História da Medicina:

conferência de M. Berger


retorno ao Blog do Paulo Lotufo 

 

"The Era of Enlightenment Ends With the Golden Calf"
Lecture given during  The Škrabanek Foundation Colloquium  "Medical Utopianism: A Threat to Health"  held at the Royal College of Physicians, London, on April 25, 2002

Autor: M.Berger

THE ERA OF ENLIGHTENMENT ENDS WITH THE GOLDEN CALF is the rather pessimistic title to a rather pessimistic lecture that the Swiss author Max Frisch gave on his 75th birthday on May 15, 1986, in Solothurn/Switzerland. Frisch reminds us of the biblical episode of the golden calf described in the Old Testament (18). Promising them the Holy Land, Moses had led the people of Israel out of Egypt. At some point during this long and cumbersome journey with no goal in sight, Moses left his people and walked up to speak to GOD on Mt. Sinai. He did not come back for 40 days, leaving the children of Israel in an atmosphere of increasing unrest, anxiety, and fear. Without their leader, they felt abandoned in the middle of the desert. Finally, in utter desparation, they went to Aaron and begged for help. Aaron told them to sacrifice their golden jewelry. He collected all the gold they had, melted it over a big fire and used it to form a golden calf. This, he declared, is your new God, who will lead you out of the desert into the holy land. And the people of Israel started to worship the golden calf as they were told; they overcame all their fears, security and happiness returned.

 

II.  Various elements of this episode are mirrored by the history of modern medicine. Up to the late 18th century, the practice of medicine was largely based upon witchcraft and voodooism.
Let me present you an example from my own discipline, diabetology. The military surgeon John Rollo is usually being praised as the father of modern diabetes care. In 1798, he published a monography which was to become the basis for his fame (12). It contains the detailed description of the sad case history of Captain Meredith who had presented himself with Type 2 diabetes and its usual symptoms. Dr. Rollo tortured the poor patient to death using some of absurd dietary and surgical therapies. Why did the poor patient accept such an absurd treatment? Maybe it is explained because the doctor-patient interaction took place within the world of the military. In any case, as a physician Rollo must have been a lunetic - strange that he is still being looked upon as a pioneer of clinical diabetology.

During the following two centuries, the evolution of health care is represented by an extreme dichotomy. On the one hand, there is the stepwise and often difficult process of enlightenment: a rational approach based upon observation, quantification and experimentation with the aim to reproducibly improve patient-oriented outcomes was developed and gradually implemented. It is fascinating to see how this development to rationalize medicine was initiated by a handful of physicians in England. In fact, the 18th century physician George Fordyce started systematic efforts to "improve the evidence of medicine".

These early efforts are described in a wonderful book which was edited by the Edinburgh Royal College of Physicians two years ago (19). Lind's test of oranges and lemons against scurvy in 1747 is the first account of a controlled clinical trial (10) - even though he did not quite trust his findings himself. In the early 19th century, these efforts were strengthened in France by the Hôtel Dieu physician Pièrre Charles A. Louis, by Claude Bernard and elsewhere. However, I am sure Green was right when he suggested in a lecture given in this house, maybe in this very room, on November 11, 1954, that the controlled clinical trial is a very characteristic and respectable British institution - attributable to the native skepticism of the British (8). Moreover, there is no doubt: the prestige of the randomized controlled trial as a cornerstone of rational medicine, is due to Sir Austin Bradford Hill and his colleagues in this country. Still, for a long time rational thinking in medicine remained the exception, i.e. in opposition to the opinion leaders of the medical profession.


Again, I would like to present you with a few telling examples. A cornerstone of clinical diabetology has been that patients were not allowed to consume any sugar. A justification for this dogma is difficult to find: one day before Christmas eve in 1913, Dr. Frederick Allen, the leading diabetologist in the pre-insulin era, almost-total-pancreatectomized his dog # B2-31. When he fed the dog sugar containing nutrients, the blood sugar went up - did he feed the dog with starch the rise of blood sugar was comparably minimal - because the poor animal had no pancreatic amylase to digest the carbohydrates. Nevertheless, Allen concluded, "it may thus be inferred that sugar is a more dangerous food for human beings with diabetes than is starch" (1). Even though this conclusion - as flawed as it was - had been formulated with some caution - it became the basis for the SUGAR-VERBOT, which has, been used to torture millions of persons with diabetes up to the present time (3).
Before the availability of tuberculostatic agents, in
Germany a wide variety of humbug and quackeries was used to combat pulmonary tuberculosis; Thomas Mann has described some of this nonsense in his Zauberberg. It included the regimen to reduce the daily salt intake to less than 3 g as propagated by the Austro-German Professor Gerson in 1934. The treatment was not only crazy, but at the same time cruel to the patients. And it goes without saying that as soon as the tuberculosis exacerbated dietitians and doctors accused the dying patients to have violated their SALT-VERBOT (6)
Up to very recently, worldwide millions of patients with peptic ulcers have been tortured by gastrectomies, psychoanalysis and other forms of psychotherapy as well as by obscure diet and/or drug treatments - rather than by the antibiotic eradication of their upper gastrointestinal Helicobacter infection.

Why have these and so many other erroneous treatments been carried out by mainstream medical practice for such a long time - until it finally emerged that they were ineffective with regard to patient-oriented outcomes? The answer appears strange: the public and their doctors were just not interested in the eventual outcomes of therapies.

Goethe has masterly illustrated this phenomenon during an episode of his Easter Walk (7): Faust and his student Wagner happen to walk into a joyous party in the countryside. Faust is recognized by the people in the village as the brave young doctor who - together with his physician father - had worked so hard for them during an outbreak of the plague many years ago. The villagers praise and celebrate him like a hero. Later on, alone with Wagner, Faust reflects on what had actually happened at that time of the pestilence.

Without any scientific basis but in good faith, his father had fabricated some medicine which they had tirelessly used to treat the plague. "The patients died and nobody asked who recovered" - Much rather, the desperate public was more than relieved and grateful that something was done by these two unselfish and extremely hard working physicians and nobody asked about the outcome of their treatment. In retrospect, Faust realized that the medicine that they had been using was poisenous; and that their treatment was killing more people than the disease itself. "Today", Faust concludes with sarcasm "I must live to see that those who are celebrated by the enthusiastic public as medical heroes are nothing but infamous murderers". As Goethe describes it so clearly, medicine and the public had absolutely no interest in the eventual outcome of medical interventions.

 

Nevertheless, during the past decades - maybe as a positive consequence of the financial crises our health care systems are in - the need to focus medicine on evidence-based practices has become widely acknowledged. The principles of evidence-based medicine are being accepted by a growing number of leading physicians and, maybe even more so, by health care politicians and public health managers. It is becoming undisputed consensus that medical practice is to be justified by clinical investigation and clinical epidemiology. The Cochrane Collaboration and David Sackett's Evidence-based Medicine represent two recent hallmarks of success during this tedious process to rationalize and humanize medical practice.

So at the end of a cumbersome process of some two hundred years and thanks to relentless individual critics of current medical practice, sometimes called "medicine critics" it almost looks as if, after all, the practice of medicine is being reformed and changed for the better based upon a process of enlightenment .

 

III. However, on a closer look into the present reality of our health care systems it appears that at the opposite of the enlightenment - that is in the area of mysticism, non-evidenced procedures, humbug, and irrationality - the development as been quite as rapid and powerful, if not even more so. I am not talking about societies, which are notorious for their belief in witchcraft or parapsychology, such as certain developing populations or our neighbours in Eastern Europe. I am referring to solid movements within the practice of medicine in the heart of Europe.

 

In parallel to the development of a rational medicine - the population has reverted to the mysticism, to idolatry, very much as the children of Israel worshiped the golden calf during the prolonged absence of Moses. The golden calf was created at the expense of the people of Israel - but it had been demanded by the people. The reason was the people of Israel's insecurity, their growing anxiety about their future - seemingly having been abandoned in the middle of the desert by their spiritual and political leadership.
What are the anxieties that drive our present societies into the arms of irrationality? Other than, during the traditional influence of Christianity, presently our secularized society is extremely preoccupied with the death. Even though nobody wants to be or to look old, everybody wants to live long enough to become very old. Any possible measure propagated to increase life expectancy is receiving the utmost attention. Any hypothetical intervention to prolong our life span is welcomed - almost like the clutching at any straw by the drawing sailor. In such a situation of frenzy, the public is unable and unwilling to critically evaluate what is offered to overcome their despair.

Much rather, this is the fertile ground to sell irrationalities and mysticism in order to sooth and to comfort the people. Unrealistic proposals find it easy to gain popularity and turn out to be enormously profitable for those who propagate them. It may be in order to mention a number of such fallacies:
Usually the sermon begins with a lamento about coronary heart disease having emerged during the past century as the leading cause of death in our western industrialized societies. Hence, the war against coronary artery disease has been declared as a top priority of contemporary medicine. As a key to solve the problem, risk factors were defined which could identify - even in a still healthy individual - an increased probability to develop and eventually die from coronary artery disease. For a few of these risk indicators it was subsequently shown that eliminating or reducing them by therapeutic interventions is to result in a measurable reduction or delay of the incidence of coronary artery disease and death. Thus, benefits have been proven for smoking cessation and drug treatments of hypertension or hypercholesterolaemia. In absolute terms, these benefits may look pretty small: the absolute risk reduction for primary prevention of coronary deaths achieved by lowering cholesterol levels by pravastatin for five years is 0.5% - the number of hypercholesterolaemic men needed to treat in order to prevent one coronary death during five years in
Germany
would be 400.
Nevertheless, risk factors are being identified by population screening or by regular check-up examinations of healthy (but worried) individuals who can afford them. In addition, people - even though by traditional standards symptom-free and healthy - are being subjected to therapeutic interventions and management programmes - in order to decrease their risk of developing coronary artery disease and to prolong their life expectancy. Under the name of risk factor medicine this concept has long become a mainstream activity of our health care systems. Škrabanek has questioned this type of preventive medicine on many accounts (16).

 

Its fundamental irrationality manifests itself on several levels:First of all there is the relationship between longevity and causes of mortality, one of the basics of public health epidemiology. With increased life expectancy cardiovascular diseases and malignancies are bound to become the leading causes of death. In Germany, like in many other countries, myocardial infarction has become a leading cause of death for the old and very old; the average age of death from myocardial infarction is several years higher than the mean life expectancy of the population. In other words - only a relatively small fraction of coronary deaths, i.e. those called premature, before age 60 to 65, is preventable or delayable. Whereas the majority of coronary deaths coincides pretty well with presently optimal length of life.

Secondly, to end life by a coronary, maybe even by a sudden death, may not be the worst one can hope for. A much discussed anecdote illustrated this nicely some years ago: three physicians in their late fifties are driving back from a cardiology meeting. They are full of admiration about the new possibilities to identify individuals at a high risk of coronary death - and the advances on how to prevent it. Finally, one of them starts to deliberate on the most likely alternative, i.e slowly dying from a malignancy. The following discussion centers around the issue whether the three friends would actually find it prudent to seriously try to reduce their risk of dying a coronary death.

 

IV.

Of course this brings us to the more fundamental problem on how to deal with death as the inevitable end of all our lives. During the mideavals, people had no problem with death; it was seen as the end of the earthly vale of tears and the entrance into heaven. In our present secularized societies the population is given little guidance on how to deal with the inevitable and anxieties are growing.

One of the few ever addressing the issue was Jonathan Swift (17). On the island of Luggnagg, Lemuel Gulliver had the opportunity to meet with the immortals, the Struldbruggs who comprised a few percentage of the island's population. Gulliver had actually been looking forward to meet these immortal people with the greatest expectations. He anticipated to see a group of humans that - over the centuries' of their lives - had been able to accumulate endless knowledge, experience, and wisdom as well as wealth and independence along with an enormous prestige amongst the rest of the population. - What Gulliver saw was the exact opposite: a most miserable group of socially isolated and depressed cripples suffering from the most awful consequences of extreme senescence - after age eighty even deprived of some of their basic rights as citizens. The only privilege that was given to the Struldbruggs was that - in case they happened to have married another immortal - their marriage was legally dissolved when the younger one of the two became 40. It was felt that those who were condemned to a perpetual continuance in the world should at least not have their misery doubled by the load of a wife or a husband. - Gulliver described the Struldbruggs, some of them thousands of years old and very remote from any real life, as "the most mortifying sight he ever beheld". In fact the only desire they had left in life was to die - a hope which was never to be fulfilled. No wonder, the immortals were despised and pitied by the rest of the population. As a consequence of the "continual example of the Struldbruggs before their eyes", the people on the island of Luggnagg were not at all eager to extend their lives beyond their usual life expectancy of around 45 years. Even Gulliver concluded for himself that "my keen appetite for perpetuity of life was much abated". In fact he intended to send a couple of Struldbruggs back to Ireland, "to arm our people against the fear of death" - a plan which turned out to be impossible for legal reasons.

Swift's satyrical notes point to the intellectual neglect to deal with ageing and mortality in a rational manner. To this date, society has not addressed these problems, but in a superficial manner - with the persisting fear of death leading to irrational behavior and action.

Threatened by malignant diseases more and more efforts are being undertaken to develop effective means of prevention - or early detection in order to enhance the chances of curative therapies. In principle, prevention is a most sensible approach to combat diseases. However, driven by the anxieties of the public these efforts may be misled. In 4% of women, breast cancer is the cause of death. The preoccupation of the public appears comparatively excessive. Anxieties are stimulated by the publication of detailed case reports of prominent women, politicians, actresses etc., up to the very and often final details in the media. Usually, these reports end with the demand to implement population screening methods for early detection of breast cancer by mammography. Dr. Peter C. Gøtzsche, the recipient of last year's Škrabanek award, has systematically scrutinized the evidence for population mammography screening.

 Very recently, Gøtzsche has a confirmed his earlier publications and his Cochrane Review (11). The message was straightforward: there is no evidence that mammography screening reduces mortality; but it is associated with a number of untoward side effects and harm to the women and it results in a considerable financial burden. Within a week of this publication the German health minister and her consultants announced the nationwide implementation of mammography population screening. Confronted with the lack of evidence for any benefits they responded that they considered this a scientifically controversial issue irrelevant to the public. However, more important was their political reasoning: German women would no longer tolerate that population screening for breast cancer had been introduced in many European countries in order to reduce breast cancer mortality, with the exception of Germany. With a general election upcoming the implementation of a breast cancer screening programme by mammography was a triumph of irrationality over evidence-based decision making.

Other examples of widespread medical practice mainly based upon mysticism and irrationality are the (over-) supplementation of vitamins - which amounts to an expense of 750 Mill Euros per year in Germany; the popular hormone replacement after menopause as an attempt to prevent almost anything from coronary artery to Alzheimer' disease; the uncritical use of antidepressive and antibiotic drugs; and most of what is today referred to as alternative medicine. No doubt, within the real world of our health care systems the golden calf has grown beyond any reasonable dimensions. And the examples which I have referred to are not only to show the uselessness of such efforts - but as well the danger they can represent for the patient/the public.

 

V

One might want to ask who is responsible for such a development; what are the reasons for the fact that irrationality remains a decisive component in our health care system - despite all the enlightenment and the scientific progress during the past two centuries?Three causal factors may be identified:
To help them during times of threat and menace, the individual as well as the public tend to create heros, leaders with superhuman powers. Irrational demands are increasingly addressed to the physician, comparable to the cry for help formerly directed to the priest. Unfamiliar with the need to ask for any evidence, the society asks for action - no matter whether its consequences may be benign, non-existant or even malign, as in the case of Goethe's Faust. As the American physician Oliver Wendel Holmes has summarized in 1860 "The public insists of being poisened" (9).

In the beginning, the physicians do not appear to exploit this situation; Faust and his father just seemed ignorant. Likewise, the physicians in "The Doctors' Dilemma" appeared to appreciate the expectations of their patients and the decorations received by the authorities (14); but, in general, Shaw described them as benign characters.- This attitude of benevolence may have been erodet, though, by the continuous temptation inherent to the system of medical practice. In his lecture "The Socialist Criticism of the Medical Profession" read before the Medico-Legal Society on February 16, 1909 in London, George Bernard Shaw points to the problems of temptation by the organization of our health care system (15).

He describes the surgeon who is to decide on the medical indication whether to amputate his patient's leg. Will this surgeon remain unbiased in his decision-making process given the fact that he will make a personal profit if he opts pro amputation? Will the physician remain free of any consideration concerning his own and the patients' economic situation? Probably not. Considering that physicians are as temptable as anybody else, Shaw has suggested to separate the decision making process from the actual surgical procedure - which may organizationally be impossible - or else to pay the physicians a fixed salary - independent of the number of procedures they carry out.
Today it is clear that those health care systems which still remunerate their physicians on a fee-for-service basis are facilitating overdiagnosis and overtreatment and its well known consequences.
As already pointed out by Shaw some 100 years ago, such a capitalistic organization of medical practice will support and amplify the irrational craving of the public for medical interventions.

More recently, there is yet another power to support the "new irrationality" of the public. The medico-industrial complex, with the pharmaceutical industry, bioengeneering, the stock market and the medical profession, being its main players has become one of the main (and one of the very few growing) areas of our economies. The pressure to grow in turnover and profit making is the very nature of such a complex - and our political leaders actively support it. No doubt, this capitalistic monster profits from the irrational expectations of the public directed to medical interventions and its inability to recognize the respective dangers and risks.

In conclusion, any enlightenment and the progress of medical sciences, presently, expectations, and demands of the public from the medical system are still based to a large part on mysticism and irrationality. This dangerous and costly attitude is reinforced by the mis-organization of the practice of health care and by the capitalistic forces of the medical-industrial complex.
Despite all the maturation of the modern citizen as hailed by our sociologists, the golden calf has survived - I'm afraid, it has grown; at the beginning of the new millenium, it almost looks as it is proliferating.

Like in the Old Testament one may discuss who is to blame for such a development - the unstable population that is driven by insecurity, fears and impatience or those that take advantage of this weakness for their egotistic interests, take the last bit of Gold from the people and present them with the golden calf for worship in order to overcome their anxieties.
Maybe this tragic scenario is inevitable - an inborn error of human mankind and we should just let it happen.- Moses, as you know, thought differently. He destroyed the golden calf, pulverized it, spread it out in water, and forced the people of
Israel to drink it. Also, he ordered that 3000 men were slaughtered overnight in order to restore order and enforce the good faith in God and himself as the highpriest and the leader. In the long run, as we all know, such draconic measures are of quite limited success. It should be more helpful to explore the possibilities on how to prevent the implementation of golden calves, how to protect the population from the fraud of medical scharlatans. If this were to be at all possible, there appears to be only one solution: the education of the people about the principles of a practice of medicine that can be of benefit to them.

VI.

The suggestion is to inform and educate our patients as well as the public. "The right to know is like the right to live" (14). Rather than attempting to keep information within the medical profession and to withhold it from the laiety (what a telling name to call the non-professional public) - the idea is to educate the public about the values and necessities of scientific observation, quantification and experimentation. In principle, this represents nothing more or less than teaching the basic rules of logic. With a little bit of education, everybody should be able to understand the need to document patient-oriented outcome benefit for any diagnostic or therapeutic intervention before it is propagated in general and recommended to the individual. With a little bit of education, anybody should be able to value the difference between surrogate outcomes and patient-oriented benefits when therapeutic measures are at stake.

Of course, we are all aware of the widespread resistance within the medical profession (and beyond) to have the patients and the public informed and, subsequently, participate in the respective medical decision making processes. This resistance among doctors becomes all the more apparent whenever the medical issues involved are controversial within the profession. In such instances the medical profession almost tends to act like a conspiracy against the public by intentiously withholding relevant information.
In
Germany, the mainstream attitude amongst physicians, public health experts and health politicians is to withhold the controversy around mammography screening from the public - in order to be able to motivate as many healthy women as possible to participate in the programme. In this country, representatives of the medical profession expressed reluctance to inform women about the limitations of the accuracy in cervical screening - for the very reason that they were afraid that the honesty of such public information might cause a down-turn in screening.

Like during the ecclesiastical eras, truth, open questions and controversies are to be withheld from the public in order to lull the population into security - even at the risk of perpetuating unrealistic expectations. In Germany, to release controversial expert information to the less educated is called destabilization of security; for which the new word VERUNSICHERUNG was created in order to describe this unforgiveable sin.
Such attitudes are ethically questionable; in the long run, they will not bring any benefit to the population, much rather quite the opposite - almost reminding us of Moses' draconic measures at the bottom of
Mount Sinai.

Much rather the public and the individual patient have the right to obtain the relevant information they need to make an informed decision concerning a potentially useful diagnostic or therapeutic procedure. Within the evidence-based potential alternatives to proceed there is, no doubt, in most cases latitude, a room for reasonable decision making. That is to decide between alternative procedures or to opt for no procedure at all. David Sackett's evidence-based medicine has provided the formal platform for the patient by introducing "patients' preferences" into the decision making process (13). The extent to which this is possible will depend on the circumstances of the disease, the patient, and the possibility to inform him/her appropriately.

To dismiss "informed consent" as "pretty slippery" and to question the values of personal autonomy of the patient, as Theodore Dalrymple does in his recent book (4), is irritating. After describing a patient with advanced dementia who obviously can not articulate any informed consent, Dalrymple goes on arguing that nobody, not even a physician, is informed about every detail relevant to the case.

This argument is beside the point: in fact, it is exactly this lack of information and knowledge which has to be made available to the patient/consumer/client/public. - Rather than going through the trouble of such a mutual decision making process based upon informed consent of the affected person, Dalrymple paints with admiration the picture of the paternalistic surgeon who was his teacher or the paternalistic family doctor who looked into his throat when he had tonsillitis as a boy. These physicians were - by definition - characterized by benevolence, expertise and free of egotism - like Faust and Ridgeon. Of course, once in a while they could make a mistake - but, as a consequence of the non-transparent decision making and action processes - nobody would ever discover it. And as time went on the paternalistic physician gradually resumed the rôle of the benefactor and hero in his community - no matter what the quality of his professional conduct actually was.

Coming back to the tonsils, David Sackett often reminded us of the telling story of tonsillectomies reported by Bakwin in the New England Journal of Medicine in 1945 (2); of consecutive 1000 schoolchildren 11 years of age examined in New York public schools in 1935, about 60% has already had a tonsillectomy.

When the remaining 389 children were examined by a physician, for another 45% of them tonsillectomy was recommended; when the remaining 215 children were re-examined, in 46 % tonsillectomy was recommended; and in the final round of 116 children who still had their tonsils at that stage, again in 44 % physicians stated that their tonsils should be taken out. At the end 65 of 1000 children remained with healthy tonsils - but only because the study protocol did not allow for yet another medical examination. Similar figures, I am sure, can be presented about concerning appendectomies or hysterectomies. The incidence of all three operations has in the meantime reverted to a minimum - a small triumph of rationality and evidence-based medicine, let's call it of the process of enlightenment.

To enable the patient and the public to enter into informed-decision making processes about medical issues - requires a definition of the content of such information - but even more so the development of the educational methods to transfer the relevant information to the patient/the public. Both these areas are still within the infancy of its development and subject to a variety of projects worldwide. The institutionalization of consumer information and participation, e.g. in the Cochrane Collaboration Network, and development of decision aids in various areas of preventive and therapeutic medicine may serve to highlight the dimensions of this ongoing development.

An important cornerstone for the further expansion of informed decision making developments has been published by the General Medical Council under the Heading SEEKING PATIENTS' CONSENT: THE ETHICAL CONSIDERATIONS - PROTECTING PATIENTS - GUIDING DOCTORS in 1999 (5).

I do not know to what extent these courageous recommendations are being accepted or even implemented in this country. But I am convinced they outline the only way to go: the education of the public and the patients about the possibilities and the deficiencies of what medical practice and prevention can do - and what it can not - and how any available or recommended procedure is to be evaluated for its patient-oriented benefit. - I can not see any other way to protect the public and the individual patient from the threats to health by the new irrationality and by medico-industrial interests as reinforced under the roof of medical utopianism.

 

References

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Bakwin H: Pseudolexia pediatrica.
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The Era of Enlightenment Ends With The Golden Calf”

 

Lecture given during

 

The Škrabanek Foundation Colloquium

 

“Medical Utopianism: A Threat to Health”

held at The Royal College of Physicians, London, on April 25, 2002.

Michael Berger

Prof. Dr. med. Dr. h.c.

Heinrich Heine Universität - Düsseldorf