I have been blogging about the 2014 Reith Lectures currently being given by Atul Gawande. This is the final part, Part 4, and is related to Gawande’s fourth talk entitled Part 3, which responds to the third lecture’The Problem of Hubris’ is here. Part 2, which responds to the second lecture ‘The Century of the System,’ is here. Part 1, which responds to the first lecture ‘Why Doctors Fail,' is here.
In his final Reith lecture, recorded at the India International Centre in Delhi, Gawande addressed The Idea of Wellbeing. Gawande starts the lecture with some family history. His parents were both from India and his family’s fortunes have changed significantly in just three generations. This is used to illustrate the changing nature of public health in ‘advancing economies’ like India. Previous issues concerning malnutrition and diarrhea are increasingly giving way to Western illnesses like diabetes and hypertension. The message is that the major challenges to population health are changing from the acute to the chronic and the responses require a shift in perspective from health to wellbeing or, one might say, being well. Solutions, if indeed there are any, are less about infrastructure, like the provision of clean water, and more about social structures, our individual and collective behaviors, the way we eat, exercise and lead our lives.
However, whilst he returns to say more about this development, some parts of this lecture could easily have been delivered as part of the previous talk on medicine’s hubris. We spend fantastic amounts of money on the latest drugs but we cannot access medical professionals within a day. Furthermore, when we do see doctors we are often inadequately examined, listened to and diagnosed. Our doctors often fail to do the basics and often send us away with the wrong prescription. We overuse antibiotics, creating the conditions for resistant strains to emerge. Childbirth has been medicalised and since the early part of the 20th century has increasingly taken place in hospitals. But, as medically unjustifiable variation in rates of cesarean sections show, the consequences of doing so have not been entirely positive. As Gawande has it, we have trouble using technology wisely.
Another example of this hubris is the way we sometimes over-diagnose certain illnesses as a result of population screening. The consequences are that whilst some diseases are caught early and some lives saved, a greater number of individuals undergo treatments that they do not need. Such treatments are not without risks and consequences. In public health iatrogenic – physician caused- illnesses is a population-level concern. For Gawande, the point of these examples is that medicine’s focus on “insuring health and survival” needs to be tempered with a concern for well-being and “sustaining the reasons one wishes to be alive.” This was clearly a theme of the last lecture: we have an incomplete grasp of what medicine has to offer if we do not understand the patient’s values and motivation and ends.
Nevertheless, there is reason for concern when thinking about reorientating medicine towards ‘well-being’ or being well. Medicine, and the healthcare professions more generally, exercise a high degree of power over our lives. Do we really want to see them transformed into the ‘well-being professions’? As many have noted modern life is sufficed with a therapeutic ethos, meaning we are predisposed to accept the ‘wisdom' of medicine and conform to its norms and standards. In shifting the focus of medicine from ‘health’ to ‘well-being’ we not only become permanent patients - even health is medicalised (p.2) - but also increase the level of responsibility individuals bear for being well, in the past, present and future.
Concern for the values of the patient all too easily becomes an evaluation of those values from the perspective of well-being. They become subordinated to the biomedical demand to ‘live-well’: to eat our 5 a day; to attend our annual check-ups and screenings; to take sufficient exercise; and not to binge drink. It would, certainly, be good if we all did such things but not doing so is not, simply, a matter of individual will: when thousands are making use of food banks can we really suppose having 5 a day is easy? Throughout his lectures Gawande has been arguing that the power of medicine should be put in the service of the patients own ends. But perhaps this idea is the greatest medical hubris of all. The power of medicine is such that it cannot be controlled by patients and perhaps not even by doctors or politicians. The medical gaze has a weight, an inertia and an ability to impose itself. Systematically extending its influence may not be the wisest course of action.