COMMUNITY HEALTH STUDIES VOLUME IV, NUMBER 3 , 1980

TECHNOLOGY FOR HEALTH OR TECHNOLOGY FOR PROFIT

To save a lot of preliminary argument, I’d like to make two basic assumptions - first, that medical technol- ogy if used properly is very beneficial for the control of individual illness and, secondly, that the generation of excessive financial profit from medical technologi- cal interventions is generally, but not universally, regarded as morally wrong and economically undesir- able. I ’ l l concentrate on some aspects of technology-for-profit especially from the medical point of view and will start by trying to trace origins of certain practices and beliefs that influence contempor- ary issues. This seems relevant because there is a wide gulf developing between those who use the technology and those who are trying to assess its effectiveness and to regulate it. Inevitably, neither side really under- stands what the other is trying to do as can be ascertained from the correspondence columns of leading medical journals. In fact, the situation is starting to resemble other contemporary areas of social conflict invdlving such technologies as nuclear power, or the use of toxic pesticides and herbicides.

Long before science produced any health-related solutions there was a well-developed theme of exploiting the antecedents of technology for personal gain. For instance the 17th century poet, Matthew Prior having just paid an enormous fee for multiphasic blood-letting while recovering from a fever wrote a bitter verse which started:

Cured yesterday of my disease I died last night of my physician

Added to this contemptfor ineffectual treatment and costly doctors was cohfusion created by the vitriolic polemics between adherents of different medical dogma. At the end of the 17th centuIy the Florentine physician Bertini reviewed the impact of all these factors on the health serices of the city states in Renaissance Italy. He concluded “Never has medicine been so widely studied as in the present century and never has it fallen into such disrepute as in these days when, because of so many new findings, it should instead have gained in public esteem”. In essence, that is a central assumption on which 300 years later Illich based his onslaught against technological medicine and likewise, to some extent, Richard Taylor in his far more analytical and persuasive Medicine out of Control - which he subtitled the Anatomy of a Malignant Technology. In fact, only for a very brief historical period has medical technology been overwhelmingly regarded as benefi- cial to health - approximately from the late 1920s to the mid 1960s.

The first critical distinction between the non- effectiveness of medical interventions and misuse for

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personal profit appears to have been made by George Bernard Shaw in 1906. In the preface to his play, The Doctors’ Dilemma, Shaw mounted a relentless attack on scientific medicine and medical practice. He was particularly hard on the fee-for-service system for paying private doctors that we so carefully preserve 74 years later in this country. Among other things Shaw observed with reference to surgeons, “the more appalling the mutilation, the more the mutilator is paid”. In our medical system that becomes the more extensive the diagnostic or therapeutic intervention, the larger the medical benefit. Shaw noted also that the sixpenny doctor with his low prices and rapid turnover of patient visibly made much more money than the eighteen-pence doctor. Translating that into our contemporary scene, it is, I suppose, a fact that those doctors who command the means for rapidly carrying out numerous low unit-cost diagnostic procedures - like pathologists and radiologists - are in a position to earn, if they so wish, visibly more than those who don’t command such resources, such as the general physician or general oractitioner.

Shaw was a socialist and reckoned that most problems about doctors would be solved when the public came to their senses and voted in a socialist government who would put the doctors on salaries. Although he thought that this would remove the main incentive to dangerous and greedy practices, he did not foresee the oncoming complexities of the medical technological revolution. Yet the seeds of the future were there in one of the characters in his play, Sir Ralph Bloomfield Bonnington. This character rep- resented a vicious lampoon of the contemporary London physician-experimentalist Sir Almroth Wright. Wright made useful contributions to the management of infectious disease, trauma and disorders of human blood coagulation and there is no doubt that he generated a vast income from private practice by, as Shaw puts it, following up one of Metchnikoff‘s more suggestive biological romances. But Wright also recycled much of his wealth into medical research. Among other things he endowed the unit in St Mary’s Hospital where Fleming later discovered penicillin.

These early episodes of; technological develop ment by Wright and other eminent doctors had an enormous impact on the future ethos of medicine. Their exploits coincided with acceptance of Bernard- Flexner principles of scientifically-based medicine and medical education, the introduction of insulin and other useful drugs and the beginnings of a full scale medical technological industry. I might add that, according to Reiser, as early as the 1920s there were complaints from experienced physicians in US hospitals that patients were being referred , for

232 VOLUME IV, NUMBER 3, 1980

unnecessary laboratory tests before they had been interviewed or examined.

These pioneering doctors had their achievements romanticised by what passes for official medical history and thus they were set up as examples of selfless and altruistic devotion to the advancement of medical science. So a goal was created to which every bright young physician should aspire. In fact, as part of their training, specialist doctors were increasingly encouraged to undertake scientific research which Konrad Lorenz once defined as play carried into adult life.

Thus medical research became institutionalised and it is well worthwhile following its evolution because it demonstrates rather clearly some important and deeply-ingrained values of the profession which are pertinent to the present issue. The initial impetus was so strong that when the profits of eminent doctors and other benefactors could no longer pay for increasingly complex resources, it was assumed without question that the State should pick up the bill. Again, without question, governments obliged, with strong public support.

The first challenge came from a book, The Double Helix in which Jim Watson related how he and Crick won a Nobel Prize in Physiology and Medicine by brainstorming in the pubs and on the tennis courts of Cambridge, using somewhat devious means to extract vital crystallographic information from col- leagues in London and being spurred on by a great desire to beat Linus Pauling in working out the correct structure of DNA. This totally realistic but ungentle- manly behaviour dented the romantic image of medical research but when the uproar died down the real crunch came. Governments decided they could not continue to escalate funds for medical research and at the same time complained that too little research was being done on what were regarded as major national health problems. This has lead to recumng conflict between authorities who wish to direct research towards what they regard as useful ends and the researchers themselves who argue that real advances are made only by persons highly motivated towards solving some problem which excites their curiosity. The latter view was sup rted very strongly by the medical research establisEent. In 1971 Sir George Pickering wrote an eloquent defence of this stance in the British Medical Journal - a paper entitled “Science for Pleasure or Science for Profit”. To Sir George science for profit meant being contracted to solve some problem which the contract- ing authority wanted solved. In his opinion, nothing of value could come from this variety of research.

One can be sympathetic with this restricted point of view partly because so many of the useful discoveries in medicine have come from non-directed people driven by their own curiosity and partly because of some spectacular failures in government- directed research, for instance, with the hundreds of millions of ear-marked dollars that produced nothing useful in President Nixon’s War on Cancer. But new

sorts of questions are now being asked - is this technology effective? Is it being misused? Can we afford it: So here we have a divergence, the parting between the traditional medical approach, as exemplified by Pickering, and the newer challenges. Hence the need for new funding mechanisms, difficult when budgets everywhere are being constricted, and the need to develop new research resources in order to replace the rhetoric with some information.

The same values that guided medical research were implanted into main-stream medicine. It became apparent that many of the new technologies, if used properly, were very effective for curing or patching up sick people, prolonging life and reducing pain and disability. That these technologies did nothing to reduce the incidence of disease and disability was overlooked for a long time. Government subsidies increasingly met the cost of technological medicine. For a while there was no dispute about this or concern over its extent. In fact this apparent non-concern with financing health services was one of the reasons why Sir Theodore Fox felt so warmly about the Australian scene when he wrote about Medicine in the Antipodes for the Lancer in 1966. He was. of course, deluded because in those days all financial aspects of health care were kept off the agenda of governments and fixed up behind the scenes. Actually during the decades when the benefits of technological medicine were accepted uncritically, the costs were a taboo subject within the profession. The remuneration of doctors surfaced during the 1968 federal election campaign and has been prominent ever since. Yet the financing of technological resources still has elements of a taboo subject among large sections of the practicing profession.

When the new technologies were sufficiently established they naturally became a commercial proposition. Thus arose the medical-industrial com- plex almost rivalling in power and complexity the military-industrial one and producing an enormously complicated system of symbiotic relationship between the manufacturer of medical technology and those who use it.

The rise of an industrial base added a new dimension to technology for profit in the capitalist economic tradition. The impact on medicine can be interpreted in different ways. Richard Taylor provides a compelling and well-documented case for technological determinism / how the creation of new technologies stimulates attempts to fit them into the medical care system. What often happens is that new instruments and techniques are seen to have potential for management of disease affecting some usually localised part of a bodily system. A group of specialists will master the innovations, will develop a new technical language to explain their findings, and usually will create a professional association for devotees with its own specialist medical journal. So a new sub-specialty is born. Other doctors not being able to fully understand or cope with the intricacies of the new specialty feel they have to refer cases to it -

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and the sociology of teaching hospitals strongly encourages that.

Thus a new group of superspecialist doctors has emerged who owe their prestige and their livelihood to control of a new technology. There are some worrying implications. The superspecialist works in a very narrow area which reduces his capabilities to detect and manage complex medical problems, only part of which turns up in his small area of interest. If his livelihood depends on his skills there are pressures and indeed incentives to extend the limits of the new technology beyond what it is useful for. These developments have caused an extraordinary change in the role of the general physicians. Formerly they planned medical regimes from information directly obtained from patients but now they increasingly receive information indirectly from machines and superspecialists who frequently take over manage- ment of the patient.

This concept of technological determinism is distinctly unpopular within the medical profession who argue that it is nothing of the sort - that the exploitation of new technologies is part of a process of continuing improvement in strategies to combat disease. But there is another angle to it. Consider the companies who develop and retail the new machines. For instance the Technicon Corporation, a multina- tional company which nearly 20 years ago supplied many of the first generation multichannel autoanalys- ers to the laboratories of this country. When competition grew strong, the Corporation expanded into laboratory data-processing systems and then into special whole medical unit design and installation. So by anticipating institutional expectations, and creating new marketable commodities the Corporation influ- ences one pathway of technological expansion and by doing so continues to maximise its profits. This seems to illustrate another aspect of Milton Roemer’s general law of medical care utilisation -that any new facility that fits the publicly accepted norms of advanced medical systems will rapidly be adopted and utilised to its full capacity.

So strong is the scientific dogma of medicine that even those who are aware of its failings prefer instinct to logic when it comes to certain decisions. This was well put by the late John Read, who was the first medical establishment figure to provide a critical and informed view of technological medicine in Australia. Writing in the late 60s he was concerned among other things about dehumanisation in special hospital units and the emerging problems with coronary care. Despite his misgivings John Read wrote to the effect that when he had his severe coronary, to hell with tender loving care, he would want to be hooked up to all those life support machines in a coronary care unit. It is the strength of such beliefs that seems to me to be constantly underestimated in proposals for technology assessment because to people of great faith like doctors there are always ways of getting around the rules.

I am constantly aware of all this in relation to the high technology area of medical genetics. I find

myself one minute agonising over this country’s accelerating decline in obtaining new technology which would greatly benefit a handful of Australians with rare inherited diseases. The next minute I enter into discussions with my health services colleagues on the real and massive problems facing the Australian health care system. In each camp there are totally different objectives, values and ethical beliefs about responsibility and the right thing to do.

The currently rather small area of medical genetics contains several florid instances of technol- ogy misuse. One particularly troublesome area is the improper use of screening kits by the private sector - Rotably for estimating AFP levels in serum of pregnant women in order to detect raised levels which may indicate the presence of a foetus with anencephaly or spina bifida. To cut short a complicated story we in New South Wales are encountering serious problems with this screening system which constitute the precise reasons why maternal AFP screening is banned from private sector use in the United States of America and the United Kingdom.

There is also a very instructive case for those who favour rationing as a measure of limiting the use of high technology. It involves the examination of foetal chromosomes - a time-consuming and labour- intensive procedure, for which reasons it is unprofit- able for the private sector. So the public sector has to provide the resources. It is established that at the maternal age of 35 years there arises an appreciable risk that the woman will give birth to a child with Down’s syndrome (mongolism) and the risk increases almost exponentially as a woman gets older. If done properly by experts the diagnostic technology for investigating chromosomes of foetuses is now safe and reliable and, provided the woman is properly informed, the procedure is universally regarded as valid - and this is reflected by a progressively increasing demand. We and many others have demonstrated that the process is also highly cost- effective in that virtually all couples will opt for termination of an affected foetus thus averting the large medical care and support costs of those defective individuals who survive. So the service was set up for women aged 35 or over but two years ago the State referral laboratory could not handle the growing load of foetal chromosome analyses. So the age of entry was raised to 39 and over. Last year an examination of the maternal ages of those entering the service revealed an inordinate number of women aged 39 or over. The only logical explanation was that the referring doctors were lying about maternal age - and that is of course what we are doing, artificially elevating ages in the 35-38 bracket. We do this because of deep convictions about the benefits of antenatal diagnosis and because we have witnessed the personal tragedies where women aged less than 39 have requested the procedure from some other doctor, have been denied it because of the rules and then have given birth to a baby with Down’s syndrome.

This example raises many serious issues - even if one accepts fully that the state health services face

COMMUNITY HEALTH STUDIES 234 VOLUME IV, NUMBER 3, 1980.

many similar priority claims on its constrained resources. In particular is it right that the State denies an unquestionably effective and reliable service essentially because the established alternative for increasing availability of resources under our system does not operate in this case on the grounds that there is no profit in it for the private sector? Thoughtful people will also note that women once again are involved in a process which involves lying, subterfuge and deprivation of a useful medical procedure - the other instance being, of course, trying to obtain an abortion where the laws are restrictive. To me all this reflects one of the nastier and more uncivilised aspects of our society.

Turning now to those people who pontificate about solutions to the problems created by technologi- cal medicine. They always say medical students should be educated about these problems and especially about the cost aspects. For the last 12 years we have been haranguing the students at Sydney on this very matter, and probably have said all the right things, too. But I doubt if it has had the slightest effect because all the rest of their teaching is aimed at making the student do the very best he or she can for the patient. If this involves profligate use of technology or thousands of dollars worth of drugs - that’s the way it is and there is no compromise. And one can hardly argue against that approach because it is what we would all want when we get seriously ill or injured.

Again this conflict between objectives and values. In more enlightened systems of medical education where the students learn rather than being forced to absorb contemporary wisdom - it may be possible to permeate the entire program with approp riate principles but only if all involved are in full agreement. Even that approach has its danger because the evidence can change quite dramatically over 5 years, as happened, for instance, with the effective- ness of radical surgery and some systems of mass health screening.

What can be done? This brings in further dimensions, notably the economic and inevitably, the political dimension. Australian governments, most of their advisers and the majority of the medical profession seem to favour the status quo with slight adjustments aimed towards cost containment and arresting flagrant profiteering. At each extreme of the medical profession political specrum are groups who favour structural changes. On the left there is the Doctor’s Reform Society which itself contains a fairly wide spectrum of views, but which fit approximately with the policies of the Australian Labor Party. The DRS has a major interest in looking for ways to reduce technology abuse and favours reduction of fee-for- service by creating more salaried positions and a return to the Medibank concept of comprehensive health insurance.

On the right is the General Practitioner’s Society of Australia which is wedded to free market place principles with no government involvement. In fact it

goes somewhat further, supporting the confused notions of personal anarchy espoused by Ayn Rand, where there is no place for altruism nor any role for government in social policy or social welfare.

Academics in the health professions who con- sider the problems of technological medicine like dreaming up profound structural changes but seldom bother to indicate how they should be carried out. However academics try and face problems squarely in order to find the truth - which is the only real justification for their existence. In this context it is depressing to observe how bodies attempting to seek solutions shackle themselves with restricted terms of reference or take evasive action on ideological grounds. Consider the Senate Standing Committee on Social Welfare Report on Evaluation in Australian Health and Welfare Services. In vain one looks through it for guidance on how to assess the validity of enormous governmental subsidies to the private medical sector. Incidentally that report was subtitled “Through a Glass Darkly” -part of a quotation from the first book of Corinthians. If that committee really needs Biblical inspiration may 1 respectfully suggest B more appropriate quotation from Ecclesiastes, 10, 8: “He that diggeth a pit shall fall into it.”

The report of the Commonwealth’s Committee on Application and Costs of Modern Technology in Medical Practice relates some of the adjustments that could tighten up the present system. However, because the report fails to openly acknowledge that the current medical care system is open to exploitation for profit, one has considerable difficulty in sorting out what is recommended to control the resulting cost-abuse. For years in the United Kingdom and more recently in North America all concerned parties openly cover every aspect of the technological debate. Until we stop pretending thatsour health system is not deeply implicated in the problems that concern us - then I can see no useful outcome and the gap will continue to widen between those who use the technology and those who want to regulate its use. It foilows, as Richard Titmuss was always urging, that complex social problems require intense study at the source and only secondarily at their manifestations. With this particular issue we are paying far too much attention to manifestations and coyly evading the source. Professor Clark said a modern coronary care unit is a monument to man’s ingenuity and energy in devising solutions to problems. I am saying that the current Australian medical care system is a monument to man’s ingenuity and energy in re-converting home of those solutions back into problems.

Charles Kerr, Department of Preventive and

Social Medicine, Commonwealth Institute of Health,

University of Sydney

The original form of this paper was presented as a keynote address to the annual meeting of A~sERCWAPHA in Sydney in May 1980.

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