So Long, Succor

Dr. Golem is the third in a series of books by Harry Collins and Trevor Pinch that aim to make the insights of science and technology studies (STS) accessible to general readers.¹ The Golem, the first of the series, consisted of a number of chapters based on prominent case studies in the social construction of scientific knowledge and highlighted the various contingencies and uncertainties inherent in the work of scientific knowledge production.² The Golem at Large did the same for technology.³ Now Dr. Golem extends this formula to medicine. As Collins and Pinch acknowledge, however, the turn to medicine required them to confront a number of problems that they had not encountered in their previous volumes. We all come into contact with medicine many times in the course of our lives, and in ways that differ dramatically from how we generally experience science and technology. As patients and as objects of pervasive medical surveillance and advice, we not only consume medicine but constantly find ourselves making or participating in medical decisions with profound implications for our health and our lives. Collins and Pinch intend Dr. Golem to help us make the best choices in our inevitable encounters with medicine. Hence its subtitle: where the first two Golem volumes told us "what you should know" about science and technology, this book tells us "how to think" about medicine.

As in the previous Golem volumes, much of Dr. Golem is devoted to identifying and explicating the various kinds of uncertainty that beset technical knowledge and practice—in this instance, of medicine. As a science-based practice, medicine shares the epistemic uncertainty inherent in all science. Collins and Pinch illustrate this in a chapter on the controversy over vitamin C treatment for cancer, based on Eveleen Richards's detailed study.⁴ Neatly summarizing Richards, they show how the evidence generated by a series of clinical trials failed to sway either those scientists who initially advocated such treatment or those who opposed it—a nice example of a general phenomenon that Collins has elsewhere labeled the "experimenter's regress."⁵ In the case of medicine, this epistemic uncertainty is compounded by the physiological variability of the human organism and its susceptibility to complicating factors such as the placebo effect. In consequence, scientific knowledge of the effectiveness of many forms of medical treatment can only be acquired through statistical studies of populations, while the effects of those treatments on particular individuals can never be predicted with complete certainty.

In addition, the relationship between scientific knowledge and medical practice is itself often uncertain. Thus techniques such as tonsillectomy and cardiopulmonary resuscitation flourish in the absence of scientific evidence that they provide any medical benefits, while the fact that bogus doctors working in hospitals and clinics sometimes go undetected by their qualified colleagues for long periods of time suggests that formal scientific knowledge may not even be a precondition for providing satisfactory medical care. Meanwhile, public awareness of these various kinds of uncertainty has in turn fueled wider doubts about the authority of medical experts. This has been expressed in various ways. Groups of patients are increasingly inclined to take their own experience of sickness as a basis from which to argue for the existence of hitherto unrecognized diseases, often in the face of medical skepticism. In some cases, such groups have managed to involve themselves in the work of scientific-knowledge production itself, as for instance when AIDS activists successfully challenged and helped to redefine the methods by which knowledge of therapeutic efficacy is generated. More worryingly, doubts about medical authority have sometimes led to outright rejection of medical advice, for instance when the publication of highly speculative claims about a possible link between MMR vaccination and autism led many parents to decide against immunizing their children.

In outlining these various sources of medical uncertainty, Collins and Pinch also aim to provide guidance on how best to think about and respond to them. Overall, they are cautiously optimistic about the benefits that will follow from critical public engagement with medicine, particularly where the evidential basis for specific practices is weak or nonexistent and [End...