David Rothman presents us with a brilliant, finely etched study of the practice of medicine today. Since the mid-1960s, the practice of medicine in the United States has undergone a remarkable - and utterly controversial - transformation. The discretion the profession once enjoyed has been increasingly limited, and now an almost staggering number of parties and procedures are involved in medical decision-making.
Even in the post-World War II period, bedside decisions were almost exclusively the concern of individual doctors, even if they raised fundamental ethical and social issues. It was mainly doctors who wrote and read about the morality of withholding antibiotic treatment and allowing pneumonia to be an old man's best friend, of considering a newborn with severe congenital malformations as a 'stillbirth', thus sparing the parents the agony of choice and the burden of care, of experimenting on the institutionalized handicapped to learn more about hepatitis, or of providing one patient and not another with access to iron lungs when a machine was in short supply. Moreover, it was usually the individual doctor who decided these matters without formal discussions with patients and their families.
The impact of the invasion of bystanders into medical decision-making was to make the invisible visible. Medicine's outsiders - that is, lawyers, judges, legislators and academics - penetrated every nook and cranny of medicine, thereby giving medicine a unique prominence in public policy and making it the subject of popular discourse. The glare of the spotlight transformed medical decision-making, shaping not only the external conditions under which medicine would be practised (something the state, through the regulation of licensing, had always done), but the very essence of medical practice - the decisions that doctors made at the bedside.