Book Review

The Healer's Power

N Engl J Med 1993; 328:67January 7, 1993

Article

The Healer's Power
By Howard Brody. 311 pp. New Haven, Conn., Yale University Press, 1992. $30. ISBN: 0-300-05174-3

Doctors are inherently powerful. In The Healer's Power, family physician-philosopher Howard Brody argues that medical ethicists should avoid using the principle of autonomy to whittle away at physicians' power. Instead, those in the field of ethics should help doctors better understand and use their Aesculapian, charismatic, and social powers.

Aesculapian power is gained through training in the discipline, art, and craft of medicine. This power arises from the knowledge of facts, techniques, and treatments; it is an impersonal power and can be transferred to another physician. Charismatic power is based on the physician's particular personal qualities, such as courage, decisiveness, firmness, and kindness. It is not transferable. Social power arises from the high status of the physician, who generally earns a high income, lives in a good neighborhood, and uses language in such a way that others will defer to his or her wishes even when corrections are made for the influences of Aesculapian and charismatic power.

Brody illustrates these separate elements of power with several compelling stories, beginning with “The Chief of Medicine.” The Chief is a Grand Inquisitor-like physician who cynically uses Aesculapian power but relies primarily on his charismatic and social power to lord it over patients and medical students. Aesculapian power is explored through Vonda McIntyre's haunting tale “Of Mist, and Grass, and Sand.” In this story, Snake, an unattractive healer of low socioeconomic status, visits a young boy dying of an epigastric mass. Her primary tools are Grass, a small, pale green snake who calms fears and soothes pain; Sand, a rattlesnake; and Mist, an invasive cobralike serpent. After grueling and elaborate preparations, Snake directs Mist to bite the child's abdomen. The viper strikes quickly and with fury, sinking its fangs into the tumor. Later, the mass begins to shrink. As Brody explains, Snake is full of Aesculapian power but lacks any social or charismatic power. At the end of the treatment the patient is cured, but the healer slinks away exhausted and famished.

Through these and other examples, the author outlines the responsible use of power. He suggests sharing power through truthful disclosure and informed consent. He points out the tension between the physician's high income and his or her need to identify with patients. Brody points out that the virtuous physician avoids “using [his or her] power against the patient . . ., and thinking that [he or she] is a superior being, immune to the criticism that mere mortals earn.” Sometimes the best we can say about a doctor is that he or she was constantly trying to learn, recognize, and understand.

This is an important, thoughtful, and well-written book. It suffers from a number of small flaws. In an attempt to avoid sexist language, the author often calls doctors “she” and patients “he.” Since Brody links the paternalistic use of power with the misuse of power, this fixed use of pronouns seems paradoxical and even jarring. It might have been better to vary the choice of pronouns, even with the confusion this can bring. In addition, while Brody argues for empowering both physicians and patients, his arguments sometimes seem to lean too heavily on the doctor's moral obligation to talk. But the medical encounter is not an interrogation of the doctor by the patient. The sharing of power is not necessarily directly related to high-flow, high-volume conversation. But little defects like these are not enough to mar the book's fine finish seriously.

The Healer's Power is a book physicians should read. It explains why we are not qualified to “perform” medicine. In the end, the arrogant use of power brings harm to both patients and doctors. We are licensed only to practice medicine, and in practice, we can learn to use our healing powers with fear, trembling, restraint, and humility.

David Schiedermayer, M.D.
Medical College of Wisconsin, Milwaukee, WI 53226