In Defense of Doctors

The Role of Medicine

by Thomas McKeown
Princeton University Press, 207 pp., $5.95 (paper)

The angle of vision from a Chair of Social Medicine such as Thomas McKeown occupied with distinction for many years in the University of Birmingham, England, is quite different from that of a physician at the bedside or a surgeon at the operating table. The difference is embodied in the following credo:

I believe that for most diseases, prevention by control of their origins is cheaper, more humane, and more effective than intervention by treatment after they occur.

This belief, McKeown goes on to say, “does not reduce the importance of the pastoral or samaritan role of the doctor. In some ways it increases it.” McKeown firmly repudiates the notion that his message is cognate with that which is embodied in the “Medical Nemesis” by the author referred to in public by the late Professor Henry Miller as “Ivan the Terrible.”

Unfortunately the antithesis between prevention and remedy as McKeown outlines it is very seldom as simple as it might at first sight appear to be as the following examples will show.

We all know very well that the frequency of the congenital affliction known as Down’s Syndrome (formerly “Mongolism” because of Down’s racist propensities) would be greatly reduced if the mean age of motherhood were also to be reduced. But some women want to have—and may for one reason or another only be able to have—a child at the age of thirty or later. Again, the work of Brian MacMahon at the Harvard School of Public Health has shown very clearly that a woman who has had her first child as a teenager stands much less risk of becoming a victim of breast cancer than a woman who has had her first child in her late twenties or a fortiori her thirties. This finding seems to open the door to a number of salutary preventive procedures, but in real life who is going to encourage teenagers—among them one’s own daughters, perhaps—to become pregnant as soon after menarche as possible to give them extra protection in later life against a misfortune that may not befall them anyway? Prophylaxis is not enough: some women will get breast cancer no matter when their children are born, just as some people who don’t smoke will get lung cancer. So no matter how energetic our preventive measures, we must still have the resources of treatment at our command.

In spite of his seniority and distinction McKeown is not above being an enfant terrible. The philosophic doubts which form the subject of this book

…began when I went to a London Hospital as a medical student after several years of graduate research in the Departments of Biochemistry at McGill and Human Anatomy at Oxford. There were two things that struck me, almost at once. One was the absence of any real interest among clinical teachers in the origin of disease, apart from its pathological and clinical manifestations; the other was that whether the prescribed treatment was of any value to the…

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