Sunday, 6 March 2011

The Rise of Coercive Healthism

This is a follow-up of a piece I wrote recently with the rather sweeping title "Health Screening and Health Education? A Waste of Doctors' and Patients' Time!". Perhaps I need to put the record straight and to explain what I really think and why.

     I am of the view that doctors need to be circumspect in the way they may introduce into the consultation an agenda that is other than that of the patient. The reason for this is that - particularly with regard to a 'first presentation' the consultation is the patient's arena. I mean that it is her or his property, and to introduce topics that are not immediately concerned with what the patient wishes the doctor to hear or what he (she) wishes to discuss is to intrude on that patient's patch. Therefore I think it inappropriate for a doctor to comment upon, offer an opinion and give relevant advice about the fact that a patient is obese he has come to discuss a matter upon which his obesity can have no bearing. Similarly, a patient who wishes to discuss her partner's drug dependancy should not have her concerns railroaded by being asked about her own smoking habits.

     I have no problem with health education per se but believe it has only a very restricted role in the one-to-one patient initiated consultation. I do believe it has an important place in the primary care setting (for example, the local health centre). But general practitioners should not be its main providers by any means. It simply does not require the level of skills and knowledge possessed by doctors. It could just as well be given (as it often is) by nurses trained in the task. And why not receptionists and other 'non-qualified' people, for goodness' sake? No - the doctor's role is to help the patient to understand what is happening to her, why it is happening, and to quide and advise upon possible options to deal with the situation. What the patient actually does with this information and opinion is entirely up to her, and she should be supported in whatever decision she takes. Even if she does continue to engage in a lifestyle that is harming her health or may harm it in the future.

     I well remember a patient who for many years had been unwilling or unable to take on advice given to him by both doctors and nurses on his obesity and smoking habits (advice that could just as well have been given to him by his grandmother). The turning point for him was when he had a heart attack from which fortunately he recovered. I did not see him for about a year after that. When I did see him I did not recognise him. He looked great - slimmer, fitter and altogether about 10 years younger. He would be the first to admit that he might have been saved an awful lot of  hassle had he taken the advice in the first place that he followed, after his coronary, when he started to attend our nurse run cardiac rehabilitation clinic at the surgery. The blunt fact is that he just was not ready to make those changes. And for goodness' sake, why should he have done so at all if he didn't want to? Many people are perfectly well aware of the risks that their lifestyle presents to them, and that includes mountains climbers and me. For if my doctor - where I am a patient it is actually usually a nurse - were to say to me that for every black pudding I eat I will knock 5 minutes off my life expectancy, then I will continue with the black puddings, thank you very much.

     Some, I know, will harp on about what they perceive as the ethical concern in such scenarios: I really don't go much on that. You know - the persistent smoker has a duty to quit because of the ultimate drain on health service resources that his behaviour will result in. I'm not a smoker, I'm not fat. But I have no objection to others being smokers or being fat, so long as the smokers do not do it where I can smell them or the fatties are sat next to me on a long haul flight which are cramped enough as it is.
 I see no difference between those risking life and limb by engaging in hazardous sports - just because sports are deemed 'healthy' - and those doing it by taking recreational drugs (the only immoral thing about taking recreational drugs is that it gives a lifelihood to some of the most vicious criminals on the planet), smoking, gluttony etc.

     The fact - and I base this on what I have seen with my own eyes and heard with my own ears - is that the Health Service is rife with what Petr Skrabanek in his brilliant book "The Death of Humane Medicine and the Rise of Coercive Healthism" calls 'Lifestyle Surveillance'. With its obsession for preventative medicine (laudable enough if it is offered rather than imposed) the patient who is ill or worried about illness has his agenda sidelined in the consulting room and the health centre and a new emphasis placed upon his presumed responsibility to "stay well".

     Worse - there has come into being a massive industry purveying "wellness". You have only to look on the shelves of every book retailer to see the burgeoning sections on matters pertaining to health and lifestyle. Best to look upon these for what they really are: little enough altruistic concern for those who fork out and buy the stuff - a good many of those flogging this system of excercise or that diet have made a tidy fortune from doing so. And that was why they did it in the first place - not because they were concerned in any very serious way that you or I should live long, healthy and happy lives. Worst of all are those fringe practitioners and sellers of quack remedies who prey upon the credulous and foolish, relieving them of money that they can ill afford to lose and giving only false hope in return. The author and journalist John Diamond had plenty to say on these characters in his book Snake Oil and Other Preoccupations while he was dying from throat cancer. But perhaps more of that in a future posting.


  1. An excellent post. The inteference of the nanny state is increasing, and as you say, we are all entitled to make our won decisions about potentially unhealthy habits. What no-one ever takes into consideration is the fact that someone who (for example) smokes, may cost the NHS money in the short term, but will save money in the long term (from pension to bus pass). I have got to the stage where if I'm told to eat, say, the famous five-a-day (who's idea was that), it makes me want to do the opposite.

    And I was a nurse for many years, and no doubt should know better...

  2. Thanks for reading my rambling post, Frances, and nice to see that you understand the point I am trying to make.
    I always tried impress upon the many young doctors I taught that, unless their patient was unconscious or in any way not competent to make decisions for themselves, then they were not responsible for that patient's health. It is not only arrogant for a doctor to think he or she might be, but it represents the taking on of an impossibly heavy burden.
    Patients and doctors (and nurses of course) should share the decisions together. The health professional is there to give accurate and unbiased information in a way that the patient can understand and to help them come to decisions about their own lives that are acceptable to them. However, no patient should be put in a position of feeling isolated and alone at times in their lives that may be both difficult and frightening.
    I like to think that I worked "with" my patients and not "for" them. That was what made being a GP such a joy and a privilege.

  3. "There are people who strictly deprive themselves of each and every eatable, drinkable and smokeable which has any way aquired a shady reputation. They pay this price for health. And health is all they get out of it. How strange it is. It is like paying out your whole fortune for a cow that has gone dry"

    Mark Twain.

    Petr Skrabanek's book is next on my reading pile - it was recommended by a friend.

    Upon its receipt - a quick browse through its pages showed the above quote. How true it is.

    The doctor-patient consult has indeed become an arena for a perceived attack by the doc on the patients unhealthy habits - all to meet QOF? There is nothing more irritating than attending an appointment for something totally remote from smoking and being asked the same smoking question. The patient feels lectured.

    I am a nurse too and perhaps should know better - but I like smoking - but would never inflict my habit on non-smokers.

    Anna :o]

  4. One of the problems it that this kind of interference often has no effect at all on those who might benefit from advice, and puts the fear of God into the suggestible. A nervous friend of mine, recovering from cancer, has taken on board every piece of advice she's been given, including not to drink milk if you've had cancer (?), and is making her life even more difficult than it already is.

    In response to the last comment, I would say that I have never smoked, but I think the blanket ban on smoking is ridiculous.

  5. An excellent post and while i'm on the patient rather than the Doctor side of the equation I concur with what you have said. I'm 68 and still a regular smoker. Now I know it's not good for me but I enjoy it and I'm damned if I will go to my grave with some bloody do gooder taking away one of the pleasures of my life. Down here in the colonies :) (Australia)we have a Government campaign that is enthusiastically supported by all the heart on sleeve types who are quick to sniff and the mere mention of tobacco. The nett result is that smokers in this country are increasingly restricted in where we can smoke. The latest affront to our freedom as citizens is to make it illegal to smoke in public Malls! To add insult to injury we are accosted by "heart rendering" adverts on television that are sickly sweet in nature. My pet hate is an advert depicting an "angelic" child telling her Father that he "should have been there" at a sporting event. The bloke is in a hospital bed being fed oxygen! What about the poor bloody man? If it were my daughter I'd probably disinherit her!

    I spent 40 years of my life defending this country as an Air Force pilot. I've been shot at, been in fear of my life on several occasions and lived in sub standard locations, now, besides not wanting to know about it they are also trying to tell me what I should and should not do. To hell with their programs, if I took them all on and didn't eat this, drink that or do the other thing I'd end up dying before my time from boredom anyway.

    More strength to you Doctor, give 'em hell!!!

  6. Many thanks to you all for your further responses. I have not myself smoked (it was a pipe) since I was a student. And my understanding is that most smokers take it up in their teens and that most smokers in their mid twenties wished they'd never started. That said, the job of doctor, nurse or whatever is to support and help their patients who are smokers either to give it up if that is what they wish or to give uncritical support if they don't.

    I was aware of smokers who avoided seeking health advice or presentingn with worrying symptoms just because they anticipated a judgmental or patronising attitude from the health professional. In a few cases the end result was disastrous.

    One of the best compliments I ever had from a patient was from a journalist from one of the tabloids who both smoke and drank heavily. He was starting to get heart and liver problems. "But I'm glad I've got you as my doctor" said he "because I know you won't have a go at me."

    And why would I have done? The man had a sight more wit than I and knew what he was doing. It was always good to see him.

  7. I don't have a problem with health advice being given - if it's clear, simple and accurate. Usually it isn't.

  8. Of course I agree about the 'clear, simple and accurate'.
    And I would add: 'wanted'.