“Put yourself out of business"
"Put yourself out of business"I was taken aback by the title of Dr Faith Fitzgerald's editorial"Preventive Medicine and the 'Road to Hell'" (CONSULTANT,August 2003, page 1055). I have lived by the dictumof the late H. Houston Merritt (professor of neurology atColumbia College of Physicians & Surgeons) that "the objectof medicine is to put yourself out of business." This meansthat if we are treating a certain disease, we should work tofind a way to prevent its occurrence. Sir William Osler wasanother physician who held the preventive aspect of medicinein highest esteem: "upon correct knowledge depends the possibilityof the control of disease, and upon our views of itsnature the measures for its prevention and cure."1 I believethe future of medicine lies in prevention. Thus, I found itsomewhat shocking to see the word "prevention" teamedwith the phrase "road to hell."-- Richard S. Banfield, Jr, MD
New Canaan, Conn
"Shed our delusion that we are saving lives"Science continues to eliminate many of the ghosts and demonsthat arise from the darkness of ignorance. The application ofscience in modern medicine has been responsible for phenomenaland, at times, miraculous advances in the relief of humansuffering. Our "sin" is not that we have found ways to cast outdemons and reduce physical suffering but rather that we havecome to believe that the tools of scientific inquiry will providean ultimate solution to our deepest and uniquely human concerns--which, in my opinion, center around the search for themeaning of our lives and for our place in an infinite universe.We must begin to shed our delusion that we are savinglives, for there is no life that can be saved from its ultimatefate. "Saving" lives is the concern of artists and the clergy,not of scientists. What we are really doing is prolonging lifeand reducing physical suffering.If trying to live forever (or at least to extend life as longas possible) is the purpose of our life, then anything we do toprolong this life is good. Yet we offer our patients the promiseof better "health" and longer life by frightening them with demandsthat they become intensely concerned about the fatefulprophecies associated with cholesterol levels, cancer screening,and genetic testing.It seems very clear to me, however, that living forever isnot the purpose of life. The primary advantage of a prolongedlife is that it provides an opportunity for the reproductionof new life. The next advantage is that it provides anopportunity to find release from the fear of death. Once releasedfrom this fear, a person is free to explore the mysteriesof the universe.-- Thomas Richards, MD
Dr Banfield and Dr Osler are, of course, correct.I wish it were possible to prevent all disease anddeath--but we can't and won't, even in a futurerich with scientific miracles. My argument wasnot against preventive medicine but againstthe means we now use and the goals we pursue: universalgeneral mandates based on selected cohort studies, righteousexhortations and fearful prophesies to "misbehavingpatients," the imposition of guilt and shame if one does fallill, and the delusion that death as an end point is a validmarker of our success or failure as physicians.Many in preventive medicine concur that the goal oftheir work is not just to prolong biologic life and preventdeath (impossible on the face of it) but to reduce sufferingand maximize the fullness of each patient's life. To do thiswe shall have to work harder to determine, for eachpatient, what constitutes "desired life" and how much ofthis we can realistically try to ensure through preventivemeasures. We must, as a profession, admit that only ourpatients themselves can tell us what their individual goalsare. Then we must work to advise them as best we canon how they can try to achieve these goals, detailing therisks of their compliance as well as the possible benefits.Dr Richards speaks in his letter of the deeper meaning ofhuman life, and it is that which we honor when we fullyand honestly inform our patients of the limitations as wellas the aspirations of our profession.-- Faith T. Fitzgerald, MD
Professor of Medicine
University of California, Davis School of  Medicine
Osler, W. The pathological institute of a general hospital.
Glasgow Med J.