Family Practice Vol. 18, No. 6, 647
© Oxford University Press 2001
Book Review |
The tyranny of health: doctors and the regulation of lifestyle.
Michael Fitzpatrick. (208 pages, £9.99.) Routledge, 2001. ISBN 0-415-23572-3.
Primary Care Programme, King's Fund, London
Much of the first half of this stimulating book is dedicated to detailing the negative impact of various health scares and rubbishing the evidence underpinning much preventive medicine. But some of the coverage is unbalanced and I found it unconvincing. The second half of the book explores the politics of health promotion and is much more interesting. Michael Fitzpatrick presents his own diagnosis of the crisis facing modern medicine and argues for the re-establishment of a clear boundary between medicine and politics so that doctors can leave the well alone and concentrate on treating the sick.
Fitzpatrick gets into his stride analysing the radical roots of the new public health movement. The products were utopian declarations in WHO or UN conferences in exotic locations such as Alma Ata. In this country, a growing preoccupation with health inequalities was reflected in the Black Report and led eventually to the first national health strategy, ‘The Health of the Nation’. Conservative critics challenged its authoritarian character and denounced it as ‘health fascism’. But far from provoking public hostility, this right wing critique fails to explain why health promotion was received with remarkable passivity, if not outright enthusiasm.
Meanwhile, back at the surgery, doctors face the consequences of the medicalization of personality: enormously increased workload and failure to meet expectations raised by the indiscriminate application of medical labels to diverse forms of distress. Has healthism become the new religion expanding to fill the moral vacuum resulting from the decline of the churches and the increasing fragmentation of society?
The analysis of the crisis of modern medicine takes a traditional trajectory: the nihilistic critique of the 1970s, anti-professionalism, the rise of complementary medicine, etc. But it is for the medical profession's own responses—changes to medical education, clinical governance and revalidation—that Fitzpatrick reserves most disdain. Much of his analysis is astute. The growth of the ‘audit society’ may ultimately be self-defeating, as reflected in the plethora of new regulatory bodies, creating an inflationary spiral of distrust in ever more remote sources of reassurance. But his vision is also nihilistic, for he seems not to understand that there can be no going back.
Fitzpatrick's plea is for a form of medical practice that treats illness rather than regulates behaviour and he puts the autonomy of the individual and the privacy of personal life before the imperatives of political correctness. The sweep of the final chapter is appropriately grand, but his challenge to the tyranny of health amounts to retrenchment—withdrawal from a wider social role, a more restricted definition of medical practice with a reaffirmation of its scientific basis. The trouble is I don't think that it is necessarily what our patients want and I don't think it ever has been. Some patients may appreciate the benefits of what he judges to threaten their autonomy; many more would rather make those judgements for themselves. His arguments are quite as illiberal as those he reviles.
On the cover, Bruce Charlton, another great iconoclast, commends the book as "calm, reasonable ... in tone and style". Up to a point, Lord C. But "compelling" —utterly. I violently disagree with many things Fitzpatrick has to say but this is a wonderful, challenging read. Incisive and well written, cogently if not always consistently argued. All those who wonder whether GPs can safely be allowed to run the new NHS should read it.
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