Book Review

Medicine at the Crossroads: The Crisis in Health Care

N Engl J Med 1993; 329:894-895September 16, 1993

Article

Medicine at the Crossroads: The Crisis in Health Care
By Melvin Konner. 250 pp. New York, Pantheon Books, 1993. $27.50. ISBN: 0-679-40781-2

Melvin Konner, an ethnologist (and former student of the !Kung San, or Bushmen), has written five books about medicine, including one chronicling his own education, Becoming a Doctor (New York: Viking, 1987 [reviewed in the Journal, 1988;318:125-127]). From the title of his most recent book, one expects a work describing some milestone or crossroads -- a crucial turning point for medicine -- where important decisions for the future must be made. Instead, the book is a leisurely, talkative, entertaining, and readable stroll through eight biomedical or ethical problems. These are issues and misunderstandings involved in the doctor-patient relationship; the debate about primary care versus specialization; the proper uses of new drugs, genetic engineering, and new operations, specifically cardiac surgery (there is no mention of transplantation); the debate about functional as compared with organic brain disease (the central enigma of psychiatry); the problems posed by aging and death; and issues surrounding the AIDS epidemic. The author grazes in these familiar pastures, avoiding quick acceptance of iconoclastic views, setting forth both sides of the controversy in most cases. In the last chapter, curiously entitled “Epilogue,” he makes a quick pass through the thicket of health policy. Although his title might lead the reader to believe that this is the focus of the book, it is an afterthought.

The epilogue includes the usual comparisons of the U.S. system with nationalized or single-payer systems and speculates about what legislation is needed in the United States to assuage our pain. After only 11 pages of this discussion the author concludes with four mandates: simplify the bureaucracy, limit the rapid growth of for-profit corporations in patient care, avoid overspecialization, and reduce malpractice litigation. His bias against specialization is repeatedly made clear, but he never comes to grips with the fact that everyone is against specialization except the patient.

Almost inadvertently, the book expresses one of the startling enigmas of medicine today -- namely, that the substantive content of bioscience in patient care, whether in diseases of the mind, the heart, age, or immunity, has almost nothing to do with policy decisions on how new legislation should be crafted or with the nature of our grievance with a system gone awry. On the one hand the book celebrates, bemoans, or cautions against the triumphs and traps of biomedical science today., and then, all of a sudden, it shows its other side, suggesting that some sort of legislative or bureaucratic fine tuning will rectify the application and distribution of this science to suffering humanity.

At the start, seeing a teaching hospital referred to as a “temple of science,” one is frightened that this book will merely reflect another set of reportorial platitudes, an impression not lessened when new drugs are referred to as “magic bullets.” But the book is better than that. Konner comes up with some illuminating and at times entertaining discussions of pressing problems in medical science, the heart of the book.

Francis D. Moore, M.D.
Harvard Medical School, Boston, MA 02115