I’m taking a break from frequent blogging – want to take time to read, do some research, reflect, and think about what I most want to write about next. At the moment, my inclination is to concentrate on the history of medicine, starting with the Enlightenment, followed by the transformation of medicine into a science in the 19th century. I want to consider what the past might be able to tell us about the present.
How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?
Medicine is not an abstract science, like quantum physics or mathematics. Scientific biomedicine may have its foundations in the research laboratory, but the practice of medicine takes place in the real, everyday world of doctors, patients, nurses, lab techs, clinics, hospitals, professional associations, patient advocacy groups, drug firms, insurance companies, politicians, the Internet, and the health advice columns of the Sunday papers. It takes place in a particular place at a particular time, and in a social, economic, political, and historical context.
To understand our dissatisfactions with and hopes for medicine – both as patients and practitioners – it helps to examine that context. And the context is easier to see if we step back from the immediacy of the current situation and consider the recent history of medicine. The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time.
“Not to know what happened before one was born is always to be a child.” (Cicero) Or, to expand on that a bit: “He who cannot draw on 3,000 years is living hand to mouth.” (Goethe)
Enjoy your blog and tweets. Just to raise something that is of interest to me and might be interesting to debate. Medicine is not an instrumental good – but is often regarded as such. Been reading some stuff about value theory etc to try and understand this. Many think of medicine as a good in an of itself, more medicine is a good thing etc. But this is of course a fallacy, and especially as we push the technical boundaries of sustaining life at any cost. The marginal benefits of drugs is one very good example of commodified promotion by the companies involved and where skate over the trade offs of side effects and very low gains. I come from the world of shared decision making – where we try and advocate transparency about pros and cons and go with informed patient preference… but we are up against a society where there is belief in medicine as an instrumental good, particulary in the US.
Glyn Elwyn
Thanks so much for your comment, Professor Elwyn. This is indeed a line of thought worth pursuing. Is it at all useful here – or even possible — to make a distinction between medicine and health? Could one argue that medicine has instrumental value because it is a means towards health? And that the problem today is with how we define health? When the WHO decided health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” did that put medicine on the path towards psychopharmaceuticals and cosmetic surgery?
Not that medicine should be left entirely off the hook, but the medical profession has changed. It is still highly respected, but it no longer has the authority it had in, say, the pre-WWII era. In the late 1990s, there seemed to be a few doctors who were saying “Wait a minute here. You’re redefining the role of medicine as the means to solve society’s problems (addiction, domestic violence, all unhealthy lifestyles). This is not what we were trained to do in med school.” They made a good point, but the medical profession no longer had the authority to say what should and should not be part of medicine, including the things you mention: futile end of life care, drugs that do more harm than good. And I think one could argue that a good part of the problem here is that — in the US at least — medicine became a money-driven enterprise, so there was an irresistible enticement to offer anything that promised a profit.
I don’t hold the medical profession at fault for this. In the US, once the government introduced Medicare and Medicaid into the financial mix of health care, physicians lost control over how they could practice medicine. The situation is somewhat different in the UK with the NHS, which I’m less familiar with, but I see that doctors and the public are objecting to reforms that want to introduce more “competition” into the medical “marketplace.”
But back to your point. I would agree that medicine is not an instrumental good in that what it offers is not always good for people and more of it is not necessarily better. And the failure to appreciate that is a significant problem. Are you familiar with the work of Daniel Callahan? I think he would agree with you. His ideas are not well received, unfortunately, especially in the US, which is becoming increasingly dysfunctional. I write this in the final days of the US debt-ceiling crisis and the Norwegian tragedy/“multiculturalism has failed” rhetoric. In the late 1970s I taught a course called “Life in the 21st Century.” This is not the future I anticipated. Whatever happened to the Enlightenment? :-)
I would love to hear more of your thoughts on why medicine is not an instrumental good. And do you think an understanding of this – by the public, by the medical profession – could help bring about a better future. I’m sometimes encouraged by some ideas I recently tweeted (from Charles Rosenberg): Biomedicine is not a unique and necessary institutional expression of scientific knowledge and technical capacity; part of the power of our biomedical culture is that its contingency is ordinarily invisible to those who dwell within it; and because we ignore this largely invisible contingency, we fail to see that medicine need not be what it currently and temporarily is.
I should add to my previous comment that any assessment of medicine today needs to acknowledge that the issues are complex and not subject to generalizations. It’s pretty clear that cosmetic surgery is driven by commercial interests, but excessive end-of-life care is more a matter of what’s technologically possible and of medicine’s basic commitment to saving lives. End-of-life decisions are an ethical issue, but – as I’ve argued elsewhere – so, ultimately, is cosmetic surgery. Just as the medical profession should not have to shoulder the responsibility for solving society’s problems – which is one of the dynamics of medicalization – it should not be forced into the role of decision-maker when it comes to rationing health care. But then, who will decide what medicine should and should not do? I’d hate to leave it up to the US Congress.