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.
Nor is that the end of it. For medical science now recognises only one source of knowledge, that which has ‘been proven’ by statistics, and this too is a potent source of error. There are many ways of knowing, and among the most powerful is the tacit knowledge that comes from experience and is best described as ‘judgement’.5 Sir Austin Bradford Hill’s legacy, albeit unintentional on his part, has been to marginalise this tacit form of knowledge, so it is deemed less reliable and inferior to that which can be objectively and explicitly demonstrated with statistical techniques and clinical trials.
But, as has been observed repeatedly, it is this statistically derived knowledge that has consistently been shown to be unreliable, promoting the patently absurd as proven fact. Further, clinical trials cannot answer the sort of complex questions that frequently crop up in medical practice and when many are aggregated together ‘incomplete data is run through computer programs of bewildering complexity to produce results of implausible precision’. This form of knowledge, when subjected to critical scrutiny, has been shown to result in the adoption of an ineffective treatment in 32 per cent of cases and the rejection of a useful treatment in 33 per cent of cases. It is only of moderate consolation to realise that in the remaining third it must have produced the ‘right’ answer.6
Perversely, then, scientific progressivism has undermined medicine’s most important asset – knowledge based on practical experience, allied with ‘a reasoning faculty’ that can distinguish the true from the false.
We turn now to the second dynamic force of progress of the post-war years, capitalism, as represented by the pharmaceutical companies whose ‘obsession with the new’ exerts a very different, but equally destructive, influence on contemporary medicine. The reason for this ‘obsession with the new’ is obvious enough; new drugs, and the prospect of windfall profits while they remain under patent, are the lifeblood that drives the industry forward. This worked very well in the years of cornucopia, but when the rich stream of accidental drug discoveries began to dry up, the drug companies had to resort to other means to maintain their profitability. This, as has been seen, has taken the form of ‘better (but more expensive) mousetraps’ or indeed ‘useless mousetraps’, promoted on the grounds that they are better than no mousetraps at all.
It is, of course, up to doctors whether or not to prescribe these new drugs, but therein lies the problem. The drug companies are very rich but they are also desperate, because marketing their wares is now so costly. By contrast, academic doctors are poor, or at least always relatively short of funds for their research, and one way of acquiring those funds is to agree, for a fee, to investigate whether the latest wonder drug is indeed wonderful. They thus become, wittingly or not, the respectable front for the drug companies while, as was seen with the example of cholesterol-lowering drugs, providing the rationale for their almost universal prescription. In these circumstances, patients have become overmedicalised and the nation’s drugs bill continues to escalate. Who is to know whether the alleged efficacy of these new drugs is as claimed, when the head of an academic unit of a teaching hospital spends two months of the year away from his post travelling in the United States, Europe and the Far East at the behest of a drug company? When a medical academic’s ‘commercial involvement reaches this level’, observes the disapproving edito
r of The Lancet, ‘the very independence of research and opinion is put at risk’.7
This unhealthy situation is the inevitable reverse side of the dynamic and progressive nature of the pharmaceutical industry that was so intrinsic to the Rise, for, self-evidently, the drug companies as capitalist enterprises cannot escape from the imperative to innovate, they cannot impose restraints upon themselves, and thus must pursue every legitimate avenue in promoting the drugs up to, and including, subverting the integrity of the medical profession.
It is possible from these reflections on medicine and progress to make a very clear distinction. Genuine progress, optimistic and forward-looking, is always to be welcomed, but progress as an ideological necessity leads to obscurantism, falsehood and corruption. The question of how to maximise the possibilities of the former while rejecting the latter is best resolved by accepting at face value the version of events as revealed by this historical account, where the last fifty years are best seen as one episode, albeit a very glorious one (indeed a culminating one), in an historical tradition that stretches back over the past 2,500 years. The time has come to relocate medicine back within that tradition so eloquently evoked by Sir William Osler. The timeless virtues of judgement and good sense might then triumph over the shallow restlessness of the present through a reaffirmation of the personal human relationship between doctor and patient. The personal doctor listens carefully to what he is being told. He or she performs the irreducible minimum of investigations necessary to establish a diagnosis. He confines himself to the matter in hand and does not stray beyond to give impudent or gratuitous advice. He recognises the intellectual limits of human understanding and the practical limits of what medicine can legitimately be expected to achieve.8 This reaffirmation of the central tenet of medical practice may, or may not, mean that doctors in the future will be less inclined to ‘regret’ their chosen career, but the public will certainly have less reason to be unduly concerned about their health or to look elsewhere for help with their medical problems. Meanwhile, the limited prospects of future medical advance should by now be well recognised, so there is no need for the cost of medical care to continue to spiral upwards. Thus, the present discontents of medicine may be resolved and its future guaranteed.
EPILOGUE TO THE REVISED EDITION
The broad outline of the medical achievement of the post-war years is by now familiar enough: the exuberant therapeutic innovation epitomized by the Twelve Definitive Moments had by the 1980s plateaued, creating an intellectual vacuum that would be filled by the ambitious programmes of The New Genetics and The Social Theory. Many factors, as noted, have contributed to that pattern of a ‘Rise and Fall’, but the two phases also divide on ‘philosophical’ grounds, with a radically different interpretation of the nature of scientific inquiry.
Howard Florey, Philip Hench and all those who contributed to the golden age of drug discovery had a feel for the complexities of biology and, by definition, the limits of current knowledge. But they were also open to those clues and anomalous observations in the clinic and laboratory that, if pursued, might illuminate the seemingly obscure, while possessing the tenacity to turn them to therapeutic advantage. The impressive roll call of technical innovation was similarly predicated on recognizing that while a profound understanding of the pathological processes involved in, say, arthritis or cataracts might be elusive, they were nonetheless highly amenable to technical solutions.
The Social Theory by contrast is based on the almost antithetical premise, that science already ‘knows the answers’ – at least in principle – that many common diseases are due simply to the way people lead their lives, and thus can be readily prevented. The New Genetics too is grounded in an all-encompassing and misleading simplification: that the complexities of life and disease can be reduced to, or explained in terms of, the sequence of chemical genes strung out along the double helix.
The pattern of a Rise and Fall, written ten years ago on the cusp of the new Millennium, seemed to offer a grand unifying theory for the major historical developments in medicine as they had unfolded over the preceding half-century. A decade later, it is of interest to assess whether that pattern has ‘stood the test of time’ and where (inevitably) its judgements must be revised.
INTRODUCTION: TEN YEARS ON
The cautionary concluding paragraph of The Rise and Fall . . . of a decade ago – ‘The limited prospects of future medical advance should by now be well recognised’ – might appear (more than) contradicted by what happened next: a sustained and massive expansion of the medical enterprise on every front. In Britain, Health Service funding, having already doubled from £23 billion to £45 billion in the 1990s, has almost tripled again, to an eye-watering £110 billion. It is a similar story with the countries of the European Union, while by 2010 health spending in the United States had soared past the trillion dollar mark to a staggering $2.6 million million.1
This financial largesse has permitted a substantial increase in the medical workforce within Britain: 6,000 more general practitioners than ten years ago now busy writing 300 million more prescriptions (up from 680 to 979 million) while an additional 30,000 hospital doctors now perform, inter alia, twice as many cataract operations (up from 158,000 to 290,000), joint replacements, colonoscopies and much else besides. The pharmaceutical industry has predictably prospered, its global annual revenues soaring from $400 to $800 billion. And the past decade has also been ‘the very best of times’ for biomedical research, whose funding has also doubled to more than $100 billion worldwide.2,3 It can, as always, be difficult to grasp what those additional billions really signify, but by way of analogy that epitome of a financially successful company, Google, with annual revenues of around $22 billion makes for a useful comparison. Here, the current level of funding of biomedical research is the equivalent of four Googles, while the increase in the annual revenues of the pharmaceutical industry over the past ten years is, astonishingly, equivalent to sixteen Googles.
It is not immediately obvious what this phenomenal increase in resources (and in so short a time) has achieved, but it certainly might seem at odds with that pattern of a Rise and Fall . . . And, in retrospect, that judgement now seems unduly pessimistic in not giving sufficient emphasis to the further opportunities – not only for what doctors can do but also, more importantly, the vastly greater numbers on whom they do it.
Here, several factors come together. First and obviously the demographic shift of an increasingly ageing population has swelled the ranks of those requiring treatment for the (inelegantly named) chronic degenerative diseases – arthritic hips, clouded lenses, furred-up arteries and the powerfully age-determined conditions of heart disease, stroke and cancer. Next, the major technical development of the recent past of minimally invasive (keyhole) surgery, though technically very demanding, is by definition much less traumatic than the traditional operations and procedures it has replaced, thus enormously extending the age range of those who might benefit from medical intervention, up to and including those in their eighties and nineties. This in turn has accelerated the trend towards the ‘biomedicalisation of ageing’, where the physical ailments of the later decades of age are no longer perceived as the inevitable consequence of a natural process but rather so many specific problems for which medical intervention is both necessary and appropriate. It is thus possible to glimpse the degree to which the expansion of the medical enterprise in the past decade might be accounted for by its extension to include those with the greatest need for its technical solutions – whether new hips or heart valves, transplanted kidneys or replumbed arteries.4
The second aspect of that medical expansionism, the 300 million additional prescriptions written by doctors every year, requires a rather different explanation. The citizens of Britain now take half as many drugs again compared to twenty years ago and it is not unusual for many to take half a dozen or more daily. There has been no major resurgence in drug discovery to account for this therapeutic enthusiasm, which reflect
s, rather, the success of the pharmaceutical industry in redefining and expanding the definition of illness in such a way as to convince doctors (and the public) that it warrants treatment. This, as will be seen, has taken several forms.
The completion of the Human Genome Project in 2001 is the major factor contributing to the third pillar of the medical expansionism of the last decade – the explosion in the funding of biomedical research. The ability to spell out the full sequence of human genes and its many ramifications has proved immensely productive, generating gigabytes of basic biological data every week – though the practical benefits, as will be seen, remain surprisingly elusive.
We turn now to consider these distinct strands under three main headings. First, ‘Doing More’ will examine those technical developments that have extended the benefits of medical intervention to an ever ageing population. Next ‘The New Genetics Triumphant – or Not’ will chart the uncertain progress of medical research in the aftermath of the completion of the Human Genome Project. And finally (and most importantly), ‘Big Pharma Rules’ will consider the increasing influence of an ever wealthier pharmaceutical industry on the medical enterprise.
1
DOING MORE
The line is advancing. We are more willing to [intervene in those] in their seventh and eighth decade than twenty five years ago . . . and getting much better results. I remember, in training, being confronted with the dilemma of [resuscitating] an 80-year-old patient, and thinking that was just the most extreme circumstance. How could we justify preventing sudden death in an 80-year-old? And now it is commonplace. So, that’s a real change you can quantify.1
The Rise and Fall of Modern Medicine Page 39
