Indian Journal of Medical Ethics

BOOK REVIEW

The lost domains of the doctor

Meenal Mamdani

DOI: https://doi.org/10.20529/IJME.2006.029


John D Lantos. Do we still need doctors? Routledge, New York, 1997, Pp 214 ISBN 0-ISBN 415-91852-9

The author discusses whether the rapid changes taking place in the medical profession have made doctors redundant. The author is a paediatrician; his father was also a doctor. He describes medical practice as his father experienced it immediately after the Second World War. Doctors could treat fewer diseases than now. Often they could only provide comfort. Medicine then “was a form of healing that primarily involved and inevitably required a relationship between a healer and a patient.”

Lantos feels that patients no longer have that bond with their doctors. Often patients don’t even see the same doctor from one visit to the next because their doctor is not in solo practice, as was the custom, but is part of a group practice. The advances in medicine and technology have made medicine independent of the practitioner. “The new medicine can work for patients who don’t know their doctors or don’t like them,” Lantos writes. Doctors are just one component of a large health care team consisting of other professionals like anaesthesia nurses, dieticians, pharmacists, etc., performing functions that were once the sole domain of the doctor.

Another major change is that medicine today has become a business that follows the rules of the market. To some, this change was inevitable as medicine had to obey the laws of economics like any other profession. But many are alarmed at the change this has brought about where physicians have become focused on self-interest and ignore the interests of the patients as well as their colleagues.

New medicine has raised the expectations of both the patients and the medical staff. Every one expects a cure and is unwilling to call a halt to futile treatments. The author describes an infant born with an incurable disease who has lived in a chronic care hospital since birth. There is little hope that the child can survive to adulthood, yet the mother as well as the nursing staff are unable to accept this reality. Lantos admits that some futile treatments are necessary as rituals. Cardiopulmonary resuscitation is often shown on television as a miraculous treatment but it is often just manoeuvres that give onlookers the comfort that every thing that could be done has been done.

Medical education too has changed. The author describes his former teacher who refused to take his students to transplant patients for bedside teaching. He was appalled that the students were adept at mastering the complex problems of transplant patients but were unable to discuss commonplace medical problems that affect the majority of patients they would see in their practice. In the past teachers were revered, but in the current climate research grants bring in money and teachers who cannot generate revenue rarely get the recognition they deserve.

The author touches on truth telling and the arrival of informed consent in the medical profession. In the past when doctors concealed a bleak prognosis from the patient, they were accused of paternalism. Now doctors insist on telling a patient every thing, even if the patient is unprepared to hear it. Lantos gives examples of how informed consent is no longer a way of sharing the responsibility of making decisions, but has become a way, both for the doctor and the patient, of avoiding accountability. The author also discusses truth telling as it applies to medical errors. He says that though studies show that patients appreciate and respect doctors who come clean about their mistakes, the system encourages people to cover up, believing that a confession leads to a lawsuit.

In the final chapter Lantos answers his rhetorical question, “Do we still need doctors?” The answer is, “Yes we do, as disease and death will always be with us.” The author reminds us that we, as a society, have incompatible expectations: we want a doctor with the latest scientific knowledge but we also want him to maintain an emotional, human bond with us, an amalgam of the ancient and the modern. We want cost containment but also the latest treatment for ourselves even if it is futile. We want today’s medicine to respect individual rights yet be aware of societal needs. Lantos says we need to “think about what is the proper response to illness and suffering, how should we train doctors and how should we shape the institutions that deliver health care.”