Alternative Medicine, Authority, Bedside Manners, Book review., Books, Doctor, Edward Shorter, Elitism, Health, Healthcare, History, Joke, Laxatives, Medicine, N.H.S., Opinion, Paternalism, Politics, Psychiatry, Scholarship
I do not particularly care for Edward Shorter’s Bedside Manners: The Troubled History of Doctors and Patients (1985), not least because in being published before the conviction of Harold Shipman and the various popular campaigns against “rationing” within Britain’s National Health Service, it rather throws its light upon the stage before the action which it purports to observe is truly underway. Perhaps the last twenty or so years have lessened the book’s polemical force, or alternatively, its ideas about the proper relationship between doctors and patients may have been somewhat quaint to begin with. Shorter essentially calls for a revival of medical paternalism, and he argues that doctors will derive this authority from treating their patients with greater consideration and “manners.” He contends that the modern family doctor should confront a wider range of afflictions than exclusively biochemical matters, and that they should defy an unnecessary (“post”)modern distinction between medicine and psychiatry.
Terry Eagleton once wondered who would want a perspective if it was truly objective, and one agrees that a work of historical analysis should, if it wishes to have any moral significance, at some level address the great questions of its day. Some writers such as Germaine Greer and Robert Pogue Harrison manage to combine scholarship and political agitation, but Shorter is not so successful, despite both citing many fascinating historical sources and observing consultancies and medical training in the field. In both its historical and contemporary commentaries, Bedside Manners is weakened by its neglect of the economics of healthcare.
Shorter, who is based at the University of Toronto, analyses the healthcare systems on either side of the Atlantic as if they were largely the same, when both North America and Britain are characterised by quite contrary attitudes towards healthcare. Incredibly, for an extensive history of modern medicine, Bedside Manners does not once refer to Britain’s National Health Service. The book makes no attempt to compare the access to healthcare which different nations, in different historical periods, have extended to their populations, or to consider the influence which this may have exercised over the practice of medicine.
Beside Manners nevertheless submits an intriguing and provocative thesis, and one which merits some reflection. Shorter begins with a thoroughly enjoyable study of the “traditional doctor” (one practising between 1750 and 1850), who was “often ruinously incompetent and aggressively meddlesome.” Rather like the clergy, medicine was frequently the destination of bourgeois sons who were not smart enough to be lawyers. The doctor did not enjoy a “great social prestige,” and sometimes he was only distinguished from an ordinary member of the public by having a greater arsenal of laxatives at his disposable. Shorter cites a good joke which satirises the popular faith in laxatives:
Some Kentucky farmer, so went the story, was suffering from “obstruction of the bowels, and all efforts to have them move had failed. Even the best known ’yarbs,’ etc. had been tried, but to no avail.”
So a nearby doctor was sent for. “Waal,” he said, “I’m only a hoss doctor; never tended a human in my life. For a hoss in this condition I would give a half pound of salts, but I guess a quarter of a pound would do for a man.” So he gave the dose and left.
The next day he rode by and asked a neighbor chopping wood near the house, “Neighbor, hev you heard from the sick gentleman over the way this morning?”
“Oh yes, Doc,” said the man.
“Kin you tell me if the medicine acted that I gave him?”
“Oh yes, Doc, it acted.”
“I am glad ter hear that,” said the doctor. “Kin you tell me how many times hit acted?”
“Well, Doc, as well as I can remember, it acted well nigh onto twenty times before he died and nine times after he died.”
The average modern schoolchild probably has a greater understanding of the human body than all the doctors of the eighteenth and early-nineteenth centuries put together. The case of William Withering illustrates the sheer hopelessness of the medical profession:
…in 1785 William Withering published his famous book about the use of the foxglove plant, from which the drug digitalis is derived (digoxin is its active ingredient), in treating dropsy [a swelling which may result from heart failure]. One would think that this might have revolutionized medicine, for digitalis strengthened the heart, thus slowing its rate and making it possible for the kidneys to begin dumping water. But digitalis enjoyed a vogue of only a few years, peaking around 1800. Thereafter it fell into disuse because doctors became so excited about its success that they tried applying it to everything imaginable, for example, tuberculosis, and when it failed with these other diseases they gradually forgot about it.
In an age which promised many a painful and premature death, few concerned themselves with doctors, and they often treated their own illnesses with an ineffectiveness no greater than that of the medical profession. Shorter contends that it was only after 1880, when doctors became progressively more proficient in diagnosis, that they finally acquired authority over their patients. Increasingly equipped with microscopes and stethoscopes, X-Rays and ECGs, they at last affirmed a convincing distinction between medical professionals and amateur “healers.” Yet whilst doctors basked in the glow of science and their newfound social importance and status, their patients became more numerous and demanding. Moreover, “about a quarter to a third” of the symptoms which these patients now displayed were “of psychological origin.”
Shorter contends that “modern” doctors frequently countered psychological afflictions with suggestive treatments, such as prescribing sugar pills or resorting to a range of worthless surgical operations (which included removing ovaries from “hysterical” women, or extracting blood from one arm and injecting it into the other). Most importantly, however, these wily doctors were aware of the “healing power of the consultation.” Shorter cites medical guides from the 1920s which instructed the young doctor how to listen to their patients and how to appear interested in them. The cardiologist Maurice Cassidy was told by his teacher that, “…if you must sit on the patient’s bed, for Heaven’s sake don’t idly turn over the pages of his Daily Mirror while he pours forth his tale of woe.” Medical students of the 1920s were even taught how to conduct small talk at the start of a consultation: “You may always rest assured of interesting your patient if you discuss his hobby…”
Shorter assumes that one will inevitably encounter a significant constituency of patients with diseases of psychological origin. He argues, for example, that this march of the malingerers lately results from factors such as the decline of the family. The public, it seems, are a mad old lot, and they often merely need a bit of sympathy and attention. It may seem unethical to lie to patients, to treat them like children, or to encourage healthy patients in their delusions of infirmity, but Shorter suggests that these practices are a necessary component of enlightened healthcare. He concludes that modern patients often do not have family and friends to care for them, and that only the doctor can replicate the supportive roles once provided by loved ones.
Shorter reports, however, that, “Something is wrong with the practice of medicine today… medicine is currently in crisis.” He claims that the “postmodern” doctor (a term which he uses without any definition or justification) is reduced to throwing pills at every problem, and that “postmodern” patients consequently regard their doctors as unhelpful and uncaring. The subsequent “revolt against medical authority” has inspired a renaissance in “alternative” healing, “holistic” medicine, and “reflexology.” The postmodern patient will often consent to any amount of useless or even dangerous pseudo-medical practice, if they find that it addresses their needs to a greater degree than conventional medicine.
Shorter claims to be advancing “an argument in favour of medical authority,” but he rather undermines this authority – which I agree is central to furthering the progress of medicine – by insisting that the doctor addresses how their patients feel rather than how they actually are. A surprising number of doctors today value and encourage the emergence of alternative medicine, claiming that it allows them to concentrate on those who are genuinely sick. Such doctors may even cheerfully concede that alternative therapies are better for the worried-well than their own solutions. But this too is an abdication of true medical authority, which evades a fundamental responsibility to inform the patient about the health of their body.
The idea that doctors have to undertake popular, strategic concessions to alternative medicine in order to preserve a public confidence in their science, attributes an unjust degree of barbarity to the public. To argue that alternative medicine should compensate for an inadequacy within conventional healthcare is to renew a demand that doctors concern themselves with welfare rather than merely medicine. Shorter doubtlessly identifies many valid failures within (“post”)modern society, but equipping the doctor to combat these ills may paradoxically impair their authority.