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Notes on lecture entitled ‘Goals of Medicine’. Professor Michael Ashby. Week 4, 2012. It might seem odd to suggest that there is much to discuss here. Surely the purpose of medicine is self-evident and clear to everybody. A trip to one or two health provider websites, or a quick read of contemporary health policy statements should give you some idea of the tone of the rhetoric: all-embracing, universal fair access, high expectations, good outcomes, consumer focus, and ‘excellence’ everywhere. Medicine and the whole health ‘industry’ are geared towards fighting disease, recovery from disability and injury, longer life, in a context of unlimited scientific and technical progress. Nothing wrong with that you might think, and insofar as it goes, there probably isn’t. There is much to celebrate and enjoy in the massive improvements attributable to the combination of modern medicine and socio-economic conditions in wealthy countries. Research in fields such as cancer, molecular biology, genetics and neuroscience progresses on a daily basis However, at some point we all have to also look at the realities of our current situation, at what our hype and marching tunes don’t say: Escalating costs

• Difficulty in access (‘waiting list’ rationing) • Poor outcomes and high morbidity • Chronic burden of disease (often multiple conditions) • Infectious diseases still major shifting challenge • Workforce shortages.

By-products of all the success and improvement are:

• A huge and growing health ‘industry’, that consumes a large part of our common and private wealth.

• A focus on cure that neglects the reality of death and still deals poorly with care and decision-making at the end of life.

• Limited prevention. At the same time there has been an erosion of trust in medicine and its practitioners, and a growing skepticism with modern science-based approaches. Ivan Illich wrote a landmark polemical book ‘Medical

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Nemesis’ as far back as 19761, suggesting that medicine itself contributed to poor health outcomes in society. We will talk further about this. In 1993, the Hastings Center in New York2 launched a project entitled ‘The Goals of Medicine to reformulate the prevailing goals it saw at the time because ‘business as usual was:

• Economically unsustainable • Clinically confusing • Socially frustrating • Lacked inherent direction and purpose.

They questioned whether medicine’s purpose was defined internally (inherent patterns) or externally by social ‘construction’, and proposed a new focus on these matters and a dynamic two-way dialogue between medicine and society. The goals the working group came up with were perhaps not earth-shattering, but they do establish a clear focus on the limitations of medicine.

• The prevention of disease and injury and the promotion and maintenance of health

• The relief of pain and suffering caused by maladies • The care and cure of those with a malady, and care of those who

cannot be cured • The avoidance of premature death and the pursuit of a peaceful

death They commented at the time that the literature on this topic was small, and despite the challenge they laid down, it has not been overwhelmed since.3 4 Whilst acknowledging challenges and limitations, Stephen Duckett, a prominent Australian health policy academic and administrator, advises against scare-mongering and disaster scenarios, and sees much to be

1 Ivan Illich. Medical nemesis: the expropriation of health. New York: Pantheon Books, 1976. 2 http://www.thehastingscenter.org/ 3 Hanson MJ and Callahan D. The goals of medicine: the forgotten issues in health care reform. Washington: Georgetown University Press, 1999. See also Hastings Center Report 26, no 6 Special Supplement (1996): S1-S28. 4 In Australia, see former federal health minister’s Peter Baume’s book The Tasks of Medicine: an ideology of care. Sydney: MacLennan and Petty, 1998.

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positive about in Australian health system.5 He particularly cautions against the view that our ageing community is the problem, and points to major internal improvements that can be made. Eric Cassell, a noted medical thinker from New York has argued that there needs to be a change in the goals of medicine “from their narrower focus on the body [and disease] to a wider concern with the sources and relief of illness in persons.”6 This lecture will consider why, how, and by whom goals are set. It will suggest to you that a frank and open dialogue within our society (and in politics) is essential to a healthy future and the best balance between individual needs and wishes and community capacity to provide. Questions include:

• What are the definitions of health, and being healthy?

• Should assisted reproduction be funded by Medicare?

• Is cosmetic surgery part of the scope of medicine?

• How can we talk openly about death, and limitation of life-prolonging treatment?

• What is the scope of aged care?

• What are the boundaries to holism? Does it even make sense to

wonder, Are there some places the concept of holism cannot take us?

• Have we made unhappiness an illness?

• Where does the balance lie between medical and social

responsibilities? The aim of the session will be to give you approaches to looking at these key meta-issues so that you can participate in community debate, policy

5 Duckett SJ (ed). The Australian Health Care System. Third Edition. Melbourne: Oxford University Press, 2007. 6 Cassel EJ. The Nature of Suffering and the goals of medicine. New York: Oxford University Press, 1991.

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formulation and both service development and community capacity-building.