The Rise and Fall of Modern Medicine (52 page)

Medicine is, sadly, no longer as satisfying as in the past. Many of the most interesting diseases that tested the doctor's clinical acumen have simply disappeared, and a family doctor is lucky to see a patient with a serious acute medical problem from one week to the next. This lack of satisfaction has been compounded by the rise of specialisation, so the cardiac surgeon who in the early days of the pump was faced by the challenge of repairing many different complex anatomical defects of the heart now spends all his time routinely doing coronary artery bypass grafts. Further, the dearth in therapeutic innovation now means that doctors are doing much the same as they were twenty years ago and what seemed very exciting in the 1960s and 1970s, such as transplantation and CT scans, has become routine. In short, medicine is duller, as can readily be ascertained by contrasting the sparkle and interest of medical journals from two or three decades ago with those of today, where impenetrable genetics and improbable epidemiology jostle for space and no one is any the wiser.

It is most peculiar that as medicine has become more successful, the proportion of the public who apparently are ‘worried' about their health has increased. This could be because people ‘don't know when they are well off', certainly when compared to their parents' generation, who lived through the privations of the Depression and war. But equally importantly they have been encouraged by the falsehoods of The Social Theory to become more neurotic. If it were correct that so innocent a pleasure as eating bacon and eggs for breakfast can lead to an untimely demise from a heart attack, then there is no reason to doubt the myriad other hazards of everyday life that have been identified over the last decade. It would be most surprising if people did not, as a result, become more alarmed about their health. This in turn has compounded the professional discontent of Paradox 1 as an excessive concern about ‘health' can only too obviously encourage people to see their doctors unnecessarily. They in turn become frustrated at the time they have to spend dealing with the ‘Worried Well'.
³

The ‘alternatives' – in their various different guises of homeopathy, naturopathy, acupuncture and so on – are now so popular, being used by one-third of adults in any one year, that it is difficult to appreciate that prior to the 1980s they were very much a minority interest and widely perceived as quackery. The surging popularity of these alternatives might be explained by the undivided attention offered by its practitioners which, to
many, might seem preferable to being expensively overinvestigated and overtreated in a hospital bed.

But these alternatives are more than just ‘feel-good therapies'. The effectiveness of the modern drugs that came tumbling out of the drug companies in the 1960s and 1970s led to the neglect of simpler, more traditional remedies and the dismissal of anything that did not fit the ‘scientific' ideas of the nature of disease. Thus, following the discovery of cortisone and other anti-inflammatory agents, the skills of rheumatologists devolved around juggling various toxic regimes of drugs in the hope that the benefits might outweigh the sometimes grievous side-effects. Meanwhile, all the other therapies for rheumatological disorders – such as massage, manipulation and dietary advice – were abandoned virtually wholesale, only to be ‘rediscovered' by alternative practitioners in the 1980s.

The more that medicine can do, the greater will be the demand and thus the greater the cost. But it is incorrect, as is often asserted, that the demands for health care are potentially limitless. On the contrary, it is quite possible to spend too much on health. The negligible cost of the consultation for a tension headache becomes substantial when a brain scan is thrown in for good measure. Such examples could be multiplied a thousand-fold.

Further, the pattern of a Rise and Fall indicates that the future scope of medicine will primarily be directed at the amelioration of the chronic degenerative diseases of ageing, such as hip replacements and cataract operations. The rising numbers of those needing such procedures will certainly continue to push
up the cost, but this is finite and measurable. The paradox of the rise of medical expenditure rather lies in the lack of any obvious correlation between the phenomenal rise in health service funding of the recent past and any measurable or subjective impression of improvements that could justify such an increase. It is accounted for, at least in part, by the processes already described of hammering away at the obstacles to further medical progress that have already been outlined. These escalating costs are an enormous cause for concern, as the state has many other responsibilities just as, or indeed more, deserving than health.

In summary, the four paradoxes of the success of modern medicine can all be understood as different aspects of medicine's Rise and Fall. By now it will be clear there is more to the Fall than a sloping-off in the rate of medical innovation. Medicine's moral and intellectual integrity has also been eroded over the last two decades, as revealed by the obvious contrast between, for example, the protracted engagement with the profound problems posed by transplantation or curing childhood cancer and the illusory promises of The Social Theory and The New Genetics. The distinguished social historian Roy Porter elaborates on the consequences:

And yet the everyday practice of medicine belies this gloomy interpretation because, despite everything, it delivers and, thanks to the therapeutic revolution, much more so than fifty years ago. Consequently doctors do find their work satisfying and their patients do get better. The public is probably less concerned about the alleged hazards of everyday life than surveys would suggest and, when the crunch comes, most would put their trust in the orthodox rather than the alternatives. Still, this analysis of the past certainly makes sense of present discontents, which, if confronted and corrected, are the best guarantees of medicine's continuing success in the future.

A
t the mid-point of the century, a few years after this historical account opens, Lord ‘Tommy' Horder addressed a meeting on the theme ‘Whither Medicine?'. The miraculous effect of cortisone had just been described, there were encouraging signs that children with leukaemia were responding to anti-cancer drugs, both the cure of tuberculosis and the implication of tobacco in lung cancer were imminent. In the midst of such momentous events, Lord Horder suggested, a visitor from Mars would have thought the subject of his address incomprehensible: ‘“Whither Medicine?” the Martian would say, “Why, whither else than straight ahead; forging still more weapons with which to conquer disease.”' And, as we have seen, the Martian would have been absolutely right.
¹

But the burden of the history of post-war medicine that emerges from this book is that such genuine and unbridled
optimism is no longer possible. The race has been run, the Golden Age is over and so for a contemporary Martian the most likely scenario for the future would seem to be at best a continuation of the present. Medicine will continue to be a powerful and immensely successful enterprise, ameliorating the chronic diseases associated with ageing and, where possible, saving the lives of the acutely ill. But, equally, medicine's discontents are also likely to continue. The next surveys will reveal a yet higher proportion of doctors ‘with regrets', and a yet higher proportion of the public who are neurotically concerned about their health. Yet more unanticipated hazards of everyday life will be identified and the cost of medical care will continue to spiral upwards.

That is what the future
will
be, but it is legitimate to speculate what the future
might
be, if the present discontents were to be addressed. The preliminary and essential step must be to recognise and discard error, just as the great seventeenth-century British physiologist William Harvey, prior to his description of the circulation of the blood, felt it necessary to discard ‘those things that up till now have been written, but are by no means true'. In contemporary medicine this means discarding the intellectual falsehoods of The Social Theory and the intellectual pretensions of The New Genetics. The Social Theory has so undermined the authority of medicine as a source of reliable knowledge as to warrant urgent remedial action. This could take the form of an independent inquiry, with the mandate to investigate how the combination of statistical sophistry and the subterfuge of ‘expert' committees has systematically misled the public, and indeed the profession, over the last thirty years. The problem posed by the pretensions of The New Genetics is rather different. This, at least, has the merit of being genuine science, which will keep legions of molecular biologists happy
for decades working out, to the last point of decimals, the infinite complexity of the genes and the proteins for which they code. This is interesting enough for those who are interested in that sort of thing, if rather tedious for everyone else. The danger of The New Genetics, as is now widely perceived, is that it threatens to sideline medical research down the blind alley of reductionist explanations, where all biological questions are reduced to the most fundamental level of the gene, when it should be looking upwards and outwards – and sideways – probing the ‘mysteries of biology' to find the causes of disease.
²
Under the banyan tree nothing grows, and the banyan trees of genetics and epidemiology now casts such long shadows that the fresh green shoots of medical research are stifled.

The benefits of blowing away this smokescreen of false illusions and millenarian promises would be to liberate medicine to concentrate on its legitimate task of, in William Blake's memorable phrase, ‘Doing Good in Minute Particulars'.

There is, however, a further dragon that must be slain and its name, surprisingly, is Progress, or rather the ideology of progress. At first sight it is hard to imagine a more unlikely dragon as the remarkable achievements of the post-war years were fuelled by the two most progressive of ideologies – science and capitalism. Further, life would be a dreary thing were it not for the optimistic search for new ideas with which to push forward the boundaries of knowledge. All this is indisputable, yet it is obvious, at least on reflection, that medicine is not, or should not be (as it has become), synonymous with scientific progress. Its knowledge base may increase, as it has spectacularly over the last fifty years, but its concerns – what doctors do – remain the same as in Ancient Greece. ‘No other profession can boast of the same unbroken continuity of ideals [that stretch back to] the critical sense [as established by] the Hippocratic
school,' observed the magnificent Sir William Osler. ‘We may indeed by justly proud of our apostolic succession.
These are our methods
– to carefully observe the phenomena of life in all its stages, to cultivate the reasoning faculty so as to be able to know the true from the false.
This is our work
– to prevent disease, to relieve suffering and to heal the sick.'
³

There is a false antithesis in posing tradition against progress, but Osler's inspirational perspective on the historical continuity of medicine's ‘methods and work' provides the appropriate context within which to view medicine's current ‘almost exclusive homage to the shock of the new [with its] central emphasis on novelty'.
⁴
We start with the progressivist ideology of science. At its simplest, this ‘obsession with the new' ignores the wisdom of the past. This could be lived with during the Rise, when the new was genuinely new and important. But when this is no longer the case, this preoccupation with progress takes on a different guise, becoming a decoy, concealing from the public and indeed the profession itself the current intellectual state of medicine. The focus on medicine's future possibilities discourages people from looking back when they might too readily be dazzled by the scale of past achievements and thus legitimately wonder at the reasons for the lack of genuine developments in recent years. Caught between ignoring the past and fantasising about the future, it is easy for medicine to lose its grip on reality and what it should be trying to do.

This loosening hold on reality is compounded by a second feature of scientific progressivism: the belief that it can explain everything. This intellectual hubris of not recognising what is not known opens the door to false explanations where, as with The Social Theory, people are blamed for their illnesses and are deceived into believing their everyday lives are full of hazards.