Book Review

Seeds of Mortality: The Public and Private Worlds of Cancer

N Engl J Med 2003; 349:1780-1781October 30, 2003

Article

Seeds of Mortality: The Public and Private Worlds of Cancer
By Stewart Justman. 220 pp. Chicago, Ivan R. Dee, 2003. $24.95. ISBN: 1-56663-498-9

In Seeds of Mortality, Justman cleverly interweaves his own experience as a patient with cancer with reflections on works of literature, the visual arts, and philosophy to create an insightful commentary on how cancer is viewed by American society. This is not the typical pathography that has become increasingly common in bookstores, nor is it an academic thesis, despite Justman's background in academic English literature. Rather, it is a critique of how cancer and patients with cancer are viewed by the medical profession, by the rhetoricians of the cancer self-help movement, and by American society. In his critique, Justman draws on his own experience and sets his argument in the context of a cultural experience drawn from literature, art, and philosophy. Many of his insights will interest practicing clinicians in general and not just oncologists.

Justman confronts large issues in many fields of medicine. For example, he addresses the ways in which medical uncertainty affects patients' autonomy with regard to the screening for and treatment of serious disease. His experience with prostate cancer left him feeling that by choosing to have a screening test for prostate-specific antigen, he had unwittingly given up his choice not to have treatment for a disease that many men are said to die with rather than from.

Justman also discusses the notion that there is a conspiracy of silence about certain diseases. He mentions not only the extreme view that the military–industrial complex deliberately hides the release of carcinogens into the environment but also the idea that patients need to break the social silence about certain diseases. Both of these arguments are developed in the context of Rousseau's ideas that the causes of disease lie in our way of life and that transparency and self-revelation are good in themselves. However, Justman explicitly challenges the idea that transparency is always a benefit by considering what is not known about prostate cancer and whether transparency about the uncertainty regarding the best treatment is always helpful to patients. He argues that there is “a time to keep silent and a time to speak.” Transparency should be tempered with reticence — a silence that is the “depth dimension of speech.” This is not a call for paternalism but, rather, a rejection of the idea of transparency in everything. It is a call for thoughtful, sensitive communication.

The strength and at the same time the weakness of this book for physicians is the way the author brings his knowledge of literature, philosophy, and cultural history to bear on his experience of living with cancer. Justman's insights can be profound, but this type of synthesis is not one that every physician will find accessible.

Richard Meakin, M.D.
Royal Free and University College Medical School, London N19 3UA, United Kingdom
r.meakin@pcps.ucl.ac.uk