Medical Education, 1980, 14, 1-3

Editorial

1. Medical science, medical services and medical education

The question, ‘how important in medicine is science?’ would be regarded as a pressing one if the answer was not generally viewed as self-evident. The basic sciences are the first instruction given to medical students: they are regarded as the essential foundation for later professional competence. Medical students are allowed to proceed to clinical studies only when they are deemed to have learned the science subjects. And they are taught to hold science in the highest regard, the progress of medicine in the 20th century viewed as a consequence of the spectacular development of physics and chemistry in the 19th.

More recently there have been vigorous critics of medical science. Some, like Illich, can perhaps be discounted: he ‘resents medicine to an extent which is quite irrational’.* Other critics, however, come from within the ranks. Dr Hafdan Mahler, Director- General of the World Health Organization, convey- ing ‘deep concern about the health care systems that we have at present in our countries’, pointed again to the widespread preoccupation in medical circles with ‘esoteric diseases’ (World Health Organization, 1978). Elsewhere Dr Mahler has deplored that ‘so-called “health care” has been oriented towards the diseases of only a few privileged persons; this is also true of medical education, which has pro- duced not health professionals but disease pro- fessionals’ (Council for International Organisations of Medical Sciences, 1977).

Not long ago it had been accepted, with Sir Thomas Lewis as a foremost spokesman, that the effectiveness of medicine would progressively increase as clinical problems were increasingly studied with the methods of the experimental sciences (Lewis, 1930). Then leading medical

*Dollery, C . (1978) The End of an Age of Optimism: Medical Science in Retrospect and Prospect. Nuffield Pro- vincial Hospitals Trust, London.

teachers became troubled about the direction and methods of medical research, which too often con- centrated on obscure or minor observations (Platt, 1967). The point was reached that the resoundingly adverse judgement could be made: ‘almost none of modern basic research in the medical sciences has any direct bearing on the prevention of disease or the improvement of medical care’ (Burnett, 1971).

In his Rock Carling Monograph,* Professor Dollery sets out to deal with the critics of medical science. He lists the main charges: (1) Ivan Illich holds that the medical profession has become ‘a major threat to health’, and operates a conspiracy against the public (Illich, 1977); (2) Dr M. H. Pappworth (1967) accused those conducting medical research of callous experiments on patients, often without their knowledge or consent, sometimes using procedures irrelevant to the condition present or the appropriate treatment for it; (3) Professor Thomas McKeown (1976) has long held that medical science has made little contribution to improvement in health, which has been the consequence of sanitation, nutrition and better housing; (4) Pro- fessor Cochrane (1972) is a spokesman for the charge that leading clinical research workers show themselves as credulous and over-enthusiastic, and have misled clinicians and deceived patients.

Professor Dollery considers the evidence for each of these charges. He concludes by rejecting Iilich’s accusation of a medical conspiracy. Pappworth’s imputation of callousness was not warranted (‘unproven’), but the setting up of ethics committees has since increased the safeguards for human ex- perimental subjects. The incrimination of medical science as gullible, and clinical research workers as credulous optimists, is amply warranted. Many scientists have ascribed results to experimental intervention which were in fact dut to natural recuperation, the effect on patients of suggestion,

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or selective inattention to undesired research findings. McKeown’s indictment, however, that medical science has been irrelevant is rebutted: Dollery considers the charge has been overstated, and also that McKeown erred by basing his case too much on the death rate. He is quoted as conceding in subsequent conversation with Dollery that he leaned too far one way ‘to counteract the excessive claims made by medical scientists’ (p. 15).

The contention is far from over. McKeown has returned to the attack,* updating his 1976 Rock Carling Monograph. He examines not only medical science but also the prevailing outlook in medicine itself. He sets out to demonstrate that improvement in health during the past threecenturies has depended on better hygiene, protection from hazard, limiting family size, clean water, and good nutrition, and not on intervention in disease processes.

McKeown’s concern is to insist that further im- provement in health will continue to come from modification in the conditions that lead to disease, rather than from intervention in the disease mechan- ism once it has occurred. He therefore reiterates that medical education and practice cannot continue to abdicate responsibility for helping to create a healthy society. He supports Dr Mahler in depre- cating a view of the doctor as a disease professional. Moreover, he requires that attention to the patient’s personal behaviour should be the responsibility of every doctor (he points out that illnesses associated with personal behaviour, such as over-eating and smoking, continue to increase).

In expanding and revising his book, McKeown is at pains to emphasize that he is in no way under- mining the significance of the clinical approach. Sick people want all that is possible to be done for them; and inability to control the outcome of disease does not diminish the importance of ‘the pastoral or samaritan role of the doctor. In some ways it increases it.’ He adds a new chapter, in recognition of the just criticism that he had given

‘McKeown, T. (1979). The Role of Medicine: Dream, Mirage or Nemesis. Oxford: Basil Blackwell. Hardback €12, paperback f3.95.

most weight to the decline in mortality and too little attention to the treatment of morbidity.

McKeown continues to assert that medical science and services are misdirected. He rejects the out- moded doctrine that the essential medical function is the diagnosis and treatment of disease in indi- vidual patients. He maintains firmly that Medicine must be concerned with all the influences on health. Such an extended concept of medical care calls for profound rethinking about both medical research and medical education. What meiical students ‘hear and see during the years in a medical school and teaching hospital’ leads to the restricted view- point of doctors. The curriculum and the image of medicine projected at the teaching hospital are the important determinants of ‘the conventional mech- anistic approach’, and the serious isolation of teaching from some of the major health problems. To correct such damaging restriction, McKeown sides with those who advocate that the teaching centre should accept responsibility for all medical services for the population of a defined area.

References BURNETT, SIR MACFARLANE (1971) Genes: Dreams and

Realities. Medical and Technical Publishing Co., Aylesbury.

COCHRANE, A.L. (1 972) Effectiveness and Eficiency : Random Reflections on Health Services. Rock Carling Monograph. Nuffield Provincial Hospitals Trust, London.

SCIENCES (1977) Health Needs of Society: A Challenge for Medical Education. (eds A. Gellhorn, T. Fiillop and Z. Bankowski). World Health Organization, Geneva.

ILLICH, I . (1977) Limits to Medicine. Medical Nemesis: The Expropriation of Health. Pelican Books, London.

LEWIS, T. (1930) Research in medicine: its position and its needs. British Medical Journal, 1, 479.

MCKEOWN, T. (1976) The Role of Medicine. Nuffield Pro- vincial Hospitals Trust, London.

PAPPWORTH, M.H. (1 967) Human Guinea Pigs. Routledge and Kegan Paul, London.

PLATT, R. (1967) Medical science: master or servant? British Medical Journal, 4, 439.

WORLD HEALTH ORGANIZATION (1978) An Integrated Ap- proach to Health Services and Manpower Development. W.H.O. Regional Office for the Eastern Mediterranean, Alexandria.

COUNCIL FOR INTERNATIONAL 0RGANrZATrON.V OF MEDICAL