PLATFORM * TRIBUNE

Health care and medicine: the case for their divorce

John Patrick, MB, BS, MRCP, MD

N o one who qualified for medical practice more

than 20 years ago can be unaware of the changein the ethos of medicine since then. Understand-

ing why and how this change occurred is a different mat-ter, but that discontent is rampant is undeniable. This pa-per offers a view of the origin of this discontent andsome suggestions for its mitigation. My thesis is not newbut is, rather, an extension of the ethos of medicinefound in the general descriptions of the loss of our cul-tural story and the mistaken understanding of what itmeans to be human, as described by Bloom' and MacIn-tyre.2 It will be illustrated from areas as diverse as med-ical education, developing-world medicine and the insol-uble issues of abortion and euthanasia. The mitigation ofthe effects of our fractured cultural story lies in under-standing the process, but cure is probably impossible be-cause we remain divided about what should be the ul-timate concerns of our society. Tolerance and the Can-

adian capacity for compromise will not be enough. Weare engaged in a war of cultures; there will be winnersand losers, but I hope that the war can be fought withwords and hard truth, and the victors can be magnani-mous in triumph.

Medicine before the loss of cultural security

To the degree that anyone's theories on educationand on issues such as the definition of medicine are tosome extent autobiographic, let me begin by acknowl-edging my background. My training was in medicalschools with evidence of the ancient roots of the story ofmedicine in their names: St. George's and St. Thomas's.It is easy to look back on those days through rose-tintedspectacles, but in several ways my experience was ob-jectively different from that of today's students. We hadfew lectures after the first two uncivilized years of cram-ming facts into short-term memory. Instead, we talked toand examined many patients. We considered the rele-vance of the one or two social-medicine lectures lowenough that we easily slept through the talks. We had no

formal training in ethics. The hospital administrationthen easily fitted into two or three offices. Students had a

sense of being part of a great tradition that patientswarmly appreciated. Many patients' extraordinary kind-ness to us as students and young physicians reinforcedour sense of being part of a privileged profession.

Assumptions of medicine past

Medicine was practised with the assumption thatpatients had complaints that they thought were medical.The relationship between doctor and patient was basedon trust and limited to the technical expertise of the doc-tor but invoked a tacit view of the meaning of human lifeas its backdrop. Ramsey clearly described this view andits logical consequences in his book The Patient as Per-

CAN MED ASSOC J 1994; 150 (11) 1775

Resume: La pratique de la medecine est enracineedans des traditions qui remontent 'a plus de deux mil-lenaires. L'engagement des medecins de traiter leurspatients comme des etres uniques est au coeur de cestraditions. Or, selon les probabilit6s, on pratique lessoins de sant6 sur des personnes en sante: l'individucede la place au concept de la personne <<moyenne>>.L'ethique des soins de sant6 et celle de la medecineentrent souvent en conflit. L'ethique des soins desante a tendance a etre utilitaire- la fin justifie lesmoyens - tandis que la medecine s'int6resse unique-ment au bien du patient et a toujours et6 dominee parles vertus que sont la compassion et la loyaute.L'ecart entre les deux concepts n'est nulle part ail-leurs plus clair que dans les demarches face a la mort.La rationalite des soins de sante semble destinee aremplacer la sagesse d'Hippocrate.

Dr. Patrick is associate professor in the departments ofBiochemistry and Paediatrics, University of Ontawa, Ottawa, Ont.

Reprint requests to: Dr. John Patrick, Department ofBiochemistry, University ofOttawa, 451 Smyth Rd., Ottawa, ONKIH 8M5

+- For prescribing information see page 1893

son.3 For Ramsey the proper practice of medicine wasbest characterized by the Judeo-Christian concept ofcovenant. His prose illustrates the richness of the idea ofcovenant, as compared with the poverty of the modemconcept of contract.

Justice, fairness, righteousness, faithfulness, canons of loy-alty, the sanctity of life, hesed, agape or charity are some ofthe names given to the moral quality of attitude and of actionowed to all men by any man who steps into covenant with an-other man.

Thus, physicians accepted the one-sided responsi-bility to be with patients throughout illness or untildeath, and the best physicians embodied this commit-ment, although they never expressed it in this way. Pa-tients tacitly understood this and responded with loyalty.Malpractice insurance fees reflected this social ethos; asI remember it they were $50 per year in the early 1960s.

In 1950 the poet Auden gave a witty sketch of hisideal physician.

Give me a doctor, partridge-plump,Short in the leg and broad in the rump,An endomorph with gentle hands,Who'll never make absurd demandsThat I abandon all my vices,Nor pull a long face in a crisis,But with a twinkle in his eyeWill tell me that I have to die.4

Auden's physician was not concerned with resourceallocation, abortion, euthanasia or fee schedules, becausehe was firmly located within a cultural story that gavecomfort and security and to which the physician con-tributed an almost ecclesiastic reassurance that in alllife's vicissitudes "all shall be well, and all manner ofthing shall be well."-

The present

Auden's doctor was deeply rooted in a culturalstory that had nurtured the practice of medicine. Such aphysician is hardly possible today; to many he would bea laughable caricature, although the truth may be that to-day's physicians are caricatures of what they should be.Recently one of the senior physicians in our medicalschool told a student that "palliative care has no place inmedicine; it does not cure." The whole history of med-icine was shredded in one ignorant and cynical sentence.A generation who "know not Joseph" has arisen. Indeed,most would not even recognize the allusion and the cul-turally enriching story that should be evoked by thisphrase. As Bloom eloquently described in his book TheClosing of the American Mind: How Higher EducationHas Failed Democracy and Impoverished the Souls ofToday s Students' we are now trying to teach medicine toa generation of students who have no cultural history. Inthe chapter tellingly entitled "The empty slate" Bloom

compared his uneducated but culturally rich grandpar-ents with his educated cousins.

My grandparents were ignorant people by our standards, andmy grandfather held only lowly jobs. But their home was spir-itually rich because all the things done in it found their originsin the Bible's commandments, and their explanation in theBible's stories.... My grandparents found reason for the ex-istence of their family and fulfilment of their duties in seriouswritings.... There was respect for real learning because ithad a felt connection with their lives. This is what a commu-nity and a history mean, a common experience inviting highand low into a single body of belief.

I do not believe that my generation, my cousins who havebeen educated in the American way, all of whom are MDs orPhDs, have any comparable learning. When they talk aboutheaven and earth, the relations between men and women, par-ents and children, the human condition, I hear nothing butcliches, superficialities, the material of satire.6

It comes as something of a surprise to studentswhen they are confronted with their cultural deprivationand their consequent risk of being reduced to the statusof technicians. The inverse relation between the bur-geoning technical capacities of medicine and plummet-ing community respect is an uncomfortable reality oftoday's medicine. We respect wisdom but use onlyknowledge. It is embarrassing that the hospital of St.Thomas was more respected during its hundreds of yearsof technical infancy than during the last 50 of technicalwizardry. Admittedly some of that respect was simplyrespect by uneducated people for education, and this hasbeen dissolved by "universal" education, but I do notthink that is the whole story.

Behaviourally we have changed. The pressures oftoday's medicine are different. My colleagues are oftenoverwhelmed by the technical responsibilities they face,and it shows. Students are overwhelmed by the lack ofrecognition given the humanity of patients by thesephysicians, their role models.7

Other places

One has to look at the developing world to find thesense of relatedness at the heart of the story of medicine.Since 1987 my family has spent several summers inrural Zaire trying to run a nutrition project on a shoe-string budget. From their early teens onward my chil-dren, some of their friends and, lately, medical studentshave had the privilege of caring for African childrenwith minimal resources and the expected mixture of suc-cess and failure. Now, after 5 years I am deeply movedthat I am honoured in one African village because of mychildren, who have a special welcome in many of themud huts that were or are home to the young ones forwhom they provided care. Whenever my children visitthese African homes they return with a gift a livechicken, eggs or something often regardless of the

1776 CAN MED ASSOC J 1994; 150 (I U) LE I e, JUIN 1994

outcome of the care. What mattered was that theseyoung people cared; the capped water sources, which arein theory more important to the physical health of thepeople, are less appreciated.

This is the grateful world into which many idealis-tic medical students think they will enter. It is the ideal-ized story of medicine: to cure sometimes, to ease oftenand to comfort always. It is about putting banners intothe hands of people with which we may accompanythem to the gate of death.8 This may seem a romantic no-tion, yet one cannot dismiss my account of medical vo-cation.

Distinctions between health careand medicine

From the viewpoint of our bodily being health careand medicine are complementary, but the two are com-petitive in their intellectual preconceptions and theirethics. The human resources, skills, methods and organi-zation of each are different.

I would define medicine as the care of sick peopleand health care as the care of well people. Sick peoplecome to physicians; they have decided to become pa-tients, with all that this involves. Well people need to bepersuaded that they need the services of health careworkers.

Medicine is practised on individuals; health care maybe practised on individuals but is more often practised oncommunities, frequently a depersonalized activity.

Medicine was traditionally driven by covenantalethics and individual benefit; health care is driven by so-cial utility. For example, vaccination programs trade apredicted saving of unknown lives for untoward effects,including loss of life. Consent has a different meaning inmedicine and health care.

In medicine we pay for physicians, nurses and otherhealth care workers and their equipment. For centuriesthis system was supported by the public, without con-cern for the outcome measures health care professionalsso love. In health care we hardly need physicians and theskills of the persuader; the statistician, epidemiologistand economist are paramount. Health outcomes and eco-nomic outcomes fuse.

Health care executives believe we have struck an unhealthybalance between health outcomes and economic outcomes.They also recognize that a better, more professionally uplift-ing bond than money is needed to hold health care organiza-tions together.9

The methods of health care and medicine differ.Health care often uses education to change the way thepublic thinks. That physicians are paternalistic is fash-ionable to decry when we are well but seems to be whatwe seek when we are sick.

The challenge is for administrators and health careresearchers to design institutions that provide just, af-

fordable medical and health care without destroyingmedicine. This challenge might be approached by firstdistinguishing between health care and medicine.

It is true that factors such as smoking, nutrition andsocial issues are important in the development of dis-ease, but applying the knowledge of these effects islargely a question of education moulding societal behav-iour. The likelihood that people will change their habitswhen disease has developed is small. Realistic phys-icians know this and "will not make absurd demands that[we] abandon all [our] vices."4 For the sake of medicinewe need to determine what sick patients want and willaccept from what we know would be good but is alsounlikely to happen. We need to distinguish the comfortof reality-based medicine from the sometimes utopiandreams of social change that underlie health care.

Defective reasoning

The change in the ethos of medicine has resultedfrom defective reasoning. There are many diseases thatresult from unhealthy living- smoking, drinking exces-sive amounts of alcohol, exercising inadequately and en-gaging in promiscuous sexual acts- that have statisti-cally predictable outcomes. But this does not put suchactivities within the purview of physicians. Given the di-vorce of health care and medicine that I advocate, thephysician's primary role is to treat the resulting diseases,not to prevent their emergence with preemptive behav-iour modification. In the case of diseases too advancedfor treatment physicians must more often tell patientsthat they have to die rather than make absurd demands toabandon all vices. Even if appropriate it is often too lateand too difficult for patients to stop smoking or drinkingor lose weight when they finally present with healthproblems. Consider the 5-year failure rate of weight-reduction programs or the 30% rate of compliance withdiets among people with diabetes.'0 We all have to learnto die, despite the denial of this fundamental fact by thepublic and many physicians. This provides my final il-lustration of the distinction between health care andmedicine: there is presumably no healthy way to die.

Question of mortality

Auden wanted his physician to come to terms withdeath, to recognize the inevitable and to tell him that hehad to die. Because physicians can do something doesnot mean that they have to. Because a large proportionof our health care expenditure is spent during the lastmonths of our lives (28% of the health care budget isspent on the 5% of patients who die annually") Auden'sprescription has more than poetic value. Physicians needto come to terms with their own deaths before they canhumanely accompany their patients to death, encourag-ing them to use the limited time wisely. When the wis-dom Auden desired is lost, technology takes over. The

CAN MED ASSOC J 1994; 150 (1 1) 1777JUNE 1, 1994

technologic approach to human mortality is assisted sui-cide or active killing, with the illusion of control. Themedical profession's espousal of active killing is clearevidence of cultural deprivation; it is not part of thestory of medicine, despite recent claims in CMAJ. '13

Anthropologist Margaret Mead recognized many yearsago that Western medicine's traditional attitude to killingis deeply symbolic.

For the first time in our tradition there was a complete separa-tion between killing and curing. Throughout the primitiveworld the doctor and the sorcerer tended to be the same per-son. He with power to kill had power to cure, including espe-cially the undoing of his own killing activities.... With theGreeks, the distinction was made clear. One profession, thefollowers of Asclepius, were to be dedicated completely tolife under all circumstances, regardless of rank, age, or intel-lect the life of a slave, the life of the Emperor, the life of aforeign man, the life of a defective child.... [T]his is a price-less possession which we cannot afford to tamish, but societyalways is attempting to make the physician into a killer tokill the defective child at birth, to leave the sleeping pills be-side the bed of the cancer patient.... [I]t is the duty of soci-ety to protect the physician from such requests.'4

There are those who justify assisted suicide and ac-tive killing as ways of sparing people from suffering, butsuch practices do not improve the health of the recipient.I urge that we take Mead's advice. Let us separate killing(under the guise of caring) from medicine. I propose amore radical separation than that proposed by Benrubi,'5who wants a licensing system for practitioners of eu-thanasia, or Quill, Cassel and Meier," who would legal-ize assisted suicide but not active euthanasia. Those whobelieve that humans are autonomous in a universe de-void of a god clearly and, in my view, rationally justifyeuthanasia. They are a significant and very articulateproportion of the population, but they are not the major-ity. Neither are those who are opposed the majority, butin the history of medicine their influence has been domi-nant.

Abortion, the other killing service currently de-bated, is in some ways clearer, because in most cases itis proposed and practised to make the woman happierand therefore "healthier." It aims to improve the healthof the woman, but the means are repugnant to many. It,as well, has no historically justified place within thestory of medicine and has divided the profession. Be-cause neither euthanasia nor abortion requires extensivetraining they should be separated from medicine. Theirreal place in the story of our society will become clear intime, and they will be less divisive for medicine if sepa-rated. As well, it will be easier to make political deci-sions if the two activities have stories and consequencesseparate from medicine. The idea of a chain of suicideand euthanasia clinics sounds horrendously like "a bravenew world," but the logical consequences of acceptingkilling as treatment may need to be starkly stated for trueunderstanding.

Proposal

I propose that programs whose primary aim is to re-duce unhealthy living should be financially and adminis-tratively separate from medical services. Because suchprograms are directed at communities their implementa-tion and ethical constraints are different. How one un-derstands behaviours depends on one's understanding ofthe purpose of life and the nature of the human condi-tion. If the purpose of life is to pursue happiness, thensmoking, drinking excessive amounts of alcohol, inac-tivity and promiscuity are not intrinsically wrong, andthe objective will be to have pleasure and avoid pain.Others who hold more traditional views of the meaningof life will view some of these behaviours as intrinsi-cally and objectively wrong. Programs in these areas aretherefore divisive and will only cease to be so when wehave a moral consensus on what constitutes good andevil. The philosophies of people who advocate ap-proaches to, for example, preventing sexually transmit-ted diseases, vary widely. Such people are concernedwith the good of humanity. Physicians, however, shouldbe concerned with treating disease. They need to under-stand patients' beliefs about the nature of human life,which should influence the advice given.

The consequences of unhealthy living have alwaysbeen with us. We have the most success when can we al-low the appetite to continue without the risk. For exam-ple, the experience of thirst is universal; the nature of thewater drunk is immaterial to the assuaging of thirst, butif clean water is universally available the risk of diarrheais diminished. If we cannot avoid the consequences ofhuman nature the psychosocial, ethical and spiritualcomponents become apparent. However, this does notmean that patient rounds must involve psychologists,psychiatrists, social workers, chaplains and ethicists.Such professionals should be consulted only if they willaffect the immediate management of the condition andonly with the consent of the patient. Each of these pro-fessionals may want a say in managing the condition,but the physician should respect the patient's choiceabout the extent of their involvement. Large numbers ofunknown people in white coats descending on a patientwill not likely have a positive therapeutic effect. Be-cause the objective of medicine is to care for patients itis reasonable to demand that those wishing to have a saydemonstrate how they will contribute to care. If this carepresupposes the patient's positive response to education,especially the comprehension of new or emotionallyfraught ideas, a hospital is probably the most unlikelyplace for this care. Such services need first to demon-strate their effectiveness and then to be delivered moreappropriately, in the community and from different bud-gets.

Doctors are not trained in the arts of social engi-neering, which is clearly needed for a successful healthcare agenda. Usually physicians know little or nothing

1778 CAN MED ASSOC J 1994; 15() (I r) LE I1crJUIN 1994

about anthropology, sociology and academic psychol-ogy, the prerequisites of health care educators. The cul-tural sensitivity that Bloom' maintained we have lost andthat Auden4 wanted will be of much greater value tophysicians intent on comfort rather than persuasion.More appropriate than social engineering would be theapproach Coles'7 took at Harvard in introducing studentsto their cultural history and the subtleties of relationshipsbetween doctors and patients through the reading of pro-fessionally pertinent novels and stories with wonderfulnuances and ambivalences.

In the more practical area of public health, doctorsare not necessary for clean water, vaccination programsor the care of symptomless hypertension. These areas arebetter managed by others, who may occasionally needthe doctor's assistance. Recognizing the real business ofmedicine and divesting those inessential excrescencesthat have accumulated over the years will be painful butin the best interest of the community and the practice ofmedicine.

References

1. Bloom A: The Closing of the American Mind: How Higher Edu-cation Has Failed Democracy and Impoverished the Souls of To-day's Students, Penguin Books, London, England, 1988

2. Maclntyre A: After Virtue, University of Notre Dame Press, Lon-don, England, 1984

3. Ramsey P: The Patient as Person, Yale University Press, NewHaven, Conn, 1970: xi-xiii

4. Auden WH: [Untitled]. In Mendelson E (ed): Collected Poems:W.H. Auden, Random House, New York, 1976:436

5. Eliot TS: Little Gidding. In Collected Poems, 1909-1962, Faber& Faber, London, England, 1963: 223

6. Bloom A: The Closing of the American Mind: How Higher Edu-cation Has Failed Democracy and Impoverished the Souls of To-day's Students, Penguin Books, London, England, 1988: 60

7. Eichna LW: Medical school education, 1975-1979: a student'sperspective. N Engl JMed 1980; 303: 727-734

8. Berger P: The Sacred Canopy, Doubleday, New York, 1967: 51

9. Ellwood PM: Outcome management: a technology of patient ex-perience. N Engl JMed 1988; 318: 1549-1556

10. Wood FC, Bierman EL: Is diet the cornerstone in management ofdiabetes? N Engl J Med 1986; 315: 1224-1227

11. Lubitz JD, Riley GF: Trends in Medicare payments in the lastyear of life. N Engl JMed 1993; 328: 1092-1096

12. Kluge EH: Doctors, death and Sue Rodriguez. Can Med Assoc J1993; 148: 1015-1017

13. Kluge EH: Sue Rodriguez and palliative care. [letter] Can MedAssoc J 1993; 149: 1073-1075

14. Marker R, Stanton JR, Recznik ME et al: Euthanasia: a historicaloverview. Md J Contemp Leg Issues 1991; 2: 257-298

15. Benrubi GI: Euthanasia- the need for procedural safeguards.N Engl J Med 1992; 326: 197-199

16. Quill TE, Cassel CK, Meier DE: Care of the hopelessly ill- pro-posed clinical criteria for physician assisted suicide. N Engl JMed1992; 327: 1380-1384

17. Coles R: Literature and medicine. JAMA 1986: 256: 2125-2126

JUNE l, 1994

Conferencescontinuedfrom page 1761

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