book reviews : investigating disease patterns: the science of epidemiology. second edition. by paul...
TRANSCRIPT
do, it is up to those who organize, manage and fa-
cilitate professional learning to make such material
available.
Professor Noel Boaden
Senior Research Fellow
Department of Health Care Education
The University of Liverpool
3rd Floor, UCD
Duncan Building
Liverpool L69 3GA, UK
Ethical Problems in Clinical Practice: the Ethical
Reasoning of Health Care Professionals. First
edition. By S. Holm. Manchester University Press, UK.
£45 (hardback), £15á99 (paperback). pp. 222. ISBN
07190 5049 9.
To say that little is known about the ethical rea-
soning of health care professionals is rather like
saying that Columbus discovered America. Ethical
problems have always been part of clinical practice
and medicine was the ®rst profession to articulate its
own ethical standards. But in the large and growing
modern literature on bioethics, there are few empir-
ical studies of how doctors and nurses actually think
(as opposed to how they ought to think) about eth-
ical issues, and fewer still from Europe. This book,
by example and precept, begins to make up for these
de®ciencies.
The meat of the book is a research report, well
illustrated by verbatim extracts from interviews with
respondents, on how Danish doctors and nurses per-
ceive ethical problems in everyday clinical practice, how
they reason about these problems, and how their rea-
soning is in¯uenced by organizational pressures. Dr
Holm's main ®ndings include: the importance of `pro-
tective responsibility' (responsibility to protect from
harm, rather than an unlimited bene®cence) in health
professionals' thinking about patients; signi®cant dif-
ferences in what health professionals perceive as ethical
as opposed to technical problems; and the identi®cation
of particular organizational factors which can inhibit
the recognition and possible resolution of ethical
problems. While much of this sounds familiar, such a
meticulously researched and philosophically articulate
account of the subject is new and valuable. Practical
implications include the suggestion that medical ethi-
cists should take more interest in the dynamics of or-
ganizational change, and that medical educators should
be concerned with ethical perception as well as with
ethical reasoning skills.
The research report comprises about half of the
book. It is sandwiched between three introductory
chapters defending the need for descriptive ethics and
the scienti®c status of the qualitative research method
used in the study, and a ®nal chapter discussing how far
one can generalize from it. These chapters will be very
useful to anyone attempting similar work in the future.
They contain helpful philosophical as well as method-
ological insights, including a good critique of Kohlberg
and Gilligan and an accessible explication of the
methods of qualitative research. As someone quali®ed
in medicine, philosophy and research methodology,
Holm is aware that `hard-nosed' practitioners of these
disciplines may doubt that much can be learned from
his qualitative study of 49 doctors and nurses in a small
European country. But attentive readers of his book will
gain more than enough to lay such doubts to rest.
Dr K M Boyd
The University of Edinburgh
Royal In®rmary of Edinburgh
Edinburgh, UK
Investigating Disease Patterns: The Science of
Epidemiology. Second Edition. By Paul D. Stolley
and Tamar Lasky. Scienti®c American Library, New
York. Available from McMillan Distribution Network,
Basingstoke, UK. 1998. £15.95. pp. 242. ISBN 0 7167
6024 X.
With that title, this book might be a textbook with a
modern trendy approach or it might be a series of de-
tective-style case stories to introduce the methods of
epidemiology to the lay reader. It is the latter. The
approach of the book is summarized in the ®rst chapter
where the authors make their pitch for epidemiology to
be considered as a science in its own right and claim
their ground. They start with the plague ± the classic
epidemic ± and extend out to claim the right to
interpret any form of illness or ill health.
There is a good chapter dealing with the early history
of epidemiology, essentially characterized by the gath-
ering and use of statistics ± one of the continuing
themes of the book is that epidemiology is really a set of
methods that can be applied to various disciplines,
microbiology initially, then biochemistry, genetics and
molecular biology, that allow the practitioner to go
ahead of the hard science and give an idea of where to
look to solve the origins of the disease.
As the book widens its area of investigation from
infectious diseases through cancer, heart disease and
Book reviews
662 MEDICAL EDUCATION 1998, 32, 658±668 Ó 1998 Blackwell Science Ltd
the environment, each of the cases allows and requires
the introduction of new methods ± the calculation of
odds ratios, case control studies, cohort studies, ran-
domized controlled clinical trials, the concept of safe
levels, etc. as they become necessary to cope with new
problems. Thus, in the modern idiom, the concepts are
only introduced in context and hence become memo-
rable. The book concludes with modern issues of ia-
trogenic disease, screening, the maintenance and audit
of an effective health care system and a look at the
future prospects for world health.
Despite its tendency to advertise (many successes, no
failures) and its Anglo-American perspective, it is a well
written and produced book, easy to read and under-
stand. It has relatively few overt errors (two graphs have
wrongly labelled axes), but it fails to explain the real
signi®cance of the reason for measuring the LDL form
of cholesterol or of the problem of chirality in the
thalidomide tragedy. It is strange too that the story of
asbestosis is illustrated with a picture of silicosis.
`Boxes' are also used somewhat idiosyncratically, often
to give de®nitions that are also in the main text, but also
include a literary excerpt and a separate case study.
There is a question, too, about the level at which the
subject is covered. The text, for instance, mentions that
odds ratios range between two values, but does not
indicate how the range is obtained or what its signi®-
cance might be.
These issues are not a problem, however, when
presenting the subject to lay readers, and it would be
wrong to judge the book as if it were a textbook. It is
from the Scienti®c American library and designed for a
non-medical public. As such it is a glossy, easy-to-read
and well-produced introduction to the world of epide-
miology.
John A Smith & Anne S Garden
Phase 2 Coordinators
The University of Liverpool
Liverpool, UK
Basic Pathology ± An Introduction To The
Mechanism Of Disease. Second edition. By Sunil R.
Lakhani, Susan A. Dilly & Caroline J. Finlayson.
Edward Arnold Publishers, London. 1998. pp. 329.
£18.99. ISBN 0 340 67787 2.
Anyone who has a concept of a pathology textbook as a
compendium of variations in pink and purple spots is in
for a pleasant surprise if they browse through this text.
The authors have done an excellent job of pro-
ducing an integrated text which is well illustrated,
well laid out and as easy to read as it is possible for a
pathology text to be. The text is interspersed with
icons indicating short self-assessment type questions
to check knowledge and understanding; `spotters'
likely to form the basis of written examination ques-
tions; interesting snippets of information that would
be invaluable were Pathology ever to be a basis for
`Trivial Pursuit'; and de®nitions to aid the memory.
The authors have produced a text which is as user
friendly as it looks, ful®lling their objective to design
a text that should be read fully and at leisure (yes ±
really!).
The authors have worked to produce a text that is
integrated at many levels. The contents are not ar-
ranged according to systems but according to the basic
pathological tenets of `In¯ammation, healing and
repair'; `Circulatory disorders'; `Cell and tissue dam-
age'; `Cell growth and its disorders', and `Genes and
disease', with disorders of the different systems used
to illustrate the principles. The use of clinical scenar-
ios to introduce a topic allows pathological processes
to be integrated with the clinical situation throughout.
A particularly good example of this are the diagrams
illustrating myocardial infarction showing distribution
of the infarct related to vessel involvement, sequelae of
the infarct, and macroscopic and light microscopy
changes that occur in an infarct with time, even
touching on associated ECG changes. Integration with
other disciplines is also good, particularly the chapter
on infection written in collaboration with a microbi-
ologist colleague.
Criticisms are few and relatively minor. More
careful proof reading would have picked up situations
where tables are referred to as `above' when they are
in fact below the text; there is inaccurate ®gure
numbering, especially in Chapter 1, and Turner
syndrome is variously referred to, within a few pages,
as 45X, 45,X and X0. Throughout, the excellent
®gures and tables are poorly referred to in the text
and, while it is usually quite clear where they belong,
being explicit about it would be an advantage in an
undergraduate text. Having a specialist clinical col-
league to cast an eye on the chapters would avoid
such things as chemotherapy being described as `a
relatively new and rapidly evolving form of treat-
ment', while immunotherapy for cancer is described
as `being used to treat a variety of tumours with some
good effect' giving a false impression of their relative
use in clinical practice. Equally, an obstetrician
reading the chapter on detection of foetal abnormality
might be slightly surprised to see foetoscopy being
included as an invasive test still employed in clinical
practice.
Book reviews
663 MEDICAL EDUCATION 1998, 32, 658±668 Ó 1998 Blackwell Science Ltd