When we hear the words “tyranny of health” these days, it’s usually a reference to the tyranny of a government imposing unwanted health care on its citizens. It brings to mind images of protesters carrying signs that denounce the “socialism” of Obamacare.
As recently as 1994, however, the tyranny of health had a different meaning. That’s when Dr. Faith T. Fitzgerald published an article in The New England Journal of Medicine with that very title. What tyranny of health referred to – and what Dr. Fitzgerald’s readers readily understood at the time – was the idea that doctors should coerce their patients into being healthy. She objected to this increasingly prevalent attitude that expected the medical profession to be a combination of nanny and big brother.
Healthy lifestyles and the definition of health
The article begins with a reference to the recent emphasis on promoting healthy lifestyles: “Once upon a time people did not have lifestyles; they had lives.” (In 2010, it’s easy to forget that we did not always have “lifestyles.”) Dr. Fitzgerald then reminds readers of the 1946 definition of health from the World Health Organization (WHO): “A state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.”
This has become known as “wellness,” a highly desirable state. A well or healthy person is one who is not only physically whole and vigorous, but also happy and socially content. What a good idea! It is generous with implied promise, and many of us in the medical profession eagerly switched from being doctors and nurses (who take care of disease and infirmity) to being health care providers, engaging ourselves in a variety of efforts to make people both physically well and also happy and socially content. We broadened our horizon from physical problems to character flaws, poverty, crime, unhappiness, and even unattractiveness. Internal medicine, surgery, preventive medicine, family practice, pediatrics, neonatology, and especially plastic surgery, genetic engineering, prenatal diagnosis, nutrition, and psychiatry promised potential perfection.
What had happened by 1994? Both the medical profession and the public had gone from regarding the WHO’s definition of health as an ideal – something difficult to attain but worth striving for — to believing that complete physical, mental, and social well being was the undisputed meaning of health right now.
Having accepted the view that health should be a perfect state of wellness, we went on to declare that it was. But if one accepts the idea that physical vigor and emotional and social contentment are not only desirable, but also expected, there is a problem. If health is normal, then sickness and accidents are faults.
Patients should stop their “selfish” misbehavior
This is where the tyranny comes in. Not only do doctors become responsible for “correcting” the behavior of their patients when that behavior interferes with health. But patients become guilty.
If health (physical, mental, and social) is normal and the failure to be healthy is someone’s fault, then when a person becomes ill he or she may have done something wrong. If we root out that wrongness, or better yet, prevent it, we can restore that person to normal health and can benefit society. In effect, we have said that people owe it to society to stop misbehaving, and we use illness as evidence of misbehavior.
Fast forward to 2010 and we find that many people – spurred on by political rhetoric — fail to see anything wrong with this attitude. “Tyranny of health” has morphed into “personal responsibility.”
Here’s a quotation from Sarah Palin’s 2008 State of the State Address, when she was governor of Alaska (emphasis added):
Let’s take personal responsibility in all areas of life — including health. … Our choices often lead to heart disease, diabetes, underage drinking, drugs, violence, and abuse. Soaring health and public safety costs are sometimes unfairly passed on to others. But more importantly, by ignoring or accepting selfish choices that cause the abuse, children, families and entire communities are destroyed.
Personal responsibility as the backbone of prevention
The “personal responsibility for health” mantra comes not just from conservatives these days. It has merged with the concept of prevention. Not only will preventive measures – diet, exercise, diagnostic testing – keep everyone healthy. They will save the nation from the bankruptcy threatened by escalating health care costs.
Unfortunately prevention is as much an unrealistic ideal today as it was when the WHO defined health in 1946. Dr. Fitzgerald herself has written on this subject: Preventive Medicine and the “Road to Hell.” A recent issue of The Atlantic has an article on Dr. John Ioannidis, author of Why Most Published Research Findings Are False, the most downloaded technical paper from the journal PLoS Medicine. The research findings Ioannidis discusses include many recommendations for preventive measures that have now fallen by the wayside. Dr. H. Gilbert Welch explains the complexities of prevention in his excellent book Should I Be Tested for Cancer?: Maybe Not and Here’s Why.
Prevention as the solution to our health care problems is a complex topic. There’s a great deal to recommend prevention, of course. But there’s also the potential for abuse, as Dr. Fitzgerald is well aware. When we insist that individuals who fail to practice “healthy lifestyles” are the source of our health care problems, this leaves us free to ignore the social, economic, and environmental factors that make health possible or difficult.
I’ll simply conclude for now with these wise words from Dr. Fitzgerald’s 1994 article:
We must beware of developing a zealotry about health, in which we take ourselves too seriously and believe that we know enough to dictate human behavior, penalize people for disagreeing with us, and even deny people charity, empathy, and understanding because they act in a way of which we disapprove. … [W]e health care professionals are no more competent to treat social distress than other citizens. We cannot fix everything (though we do some things marvelously well), nor can our patients — no matter how intelligent or attentive — prevent all disease and death. … If we redefine health, I hope we can discover a definition that does not include a medical or social mandate to control people’s behavior for the sake of their mortal bodies; this would seem to me particularly compelling in a nation founded on the belief that one should not legislate behavior even for the sake of the immortal soul.
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Image source: Kansas Watchdog
Dr. Faith T. Fitzgerald, The Tyranny of Health, The New England Journal of Medicine, July 21, 1994, Vol. 331 No. 3, pp. 196-198
Faith Fitzgerald, MD, Preventive Medicine and the “Road to Hell,” ConsultantLive, August 1, 2003