The tyranny of health then and now

When we hear the words “tyranny of health” these days, it’s usually a reference to the tyranny of a government imposing unwanted health care on its citizens. It brings to mind images of protesters carrying signs that denounce the “socialism” of Obamacare.

As recently as 1994, however, the tyranny of health had a different meaning. That’s when Dr. Faith T. Fitzgerald published an article in The New England Journal of Medicine with that very title. What tyranny of health referred to – and what Dr. Fitzgerald’s readers readily understood at the time – was the idea that doctors should coerce their patients into being healthy. She objected to this increasingly prevalent attitude that expected the medical profession to be a combination of nanny and big brother.

Healthy lifestyles and the definition of health

The article begins with a reference to the recent emphasis on promoting healthy lifestyles: “Once upon a time people did not have lifestyles; they had lives.” (In 2010, it’s easy to forget that we did not always have “lifestyles.”) Dr. Fitzgerald then reminds readers of the 1946 definition of health from the World Health Organization (WHO): “A state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.”

This has become known as “wellness,” a highly desirable state. A well or healthy person is one who is not only physically whole and vigorous, but also happy and socially content. What a good idea! It is generous with implied promise, and many of us in the medical profession eagerly switched from being doctors and nurses (who take care of disease and infirmity) to being health care providers, engaging ourselves in a variety of efforts to make people both physically well and also happy and socially content. We broadened our horizon from physical problems to character flaws, poverty, crime, unhappiness, and even unattractiveness. Internal medicine, surgery, preventive medicine, family practice, pediatrics, neonatology, and especially plastic surgery, genetic engineering, prenatal diagnosis, nutrition, and psychiatry promised potential perfection.

What had happened by 1994? Both the medical profession and the public had gone from regarding the WHO’s definition of health as an ideal – something difficult to attain but worth striving for — to believing that complete physical, mental, and social well being was the undisputed meaning of health right now.

Having accepted the view that health should be a perfect state of wellness, we went on to declare that it was. But if one accepts the idea that physical vigor and emotional and social contentment are not only desirable, but also expected, there is a problem. If health is normal, then sickness and accidents are faults.

Patients should stop their “selfish” misbehavior

This is where the tyranny comes in. Not only do doctors become responsible for “correcting” the behavior of their patients when that behavior interferes with health. But patients become guilty.

If health (physical, mental, and social) is normal and the failure to be healthy is someone’s fault, then when a person becomes ill he or she may have done something wrong. If we root out that wrongness, or better yet, prevent it, we can restore that person to normal health and can benefit society. In effect, we have said that people owe it to society to stop misbehaving, and we use illness as evidence of misbehavior.

Fast forward to 2010 and we find that many people – spurred on by political rhetoric — fail to see anything wrong with this attitude. “Tyranny of health” has morphed into “personal responsibility.”

Here’s a quotation from Sarah Palin’s 2008 State of the State Address, when she was governor of Alaska (emphasis added):

Let’s take personal responsibility in all areas of life — including health. … Our choices often lead to heart disease, diabetes, underage drinking, drugs, violence, and abuse. Soaring health and public safety costs are sometimes unfairly passed on to others. But more importantly, by ignoring or accepting selfish choices that cause the abuse, children, families and entire communities are destroyed.

Personal responsibility as the backbone of prevention

The “personal responsibility for health” mantra comes not just from conservatives these days. It has merged with the concept of prevention. Not only will preventive measures – diet, exercise, diagnostic testing – keep everyone healthy. They will save the nation from the bankruptcy threatened by escalating health care costs.

Unfortunately prevention is as much an unrealistic ideal today as it was when the WHO defined health in 1946. Dr. Fitzgerald herself has written on this subject: Preventive Medicine and the “Road to Hell.” A recent issue of The Atlantic has an article on Dr. John Ioannidis, author of Why Most Published Research Findings Are False, the most downloaded technical paper from the journal PLoS Medicine. The research findings Ioannidis discusses include many recommendations for preventive measures that have now fallen by the wayside. Dr. H. Gilbert Welch explains the complexities of prevention in his excellent book Should I Be Tested for Cancer?: Maybe Not and Here’s Why.

Prevention as the solution to our health care problems is a complex topic. There’s a great deal to recommend prevention, of course. But there’s also the potential for abuse, as Dr. Fitzgerald is well aware. When we insist that individuals who fail to practice “healthy lifestyles” are the source of our health care problems, this leaves us free to ignore the social, economic, and environmental factors that make health possible or difficult.

I’ll simply conclude for now with these wise words from Dr. Fitzgerald’s 1994 article:

We must beware of developing a zealotry about health, in which we take ourselves too seriously and believe that we know enough to dictate human behavior, penalize people for disagreeing with us, and even deny people charity, empathy, and understanding because they act in a way of which we disapprove. … [W]e health care professionals are no more competent to treat social distress than other citizens. We cannot fix everything (though we do some things marvelously well), nor can our patients — no matter how intelligent or attentive — prevent all disease and death. … If we redefine health, I hope we can discover a definition that does not include a medical or social mandate to control people’s behavior for the sake of their mortal bodies; this would seem to me particularly compelling in a nation founded on the belief that one should not legislate behavior even for the sake of the immortal soul.

Resources:

Image source: Kansas Watchdog

Dr. Faith T. Fitzgerald, The Tyranny of Health, The New England Journal of Medicine, July 21, 1994, Vol. 331 No. 3, pp. 196-198

Faith Fitzgerald, MD, Preventive Medicine and the “Road to Hell,” ConsultantLive, August 1, 2003

Some months after Dr. Fitzgerald’s article was published, the NEJM printed a series of letters to the editor. I’ve always liked this one, from a doctor in Texas:

After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.

Here’s another example from a doctor who’s able to understand the patient’s perspective:

“Who made ‘health’ the central issue of our life?” they ask, when the physician is too heavy-handed about compliance or patient education. “The point of my life,” they’ll say, “is to be a rancher. I only want a doctor when I can’t break my bronco and my bronco breaks me.” Physicians are always thinking of longevity: “How can I help someone to live longer?” But for these ranchers and farmers in west Texas, medical care is not their first priority.

Casting moral blame on people who don’t follow healthy lifestyles is related – in my mind — to the increasing medicalization of life. The more conditions and behaviors we regard as “unhealthy,” the more grounds we have for accusing ourselves and others of misbehaving.

Here’s something from one of my favorite doctors, H. Gilbert Welch. I especially like what he says because it touches on how an increasingly broad definition of health — broad in the sense that the smallest deviation from so-called normal becomes grounds for medical attention — increases anxiety about health and changes how we relate to our bodies. This was my experience in the 1980s and 1990s, which is why this topic is so important and meaningful to me.

So the most fundamental life events — birth and death — increasingly involve more and more medical care. Why should you care about this increasing medicalization of birth and death?

Simple. Because it exemplifies the medicalization of life. Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed, and our ability to affect the course of normal aging get exaggerated. And we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.

Medicalization is the process of turning more people into patients. It encourages more of us to be anxious about our health and undermines our confidence in our own bodies. It leads people to have too much treatment — and some of them are harmed by it.

And it’s big part of the reason why medical care costs so much.

There are many areas in which medical care has a great deal to offer. But it has now gone well beyond them. There may have been a time when the words “Do everything possible” were indeed the right approach to medical care. But today, with so many more possibilities for intervention, that’s a strategy that is increasingly incompatible with a good life. We all need to be a little more skeptical and — to really be healthy — willing to ask “Why?”

Thanks for your thoughts, Roberta.

2 Responses to The tyranny of health then and now

Roberta says:

October 22, 2010 at 5:52 pm

I agree with the ending statement of Dr. Fitzgerald.

I want to live a healthy life as long as possible. I am lucky I inherited fairly good genes.

But I also want to enjoy life.

And sometimes those two goals clash.

I have real problems with the food police and health police, etc., in what is supposed to be a free society. You cannot MAKE anyone do anything unless you jail them or put a gun to their head.

How did we get to this point? I hate a nanny state! And I fear that is where we are headed. Maybe we are there already.

I want my doctors to tell me what they think and what they think I should do about any physical or medical problem. And I want to consult several doctors and do research on my own. Then I will try to make the best decision humanly possible.

But rock bottom; ultimately what I do IS MY DECISION. Think Norman Cousins. I rest my case.
- Jan says:
  
  October 24, 2010 at 9:43 pm
  
  Some months after Dr. Fitzgerald’s article was published, the NEJM printed a series of letters to the editor. I’ve always liked this one, from a doctor in Texas:
  
  After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.
  
  Here’s another example from a doctor who’s able to understand the patient’s perspective:
  
  “Who made ‘health’ the central issue of our life?” they ask, when the physician is too heavy-handed about compliance or patient education. “The point of my life,” they’ll say, “is to be a rancher. I only want a doctor when I can’t break my bronco and my bronco breaks me.” Physicians are always thinking of longevity: “How can I help someone to live longer?” But for these ranchers and farmers in west Texas, medical care is not their first priority.
  
  Casting moral blame on people who don’t follow healthy lifestyles is related – in my mind — to the increasing medicalization of life. The more conditions and behaviors we regard as “unhealthy,” the more grounds we have for accusing ourselves and others of misbehaving.
  
  Here’s something from one of my favorite doctors, H. Gilbert Welch. I especially like what he says because it touches on how an increasingly broad definition of health — broad in the sense that the smallest deviation from so-called normal becomes grounds for medical attention — increases anxiety about health and changes how we relate to our bodies. This was my experience in the 1980s and 1990s, which is why this topic is so important and meaningful to me.
  
  So the most fundamental life events — birth and death — increasingly involve more and more medical care. Why should you care about this increasing medicalization of birth and death?
  
  Simple. Because it exemplifies the medicalization of life. Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed, and our ability to affect the course of normal aging get exaggerated. And we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.
  
  Medicalization is the process of turning more people into patients. It encourages more of us to be anxious about our health and undermines our confidence in our own bodies. It leads people to have too much treatment — and some of them are harmed by it.
  
  And it’s big part of the reason why medical care costs so much.
  
  There are many areas in which medical care has a great deal to offer. But it has now gone well beyond them. There may have been a time when the words “Do everything possible” were indeed the right approach to medical care. But today, with so many more possibilities for intervention, that’s a strategy that is increasingly incompatible with a good life. We all need to be a little more skeptical and — to really be healthy — willing to ask “Why?”
  
  Thanks for your thoughts, Roberta.