>> So our next speaker -- I'm really delighted that Iona's here and is going to speak to us.
My links with Iona go back a long way.
She's written for the BMJ.
She chaired our ethics committee.
And she's a Royal College of General Practitioners' most recent former president.
She's a woman of enormous intellect.
She writes fantastically well on a range of topics, so much so that whenever I used to want
to mention her columns in my editor's choice column,
I just found myself wanting to quote the entire thing.
So it was rather, rather problematic.
But anyway, I know Iona has been a fantastic advocate, very intelligent, thoughtful,
and with her clinical background completely appropriately concerned about over-diagnosis
and over-treatments, so she's going to tell us what we will do.
Where is Iona?
Here she is.
[Clapping]
>> Thank you very much.
I'm also in a foreign country.
Uh. Um. How do you make it [inaudible]?
[ Whispering ]
>> We're in.
>> No. No, that's not the point.
I mean there is the [inaudible].
Sorry. So over the past two days, we've heard so much about the pervasiveness
of over-diagnosis and over-treatment.
About how deeply embedded it's become in healthcare systems around the world.
Under pinned.
My language is slightly more moderate than Peter,
but I'm probably saying exactly the same thing.
Under pinned by webs of financial imperatives and conflicts of interests permeating
and polluting the pharmaceutical and medical technology industries, medical research
and regulatory bodies, clinical work, payment systems,
guideline production, and national healthcare systems.
What can, let alone will, we do about it?
My argument is that the responses will necessarily be driven by ethics and politics
because they are the only defenses that we have ever had to confront the abuse of power
and money to the detriment of the weak and vulnerable.
The whole discipline of medicine -- every one of us, whatever our connection to medicine --
has colluded in a wider societal project that seeks technical solutions
for the age old existential problems posed by the finitude of life
and the inevitability of aging, loss, and death.
And so often, it is not knowledge that we lack.
What is missing is the courage to understand what we know and to draw conclusions.
The only solutions to these profound existential problems that have challenged humanity
since the beginning of time are to be found in courage and endurance
and acceptance of the limits of life.
They are to be found in thinking differently and more deeply.
And I think one of the wonderful things about this conference is
that I think we've been trying to do that.
I think we have really been trying to do that.
Ray's [assumed spelling] article about the expanded definition of chronic kidney disease
in last month's BMJ treated a typical example of the sort of thinking that is everywhere
within medical discourse and rapidly spreading beyond medicine.
A rapid response was submitted from Koresh [assumed spelling] and colleagues.
Now Joseph Koresh is a highly esteemed professor of epidemiology at Johns Hopkins,
and his very lengthy response included this sentence --
"We find the attitude that disease
in older people should be ignored and untreated to be disturbing."
Now, I find it disturbing on at least three counts that this sentence --
firstly, there was no such attitude in the original paper.
I looked very carefully and I really could not find it.
Secondly, a reduced estimated [inaudible] filtration rate is not a disease.
It's a respect.
And thirdly, and for me most importantly,
this completely ignores the realities of normal physiological aging.
A process in which I am well embarked.
[ Laughter ]
>> It is surely time that we stopping trying
to correct every biometric parameter to the norms of younger adults.
I don't want to be 24 again, thank you very much.
I'm quite happy.
Don't worry, be happy.
And I don't want my biometrics to look like a 24 year old either.
But this approach to numbers is becoming more and more pervasive and it's resulting
in the over-medicating, the extraordinary degree of over-medicating of a whole generation
of older people with all the adverse affects on the quality of life that poly-pharmacy creates.
At every level, this is a story of unsustainable greed.
It's the greed of those living in the richer countries of the world,
forever great in longevity,
and most particularly it's the greed the drives the commercial imperatives of the pharmaceutical
and the medical technology industries in which I think we have
to include ourselves as physicians.
The 2012 world health organization global health expenditure atlas reports
that the OECD countries consume more than 80 percent of the world's healthcare resources,
but experience less than 10 percent of the world's disability adjusted life years.
This must be untenable in terms of both global justice and the world's capacity.
And the problem is that where the OECD countries lead, the rest of the world tends to try
and follow or even to be pushed to follow.
There are at least three serious ethical implications.
The first is the extent of harm to individuals caused by being labeled at being at risk
or as having a disease based entirely on numbers and the unnecessary fear that this can engender.
Because that, in itself, undermines health and wellbeing.
And the second concerns the potential of over-diagnosis and over-treatment
to render healthcare systems founded on social solidarity unviable
because of the escalating costs involved.
And I think we've seen that happening across Europe
and we're also seeing how closely linked under-diagnosis and over-diagnosis are.
Because if you widen the pool of a disease, what you do is take resources away
from those who are most seriously hurt.
Is that really what we want to be doing in medicine?
And the third thing is the marginalization, the way biotechnical activity --
which is what this is all about -- marginalizes and obscures the socio-economic causes
of ill health and the lack of justice within our society.
So what of politics?
Back in 1964 -- you can tell I am well into the aging process --
this German American political theorist, Herbert Marcuse,
wrote "Totalitarian is not only a terroristic political coordination of society,
but also a non-terroristic economic technical coordination which operates
through the manipulation of needs by vested interests."
This is what large tracts of our healthcare systems have become.
A non-terroristic economic technical coordination which operates
through the manipulation of needs by vested interest.
It's a perfect description.
The fears of politicians, practitioners, and the public and the enduring human craving
for a predictable future are making us all into willing participants.
Reviewing George Orwell's 1984 in a review written in 1949,
this wonderful chain smoking American critic, Lionel Trilling, wrote about George Orwell --
"He is saying indeed something no less comprehensive than this --
that Russia, with its idealistic social revolution, now developed into a police state,
is but the image of the impending future and that the ultimate threat
to human freedom may well come from a similar and even more massive development
of the social idealism of our democratic culture."
Arguably, the current ascendancy of medical technology is just
such a manifestation of social idealism.
War is peace.
Ignorance is strength.
Freedom is slavery.
And now we have the latest example of Orwellian doublespeak, disease is health.
Trilling continues, "The essential point of 1984 is just this --
the danger of the ultimate and absolute power which the mind can develop when it frees itself
from conditions, from the bondage of things and history."
The sorts of measurements which underpin the imperatives of contemporary medicine --
blood pressure, serum cholesterol, bone density, PHQ 9 depression score, body mass index,
estimated [inaudible] rate, just to mention a few --
are all held to be universally applicable, whatever the circumstance
of the individual life to which they are applied.
They are in Trilling's words, "freed from conditions," and therefore they are dangerous.
This kind of utilitarian medicine which treats every individual
as identical can very easily erode the stature and autonomy of patients.
More than 20 years ago, David Metcalf warned general practitioners in the UK,
the WHO definition of health is complete physical, social, and psychological wellbeing,
says something that we must acknowledge.
It is about a person's potential for living, which is a matter of autonomy
and personal space, of having room to make choices.
These are the concerns of general practice because our professional objectives are wider
than the diagnosis and treatment of disease.
But we too need to be careful, lest diagnostic or therapeutic exuberance
in the individual case blinds us to our patients' needs for space and stature.
How much more important is that warning today?
We are developing a culture of conformity, which pays lip service to autonomy and choice,
but within which the individual is only really free
to make the choice which is approved by the state.
It is assumed that once the healthy choice is pointed out, everyone will select it.
And no account is taken of the very differing circumstances
and aspirations of different people's lives.
It's become difficult to question the means because the ends of curing
and preventing disease is so obviously worthy.
Nonetheless, the means are damaging, not least because they are so unidimensional
and because they propagate such an intensely normative view of what it means to be healthy
and indeed what human life should be.
We all need to urgently to rediscover an acute sense of waste as a moral and political issue.
Far too much that we do is wasteful, futile, and harmful.
It is not knowledge that we lack.
What is missing is the courage to understand what we know and to draw conclusions.
Great American thinker, William James, declared that doubt and hope are sisters.
In our doubt lies our hope.
Unless we are prepared to doubt the truth of existing explanations, we will never look
for better ones that could bring us hope.
So let's finally remember Kierkegaard had a thing about stance.
And Kierkegaard wrote, "It is quite true what philosophy says --
that life must be understood backwards.
But then one forgets the other principle -- that it must be lived forwards."
Life is lived forwards, but understood backwards.
We always act in advance of our understanding.
We are taught as medical student and learn to expect benefits from our interventions.
We need to be much, much more rigorous in our expectation of the stable house
and to teach our students to look always for the possibility of harm alongside that of benefit.
Much of what we regard as standard, even excellent, practice today will, I am sure,
eventually be consigned to what the novelist, Amatar Goshe [assumed spelling],
describes as medicine's vast graveyard of discredited speculations.
In a world where it has become acceptable to treat risk factors however weak as diseases
in their own right, we must and will learn to resist over-diagnosis.
And perhaps one of the best places for us to begin is
in remembering what James McCormac wrote in a [inaudible] nearly 20 years ago,
"Health promotion falls far short of meeting the ethical imperatives for screening procedures
and moreover diminishes health and wastes resources."
General practitioners -- this is where I chime with Peter --
would do better to encourage people to lead lives of modified [inaudible],
so that they may enjoy in the full the only life that they are ever likely to have.
No one was listening then.
Let's make sure they're listening now.
And lastly -- little bit of advertising for our workshop immediately after this session
and how we could make governments help us in that process.
Thank you very much.
[ Clapping ]
>> That's what I call a sitting ovation [inaudible] marvelous.
Thank