do, it is up to those who organize, manage and fa-

cilitate professional learning to make such material

available.

Professor Noel Boaden

Senior Research Fellow

Department of Health Care Education

The University of Liverpool

3rd Floor, UCD

Duncan Building

Liverpool L69 3GA, UK

Ethical Problems in Clinical Practice: the Ethical

Reasoning of Health Care Professionals. First

edition. By S. Holm. Manchester University Press, UK.

£45 (hardback), £15á99 (paperback). pp. 222. ISBN

07190 5049 9.

To say that little is known about the ethical rea-

soning of health care professionals is rather like

saying that Columbus discovered America. Ethical

problems have always been part of clinical practice

and medicine was the ®rst profession to articulate its

own ethical standards. But in the large and growing

modern literature on bioethics, there are few empir-

ical studies of how doctors and nurses actually think

(as opposed to how they ought to think) about eth-

ical issues, and fewer still from Europe. This book,

by example and precept, begins to make up for these

de®ciencies.

The meat of the book is a research report, well

illustrated by verbatim extracts from interviews with

respondents, on how Danish doctors and nurses per-

ceive ethical problems in everyday clinical practice, how

they reason about these problems, and how their rea-

soning is in¯uenced by organizational pressures. Dr

Holm's main ®ndings include: the importance of `pro-

tective responsibility' (responsibility to protect from

harm, rather than an unlimited bene®cence) in health

professionals' thinking about patients; signi®cant dif-

ferences in what health professionals perceive as ethical

as opposed to technical problems; and the identi®cation

of particular organizational factors which can inhibit

the recognition and possible resolution of ethical

problems. While much of this sounds familiar, such a

meticulously researched and philosophically articulate

account of the subject is new and valuable. Practical

implications include the suggestion that medical ethi-

cists should take more interest in the dynamics of or-

ganizational change, and that medical educators should

be concerned with ethical perception as well as with

ethical reasoning skills.

The research report comprises about half of the

book. It is sandwiched between three introductory

chapters defending the need for descriptive ethics and

the scienti®c status of the qualitative research method

used in the study, and a ®nal chapter discussing how far

one can generalize from it. These chapters will be very

useful to anyone attempting similar work in the future.

They contain helpful philosophical as well as method-

ological insights, including a good critique of Kohlberg

and Gilligan and an accessible explication of the

methods of qualitative research. As someone quali®ed

in medicine, philosophy and research methodology,

Holm is aware that `hard-nosed' practitioners of these

disciplines may doubt that much can be learned from

his qualitative study of 49 doctors and nurses in a small

European country. But attentive readers of his book will

gain more than enough to lay such doubts to rest.

Dr K M Boyd

The University of Edinburgh

Royal In®rmary of Edinburgh

Edinburgh, UK

Investigating Disease Patterns: The Science of

Epidemiology. Second Edition. By Paul D. Stolley

and Tamar Lasky. Scienti®c American Library, New

York. Available from McMillan Distribution Network,

Basingstoke, UK. 1998. £15.95. pp. 242. ISBN 0 7167

6024 X.

With that title, this book might be a textbook with a

modern trendy approach or it might be a series of de-

tective-style case stories to introduce the methods of

epidemiology to the lay reader. It is the latter. The

approach of the book is summarized in the ®rst chapter

where the authors make their pitch for epidemiology to

be considered as a science in its own right and claim

their ground. They start with the plague ± the classic

epidemic ± and extend out to claim the right to

interpret any form of illness or ill health.

There is a good chapter dealing with the early history

of epidemiology, essentially characterized by the gath-

ering and use of statistics ± one of the continuing

themes of the book is that epidemiology is really a set of

methods that can be applied to various disciplines,

microbiology initially, then biochemistry, genetics and

molecular biology, that allow the practitioner to go

ahead of the hard science and give an idea of where to

look to solve the origins of the disease.

As the book widens its area of investigation from

infectious diseases through cancer, heart disease and

Book reviews

662 MEDICAL EDUCATION 1998, 32, 658±668 Ó 1998 Blackwell Science Ltd

the environment, each of the cases allows and requires

the introduction of new methods ± the calculation of

odds ratios, case control studies, cohort studies, ran-

domized controlled clinical trials, the concept of safe

levels, etc. as they become necessary to cope with new

problems. Thus, in the modern idiom, the concepts are

only introduced in context and hence become memo-

rable. The book concludes with modern issues of ia-

trogenic disease, screening, the maintenance and audit

of an effective health care system and a look at the

future prospects for world health.

Despite its tendency to advertise (many successes, no

failures) and its Anglo-American perspective, it is a well

written and produced book, easy to read and under-

stand. It has relatively few overt errors (two graphs have

wrongly labelled axes), but it fails to explain the real

signi®cance of the reason for measuring the LDL form

of cholesterol or of the problem of chirality in the

thalidomide tragedy. It is strange too that the story of

asbestosis is illustrated with a picture of silicosis.

`Boxes' are also used somewhat idiosyncratically, often

to give de®nitions that are also in the main text, but also

include a literary excerpt and a separate case study.

There is a question, too, about the level at which the

subject is covered. The text, for instance, mentions that

odds ratios range between two values, but does not

indicate how the range is obtained or what its signi®-

cance might be.

These issues are not a problem, however, when

presenting the subject to lay readers, and it would be

wrong to judge the book as if it were a textbook. It is

from the Scienti®c American library and designed for a

non-medical public. As such it is a glossy, easy-to-read

and well-produced introduction to the world of epide-

miology.

John A Smith & Anne S Garden

Phase 2 Coordinators

The University of Liverpool

Liverpool, UK

Basic Pathology ± An Introduction To The

Mechanism Of Disease. Second edition. By Sunil R.

Lakhani, Susan A. Dilly & Caroline J. Finlayson.

Edward Arnold Publishers, London. 1998. pp. 329.

£18.99. ISBN 0 340 67787 2.

Anyone who has a concept of a pathology textbook as a

compendium of variations in pink and purple spots is in

for a pleasant surprise if they browse through this text.

The authors have done an excellent job of pro-

ducing an integrated text which is well illustrated,

well laid out and as easy to read as it is possible for a

pathology text to be. The text is interspersed with

icons indicating short self-assessment type questions

to check knowledge and understanding; `spotters'

likely to form the basis of written examination ques-

tions; interesting snippets of information that would

be invaluable were Pathology ever to be a basis for

`Trivial Pursuit'; and de®nitions to aid the memory.

The authors have produced a text which is as user

friendly as it looks, ful®lling their objective to design

a text that should be read fully and at leisure (yes ±

really!).

The authors have worked to produce a text that is

integrated at many levels. The contents are not ar-

ranged according to systems but according to the basic

pathological tenets of `In¯ammation, healing and

repair'; `Circulatory disorders'; `Cell and tissue dam-

age'; `Cell growth and its disorders', and `Genes and

disease', with disorders of the different systems used

to illustrate the principles. The use of clinical scenar-

ios to introduce a topic allows pathological processes

to be integrated with the clinical situation throughout.

A particularly good example of this are the diagrams

illustrating myocardial infarction showing distribution

of the infarct related to vessel involvement, sequelae of

the infarct, and macroscopic and light microscopy

changes that occur in an infarct with time, even

touching on associated ECG changes. Integration with

other disciplines is also good, particularly the chapter

on infection written in collaboration with a microbi-

ologist colleague.

Criticisms are few and relatively minor. More

careful proof reading would have picked up situations

where tables are referred to as `above' when they are

in fact below the text; there is inaccurate ®gure

numbering, especially in Chapter 1, and Turner

syndrome is variously referred to, within a few pages,

as 45X, 45,X and X0. Throughout, the excellent

®gures and tables are poorly referred to in the text

and, while it is usually quite clear where they belong,

being explicit about it would be an advantage in an

undergraduate text. Having a specialist clinical col-

league to cast an eye on the chapters would avoid

such things as chemotherapy being described as `a

relatively new and rapidly evolving form of treat-

ment', while immunotherapy for cancer is described

as `being used to treat a variety of tumours with some

good effect' giving a false impression of their relative

use in clinical practice. Equally, an obstetrician

reading the chapter on detection of foetal abnormality

might be slightly surprised to see foetoscopy being

included as an invasive test still employed in clinical

practice.

Book reviews

663 MEDICAL EDUCATION 1998, 32, 658±668 Ó 1998 Blackwell Science Ltd