Richard Smith: Medicine needs to feel defeat

Richard SmithDefeat is a marvellous thing. It can refresh in a way that never happens after victory. Wouldn’t it be wonderful, I thought this morning as I awoke, if medicine were to feel defeated and have to rethink its purpose?

I thought this as I awoke because I’d been dreaming about the Labour leadership contest. Ed Balls and the Millibands had appeared to me (not Andy Burnham and Diane Abbot, note well) and had created images of how they saw the future of the Labour party and so the country.

Every political party has to rethink itself after defeat, and it’s a difficult, painful, prolonged but ultimately creative process. The Tories went very wrong after their heavy defeat in 1997 but eventually found themselves a story that (almost) convinced the public. The Republicans are doing it now in the US and getting very confused.

Medicine doesn’t get defeated and so has no stimulus to undergo a fundamental rethink. But I’m sure that such a rethink is needed.

We may not be defeated in medicine, but we have had stern and convincing critics. Hearing Ivan Illich in 1973 condemn medicine as “the major threat to health in the world today” is still the defining moment of my medical career. And his books Medical Nemesis and Limits to Medicine did gain worldwide coverage, but his critique didn’t lead to the kind of major self examination and renewal that follows an electoral defeat. Medicine was still self confident in the 70s.

Since Illich there hasn’t been such a profound critique, although Szaz and Laing did deconstruct psychiatry.

The Royal College of Physicians has, to its credit, had a working party examine the future of medicine, but without the agony of defeat there isn’t enough passion in the rethinking. The examination is simply a sideshow.

I think that medicine would benefit from feeling defeated. Things are not right, but they don’t feel wrong enough to lead to a fundamental rethink. How could we find the energy that comes from defeat?

Many health systems do feel defeated–with severe problems of safety, quality, access, cost, and responsiveness. But somehow medicine sits on the side, bemoaning the state of health systems but not feeling the need to fundamentally re-examine itself.

Maybe the feeling of defeat can grow slowly, and I think I see it growing. Why are we using more and more resources to achieve less and less? Have we gone beyond “flat of the curve medicine” to the point where more inputs produces harm rather than benefit? Is our relationship with death all wrong? What should be our aims and priorities? How do we feel about medicine when huge resources may be spent keeping tiny babies alive while millions die for lack of clean water? Have we medicalised too much of life? Is our relationship with patients all wrong, too infantilising? Have we promised too much?

Our failure to answer these questions and many others convincingly lead, I fear, not to the stunning pain of defeat but rather to growing disillusionment and cynicism.

How can we find the energy for renewal that comes from defeat? Might a new critique from a new Illich do the trick? Could you produce that critique? I wish you could. I’d love to read and hear it. And medicine could then renew itself.

Richard Smith was the editor of the BMJ until 2004.