Dr. Golem: How to Think about Medicine (review)

There is one thing that Harry Collins and Trevor Pinch did not need to worry about as they completed their interesting and perceptive book on medical practice: that someone would steal their title. Dr. Golem is one of a series of books they have written that explore the diffusion of science and technology into society. In Jewish mythology, the golem is an animated being made of clay and water that is both powerful and clumsy. Collins and Pinch argue, as would be imagined, that medicine is both powerful and clumsy. Through a series of case histories, they tell complicated stories about a series of interesting topics—including tonsillectomy, chronic fatigue syndrome, and cardiopulmonary resuscitation (CPR)—in which medicine does both good and bad. Throughout the book, the authors return to two themes: the challenge of using population-based data in individual cases, and the double-edged sword of patient activism. "Our topic," they write, "is the making of medical judgments in the face of the uncertainties and tensions found within even the most well-conducted and unbiased of sciences" (p. 17).

Collins and Pinch, both sociologists involved in the field of science and technology studies, would surely be the first to note that their book is uneven. A chapter on the placebo effect goes into almost numbing detail about the methodology of the randomized controlled trial. A chapter on frauds who pretend to be physicians seems out of place. In addition, beyond the book's episodic nature, it is curious from a historiographic perspective. Many of the chapters rely heavily on the work of other authors (all duly cited). The chapters on alternative medicine, chronic fatigue, and AIDS activism, for example, regularly cite Evelleen Richards, Robert Aronowitz, and Steven Epstein, respectively. The AIDS chapter is essentially reprinted from one of the earlier "golem" books, The Golem at Large. As a result, those well read in the history of medicine may feel they are simply revisiting old material.

But for those interested in the epistemological quandary of the book's subtitle, "How to Think about Medicine," the repackaging of this familiar material will prove valuable. Collins and Pinch argue convincingly that the recent history of medicine contains more uncertainty than certainty. And central to medical decision-making has been the challenge of balancing available research data with the care of individual patients. Why did such a brilliant scientist as Linus Pauling incorrectly conclude that research studies proved that Vitamin C cures cancer? Why is CPR, the limited value of which has been known for decades, used so widely and indiscriminately? Were AIDS activists right to insist on obtaining AZT before its worth had been proven or disproven in clinical trials? The authors use these anecdotes to describe how modern patients frequently confront similar issues in their doctors' offices. Of particular value are the discussions of statistics. How applicable are randomized controlled placebo trials to the care of individual patients? When, if ever, does it make sense to buck current scientific thought and embark on experimental therapy? Should patients sometimes, as in the case of childhood vaccines, tell their well-meaning physicians "No thanks"?

The authors clearly admire patients—for example those with chronic fatigue, fibromyalgia, and autism—who research information about their diseases before they go see the doctor. Such people, they believe, can more effectively question physicians about their diagnoses and possible treatments. But at the end of the day, Collins and Pinch emphasize that there are limits to lay knowledge: "Science can be wrong . . . but this does not make the opposite view right" (p. 202).

Perhaps Dr. Golem is best exemplified by chapter 8, in which Collins and Pinch chronicle the recent surge of opposition to the routine vaccination of children. For example, they discuss the value of the Measles, Mumps, and Rubella (MMR) vaccine as well as the claims that it may cause autism. Their conclusion—that there is no proof of the...