Medical Paradox

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7 Augustus 1976 S A M E D IE S E T Y D S K R I F 1327

A Medical Paradox: Curative versus Preventive MedicineJ. F. BROCK

SUMMARY

A familiar medical contrast is presented as part .of amodern medical problem. The problem it reflects is there la t ive importance of preventive and curative services

fo r medica l p rac ti ti oner s, which is already, or will shortly

resolve itself into, a dilemma of whe th er med ic al mens houl d s tr es s p re ve nt iv e med ic in e to t he p os si ble d et ri-

ment of cu ra ti ve med ic ine.

It is submitted that t he s ol ut io n to both problem anddilemma should be sought a ga in st t he b ac kg ro un d ofhistory and p hilosophy, where th ey are seen to beexpressions of an e te rna l par adox - that of the relative

value of t he i nd iv id ua l in relation to t he f am ily, group,

o r communi ty.

If t he s ubmi ss io n is valid, then the answer to the

problem is no t a purely med ical exe rc is e, nor is thedilemma purely a 'doctor's dilemma'. The paradox, beinge te rnal , is not soluble in ou r time, bu t the community

must, on the urging of the medical profession, find ageneral solution to th e problem - 'a public consensusf or ou r time'. This must be followed by pub li c demand fo r

a parliamentary solution - ' decis ion-making ex consensus'.It is argued that although the latter p rogramme does

not come easi ly to democracy, i t can be achieved through

pub li c consensus if action is taken by the leaders of

thought in a pp rop ria te categories. I nitiative must beexercised by t he med ic al p ro fe ss io n, bu t public consensuscan only be ach ieved i n c on su lt at io n wi th t he leaders ofall l ea rned p rofes sions, civil servants and legislators.

It must then be presented fairly and without bias to thepublic.

In th e meantime, t he med ic al p ro fe ss io n must formulate

its own 'medi ca l c on se ns us ' and th e doctor mus t r esolve

his personal dilemma according to formulated law, public

o r med ic al c on se ns us or, in the last resort, according tohis conviction and conscience.

This met ho d o f s ol vi ng a problem w il l a lmos t certainly

be applicable to other and mor e r ec en t med ic al p ro bl ems

such as th e popul at ion exp lo sion , s el ec ti ve abortion andeuthanasia.

S. A fr . m ed . l. , 50, 1327 (1976).

Medical ethics is f aced with many philosophic problems,of which three ar e at present being widely examined bythe profession and by intel ligent laymen, lawyers, clergy

Department of Medicine, Groote Sehuur Hospital andUniversity of Cape Town

J. F. BROCK, n .M. , F.R.C.P. , Emeritus

Paper presented at a meeting of th e Adler _Museum of th e History ofMedicine Johannesburg, on 23 Oct o be r 1 97 ,.After ha'ving submitted this paper f or p ub li ca ti on , I saw a rel'ly byMoore H to an article b y M ahl er 15 entitled Health - Aof Medical Technology. This r em in ds m e that I am not alone 10 myanxiety about tbe futur e of Hippocratic medicine.

an d politicians. They ar e the problems o f popul at io nexplosion, of elective a bo rt io n a nd of euthanasia. Theyoverlap, but are distinct from an older problem to bedi cus ed here. Daily, as o ne l ook ou t from the windowsof Groote Schuur Hospital, on e pictures the greatproblems of indifferent health, sickness an d unnapptnessresulting f rom malnutr i tion and defectlve nygiene amongthe dwellers in th e Cape Flats townships, while in th ehospital, large resources of public money an dpersonnel ar e being poured into OU I salvage activitiesfo r the elderly and infirm, ou r intensive c ar e war ds an dunits for cardiac, respiratory an a metabolic resuscitation,an d in other divisions of the hospital for traum a a ndabortion.

The alternatives in the subtitle, of course const i tutean oversimplification because both are good an d neithernecessarily excludes the other. However, re cent r api ddevelopments a re so demanding, expensive and competitivethat a choi ce of emphasis is necessary fo r the immedia tefuture. Thi s p robl em of choice is thought about by manyintelligent laymen and is most vigorou Iy discussed anddebated among medical and other university students.

I t is no t easy to dec ide which of the two services,preventive or curative, should be given preference bythe medical profession. To the modern university student,whose ideal ism is half formed, there can be l itt le doubtthat the medical profess ion should do 'the g reat es t goodto the greatest number of sick people'. Preventive medicinemust be pu t before curat ive medic ine, even if th e resultis a population explosion so great th at afte r t he l ates t

decade the am oun t of food available per capita is lessthat it was i n the previous decade.

But the ordinary university student has no t ye t app re -c ia ted the anguish of t he y oung mother to whom a singledying chi ld (o r husband) is more deserving of th e in-formed, unhurried, an d exper t a tt en ti on of t he med ica lprofession than any impersonal group of malnourishedsi um -dwellers.

Here the paradox begins. The core of t he 'cur at iveversus preventive' problem in ou r present structure isthat medical personnel appear t o have insufficient time,and t hat t he re ar e insufficient fu nd s a nd public resourcesto meet the obvious an d growing needs in both fields.Many doctors ar e troubled by this; t he ir consci ences ask

which need is greater, and to which need they should devotethe ir t ime and skill. Some have found a way out of'doctor' dilemma' through pecialisation in either clinicalor public health practice or in curative or preventivemedicine. Th o e doctors who elect to remain in clinicalpractice, whether it be private or i n t it ut iona l, foll owthe age-old Hippocratic ethic and distribute their time,knowledge, ability and resources to individual pat ientsaccording to medical need. Th e others, who pur sue careersin publ ic health and preventive medicine, try to distributethe ir talen ts and the public funds tbey control so that



132 A M E D I C A L J O U R AL 7 August 1976

the greatest good i achieved for the greatest numberof the community.

Bu t this pragmatic solution fo r the doctor's consciencemerely hifts the problem back to the community, re-pre ented in theory by the voter, bu t in pract ic e by civilervants and politician. In outh Africa ou r politicaly tern provides an effective way of dodging the problem.It gives most of the responsibility fo r subsidising clinicalpracti ce to the Provincial Council, while dividing therespon ibility fo r providing funds fo r preventive medicinebetween local authori t ies and the Republican Government.Gbody can ee what i really happening through thismoke-screen, and the problem is no t even appreciated,much le tackled, so the pragmatic answers appl ied bythe medica l estab li shment and by community governmenterve only to bury the real p robl em under the carpe t.

I f we dig it out, does it constitute a dilemma? Onedefinition of a dilemma is 'a position which leaves onlya choice be tween equal ly unsat is factory a lterna tives' . Intbis ense it may become a dilemma, since, i f the l imitat ionsare accepted as rea l, p revent ive medic ine can only be setforward at the expense of curative medicine. Are the

l imi tat ion r ea l?

THE ROLE OF PHIWSOPHY

In another study' I expressed the view that any doctorwho had spent a lifetime trying to help the sick must,through his exper ience, have been forced into some sortof philosophy. He must have contemplated what JuIianHuxley' r ef er red to in his quest ion 'What ar e people for?"In other words, he must have become a medical philo-opher. I urged a younger generation of medical graduandsto attempt consciously to formulate a medical philosophy.I have come to believe that ou r dilemma represents oneof the great problems of ou r age and arises from thecentral paradox of our medical and social philosophy.

I t is worth while to l ook at the natur e and definition ofa paradox. The word comes, of course, fr om the Greek'doxa ', meaning opinion or dogma, an d the prefix 'para',meaning 'beside' or, bet ter perhaps , 'over against' in acomparative and competitive sense.A classical paradox of theology an d metaphysics is the

assertion or sentiment t ha t God is omnipresent, omnipotentand infinitely loving, and yet does no t intervene mira-culously to cure the pain an d suffering of his children.Philo ophers and theologians have writ ten many treatiseson how to solve or dodge thi paradox, but most of ushave found ou r own answer in one of 4 ways:

(I ) to deny the existence of Go d (atheism or humanism);(2) to escape the paradox by cal ling ourse lves , after

tudy and thought, agnostics;(3) to escape the paradox by ignoring the evidence -

the lazy way - or(4) to find a satisfactory answer through religious

concepts of free choice and of the educa tive valueof pain an d uffering.

Of the dictionary definition of a paradox, I should liketo quote one; 'a tenet or proposition contrary to receivedopinion'. Th e paradox I have chosen to examine maybe et out in the following fashion in terms of this

definition. One 'received opinion' or dogma contained inthe Hippocrat ic Oath as further developed through Judeo-Christian philosophy, may be tated: 'Individual humanlife is infinitely valuable and no effort or resource shouldbe spared in the attempt to rescue it from dea th o r h arm. 'This 'received opinion' ha been, within an d withoutthe medical profession , the root of some of the greatestacts of heroism in the h is to ry of man ; act s which involvedendangerment or even loss of per sonal life in a n a tt emptto salvage an otherwise doomed indiv idual . Within themedical profession, since at least the t ime of Hippocrates,its cor ol lary has been that a doctor must set aside thewelfare' of himself and his family, w it hou t count ing thecost, to answer a call fo r urgent medical service, underall circumstances and at a ll times, unless he believes thathe is already engaged on an even mor e impor ta nt p ro -fessional service. In the modern days of scientific medicine,i t has developed f ur ther t o mean that expensive diagnosticand investigatory services, and eventually curative services,must be applied without est imat ion of the cost. Th eparadox is immediately obvious when a seemingly contrarytenet or proposition is pu t in such terms as the fo llowing:

'I t is the duty of a doctor to devote his time an d theavailable physical a nd o th er resources which he commandsin his communi ty, to do the greatest good f or the greatestnumber of people.' In my opinion, this proposi tion iso ft en necessarily a di rect ly ' cont ra ry t enet ' to 'receivedopini on' deriving fr om the Hi ppocr ati c Oath. The onusmay ther efor e be on each medical practitioner, accordingto his conscience, to decide whether this apparently contraryassertion is or is no t valid. I have used the words 'maybe' because there are some who feel that the decision istoo difficult, and that doc to rs mus t be r es cued from theirdi lemma by a resolut ion of the community: I shall latercontend that the community must resolve and thatParliament must choose, bu t t ha t the medi cal profes si onmust first s timulate consensus.

mSTORICAL PERSPECTIVES

I have no pretensions to being a formal medical historian,but since I am interes ted in the evolu tion of trends andconcepts, I like to sec a problem against the perspectiveof history. Reviews in stan da rd textbooks of medicalhistory leave one with the impression that the pract iceof medic ine in Sumer ian, Babylonian, Egypt ian, Indianand Chinese cul tures var ied qui te considerably, bu t thatits approach was l argely clinical or curative. Hebrewculture probably went furthest in the direct ion of com-munity prophylaxis or public health. Fo r example, Leviticusin the Old Tes tament has been r ef er re d t o as 'the firsttextbook of publi c hea lt h' . Ear ly Greece bor rowed fromher neighbours in Asia Minor, and one of he r philosophers,Empedocl es, while pr act is ing as a physici an, is reportedto have checked an epidemic (presumably malar ia ) in hishome town by draining a swamp an d fumigat ing thehouses. The Golden Age of Greece brought Hippocrates( bo rn 460 BC), whose oath is still part of the graduationceremony of medical students. His name an d those ofhis daugh ter s, Hygi ei a an d Panacea, have dominatedWestern medical pract ice for nearly 2500 years. I have



7 ugustu 1976 A M E D I E E T Y D K R I F 1329

vi ited Co , the Greek Island on which he wa born,and where he practi ed and taught under the famouplane tree which is alleged to be 2 500 year old. Fo rthose who are not his torians, a del ight fu l nove l ent it ledThe Torch ' gives a fascinating perspective of the life andtimes of Hippocrates.Hippocrates has dominated t he though ts of Western

medical pract it ioners so much that I spent some timestudying hi writings. What is known as the HippocraticCorpl/s consists of a large number of books attributed toHippocrates himself or to the writings of his pupil s.I have used particularly The Medical Works of Hippocrates,t ranslated by Chadwick an d Mann.' These writings conveythe plea that t he physi ci an should s tudy the ent ir e pat ientand his env ironment , an d should view disease with theeye of a natural is t. Never theless, most of the titles ofthe chapters ar e clearly directed towards clinical medicine.Some have tit les which suggest a n app ro ac h to preventivemedicine or public health. They include 'A Regimen forHealth', 'Epidemics' an d 'Airs , Waters an d Places'. How-ever, when these chapters ar e perused, it is clear that theyare directed at the dai ly habit s and activities of individualmen. The r egimen is fo r individuals, an d no t fo r com-munit ies. 'Airs , Waters and Places' is concerned withclimatology, an d its objective is to help indiv idua l peopleto adjust themselves to t he vagaries of climate andsurroundings, and there is little, if anything, about whatthe community or the Sta te Gove rnmen t could do tomake the ir c limate more healthy, e.g. by draining marshes.In that particular respect Hippocrates seems to havebeen behind ra th er th an in advanc e of his predecessor,Empedocles. ever theless , it is no wonder that, underthe leadership of thi s intel lectua l g iant , Wes te rn medic inewas orien ted large ly or ent irely towards c linica l pract iceuntil the early 19th century.

A NEW EMPHASIS

Even then, the new emphasi s came no t to any impor tantextent from the medical profession, but rather fromhumanitarians, an d it started as part of a more generalhumanitarian philosophy in Britain. Jeremy Bentham(1748 - 1832) was known both as ' the utilitarian philosopher'and as the 'father of modern prevent ive medi cine'. As aphilosopher, he insistently preached the doc tr ine of 'thegreatest happiness of the greates t number' . H is views areet ou t in his Introduction to Principles of M orals an dLegislation." His work was intens ively fol lowed up bya lawyer, Edwin Chadwick (1800 - 1890). He was a friendo f Jer emy Bentham, an d pu t pressure on t he Gover nmen t

to apply the latter's humanitarian philosophy u nd er t hename 'The Sanitary Idea' . He succeeded in persuading theGovernmen t to appoint a Sanitary Commiss ion in 1839,and this led to the establishment of a general Board ofHealth i n 1848.' Time was no t ripe fo r radical reform,and the Board was dispersed 10 year s l at er. evertheless,Chadwick's enthusiasm was undiminished, an d before theend of his life he was rewarded fo r his persistence.These two reformers were supported in Britain by

Thomas Southwood Smith (1788 - 1861), a physician at theLondon Fever Hospital. He implemented the farsigh ted

request of Je remy Bentham that hi body hould bedi ected ' 0 t ha t mankind ma y reap ome mall benefitin and by my decease'. Smith wrote a book entitledThe Philosophy of Health," in which he empha i ed theimportance of national health. He upported Chad wick onthe Genera l Board of Health, and his de cript ion of theprevalence of preventab le icknes among the poor illus-

trated the needfo r

theBoard'

activities.These three pioneers were fol lowed by a famou L ond onmedical trio, William FaIT (1807 - 1883), J ohn Snow (I813-1858), an d Sir John Simon (1816 - 1904). These three menall, presumably under the impetus of the health philosophyof Bentham, Chadwick and Smith, devoted their livesin qui te eparate ways to the common idea of preventivemedicine. Farr had l it tl e formal educa tion , and spent mostof hi life in the office of the Registrar-General in London,a lthough he ha d ome short exper ience in medical prac-tice." He devised and published a book on the classificationan d nomenclature of diseases, which is still the basis ofvital statistics. John Snow, before the bacterial origin ofdisease had become known, pointed ou t that chol er a inLondon was water-borne, an d made hi famous remarkabout the communa l pump in Broad Street. John Simonsystematised the advancing knowledge an d became MedicalOfficer to the General Board of Hea lt h, a nd l at er MedicalOfficer to the Privy Council. His book English SanitaryInstitl/tions (1890)" summarised the me sage of the trio.In the rest of Eur op e a n outstanding figure was Max vonPettenkofer (1818 - 1901), a pupi l of Von Liebig. In 1866he founded the Ins ti tu te of Hygiene at Munich, an dinvestigated the relation of soil a nd a tmosphe re t o health,par ticu la rly in relat ion to the preva il ing cholera epidemic.He fell slightly ou t of line in that he did no t accep t theviews of Koch regarding the role of organisms in disease.

In the United Stat es , the ci ty of Boston and the stateof Massachuset ts led the movemen t under the impe tu

of Lemuel Shattuck, a booksel le r an d publisher with akeen interes t in soc ia l wel fa re. Medical v is itors to Bostonwill know Shattuck Street, which is almost the heart ofthe Harvard Medical School. Lemue l was appoint ed to aSanitary Commission to survey the Sta te of Massachusetts,an d ed it ed the Report of Massachusetts Sanitary Com-mission 1850.'° Most of his suggest ions were adopt ed andpublic interest was awakened. Boards of Health wereestablished, the first being instituted in ew Orleanin 1855.

John Ryle

For a few years before I came to the Chair of Medicine

in Cape Town I was Assistant Director of Research inMedicine at the University of Cambridge. My chief therewas John A. Ryle, a member of t ha t gi fted f ami ly whichin three generations gave Britain a leading bi hop, anapostle of athei sm, a humanist phys ic ian, a phi lo opherand an astrophysici t. Befor e his appointment as RegiuProfessor of Medicine at the Univers ity of Cambridge,John Ryle had achieved gr eat distinction as a physicianat Guy's Ho pital and a a leading con u lt an t in London.His book The ' atural His to ry of Disease" is till amodel of de cript ive clinical medic ine and of the art of



S A M E D I C A L J O U R N A L330

a consu lt ing physician . In 1938 I left his department tocome to Cape Town, and when I next saw him in 1948

he wa Profes or of Social Medicine at th e Univer ityof Oxford, and author of a book published in 1948 -Changing Disciplines - Lectures on the History, Methodand Mot ives of Social Pathology."

I quote two par ag raphs f rom one o f his chapters, headed'Prevention or Cure?':

'For a very long time we have accepted th e old adage'Prevention is bet te r than cure' . In our new era the beliefin it - for of its truth there can be no doubt - mustbe made ever more mani fest i n ou r research an d itsdirectives and in ou r teaching. Th e most consp icuousinterest of the student ten or twenty years henc e will,I hope, no longer be in the rare or difficult and too oftenincurab le case , but in the common a nd more understand-able and preventable disease. M ay the daily quest ionson his lips become not 'What is the treatment?' but·What are the causes?' an d 'I f preventable, then whyno t prevented?' . . . (my italics).

'The training of th e doctor, which began with obser-vations on and the care of the sick individual, is due

now for a great forward stride. Obse rvat ions on who lecommunities, whe ther g reat or small (or on appropriatesamples) and improved health provisions fo r t hem, musthenceforword become The prior objective.' (My italics.)

How much progress has English-speaking medical scienceand practice made towards these objectives? Ha s it indeedaccepted them? My impression is that there ha s beenwide acceptance of them as ideal s and, to a lesser extent,as educa ti onal p ri nci ples. There ha s even been some·attempt to apply scientific inquiry to them. I refer toscattered attempts to apply mathematical sta tisti cs tomorbidity and mortality trends, to new ideas about humanecology in the p revent ion of pol lut io n a nd t o a tt empt s toapply economic principles of cost/ benefit analysis toalternative programmes fo r prevention and treatment.These trends ar e very scattered, tentative and unrelated.But even at this early stage, I see some signs of an un-healthy overswing of the pendulum. In pursu ing thi s lineof thought I have rearranged an d partly rephrased his twoquoted paragraphs as follows:

'For a very long time we have accepted the old adage'prevention is better than cure'! In ou r new er a thebelief in it - for of its truth there can be n o do ub t -must be made ever more manifest in our research a ndits directives and in our teaching. The most conspicuousinterest of the student ten or twenty years hence will, Ihope, no l ong er be in the rare or difficult and too o ft enincurable case, but in th e common an d more understandablean d preventable disease.

The training of the doctor, which began with observationson an d the care of the sick individual, is du e now fora great forward stride. Observations on whole communities,whether great or small (or on appropriate samples) andimproved hea lt h provisions for them, must henceforwardbe an educa tional objec tive as important as the diagnosisand treaTment of th e sick individual. May the dailyquestion on the studem's lips become ·WhaT is The

diagnosis?' 'What are the causes? ' 'I f prevenTable, Then

why noT prevented?' an d 'What can be done to cure or

7 August 1976

relieve This patient and those who are close to him?'(My rearrangement an d italics.)I like to believe, from close personal knowledge of

John Ryle, that he would agree with this rephrasing.This is, I think, clear when the unde rli ne d sections inthe origina l quo ta ti on and in its rephrased version ar ecompared with each other. What I have tried to do, inessence, is to avoid the implicat ion that preventive servicesmust have p ri or a tt en ti on and must be regarded as moreimportant than the Hippocratic ideal of th e diagnosis,cure or alleviation of the sick individual an d hisimmedia te fami ly. I knew Ryle as a man of compassionwho would save no trouble nor u nd er ra te this latterobjective. This bel ie f stands ou t in every page of TheNatural History of Disease, an d I do not believe that heretracted one iota from what he wrote in this book whenhe wrote Changing Disciplines.

THE MAKINGS OF A DILEMMA

Life is full o f par adoxes , such as th e classical one ofgood and evil. Most ly they remain unsolved as generalproblems, bu t one face t of a general problem impingesat a particular time on the individual or the communityand demands decision and action. I t then const itutes adi lemma . I submi t that this is the point we have rea chedin ou r medical p ar ad ox . Why has this dilemma beenpr ec ip it at ed in the 1970s? Th is que st ion deserves a whol electure on what ha s happened in the quarter-century sincethe end of the Second World War. I t can only be summa-rised he re in 3 se ctions:

I. 'Death control', th rough communi ty hygiene, healtheducation and effective modern drugs , has been effectivelyapplied to a high proportion of the wor ld 's populat ion.But i ts necessary counterpart, birth control (better cal ledfamily limitation), has been accepted by only a smallproportion of the same population. Th e result is the

20th century population explosion.2. The success of ' dea th cont rol ' ha s prompted a new

worldwide approach to preventive medicine. Startingthrough the UN agency WHO, this ha s spread to nationalpublic hea lth departments and resulted in a worldwidedemand fo r more public health medical officers.

3. In the s ame quarter-century, a wave of technologicalsophist icat ion has swept into curat ive medic ine. This wavehas pinpointed diagnosis by machines an d physicochemicaltests. I t has made previously incurable conditions amenableto cure or worthwhile salvage, but it ha s done so atenormous cost in terms of finance and of multiplicationof hosp ital doctors in intensive care units.I s ubmi t, th er efo re , that we have a dilemma on ou r

hands which is only a '1970 facet' of an eternal paradox.How do we approach th e problem and solve th e dilemma?

THE PROBLEM OF MEDICALRESPONSmILITY FOR PUBLIC EDUCATION

The individual doctor c an mak e a persona l choice betweena career in clinical or public hea lth medic ine, but hili re-sponsibility does not end with h is persona l choice. He hasto lead t he public, th e community and, eventually, Parlia-ment, to an abi lity to so lve the problem on a national basis .



7 Augustus 1976 S A M E D IE SE T Y D S K R I F 1331

I t has to be exposed an d analysed, until eventuall yParliament is faced with a dilemma which demandsdecision.

In respect of exposure, we already have a position inwhich, as a result of urbanisat ion , the deleterious effectson hea lt h of poverty an d unhygienic slums have becomeglaringly obvious. As a result o f popul at io n pressure,

the addi ti ve effects of undernu tr it ion and malnutritionare to be seen everywhere. I t takes no effort of imaginationfor the public to see the connection between lack ofhygiene, slum housing an d malnutrition. They can seeit around them in every poor di str ict ; the cor re la teddifferentials in infant mortality, morbidi ty f rom 'socialdiseases', an d life expectation respect ively between theraces an d social groups ar e evident. Th e Poverty DatumLine is a concept familiar to most intelligent city-dwellers,and its relat ionship to sickness is apparent. Th e publicconscience has been aroused an d from many sides demandsare being made for public medical prevention. In th edeveloping nations, the example of th e British social andmedical reformers of th e late 18th an d early 19th century,from Chad wick to Simon, is being renewed. This ispowerfully su pp orte d b y Uni te d Nat io ns agencies suchas WHO, FAO an d Unicef. The connection between causeand effect is now general ly appreciated . We no longerneed a John Snow to demonstrate th e cause and effectrelationship of the parish pump and th e cholera epidemic.Fo r the same r eason , t he public now has to recognisethat the solution to the problems of slums an d sicknessis no longer a strictly medi cal matter - it is a matterof economics, education an d politics. This is a point ofthe utmost importance, bu t t he re is no time in this t al kto deve lop it properly. We are concerned here with theduties and responsibilities of th e medical profession. Wheredo these begin and end in the modern context? How domedical pract it ioners individually, and collectively as amedical profession, educate the public?First ly, medical men must be r esponsibl e fo r th e

collection of facts in their field of expert knowledge.Jeremy Bentham a nd E dwi n Chadwick gave the impetusto knowledge of th e r el at ion sh ips between pover ty an ddisease, bu t it required a medical man, John Snow, toshow that the water of th e parish pump in Broad Street,London, was the cause of a cholera epidemic, even beforeth e existence of bacteria had been discovered.Secondly, they must b e pace-setters in health education

an d in persuading legislators to apply its lessons. Sir EdwinChadwick, a l awyer, persuaded the Br it is h Governmentto appoint a Sanitary Commission in 1839, bu t it lapsedan d would have died, had Southwood Smith, a physician,not reformulated it as a General Board of Heal th. LemuelShattuck of Bos ton, a med ical man , spread the doctrinethroughout t he Un it ed States. In 1866 Max van Pettenkoferfounded the Institute of Hygiene in Munich. Finally,Sir John Simon Medical Officer to the British GeneralBoard of Health systematised (1890) th e new trends inhis book English Sanitary Inst itut ions. ' Later he becameMedical Officer to the Privy Council, an d showed whata medical man could do to shape the legislative programmeof public government. Th e pattern was set fo r a newbreed of medical administrators.

Public Health Doctors

These ar e t he men who mus t i nt erpr et t o legisl ators andadminis trators, whether they be central or local , the needfo r and th e steps to be t aken towards an evolving preventivemedical service.However, they must be fully a ware of the paradox

which we ar e discussing, and they must no t wing thependulum of legislation and admin is tr at ion too fa r or toorapidly so that the central importance of individualdiagnostic and t he rapeut ic services is al lowed to de ter io-rate. This objective can partly be met if the teachers ofpreventive medicine regularly attend t he medi cal f acu ltyboards and subcommittees of their local univer ities.

An impor ta nt link at the to p in o ur c ou nt ry is theex .officio membership of the South African Medical andDental Council which is bestowed upon t he Sec re ta ryfor Health (our Chief Medical Officer). Preferably, hi stwo s enior assistants should regularly attend meetingsof the Council . Tn addition, hi representatives shouldplay the ir part in the activities of local branch Councilsan d meetings of the Medical Assoc ia tion . At congresses

of the Medical Association there should regularly beplenary sessions aimed at keeping the profession general lyaware of t rends in government health an d sickness policy.This is asking a lot, bu t a r ec ip rocal interest in theproblems of community and preventive medicine mustbe expec ted from clinicians. Unless regular an d intimatecontact is maintained between this new breed of medicaladministrator and the leaders of clinical medical practice,they will be inclined to resolve the p ara do x i n fa vo ur of'the greatest good to the greatest number of people'.To maintain a l ast ing sense of th e value of Hippocratictradition is difficult fo r a man who is no t in dai ly cl inicalpractice.

One aspect which is relevant is th e appropriate termi-

nologyfo r

distinction betweenwhat is

refer red to through-ou t this talk respectively as curative and preventivemedicine. In a recent address at the Jubilee Congress ofth e Medical Association, th e Secretary fo r Health I

quoted as using th e following words wh en re fe rr ing toHealth Services: 'The service wil l have to succeed inestablishing an d maintaining the opt imal ba lance betweenth e preventive, th e curative, the health-promotive and therehabilitative components of a comprehensive healthservice.''' This quotation expresses an entirely logical an ddesirable objective, bu t i gnor es t he point that individualcurat ive medic ine is thousands of years old, whe reas theother 3 component s a re new competitors fo r personnelan d funds.

Therefore, to avoid ambiguity, I am using the followingwords an d terms as defined:

1. Medicine or medical services denote tho e activit iesapplied or directed by medical graduates (registeredmedical practitioners);

2. Curative or individual medicine denotes those medicalservices applied to sick individuals fo r their diagnosis,cure, rehabil it at ion or symptomatic relief. When itattempts to see th e individual's sickness problem againstth e background of family and community we call itcomprehensive medi cine , p rovided that it is appliedp rima ri ly to the individual .



1332 S A M ED I C A L J O U R tA L 7 August 1976

3. Prevent ive medic ine denotes those medical serviceswhich direct the promotion of health and the preventionof illness in communities. I t ha s been cal led public health,environmental medicine, social medicine a nd mor e recently,community medicine.

At the moment I am conce rned with the inevitablyemerg ing competi tion for service and national funds onbehalf of preventive medicine, to the possible detriment of

curative medicine.A great deal ca n be done in the future to relieve the

burden of work falling on the public health doctor bytraining health assis tants, health nurses and other classesof medical aUXiliaries. This should enabl e him to shepherdhis special ised training into the direction an d planning ofprogrammes. At the same time, it will ease the financialburden of preventive medicine an d its threat to theresources available fo r curat ive medicine. Likewise, inthe curat ive field, the doctor's time can be saved by othertypes of medical auxiliaries, so that he is able to continueto give his personal medical attention to the sick individualfo r whom it is so vitally needed.

The Importance of the Sick IndividualI f I am right that so a rd en t a nd expert a clinician as

myo id teacher John Ryle missed the importance ofthis medical paradox when he became Professor of SocialMedicine, then clearly we must beware. In reflecting onthis possibility, I have become more than ever convincedthat the undergraduate programme of medical educationmust remain common gro und fo r all intending medicalpractitioners, whatever their postgraduate speciality maybecome, and whether the latter be or iented towardsindividual or community medicine. Only thus ca n theimportance of the clinical approach to diagnos is andtreatment of the individual be retained in the mindsof those who proceed to postgraduate studies in com-munity medicine. My conviction implies that in correctingthe too exclusive concentration of medical education,dur ing the first half of the 20 th c en tu ry a nd throughoutmedical history, on the wards of the hospital, we mustno t swing the pendulum to a point where there is anydoubt in the student's mind about the infinite importanceof the 'sick soul' . I use this te rm del ibera tely at this pointin the a rgumen t, no t in a religious or theological sense,bu t in the psycho-emot ional sense that distinguishes aperson from an animal. However , I shall no t repeat it,bu t will t alk of th e 'sick individual' .

As a side-thought, one may reflect that the increasingnumbe r o f married medical students in ou r modern medicalschools may be important in pr es erving the 'importanceof the sick individual', because it is often in marriagethat the student relea rns the forgotten priorities of thep ar en tal h om e wh er e the claims of the ind ividual childar e always impor ta nt . H er e he tends to outgrow hisadolescent enthusiasms fo r political answers to the plightof mankind.

CONSENSUS AND DECISIONI believe I have now given my personal answer II I

philosophic principle to my medical paradox. To fill to

a 'blue-print fo r decision and action is a taxing taskwhich will certainly go wrong if the 'pr inciples andpriorit ies' are ignored. In my opinion , cer ta in decis ionsmust be made before a programme of action can evenbe outlined. Consensus must be r eached on toe rightnessor wrongness of app ly ing cer ta in log ical developmentsarising fr om scientific technology to ou r Hippocratic-Judeo-Christian principle of the infinite value of eachindividual. Must heart transplants be provided fo r all thosethreatened by progressive heart fai lu re , or kidney trans-plants fo r all those affected by progressive renal failure?I think that decision has already been made in thenegative, by gener al agr eemen t that quality of life ismore important than quantity of life, and that heroicmeasures fo r the extension of a disabled life will only beoffered to those who ar e likely to enjoy, an d be enjoyed,in their extended lifespan. I submit that this dec is ion hasbeen made, and is already being applied.

A difficult decision which mus t soon be resolved byconsensus is whether there may be selective terminationof pregnancy when prenatal tes ts declare that the fetuswill no t be capable of 'meaningful ' independent existence.

Vir tually everyone is agr eed in the case of monsters andseverely demented persons. Bu t w hat about Down's syn-drome (mongolism) in its varying degrees, the severityof which can only be assessed after b irth ? Can we saythat persons with the mildest degrees of Down's syndromear e incapable of meaningful existence? Here there is noconsensus , because science teaches us little, if anyt hi ng,about t he content of meaningful existence. That is aphilosphic and ethical topic of ten tinged with theology.whi le sec ta rian rel igion or h uman ism l en d controversyin which consensus becomes difficult. I contend, however,that there ar e degrees of this a nd o th er congenital defectswhich we could define. I believe we must do this.

H excep tions ar e to be defined, there must be someimprovement in machinery. At present they ar e defined bythe well- tr ied method of consultat ion between doctors ,close relatives and selected colleagues. I t h as wor ke d wellin the sphere of early selective abortion on strictly medicalindications. The l at te r is now legal in this country, bu tthe machinery will require some more generally acceptablelegal standing in the near future.

How many and what classes o f p eo pl e are to be con-sulted, an d who takes the final deci sion in the absence ofa consensus? Should neona ta l resusci tation be withheldfrom th e infant who is obviously s everely malformed?What physical supportive steps ar e to be offered to thosewho ar e approaching or already at the end of purposefulphysical existence? Who turns off the pump and · atwhat point in, fo r example , t he p rog res s of a patient

with irreversible traumatic brain damage, who has to bemaintained on an artificial respirator? I believe tbatthese problems will easily be solved if we agree on tbedecisions which ha ve alr ead y been taken and appliedby consensus. That consensus is, I believe, express ed inthe frequently quoted Thou shalt no t kill , yet need'st no tstrive, officiously to keep alive'. I t seems easy now, bu tit was difficult when it first became a problem fo rdecision.



A M E D I E E T V D S K R I F7 Augustus 1976

The Curative Limb of the ParadoxWe have cleared th e ai r lightly i f we agree that the

traditional dogma of th e infinite value of the individualhas acquired some definable exceptions. Th e applicationof scientific technology has a lready reduced some of thetraditional implications of the dogma to absu rdi ty, e.g.the maintenance of artificial respiration for an individualwith irreversible brain-damage when ther e i no meaningfullife. Other advances in scientific and medical technologywill certainly force us into the recognition that othertraditional implications ar e wrong, e.g. that the recentlyfertilised ovum or even the early fetus is an 'individual'.Never theless, to me, the dogma of the inf in ite va lue of

the individual is one of the h ighest express ions of ou rcivilisation and of our medical idealism. I t has served uswell since before the days of Hippocrates. I t is a source ofcompassion without which there is no satisfactory medicalpractice. That scientific advances should show up some ofits tac it ly accepted implica tions as out of date, does notdestroy the dogma. But it does demand its revision incer tai n respects, as fo r example, in the acceptance ofdefinable exceptions to i ts applicabili ty.

In discus ing the nature of a paradox I quoted as a'received opinion' or dogma the propos i tion that 'individualhuman l ife is infini tely valuable' . I am now proposing theaddition of a few words so that the dogma becomes'individual human life, with certain definable exceptions,is infinitely valuable'. Th e contrary tenet of ' the greatestgood for the greatest number' is now less clearly contrary,and we may be on the way towards a solution of ourparadox 'fo r o ur time'.

The Preventive Limb of the ParadoxCan the apparently insatiable demands of this other

limb of th e paradox be sca led down? I bel ieve that theycan be. Such necessary action as the provision of nutritiousfood, housing, hygiene, etc. is in no ense a medicalresponsibility. Th e shortages ar e determined by ou r socio-economic sys tem, which in turn depends on ou r politics.The programme of preventive medicine should rightlybegin only after all t he physical, educational and otherneeds of the whole population have been provided. I t

should then be the task of preventive medical services toensur e · through hea lt h education their proper use, i.e.consumption of the r ight k inds of food, control of popula-tion pressure. t he application of the principles of clean-liness and hygiene. This is largely a task fo r non-medicalpersonnel acting under th e direction of preventive medicalpractitioners. The latter shoMld not have to spend timetrying t o per suade the government that the populat ion orany part of it needs more or better food. Th e requirementsof millions of people of any class or colour ar e laiddown in tables of nutrients which ar e easily translatedinto those foods which the country can most easily growor rear. This should be the work of agronomists, notof medical practitioners. Unfor tu na te ly our preventivemedicine practitioners will fo r a long time have to keepup the hue an d cry against bad government.Similar a rgumen ts app ly to housing. hygiene and general

education.

1333

CO CLUSIOAlthough 1 cannot pretend to have resol ed the paradox.I have suggested some way in which the apparentcompeti tion between prevent ive and curat ive medic inefor nat iona l funds an d medical personnel ca n be relieved.These mea ure depend upon a medi cal consen us between

all br anches of the medical profe ssi on and continuedmutual understanding and respect between its curativeand it preventive wings. I believe that a recapitulation ofprinciples and priori tie upon which a con ensus can bebased will al 0 erve as a summary of my an wer to th i

particular medical paradox.

Principles and PrioritiesI. The historic 'dogma' of th e infinite value of th e

individual must be reaffirmed again and again by th emedical profession an d su pp orte d by the community.Its emerging threat to engul f ou r resources can be neutra-lised by def ining exception .2. The compara tive ly new special i ed group of public

health practitioners or practit ioners in preventive medicinemust support their curat ive or c linica l col leagues in thisfirst principle and must help to develop machinery fo rmedical consensus on principles, priorities and exception.

3. They must, as the mouthpieces of the medicalprofess ion to government and par li amen t, analyse theproblem of curat ive versus preventive medicine, and soformulat e a publ ic consensus.4. This consensus must recognise that the provision of

most of the requi rements for hea l th such as food, housing ,hygiene and general educa tion . is a matter of goodgovernment upon which prevent ive medical services canbuild through medical educati on. Doctor should no thave to spend their specialised time urging governmentto provide these physical necess it ies .

5. Both the curat ive and the preventive medical servicesca n be di lut ed with specially trained medical and healthauxiliaries so that the long and expensive training of themedical practitioner can be used where it will always bemost needed, namely in the direct or indirect care of th einfinitely valuable individual in the context of his homeand community.

REFERENCES

I. Brock. J. F. (1971): Unpublished data.2. Hux le y, Si r J . ill Wolstenholme, G .. ed . (1962): Man alld hi s Flit "re.

14th Ciba Found at i on Annua l Lecture. London: Churchill.3. Pollard. A. H. (1972): Med. J. Aus!.. 2, 1025.4. Pen fi el d. W. (1961): Th e Torch. London: Harrap.5. C ha dw ic k. J . and Mann. W. . (1950): Th e Medical Works of

Hippocrares. Oxford: B la ckwe ll Med ic al Pub li ca ti on s.6. Bentham. J. (c. 1775): Collected Works o f Jeremy Bell1ham.

edited b y B ur ns , J. H. and H art, H. L. A. University o f L on do n:The A th lo ne Press.

7. Chadwick. E. (1842): Th e Sani t ary Cond i ti o ll s of th ePopulation 0/ Gre at B ri ta in . Edinburgh: Universi ty Press .Sou thwood Sm it h. T. (1847): Th e Philosophy of /-lealrh. 3rd ed

L on do n: Co x.9. Simon. Sir J. (I 90): English Sani t ary In st it u ti on s . USA: Johnsoll

Rep ri nt C o rp o ra L on .10. S ha tt uc k. L ., B an ks. . P. and Abbot!. 1. Unpublished d31a.11. Ryle. J. A. (1936): Nfllural History of Disease. London: Humph re y

Milford.12. Idem (1948): Challgi llg Discipl ines . London : Oxf or d Universiry Press13. De Beer, J. (1975): South Afri cal l Medical Post, March, p. 4.14. Moore, F. D. (1976): Lancet, 1, 3.1-. Mah le r, H . (1975): Ibid., 2, 29.

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