What’s the point of health care? Does that seem like a question with an obvious answer? It would be reasonable to expect that the answer would be that health care is about caring for people’s health. But that’s an answer which is not really an answer. It raises the question, what is health? Stop and think about this for a moment, because it’s not a straightforward question to answer. My answer is that health is a phenomenon in its own right – it is NOT the mere absence of disease. It has distinct characteristics – adaptability, creativity and engagement. Others will have other answers, other characteristics to add, other qualities. It’s difficult to extricate health from the old concept of “eudaimonia” which tends to be translated as “happiness”, or even “wellbeing”, but I prefer the word “flourishing”. Surely health is about flourishing? The less we flourish, the less we rate ourselves as being healthy, well, or good.
This way of thinking about health is holistic. It demands that we consider the whole of a person’s life, and by that I mean the whole of their present time life (a biopsychosocial approach), and the whole of their life from start to finish. This has at least two consequences. Firstly, it means that all health care must take into consideration, not just objective disease in the form of pathology or lesions, but it must consider the individual patient’s story. No two patients have the same life, and therefore, no two patients share the same experience. With the same disease, two people will experience different symptoms and those symptoms will mean something different to each of them. In addition, each individual will have their own ways of coping, adapting to and dealing with their illness. Health care needs to relevant to the individual who is being cared for.
Secondly, it means that health care interventions will alter the experience and course of a person’s life, but they do not, ultimately, prevent death. The overall mortality for human beings is 100%. We do all die. But much of contemporary health care is predicated on the basis of death avoidance. We are bombarded with claims about “life-saving” medicines and Public Health policies which claim to reduce death rates. Statins, for example, are even promoted for healthy people, to reduce their risk of death from heart attacks and strokes. Whilst nobody would really like to have a heart attack or a stroke, no-one is asking the question, what do people who would have died from a heart attack or a stroke die from instead? The focus is on death avoidance. People are classed as being “at risk” – at risk of dying from disease x. But to make an informed choice about a treatment don’t you need to have an idea of the possible and likely consequences of that treatment? To say a treatment reduces your risk of dying from disease x is all very well, but it doesn’t say much about whether or not you’ll experience a life of greater flourishing. Especially if you develop another more disabling, painful condition instead. The logical extension of this death avoidance thinking is to try to avoid death from all causes. For example, some doctors and scientists have promoted what they call the “polypill” – a combination of drugs all in one pill, which, if taken by the whole population (or in this case the whole population over the age of 50), would significantly reduce the death rate from cardiovascular disease. Well, if you don’t die from cardiovascular disease, what do you die from? Cancer? Nervous system disease? Liver disease? Blood diseases? There’s no way to know of course but isn’t it true that it will be something else? Or do you think healthy people die disease-free?
It’s likely that a person will fight hard for life at all times. (Well, not everyone, as Dylan Thomas wrote, “Do not go gentle into that dark night. Rage, rage against the dying of the light.” exhorting his father to fight for life at the end of his life). Around a third of all health care expenditure is on people in the last year of their lives. (see New England Journal of Medicine 1993:328:1092-6 for example) You might hope to live three score years and ten, and if you do, you can expect that most health care you receive will be in your last year of life. Think of it this way – assuming 70 years of life (I know, that’s quite an assumption!), one third of your health care will be in one seventieth of your life and two thirds for the other sixty-nine seventieths. Why is that? Because you can expect to flourish for 69 years and suffer for one? I’m not sure that’s most peoples’ experience. If health care is about improving life as opposed to merely trying to avoid death why don’t we direct more of it to life instead of death avoidance?
It seems that our so-called “health care” isn’t focussed on health at all. It’s focussed on death avoidance. That was the goal of the alchemists – the elixir of life which would produce immortality. But that’s a myth isn’t it? Shouldn’t we have health care which is more realistic? After all, if we do address illness holistically, reducing suffering, encouraging healing, resilience and growth, aren’t we likely to also increase the length of life? Might that not be a better way to avoid “premature deaths”?
Maybe we should be concentrating on increasing health, in a eudaimonic sense, instead of concentrating on avoiding death, which, realistically, is ultimately impossible.
Such a great point…. I think people mist that point completely. I think we are so conditioned now to taking the next pill.. rather than focus on overall lifestyle that its downright sad.
Did you see the interesting new research in cancer spreading how there is a missing strand in the DNA which allows it? So really cool. They think they really have something there!
http://www.mja.com.au/public/bookroom/2006/dwyer/dwyer.html
Will the last well person please stand up ……
Does universal statin prescribing reduce cardiovascular incidents ? Kendrick thinks the whole theory is suspect…..
http://www.thincs.org/Malcolm2006.htm
Life is living and the ‘healthiest’ people i know are curious,engaged and ‘outraspective’ …often they have things wrong with them but prefer to ‘keep’ them. My father is 78 and most things that the Dr has put him on to ‘improve’ his health have made him feel much worse –especially statins.Cycling, art and smoking his pipe seem to help a lot more !
ian
i have just had a look at mark vernon’s blog and the last post reviews this book –it looks very worthwhile and adds to your post . I will be buying it!
ian
Bravo! Excellent thoughts. This should be read by all, most of all the medical professionals. This form which we inhabit for this part of our journey is a temporary vessel which will die. If we could understand that the death of form is not the end then we would not live in avoidance of death, rather we would live in health as you have so eloquently stated.
[…] researchers highlight the value of interventions which make living better. I recently wrote about death avoidance and made a plea for health care which is focused on living. This little trial is a piece of that […]
Bob,
Thanks for the reference to the New England Journal of Medicine. I thought the number was much higher, ninety percent. But you know how it is with numbers. I’d like to see more discussion around what it means to live a life without avoiding that end point. I wonder if death could be a celebratory event for those of us left?
I have this image of life like great lungs breathing in the newborn and exhaling the dying. Even as a small boy, I wondered at life going on before I was born. Don’t we practice dying every time we surrender to that oblivion we call sleep?
I had to laugh at Ian Stevens’ comment of his dad smoking his pipe.
And on the subject of eudemonia, I read a book by Adam Phillips called Going Sane. I think it has another title in the UK. We have ideas about what insanity is but not sanity. He has a stab at it though. “The sane are the people who can accurately calculate what they need and want…”
So how much life is enough? That quantity will be different for everyone.
The question i would like to ask is regarding function. In evolutionary terms it is the function which brings about the organism. The function of seeing brings forth the eyes etc. So does the life of an organism have a function? We know we have been born and we know we are to die and that is all we can know. Yet there is still this question of function, the definition of function is “action, activity, performance and adaption. It is an expression of motion and change or something that is dynamic.”
Life is something that is dynamic and active. There is constant change, growth and development. It is not a quantifiable experience it is just experience. Watching children grow and play with their grandparents i am struck by the differences in their dynamic. The young hoon around as if there is no tomorrow and everything is new and changing. And the aged are now on the surface less mobile and aware of their tomorrows. Yet each has their function. The young to bring their energy and the old their knowledge and wisdom.
Within this ever changing dynamic there is hope and there is tragedy and yet there is still always function. What is that i wonder???
Well Paul, a really thought-provoking question! I’m going to suggest you explore the work of Giles Deleuze. The work he did, especially with Guattari, really wrangles with these kinds of concepts. It’s from Deleuze that I take the “becoming not being…..” at the top of my blog. He really does change the focus of our enquiry from entities (including organisms) to phenomena and forces – which, it strikes me, is pretty close to your use of the word “function”.
Thanks for your comment
Hi Bob,
Thank you for the suggestion. I will endeavour to to take up your suggested reading. It is always intersting to have an opportunity to trade thoughts with other open minds. I have worked as a psychiatric nurse for the last twenty years along side studying to be a lay homeopath for the last 10 of those. It is an area that tests ones own understanding of what is a “real” experience. There are a great many increadibly compasionate people who follow the view that these abstract thoughts are a derangement and therefore need to be removed. It would be so much more beneficial to all concerned if there was more emphasis placed upon an understanding of the relevance of peoples experiences. The curtan between madness and sanity is but a thin veil and we are all more able to pass through and experience both sides than we would perhaps like to acknowledge.
Regards
[…] The neurologist when discussing differential diagnoses of certain chronic neurological diseases, mentioned a particularly nasty, completely untreatable, progressive, degenerative disease and, again in a throw away remark, said you could hope the poor patient might be released by a heart attack or something before it got to this stage. I’m not arguing that preventing heart disease is a bad thing, just that it’s not an informed choice to make if you don’t consider what alternatives might then be your more likely future. (that would take me off down my hobby horse about the stupidity of basing health care on death avoidance, but I’ve done that elsewhere!) […]