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Follies and Fallacies in Medicine.

This frustrating book is sound in conception but disappointing in execution. The authors' avowed "goal is an ordinary person's guide to the limitations of medicine," in pursuit of which objective they argue for careful criticism and rational inquiry. Their often sprightly, always iconoclastic expose of false beliefs and faulty reasoning comes in chapters on placebos, fallacies, diagnosis and labelling, prevention, alternative medicine, and morality and medicine. So far, so good. But the text--which appears to be partially fleshed out notes from lectures to medical students--has the character of a promising but unfinished preliminary draft.

The chapter "A Fistful of Fallacies" identifies twenty-six distinct ways in which careless thinking infects reasoning and judgement about medical matters. The reader is advised that to keep the truth from being obscured or mangled, "we must become sensitive to subtle signs." One expects rigor to pervade such a chapter, yet in places there is an almost stultifying superficiality, if not outright error. For instance, one page after correctly affirming the need for care in making casual judgments, and even claiming that faulty imputation of casuality "is the most important reason for error in medicine," the authors write, "If A is associated with B but precedes B, it still remains possible that B is the cause and not the consequence of A." No subtleties here!

Their seventeen-line dismissal of consensus conferences is dazzlingly facile. "One thing at least is certain--no one knows the truth; if they did there would be no need for the conference." Yet the same paragraph later affirms that in an argument between two extreme views, one of them may be true. The implicit assumption here is that persuasion based on the merits of the case cannot occur.

In discussing "the Fallacy of Obfuscation," they claim that "'uncompensated care' refers to the absence of care for those citizens of the United States who do not have health insurance," thereby exemplifying the fallacy they purport to scorn. Then, "Diseases that do not have names do not exist." Is it a comfort to the families of those thought to have died of Legionnaire's disease before it was named to learn now that they just died, but not of any disease? And after lauding "critical appraisal, good data, and sound experiment," the authors describe a large study of hypertension, writing, "By twelve weeks 16 percent of those men tking the diuretic, 14 percent of those taking propranolol, and 9 percent of those taking the placebo had become impotent; ...this suggests that attaching the label 'hypertensive' has, of itself, deleterious effects." Yet that suggestion is premature unless we have data about the natural incidence of impotence in a suitably selected and unlabeled control group. And there's not a word about that.

The chapter on prevention comes out vehemently against a broad array of public health efforts, especially those aimed at obesity and smoking. But the tone of the book hits its nadir late in the six-page chapter entitled "Morality and Medicine," where we are brought up short by the assertion that "concern for 'national health' is one of the hallmarks of totalitarian societies." That it is also a hallmark of free societies goes unmentioned. The chapter ends with a quotation from Hitler in opposition to smoking, the point presumably being that to oppose smoking is in some nontrivial way to be like Hitler.

On the last page of this ostensible encomium to meticulous reasoning, we actually find as "an indictment of our selfish world" the claim that medical advances have done little to help "those millions of our fellows who are still 'nasty, poor, brutish, solitary and short [sic].'" The absence of a deeper development of important points is not due to lack of space; this book, at 115 pages of text, could easily have been expanded in the interest of greater accuracy. That is was not is a pity; a carefully done book of this kind could have been very useful. But given its disdainful tone, crude reasoning, and brevity, the book itself calls Hobbes to mind; it is "poor, nasty, brutish, and short."

[Samuel Gorovitz is dean, College of Arts and Sciences, Syracus University, Syracuse, N.Y.]
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Author:Gorovitz, Samuel
Publication:The Hastings Center Report
Article Type:Book Review
Date:May 1, 1992
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