Originally Posted by
gingernut
...maybe Ivan has got a point
There is certainly a good point to be made that there is unnecessary medication (and to a lesser extent surgery) going on. Unfortunately Illich didn't make it. Illich's belief (or what can be made out of it, for he is awfully woolly) is that the whole of Western though (not just medicine) is wrong. For all that, I think it is useful to read.
The point that Illich makes (which I have emphasised at length elsewhere in these forums) that most of the advances in public health have been by improvements in sanitation, clean air, clean water and housing is not a new one. The Victorians were well aware of it, which is why, among other things, Bazalgette was taxed with building the London sewer system.
"Illich sees three levels of iatrogenesis. Clinical iatrogenesis is the injury done to patients by ineffective, toxic, and unsafe treatments."
That this can occur is indisputable. That it occurs on the scale that Illich and Gingernut maintain is poorly supported. That doctors wholesale are indifferent to such harm is even less supported. Incidentally, many "alternative" treatments are either ineffective (e.g. Zuma's garlic, beetroot and potato for HIV/AIDs) or toxic and unsafe (e.g. Virodene and Laetrile).
"Social iatrogenesis results from the medicalisation of life. More and more of life’s problems are seen as amenable to medical intervention."
This I agree with. Simple anxiety and depression (I'm not talking about major depressive illnesses) are no longer seen as normal variations in the spectrum of experience but bad things to be medicated away. Medicine is a victim of it's own success here - drugs justifiably used for major problems are extended to minor ones, with little success and significant problems. Misguided attempts by a nanny State to legislate away "the slings and arrows of outrageous fortune" have led to a culture of entitlement and undermined self-determination and personal responsibility.
But this is part of a greater problem. Western society continues to evolve at a vertiginous pace and pressures on people come on faster and are greater than ever before. The near extinction of the extended family means that young persons rarely have an Uncle Bob or a Gran within easy reach to turn to for consolation or advice. Women are under pressure to perform not only as mothers but as businesspersons in their own right. The gimme-gimme ethic that measures success purely in terms of bling and money is profoundly selfish and doesn't seem to lead to much happiness.
"Worse than all of this for Illich is cultural iatrogenesis, the destruction of traditional ways of dealing with and making sense of death, pain, and sickness. "
This is true too, but again it is a function of societal change rather than medical malevolence. The old-style wake may well have allowed a group to integrate a death more easily but would be hard to revive since the old extended groupings are mostly gone. The sin-eaters of Wales (and elsewhere) would hardly be acceptable now. Funerals are no longer the formal affairs that they used to be (burial is expensive) - Grandpa's ashes sit on the mantelpiece for a while until they're thrown out in the next move.
"The overwhelming majority of modern diagnostic and therapeutic interventions which demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members."
This is mostly nonsense unfortunately. Because of the stringent safety rules, the medicine that keeps Uncle Jim's blood pressure from spraying out of his ears cost a fortune to develop and the company has to get their money back somehow. And the artificial hip that allows Auntie Dot to walk to the shops again could hardly be installed by the family.
He does make some very silly statements - "Depression, infection, disability, dysfunction, and other specific iatrogenic diseases now cause more suffering than all accidents from traffic or industry." None of these are generally or even specifically iatrogenic, indeed, apart from infection all are functions of society rather than medicine (with a few tiny exceptions).
His belief that pain somehow empowers or enriches people's lives is a very old idea. Many many writers and philosophers have explored this alley. The Catholic Church (and Illich was a Catholic priest before he became a critic of industrial society) tells us to "offer up our pain to the Holy Souls". Solzhenitsyn in particular, in the last part of "The Gulag Archipelago" embraces this belief. Personally I believe that a modicum of suffering (in the larger sense) is needed for us to be wholly human, but that severe or unrelieved suffering impoverishes rather than enriching. Only sadists think it is good for you.
Originally Posted by
gingernut
..medicine isn't actually that good at stopping people dying, is it?
Ultimately no - for life's a dying disease. In the interim - well, I wonder what planet you're living on! That is really a pretty silly statement if you think about it for a bit.
I think that the real problem is that young medics and paramedics are not taught the history of medicine, know very little history generally and have little or no experience of what societies are like without any effective medicine. Being at two removes from clinical medicine, medical administrators and medical theorists (particularly those with a political axe to grind) are particularly prone to these errors.
A little story. Once upon a time in 1890 (or 1940) a child was feverish and coughing. Someone went to get the GP and he eventually came round in his gig or his motor and was ushered into the normally unused parlour. The child was produced and he gravely examined the child, percussing and auscultating the chest. A few nostrums were prescribed (there was nothing else) and advice about diet and warmth given before he left. The next day he came to see the child again. High fever, tachycardia and tachpnea - a real pneumonia. That evening no improvement. The next morning worse, the fever is spiking at 104F - the doctors shakes his head, "It's touch and go now I'm afraid Mr Brown, I'll be back later". That evening the child is delirious, nothing will persuade her to drink. "I think I'd better stay for a while Mrs Brown", and the doctor, wrapped in his old ulster, settles down by the cot with a teaspoon and some cold sweet tea. At 3am the fever is 105F, the child is burning up, the crisis. At 4am the child is suddenly soaked with sweat and the temperature is 99F - is this the lysis or just another hope? At 6am the temperature is still down and the child is awake and asking for her mum. "I think she'll be alright now Mrs Brown", he says and sets off for his morning surgery.
Fast forward to 2006. Another child is feverish and coughing. A phone call is made and an appointment booked. The child is seen by the practice nurse who diagnoses a lower respiratory tract infection. She intercoms the doctor, "Little Lucy Brown has got a nasty chest infection. I think some Augmentin will sort her out", "Sure, carry on". The family exit, clutching their bottle of Augmentin. By that evening the temperature is down and the child is feeling better. Next morning she is apyrexial and there's a check call from the practice, "Oh good, I'm so glad. I'd keep her off school for a few days though. Pop down to the practice and I'll leave a chit at reception".
Which doctor gets the most satisfaction? Which doctor gets the love and respect?
This is a serious problem for medicine today. So many potentially serious illnesses have become trivialised by therapeutic advances that the role of the doctor has become almost marginal for many of them. The real heroes (unsung most of the time - who today remembers Banting and Best) are the pharmacologists and researchers who created the medicines. The antiheroes are of course the drug companies, especially when things go wrong..
Originally Posted by
gingernut
Some of it works, some of it we don't know if it works, and some of it is positively dangerous.
Antibiotics work and we know how and why
Beta-blockers work and we know how and why
Analgesics work and we know how and why for most of 'em
Proton pump inhibitors work and we know how and why
Antihistamines work and we know how and why
Steroids work and we know how and why
Antihypertensives work and we know how and why
Chemotherapy often works (ask the guys in the Hodgkins thread) and we know how
NSAIDS work and we know how and why
Anaesthetics work, but we still aren't quite sure how! Forgo them if you're a purist.
Antiarrhymics work and we mostly know how
Antiepileptics work (mostly) and we know some of how
ALL of them are dangerous if misused - are you insisting that medicines have an infinite therapeutic index? That isn't realistic. I'm reminded of my great-grandmother who'd never been to the movies in her life - when asked why, she said, "I'll go when they've got it right".
I think it's good to question and I teach my students to doubt and investigate. I myself question many of the wonder procedures that emerge from time to time as well as wonder treatments both conventional and alternative.
To be a doctor and a surgeon is for me the most thrilling and exciting thing in the world. In exchange for this one assumes grave duties and arduous responsibilities. To be worthy of the trust that patients place in one demands self-discipline, continued study and moral rigour.
I think it is terribly sad that a young person like Gingernut, in an administrative position, feels such scepticism about the motives of his medical colleagues and so many doubts about the usefulness of medicine at all.
Perhaps a little real primary medicine and surgery out in the bush would renew his faith.