The Healer's Power (review)

Abstract

Book Reviews 319 NOTE 1. Erving Goffman, Frame Analysis: An Essay on the Organization of Experience (New York: Harper and Row, 1974). —Samuel A. Banks Eckerd College Howard Brody, The Healer's Power. New Haven, Conn.: Yale University Press, 1992. xiii + 311 pp. Clothbound, $30.00. Philosophers tend not to be the most reliable guides through the precincts of power. Their penchant for precision, clarity, and consistency tends to be frustrated by the general untidiness of power relations. But Howard Brody is a distinctively positioned philosopher in that he is also a family doctor and a teacher of aspirants to the art. He philosophizes about physicianly power as a wielder of such power and from familiarity with the ambiguities and incongruities of ordinary lives. Brody argues that medical ethics is chiefly about the responsible use of power—Aesculapian power, charismatic power, and social power. Aesculapian power derives from knowledge that the doctor acquires by studying human anatomy and physiology and by rehearsing the use of stethoscope, scalpel, and magnetic resonator. It is impersonal and transferrable to anyone with the requisite physical and mental capabilities. By contrast, charismatic power is thoroughly personal. No mere catalog of physicians' virtues, charismatic power is the name for the ways in which doctors are present to patients in person. Social power derives from medicine's social contract and takes the form of a virtual monopoly on authority to define disease and its remedies and to designate who is to be deemed sick. Beyond these privileges, in consumer societies, social power is rewarded and reinforced by affluence and other signs of status. Brody believes that responsibly mixing and modulating these aspects of the healer's power are what morally sound medical practice is about: "The problem is to empower physicians for the performance of their essential tasks while protecting the patient from the potential misuses and abuses of power" (p. 36). And if this is the problem, then the solution, in Brody's view, is to share power. The book begins with a long, lightly veiled monologue deUvered 320 BOOK REVIEWS by an ascetic, authoritative Chief of Medicine to a well-meaning but wayward neophyte, whose sensitivity to a dying patient's family has led her to break the code of silence surrounding the patient's true condition . This beginning suggests that Brody believes that there is, for his present purposes, something seminally instructive about Dostoevsky's "Grand Inquisitor." The Chief of Medicine, a severe character, but not altogether unsympathetic, excoriates the novice for failing to appreciate that "in times of great need and fear, the millions do not want meaning; they want magic . . ." (p. 6). It is all well and good to offer people choices in sickness, but only the few can freely choose and then Uve with the consequences. What most patients, most of the time, want from medicine is miracle, mystery, and authority. Freedom is too hard; "patients have a need to recognize authority and bow down to it" (p. 8). In doing so, they find comfort and even cure. By modifying the Inquisitor's view of human nature—that freedom is beyond the reach of the many—to apply only to the sick, Brody makes the Chief of Medicine's view as plausible as possible before rejecting it. The bulk of the book is devoted to arguing that patients' interests are best served, and even the most enlightened medical paternalism is best kept in check, by sharing power in the doctor-patient relationship. The Chief of Medicine clearly believes that physicians possess the power to heal. So does Brody, though he disputes that the power to heal depends on keeping patients in the dark about its limits. But doctors do not possess power, except in the obvious sense that, as trained professionals, they command a body of knowledge. However useful that knowledge may be as a means to diagnosing and treating disease, it is not healing knowledge. Dostoevsky's Christ-figure knows (as does the Inquisitor, though he pretends not to know) that healers are instruments of power, not its possessors. Their power is on loan. It is theirs to wield but not to own. For medical ethics, the merit of a...