ill? Or are disease names simply labels we attach to loosely connected clusters of phenomena to explain deviations from the norm? Is the concept of disease univocal such that mental disease, skin disease, and heart disease share some common feature, or does 'disease' refer to a vaxiety of phenomena that bear only a Wittgensteinian family resemblance to each other? Do what count as diseases bridge socio-cultural differences, or do we label states and processes as pathological partly by reference to socio-cultural norms, environmental conditions, age, and sex? To what extent are we responsible for our own health and illness, and to what extent is the notion of involuntariness built into the very concepts of health and disease? These are only a few of the conceptual questions surrounding 'health' and 'disease' tackled by the authors in Concepts ofllealth and Disease. This book is an impressive anthology. The editors have brought together into one weighty sourcebook a significant array of literature dealing with two of the most basic concepts in philosophy of medicine. In their selection of articles, the editors have been sensitive to the complexity of conceptual questions about health and disease and to the practical implications that any one understanding of health and disease may have. The 48 articles contained in Concepts of Health and Disease come from such diverse disciplines as medicine, philosophy, psychology, history, economi~s, and biology. And the selections range from 17th century accounts of disease and the role of medicine to contemporary, hitherto unpublished reflections on the nature of health and disease. Organized into six parts, this anthology takes the reader progressively through the multifaceted discussion of health and disease. Part I introduces some of the conceptual perplexities and practical implications of our understanding of health and disease. Part II sets up the historical framework for contemporary discussions, while Part III delves into the impact that societal values have on medicine and the way that medical diagnoses and explanations may reflect and support societal expectations. Part IV attends to the special difficulties posed by the concepts of mental health and disease. Finally, Parts V and VI provide a sampling of ongoing debates and research. Leon Kass' 'Regarding the end of medicine and the pursuit of health' sets off Part 1 (Health and disease: Basic interdisciplinary reflections) with a provocative discussion (as much for what it doesn't say as for what it does) of the aim of medicine, the nature of health, and the desirable limits of social health care policies. The business of medicine, Kass claims, is simply to promote health. It is not to pander to people's wishes (e.g., providing cosmetic surgery and hair implants), or to enforce social control (e.g., through psychosurgery), or to prolong life. In an Aristotelian vein, Kass argues that health is a matter of the excellent functioning of the body as a whole; and what count as states of health or disease are natural, biological norms, independent of socio-cultural variation. His article culminates in an attack on social health care policies on the grounds that health and disease are largely a product of the individual's habits and lifestyle, and social health care policies deter individuals from taking responsibility for their own health. Kass's claims that medicine can be sharply delimited from other social institutions, that health and disease are universal natural norms, and that the burden of responsibility for health and disease rest on the individual might all be challenged, and the succeeding articles in Paxt I do just that. Tristram Engelhardt, for example, argues that diseases are simply patterns of phenomena, involving pain and suffering, which are not chosen. And which patterns count as diseases can only be judged contextually by reference to the individual's constitution and environment and the laws of physiology (a normal physiological process
Theoretical Medicine 4 (1983).
330
REVIEWS
in the elderly, for example, might well be a disease in the young). In a companion piece, Abraham Maslow and Bela Mittehnann argue that judgments about psychopathology are also contextual. The same psychological reaction may be pathological or healthy depending on the individual's life situation, culture, age, sex, and social status. Talcott Parsons carries this line of thought one step farther, arguing that not only are what count as states of health and disease relative to particular social systems, but the importance placed on health, the attitudes adopted toward the sick, and the resistence to or promotion of social health care services are determined by socio-cultural factors. Part II (Historical development of disease concepts) provides a backward glance at the evolution of thought about both the nature of disease and the role of medicine. The first selections are drawn from works by prominent 17th, 18th, and 19th century physicians, anatomists, and physiologists. Prior to the 17th century, the medical corpus comprised a more or less eclectic collection of cures. Very Tittle attention was given either to understanding the nature and causes of disease or to systematically classifying diseases. Medicine as a science had yet to be born. The 17th century inaugurated the related efforts to make medicine more scientific and to come to grips with the nature and natural causes of disease. Making medicine more scientific meant, first of all, introducing systematization into the corpus of medical knowledge. Selections from the works of Thomas Sydenlaam, G. B. Morgagni, and Xavier Bichat illustrate this concern. Making medicine more scientific also meant abandoning descriptions of individual case histories in favor of general inductive hypotheses about diseases that could be experimentally tested by making comparative observations of different patients or by animal experimentation. This concern comes out clearly in the selection from Claude Bernard's Introduction to the Study o f Experimental
Medicine. Selections from works by Rudolph Virchow and Walter Cannon introduce two significant contemporary themes. Virchow rejects the ontological concept of disease as a disease 'entity' (i.e., some self-subsistent thing over and above the pattern of symptoms) in favor of a more descriptive concept of disease as simply a deviation from normal physiological processes; and Cannon stresses the interdependence between biological health and social well-being. The editors omitted any original sources prior to the 17th century. To some extent, the last four selections in Part II, which are contemporary reviews of the history of the concept of disease and medical explanations, fall this gap. Henry Cohen's 'The evolution of the concept of disease' succinctly highlights the changing areas of concern from the time of the early Greeks through the 19th century and neatly places into historical perspective the original sources contained in Part II. Both Ilza Veith's and Lester King's articles focus on earlier supernatural explanations of disease and the identification of disease with demonic possession - a notion which is at the historical root of more modern notions of disease as a disease entity. While many o f the selections in Part I suggested in a general way that societal norms and expectations influence medical disease classifications and explanations, the articles in Part III (Disease versus values: Sex, race, addiction, and sexual preference) illustrate this interface between medicine and morality. Tristram Engelhardt's 'The disease of masturbation' and Carroll and Charles Rosenberg's 'The female animal' explore the impact of 18th and 19th century morals on medical explanations. Engelhardt documents the medical profession's classification of masturbation among diseases, the surprising variety of physiological and psychological disturbances that it was thought to cause, and the sometimes barbaric treatment of this 'disease'. In a similar vein, the Rosenbergs show how Victorian theories o f female physiology supported existing sex roles by suggesting that a woman's departure from traditional nurturing roles would have deleterious physiological repercussions. These two pieces are followed by a reprint of Samuel Cartwright's startling 1851 report to the Medical Association of Louisiana in which he defends slavery and slaveowners' stereotypical views of Negro personality traits on the basis of alleged physiological
REVIEWS
331
differences between the Negro and Caucasian races. The f'mal two selections canvass debates over whether or not morphine addiction and homosexuality should be classified as diseases. All five articles underscore the dangers of medicine's being the handmaiden of conventional morality. The difficulties of formulating an adequate definition of physical health and disease pale by comparison to the quandaries faced by theorists who attempt to define mental health and disease. As many of the authors in Part IV (Disease versus values: Mental health and illness) point out, the concept of mental disease expands elastically over an enormously varied set of behavior disorders, from catatonic schizophrenia and neuroses to unstable personalities and antisocial behavior. The selections in this part are critical of attempts to define mental health and illness. But this criticism is not all of a piece. Many authors simply express dissatisfaction with existing definitions (though acknowledging the need to define mentat health and disease), while Thomas Szasz totally rejects the applicability of the medical model in the mental arena. The three leading articles by Heinz Hartmann, F. C. Redlich, and Ruth Macklin criticize attempts to define mental health in terms of statistical normality, social conformity, or psychoanalytical catalogues of pathological symptoms such as defense mechanisms and regressive tendencies. The central problem is to find some definition of mental disease which applies to all and only disturbed individuals. Unfortunately, neither statistical, normative, nor psychoanalytical approaches to the definifion of mental disease meet with success on this score. The situation is further exacerbated, as Aaron Lazare points out, by the use within psychiatry itself of different, competing conceptual models for evaluating and treating psychological disturbances. Adopting any one conceptual model determines the description of the psychological problem, the relevant 'facts', and the course of treatment. Whether or not one should even attempt to shed light on the conceptual darkness surrounding 'mental health' and 'mental disease' is itself debatable. Thomas Szasz, for instance, argues that the whole concept of mental illness should be abandoned in favor of the concept of 'problems in living' on the grounds that there is no substantial analogy between what are called physical and mental diseases. By contrast, Ruth Macklin, R. E. Kendell, and Baruch Brody argue, though in very different ways, that mental and physiological problems are not so disparate. Underlying many of the critical articles in this anthology are qualms about the correctness and utility of the medical model of disease. Described most simply, a disease is an undesirable deviance from a normal state of functioning. But this description is obviously too broad. There are many kinds of deviance, some moral, others religious, social, or legal. Whether or not a deviant state falls under the medical model and is treated as a disease depends (as Veatch notes in 'The medical model') on its being involuntary, organic, properly referred to physicians for treatment, and its falling below some minimal standard of acceptability. On a traditional view, like that espoused by Christopher Boorse ('On the distinction between disease and illness'), the minimal standard of acceptability is a discoverable natural norm of human biological functioning;' and the deviances classified as diseases differ from, say, social or legal deviances by being totally involuntary (and hence blameless) as well as describable in purely physiological terms. Most of the selections in Part V (Contemporary analysis of disease and health) question this medical model of disease. Whether or not we contract diseases frequently depends in part at least on our own choices - choices about exercise, diet, inoculation, smoking, etc. - while some nonmedical deviances may not be completely voluntary (consider the role that many think the environment and social conditioning play in fostering crime). That diseases are only or are best described physiologically is also questionable. One might, as Horacio Fabrega points out in 'Concepts of disease', describe diseases by behavioral discontinuities (eating less, having a diminished work output, crying, etc.). Moreover, some diseases, such as narcotic addiction, have striking behavioral and social symptoms. Finally, that there are absolute standards for when a condition fails to be minimally acceptable and should be referred to physicians for treatment is, at least from a sociological point of view, doubtful. Individuals' perception of
332
REVIEWS
themselves as ill, and their motivation to seek medical help depend on economic, practical, personal, and ideological variables. Persons in lower income strata seek medical help less readily than those in higher income brackets and differ in their assessment of minimal standards of acceptable functioning. Furthermore, assigning to the medical model only those deviances which violate minimal standards implies that promoting a positive state of health is not a specifically medical goal. In short, the selections in Part V illustrate how, in addition to its inadequacy for describing mental disease, the medical model may also need serious revamping in the case of nonmental disease. Part VI (New directions) contains a sampling of contemporary, previously unpublished work on health and disease. Some selections further the analysis of health and disease, while others show how particular analyses of health and disease have affected the nursing profession and the debates about whether aging and homosexuality are diseases. Overall, Concepts o f Health and l~'sease is a valuable anthology. Intended by its editors to be a sourcebook for both scholars and students, it succeeds admirably on the former count. But as a text for students, its utility is handicapped by the combination of limited topic and large size which limit its use as a primary text to advanced courses and make it an unwieldy supplementary text. The omission of a bibliography is regrettable, given that the editors ~ avowed intention in creating this anthology was to introduce readers to the wealth of literature concerned with the concepts of health and disease. At least a few of the selections are sufficiently repetitive that they might have found a better home in a bibliographic reference. The greatest flaw, particularly from a pedagogical point of view, is the absence of extensive introductions to the work as a whole and to the individual parts. The editors' introduction to the work is far too abbreviated to provide anything more than the most superficial flavor of what is to come; and while each part begins with a brief introduction, these, once again, are far too sketchy to help the novice key in on the major issues. The historical selections in Part II suffer the most from the lack of editorial comments. Many of these are drawn from large works, and without adequate forewarning, it is difficult to spot the signficant points that are embedded in peripheral remarks. Finally, given that the anthology as a whole is slanted toward more relativistic, contextual, and interdisciplinary analyses of health and disease, its value would have been enhanced had the editors supplied more background information about the traditional analysis of health and disease with which the anthologized selections take issue. These critical remarks notwithstanding, the book is a valuable contribution to the literature in philosophy of medicine. CHESHIRE CALHOUN
Department o f Philosophy, The College o f Charleston, Charleston, South Carolina
Locally Interacting Systems and Their Application in Biology, edited by R. L. Dobrushin, V. I. Kryukov, and A. L. Toom, Vol. 653 of Lecture Notes in Mathematics, Springer-Verlag, Berlin/Heidelberg/New York, 1978, XII + 202 pages, soft cover, DM 24,80 US $12.40. This book, which is divided into two parts, contributes to the development of solutions to theoretical problems which can be expressed in mathematical models with a large number of locally interacting random components. In Part 1, the applicability of such systems is examined under deterministic conditions, before random noise is added. Systems with continuous space and time (Toom), a nonergodic one-dimensional random system with local, non-degenerate interaction (Cirerson) and a deterministic monotone homogeneous system (Galperin) are examined. Shnirman
TheoreticalMedicine 4 (1983).
REVIEWS
333
explores new aspects of nonergodic systems, and Kurdyumor proves the algorithmic insolvability of the problem of discriminating ergodic and nonergodic random media. Borisyuk provides a more biologically oriented conception of the information capacity of Purkinje cells. In Part 2, Averinstev describes a class of fields only by the pair potential. Stavskaya, Vasilyev and Kryubov consider various cases of an evoluting system having a stationary Gibbs distribution without presupposing reversibility in time. The book ends with a consideration of the number of fields with a given Gibbs potential (Molchanov), a theory of multicomponent montone systems (Chetayev), the development of a spectral theory of interacting Markov processes on the spaces of states which are encountered in the quantum field theory (Malyshev), and finally Evstigneev's extension of the ideas of discrete random fields to continuous fields by means of a new interpretation of Gibbs representation. MANFRED GESSLER Inst. f. Theorie & Gesch. d. Med., D-4400 Miinster
Johanna Bleker, Die Naturhistorische Schule 1825-1845. Ein Beitrag zur Geschichte der Klinischen Medizin in Deutschland, Gustav Fischer Verlag, Stuttgart/New York, 1981, X+175 pp., soft cover, DM 48. Although this work cannot be considered a definitive history of the so-called 'natural history' school of German medicine, its author has successfully clarified the issues and personalities associated with this movement. Students of early 19th century medicine will be grateful for Bleker's careful analysis of previous historiography, available source material, and separation of the doctrines of Karl W. Stark and Johann L. SchiSnlein. What emerges in the end is a better understanding of clinical medicine, its methodology and goals, for a period in history when the basic sciences were still in their infancy and therefore incapable of providing the necessary foundations. Bleker begins with an appraisal of about 25 previous historical accounts of the 'natural history' school beginning with Haeser's text of 1853. She demonstrates the existence of two basic but opposing judgments: for a majority this movement was associated with SchiSnlein and characterized by its stress of nosology and introduction of scientific methods into clinical medicine. More recently, however, several historians have seen Karl W. Stark with his parasite theory as the real leader and therefore linked the school to its predecessors. Since biographical accounts of the main actors fail to shed additional light on the historiographical question, Bleker turned to the few surviving manuscript sources of SehiSnlein and a series of doctoral dissertations written by his students at the universities of Wiirzburg and Ztirich between 1819 and 1840. The author's next task was to explain the meaning of 'natural history' in the context of clinical medicine. She convincingly concludes that this method sought to distinguish pathognomonic symptoms and signs of bedside phenomena, and compare them employing a retrospective 'historical' view of their development. The aim, of course, was to arrive at so-called 'natural' systems of disease classification. The way to proceed, stressed by SchiSnlein, was thought to be strictly empirical and implied the optimistic view that such observations and comparisons were conducted without any a-priori prejudices and would therefore successfully uncover the true genetic relationships between nosological entities. Seen in this light, it appears that Sch~Snlein's method was formulated to stem the tide of 'Naturphilosophie' in medicine with its intuitive a-priori speculations. Bleker then moves on to explain the life and doctrines of Karl W. Stark (1787-1845), concluding that the ideas expressed by this physician were wrongly labeled 'natural historical'
Theoretical Medicine 4 (1983).
334
REVIEWS
and belong more properly to the speculative views espoused by the so-called 'romantic' authors including Stark's colleague at the University of Jena, Dietrich G. Kieser ( 1 7 7 9 1862). As she convincingly demonstrates, freely utilizing analogy and induction from conjectural principles was erroneously called 'natural historical' and quite different methodologically from the program elaborated by Sch6nlein and his disciples. The two final chapters treat in greater detail the life and medical concepts of Schfnlein. Bleker uses a previously unpublished manuscript of the physician concerning a 1818 lecture on whooping cough to illuminate this historical approach. Disease is a process in which a quite complex series of factors constantly interact. The often confusing manifestations not only need to be observed, but ordered and related with the help of anatomical and physiolological knowledge. Thus using the 'historical' approach, Schfnlein tried not only to establish an improved nosological system, but create closer ties between medical theory and practice. Bleker's book is a welcome addition to our understanding of 'pre-scientific' medicine in Germany. For those interested in the history of the concepts of disease, she provides the necessary clarification concerning the doctrines of Sch/Snlein and Stark. Our author has greatly eliminated the hitherto confused picture of a very influential movement in German medicine. Rightfully restored to its place in history, Sch/Snlein's ideas can now be subjected to further analysis both with its predecessors - notably R6schlaub - and the successors, generally proponents of the so-called 'physiological' medicine program of the 1840s. G U E N T E R B. RISSE Dept. of the History of Medicine, University of Wisconsin Medical School
Stuart F. Spicker and H. Tristram Engellaardt, Jr. (eds.), Philosophical Medical Ethics: Its Nature and Significance, D. Reidel Publ. Co., Dordrecht/Boston/London, 1977, VI + 248 pp., Cloth, Dfl. 55.-/US$28.95. This volume contains the proceedings of the third transdisciplinary symposium on Philosophy and Medicine, Farmington, 1975. The papers present, firstly, original contributions concerning widely discussed issues in medical ethics. Jonsen analyzes the principle of primum non nocere according to its various layers of meaning. The moral problems attending abortion and euthanasia are discussed, either in themselves (as in Hare and Rachels), or in connection with the right to life and with the notion of persons as bearers of such rights (in Kohl, Troyer, Chisholm, Engelhardt). Morgenbesser and Abrams concern themselves with conditions under which a patient's or volunteer's consent to participate in medical research may be called voluntary and rational. The papers, secondly, relate to the moral self-understanding of the medical profession. This self-understanding concerns both the individual practice of physicians as seen in the context of legal and institutional regulations (Jonsen, Lesagna, Morgenbesser, Callahan) and the moral implications of medical practice as a whole (Owens, Spicker). Many of the papers, thirdly, discuss those first two sets of medico-ethical issues on the basis of more or less explicitly avowed philosophical presuppositions. A specifically analytical procedure is followed by Jonsen, Hare, and Chisholm. The ethical considerations of Hare and Kohi bear witness to a utilitarian position, whereas their commentators, Rachels and Troyer, are committed to a deontological standpoint. Finally, Owens and Towers argue for Aristotelean and Teilhardian world-views. The title of the book, however, as well as the Introduction, indicate that the editors had more in mind than merely collecting applications of philosophical skills to the field of medical practice, however worthwhile in their own right. They rather attempted to initiate
Theoretical Medicine 4 (1983).
REVIEWS
335
a more radical reflection on the conditions for the possibility of such applications. In view of this more difficult, meta-ethical endeavor the volume presents valuable study materials. Three papers are particularly important. Owens has shown, by using as example Aristotle's ethical theory, how the possibility of applying ethical categories to medicine can be philosophically accounted for. In his commentary on Towers and Chisholm, Engelhardt indicates which conceptual refinements are needed if what appears as mere translations of biomedical facts into philosophical vernacular is to yield genuine philosophical problems. Maclntyre not only poses a new question concerning the addressee (the patient, not the physician) of medico-ethical considerations. He also contends that the moral problems of individual medical practice can only be solved in connection with a more general theory on the position of medicine within modern society. He thus endorses a meta-ethical position similar to that known from the marxist literature on medical ethics, adding however the premises of a pluralist political theory. These three contributions provide constructive impulses toward understanding the relationship between philosophical ethics, medical ethics (as treated by Burns) and medical practice (as analyzed by Pellegrino), and thus simultaneously on philosophy's own serf-understanding (which is also addressed by Hare). The discussions by Hellegers, Bok, and Daly provide further important glimpses of the difficulties attending this interdisciplinary endeavor of philosophers and those physicians who reflect on their practice. It is to be hoped that future volumes will focus in still greater detail on the study of the nature and significance of philosophical medical ethics. CORINNA DELKESKAMP-HAYES D-6463 Freigericht
Nelly Tsouyopoulos, Andreas R6schlaub und die Romantische Medizin. Die philosophisehen Grundlagen der modernen Medizin, Gustav Fischer Verlag, Stuttgart/New York, 1982, VIII + 259 pp., soft cover, DM 58. Die sogenannte Romantische Medizin war eine mR der Naturphilosophie des transzendentalen Idealismus verbundene Richtung, die das Denken in der deutschen Medizin zwischen 1795 und 1825 stark beeinflusst hat. Sie wurde danach durch die aus ihr erwachsene naturhistorische Schule verdrS_ngt. Seit der Etablierung der naturwissenschaftlichen Medizin um die Mitre des 19. Jahrhunderts gait sic als eine Verirrung des ~ztlichen Denkens in realit~itsferne Spekulationen, die den wissenschaftlichen Fortschritt nur gebremst habe. Dieses Pauschalurteil wird mitunter bis beute gepflegt. Die Verfasserin unterzieht Andreas R6schlaub (1768-1835), einen der wichtigsten Verterter der Romantischen Medizin, und sein umfangreiches literarisches Werk tiber Medio zinalwesen, theoretische und praktische Heilkunde einer eingehenden Analyse. Sie stellt dabei fest, dass dieser Mann ganz und gar nicht in jenes Schema passe, sondern vielmehr ein Wegbereiter der naturwissenschaftlich denkenden und handelnden Medizin, gewesen sei. R6schlaubs wichtigstes Anliegen sei es gewesen, der praktischen Medizin am Krankenbett, die bis dahin keine brauchbare Theorie zur Begrtindung und Leitung ihres Handelns besessen habe, den Anschluss an die Physiologie und die anderen Naturwissenschaften zu erm6glichen und sic damit yon der Stufe der Empiric zu der einer angewandten Wissenschaft zu erheben. Es gelingt der Verfasserin, dieses Anliegen R0schlaubs und seine Gedankengange sichtbar zu machen. AUerdings kann ihr der Rezensent nicht folgen, wenn sie erklS_rt, dass die praktische Medizin bis zu jener Zeit keine brauchbaren Theorien besessen habe. Dies ist ebenso ein Pauschalurteil aus der Sicht der modernen naturwissenschaftlichen Heilkunde wie jenes oben genannte tiber die Romantische Medizin, gegen das Frau Tsouyopoulos zu Felde zieht. Die Heilkundigen haben fast zu jeder Zeit ihr Erkennen und Handeln am K.rankenbett theoretisch begriindet bzw. aus theoretischen Vorstellungen abgeleitet, und zwar oft mit gutem Erfolg.
Theoretical Medicine 4 (19 8 3).
336
REVIEWS
Dies hat erst im Jahre 1978 K. E. Rothschuh in seinem umfassenden Werk Konzepte tier Medizin dargelegt (cf. Band 4/1 dieser Zeitschrift, Seite 114 f.). Die ausftihrliche Darstellung yon Frau Tsouyopoulos bleibt sehr abstrakt. Der Leser muss sich durch viele Seiten theoretischer, philosophischer und methodologischer Er6rterungen hindurcharbeiten, ohne dass ibm anhand praktischer Beispiele die Anwendung dieser Theorien und Methoden vor Augen geftihrt wird. Und dabei ging es R6schlaub gerade um die praktische Medizin, genauer, um die theoretische Fundierung des Handelns am Krankenbett und um den praktischen Unterrieht in der Klinik. R6schlaub war selbst praktizierender Arzt und bildete als Professor der Universit/itsklinik in Landshut Medizinstudenten aus. So w/ire es sinnvoll gewesen, anhand yon konkreten Beispielen, wie Krankengeschichten und ~ztlichen Erfahrungsberichten, darzustellen, wie er seine Methode zur Praxis anwandte und seinen Studenten lehrte. Diese mussten, wie wir lesen, unter seiner Aufsieht in der Klinik Kranke untersuchen und behandeln und dariiber Krankengeschiehten abfassen. Solche Krankengeschichten w/iren wiehtige QueUen ftir diese medizinhistorische Untersuchung gewesen. R6schlaub hat, wie das Literaturverzeichnis ausweist, medizinische Erfahrungen ver6ffentlicht. Es ist zudem m6glich, class handschriftliche Kxankengeschichten in Landshut erhalten geblieben sind. Die M~ingel, die R6schlaub am Medizinalwesen des ausgehenden 18. Jahrhunderts konstatierte, und seine Projekte far eine Medizinalreform werden ansfiihrlich dargestellt. Doch es ist der Verfasserin anscheinend entgangen, class der bayerische Staat, dem R6schlaub seit 1802 als Professor und Beamter diente, yon 1799 an eine Medizinalreform durehgeftihrt hat, die bis 1808 wesentliehe Forderungen R6schlanbs erftillte: Absehaffung des Collegium medicum und Einrichtung eines staats~ztliehen Dienstes anf drei Beh6rdenstufen mit zentraler ministerieller Leitung, Reform des Medizinstudiums mit Schwergewichten auf der naturwissensehaftlichen und der klinisch-praktischen Ausbildung, Vereinigung yon Medizin, Chirurgie und Geburtshilfe in der Hand der ~[rzte, klare Unterordnung des nieder~rztlichen Personals (Land~zte, Wund~zte. Bader, Hebammen) unter die Weisungsgewalt der .~rzte, Verbot jeglicher Laienmedizin (der sogenannten Kurpfuseherei) usw. Diese Reform strebte die Sehaffung einer einheitliehen Heilkunde fiir die gesamte Bev61kerung der bayerischen Monarchie an. R6schlaubs Berufung nach Landshut war Tell dieser Reform. Er selbst hat ohne Zweifel die verschiedenen Reformmassnahmen hautnah miterlebt, m6glicherweise auch daran mitgewirkt und miisste sieh eventuell auch dazu ge~iussert haben. Am Beispiel Andreas R6sehlaubs h~itte man wohl zeigen k6nnen, dass die Romantische Medizin nicht in wirklichkeitsfremder Spekulation steckengeblieben ist, sondern auch praktische Aufgaben angeg~iffen und wie sie diese bew/iltigt hat. Leider begniigt sich die vorliegende Arbeit mit einer philosophiegesehichtliehen Darstellung und verziehtet darauf, diese heilkundliche Richtung in ihrer konkreten Anwendung vorzuf~hren. Eine ausfdarliehe Bibliographie, ein Namens- und ein Saehregister sehliessen das Bueh ab. CHRISTIAN PROBST Inst. f Geschichte d. Medizin, Technische Universitiit Miinchen
