Map of life expectancy at birth from Global Education Project.

Monday, January 07, 2008

Bit of a thumbsucker

I'm not going to give much in the way of references or concrete history in this post -- it's basically for conceptual background. But, just pulling it out of an orifice, the story goes something like this.

Until around about the 1960s -- by which I really mean the early 1970s, since the 60s lasted from about 1965 through 1974 -- there was very little questioning of the medical enterprise from within -- or from without, for that matter. Or at least there hadn't been for a long time, since the critical ferment surrounding the Flexner Report in 1910. Back then, the criticism was essentially that medicine was largely unscientific, but in the 1960s, the problem turned out to be just the converse -- that medicine had become too narrowly biological, in the process becoming patriarchal, inhumane, and even contrary to the interests of patients.

There were many critical approaches, complexly interrelated, some mutually reinforcing, others arguably contradictory. The generally accepted relationship between physicians and patients in the West was of a nature now characterized as "benevolent paternalism." The expertise and wisdom to choose the appropriate treatment of disease resided entirely with the physician. The patient's role was to trust the physician and to follow "doctor's orders" --a condition analogous to childish dependency.

Patients ordinarily could be said to have consented to treatment, if only because, as a practical matter, they had to physically submit to the surgeon's knife or swallow the doctor's potions. However, there was no expectation that the patient would be specifically informed about the physician's theory of the patient's disease state, the theoretical basis of the proposed remedy, possible adverse effects, or alternative treatments.

The U.S. Congress, in 1981, mandated a study of "the ethical and legal implications of the requirements of informed consent" in medical practice. The Commission proposed an ideal model of medical decision making in which physicians and patients are partners. While physicians possess expertise about diseases and treatments, the patient is the expert on his or her own tolerance for pain and inconvenience, fear of disability or death, and other subjective factors essential to determining the consequences of a treatment choice for the patient's well-being. The report also puts forth self-determination as having intrinsic value.

At the same time, the very definition of health was subject to reconsideration. Doctors were trained in biological science, but people do not only value their biological state. Most basically, obviously, we also care about our psychological, social and spiritual conditions. Furthermore, our biological state matters to us largely as it affects the latter three. Yes, we need to be alive and conscious even to care, but beyond that, physical abilities and limitations are meaningful only in context. I can't dunk a basketball but I can live with that, whereas Kevin Garnett cannot. Sociologists such as Elliot Mishler -- who found doctors thwarting patients' efforts to tell their stories in their own terms, in which their physical condition was interwoven with their lives as social beings -- and Irving Kenneth Zola -- who found that disability emerged largely in the setting of social demands and physical environments -- recast the very foundation of the medical enterprise. Howard Waitzkin linked it to economic oppression, and Alexendra Dundas Todd to gender oppression. Epidemiologists discovered that low social status was a powerful predictor of disease and death, and found medical intervention to be of little importance to people's health in comparison with the basic conditions of their lives. Holistic views of the human person found medicine to be absurdly reductionist -- doctors didn't treat people, they treated body parts -- livers, kidneys, hearts, colons. But we aren't just the sum of our organs.

But then many of the same critics, such as Irv Zola, who had discovered the inadequacy of the underlying philosophy of medicine, became alarmed by the response, which seemed to be to convert every problem into a medical problem. The medicalization of every social problem from excessive drinking to child abuse to sadness to hunger was often seen, not as an effort to make medicine more humane and patient centered, but as a new form of oppression, displacing social criticism with efforts to locate problems in the damaged individual, and replacing the agency of individual and community with the benevolent paternalism of the medical institution.

So, the intent of this post has been to introduce these problems. Next, let's see how we can untangle them.

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