Q J Med 2003; 96: 695-697
© 2003 Association of Physicians
Editorial |
The politics of medicine
Medicine and politics are inextricably intertwined, and yet they are very different enterprises. Political conditions can have a dramatic effect upon life expectancy: famine, for example, is now believed to occur only in conditions where there are few freedoms, including that of information.1 In the modern state, the institutional arrangements under which medicine is practised are determined by the central government, according to its political philosophy. Medical achievements, real or imagined, have often been used to make political points: the Dean of St Paul’s, the Rev. Hewlett Johnson, once extolled blood transfusion as if it were unique to the Soviet Union,2 the thought of Mao Tse-Tung was once credited with astonishing medical powers,3 and not only by the Chinese,4,5 one visitor saw a political lesson in the absence of acne in Hanoi,6 and Cuba’s health-care system has frequently been used to justify the revolution there (e.g. reference 7). By contrast, the fact that by the end of Franco’s rule in Spain, the Spanish population had one of the highest life expectancies in the world8 has rarely, if ever, been used to justify the nationalist rebellion, and quite rightly so.Given that almost everyone finds it difficult to be politically even-handed, and resorts at some time to the rhetorical devices of suppressio veri and suggestio falsi, to what extent should medical journals, especially those such as the NEJM, JAMA, BMJ and the Lancet that are designed for a general medical audience, indulge in ex cathedra political commentary? Should they confine themselves to severely technical matters such as the effect of enalapril on 12-year survival and life expectancy in patients with left ventricular systolic dysfunction,9 to take one example at random? If they cannot be expected to obey such a self-denying ordinance, how much political commentary should they indulge in, and what political philosophy, if any, they should espouse?
Even the idea that there are severely technical matters to which medical journals could theoretically confine themselves if they so wished has come under attack. For example, a recent editorial in the Lancet, written by the editor himself,10 suggests that the journals’ choice of subject matter for publication, as well as the membership of their editorial boards, is institutionally racist. This is because the research that they report is overwhelmingly about diseases that affect the richer part of the world’s population, and their editorial boards are likewise drawn overwhelmingly from the developed world, though the journals are, or aspire to be, global in reach and are clearly very influential beyond their immediate borders. According to the editor of the Lancet, the staff of major medical journals are deeply unrepresentative of the world’s population as a whole, and the contents of the journals unconcerned or insufficiently concerned with the medical problems that most people in the world face. The solution to this problem, in the editor’s opinion, is systematic positive discrimination in favour of under-represented groups and medical subject matter.
Unfortunately discrimination in favour of one group of people on ethnic grounds is necessarily discrimination against another group of people on ethnic grounds. Thus the Lancet’s proposal could be described, by its own logic, as institutionally anti-Semitic if, as seems likely, a disproportionate number of eminent medical researchers whose work is currently being published, but would not be published under the new dispensation, are Jewish. The promotion of scientific work not on the basis of its intrinsic worth, but according to the ethnic or social category of its authors, is an idea with a very bad, indeed murderous, pedigree. Moreover, it is not possible to predict with any degree of accuracy the practical long-term consequences of any piece of research that at first sight seems far removed from current problems. It was a very long time before Vesalius’s or Harvey’s researches were of much practical benefit to mankind, but that is surely not to say that their publishers should have withheld publication and published something else instead. The Lancet’s proposal would result in the complete and short-sighted politicization of medical journals.
Doctors as a group have no more insight into political questions than other people of similar levels of intelligence and education, nor do they always agree with one another on political matters. They are interested in the health of their patients and in the public health as well, but are inclined to forget that there are other desiderata than longevity. While good health is obviously a blessing, it is not the only thing in life that is worthwhile. Indeed, it is a now a commonplace of political philosophy that not all human goals are compatible:11 for example, the desire for excitement and that for safety. It does not follow, therefore, that because the prohibition or promotion of something would be good for health, it should be prohibited or promoted. This is something that medical journals in their political pronouncements are apt to forget. If a few people could be saved from drowning each year by the banning of swimming pools, it does not in the least follow that swimming pools should be banned.
The pronouncements of the major medical journals on broad political matters are inclined to be naïve, and often do not seem to recognize that other points of view are possible. Equality is almost always treated as if it were unequivocally a benefit, and reference is rarely if ever made in medical journals to the fact that one attempt to bring about equality, communism, resulted in up to 100 000 000 deaths in the twentieth century,12 an undesirable medical outcome if ever there was one.
Equality, equity, fairness and justice are often treated in medical journals as if they were synonymous, so that, for example, any increase in differences in outcome between social groups is taken ipso facto as evidence of increased injustice. Of course, such an increase might be the result of injustice; but then again, it might not be. Indeed, it might even be evidence of increased justice, if justice means that people receive their deserts. The fact that more burglars than law-abiding householders end up in prison is not evidence of systematic injustice. Equality, if it be equality of misery and impoverishment, does not have much to commend it. Moreover, justice, like health, while extremely important, is not the only good that human beings desire. Many things are important, but none is all-important. Civilization is not reducible to justice, and is ultimately more valuable than justice.
Likewise, the major medical journals, in their approach to the so-called Third World, almost invariably treat increased aid from the developed world as not merely desirable but as a moral imperative, a duty incumbent upon the rich. They seem unaware that there is a considerable body of opinion that, far from producing benefits, such aid actually worsens the plight of the Third World by the very kind of politicization of life that the journals favour.13 This is not to say that the view that aid should be increased should get no proper hearing, of course it should: but an awareness that another view is possible and intellectually respectable, with a considerable body of evidence to support it, would be welcome. You can read most of the major medical journals, for example, without realizing that many observers concluded that aid to Somalia prolonged and exacerbated rather than alleviated the civil war there. They might not have been right, but they were not stupid.
By their very nature, political questions do not admit of straightforwardly empirical answers. The person who values freedom more than longevity will suggest a different policy with regard to tobacco, licensing laws, speed limits and a host of other measures than a person who values longevity more than freedom. Neither of these two people can be proved correct by mere empirical evidence: the dispute cannot be settled in the way that the famous dispute between Platt and Pickering over the continuous or discontinuous distribution of blood pressure could (at least in theory) be settled. The distinction between the kingdom of ends and that of means may not be quite absolute, but it exists nonetheless.
If the principal purpose of medical journals is to communicate strictly medical information, if they are more concerned with the kingdom of means rather than those of ends, political material should form a relatively small proportion of the total material published in them, and it should be set aside in a clearly marked way. Moreover, the journals should act more as fora for debate on these contentious matters than (as at present appears) as bully pulpits from which unrepresentative people, the editors, can hold forth and claim to be speaking on behalf of the entire human race, when they do not even represent doctors. The political uniformity, indeed conformity, of most of the major general medical journals is dispiriting to observe, dull to read and will ultimately be counterproductive, as it will alienate a readership that is much more diverse in its viewpoint. There is more to be gained from debate than from preaching. The major medical journals of the western world badly need their own glasnost and perestroika.
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West Midlands Poisons Unit City Hospital Birmingham UK e-mail: ADan211530{at}aol.com
References
1. Sen AK. Development as Freedom. Anchor Books, 2000.
2. Johnson H. The Socialist Sixth of the World. Gollancz, 1939.
3. Urban G. The Miracles of Chairman Mao. Tom Stacey, 1971.
4. Leys S. The Burning Forest. Paladin, 1988.
5. Snow E. Red China Today. Penguin Books, 1970.
6. McCarthy M. Hanoi. Weidenfeld and Nicolson, 1968.
7. Nicholson J. Inside Cuba. Sheed and Ward, 1970.
8. www./trr.arizona.edu/webhome/ic/nats101c/hw4/hd2n_2000.pdf
9. Jong P, et al. Effect of enalapril on 12-year survival and life expectancy in patients with left ventricular systolic dysfunction. Lancet 2003; 361:1843–8.[CrossRef][Web of Science][Medline]
10. Horton R. Medical journals: evidence of bias against the diseases of poverty. Lancet 2003; 361:712–13.[CrossRef][Web of Science][Medline]
11. Berlin I. The Proper Study of Mankind. Chatto and Windus, 1997.
12. Courtois S. Le livre noir du communisme. Robert Laffont, 1997.
13. Bauer P. Dissent on Development. Weidenfeld and Nicolson, 1971.
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