Strangers at the Bedside

<p>David Rothman gives us a brilliant finely etched study of medical practice today. Beginning in the mid-1960s the practice of medicine in the United States underwent a most remarkable--and thoroughly controversial--transformation. The discretion that the profession once enjoyed has been increasingly circumscribed and now an almost bewildering number of parties and procedures participate in medical decision making.</p><p>Well into the post-World War II period decisions at the bedside were the almost exclusive concern of the individual physician even when they raised fundamental ethical and social issues. It was mainly doctors who wrote and read about the morality of withholding a course of antibiotics and letting pneumonia serve as the old man's best friend of considering a newborn with grave birth defects a stillbirth thus sparing the parents the agony of choice and the burden of care of experimenting on the institutionalized the retarded to learn more about hepatitis or of giving one patient and not another access to the iron lung when the machine was in short supply. Moreover it was usually the individual physician who decided these matters without formal discussions with patients their families or even with colleagues and certainly without drawing the attention of journalists judges or professional philosophers.</p><p>The impact of the invasion of outsiders into medical decision-making most generally framed was to make the invisible visible. Outsiders to medicine--that is lawyers judges legislators and academics--have penetrated its every nook and cranny in the process giving medicine exceptional prominence on the public agenda and making it the subject of popular discourse. The glare of the spotlight transformed medical decision making shaping not merely the external conditions under which medicine would be practiced (something that the state through the regulation of licensure had always done) but the very substance of medical practice--the decisions that physicians made at the bedside.</p>