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Limits to medicine
Health Policy, 6 (1966)
207-209
201
Elsevier HPE
00090
Report on a Conference
Limits to medicine Heleen M. Dupuis Department for Metamedica, State University of Leiden, The Netherlands Accepted for publicition
5 March 1996
Whilst in developing countries basic medical care is not yet available to all, in the affluent western societies discussions are already starting on the limits of medical care and cure. The limits that are being considered are not mainly economic, but have to do first and foremost with a delay in scientific progress, and also with restrictions imposed by moral considerations. People are also becoming gradually more aware of the applicability to medical practice of the famous Marxist law of diminishing returns. It seems, for instance, that the most arduous efforts in the field of oncology do not lead to breakthroughs. The investment of more energy and more manpower in many fields of medicine apparently results in only relatively small effects on health and wellbeing of the people. Next to these limits to medicine, there is also the problem of the scarcity of medical provisions, even in wealthy countries. This scarcity seems to be created largely by an almost built-in capacity of medicine for endless expansion, but is also influenced by a decrease of economic growth. On December 6th 1985, about 150 scholars and officials in the field of medicine and health care assembled in the Royal Palace of Amsterdam to discuss and evaluate the role of medicine in modem western societies in the presence of Her Majesty Queen Beatrix and her husband, Prince Claus. Four eminent scholars were asked to present papers on the real theme of the day (as the president of the symposium Prof. B. Polak rightly stated): - What ought to be done (i.e. in health care)? - What can be refused? Prof. Polak pleaded for a conscious consumership of the patient and also for a less unwieldy structure of health care in order to enable public authorities to react more adequately to changes in both the demands for and the supply of medicine. The first to comment on the theme was Prof. H. Galjaard (Rotterdam). He showed
Address for correspondence: Prof. Dr. H.M. Dupuis, Vakgroep Metamedica, Rijksuniversiteit Leiden, Postbus 9603, 2300 RC Leiden, The Netherlands. 0168-8510/86/$03.50
Q 1986 Elsevier Science Publishers
B.V. (Biomedical
Pathologisch
Division)
Laboratdrium,
208
quite convincingly that no factual limit to either the development or the application of medicine can be seen so far. On the contrary, even in a country with the highest life expectancy figures in the world, people are tending to rely more and more on medicine in search for their wellbeing. Neither spontaneous restrictions in the use of medicine, nor a change in the attitudes and behaviour of people, can be observed. Moreover, people do not tend to make a wise and rational use of medicine, and one could even say that modern medicine seems to break people from the acceptance of disease, pain and suffering. Galjaard suggested that while other approaches could be devised to cope with the major problems of life, this would require a fundamental change in lifestyles. Should and could people be educated to refrain from a boundless use of medicine, in order to enhance their own wellbeing and to reduce the ever rising costs of medicine? In addressing this question the sociologist Prof. Thoenes (Utrecht) pointed out that learned attitudes and behaviour can be unlearned, but only under specific conditions, and provided those involved stand to benefit. Indeed some examples of successful changes can be found. But the fact remains that in a permissive society such as ours, severe punishments for undesirable behaviour are very difficult to implement, and inducing people to change certain attitudes can only take place through persuasion and through offering adequate rewards. One of the main issues in discussions about the limits of medicine focusses on the idea that demands for medical care and cure could be reduced by an emphasis on preventive medicine. Prevention is often claimed to reduce the costs of medicine, but this is a myth, as Prof. J. Blanpain (Leuven, Belgium) stated in his contribution. Rather, the reverse is true: successful prevention will inevitably lead to an increase in the demand for and use of medicine. So prevention is not “the best buy” - that is, economically speaking; of course there may be, and there are, other reasons for emphasizing prevention. Prof. Blanpain, an authority on hospital administration and medical care organization, also referred to some other myths, which like Bacon’s idola previously, prevent people from a rational analysis of the problems they want to discuss. The second myth is the one of the stagnating survival rates; Blanpain demonstrated that the assumption that we have reached the limits of our life expectancy (in the Netherlands 79 years for women, and 71 years for men) is false: medical care is very well able to improve upon these high figures. But we should not - another myth - evaluate medicine only on the basis of survival rates: this is not an adequate nor the sole criterion for assessing medical results. Blanpain also attacked the myth of infinite morbidity. In general, Blanpain’s view of medicine is rather optimistic, and one can very well appreciate his apprehension in connection with all the present efforts in our countries to control medicine, which in his eyes may lead to an “oversteering” of health care. The final, more serious myth Blanpain addressed is what he described as “the fiction of the uncontrollable costs of medicine”, where he defended a view rather different from most contemporary ideas. It would have been very interesting to start a debate on this issue, but, at least at this conference, no real discussion took place, and certainly not on this most important counterplea from Blanpain. Although the discussions arising from the symposium were in general rather disappointing, this was certainly not true for the various papers that were presented. The
209
final speaker was Dr. L. Stuyt (specialist in internal diseases, former Minister of Health and former president of the Dutch Health Council), who in his paper discussed the position at large of today’s medicine, and who went into the present doctor-patient relationship with all its good and less desirable aspects. Dr. Stuyt criticized the lack of expertise in the management of health care and medicine, and disagreed with the application to medicine of the economic model. Medicine should be governed by both a human doctor-patient relationship and a sound scientific basis and interest. It is clear that the issues under discussion require further analysis and debate. But at least a serious start has been made.
207-209
201
Elsevier HPE
00090
Report on a Conference
Limits to medicine Heleen M. Dupuis Department for Metamedica, State University of Leiden, The Netherlands Accepted for publicition
5 March 1996
Whilst in developing countries basic medical care is not yet available to all, in the affluent western societies discussions are already starting on the limits of medical care and cure. The limits that are being considered are not mainly economic, but have to do first and foremost with a delay in scientific progress, and also with restrictions imposed by moral considerations. People are also becoming gradually more aware of the applicability to medical practice of the famous Marxist law of diminishing returns. It seems, for instance, that the most arduous efforts in the field of oncology do not lead to breakthroughs. The investment of more energy and more manpower in many fields of medicine apparently results in only relatively small effects on health and wellbeing of the people. Next to these limits to medicine, there is also the problem of the scarcity of medical provisions, even in wealthy countries. This scarcity seems to be created largely by an almost built-in capacity of medicine for endless expansion, but is also influenced by a decrease of economic growth. On December 6th 1985, about 150 scholars and officials in the field of medicine and health care assembled in the Royal Palace of Amsterdam to discuss and evaluate the role of medicine in modem western societies in the presence of Her Majesty Queen Beatrix and her husband, Prince Claus. Four eminent scholars were asked to present papers on the real theme of the day (as the president of the symposium Prof. B. Polak rightly stated): - What ought to be done (i.e. in health care)? - What can be refused? Prof. Polak pleaded for a conscious consumership of the patient and also for a less unwieldy structure of health care in order to enable public authorities to react more adequately to changes in both the demands for and the supply of medicine. The first to comment on the theme was Prof. H. Galjaard (Rotterdam). He showed
Address for correspondence: Prof. Dr. H.M. Dupuis, Vakgroep Metamedica, Rijksuniversiteit Leiden, Postbus 9603, 2300 RC Leiden, The Netherlands. 0168-8510/86/$03.50
Q 1986 Elsevier Science Publishers
B.V. (Biomedical
Pathologisch
Division)
Laboratdrium,
208
quite convincingly that no factual limit to either the development or the application of medicine can be seen so far. On the contrary, even in a country with the highest life expectancy figures in the world, people are tending to rely more and more on medicine in search for their wellbeing. Neither spontaneous restrictions in the use of medicine, nor a change in the attitudes and behaviour of people, can be observed. Moreover, people do not tend to make a wise and rational use of medicine, and one could even say that modern medicine seems to break people from the acceptance of disease, pain and suffering. Galjaard suggested that while other approaches could be devised to cope with the major problems of life, this would require a fundamental change in lifestyles. Should and could people be educated to refrain from a boundless use of medicine, in order to enhance their own wellbeing and to reduce the ever rising costs of medicine? In addressing this question the sociologist Prof. Thoenes (Utrecht) pointed out that learned attitudes and behaviour can be unlearned, but only under specific conditions, and provided those involved stand to benefit. Indeed some examples of successful changes can be found. But the fact remains that in a permissive society such as ours, severe punishments for undesirable behaviour are very difficult to implement, and inducing people to change certain attitudes can only take place through persuasion and through offering adequate rewards. One of the main issues in discussions about the limits of medicine focusses on the idea that demands for medical care and cure could be reduced by an emphasis on preventive medicine. Prevention is often claimed to reduce the costs of medicine, but this is a myth, as Prof. J. Blanpain (Leuven, Belgium) stated in his contribution. Rather, the reverse is true: successful prevention will inevitably lead to an increase in the demand for and use of medicine. So prevention is not “the best buy” - that is, economically speaking; of course there may be, and there are, other reasons for emphasizing prevention. Prof. Blanpain, an authority on hospital administration and medical care organization, also referred to some other myths, which like Bacon’s idola previously, prevent people from a rational analysis of the problems they want to discuss. The second myth is the one of the stagnating survival rates; Blanpain demonstrated that the assumption that we have reached the limits of our life expectancy (in the Netherlands 79 years for women, and 71 years for men) is false: medical care is very well able to improve upon these high figures. But we should not - another myth - evaluate medicine only on the basis of survival rates: this is not an adequate nor the sole criterion for assessing medical results. Blanpain also attacked the myth of infinite morbidity. In general, Blanpain’s view of medicine is rather optimistic, and one can very well appreciate his apprehension in connection with all the present efforts in our countries to control medicine, which in his eyes may lead to an “oversteering” of health care. The final, more serious myth Blanpain addressed is what he described as “the fiction of the uncontrollable costs of medicine”, where he defended a view rather different from most contemporary ideas. It would have been very interesting to start a debate on this issue, but, at least at this conference, no real discussion took place, and certainly not on this most important counterplea from Blanpain. Although the discussions arising from the symposium were in general rather disappointing, this was certainly not true for the various papers that were presented. The
209
final speaker was Dr. L. Stuyt (specialist in internal diseases, former Minister of Health and former president of the Dutch Health Council), who in his paper discussed the position at large of today’s medicine, and who went into the present doctor-patient relationship with all its good and less desirable aspects. Dr. Stuyt criticized the lack of expertise in the management of health care and medicine, and disagreed with the application to medicine of the economic model. Medicine should be governed by both a human doctor-patient relationship and a sound scientific basis and interest. It is clear that the issues under discussion require further analysis and debate. But at least a serious start has been made.