IJE Advance Access originally published online on July 26, 2006
International Journal of Epidemiology 2006 35(4):1112-1114; doi:10.1093/ije/dyl152
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Published by Oxford University Press
Book Review |
Dr Golem: How to think about medicine. Harry Collins and Trevor Pinch. University of Chicago Press, 2005, pp. 241, $25.
E-mail: m.bartley{at}ucl.ac.uk
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The present reviewer experienced a degree of disappointment in that the radical analysis of science in society pushed forward by Collins, Pinch, and others in the 1980s is not very much reflected in this book. However, my own feelings about the decline of a critical sociology of science will be of little relevance to most readers. From the point of view of potential readers from epidemiology and public health, what are its strengths and weaknesses? Perhaps one of the main problems will be that some of what is covered is already familiar. For example, whereas the explanation may be very useful for lay readers, the great majority of readers of the IJE will already know why it is necessary to carry out double blind control trials.
The discussion of the ‘experimenter's regress’ is of great interest to the sociology of science and to public health alike. This translation of the work of the philosophers Duhem and Quine into modern studies of science was one of Collins' many major contributions in the 1980s. The Duhem–Quine Paradox pointed out that it is in fact impossible to know whether an unexpected or undesired result of any experiment is due to nature telling you your hypothesis is wrong, or to some kind of problem with the equipment or conduct of the experiment. My favourite example is of Madame Curie repeating her pitchblende experiments over and over until she attained a result that was compatible with her theories. Nowadays we might say, her theories were correct. But at the time, there could have been no logical reason, no reason coming from scientific method alone, which would have justified what she did. In the 1980s, the conclusion that was drawn from this paradox was that the ‘closure’ of a scientific debate, the arrival at a ‘right answer’, was a socially organized event, an event that cannot be regarded as constrained by nature and logic alone. The task of sociology of science and technology was to understand the ways in which those social forces construct the picture of nature that we work with at any particular historical moment. However this is not the main thrust of the rest of the text and would perhaps have been inappropriate for the kind of work the authors were trying to do.
The chapter on bogus doctors may also be interesting to those engaged professionally in public health and epidemiology. As will the chapter on tonsillectomy. The latter is based largely on the brilliant work, many years ago, of the medical sociologist Mick Bloor, who showed that highly experienced doctors gave very different verdicts when shown identical case histories of tonsillitis, as to whether or not surgery would be necessary. Both of these chapters give a fascinating picture of the craft element in medicine, and the importance to everyday practice of medicine's role as an agent of social control. As Collins and Pinch point out, several of the case studies of bogus doctors concerned people with very high levels of competence, in which ‘professional boundary maintenance...[was]...confounded with medical incompetence’. The great majority of bogus doctors were not caught because they harmed anyone, but because it emerged for some organizational reason or other that they were not registered. Imagine what would have been the reaction if Harold Shipman had turned out not to have been on the UK Medical Register. But would this have made his crimes any worse?
In their chapter on Vitamin C the authors point out that since a large amount of what is regarded as orthodox medicine does not do any good, it is hardly surprising that a large proportion of the populations of the USA and UK also use alternative (or as it is now termed, complementary) medicine in addition. It would be interesting to see a study comparing the amount of harm done by each style of practice. But here and in the chapters on CFS and MMR, an opportunity seems to have been missed. Even without reference to the sociology of science of the 1980s, the authors could perhaps have made rather more out of the demand for healer–patient relationships that simply give more time and attention to the patient. As they themselves point out, there is an inherent (but not inevitable) conflict between ‘medicine as science’ and ‘medicine as succour’. This is one of the strongest themes throughout the book. Bogus doctors can practice to good effect for decades because their patients have such trust and affection for them. Similarly, the point could have been made more strongly that there is a huge demand in modern industrial societies for greater understanding about emotional relationships, for help to overcome alienation, loneliness, and unhappiness. Medicine toys with this need, sometimes regarding it as legitimate when it increases the market for medical expertise, sometimes labelling it as a plague of ‘crock’ or ‘heartsink’ patients.
Not enough is perhaps made of the ways in which the MMR affair arose, and persists, because of actions by groups of parents alarmed by the fast-growing numbers of diagnosed autistic children. One of the darkest secrets in the conspiracy that maintains our societies' present troubled relationship to medicine involves intimate relationships between family members, lovers, and close friends. The failures of these relationships are, in my view, not actually any business of medicine. However, in the absence of other institutions to which one may turn when such troubles occur, medicine figures in a major way. And when people are turned away by orthodox medicine, or offered only chemical solutions, alternative or even perilous forms of medicine may be the next port of call.
However, this is not the line followed by Collins and Pinch. They give us instead an overall picture, a very interesting and intriguing one, of the major conundrums in present day medicine. This goes something like as follows. If every disease could be understood as well as we understand a broken leg, then every form of therapy would be as straightforward as setting a bone in a cast. However, for the great majority of diseases, this is not so. As a result we need epidemiological studies to tell us whether, on average, many treatments do any good, or even whether they do more good than harm. However, this indeterminacy has two important social consequences. The most important of these is that knowing ‘how to think about medicine’ in many cases depends on believing the outcomes of procedures like trials, but the Duhem–Quine paradox tells us that we can never in fact know conclusively how far experimental error has influenced these outcomes. Hence the continual debates that we see in the literature, and the importance of meta-analyses (not that these will be totally free of the same paradox). The less important consequence, because it applies in many fewer cases, is the conflict between individual and population health. Taking the MMR debate as their final example they point out that it is possible that very few children may be harmed by the vaccine. However, if a large number of people, due to this uncertainty, fail to immunize their own children, it is certain that a much greater number of children will get the disease, with a proportion of these suffering serious consequences more or less for certain. The individual parent is, therefore, left with an unavoidable conflict between individual and collective interests.
Sociologists have long been uneasy about the kind of apparent moral conflict involved in vaccination debates. All too often, situations that seem to inevitably pit the interests of the individual against those of society turn out to have been avoidable if only the interests of a dominant social group had not been given priority in the first place. In war, individuals often feel they must sacrifice themselves to the collective, but it would have been far better to have peace. It is, therefore, disappointing in some ways to see scholars of the standing of Collins and Pinch not referring even in passing to the power of the pharmaceutical companies, or the interests of the state in using ‘science’ to cover up the damage done by social and economic inequality and domination (what kind of social relations do we have when people feel they must risk their lives in order to express their sexuality?). This does not take away from the quality of ‘Dr Golem’ as a refreshing way to understand a lot of what goes on behind the white coats.
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