Book Review

Humane Medicine

N Engl J Med 1996; 334:670-671March 7, 1996

Article

Humane Medicine
By Miles Little. 195 pp. New York, Cambridge University Press, 1995. $49.95 (cloth); $16.95 (paper). ISBN: 0-521-49513-X (cloth); 0-521-49863-5 (paper).

Because the epistemologic basis of medicine is probabilistic, it is difficult for patients to give truly informed consent for a treatment. The patient seeks a factual answer to questions: “Will I get better?” “Will I have a complication?” The clinician offers a probability: “You have a 90 percent chance of getting better.” So says philosopher and surgeon Miles Little. From this he deduces that better doctor–patient communication is essential if medicine is to be more satisfying to its customers, the patients, and that a humanistic education will lay the proper foundation for better communication.

This recommendation, which many physicians have advocated, will interest readers less than Little's rigorous critical thinking as he builds toward his conclusion. Along the way, the reader will encounter some definitions of basic schools of philosophy and receive a grounding in the philosophy of science. Little is concerned about autonomy, and he points out that illness, any illness, diminishes autonomy. He devises a utility–cost ratio that takes into account the effect of this loss of autonomy on the quality of life. He explores ethics from the viewpoint of professionalism, which he defines as “knowledge of a department of learning applied to the affairs of others”; hence, professionals could not, in Adam Smith's words, “be people of very mean or low condition,” since others must entrust their health and welfare to the professional. Professional ethics, therefore, stress moderation in fees and self-advertisement, respect for the autonomy of clients and for others in the profession, confidentiality, and abhorrence of fraud, says Little. Trustworthiness would appear to be at the heart of professional ethics. From this comes the insight that professional bodies work by consensus and cannot insist on altruism or discourage competition; instead, they should try to encourage the preservation of “the service ideal, seen in the context of the purpose of the profession.”

Little traces the bioethical movement in normative ethics, which seeks justifications for codes governing moral behavior, to utilitarian or deontological foundations. To his mind, it is confusing that so many clinicians adopt willy-nilly whatever seems useful to buttress their arguments, thereby mixing utilitarian concerns with arguments based on individual or universal values.

Little explores the distinction between solicited and unsolicited paternalism, on the one hand, and true paternalism, on the other; he believes the latter is justified in the case of incompetent patients. He traces modern ethical movements to the Nuremberg Code governing research involving human subjects, which evolved from the Nazi war-crime trials. This code placed informed consent at the heart of ethics involving human subjects. He traces another source of disagreement to that between professionals who are deontologists and “contend that the proper motives and aims of professionals ensure adherence to ethical practice,” and activists, who are utilitarians and believe that outcomes should be measured and used to control professional behavior, thus applying an external standard.

All this may be fascinating to physicians and students of medicine interested in its philosophical basis. The beauty of Little's book is its lucidity. It is at once sophisticated and clearly written. It presumes some basic knowledge of medical ethics and is not a primer. Little provides some interesting examples of ethical problems, revealing himself as more a deontologist than a utilitarian. As such, his clear thinking may be convincing to readers and may clarify some of their thinking.

Humane Medicine will increase one's understanding of the moral basis of medical practice. The reader, however, will still be left to struggle with the timeless moral predicament of one human being who takes responsibility to care for another, who has diminished autonomy. How can we appreciate the scope of this responsibility, its importance, its demands on one's skills and appreciation of another? Little's book opens many avenues that will enhance physicians' philosophical and humanistic background in relation to this basic moral stance of medicine. His belief that a humanistic education, one that includes an understanding of literature and an appreciation for it, will be helpful may be true. I suspect that it is life experience, however — dealing with and experiencing pain and suffering oneself and in one's family — that may best equip physicians for their responsibilities. Patients seem to understand this, and often seek a doctor with experience. This essential aspect of medicine can be learned, and perhaps it can also be taught a little.

William T. Branch, Jr., M.D.
Emory University School of Medicine, Atlanta, GA 30303