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August 31, 2006

"Wootton is so at sixes and sevens as to his own purposes that he sets up a defiance in at least this reader" - Richard D. North on Bad Medicine: Doctors Doing Harm Since Hippocrates - David Wootton

Posted by Richard D. North

Bad Medicine: Doctors Doing Harm Since Hippocrates
by David Wootton
Pp. 304. Oxford: Oxford University Press, 2006
Hardback, 16.99
www.badmedicine.co.uk

So don't be misled by the title of this book. This is neither an attack on the medical profession nor an indictment of modern medicine.
Or so writes the infuriating David Wootton, Anniversary Professor of History at the University of York: Pity: one doesn't say such an enterprise is likely to have succeeded, but it would have been good fun if he had pulled it off. The author's admission that it isn't going to happen comes on the twenty-fifth page of a book which we had by then long realised would not deliver its advertised subject.

One of the arguments Prof Wootton does make is uncontroversial. He remarks:

Until 1865 (when Lister introduced antiseptic surgery) virtually all medical progress [..] enabled doctors to get better and better at prognosis, at predicting who would die, but it made no difference at all to therapeutics.
As we go on, we hear most of the stories one expects: of drains and veins, of laying-in hospitals, and doctors operating in coats caked with mud and blood. They are exciting stories and Wootton tells them in decent prose and at a fair pace.

He acknowledges the unremarkable fact that after 1865, with surgical antisepsis, and much more soon thereafter, doctors made huge strides in making our lives pleasant and long. This can only be made to equate to the idea of "doctors doing harm since Hippocrates" by the tortuous device of pretending that something happening "since Hippocrates" does not imply that it has still been happening quite recently.

We were in with chance that Wootton would deliver on his secondary proposition that

if we do start looking at progress we find that we actually need to tell a story of delays as well as a story of discovery.
But he's just teasing us. Reasonable and exhausted, he lapses back into the uncontroversial, when he says that "failures of the imagination" may have been at work. We are in the bog-standard territory outlined by Thomas Khun in the 1960s, then. Scientists knew more and more stuff, but couldn't put it to work because they were still locked in an old paradigm.

Instead of his vaunted claim to be the first to deliver an account of the delays in medical progress, our professor is screamingly inadequate on this topic. For instance, he describes how 19th century fairground showmen understood how to kill pain with nitrous oxide. He says American dentists eventually used the stuff, but that surgeons were (as it were) very sniffy about it. He say this is because they were committed to the ethos of their particular skill and attitude, in which they took such pride that they couldn't bear to be subverted by a "Yankee dodge". He doesn't really stand up this assertion. And then admits that it was a surgeon, Robert Liston, who was famously good at the old craft, who got into using the new painless techniques.

As we read on, we learn about other mismatches between knowledge and therapy, and they aren't like this case. Indeed, what's interesting is that the knowledge mismatch sometimes didn't matter: Snow knew how to stop London's water killing people but had no idea of the science underlying his success. His paradigm didn't hold him up.

Similarly, in his conclusion Wootton says that 17th century doctors "pushed the microscope" out of medicine the better to keep with their fanciful pre-modern ideas. But his own account of that process, pages earlier, suggests that the very people who understood best the value of the microscopic couldn't then see how to apply it. They weren't being Luddite, they just didn't have 20:20 hindsight.

In short, not malice or stupidity or lack of imagination made delays inevitable, merely the fact that people aren't divine.

Along the way, we get some very peculiar remarks about vivisection. Wootton seems to think we should be leery of the conventional story of the value of live dissection because the pain it involved didn't lead to therapeutic improvement. He thinks we've written the pain out of the story, the better to feel OK about the practice. And yet we are surely mesmerised by the many accounts, on television and elsewhere, of the brutality of vivisection. We are wincingly aware of the pain inflicted by researchers and doctors as they learned. But we don't suppose the progress to have been linear: today's scream, tomorrow's insight, next week's treatment, Bob's your uncle. We understand perfectly well that even (and perhaps especially) now, "pure" research - and torturing animals in its name - is ethically defensible. We reasonably suspect a winding road from A to C even if we don't yet know what C is or where B is hidden.

He is hardly better on the history of the war on smoking. He tells us the conventional story of the way epidemiology was ahead of physiology in finding the smoking gun behind postwar lung cancer figures. And then, as though to prove that we're just as silly as Galen was, and just as proof against progress, he insists that we ignored those sensible people who insisted that smoking was addictive. If only we'd grasped that, he suggests, all would have been well. But there are lots of problems with this idea. One is that everyone has always known that giving up smoking is difficult. Secondly, there is every reason to think that it is not addictive in quite the way that alcohol or heroin are. Addicts of smoking don't become progressively excessive in their use of cigarettes, nor do many of them become criminals. And thirdly: people know all about every aspect of smoking, and it's still cool.

And then, as though to be sure to attempt controversy to the end, he dips into the evidence that it was plumbing and food that did most of the post-1865 good, not doctors. He misses the fact that the more this is true, the less it matters that doctors didn't get better at their jobs, quicker and earlier.

His reading of the evidence is sensible: everything's played a part, and dividing the spoils is complicated. To be this equivocal, he has blithely to ignore the question of quality of life, and the quality of death, which doctors have delivered or could. If I had to be in Nelson's shoes, I'd risk a bet that 2005 would have suited him better than 1805. I have an elderly friend who became a double-amputee at the age of 87: he says he wishes he was dead, but my bet is that he's pleased that he has some pretty powerful pills for his phantom leg pain, and might not top himself even if - happy day - the state let him make the choice with ease. Lots and lots of conventional medicine has kept the old boy alive, and it's the piles that most damage his quality of life. Does that make Wootton's case in some way I'm missing?

Professor Wootton's biggest problem is his grandest. He affects to have found a good deal wrong with the history of medicine, and yet admits that most of his anti-progress remarks follow in a thirty-year tradition of medical history, much of which is dubious. He says he admires the late Roy Porter, and who doesn't? But I don't recognise much Porteriness in Wootton's work. The latter is at pains to distance himself from Ivan Illich. He doesn't like what he takes to be the spoiled priest's crude theories of "iatrogenesis" (doctor-induced illness). My memory of Illich's case - which was almost certainly both inspired and potty - was that he thought doctors had professionalised medical practice, and thereby damaged it. It wasn't the medicine that was wrong, but the institutions within which it was practised. Wootton seems to admire Michel Foucault, but as in his discussion of Illich, gives us slender evidence as to why he finds them interesting.

Professor Wootton seems to think that the principles of Whig historiography have been wrongly applied to medical history. But he gives us very little of the historiography on which he bases this view and by which he might persuade us of it. Instead, he is so at sixes and sevens as to his own purposes that he sets up a defiance in at least this reader. I shall now revert to the happy Enlightenment view of Francis Bacon and the rest: our quest for knowledge has set us on a path, and it leads toward the sunny uplands. Devil take the hindmost and the falterers.

Richard D. North is the author of Rich is Beautiful: A Very Personal Defence of Mass Affluence.

To read Seamus Sweeney's rather different take on Bad Medicine, see: "Anyone with an involvement with medicine - and that means anyone with a body and a brain - should read this brilliant, bracing and erudite book" - Seamus Sweeney on Bad Medicine: Doctors Doing Harm Since Hippocrates.

To read David Wootton's response to Richard D. North's review, see Richard D. North is wrong about my book, Bad Medicine: Doctors Doing Harm Since Hippocrates - argues David Wootton.


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