The Courage to Fail By R. C. Fox and J. P. Swazey (review)

The Courage to Fail. By R. C. Fox and J. P. Swazey. Chicago: University of Chicago Press, 1974. Pp. 395. $12.95. Therapeutic innovation—the trial of new drugs, operations, or medical procedures—involves many difficult decisions, both technical and human or emotional in nature. It is a feature of our medical life which must be nurtured, cherished, supported, and made as safe as possible, if we are to continue to progress with diseases still plaguing men and women in the prime of life. Of these several aspects, this book concentrates on one—the human or emotional aspect, with a few bits on the scientific aspects. The authors mix in, in about equal proportions, some historical notes on the development of dialysis and transplantation (particularly of kidney and heart), reportage including newspaper accounts and dialogues from scientific meetings, and a series of interviews with patients and their families. The object is to set forth some of the ethical and sociological aspects of dialysis and organ transplantation. This work invites the authors to be more specific about the patients themselves . This would have been an opportunity to analyze attitudes toward poor prognosis and death, with possible modification by transplantation or dialysis. It might have been interesting to compare some of these findings with those in the Kübler-Ross book on death and dying. Part 1 deals with issues raised by giving and receiving organs—the "gate function " of sorting out who gives and who receives. The technical problems of rejection are reviewed with their implications to the patient and surgeon. This is a well-documented and detailed discussion, largely of kidney transplantation. Part 2 presents an emotional-sociological portrait of the "transplant surgeon." He has "the courage to fail." There follows a long discussion of the problems of heart transplants, with apparently little recognition of the fact that the 1968-1969 development of heart transplantation in Texas was probably one of the saddest periods in the history of American surgery. While the book builds up the physician and surgeon as having the "courage to fail," he can also misunderstand the nature of biological and biochemical science. The authors should emphasize that the "gate-keeping" function (i.e., decision making for entry into a therapeutic system) is not in any sense unique to new trials but is commonplace throughout medicine. It is exercised daily with such problems as electrical defibrillation, an operation for cancer, or chemotherapy. There are much detailed case study material and frequent references to the literature. There are also many quotations loosely selected from interviews, as well as newspaper clippings. The organization and structure are in vivid contrast to Tillich's The Courage to Be, which is a closely reasoned, systematically developed book expanding on the meaning of the title. The writing is excellent and the breadth of view is most refreshing. The authors put their finger on one very important point, namely, the highly questionable political ethics involved when the United States government singles out but one specific disease for federal support—in this case, kidney disease. They write: ". . . although HRl provides economic relief to persons suffering from grave kidney conditions, it raises the question of why renal disease should have been singled out for coverage while other catastrophic illnesses were ignored." That a patient's bodily organ disease should become a mechanism of selfselection for federal dollar subsidy is quite unacceptable. If one is chronically ill 428 I Book Reviews and suffering, and tax dollars are to help, such help should not be conditional on anatomy: on the kidney as opposed to the liver, the spleen, the bone marrow, the intestine, or some other part of the body! Despite a few shortcomings, this book is a "must" for every young physician and surgeon who is involved with the trial of new procedures in the environment of the modern teaching hospital. Francis D. Moore, M.D. Mitchell Goldman, M.D. Christopher Gates, M.D. Department of Surgery Howard Medical School What Are We Living For? Practical Philosophy. Vol. 2. The Logics. By Chauncey D. Leake. Westbury, N.Y.: PJD Publications, 1974. Pp. 202. $7.00. The author is a statesman of science, medical scientist, historian, teacher, administrator...