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Edited by M Lock, A Young, A Cambrioso. Cambridge University Press, 2000, £15.95/US$24.95, £42.50/US$59.95, pp 295. ISBN 0521652103
This collection of essays is the outcome of a conference addressing the problems arising from the conjunction of medicine and the humanities with the ever more pressing concerns of bioethics. Since this is a fairly recent development the introduction summarises the argument about what constitutes science and whether it is culturally located. Throughout this well-produced book there is room for discussion and dispute as is inevitable in any interdisciplinary work.
The first part of the book lays the theoretical foundations. Rheinberger discusses the enormous change in the ability to control the biological make up of mankind that molecular medicine and gene therapy offer. This will effectively end the nature/culture juxtaposition. These deliberations are then placed into a philosophical perspective by Rabinow.
Part 2 moves into the real world of laboratories and clinics. Lowy discusses the important role that the concept of controlled randomised clinical trials plays in introducing scientific rigour into medicine (in fact this preceded molecular biology by many years), leading ultimately to the development of centralised, multicentre trials of cancer drugs involving close collaboration between research labs, industry and clinics, this in turn leading to quasi routinisation of dealing with incurable diseases. A comparable case is the search for anti-HIV drugs by desperate patients, which has become an interplay between pharmaceutical firms and governmental agencies dependent on the cooperation of patients willing to take part in the trials. Thus politicisation begins to move the debate out of the purely scientific arena; and AIDS activists have gained a definite, though limited, influence which highlights the social science component of modern medicine. Clinical interviews in relation to pathological investigations show that patients have a part to play in making both clinical and surgical decisions, which in turn are influenced by wider social considerations of cost and efficacy. Throughout it is emphasised that decision making in diagnosis and subsequent treatment depends on various kinds of authority, literature, people's own experience, and a spontaneous sociology or philosophy of the science in question. Young's discussion of post traumatic stress disorders also emphasises fashion in psychological diagnosis and the sociocultural location of interpretation of mental states.
In part 3 Kaufert examines breast and cervical screening as techniques and airs the debate on whether such screening is cost-effective and at what price to individuals at risk from false positives. Looking at Down's syndrome children, Rapp highlights the disjunction between technological advance in genetics and biotechnology and the human response of families who care for such children. A further chapter deals with “biomental” or “biosocial” conditions, notably MCS (multiple chemical sensitivity) and finds that in the light of conflicting interests and under-funded research any explanation of these sociomedical disorders is likely to be temporary and locally determined. The last two essays deal with organ transplantation and unpack the problem of the dichotomy of the “gift of life” that organ donation from brain dead persons presents, versus any sentiments concerned with keeping dying patients intact—a dilemma that is much felt even within the medical profession. Approaches differ between the US and Japan. The ethical dilemma is compatible but at present there are various solutions. Ethics are generally more implicit than overt but it is agreed that they are diffusely socially determined. The final essay, which considers the ethics involved in transplant procuring whether by gift, selling or cadaver donation, finds that regulations aimed at safeguarding certain rights may themselves infringe customary perceptions of what is moral. Some of the problems would benefit from an anthropological approach that takes account of the specificity of small local communities.
There are no final answers in this book, but the at times diverse essays bring together highly topical discussions about the rights and wrongs of a world that is just opening up.
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