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September 04, 2006

Richard D. North is wrong about my book Bad Medicine: Doctors Doing Harm Since Hippocrates - argues David Wootton

Posted by David Wootton

Bad Medicine: Doctors Doing Harm Since Hippocrates
by David Wootton
Pp. 304. Oxford: Oxford University Press, 2006
Hardback, 16.99
Review by Seamus Sweeney
Review by Richard D. North

David Wootton's recent book, Bad Medicine: Doctors Doing Harm Since Hippocrates, has been reviewed on the Social Affairs Unit Web Review by both Seamus Sweeney - "Anyone with an involvement with medicine - and that means anyone with a body and a brain - should read this brilliant, bracing and erudite book" - and, taking a very different view of the book, Richard D. North - "Wootton is so at sixes and sevens as to his own purposes that he sets up a defiance in at least this reader". Here Prof. Wootton responds to Richard D. North.

My book Bad Medicine: Doctors Doing Harm Since Hippocrates has been reviewed by both Seamus Sweeney and Richard D. North on this site. Their views are strikingly divergent. How can a book that one reviewer finds "brilliant, bracing, and erudite" seem "screamingly inadequate" to another? How can a book in which, as even its critics acknowledge, the "reading of the evidence is sensible" be at the same time so "infuriating" as to provoke "defiance"?

The argument of Bad Medicine is pretty straightforward (Seamus Sweeney gives an excellent and detailed account of its central elements), but the context is complicated: it is an intervention in three highly contested debates:
1) A debate about history: Can historians legitimately write about progress?

2) A debate about science: Do scientists discover or construct scientific truth?

3) A debate about medicine: How good is medicine at extending life and relieving pain?

On each of these questions people hold strong views, and one of the many interesting things about bringing the three questions together is that the views they hold on one question don't necessarily fit very well with the views they hold on the others.

For example, Richard D. North thinks it is "uncontroversial" that medicine did no good before 1865. It isn't uncontroversial: if he had heard the Today programme on 23rd June 2006, when my book was discussed, he would have heard Professor Harold Cook, Roy Porter's successor as Director of the Wellcome Institute for the History of Medicine in London, roundly rejecting this "uncontroversial" claim. At the same time as North believes that there was no progress in therapy before 1865, he concludes, amazingly enough, that:

our quest for knowledge has set us on a path, and it leads us toward the sunny uplands.
Well, doctors have been involved in a quest for medical knowledge since 500 BC, so how come they made no practical progress before 1865? How come people believed Hippocratic/Galenic medicine worked, when it didn't? Why were nineteenth-century doctors able to make progress when their predecessors had so signally failed? How much progress has medicine made since 1865? These should be central questions for any adequate history of medicine.

Unfortunately thirty years ago the historical profession decided to stop writing about progress. If the quest for knowledge is, as North believes, an upward path, shouldn't the history of knowledge be a history of progress? North appeals to the Baconian tradition, so I guess he believes that science deals in facts. Why then is there a two hundred year gap between the discovery of germs and the triumph of the germ theory of disease? Why did penicillin have to be discovered not once, but five times? These are some of the questions my book asks and answers.

Part of the answer to all these questions is, as North puts it, "that people aren't divine". A theologian or even a philosopher might think that's a complete answer to some question that makes sense to them; but I'm an historian. When I was fourteen my history teacher (the late great Joe Hunt) wrote on one of my essays:

Yes, but this would be true of anyone, in any place, at any time.
The questions I'm asking in Bad Medicine are historical questions, and so they need a particular sort of answer. I'm sure - for like North I believe in progress - my answers can be improved on. My central claim (the one that North apparently can't grasp) is that I'm asking the right questions.

North thinks I'm at sixes and sevens as to my own purposes. Perhaps he should have paused to consider the possibility that he hadn't understood what I was trying to do. But I'm happy to admit that my answers to the three big questions aren't necessarily the obvious ones, and they aren't necessarily ones that North (or anyone else) would share: I wouldn't have thought the book worth writing if I was simply repeating the received opinions. And it would have been even shorter if I thought the three big questions were susceptible to yes and no answers:
1) I think we can have a history of progress, certainly (though not only) where technologies are concerned.

2) Overall (and this is where things may seem complicated), I refuse to choose between empiricism and constructivism as I think it's a false choice. But on specific questions, in the context of specific debates, I'm prepared to come down on one side or the other. I think you need to be a constructivist (or more of a constructivist than most historians have been prepared to be) to understand why a belief in spontaneous generation and in miasmas survived into the late nineteenth century, despite the invention of the microscope. But I think you need to be an empiricist (or more of an empiricist than most historians have been prepared to be) to understand how Galileo's telescope revolutionised astronomy.

3) I think medicine isn't nearly as good at extending life as most people think it is (but it's better than McKeown thought it was).

The evidence and the arguments I deploy fit neatly with these answers to these questions.

North's big misunderstanding of my purposes is linked to a number of indicative and straightforward misreadings. He thinks my book is sympathetic to Foucault; Sweeney, on the other hand, thinks it is contra Foucault. Sweeney is right and North is wrong - the evidence is there in Sweeney's review. North says I don't agree with Illich on iatrogenesis, but I do agree with him on this, even though I disagree with him on other things - and I'm delighted that Christopher Peachment learnt about iatrogenesis by reading my book.

One of the new questions that I ask and answer is when did doctors first recognize the central importance of iatrogenesis? You can see where North might have misled himself. He may have thought that anyone who is prepared to take a constructivist line on a key topic in the history of science must be an admirer of Foucault; he may have thought that anyone who admires the achievements of modern medicine must disagree with Illich on iatrogenesis. But if this is what he thought, then the moment he started thinking like that he stopped reading the book he had in front of him.

I'll be posting shortly on my website ( a list of other reviews and discussions of Bad Medicine, with web links where available, and in the near future I'll be writing and posting an extended response to my critics, both temperate and intemperate. There I will discuss their peculiar reluctance to engage with a topic which Seamus Sweeney rightly sees is at the very centre of my book: the history of evidence based medicine. There I will also discuss what we can call for present purposes "the winding road" argument: that, in the version propounded by North, torturing animals is ethically defensible, even if we have no idea what purpose it will serve - in this form, it's not an argument on which one needs to waste many words. And I'll discuss the important and interesting issue a number of my reviewers (including both North and Sweeney) have raised: the role of hindsight in historical understanding, particularly in our understanding of progress. But first, I urge you to follow Seamus Sweeney's excellent advice: read the book! After all, when did you last read a book that was "short, brilliant," and "bracing"?

David Wootton is Anniversary Professor of History, University of York.

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