Edited by D Thomasma and J Kissell. Georgetown University Press, 2000, £46.75, pp 300. 0-87840-810-X

• Thomasma D, Kissell J, editors The Health Care Professional as Friend and Healer: Building on the work of Edmund Pellegrino

This book is dedicated to Dr Pellegrino and the editors invited those to whom he was leader and friend to contribute chapters on topics that have marked his career over the years. It is in four parts: the nature of the health care professional; the moral basis of health care; current challenges, and medical education. The tone is set by an initial seminal chapter from Leo O’Donovan SJ entitled A Profession of Trust: Reflections on a Fundamental Virtue. As the subtitle indicates, it builds on Pellegrino’s work to do with the idea of the internal morality of medicine. Both Pellegrino and MacIntyre have developed this concept, originating in the work of both Aristotle and Plato. In the first chapter of part II Veatch analyses the concepts of internal versus external sources of morality for medicine. He argues that a purely internal morality is impossible since the ends of the practice of medicine cannot be derived without considering the external ends of human living itself.

Despite the fact that 20 of its 24 contributors are not from Georgetown University, this book emphatically and unashamedly carries the Georgetown imprimatur. It originated in the somewhat controversial thesis of John F Monagle that the special characteristic of the relationship between “healer” and patient lies in the idea of friendship. This is well weighed and criticised in a chapter by Davis entitled Friendship as an Ideal for the Patient-Physician Relationship: a Critique and an Alternative. He points to the problems inherent in the friendship model, which are mainly centred on the power imbalance.

Among the contributors, one is a nurse, another is a dentist, and six are physicians. Clearly not all of these are still working at the clinical “coalface” and, if this is so, neither of the editors and none but a few of the contributors are working in what a philosopher colleague of mine has called “the dirty end of the business”. On the one hand this means that, for me as a card carrying clinician very definitely at that end, the book is far too metaphysical and, therefore, unbalanced. My main objections are, first, that nowhere is the necessary concept of the health care professional (HCP) as a risk assessor and manager considered. Second, the concept of the physician (and by extension, other HCPs) as healers is taken as a given. Regrettably the concept of healing is nowhere defined or analysed satisfactorily.

It must be emphasised, however, on the other hand, that those trained as physicians who have moved to “higher things” and those whose expertise is in other disciplines, have a great deal to teach us “jobbing physicians”. This book, therefore, contains a great deal to which we should pay particular attention now. The deprofessionalisation of medicine (that has been a clear, politically driven process under successive governments in the UK) is well considered by Donovan in his chapter on The Physician-Patient Relationship. I agree totally that these trends “do not bode well for society” (page 15). I kept on returning to the aforementioned chapter by the Jesuit, O’Donovan, A Profession of Trust: Reflections on a Fundamental Virtue. He reminds us that, while trust is at the heart of being a good doctor, we practise “in a society in which the corrosive signs of mistrust are ever present and ever powerful” (page 3).

Although I have reservations about this book I found many sections of it very meaningful. “The health care professional as friend and healer” is, however, only part of the picture.