{"id":44067,"date":"2019-02-13T12:29:13","date_gmt":"2019-02-13T11:29:13","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=44067"},"modified":"2019-03-05T16:34:49","modified_gmt":"2019-03-05T15:34:49","slug":"richard-smith-most-devastating-critique-medicine-since-medical-nemesis-ivan-illich","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/02\/13\/richard-smith-most-devastating-critique-medicine-since-medical-nemesis-ivan-illich\/","title":{"rendered":"Richard Smith: The most devastating critique of medicine since Medical Nemesis by Ivan Illich in 1975"},"content":{"rendered":"

\"richard_smith_2014\"<\/a>Seamus O\u2019Mahony, a gastroenterologist from Cork, has written the most devastating critique of modern medicine since Ivan Illich in <\/span>Medical Nemesis<\/span><\/i> in 1975. O\u2019Mahony cites Illich and argues that many of his warnings of the medicalisation of life and death; runaway costs; ever declining value;<\/span>\u00a0patients reduced to consumers; growing empires of doctors, other health workers, and researchers; and the industrialisation of healthcare have come true. There is a widespread feeling that medicine has lost its way, and <\/span>Can Medicine Be Cured? The Corruption of Medicine, <\/span><\/i>which has been published this month<\/span>, <\/span><\/i>describes the loss. The book is as readable as O\u2019Mahony\u2019s last book <\/span>The Way We Die Now<\/span><\/i>, and the book provides a strange cocktail of pleasure and despair.<\/span><\/span><\/p>\n

From a golden age to the age of disappointment<\/b>
\nUnlike Illich, who believed that modern medicine counterproductively created sickness, O\u2019Mahony does see what he calls a golden age of medicine that began after the Second World War with the appearance of antibiotics, vaccines, a swathe of effective drugs, surgical innovations, better anaesthetics, and universal health coverage for most of those in rich countries. It ended in the late 1970s, meaning that O\u2019Mahony, who graduated in 1983 and is still practising, enjoyed little of the golden age. We are now \u201cin the age of unmet and unrealistic expectations, the age of disappointment.\u201d <\/span><\/p>\n

Golden ages are always in the past or the future and never now (except perhaps for television), but many older people who remember when people died of polio, diphtheria, and tuberculosis would agree that a golden age did begin around the birth of the NHS in 1948; many older doctors also see that time as a golden age when there was more curing of diseases, patients were mostly grateful and respectful, and doctors had clearer roles and more power and status.<\/span><\/p>\n

With his liking for religious imagery, O\u2019Mahony describes himself as experiencing apostasy at the age of 50. He has not lost faith in \u201cthe clinical encounter, and old-fashioned doctoring\u201d (although still doing an acute take in general medicine, he finds it increasingly exhausting and frustrating), but he has lost faith in \u201cmedical research, managerialism, protocols, metrics, and even progress.\u201d The book dissects those realms one by one. Medicine has become \u201can industrialised culture of excess\u201d and Illich is now right that medicine is a threat to health.<\/span><\/p>\n

Medical research: good for science, less good for patients<\/b>
\nO\u2019Mahony begins his dissection with medical research, \u201cthe intellectual motor of the medico-industrial complex.\u201d Governments see life sciences as a saviour of economies, and charities urge us to give more to cure every disease. Big Science, which appeared after the golden age, has provided jobs and status but \u201cbenefits to patients have been modest and unspectacular.\u201d A study of 101 basic science discoveries published in major journals and claiming a clinical application found that 20 years later only one had produced clinical benefit. Big Science is corrupted by \u201cperverse incentives, careerism, and commercialisation.\u201d Medical research has become disconnected with medical practice, which when premature mortality has fallen so far is dealing mainly with pain, suffering, and disability. Medical research is still fighting an \u201cunwinnable and unnecessary battle\u201d against death.<\/span><\/p>\n

Practitioners of genomics promise great benefits for tomorrow (it\u2019s always tomorrow), but the Nobel Laureate and former director of the National Institutes of Health Harold Varmus said that \u201cgenomics is a way to do science, not medicine.\u201d Robert Weinberg, a cancer biologist, says that clinical applications from the Human Genome Project \u201chave been modest\u2014<\/span>very<\/span><\/i> modest compared with the resources invested.\u201d <\/span><\/p>\n

Macfarlane Burnet, another Nobel laureate wrote, wrote in 1971 that \u201cthe contribution of laboratory science [to medicine] has virtually come to an end.\u201d Yet another Nobel laureate Peter Medawar took him to task, predicting in 1980 cures for juvenile diabetes and multiple sclerosis within 10 years. As O\u2019Mahony concludes \u201chistory sided with Burnet, not Medawar.\u201d He then makes an amusing, and to some insulting, comparison between contemporary biomedical science and the medieval pre-Reformation papacy: \u201cboth were taken over by careerists\u2026[who] saw the trappings of worldly success as more important than the original ideal.\u201d Biomedical research is waiting for its Reformation, perhaps it will come with a shift to much more practical research and an emphasis on making a difference rather than publishing papers.<\/span><\/p>\n

Inventing and marketing new diseases: the case of \u201cnon-coeliac gluten sensitivity\u201d<\/b>
\nAs a gastroenterologist who has done, as he admits, some lacklustre research on gluten sensitivity, O\u2019Mahony tells the story of \u201cnon-coeliac gluten sensitivity\u201d to illustrate the modern medical fashion for inventing diseases, which seems to be easier than curing some of the old ones. Willem-Karel Dicke, a Dutch paediatrician, identified wheat as causing coeliac disease during the wartime winter of starvation in the Netherlands. American paediatric journals didn\u2019t even acknowledge Dicke\u2019s submissions, but eventually gluten was identified as the cause of coeliac disease and some very sick children were cured. Now most adults O\u2019Mahony diagnoses with coeliac disease have minimal or no symptoms.<\/span><\/p>\n

But as every doctor, and particularly gastroenterologists, know there are many patients with \u201cmedically unexplained\u201d or psychosomatic conditions. The stigma attached to mental health problems, reluctance to diagnose what O\u2019Mahony calls \u201cshit-life syndrome,\u201d and the appetite for the medico-industrial complex for inventing diseases means that there is substantial demand for new \u201cphysical diseases.\u201d Some patients with gastroenterological symptoms had already experimented with gluten-free diets, and the placebo effect and the fluctuating nature of their symptoms inevitably mean that many would feel better. O\u2019Mahony describes how in February 2011 15 coeliac-disease researchers met in a hotel at Heathrow sponsored by Dr Schar, a leading manufacturer of gluten-free foods, and gave medical credibility to \u201cnon-coeliac gluten sensitivity.\u201d<\/span><\/p>\n

Dozens of scientifically weak scientific papers, review articles, and consensus conferences have followed; and O\u2019Mahony lists from a review article resulting from a consensus conference sponsored by the Nestle Nutrition Foundation 41 symptoms and problems said to result from gluten sensitivity, including tiredness, anxiety, depression, weight loss and gain, disturbed sleep patterns, autism, schizophrenia, and even \u201cingrown hairs.\u201d \u201cNon-coeliac gluten sensitivity has been decreed by edict,\u201d writes O\u2019Mahony, \u201cjust as papal infallibility was decreed by the First Vatican Council.\u201d And the edict means that probably most of the patients seen in general practice each day could be suffering from the condition. Indeed, about 10% of the British population is cutting down on gluten, and the \u201cfree-from\u201d food market, 59% of which is gluten-free foods, is huge and growing at 30% a year.<\/span><\/p>\n

We have arrived, writes O\u2019Mahony, at a \u201cstrange paradox: the majority of people who should be on gluten-free diet (those with coeliac disease) aren\u2019t, because most people with coeliac disease remain undiagnosed. The majority of those on a gluten-free diet shouldn\u2019t be, because they do not have coeliac disease.\u201d<\/span><\/p>\n

With his talent for storytelling and humour, O\u2019Mahony, describes the parallel between current fears of gluten and the \u201cgrain-free\u201d monks of China 2000 years ago. They believed that the \u201cfive grains\u201d were the \u201cscissors that cut off life,\u201d leading to disease and death. A diet avoiding the five grains would lead to perfect health, immortality, and even the ability to fly.<\/span><\/p>\n

\u201cNon-coeliac gluten sensitivity\u201d may be one of the most successful non-diseases, but it is by no means alone. Competitors include seronegative Lyme disease, female sexual dysfunction, social phobia, and chronic procrastination syndrome. Inventing and promoting diseases is known as disease-mongering, and a variant of the phenomenon is to lower levels of risk for conditions like hypertension and diabetes, so creating tens of millions more patients overnight.<\/span><\/p>\n

The marketing of diseases<\/b>
\nNon-coeliac gluten sensitivity has been well marketed, but, as far as I know, there is not yet a non-coeliac gluten sensitivity day, week, or month, although there soon may be. O\u2019Mahony was writing his chapter on awareness, or competition between diseases and their followers for resources, in April, which has World Days for autism, health, homeopathy, haemophilia, and malaria. Every disease, like every dog, has its day, but excessive marketing of disease leads to misallocation of resources (\u201c78% of students telling their union that they have mental health problems<\/a>\u201d), and dubious protocols that distort medical practice.<\/span><\/p>\n

Twelve year old Rory Staunton died of septicaemia in New York in 2012 after injuring himself playing basketball and his doctors failing to recognise how sick he was. His father, a political lobbyist, set up the Rory Staunton Foundation for Sepsis Prevention, which has led to all state hospitals in New York having to use protocols for screening and treating sepsis and all children in the state having mandatory sepsis education. <\/span><\/p>\n

Hospitals around the world now have mandatory sepsis protocols, but unfortunately the warning triggers are so vague that they lead to tens of thousands of patients, particularly older ones, being treated unnecessarily with intravenous fluids, antibiotics, and a catheter in their bladders\u2014all of which carry risks. The protocols also lead to \u201cdiversion of scarce ICU capacity, and delayed identification of non-sepsis diagnoses.\u201d<\/span><\/p>\n

Cancer: the number one disease<\/b>
\nNo disease is better marketed than cancer, and after Richard Nixon\u2019s War on Cancer, Barack Obama launched his Cancer Moonshot, which is now renamed Cancer Breakthroughs under Donald Trump. As O\u2019Mahony writes, the language around cancer \u201cis infected with a sort of hubristic oedema.\u201d For Big Science cancer is a blessing, leading to huge investments in molecular biology and genetics, but, as cancer researcher David Pye put it: \u201cHow can we know so much about the causes and progression of disease, yet do so little to prevent death and incapacity.\u201d<\/span><\/p>\n

In contrast with the paucity of new drugs for brain disorders, many new drug treatments for cancer are appearing\u2014but the gains are tiny and the price astronomic. One review of 14 new drugs found that the average extra life saved was 1.2 months. The treatments often have serious side effects, meaning that the quality of life in those few extra weeks is often poor.<\/span><\/p>\n

O\u2019Mahony tells the story of A A Gill, the gifted journalist, who had metastatic lung cancer, and was denied by the NHS a new immunotherapy drug nivolumab, which costs \u00a360 000 to \u00a3100 000 a year. His oncologist said that if he could he would prescribe the drug \u201cas would every oncologist in the First World.\u201d Gill did get the drug but only shortly before he died. A trial published after Gill\u2019s death showed that treatment with nivolumab added 1.2 months of life to that achieved with standard treatment. O\u2019Mahony calculates that offering the treatment to all those in Britain who might benefit would cost around \u00a31 billion, about the annual cost of hospice care.<\/span><\/p>\n

\u201cThe medical profession,\u201d he writes, \u201chas become the front-of-house sales team for the [drug] industry.\u201d He argues that \u201cdoctors\u2019 professional culture obliges them to do something\u2014anything,\u201d but he is too easy on doctors, who could push back. Society, he says, displays \u201cchildishness\u201d in going along with these expensive treatments: \u201cwe must have higher, and better, priorities than feeble, incremental and attritional extension of survival in patients with incurable cancer.\u201d Cancer is a disease of age, and as the population ages \u201ccancer keeps outrunning us . . . Progress in curing cancer is now reminiscent of the trench warfare of the First World War, where a few hundred yards of territory might be gained at the expense of thousands of lives.\u201d<\/span><\/p>\n

Oncology is the specialty that is always quoted in these discussions, partly because the data on both benefit and cost are good, but what the economist Alain Enthoven called \u201cflat of the curve healthcare,\u201d where large investments bring small benefits (or even more problems), occurs across medicine. The rising costs are driven primarily by \u201cadvances\u201d: \u201cevery advance in medical science creates new needs that did not exist until the means of meeting them came into existence.\u201d These advances can also create new and painful problems: should a wife sell the family home in order to get treatment for her dying husband? Should premature babies be kept alive, even though the chances are high that they will be severely disabled, changing instantly the lives of their parents and siblings?<\/span><\/p>\n

People increasingly know, argues O\u2019Mahony, that health services cannot expand indefinitely \u201cbut there is no political or public appetite for . . . [the] difficult conversation\u201d of how to get out of this health arms race.<\/span><\/p>\n

The decline in the power and influence of doctors<\/b>
\nDoctors might have been the ones to lead the difficult conversation, but the power of doctors, argues O\u2019Mahony, has been declining for decades, with much of the decline being their own fault. A series of scandals in the NHS, the appearance of the internet, and the increasing politicisation and monetisation of healthcare have provided the context, and \u201cthe medical profession sleepwalked through all of this, ceding leadership to managers and Big Science academics.\u201d <\/span><\/p>\n

O\u2019Mahony believes that doctors have become \u201canti-harlots,\u201d with responsibility but no power. He very much has the perception of the acute physician doing the \u201csafari ward round\u201d after a night of multiple admissions, traipsing around the hospital with inadequately trained and overworked junior staff in search of patients, most of them elderly with multiple problems, many of them admitted primarily for social problems\u2014and with politicians promising ever more but insisting on increased productivity and with managers concentrating on targets and finances. Doctors are treating but not healing.<\/span><\/p>\n

But O\u2019Mahony does not, as do many doctors, blame politicians, managers, journalists, and lawyers for medicine\u2019s woes. \u201cOur complacency and collective cowardice have placed us where we are now . . . Doctors are so divided by factional fighting and ‘boosterism’ for our diseases and services that we no longer function as a cohesive profession pursuing a common good. We have poisoned the well of our craft and tradition.\u201d<\/span><\/p>\n

Can medicine be cured?<\/b>
\nO\u2019Mahony\u2019s book is titled <\/span>Can Medicine Be Cured?<\/span><\/i> He doesn\u2019t give a yes or no answer, but he is pessimistic about the profession\u2019s capacity for reform. \u201cLeadership\u201d has become the standard solution to reform of medicine and healthcare, and he goes along with the idea\u2014but says the leadership must not be \u201climp-wristed virtue signalling,\u201d and he cannot see where it will come from. \u201cToo many have a vested interest in unreformed medicine continuing.\u201d<\/span><\/p>\n

Crisis drives reform, and O\u2019Mahony thinks that some combination of economic collapse, a global pandemic of an untreatable infection, and climate catastrophe will force medicine back to \u201cproviding basic measures such as immunisation, trauma care, and obstetrics.\u201d<\/span><\/p>\n

The first thing that I ever had published in a medical journal was a letter to the <\/a><\/span>Lancet<\/span><\/i> in 1974 <\/span> asking why there had been no response to an article in the journal by Ivan Illich<\/a> describing in detail how modern medicine was a threat to health.<\/span>\u00a0(It would cost me $35.95 today to access the letter, about 50 cents a word from memory.) As a medical student I expected that the leaders of medicine would carefully dissect Illich\u2019s argument and with evidence show him to be wrong. But such a response never came. I was naive: I know now that it\u2019s easier simply to ignore cogent criticisms. I hope that O\u2019Mahony\u2019s book, a <\/span>Medical Nemesis<\/span><\/i> for 2019, will not be ignored. It deserves to be taken very seriously.<\/span><\/p>\n

Richard Smith<\/strong>\u00a0was the editor of <\/em>The BMJ until 2004.<\/em><\/p>\n

Competing interest.<\/strong> RS and Seamus O\u2019Mahony serve together on the Lancet Commission on the Value of Death. RS reviewed O\u2019Mahony\u2019s book <\/a><\/span>The Way We Die Now\u00a0<\/span><\/i>and is thanked in the acknowledgements of <\/span>Can Medicine be Cured?<\/span><\/i><\/p>\n","protected":false},"excerpt":{"rendered":"

Seamus O\u2019Mahony, a gastroenterologist from Cork, has written the most devastating critique of modern medicine since Ivan Illich in Medical Nemesis in 1975. O\u2019Mahony cites Illich and argues that many […]<\/p>\n

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