7cil Book Reviews

mcatlon field has a very nch tradmon dating back to the Class& penod of Anstotle and has much to offer those who are about the busmess of researchmg or lmprovmg commumcatlon m medlcme and the health care context more generally

It IS unfortunate the Knapp and Mdler’s Hundbook of Interpersonal Communrcatron offers very httle to those who are attemptmg to apply commumcatlon theones to the medical context Only the final secnon of the book deals with commumcatlon contexts, and medunne/health care IS not represented One 1s also struck by a self-consciousness that pervades most of the essays m tms book The readings seem to focus largely on esotenc commurucatlon issues, wntten by commumcatlon scholars for commumcat~on scholars The same cnucrsm, of course, has been leveled agamst medmal texts by social sclentlsts lookmg for a more general understandmg of modem medlcme In both cases, drsclphnary cross-over 1s dlfficult at best If commumcatlon offers to be the dlsclphnary bndge, the Handbook of Inter- personal Commumcat~ons takes us across only a mmor tnbutary

Socml sclentlsts wrll gam more from this book than ~111 their medical colleagues but they too ~111 find this volume lackmg The selection of essays lacks real coherence They seem to be loosely coupled articles meandenng toward no partmular pomt of view This IS not to say, however, that some of the selections may not be useful to social sclentlsts or those m the field of mednnne Bochner’s ‘Perspectives on Inqmry’ provides an excellent example of the dlversuy of scholarly inqtury w&m the commurucat~on field Poole and McPhee’s essay on commumcatlon methodology IS an excel- lent compamon piece to Bochner’s article It has a great deal to offer social wentlsts and medlcal researchers Interested m going beyond parocmal studies of doctor-patlent com- mumcatIon Fmally, Berger’s piece on social power and communication helps underscore the importance of control and power m health care relatlonshlps It may also support the emergmg agenda among many younger physlclans not to take issues of power for granted

These three essays are especially relevant to those mter- ested m human commurucatlon processes m me&me and health care The book as a whole does not warrant either the purchase pnce nor the attentton of scholars or practmoners outsrde the field of commumcat~on Its shortcommgs rest with a fadure to address coherently the notlon that the commumcahon process may be the stuff which ties soclal sclentdlc mqmry with unique human contexts such as medlcme

Department of Commumcatton Unwerstty of South Florrda Tampa, Fla, US A

LOYD S PEllXGREW

Virtue and Me&me: Explorahons m the Character of Med- mine, edned by EARL E SHELP Reldel, Dordrecht, The Netherlands, 1985 363 pp Dfl 135/E34 5O/S48

The most useful essays m this volume aren’t those that take an uredentlst view of vutue as the once and future core of medlcal etmcs A sounder case IS made by those who argue that vutue, whether that of physslan, nurse, or patlent, IS one necessary mgredlent, balancmg duty- and r&s-based approaches (We can grant that the last of these, at least, had perhaps begun to get out of hand m the wake of the clv11 nghts movement )

Four groups of essays are presented Not even the ednor, one Imagmes, would expect all readers to track all of them to the last word Hlstonans of medlcme or ethics ~111 find an alBmty for the first section, those more concerned with vutue theory m Itself, with the second How vutue and medlcrne are related IS the thud focus The book concludes

with a hvely exchange m which vtrtue as a cntenon of medlcal ethics IS welghed, assaded, and praised

Repetmon m moderatlon Isn’t an unreasonable pnce to pay for what IS astutely assembled and comprehensively treated Yet one does tire of readmg about Anstotle’s and MacIntyre’s theones of virtue (22 and 27 index entnes) Equally trymg IS to be recurnngly catechized on ‘excellence,’ ‘dlsposmon,’ and ‘Internal correlauves to practice’ as the orthodox stuff of vutue Still, fresh ways of speakmg of vutue and the vutues m medlcme are found here They “blunt the physIcIan’s self-Interest and duect him to the best mterest of the patlent” (Laurence B McCullough, after Austm Flmt, p 90) They serve as “reasons for preference m the exlgencles of hfe” (Edmund L Pmcoffs, p 126) They shape “how persons present themselves as choosers who take themselves senously and take their commuruty senously” (Edmund L Erde, p 201) There IS even a Taoist version of health-care vutues, msunng “that mdlvlduals have the fewest possible departures from a ‘natural re- latlonshlp’ to their envuonment” (Marc Lappe, p 294)

Vutue IS best understood, finally, as part of a consortmm of ethics loci, not as an Independent standard “In the vutuous physician,” writes Edmund D Pellegnno, “exphat fulfillment of nghts and duties IS an outward expression of an mner dlsposmon to do the nght and the good” (p 247) Or as Tom L Beauchamp succmctly puts It, “Moral pnn- clples of duty correspond to moral standards of vutue” (P 315)

If tms volume helps to restore vutue to Its due place m medical ethics-by showmg how it IS the Inward aspect of outward conduct-n often falls to rescue the correspondmg notlon of duty Wnters on virtue tend to thmk of duty m a pseudo-F’untan sense m which one IS presumably dra- gooned under protest mto doing what IS proper But Immanuel Kant, for all his allegiance to law, didn’t mean anythmg hke that Duty always proceeds, he mslsts, out of a “good and acuve ~111” Thus the great champion of deontologlcal (or duty-based) ethics says about the same thing that the fetchers of the virtue-based mlllemum do Once we see that, we are onto a substantial insight for medlcal ethics Virtue, duty, and nghts are not only essential to any practical ethics, but they also have a good deal m common Still, they pomt to different parts of a whole To leave any of them out IS to lmpovensh the moral enterpnse m health care T’hls volume IS a large help toward reahzmg that conclusion

Department of Reltglour Studtes Race Umversrty Houston, Tex , US A

JAMES SELLERS

The Experience of IBnesa, by RAY FITZPATRICK, JOHN HINTON, STANTON NEWMAN, GRAHAM SCAMBLER and JAMES THOMPSON Tavlstock, London, 1984 292 pp $16 95

More than two decades ago Ehot Freldson conceptualized the dlffenng perspectives and pnorltles of patients and practltloners as a ‘clash of perspectives ’ Those who have an Illness and those to whom they go for medlcal help may have fundamentally different stances on the defimtlon and treat- ment of the ailment In a book entltled The Experrence of Illness one would expect a definite emphasis on the patlent’s or sufferer’s perspective, especially since the author’s stated purpose IS understandmg the expenence of illness and treatment (p 4) However, this IS only partly achieved

Social scientists have argued for a conceptual dlstmctlon between disease and Illness, with disease constltutmg the blomedlcal reahty and Illness the social reahty But wnhm the frame of Illness, social sclentlsts have been less clear and consistent In dlstmgulshmg between behavior and expen- ence To overslmphfy a comphcated dlstmctlon, Illness behavior takes an ‘outsider’s’ vlewpomt focusmg on behav-

Book Reviews 701

1or and obJecWe action while illness expenence takes an ‘insider’s’ vlewpomt focusing on subJectlve expenence and meaning At the very least, an expenence of illness approach focuses on the sufferer’s or patient’s perspective of illness and medical encounters, m a more developed form, It examines how people expenence and manage their illnesses m their everyday lives

By such a definition this book is mconsistent in Its approach to the expenence of illness The chapters are mdmdually wntten by one or more of the authors and m general are dlscusslons of published literature rather than new research Several of the chapters focus directly on the expenence of illness Fltzpatnck’s excellent chapter mtegrat- mg soc~ologcal and anthropolo@cal work on lay concepts of illness and Scambler’s provocative chapter on percelvmg and managing stlgmating illnesses are fine contnbutlons to understandmg illness expenence The chapters on patients’ satisfaction with health care (concludmg that patients’ greatest dissatlsfactlon was wth the lack of mformatlon provided by their medical caregivers) and anxiety and hospitalization deal generally with important aspects of patients’ expenence Other chapters, however, present a murkier view of the expenence of illness The chapter on illness behavior, while a fine review m its own right,, doesn’t dlstmgmsh clearly between behavior and expenence and thus obscures as much as it enhghtens The chapters on social class, ethmclty and compliance lose the expenence of illness focus altogether For example, the dlscusslons of social class center on the use of health services but not from the perspective of the user In the compliance chapter, the patient’s point of ylew 1s not developed beyond the health belief model and the focus IS more on achlevmg compliance than on understanding expenence

Whde this book 1s dlsappomtmg as a exposition on the expenence of Illness, It contains some very competent and comprehensive review articles that should be useful to social scientists interested m health and illness

Department of Socrology Brandeu Unrverstty Waltham, Mass, US A

Montefiore: The Hospital as !Sacial Instrument, 18844984, by DOROTHY LEVENS~N Farrar, Straus & firoux, New York, 1984 338 pp $19 95

Dorothy Levenson’s MonteJore traces the history of a maJor mstitutlon from its phllanthroplc ongns to Its late twentieth century position as teachmg hospital and medical empire Published for Montefiore’s amtenmal, this account mcorporates the virtues of mstltutlonal htstory and over- comes some of its limitations

Montefiore 1s of more than local interest for two reasons It 1s unusual, a highly promment mstltutlon that helped shape hospttal admnustrahon, innovated mth new servtcq and produced sqruficant medical research In other ways, It is typical, a case study m the larger and as yet unwntten hlstory of hospltdls m the twentieth century

Levenson IS most successful m her presentation of Montefiore’s special character Like the best mstltuhonal histones, Montefore conveys the nch partlculanty of its SubJect Levenson skillfully develops the narrative of the hospital’s growth Its physlcal expansion, Its changing char- acter as medical therapeutics became more sophstlcated, Its shifting constituency as the city around It changed, the Jewish phdanthroplc tradition that informed its politics and pnonties The strongest focal points are the changes wrought under different admmlstrators, Levenson evokes the personahtles and politics that shaped the hospital over a century

The book reaches beyond these particulars to situate the hospital within urban, medical, and social history Here

Levenson’s ambitious agenda IS only partly met In an engagmg introduction, she remmds us that the history of a hospital IS more than the record of sczntdic achievement Hospitals are powerful forces and valuable resources m the pohhcs and everyday life of the city they serve diverse and sometimes wamng constltuenaes, mcludmg phdanthroplc supporters, taxpayers, educators, doctors, patients and ur- ban neighbors And if hospitals are sometimes the stages for dramatlc medlcal miracles, Levenson also recogmzes the more mundane feats of integration and coordmatlon that make complex mstitutlons work the hlstory of the hospital IS also the record of the dady labors of nursmg, house- keeping, laboratory work, record-keepmg In colorful vignettes and hvely descnption, Montefiore portrays the changmg scene at the hospital, from the care of long-term inmates at the nmeteenth-century home for chrome mvahds to the tension and con&t that surround the mstltutlon m the embattled Bronx of more recent years Levenson sketches the politics and environment of New York City, and makes some effort to place Montefiore’s history m a natlonal context But her laudable comnutment to a broad presentation IS not matched by an adequate synthetic style, one that would control the difficult balance of chronology, thematic development, and mterpretatlon Though the chapter headmgs suggest a thematic orgamzatlon, the nar- rative skips abruptly from one subJect to another, wlthout clear signposts or mdlcations of the relative importance of each topic

Nonetheless, Montefiore represents a slgmficant step to- ward the kmd of hospital history that Levenson prescribes Its fadures are not entirely the fault of the author m the absence of scholarly research on the history of hospitals after 1930, Lcvenson 1s wntmg m an hlstoncal vacuum Her careful and highly readable story of Montefiore provides the kmd of case study that others may btnld on to assemble a fuller account of the lustory of hospitals m the twentieth century

Medical Sctences Dawon BARBARA MELOSH Natronal Museum of American HIstory Smlthsoman Instttutton Washmgton, D C , U S A

Enghsh and Amencan Studtes George Maron Untverslty Fawfax, Va, US A

NoSeaseofPlace:lRehpsctoflGetro~Mediaaa~ Rehior, by JOSHUA MEYRO~~~Z Oxford University Press, New York, 1985 416 pp 322 50

In this readable, well-supported book, Meyrowltz reylews the traditional views of Goffman’s dramaturgcal model and McLuhan’s medium theory Meyro\krltz uses these unusual compansons to draw new insights At the same urne he examines changes m social behavior when new media merge or dude exlstmg mformatlon systems

In the book’s second sectlon, ‘From Prmt Sltuatlons to Electronic Sltuatlons,’ the author argues we are now ex- posed to the ‘backstage’ of social life because the electronic media expose us to more mtlmate and informal messages than pnnt Moreover, the traditional defimtlons of social posltlon and place are undergomg redefimtlon Dlstmct roles of public and pnvate behavior are now blurred, he suggests, as a result of cameras allowmg us to witness events that once were vlewed only by those m the lmmedrate environment

Meyrowtz focuses his attention on three roles undergoing change masculinity and femmmlty (group Identity), chdd- hood and adulthood (soclahzation), and poht~cal leaders and followers (hierarchy) He concludes that changes m media from pnnt to electronic may have much more to do