The Role of Medicine

The Role of Medicine: Dream, Mirage, or Nemesis?

Thomas McKeown
Copyright Date: 1979
Pages: 224
https://www.jstor.org/stable/j.ctt7zvwjp
  • Cite this Item
  • Book Info
    The Role of Medicine
    Book Description:

    In analyzing the factors that have improved health and enhanced longevity during the last three centuries, Thomas McKeown contends that nutritional, environmental, and behavioral changes have been and will be more important than specific medical measures, especially clinical or curative" measures.

    Originally published in 1980.

    ThePrinceton Legacy Libraryuses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist of Princeton University Press. These paperback editions preserve the original texts of these important books while presenting them in durable paperback editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905.

    eISBN: 978-1-4008-5462-2
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. PREFACE TO THE SECOND EDITION
    (pp. vii-x)
  4. INTRODUCTION
    (pp. xi-xvi)

    Speaking of the origin of an idea a historian once remarked: ‘It is always earlier than you think’; and certainly it is not possible to name the sceptic who first questioned the effectiveness of medical procedures. But at least from the time of Montaigne, the notion that treatment of disease may be useless, unpleasant, and even dangerous has been expressed frequently and vehemently, particularly in French literature. Molière’sLe Médecin Malgré Lui, the famous operation inMadame Bovaryand Proust’s account of the psychiatrist’s cursory examination of his mortally ill grandmother (‘Madame, you will be well on the day when...

  5. PART ONE. CONCEPTS OF HEALTH AND DISEASE
    • 1 Evolution of Health Concepts
      (pp. 3-11)

      The aims of this book are: (a) to examine the validity of a concept which is rarely stated explicitly but on which medical activities largely rest, namely that human health depends essentially on a mechanistic approach based on understanding of the structure and function of the body and of the disease processes that affect it; and (b) to consider the significance of the conclusions for medicine, particularly in relation to health services, medical education, and medical research. These themes are discussed in the three sections into which the book is divided, the first two concerned with concepts and determinants of...

    • 2 Inheritance, Environment and Disease
      (pp. 12-26)

      When I began medical training at a London teaching hospital just before the Second World War, some observant clinicians were already aware that cancer of the lung was becoming a common disease. The surgeon who specialized in thoracic work referred frequently to the seriousness of the problem, and urged that ‘Doctors must become cancer of the lung conscious, in the same way that they are already cancer of the bowel conscious.’ We were told that the condition was being discovered too late for surgery to be effective, and the solution, it was implied, was in early diagnosis. So far as...

  6. PART TWO. DETERMINANTS OF HEALTH
    • 3 Decline of Mortality
      (pp. 29-44)

      Although the documentary evidence was very unsatisfactory before births and deaths were registered nationally, there is no doubt that there has been a vast improvement in health during the last three centuries. During most of man’s existence it is probable that a considerable proportion of all children died or were killed within a few years of birth. Such records as are available, taken with recent experience in developing countries, suggest that although there was considerable variation from time to time and from place to place, out of 10 newborn children, on average, 2-3 died before the first birthday, 5-6 by...

    • 4 Infectious Diseases
      (pp. 45-65)

      I have concluded that the fall of mortality since the end of the seventeenth century was due predominantly to a reduction of deaths from infectious diseases. However, non-infective causes of death were associated with about a quarter of the decrease of deaths in this century. To understand the influences which have brought about the modern improvement in health it is therefore necessary to examine the reasons for the decline of the infections and of certain non-infective conditions. These are the subjects which will be discussed in this chapter and the one that follows.

      This brings us to an important question...

    • 5 Non-Infective Conditions
      (pp. 66-70)

      The evidence for England and Wales suggests that with the possible exceptions of infanticide and starvation, about which information is lacking, non-infective causes of death were not associated with the decline of mortality before 1900. In the twentieth century, however, the reduction of deaths from non-infective conditions was considerable; moreover it has been concealed to some extent by the increase in mortality from lung cancer and myocardial infarction, brought about by smoking and other influences. In this brief examination of reasons for the decline of non-infective deaths the effect of these increases will be ignored (it would be very difficult...

    • 6 Health in the Past
      (pp. 71-78)

      The preceding chapters were concerned with the modern improvement in health, as indicated by the reduction of deaths from infective and non-infective causes during the past three centuries. We must now consider, in the light of the conclusions drawn in these chapters, the nature of the disease problems and of the influences – nutritional, environmental, behavioural and therapeutic – that have been at work at different times in man’s history to the present day.

      There are various ways in which history might be divided for this purpose, for example, in relation to economic conditions (poverty and affluence), or by the nature of...

    • 7 Health in the Future
      (pp. 79-90)

      The appraisal of influences on health in the past three centuries suggested that we owe the improvement, not to what happens when we are ill, but to the fact that we do not so often become ill; and we remain well, not because of specific measures such as vaccination and immunization, but because we enjoy a higher standard of nutrition and live in a healthier environment. In at least one important respect, reproduction, we also behave more responsibly.

      However, it is unlikely that these influences will have the same relative importance in the future. In industrialized countries the decline of...

    • 8 Medical Achievement
      (pp. 91-114)

      In Part One I concluded that the contribution of clinical medicine to the prevention of death and increase in expectation of life in the past three centuries was smaller than that of other influences. This is not of course the only index of medical achievement; doctors are also concerned largely with postponement of death (from specific causes) and treatment of non-fatal diseases, as well as with the care of patients for whom little can be done by active intervention. However, while recognizing that all these contributions are important, I think it is desirable to put them into perspective, and this...

  7. PART THREE. THE ROLE OF MEDICINE
    • 9 Non-Personal Health Services
      (pp. 117-130)

      In Part One the determinants of health were assessed in two ways: by examining conceptually the role of heredity and environment in the aetiology of disease (Chapter 2); and by appraisal of influences on health which have operated in the past and, having regard to the change in disease problems, can be expected to operate in future (Chapters 3-8). The conclusions derived from these different approaches are broadly consistent.

      1. Most diseases, including the common ones, are not inevitable. They result from environmental influences on genetic material which is varied, complex, and, at present, little understood. In relation to the...

    • 10 Clinical Services
      (pp. 131-142)

      The conclusion that medical intervention has made, and can be expected to make a relatively small contribution to prevention of sickness and death could not fail to have large implications for personal health services. They have evolved on quite different assumptions; treatment by surgery and drugs is widely regarded as the basis of health and the essence of medical care, and nearly half of the total expenditure in Britain (46.0 per cent in 1970/1) is on acute hospitals. These hospitals do not care for most sick people, of whom the large majority are in their own homes under general practitioners...

    • 11 Medical Education
      (pp. 143-155)

      In this chapter I shall suggest that the aims of medical education should be broader than they are at present; that it should be concerned with all the influences on health, non-personal as well as personal, and that in the field of patient care attention should be extended to all types of patients and all phases of illness.

      A proposal of this kind is certain to provoke what many will regard as an insuperable objection. It will be said that patients come to doctors for assistance when they are unwell, and that the essential medical function is to meet this...

    • 12 Medical Research
      (pp. 156-175)

      In his poem, based on the myth of Leda and the Swan, Yeats asked whether the girl, seduced by the transformed god, ‘put on his knowledge with his power’.¹ The same question when inverted might be asked about medicine today: Did it put on its power with its knowledge? However, it is one of the charms of the fable that it is open to more than one interpretation, so I must avoid misunderstanding by stating the issue more precisely: Are the improvements in health with which medicine is commonly credited determined essentially by medical science, or are they due largely...

    • 13 Dream, Mirage or Nemesis?
      (pp. 176-189)

      In Dostoevsky’s novelThe Possessedthere is a hilarious chapter which describes a meeting of provincial liberals who have assembled to hear a message from two prominent radicals. Unfortunately the great men seem less interested in revolution than in brandy and cards, and the conversation becomes trivial, heated, confused, irrelevant to the great issues they have come to hear discussed. Finally the host despairingly begs someone to make a statement, and they proceed to vote on the question whether they are a meeting in some formal sense, or merely a group of friends who have met to celebrate a name-day....

    • 14 Medicine as an Institution
      (pp. 190-198)

      Having touched on various ideas related to the medical role, I must now try to bring them together in a more coherent form. Before doing so, however, it will be desirable to remove some possible sources of misunderstanding.

      First, the aim of health services. We know from personal experience that the feeling of well-being, sometimes referred to as positive health, is something more than the absence of recognizable disease and disability, and it is tempting to define objectives, as the World Health Organization has defined them, in terms which recognize this.¹ However, there are at least two objections to so...

  8. Index
    (pp. 199-207)
  9. Back Matter
    (pp. 208-208)