05/20/2016

Medicine and Degrowth: Adversaries or Allies?

Seminar by Pietro Majno, May 20, 2016

Pietro Majno heads the hepatobiliary centers of Geneva’s teaching hospitals. He is specialized in liver transplants and a member of the Rassemblement des objecteurs de croissance (a group made up of growth objectors). He agreed to give this seminar on the apparent contradictions existing between his job as a doctor, which is very much dependent upon technique, and his day to day experience with degrowth.

His presentation will be voluntarily provocative in that some growth objectors hold very hostile positions towards technical medicine and rather favor alternative medical treatments. Some of our friends have died because they have refused to seek treatment in the name of their critical perception of technical medicine.

Today’s presentation will go as follows:

I will first present what it is, in terms of day to day life, to be a doctor. I will then seek to illustrate modern medicine by drawing on its results and values, which is a more of a mainstream type of approach. I will end by comparing the illustration I have given with Medical Nemesis, written by Illich.

But first some preliminary considerations:

I will speak from a climate-concerned rather than peakiste (exception made of metals, see Bihouix) perspective: humanity is better at dealing with problems associated with empty fridges rather than overflowing trashcans.

 

Working as a liver transplant surgeon

The first 50 attempts at liver transplantation in the world have all resulted in deaths. Today, this would have justified that the research be stopped. However, some have persevered and liver transplantation now works and saves lives. In Geneva the rate of success is of 93%.

We are now able to cut a liver in half to give a small portion of the latter to a child, for example, and a larger portion to an adult, thereby saving two lives with a single liver.

Some doctors are now also specialized in liver cancer but the results are not as good: only one third of the patients are still alive five years after being diagnosed.

Being a doctor has essentially a symbolic value: these sicknesses concern only a small percentage of the Swiss population, yet, it embodies certain values and symbols.

Principles which structure this job:

Working with a limit: there are 100 transplants available per year, which is less than the number of people in need of these transplants, thereby implying rationing (see Szuba). This could have been a problem in terms of distributive justice but satisfactory solutions have been found almost everywhere around the globe. In this sector, rationing is the norm: criterions have to be defined, transparence, responsibility, balancing utility VS urgency, equity are all crucial.

Anticipation is key: this is a job in which you are able to anticipate complications and, if you do nothing about the latter, wind up with unsolvable problems. This is professional misconduct for which you can go to jail.

Caution and cooptation of patients: this may differ from the medicine of which Illich wrote about because, now, the patient needs to give his/her approval.

Above and beyond its symbolic value, what are the accomplishments of modern medicine? Has it accomplished nothing, has it made things worse, as reading Illich would let one assume?

 

Modern medicine in numbers

What is its impact on life expectancy? Looking at the curves one may thing the answer to be easy: life expectancy rises substantially.

But the answer is more complicated than that: in 1871 the life expectancy for a man in the United Kingdom is 44 years. However, without child mortality it rises up to 71 years. Today, a man in the United Kingdom has a life expectancy of 77 years and a woman 81, yet, social and economic inequalities have a huge impact on life expectancy.

Factors which influence life expectancy (non-exhaustive list):

20/30% of genetics (nothing you can do about it).

Moving around.

Not smoking.

Eating five fruits and vegetables per day.

Healthy eating.

Laughing and sleeping.

Climbing the career ladder (in order to evolve in a stress/frustration-free workplace environment one has to be in a position such that one can manage one’s own time).

Not having an accident.

The obesity rates are awful and continue to increase: 25% of the American population suffers from pathological overweight.

So was Illich right? Not about everything!

According to him medical treatment is useless and, most of the time, harmful. To support this statement he used the concept of iatrogenesis. There are three types of iatrogenesis according to Illich:

Clinical iatrogenesis.

Social iatrogenesis.

Cultural iatrogenesis.

 

Clinical iatrogenesis

There are two very strong ideas put forward by Illich in Medical Nemesis:

First, the environment in which one evolves is more determining, in terms of life expectancy, than is access to health services: this is completely true!

Second, medical treatment is not really effective: things have changed in this respect, it was maybe true in 1977, but it is not today.

A few examples to illustrate this disagreement:

Pain management: today progress has been made in regards to pain management of arthritis, fractures, kidney stones etc. Pain used to be a frequent and terrible experience, still so for our grandparents. Providing pain relief with limited means is a real improvement.

Treatment for chronic and debilitating diseases: diabetes, fistula, prostate, epilepsy, cataract, etc. Tremendous progress has also been made in this domain as these diseases used to prevent people from living their lives. This is also the case in respect to infections: TBC, HIV, hepatitis, vaccines etc.

Treatment for cancer: Illich argued that people died from cancer no matter whether they sought treatment but, if this was indeed true in 1977, it is not anymore. Survival rates have gotten up for some cancers since then.

Therefore, as regards clinical iatrogenesis: technical progress has been made since Illich wrote Medical Nemesis, which contradict some of his arguments.

 

Social iatrogenesis

Regarding social iatrogenesis Illich argued that orthodox medicine held a monopoly: I believe he is right about that. There are no health services without an orthodox medicine exercising monopoly power, but this entails:

A sustained rise in costs,

Inequalities in the face of access to health services, which cost more and more,

The invasion of pharmaceutical companies characterized by large corporations looking to patent and sell.
Getting caught up in a macabre ritual, dying at home being replaced by dying at the hospital.

He was right about all this in 1977, however, things have since then evolved:

The therapeutic alliance: telling the patient the truth has become the norm; of course you have to be careful of the conditions in which you do – better to do so in the morning rather than at night; choose your words carefully – but it is now mandatory. Health students are now also evaluated according to their ability to explain, in a comprehensible manner, to the patient what he/she is sick with. It is demanded that this not be done in a paternalistic way and that the autonomy of the patient be preserved. This concern has led swiss hospital to allow the practice of assisted suicides. Moreover, precautions are being taken to limit therapeutic obstinacy: the patient has to give his/her approval to each and every treatment and has the rights to demand the termination of care.

Trend towards demedicalisation: taking up biking rather than taking antidepressants, anamnesis VS medical instrumentation, antibiotics VS fecal transplantation, using generic drugs.

Simplification and personalization: this has changed a lot since Illich’s analysis.

What I mostly disagree with Illich about is that he thought social iatrogenesis was intrinsic to the medical sector: social iatrogenesis is a real problem but it results from market rules.

 

Cultural iatrogenesis

Above all, I disagree with Illich with respects to cultural iatrogenesis: Illich believes that the medical staff is the source of the spoliation of what he calls “coping”, which, he believes, should be exercised by humans in their day to day lives. He holds a doloristic perception of existence (which may be tied to the Christian dimension of his thought). He believes that pain management has the effect of reducing problems associated with pain to technical issues, and that treating pain is missing the opportunity to be autonomous in assessing one’s health.

Illich also argues that only humans can suffer, that it is part of what makes them human, but that is not true as we know animals can experience suffering pain as well.

Today, pain does not necessarily entail treatment, and when treatment is offered over-medicalization is avoided, yet, it is hard, I believe, to argue, like Illich, that pain is a virtue of some sort.