Where's the Evidence? Debates in Modern MedicineBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7172.1599a (Published 05 December 1998) Cite this as: BMJ 1998;317:1599
William A Silverman
Oxford University Press, £39.50, pp 278
At first glance, a collection of short essays originally published under the nom de plume “Malcontent” in an unfamiliar journal—Pediatric and Perinatal Epidemiology—with the intention of allowing the author the opportunity to vent his spleen whenever he felt the need does not seem promising material for a book intended for general readers. However, preconceptions are soon set aside. This book reminds me of Alastair Cooke's classic radio broadcasts “Letter from America.” Like Cooke, Bill Silverman has the ability to select a topic that you didn't know you were concerned about, capture your interest with an intriguing introduction, and then hold your attention with an avuncular, reflective, and civilised commentary.
The title of the book is misleading (the subtitle more so; on the title page it reads “Controversies in Modern Medicine,” on the jacket it is “Debates in Modern Medicine”). “Where's the evidence?” implies that the focus of the book will be on evidence based medicine, a promise reinforced by the publisher's blurb. Although Silverman has a passionate and well argued belief in the primacy of evidence, in particular for well conducted randomised controlled trials, there are no 2£2 tables, odds ratios, or relative risk reductions in sight. He is mainly concerned with the consequences of the decisions doctors make, and their implications for society as a whole and for patients in particular. He explores the grey area where evidence ends and ethics begin. His personal philosophy is, I suspect, summarised by the quotation from Claude Bernard that he selects to begin his introduction: “Science teaches us to doubt and, in ignorance, to refrain.”
The themes he chooses are universal. How do we know if and when to intervene? Is the goal of medicine to prolong life or improve its quality? If those goals clash who should make decisions about treatment, the healthcare professionals or those patients and families who will be left to pick up the pieces? A gem of a quote from an anti-war song summarises the debate:
Once the rockets are up, who cares where they come down? ‘That's not my department,’ says Wernher von Braun.
Most of the essays relate to neonatology, and the ability of neonatologists to resuscitate ever smaller babies. “Can we” clashes with “Should we” when some parents are left alone with the awesome challenge of coping with a severely handicapped child. If that sounds too narrow a focus, don't let it put you off. All the themes are readily generalisable to medicine as a whole and relate equally as well to a geriatric unit or a general practice surgery.
Each essay is short, usually not more than two or three pages, and to the point. You can pick up the book, dip into it, and put it down again without losing the thread of any argument. Inevitably for an author concerned with the pros and cons of the resuscitation of tiny babies, some of the topics are repetitive, but always with a fresh slant. In particular, ethical issues are dealt with head on throughout the book, and, happily, Silverman avoids the polysyllabic fence-sitting beloved of professional ethicists.
A feast of quotations, a sense of humour, and pointed but gentle challenges to conventional wisdom. If this is Silverman's valediction as he enters his eighth decade I, for one, will miss him.