Skrabanek Death of Humane Medicine
Skrabanek Death of Humane Medicine
Skrabanek Death of Humane Medicine
THE DEATH OF
HUMANE MEDICINE
AND THE RISE OF
COERCIVE HEALTHISM
Petr Skrabanek
ISBN 0 907631 59 2
TO PAUL SACHET
The Author 7
Preface 9
Robin Fox
Foreword 11
Acknowledgements 13
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6
The Author
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Preface
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10
Foreword
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12
Acknowledgements
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I
Healthism
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Healthism
2 After Illich
In his 1975 book, Medical Nemesis, Illich diagnosed medicine
as sick. The reaction of the 'patient' was predictable - the
4
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Some doctors became so blind with rage when the red cloth
of Medical Nemesis was waved before them that they became
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Healthism
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Healthism
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Healthism
It will not make people healthier; it will only shift the scene
of the action. Neither medicine nor anything else can take
death, disease and suffering away from individuals and
therefore from the species; perhaps it is time to acknowl-
edge the fact.
3 Before Illich
In ancient times, doctors were not held in great esteem. In
the Old Testament, physicians are mentioned twice: once as
servants good at embalming (Genesis 50.2), and once as
'forgers of lies' and of 'no value' (Job 13.4). In the New
Testament, they get a passing mention, when a woman 'had
suffered many things of many physicians, and had spent all
that she had, and was nothing bettered, but rather grew
worse' (Mark 5, 26). This was not a view held only by Chris-
tians. Henri de Mondeville, in his Chirurgie, written in the
14th century, noted that 'since dim antiquity the people have
believed surgeons to be thieves, murderers and the worst
kind of tricksters'.18
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Healthism
race, because the sun shone on their successes and the earth
hid all their failures.
Montaigne laughed at their medicaments ('the left foot of
a tortoise, the urine of lizard . . . pulverised rat turds and
other monkey tricks'), their unintelligible language, their pre-
tence of being masters of the mysterious, their contradictory
doctrines, their incredible promises, their magical reasoning.
They made the terrible mistake of not being even more
secretive and not keeping a unified front,
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Healthism
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Healthism
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Healthism
5 'Anticipatory' medicine
The abrupt change from old-style doctoring, which was in
the main care for the sick, to a new style of 'anticipatory'
care has taken place in the past two decades. It would seem
that the two approaches are not antagonistic, since curative
and preventive medicine have always been part and parcel
of medical practice. However, anticipatory medicine is not
the same as traditional preventive medicine which was limited
mainly to vaccination against specific diseases, and the
reduction of the spread of infection by maintaining a clean
water supply, abattoir inspection, control of the food chain,
etc. Anticipatory medicine, on the other hand, does not con-
trol the identifiable agents of disease, rather it indulges in
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32
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Healthism
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Healthism
cancer, you will hear from her through her solicitors. If, on
the other hand, you refer 10 per cent of your patients for
colposcopy and various unpleasant 'treatments', they will
think that your use of speculum is too speculative and avoid
you next time. The argument that they have been asking for
it is not going to hold water for much longer, as the demand
has been created by false promises emanating from the
medical profession.
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and without the hope that one's children will continue in the
search for decency pursued by our forefathers, human life
suddenly shrinks to the individual's life span. One's death
becomes an injustice, an unfair confiscation of one's only
asset - life - and must be fought against, avoided and tricked.
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Healthism
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Healthism
The signatories expressed their hope that by the year 2000 the
WHO objective of Health for All would become a reality. 57
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Physicians are not content to deal only with the sick, but
they will moreover corrupt health itself, for fear that men
should at any time escape their authority. 59
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Healthism
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Healthism
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who spent every day of his life 'keeping fit', avoiding the sun
(jogging in a wide-brimmed hat?), cholesterol and smoking
friends, and depositing daily bulky stools (bran is good for
you)?
The Guardian reported that an 'intelligent toilet' was being
developed in Japan. It automatically measures indices of
72
health and disease in the stool and urine, and if the user
inserts a finger into a device built into one side of the toilet,
it gives an instant record of pulse rate and blood pressure.
The spokesman for the research team said:
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8 Green healthism
A return to nature is a recurrent dream of those who cannot
cope with the complexities of life, who prefer a simple vision
to the confusing kaleidoscope of industrial societies, who
wish to regress to an infantile stage and to bury their faces
between the welcoming breasts of Mother Nature. Some may
romp naked in the woods, others grow their own 'organic'
vegetables and make their own sandals, while those more
philosophically minded conjure up Utopian vistas of the holis-
tic harmony of Man and Universe. These harmless yearnings
can be harnessed by the ideologies of healthism and forged
into a political movement. Such romantic tendencies tend to
flourish when times are out of joint, when traditional idols
of authority have fallen. The feeling of emptiness and aliena-
tion, and the fear of the future facilitate the spread of the
'green' ideas.
The ecologist John Horsfall noted that green ideology
appeals to the scientifically innocent, who worry a lot about
the environment, but cannot distinguish between real dangers
and mere scare stories, between science and pseudoscientific
apocalyptics. And Andrew McHallam, of the Institute for
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Healthism
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II
Lifestylism
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For the Jews, the source of disease was God who used it
as a means of punishment. Thus, for example, sinners were
smitten with pestilence {Exodus 9, 14), burning ague {Levit-
icus 26, 21), consumption, inflammation, extreme burning
{Numbers 15, 37), leprosy (2 Kings 15, 5), or other scourges,
such as 'the emerods', the scab, the itch, madness and blind-
ness {Deuteronomy 28, 15). In such circumstances, a correct
lifestyle was blind obedience to God's commandments, and
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century.
In a 16th-century Gaelic manuscript, used by physicians to
the Scottish kings, edited by Gillies in 1911 under the title
Regimen Sanitatis, similar advice to that of the Salernian
Regimen is given (eat but a little food, take exercise, and be of
cheerful mind), but, in addition, the first signs of the British
preoccupation with the bowels appear - two to three evacu-
ations every 24 hours are deemed necessary for one's health. 9
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at the age of 110. She was said to have been fond of a glass
of punch and smoked a very black dudheen. The Provincial
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Yet this was also the time when Britain was awash with
drink. Health fanaticism existed side by side with the Gin
Craze, made memorable by Hogarth's print; puritans
coexisted with hedonists. Samuel Johnson, the British insti-
tution of lexicography and witticism, declared that the great-
est pleasure in life was 'fucking, and the second was drinking'.
He wondered why there were not more drunkards, 'for all
could drink tho' not all could fuck'. This pearl was recovered
from the dross of literature by Roy Porter. 22
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in the USA crept in at the same time, between the 1870s and
1880s. When a circumcised New Yorker eats his morning
cereals, he may not be aware of the connection.
Kellogg's teaching that disease is 'a consequence of some
wrong-doing on the part of the individual' has been modern-
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Lifestylism
I'm conscious all the time of what fat does to blood choles-
terol and that it is fat that mainly puts on fat - so I deliber-
ately avoid chocolate, which I love [emphasis added] and
things such as pies, biscuits, and cakes, which are just
stuffed with hidden fat. The one thing, though, that I really
miss is sausages. I still dream [emphasis in original] about
sausages. 30
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the 'well-to-do and easy going, who habitually eat more than
is good for them'. Professor Richard Doll, in his early book
32
out sex.
In the programme announcement for a conference on
cancer prevention, organised by the official cancer prevention
bodies in Britain and co-sponsored by EC health bureauc-
racy, the causes of cancer were summarised as follows:
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I don't smoke nor drink. I don't stay out late and don't
sleep with girls. My diet is healthy and I take regular exer-
cise. All this is going to change when I get out of prison.
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doubt that the saddle with the falcon pommel may prove a
serious source of sexual excitation'. Another specialist in
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may insist that before anyone starts jogging he should see his
doctor and get a medical 'clearance', this is not practicable
and of little value as tests, such as exercise-stress testing, are
unreliable. Mass screening of millions of joggers would also
be very expensive. Graboys estimated that in the USA, such
testing would cost two billion dollars annually, with the
additional cost of treating subclinical abnormalities,
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Alistair Cooke, who read this letter in one of his BBC letters
from America, added: 'Here in a nutshell is revealed the
absurdity of seeking to prolong life by a process that shortens
it'. Another simple calculation would show that watching
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Timothy, we read:
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and 'attempre diete was al hir phisik, and exercise and hertes
sufficaunce', that is to say, her only medicine was a moderate
diet, exercise and heart's contentment. When, however, a
natural and spontaneous human activity such as moving
around during work or leisure, or taking part in the various
sports and diversions of homo ludens, becomes a prescription
item, and when 'lack of exercise' is medicalised into a 'risk
factor' for early death, caveat emptor.
3 Foodism
The term 'diet' comes from the Greek, where it meant a
'mode of life', and this sense was preserved in the old English
when diet meant a 'way of living and thinking'. We have
now come full circle. When the Government speaks of the
'nation's diet' they mean more than skipping an occasional
bar of chocolate or a bag of chips; they imply that the road
to happiness and health is open only to those who change
their ways and adopt a 'healthy' diet. It was Thomas Jeffer-
son, the great liberal American President, who observed that
if the government were to advise on people's diet, their
bodies would be in the same sorry state as their souls. The
common meaning of the word 'diet' is some kind of depri-
vation: criminals are put on a prison diet, and patients are
put on a doctor's diet. Dr John Harvey Kellogg believed that
the 'degeneracy of nations which once ruled the world began
with luxuriousness in diet'. The thought was shared by many
dictators. Food shortages in China made the party leader
Zhao Zhiang put the Chinese on a 'health-food diet', which
meant eating less meat, fish, and eggs; while the Romanian
dictator, Ceausescu, warned the public that over-eating was
a serious threat to their health.
Diet and the pleasure of eating are two different things.
A gastroenterologist knows no more about gastronomy than
a gynaecologist knows about the love between Tristan and
Isolde. Eminent epidemiologists now claim that up to 85 per
cent of all cancers have something to do with eating, while
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While priests are concerned with the future of the soul, their
prescriptions often coincide with those of doctors. The
renunciation of delicacies, meat avoidance, and fasting are
part of the penance for sins. Thus, for example, in the sum-
mer of 1985 in Ireland, when exceptional rains threatened
the livelihood of farmers, Cardinal O Fiaich directed prayers
urging the faithful to make a personal sacrifice by cutting
down on smoking, drinking and entertainment, and by fast-
ing. This avoidance of pleasures for averting God's anger is
strikingly similar to the recommendations by medical puritans
who maintain that the 'diseases of civilisation' may be averted
by eschewing tobacco, alcohol, sex outside marriage, and by
adhering to a restricted diet, which does not contain basic
foodstuffs, such as red meat, butter, salt, sugar, or eggs.
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Graham himself did not live long - he died at the age of 57.
His pupil, Dr William Alcott (1798-1859), added his medical
erudition to Graham's intuitive grasp of the healthy value of
bran cum vegetables, and of the dangers of tobacco, alcohol,
spices, sugar, coffee, tea and sex. Alcott founded a magazine,
The Moral Reformer, and was the founding member of the
American Vegetarian Society.
Vegetarians are a mixed bag. Some are quite normal and
simply do not fancy meat. Others explain their meat avoid-
ance by religious or moral principles, such as that meat
arouses animal passions. A subgroup believe that vegetarian-
ism makes them live longer. Animal rightists abhor eating
corpses of murdered animals. J B Morton of the Daily
Express thinks that
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In the 1930s and 1940s, a high fat diet was still recom-
mended by the medical profession as the diet for health. But
from about 1950 onwards, dairy fats and meat became suspect
as the cause of heart disease, although as late as 1966 the
National Academy of Sciences and the National Research
Council in the USA, in their report on dietary fats and health,
could still maintain that there was not enough evidence of
benefit from dramatically reduced fat consumption and they
expressed concern that such a change could have 'unpredict-
able, possibly deleterious effects'. There has been no new
66
evidence since 1966 to reverse this wise counsel, but what has
changed since is the readiness of various expert committees to
issue guidelines which are not supported by evidence and
often in conflict with it. Thus, for example, in 1970, a group
of American experts, led by the indefatigable anticholesterol
campaigner, Jeremiah Stamler, issued specific guidelines for
all Americans, including infants, pregnant mothers and the
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This panic has now spread to all kinds of everyday food and
beverages. If an example is needed, it suffices to quote the
case of an American hostage during the Gulf War, who,
having been kept blindfolded and handcuffed for two days
without food, was offered a mug of tea by his Arab captors.
He refused to drink it because it contained caffeine. 69
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Panic set in when this body claimed that the US diet 'rep-
resents as great a threat to public health as smoking', that is,
competing for the title of 'Public Enemy No 1', and that 'six
out of the ten leading causes of deaths in the USA have been
linked to diet'. It appears that people who eat, die.
One of the rare critics of the report of the Select Commit-
tee was Alfred Harper who complained that the recommen-
dations drew unwarranted conclusions from insufficient and
inappropriate research, and compared the guidelines with
other food advice given by cranks and faddists, who use their
magical thinking to promise a panacea for diseases which
they do not understand. Harper, a distinguished professor
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He then opted for the consensus that 'the fat content of your
diet should constitute no more than 30 per cent (or even 20
per cent) of the total caloric intake. The saturated fat intake
must be less than 10 per cent (or even 6 per cent or 8 per
cent)'. The consensus experts, on the other hand, had 'no
doubt that appropriate changes in our diet would reduce chol-
esterol levels', and that such changes 'will afford significant
protection against coronary heart disease'; such a diet 'should
be available to all family members except those younger than
2 years' In other words, in the absence of scientific evidence
the experts had no doubts that 'consensus' could fill the gap,
since they could not entertain the possibility that the wishful
thinking of so many was not a representation of reality.
Philip Payne, Head of the Department of Human Nutrition
at the London School of Hygiene and Tropical Medicine,
said in a lecture that he would personally ignore such recom-
mendations as 'gratuitous advice, at best over-zealous and at
worst impertinent', but he worried about the harm such
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has gone down, they drink more low-fat milk and the pro-
portion of polyunsaturated fats in their diet has increased.
Yet, despite all these efforts of brainwashed Britons, popu-
lation plasma cholesterol remained the same. However, a
95
several decades (!) in a man who said that he hated eggs but
could not help it, had no effect on blood cholesterol. 99
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engineers of our diet do not mean this when they talk about
the 'Mediterranean diet'; they just mean olive oil and greens.
The simplistic reasoning behind this idea could be sketched
as follows: in Mediterranean countries the mortality from
coronary heart disease is lower, much lower, than in Britain.
We want to prevent heart disease. Heart disease is caused
by fat in food, but obviously olive oil must be a 'good' fat.
Therefore, the prescription is olive oil, a tablespoon three
times a day. No butter please. As often happens with single-
issue fanatics, they conveniently forget that people in the
Mediterranean region do not on average live any longer than
the British; they simply die of something else, or, to be pre-
cise, something else appears on their death certificates. The
life expectancy at birth for English men in 1988 was 73 years,
the same as in France or Italy. (For English women, the life
expectancy was about five years more.)
More bizarre suggestions take their lead from the Orient.
The Chinese population has been presented as an example
of what could be achieved in the Western countries as regards
blood cholesterol. Chinese peasants were said to have very
low blood cholesterol levels and very low mortality from
heart disease. What we were not told was how long they
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live, but nearly half of all their deaths were from cancer.
There was little difference in overall mortality in those with
the lowest cholesterol and those with the highest cholesterol.
Yet, the message was clear: follow the Chinese.
The Japanese are even more intriguing. They eat strange
things, but they have the highest life expectancy in the world.
And heart disease in Japan is far lower than even in the
Mediterranean countries. So why not eat Japanese? We
already have Japanese cars, Japanese hi-fis, Japanese
cameras. The silence of the consensus experts on this issue
is deafening. And what's even more interesting, while,
between the 1950s and the 1980s, the Japanese increased their
consumption of saturated fats and maintained their phenom-
enally high rates of smoking, their heart disease rate was still
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had not noticed. The truth is that the hypothesis of the caus-
ation of heart disease is unproved, untestable because unfalsi-
fiable, extremely complex, on occasions misinterpreted and
some of it contradictory. 113
that Scotland 'has the world's highest rate from the dis-
ease'. Surely the Scots had not suddenly discovered the
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least was true for cholesterol in diet, since 'the optimal intake
of cholesterol is probably zero, meaning the avoidance of
animal products'. The WHO report stopped short of
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There are times when the term 'health fascism' does not seem
to be an exaggeration when describing the methods of the
latter-day health preventionists.
In the envisaged system of information monopoly, 'ben-
eficial to the government', it will be virtually impossible for
critical voices to be heard and to have an open discussion
on evidence which contradicts the official line. While wars,
disease and famine rage, the loyal citizens of the Health-for-
All-by-the Year-2000 Utopia will be instructed by the Minis-
try of True Lifestyle to measure the amount of fibre in their
food and to weigh their bulky stools. Being no longer civilised
they will not suffer from diseases of civilisation. They will
have earned their death from dementia. Exaggeration? Per-
haps. But many thought the same about the societies
described by Zamyatin, Huxley and Orwell.
While bureaucrats fiddle with health statistics, the world
burns. In the 1950s, there were 12 wars world-wide; in the
1970s, 32; in the 1980s, 40, and in 1992,52. The solipsistic nar-
cissism of a jogger may serve as a metaphor for man running
away from his own image. The past is 'irrelevant'; the future
is threatening. And so the jogger starts another round.
Measuring man's condition on the cholesterol scale is an
absurdity justifiable only by providing comic relief in a world
theatre of cruelty.
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The prolific mother has been ever the type of ideal happi-
ness, because the family makes the State, and because each
State wants her citizens.
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guinea pigs were told that they had 'bad blood' and for their
cooperation in submitting to various tests they were promised
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say, 'now let us get rid of tobacco, and then we will help
you'. 170
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6 Damned tobacco
Tis a plague, a mischief a violent purger of goods, lands,
health; hellish, devilish, and damned tobacco, the ruin and
overthrow of body and soul. * 1 2
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This goes to prove that when doctors deal with boys, they
should prescribe in exact opposition to their wishes in order
to give a fair chance to the science of medicine. 211
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spotted, and the brain smoked like the backside of the pig-
woman's booth'. This phenomenon is now known as the 'fag-
fiend's face', and in 1985 the British Medical Journal published
a gallery of mug shots of inveterate smokers, including that of
W H Auden, to show how ugly they were. The 'smoker's
223
example, the law stated that anyone who sold or gave ciga-
rettes to a person under the age of 21 should be punished by
a fine or imprisonment. Possession of cigarettes by a minor
was also a punishable offence. Then, however, profits took
precedence over morals and by 1927 all the 14 states repealed
their anti-cigarette laws. After a long lull, the pendulum swung
again with the publication of the Surgeon-General's report on
Smoking and Health in 1964. Within a year health warnings
appeared on cigarette packages, and television commercials
were banned in 1971. Cigarette producers in the USA, how-
ever, did not suffer, as the reduced consumption at home was
more than compensated for by increased exports, especially to
the Third World. As Nuehring and Merkle observed,
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Ill
Coercive medicine
dom which deserves the name', was John Stuart Mill. But
not many school leavers have heard of Mill since providers
of compulsory state education are careful not to allow his
essay On Liberty to fall into the hands of their charges.
Until the 18th century, the place of man in the universe
and the rules of right conduct were defined by the Church.
Then for the first time in human history, 'the pursuit of happi-
ness', codified in the American Declaration of Independence,
became a new right, guaranteed to each citizen by a secular
government. It was another 200 years before the state began
to use its resources to enforce the increase of the sum total
of human 'happiness', no longer understood as the rugged
individualism of the Founding Fathers, but as adherence to
a state-prescribed 'lifestyle'. The change was facilitated by
the emergence of a new class of experts on human happiness
who succeeded in convincing the masses that the false glitter
of old Utopias could be transmuted into objective methods
of 'behavioral modification', based on strictly scientific and
rational principles. The term 'happiness' was no longer used,
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Coercive medicine
2 Coercive altruism
What motivates health educators to devise strategies for
'behaviour modification'? Why does the medical profession
willingly take on the task of behaviour control? Is it a purely
altruistic concern? A benign form of paternalism or a puri-
tanical zeal to establish behavioral conformity? The 'risky'
lifestyles that we are encouraged to avoid are often those
which depart from the puritanical, middle-class view of what
ought to be; the view that such pleasurable activities as drink-
ing, overeating and sex must be harmful and therefore ought
to be eradicated.
While the medical profession is not renowned for an
exemplary puritanical lifestyle, the control of the lifestyle
of others enhances their power. The power of the medical
profession is jealously guarded and is vested in their moral,
charismatic and scientific authority. The moral authority of
doctors has rarely been questioned as doctors are on the
side of the angels; they fight evil, suffering and death. Their
charisma is enhanced by the nature of their task: they can
'see through' the patient by means of X-rays, they can put
the patient into a death-like state with anaesthetics and hold
his heart in their hands, operate on his brain, and implant
spare parts. Their scientific authority stems from doctors'
impersonation of scientists. For example, doctors' white coats
became a standard uniform in the 19th century, in imitation
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I love hamburgers and chili con carne and hot dogs. And
foie gras and Sauternes and those small birds known as
ortolans. I love banquettes of quail eggs with hollandaise
sauce, and clambakes with lobsters and crepes filled with
cream. And if I am abbreviating my stay on this earth for
an hour or so, I say only that I have no desire to be a
Methuselah, a hundred or more years old and still alive,
grace be to something that plugs into an electric outlet. 7
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Coercive medicine
The seed planted 100 years ago has grown into stifling ivy.
Blueprints for the health of the nation, the health of Europe
and the health of the world have been drafted, approved,
and are being implemented. Computerised information of
lifestyle profiles is systematically collected, classified and
stored. Healthy people are invited for annual 'check-ups'.
Screening is now de rigueur. And eugenic control is around
the corner. It has taken two and half millennia to turn Plato's
Utopia into reality.
The ultimate perversion of medicine's noble calling is the
participation of doctors in executions. In the 'civilised' world,
the worst record is provided by the United States. Many
American physicians believe that giving a helping hand to
the executioner is not only ethical but a civic duty. The 20
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4 Totalitarian medicine
The path to enforced happiness for all was paved with the
doctrinal stones of the French philosophes. J L Talmon traced
the origins of totalitarian democracy to Jean Jacques Rous-
seau ('one of the most ill-adjusted and egocentric natures')
and his ideological followers, who included Robespierre,
Saint-Just and Babeuf , Religious Utopias were replaced by
28
150
Coercive medicine
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152
Coercive medicine
153
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154
Coercive medicine
155
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156
Coercive medicine
5 Pregnancy police
Women's sexual organs have always been the object of men's
inquisitive gaze. 19th century medical literature was preoccu-
pied with examining, probing, cutting, excising and mutilat-
ing female genitalia. The womb, traditionally described as a
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wild animal, could attack any part of the woman's body, and,
unless tamed, cause serious disorders. The main function of
a woman's body was to produce bouncing offspring for her
impregnator, and thus women's reproduction had to be under
the control of a male-dominated profession. In our 'liberal'
age it may come as a surprise that women are still treated
as breeding machines, or containers for foetuses. Most
examples are provided, as can be expected, from the USA.
According to the Christian Science Monitor, 'at least 50
women have been charged with crimes for their behaviour dur-
ing pregnancy'. The criminalisation of motherhood was dis-
45
positive for drugs are removed from their mothers and placed in
foster care. Drucker illustrated this practice in a case of a poor
Puerto-Rican woman, whose baby was taken away from her
after birth. When she returned to the hospital and took her
baby away with her, her action was described as 'kidnap'. Kid-
napping one's own baby is a new crime. Drucker commented
that perhaps she was a bad patient but she was a good mother.
George Annas, a professor of medicine and law, analysed
the first American case in which a woman was charged with
the crime of 'foetal neglect.' She did not adhere to her
47
158
Coercive medicine
159
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160
Coercive medicine
6 Lifestyle surveillance
Examination and diagnosis are central to the medical metier.
Examen means 'tongue of a balance', and consequently, the
scrutiny of deviation from the mean. Michel Foucault in Surv~
eiller etpunir held 'examination' to be the essential means of
59
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Even though the majority of such people may not suffer the
expected consequences of 'having' a particular 'risk factor',
once the risk factor has been identified, it is then reified into
something real - part of the person's constitution.
This new statistical or actuarial concept of risk only became
part of health promotion rhetoric in the 1970s. In 1975, L
White warned that 'lifestyle has become the prime health
hazard' and in 1979, the Surgeon-General's report on health
63
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163
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164
Coercive medicine
165
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166
Coercive medicine
167
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168
Coercive medicine
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170
Coercive medicine
8 Genetic tyranny
It is a human characteristic to seek blame for the misfortunes
of the righteous, and an explanation for the luck of the liber-
tine. Medicine, competing with theology, offers apparently
scientific, and thus more credible, answers to the vagaries of
human fate. The Calvinist fatalism of salvation through grace
has been replaced by 'genetic blueprints'; salvation through
good works has been replaced by lifestylism. Timeless
philosophical debates about free-will versus determinism
and heredity have been taken over by lifestylism and gen-
etics. The political manipulation of these two, mutually
exclusive, positions allows preventionists to claim in one
breath that people have control over their health and mental
equilibrium by adopting a healthy lifestyle, and that the risk
of most diseases can be detected by genetic screening. As
with all half-truths, neither genetic nor environmental expla-
nations are wholly wrong, yet, even when combined in vari-
ous proportions, they still fail to 'explain' the human
predicament, our fears and desires, loves and hates, egoism
and self-sacrifice.
The idea that man's fate is written in his genes was current
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172
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174
Coercive medicine
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176
Coercive medicine
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178
Coercive medicine
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risk their lives for a paltry gain, and, when caught, face long-
term prison sentences, while those who use them as pawns
thrive on huge profits. The interception of these 'body-
packers' takes place at airports, where doctors acting as
agents of the state carry out 'a simple manual examination'
[of the rectum and vagina], rectoscopy and rectal lavage,
abdominal x-ray and examination of faeces. At Heathrow
117
180
Coercive medicine
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182
Coercive medicine
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184
Coercive medicine
10 Autonomy
Where the idea comes from that men hold despotism in detes-
tation, I do not know. My view is that they delight in it.
(Bertrand de Jouvenel)
185
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Or,
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187
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188
Coercive medicine
189
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190
Notes and references
PART I
1. K R Popper, The open society and its enemies, Vol 2, 5th edition,
London: Routledge and Kegan Paul, 1966, p. 304.
2. G Rose, 'Strategies of prevention: the individual and the popu-
lation', in M Marmot and P Elliott (eds), Coronary heart disease
epidemiology, Oxford: Oxford University Press, 1992, pp. 311-324.
3. J H Knowles, T h e responsibility of the individual', Daedalus, 1977
Winter, pp. 5 7 - 8 0 .
4. I Illich, Medical Nemesis. The expropriation of health, London:
Calder and Boyars, 1975.
5. P Rhodes, 'Indictment of medical care', British Medical Journal,
1974, 4, pp. 576-577.
6. A Paton, "Medicalization' of health', British Medical Journal, 1974,
4, pp. 5 7 3 - 5 7 4.
7. H R Rollin, 'Era of instability', British Medical Journal, September
17, 1977, pp. 759-760.
8. D F Horrobin, 'Whither medicine? Nemesis or not? A reply to Ivan
Illich', World Health Forum, 1980, 1 ( 1 - 2 ) , pp. 139-141.
9. I Illich, 'Body history', Lancet, 1986, ii, pp. 1325-1327.
10. J T Winkler, 'The intellectual celebrity syndrom', Lancet, 1987, 1,
p. 450.
11. I Kennedy, The unmasking of medicine, London: George Allen and
Unwin, 1981.
12. A Clare, 'The threat to political dissidents in Kennedy's approach
to mental illness', Journal of Medical Ethics, 1981, 7, pp. 194-196.
13. I Kennedy, 'A response to the critics', Journal of Medical Ethics,
1981, 7, p. 2 0 2 - 2 1 1 .
14. T McKeown, The role of medicine: dream, mirage or nemesis?,
London: Nuffield Provincial Hospitals Trust, 1976.
15. D H Spodick, 'Revascularization of the heart - numerators in search
of denominators', American Heart Journal, 1971, 81, pp. 149-157.
16. P Rhodes, The value of medicine, London: George Allen and
Unwin, 1977.
191
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192
Notes and references
193
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PART II
1. A Heidel, The Gilgamesh epic and Old Testament parallels, Chicago:
University of Chicago Press, 1949.
2. EH Ackerknecht, A short history of medicine, Baltimore: The John
Hopkins University Press, 1982.
3. F Kudlein, 'Cynicism and medicine', Bulletin of the History of Medi-
cine, 1974, 48, pp. 305-319.
4. M-C Pouchelle, op cit.
5. C W Bynum, 'The female body and religious practice in the later
middle ages', in M Feher (ed), Fragments for a history of the human
body, Part I, Cambridge MA: MIT Press, 1989, pp. 160-220.
6. J Le Brun, 'Cancer serpit. Recherches sur la representation d'une
194
Notes and references
195
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196
Notes and references
197
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198
Notes and references
94. K L Blaxter, 'Animal production and food: real problems and para-
noia', Animal Production, 1991, 53, pp. 261-269 .
95. J I Mann et al, 'Blood lipid concentrations and other cardiovascular
risk factors: distribution, prevalence, and detection in Britain',
British Medical Journal, 1988, 296, pp. 1702-1706.
96. A n o n , 'The food we eat', Lancet, 1989, i, p. 740.
97. L E Ramsay, W W Y e o and P R Jackson, 'Dietary reduction of
serum cholesterol: time to think again', British Medical Journal,
1991, 303, pp 9953-9956.
98. F J Stare, R E Olson and E M WHelan, Balanced nutrition: beyond
the cholesterol scare, Holbrook MA: Adams Inc, 1989.
99. F Kern, 'Normal plasma cholesterol in an 88-year-old man who eats
25 eggs a day', New England Journal of Medicine, 1991, 324,
pp. 896-899.
100. A D Hargreaves, R L Logan, M Thomson, R A Elton, M F Oliver
and R A Riemersma, 'Total cholesterol, low density lipoprotein
cholesterol and high density lipoprotein cholesterol and coronary
heart disease in Scotland', British Medical Journal, 1991, 303,
pp. 6 7 8 - 6 8 1 .
101. J McCormick and P Skrabanek, 'Coronary heart disease is not pre-
ventable by population interventions', Lancet, 1988, ii, pp. 8 3 9 - 8 4 1 ;
M F Muldoon, S B Manuck, K A Matthews, 'Lowering cholesterol
concentrations and mortality: a quantitative review of primary pre-
vention trials', British Medical Journal, 1992, 304, pp. 309-314 ; M
Oliver, 'Doubts about preventing coronary heart disease. Multiple
interventions in middle-aged men may do more harm than good'
(editorial), British Medical Journal, 1992, 304, pp. 303-394.
102. Editorial, 'Dr Koop's diet', Lancet, 1989, i, pp. 306-307.
103. Nutrition and your health. Dietary guidelines for Americans, Wash-
ington D C : US Department of Agriculture and US Department of
Health and Human Services, 1990.
104. T Gordon and N B Kannel, 'Drinking and its relation to smoking,
blood pressure, blood lipids and uric acid', Archives of Internal
Medicine, 1983, 143, pp. 1366-1374.
105. J S Gill, M J Shipley, R J Hornby, S K Gill and D G Beevers, 'A
community case-control study of alcohol consumption in stroke',
International Journal of Epidemiology, 1988, 17, pp. 542-547.
106. M J Stampfer, G A Volditz, W C Willett, F E Splizer and C H
Hennekens, 'A prospective study of moderate alcohol consumption
and the risk of coronary heart disease and stroke in women', New
England Journal of Medicine, 1988, 319, pp. 211-216.
107. E B Rimm, E L Giovannucci, W C Willett, G A Volditz, A
Ascherio, B Rosner, M J Stampfer, 'Prospective study of alcohol
consumption and the risk of coronary heart disease and stroke in
men', Lancet, 1991, 338, pp. 464-468; R Jackson, R Scragg and R
199
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200
Notes and references
201
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202
Notes and references
203
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204
Notes and references
PART III
1. B de Jouvenel, Du pouvoir: Histoire naturelle de sa croissance,
Geneva: Cheval Alle, 1945; English translation by J F Huntington,
On power: its nature and the history of its growth, London: Hutchin-
son, 1948; reprinted by Liberty Fund, Indianapolis, 1993, p. 12.
2. P Skrabanek, 'The epidemiology of errors', Lancet, 1993, 342,
p. 1502.
3. de Jouvenel, op cit, p. 403.
4. M Nirmala, 'Obesity grades to be recorded in students' report
books', Sunday Times (Singapore), 1 December, 1991.
5. Straits Times, 6 December, 1991.
6. 'Chewing freely', Times (Singapore), 21 January, 1992.
7. D I Wikler, 'Persuasion and coercion for health. Ethical issues in
government efforts to change lifestyles', Millbank Memorial Fund
Quarterly, 1978, 56, pp. 303-338.
8. Quoted in R Crawford, 'You are dangerous to your health: the
ideology and politics of victim blaming', International Journal of
Health Services, 1977, 7, pp. 663-680.
9. D E Beauchamp, The health of the republic. Epidemics, medicine,
and moralism as challenges to democracy, Philadelphia: Temple
University Press, 1988.
205
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206
Notes and references
207
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208
Notes and references
209
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210
Notes and references
111
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150. Ibid.
151. K R Popper, Conjectures and refutations. The growth of scientific
knowledge, 5th edtn, London: Routledge and Kegan Paul, 1974,
p. 370
152. R E Barnett, 'Curing the drug-law addiction. The harmful effects
of legal prohibition', in Hamowy and Freedman, 1987, op cit.
153. K R Popper, The open society and its enemies. Volume 2: Hegel and
Marx, 5th edtn, London: Routledge and Kegan Paul, 1956.
154. Hastings Center Reports, 1984.
212
THE SOCIAL AFFAIRS UNIT
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PREVENTIONITIS
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