How a tyranny of health is bad for both patients and physicians
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in Physician practice 
by Jan Henderson, PhD

Something happened to the public perception of health and medicine in the
1970s. People began to adopt - and financial interests and the media began
to profit from - "healthy lifestyles."

This was not without consequences.

. Americans became increasingly preoccupied with diet, exercise, and health
habits.

. There was a big uptick in the use of alternative "medicine" and stress
reduction practices - acupuncture, chiropractic, herbalism, naturopathy,
nutritional therapies, yoga, massage, biofeedback.

. The increase in news and advice columns on health and wellness made people
more anxious about their health.

. The public sought medical care much more frequently for symptoms that
would have been considered insignificant in the past.

Was "healthy lifestyles" a medical idea?

Health awareness and anxiety are nothing new. Throughout history people have
been concerned about threats to their health. Bubonic plague killed 200
million people. The death rate for women who gave birth in the 19th century
was 400 per 100,000 births, compared to 10 per 100,000 today.

Before the last century, physicians had very little to offer patients that
would cure or prevent disease. This left the field wide open for quacks and
charlatans, who could prey on health anxieties to sell their wares. By the
late 20th century, however, modern medicine had a great deal to offer. Plus,
it had won the confidence of the public - something medicine lacked in the
days when the only "cure" was bloodletting or purging (the use of
ultra-strong laxatives).

It seems reasonable to ask, then, if the emphasis on healthy lifestyles in
the 1970s originated with the medical profession. Americans were living
longer and suffering from the diseases of old age (cancer, heart disease,
arthritis). Epidemiological research - observing the health and habits of
citizens in various countries or ethnic groups - identified associations
between lifestyles and diseases (eat yogurt and live to be 100, like the
citizens of Georgia; eat soy products and avoid breast cancer, like the
Japanese). One can easily imagine that the idea of telling people to be
responsible for their health habits came from the medical profession.

But no, it did not.

The dark side of medicine

The emphasis on healthy lifestyles, although salutary in many ways, has a
very dark side to it and has led to the increasing peril of a tyranny of
health in the United States.

The quotation is from Dr. Faith Fitzgerald, writing in The New England
Journal of Medicine in 1994. This was followed in 2000 by Dr. Michael
Fitzpatrick's book, The Tyranny of Health: Doctors and the Regulation of
Lifestyle
<http://www.amazon.com/gp/product/0415235723?ie=UTF8&tag=janhenderson-20&lin
kCode=as2&camp=1789&creative=390957&creativeASIN=0415235723> How a tyranny
of health is bad for both patients and physicians. There was also this
statement from O. H. Forde of the Institute of Community Medicine in Tromso,
Norway:

The moral and coercive crusade for increased risk awareness and purity in
life style can too readily take on the form of cultural imperialism towards
conformity. Epidemiologists and the health care movement in general have a
mandate to fight disease and premature death: they have no explicit mandate
to change culture.

Dr. Fitzgerald's article in the NEJM addressed the down side - or, as she
calls it, the "dark side" - of a medical climate that holds individuals
responsible for their health. Such a climate assumes that those who are
unhealthy have committed a crime against society. After all, society must
pay their health care costs, whether it's through Medicare and Medicaid,
lost time from work, or treatment centers for substance abuse.

Society in turn will expect physicians to educate their patients, to
eliminate their unhealthy behaviors, and somehow to coerce them into
adopting healthy habits. A "tyranny of health" is bad for both patients and
physicians.

What penalty should we impose on the irresponsible?

The push for healthy lifestyles came not from the medical profession, but
from political, economic, and social forces of the 1970s and 1980s. It was
presented to the public as the need to take "personal responsibility" for
one's health.

The shift in health responsibility from the state to the individual - known
as "healthism" - was very successful. Medical journals today - as well as
health advice columns - write about the importance of the individual's
behavior in preventing disease.

A recent commentary in the Journal of the American Medical Association asks:
If individuals don't use preventive services, "what kind of penalty . would
be ethically and morally acceptable?" The question wasn't "How do we account
for unhealthy behavior," but what punishment would be sufficient either to
change that behavior or at least to save money by denying these people
health care.

When "personal responsibility" is endorsed by the authority of the medical
profession, we no longer see that healthism is a political position, not
simply a medical opinion. And because we don't see this, it doesn't occur to
us that our attitude towards our own health could have taken a different
path, and perhaps it still should.

Jan Henderson is a historian of medicine who blogs at The Health Culture
<http://www.thehealthculture.com/> .

http://www.kevinmd.com/blog/2010/10/tyranny-health-bad-patients-physicians.h
tml

 
Melissa Raven
Adjunct Lecturer, Department of Public Health, Flinders University,
Adelaide, South Australia 

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