The Value of Medicine* (1977)

In a letter to the chemist Joseph Priestley, Benjamin Franklin prophesied that the time would come when ‘all diseases may by sure means be prevented or cured, not excepting that of old age’. In a recent book, Dr Philip Rhodes, now Dean of the Faculty of Medicine in the University of Adelaide, Australia, and formerly Dean and Professor of Obstetrics and Gynaecology at St Thomas' Hospital Medical School, London, argues the contrary. He writes, ‘Everyone knows that the aim is unrealistic and cannot be achieved,’ and he adds, ‘nor would it be desirable to achieve it.’ Indeed, he continues, ‘There is some evidence that what is needed for the good of man as a whole is fewer lives on this planet, so that its resources may be conserved. It seeks to maximize longevity and to help each life to be lived more fully.’ For Dr Rhodes, the welfare of man as a species transcends that of man as an individual. The ‘special role of Christianity in medicine has been its emphasis on the importance of the individual’ and from this confining role Dr Rhodes asserts that medicine has been rescued in the past century through the influence of Darwin and Freud, since when man has been increasingly looked upon ‘holistically’, both as an individual and a social animal—‘more based in humanism and hedonism than in Christianity’. This is the central theme which pervades this well-written and closely argued book, and in relation to it Dr Rhodes, after an all too brief historical introduction, discusses medical education, the available resources in health personnel and finance and their global distribution, contraception, abortion, euthanasia and a host of other topics in seeking an answer to such questions as: Does medicine have an intrinsic value? Are all its consequences desirable? Should lives be saved whatever the cost? How much is comfort and relief worth in terms of hard cash and resources? And of special interest to our readers, what are Dr Rhodes' views on medical education and what of the future of medicine? It is encouraging to learn that Dr Rhodes believes that medicine has served society well both in its own and society's eyes. ‘Its practitioners have been very responsive to society's changing needs, have often been self-critical and have often led society's thinking. So that the traditional system of medical education … has not seriously failed at least the developed societies which it exists to serye’; and he calls for no ‘totally radical revision of medical education’. But he surely errs in stating that ‘the opinion is still often held that the object of present-day medical education is to produce a general practitioner’. True that in 1944 the Goodenough Committee accepted this as the aim of the medical curriculum but since then several reports have led to the currently held and widely accepted view (shared by Dr Rhodes) that the undergraduate curriculum should provide a foundation for medical training on which must be built vocational training; and both must stimulate the appetite for the continuing education of the perpetual student keeping abreast of advancing knowledge. Dr Rhodes' anxieties about the difficulties of acquiring a ‘core’ or basic curriculum need not cause concern, for it would not necessarily be identical for each school or, indeed, for each student whatever his ability or special interests. There could be formulated a readily acceptable corpus of knowledge to which all reasonable educators would subscribe. It would not include the twenty-eight or more branches of the internal maxillary artery even when aided by an inelegant mnemonic, but would include the aorta and its major branches! The essential purposes of the ‘core’ curriculum are the teaching and learning of such basic facts and theories and methods—fewer rather than more—which are needed for rational discussion as an educative process. You cannot reason in a vacuum! And, of course, the content of the ‘core’ curriculum will change with time. No curriculum is ever final. We may seek to approach this end but we never reach it. Most readers will support Dr Rhodes' plea for the introduction of history into the curriculum in order to appreciate the evolution of our present knowledge and practices and better to gain a long-term perspective. In his desire to limit the extent of potential medical needs, Dr Rhodes is plain spoken. He appears, for example, to condemn all screening procedure for the detection of subliminal and early disease. He writes: ‘And as with medicine itself they generate (sic: ‘unmask’ is their purpose) more and more ill health by going out to find it in the country.' No one can deny that in some areas screening has been unrewarding but would not Dr Rhodes agree that the early recognition of pulmonary tuberculosis by population screening made a valuable contribution to community health as well as to the welfare of the individual? Dr Rhodes' philosophy appears to be summed up in these words: ‘Suffering, disease and death are the lot of Man. They cannot be banished, they can only be minimized to some extent. Medicine is one of the agencies for this. But like everything else it cannot be brought in full measure to everyone. It is a commodity which some can afford and some cannot. Much as it may be desired, medicine is not everybody's right. The alternative for Man as a species can easily be borne, as it is at present in many parts of the world. Men, women and children suffer, fall ill and die. It is possible that those with access to medicine have less troubles with these individual disasters but that is by no means proven' (p. 117). The last sentence is hardly consistent with the spectacular triumph of immunization over, for example, diphtheria and poliomyelitis, and of many major therapeutic victories in the past few decades. Moreover, policy (as well as politics) is the art of the possible. Can it in truth be thought that the public generally will be willing to subordinate individual suffering to the good of the species? The credit and debit sides of individual and social or species good are, in any particular instance, far too complex to allow of a precise balance sheet. What of the future? Dr Rhodes rightly emphasizes the need for a fair distribution of resources; to this end he avers that ‘the government should not be allowed to interfere directly with any running of the health service’. Instead, a Health Commission should be established which would have the task of running the service and take over all present health resources once the Government had allotted appropriate monies for the service although ‘agitation for increased salaries and increased resources would be directed where it should be, which is at government’. A similar suggestion that an independent body, analogous say to the British Broadcasting Corporation, should be in control of health services has been canvassed since the creation of the National Health Service, and has recently been resuscitated by some organizations in their evidence to the present Royal Commission. But it has always been rejected on the grounds that it would be contrary to all principles of democratic control if a service so costly (in England and Wales the present cost is £5,500 millions yearly) and so intimately affecting the lives and welfare of the people, were to be removed from direct parliamentary control through a government department. It is possible to touch upon only some of the topics discussed by Dr Rhodes. That many readers will reject some of his views and conclusions will not detract from the importance of this book even when it provokes dissent and protest. It is worthy of a place with Rene Dubos' The Mirage of Nature and Man, Medicine and Environment and this year's Rock Carling lecture by Professor Thomas McKeown, The Role of Medicine: Dream, Mirage, or Nemesis.