BOOK REVIEW / The wounded surgeon: 'The Healer's Power' - Howard Brody: Yale, 18.95 pounds

AT THE heart of medicine lies the physician's power: the technical power to heal; the charismatic power exerted by the doctor's personality and presence; and the social power to remodel the world through genetic screening, selective abortion, or euthanasia. But doctors understand, and so increasingly do their patients, that with power may come its abuse. The ethical practice of medicine is about the responsible use of the physician's power, and in his latest book Howard Brody, a family practitioner who is also trained in moral philosophy, has set out to write a prescription for just such good practice.

Until the Second World War it was generally agreed that disease was an unmitigated evil justifying the forceful, aggressive use of all the doctor's powers. In the absence of many effective specific remedies, the exertion of charismatic power, a good bedside manner, was about all doctors had to carry out their tasks. All that has changed. Doctors have increasingly effective remedies and procedures; their technical power to do good has increased enormously, but so has their ability to cause undesirable, sometimes catastrophic side-effects.

Out of this change has come what Brody calls 'the new medical ethic' - the notion that what is done to patients, however good the physician thinks it might be, ought only to be done with the patients' own consent. Much of the western world now accepts a medical ethic of patient autonomy, even if it is more honoured in the breach than the observance.

Brody is at his best in the first part of this book, where he mounts a critique of this ethic of patient autonomy. He finds it feared by doctors and not much desired by patients; and believes that the transfer of power inevitably deprives the doctor of charismatic healing power, the placebo effect, one of the most important tools of the doctor's trade.

To remedy this, Brody sets out to develop an ethic of the virtuous physician, based on the explicit recognition and responsible use of the physician's power. 'We can have the highest degree of confidence that the healer's power is being used ethically and responsibly,' he writes, 'when that power can be described as acknowledged, shared, and aimed.' For the remainder of his book Brody describes the ways in which a virtuous physician, responsibly seeking to exercise the powers for which patients come to him, might actually do so in various problematic situations in which a general practitioner may find himself. The author's fond hope is that doctor and patient will arrive at agreement by conducting a conversation.

Although his book may be a comfort to many doctors, Brody never adequately deals with the crucial question addressed by an ethic of personal autonomy: when is a physician justified in forcing risks and harms upon a patient without his or her consent, or even against his or her will?

For all his interest in the history and literature of doctor-patient encounters, Brody seems to have misunderstood the sorts of medical dilemmas for which the ethic of respect for personal autonomy was designed. The reason may lie in his medical speciality: general practice. GPs tend to have known their patients and their families over time, and their patients know them. Moreover the GPs' medical choices are often uncontroversial, his alternatives minor, and the risks to patients rather limited.

As Brody knows, this is emphatically not the case for many seriously ill, hospitalised patients who are suffering from conditions whose therapy invariably carries unwanted risks, costs and harms, and who are faced with doctors who cannot be expected to know much about their patients' individual values or preferences. Such patients are truly without power.

It was for this scenario, one where it is principally the physician's great technical power that decides the outcome, that the 'new medical ethic' was developed. But under these circumstances physicians will never have the opportunity to engage in the kind of extended conversation with patients that Brody sees as necessary for the sharing of power.