Book Review

Profession of Conscience: The making and meaning of life-sciences liberalism

N Engl J Med 1995; 332:1523June 1, 1995

Article

Profession of Conscience: The making and meaning of life-sciences liberalism
By Robert Hunt Sprinkle. 257 pp. Princeton, N.J., Princeton University Press, 1994. $24.95. ISBN: 0-691-03365-X

In the doctors' coatroom, maybe 10 years ago, I heard a colleague say that he had had enough — now he was doing it only for the money. For money alone? Could you make enough, I wondered, not to live in resentment against the fatigue, the perpetual responsibility, the constant worry about error, the interminably intrusive telephone, the second-guessing . . . ? Provide your own list. Imagine what it would be like, I thought, to practice medicine without ideals. The more I reflected on it, the more I realized that there could not be good medicine without the engine of ideals. Good medicine? Medicine that is knowledgeable, technically expert, necessary, and responsible, appropriate to the person (sick or well), the pathophysiology, and the context. But more, medicine that would make the great chief resident in the sky smile down on us. Were all the details attended to, is there someone in the house to help, is the pain really controlled, does the patient know how to use the inhaler, were the patient's questions answered, were all the calls returned, were irritability and bad temper pushed aside (even if with difficulty) by kindness and gentleness?

Good medicine — let us face it — is an unnatural pursuit. We want doctors to function as well when they are tired as when they are rested, to admit error freely to themselves and others, to care more about the patients' being okay than about whether they are right, to put their patients' interests ahead of their own (the unknowing think this is about money; how about time, family, privacy, or freedom?). Surprisingly, over the years this is generally what we have gotten from our doctors, probably because the rewards have, in the past, been so great that they overwhelmed the price. I know why I get up in the morning, that what I do has intrinsic value. Much has been written over the ages about these ideals and about the ethics meant to guide the conduct of individual physicians.

But what about the politics of these ideals? By now, who is not aware that medicine exists in a political context that greatly influences the ability of the individual doctor to live a life devoted to medicine? On the other hand, the ideals of medicine have been brought to bear on large political struggles. “Since the Nuremberg Trials following World War II,” Dr. Sprinkle points out, “ethically principled political activism among life scientists, physicians, midwives, and nurses has been widely and, for the most part, favorably noted.” Why, he asks, did the world movement of physicians against nuclear war stop at that problem? There are so many issues, from chemical warfare through the insufficiency of health care to pharmaceutical profiteering, where the heritage of the ideals of the life sciences (he expands the tradition to all the life sciences) has something important to say.

The basic principle of our tradition he calls life-sciences liberalism, the belief that “the life-scientist serves all best by serving each alone.” This whole compelling book revolves around proving that “it is service to the individual, seen or unseen, present or future, that makes moral sense of research and practice. It is service to aggregates of individuals — state, corporation, institution, society — which has led again and again to trouble.” The book is in some sense a history of this tradition, which Sprinkle grounds in the writings of John Locke (1632–1704). Most of us know Locke as the political philosopher whose writings profoundly influenced Thomas Jefferson and the American Revolution. Sprinkle never lets us forget, however, that Locke was a working doctor, whose ideas were nourished by medicine and grounded in the actual experience of suffering humankind. Locke's empiricism was greatly indebted to Thomas Sydenham's mentorship and example.

Thence through Sir William Osler himself and Osler's interest in Locke, the tradition is seen to grow in intellectual strength and influence. Albert Schweitzer, Sprinkle argues, rounded out the basis of the tradition in coming on the idea that medicine's moral compass, grounded in service to the individual, was completed by the fundamental concept of reverence for life. Sprinkle is very concrete and practical about what he means by life-sciences liberalism, its assumptions and assertions, its general and internal conditions, all of which he summarizes in eight rich paragraphs; all are based on the best tradition of clinical medicine — acute, unbiased, historically fastidious, plainly argued clinical empiricism. Liberal he is, arguing for the primacy of the individual over the state, corporation, marketplace, political party, or any other conglomerate — no matter how right it may believe itself to be. In a number of sometimes cranky chapters he nails his points home, example by example.

Look at the scattered landscape of contemporary medicine, where ideals have been blighted, and not just by the marketplace. Look at medicine in your own terrain and compare it with the ideals that the care of the sickest demands. Robert Hunt Sprinkle has a message for us.

Eric J. Cassell, M.D.
Cornell University Medical College, New York, NY 10021