CLASSIC TEXT: THE UNMASKING OF
MEDICINE
Classic Text: The Unmasking of Medicine
by
Ian Kennedy, London: George Allen & Unwin, 1981, based upon The
Reith Lectures, Unmasking Medicine, pub. The Listener, Nov to Dec
1980.
Professor Sir Ian Kennedy, a professor of Law, and
member of the GMC, is Emeritus Professor of Health Law, Ethics and Policy
at University College London, and a former president of the Centre of
Medical Laws and Ethics. He has held numerous posts, most recently
chairing the Public Inquiry into children’s heart surgery at the Bristol
Royal Infirmary; he is currently Shadow Chair of the Commission for
Healthcare Audit and Inspection, (CHAI). In 1991, he published “Treat
Me Right: Essays in Medical Law and Ethics” [Nov 1991], and in
2001 Principles of Medical Law, with Andrew Grubb. He has been
described as “the expert outsider…a lawyer, academic and
ethicist…prepared to think the unthinkable if it stands up to intense
intellectual scrutiny.” [Guardian, 25 June 2003]
Despite its age, The Unmasking of Medicine
remains a classic that repays study by health professionals. Kennedy
mounts a brilliant and fundamental critique of medicine. Partly inspired
by Illich’s Medical Nemesis [1977]—translated into a British
context, and considerably widened in its remit—his sweeping thesis, was
dismissed by some as unhelpful, interfering by a medical outsider, while
praised by others as an invaluable spur to timely public debate.
Infinitely richer, profounder, and more subtle, it leaves Illich in the
shadows.
The book’s first chapter identifies the medical
profession as enslaved to a spurious definition of disease, which
disfigures every conception of sickness and treatment. Though doctors are
probably too busy to contemplate such matters, there is some
acknowledgement in primary care that the definition of disease is
inadequate. Even with the psycho-social approach, including employment
factors, disease remains an insubstantial category for the individual
patient, while doctors find it a convenient source of medical power.
Kennedy’s second chapter pinpoints scientific
reductionism as ‘the wrong path’ medicine has taken. He criticizes
excessive dependence on high technology. Two decades on, we have even more
science—medicine retains an exclusively reductionist agenda. He contends
that doctors’ decisions are not scientific or medical, but often social
and political in nature, and the requirement of an exclusively scientific
training for medical practice as ludicrous. Kennedy urges that medical
science should serve patients, not health professionals; that medicine is
not a matter of weighing objective scientific facts; each diagnosis and
medical judgement includes an ethical, social and political dimension.
Medical education has been broadened since 1981.
His third chapter depicts sickness prevention as a path
insufficiently invested in by the medical profession, governments or
others. He castigates hospitals as wasteful and excessively distorting
medical teaching and research. Since Kennedy, patient awareness and
involvement in health measures have dramatically increased. Prevention,
community care, and health education, have all made steady progress.
Identifying disease co-factors and good screening have improved; helpful
governmental interventions like increasing tax on alcohol, mandatory
seatbelt laws, reducing salt and sugar in foods, banning smoking,
encouraging exercise, recommending low-fat diets, or the whole lifestyle
movement; improvements in housing and education—these have also
contributed.
The fourth chapter explores the ethics of medical
decisions and how patient involvement might be increased; at that time,
the doctors dominated consultations, rather than the negotiated
partnership Kennedy envisaged. Kennedy’s argument that doctors made
ethical decisions on medical matters without adequate consultation with
patients and relatives, called for greater participation, and this has
changed enormously in the last two decades. Today, there exists a more
genuinely balanced partnership between doctors and their patients. Though
some patients prefer the reassuring patriarchal approach, increasing
patient involvement has been largely forced upon the profession, e.g. the
empowerment of women during childbirth, concerns over tranquillisers, and
HRT; diabetes, epilepsy and asthma treatments all benefit from greater
patient input. Though chronic understaffing can create a hurried and
doctor-centred approach to patients, [‘cattle market’] longer
consultations enhance patient satisfaction and reduce prescribing, though
requiring more doctors.
The medical profession has rolled out a red carpet of
partnership, negotiated treatment options and ethical aspects of medical
practice to their patients since 1980; changes which Kennedy identified as
desirable. Some changes over the last two decades—such as diet fads and
vitamin supplements—might be due to globalisation and mass consumption.
Others involve government policies; such as the Wanlass report [2002]
highlighting chronic under investment in UK health.
Since 1981, patient power has been enhanced; patients
accept a contributing role in disease creation and mitigation; people
choose healthier lifestyle options that were unperceived in the sixties
and seventies; they take greater responsibility for their own health.
Examples include marathons, jogging, gyms, seatbelts, airbags, healthier
diets, cycling helmets, anti-smoking campaigns, with many patients
increasingly viewing themselves as health consumers, who exercise their
power to select treatment options and improve their own health. Shifting
fashions in society also underpin such trends, which cannot be ascribed to
Kennedy’s critique.
Many more citizens today are involved in making their
own healthcare decisions, whether in lifestyle, or fitness terms, in
dietary considerations, and in choosing relaxation, seeking holistic
therapies, etc, than in 1980. The map of medicine has changed appreciably
since Kennedy, but not necessarily because of him. Many changes have
occurred for entirely different reasons. The decline in industrial
diseases, improvements in nutrition and air pollution, for example, and
the decline of smoking cannot be attributed to Kennedy, or even to his
influence; they flow from socio-economic and political changes.
The fifth chapter concerns psychiatry, and the social
and political consequences of a person being given a ‘mental illness’
label. This field remains riven with conflicting views about the causes of
mental illness. If anything, the pharmaceutical domination of treatment
has increased in the last two decades, and psychiatry appears to have
regressed into a conservative, biochemical approach to mental illness that
remains open to criticism.
In the sixth chapter, Kennedy portrays patients
as consumers in a medical market who are short-changed and deserve better.
Patient consumerism has obviously come of age since 1980. There has been
greater acceptance of medical liability and compensation payouts for
medical errors. The concept that health is something to be purchased has
certainly gained ground [e.g. BUPA]. The ‘natural health’ movement is
part of this too. GPs have rationed budgets to maintain high levels of
generic prescribing. A seventh chapter looks at geriatric medicine.
Kennedy’s contentious and often abrasive tone
engendered heated reactions in the medical press, disclosing their
sceptical grasp of his alleged focus on debating ideas. Yet, his work
pioneered the airing of many fundamental issues in medicine, which had
never received such exposure to critical public gaze before.
Improvements since Kennedy include the rise of CAM,
narrative, complexity, and patient-centred dialogue, increased patient
choice—an emergent medical pluralism, which has weakened the
authoritarian posture of doctors, which Kennedy condemned as ubiquitous.
However, doctors’ role as relentless ‘pill-pushers’ to society, of
being preoccupied more with treating spurious disease labels and fixing
parts in preference to a more holistic approach—these issues are
probably as rampant as ever. Kennedy’s charge of adopting a narrow ‘fix-it’
mentality, rather than tackling the wider causes of sickness in society,
still broadly applies. Medicine retains its materialistic and reductionist
construction of sickness and the only shift evident on this critical
point, is in the holistic therapies.
Dismissive of holistic dimensions of sickness, medicine
appears stuck in a molecule-dominated groove, with the doctor pressurized—now
as then—into doing something to a ‘disease entity,’ with what
Kennedy calls ‘pseudo-scientific wizardry.’ For Kennedy, doctors are
monopolistic and too reluctant to accept responsibility for the control
they exert over people’s lives; too preoccupied with treating the ‘disease,’
not the patient. Their precious unquestioned professional autonomy seems
intact. Kennedy stresses less science and more caring; a concern for
lifestyle factors impacting on health, and resolving the continuing health
inequalities between social classes. Therefore, negligible progress has
occurred in these key areas of Kennedy’s critique, with medicine
resistant to change. In snapshot, Kennedy portrays doctors primarily as
servants of society, yet they prefer to see themselves as trained
professionals responding to the needs of individual patients.
I gratefully acknowledge documents kindly supplied by
Gregory Vlamis and valuable proofreading feedback from Dr Jim Hardy.
Reviewed by Peter Morrell, Hon Research Associate,
History of Medicine, Staffordshire University, ST4 2DE, UK
The book gets a 5 star rating. [1389 words]
Acknowledgement
I acknowledge my
grateful thanks to Gregory Vlamis of Chicago for supplying some
invaluable source material without which writing this essay would have
been rendered much more difficult.