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To Do No Harm

To Do No Harm: DES and the Dilemmas of Modern Medicine

Roberta J. Apfel
Susan M. Fisher
Copyright Date: 1984
Published by: Yale University Press
Pages: 204
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  • Book Info
    To Do No Harm
    Book Description:

    "Apfel and Fisher raise important questions about the explosion of modern medical technology. They vividly delineate the factors contributing to experimentation with new techniques and drugs and how the pressures experienced by physicians, coupled with their fantasies of heroism, meld with pressures from their patients to tempt them to take risks prematurely…. The volume is provocative and effective. It should be read by all who take part in the health care system, patients and their caretakers." -Carol Nadelson, M.D.,Journal of the American Medical Association

    eISBN: 978-0-300-15916-5
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-xii)
  4. Introduction
    (pp. 1-10)

    Diethylstilbestrol (DES) is a synthetic estrogen first produced in 1938. It has since been used for a wide variety of medical conditions, including prevention of pregnancy complications from the 1940’s until 1971 when the Food and Drug Administration (FDA) required product labeling to state that DES was contraindicated for use in the prevention of miscarriages. It is estimated that 4 to 6 million Americans (mothers, daughters, and sons) were exposed to DES during pregnancy. Although DES is a synthetic estrogen and differs in structure and metabolism from naturally occurring estrogens, many investigators believe that there is no evidence that natural...

  5. 1 The History of DES
    (pp. 11-28)

    Five years after making this remark, Dodds was knighted for his key role in the synthesis of sex hormones.

    The middle years of the twentieth century saw an explosion of medical research, new drug therapies, and advances in medical technology. An America that could win great wars, create nuclear arms, and send rockets into space surely could attack the everyday problems of personal health. There was a renewed belief in medicine as a source of answers to the basic questions and yearnings of mankind. It was a time of optimism about conquering human ills. Medical warfare could be waged against...

  6. 2 The Historical Context
    (pp. 29-42)

    The introduction of any new medical treatment involves a complicated interplay between research findings, the doctor’s personal experience, and the patient’s needs. On many occasions in medical history, techniques or medications have been accepted on the basis of anecdotal reports only to be rejected later, after other reports have revealed them to be ineffective or harmful. There is no way to tell what might have happened with DES had the link to cancer not been discovered. Only after a cancer scare were the negative research results heeded; only then was the prescription of DES to pregnant women stopped.

    The DES...

  7. 3 An Event in the Human Body
    (pp. 43-58)

    The first article statistically linking DES with vaginal clear cell adenocarcinoma in daughters exposedin uteroappeared in 1971 (see Herbst et al. 1971). Since that time articles and radio and television programs about DES have appeared steadily in the medical and popular media. There have been studies of mothers and offspring, both male and female, as well as papers that speculate about the effects of DES on body tissues and about the pathological conditions associated with its usage. Some articles trace the natural history of DES usage in particular populations. Others discuss new treatments and the prevention of problems...

  8. 4 A Quiet Trauma
    (pp. 59-68)

    From the beginning, a central problem with DES has been how to understand what happened. The DES event has engaged a wide range of specialists: biochemists, endocrinologists, pathologists, oncologists, epidemiologists, public health officials, sociologists, and legal scholars, as well as obstetric and gynecologic physicians. It is our contention that the DES phenomenon needs to be analyzed and understood as a whole rather than divided into a dozen different specialist perspectives; for this a central concept is necessary. We believe that it is within the framework of the concept of psychological trauma and the terms appropriate to it that the entire...

  9. 5 Mothers and Daughters
    (pp. 69-84)

    Modern psychiatric knowledge might dispute this folk wisdom but would acknowledge that the mother-daughter relationship is intimate, powerful, and crucial to the daughter’s emergence as a mature woman. It is fraught with possibilities for intense competition and greater hostility than obtains in cross-gender relations. Competition between father and son is more open, a socially accepted step in a boy’s progression toward maturity. Women are socialized to subvert their aggressive feelings; thus the negative and hostile dimension of the relation between mother and daughter has fewer explicit outlets. This does not mean that relations between fathers and sons are easier, but...

  10. 6 Patients and Doctors
    (pp. 85-106)

    It is impossible to understand the DES experience without a deep appreciation of the complex nature of the patient-doctor relationship. The special bond between patient and doctor is based in part on the earliest needs for body care and protection, needs that stem from infancy and childhood. This bond exists between all doctors and their patients, in health and in sickness. The patient, much as he or she may disguise it, on some level feels vulnerable and helpless when ill and wants to view the caretaker as omniscient and invincible, like the good mother of childhood who can take care...

  11. 7 The Doctors’ Dilemma
    (pp. 107-125)

    Doctors prescribed DES for thirty years in a regimen they believed would prevent and treat reproductive failures. This prescription was motivated, as we have seen, by the wish to heal and to rescue. In a single therapeutic gesture the doctor could integrate his desires to heal, nurture, and create with his rescuing, grandiose, and heroic impulses. But the medical art, twenty-five centuries after Hippocrates, remains imperfect. DES, the drug that promised to improve on nature and to create life, instead led to anomalous physical conditions for many and death for a few. And the implications of DES have been as...

  12. 8 Final Reflections—What Next?
    (pp. 126-130)

    The story we have told is a somber one. We have tried to describe the events attending the use of DES without either muckraking, on the one hand, or denying their seriousness, on the other. Our objective has been to learn from the experience. DES is not the only scandal in modern medicine, perhaps not even the worst. And though much has changed in the practice and structure of medicine in the past forty years, the likelihood of another iatrogenic disaster of similar proportions is still with us. It is to this likelihood and the reasonable hope that we can...

  13. Notes
    (pp. 131-152)
  14. Glossary
    (pp. 153-160)
  15. Bibliography
    (pp. 161-192)
  16. Index
    (pp. 193-199)