Medicine: The Public Good and One's Own

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 21 ¦ Number 2 ¦ Winter 1978 MEDICINE: THE PUBUC GOOD AND ONE'S OWN* WALSH McDERMOTTf Medicine, like so many of our other institutions, is under intensive scrutiny today. Long immune from serious outside looks, medicine now has extramural critics by the score, and they join forces or dispute with those medically trained. Much of what they have to say is familiar to us all. Indeed, some of it is more than 50 years old. A fair amount of the criticism is knowledgeable and pertinent; some of it is not. In view of its familiarity, to take up this subject at all might properly call for the standard wine-in-new-bottles apology. The apology can be skipped, however, because recently a new idea has been going around. It is not really a single new idea but a whole range of ideas—whole schools of thought, if you will—that are all based on one central conclusion, namely, that that part of our health care system that is operated by individual doctors and their hospitals has very little demonstrable influence on the health status of our society. In short, with increased medical costs has not come increasing benefits in terms of health. This situation is bound to continue—so goes the argument—because today's major health problems are so heavily related to environment and life-style. Consequently, they can be alleviated only by major social changes. From this it is concluded that further investments in the system of individual doctors caring for individual patients should be curtailed in favor of what in the trade has acquired the tide "alternative strategies for health. " *The fourth William S. Paley Lecture on Science and Society, Cornell University Medical College, New York, October 7, 1976. tSpecial adviser to the president, the Robert Wood Johnson Foundation. Emeritus professor of public health and medicine, Cornell University Medical College. I express my thanks to Ms. A. John Klebba of the National Center for Health Statistics, Dr. Lewis Clayton of the American Lung Association, and Donald C. Weir of the New York Lung Association for their considerable help in supplying data. © 1978 by The University of Chicago. 0031-5982/78/2102-000101. 00 Perspectives in Biology and Medicine ¦ Winter 1978 | 167 I do not propose to present a detailed review of these strategies because the purpose ofthis paper lies not with them but with the validity of major arguments used in their presentation. About all I shall say is that they mostly take the form that there is a known set of health habits which, if learned, taught, and practiced by us, would result in significantly longer and healthier lives. This is to say it is postulated that the group as a group would have longer and healthier lives. To what extent this would comfort the individual cannot be stated. I am trying to avoid being pejorative when I say that, except for the long-known obvious excesses, there is really no solid evidence that could identify one way of living as significantly different from another in terms of health. Indeed, such evidence would be very hard to come by for it would involve careful lifelong epidemiologic studies of people whose life habits could be periodically observed and recorded. Retrospective studies, as pointed out by the authors of a recent one 1 can at best be only suggestive, although certainly the careful accumulation of even suggestive evidence is to be encouraged. But as things stand, what seems to be the principal case presented for the serious consideration of major investment in these alternative health strategies comes from the proposition on which they are all founded, namely, that the personal encounter physician system has failed and will continue to fail to improve our people's health. It is my analysis of this proposition that I plan to present today. Those who base the major part of their case on this assumption by no means agree on anything else. For the group ranges all the way from passionate spokesmen such as Ivan Illich and Rick Carlson, with their books Medical Nemesis 2 and The End of Medicine 3, to the physician-historian Thomas. . .