Post by: Henk den Uijl – Policy advisor at NVTZ | PhD candidate at VU Amsterdam | Dutch EVY team
In our search for a better future health care in Europe, the central problems that are usually brought forward are an aging population, low health literacy, medical paternalism, high costs and ‘over-treatment’ or iatrogenesis. This is not an exhaustive list, more topics may be relevant and dominant. Although these are very important and relevant topics, it seems to me that these problems are ‘mere’ symptoms of a more fundamental discussion which in my opinion is underexposed in the ‘professional’ health care discourse of clinicians, science, politics and the consultancy industry. This fundamental question seems to be: how does western man (including patients and clinicians) relate to health care, its promises, its technology, its ideology.
In The Netherlands each year a survey study is done by the Dutch Social
and Cultural Planning Institute (SCP). There is a remarkable pattern: Dutch people find, more and more, health the most important ‘thing’ in life. Though it seems obvious that being healthy is pleasant, it worries me that this seems to become the most important value of life.
Ivan Illich wrote in the 70’s his remarkable book ‘Limits to Medicine’ in which he describes the way health care is taking over our capability to deal with or relate to questions of pain, sickness and death. A healthy culture, following Illich, is a culture in which people independently relate to these questions by for example religion or ethical values. Illich argues that the medical industry has stolen this capability of people by medicalization and iatrogenenis. In the 70’s, of course, his main attack was on the paternalism of the medical industry and clinicians. Today, with an emphasis on self-management and autonomy, this seems to have changed a bit. But this is misleading. Although both ‘normal people’ and clinicians are aware of the rise of self-management and patient’s autonomy,
the promises of health care practices have not changed. Quite the contrary, we believe – perhaps implicitly – that by new technology, ‘quality improvement’, better research and self-management, we can master not only specific diseases, but pain, sickness and even death itself. Whereas for Illich autonomy or independency – ‘self-management’ – was a value in itself, in the modern discourse self-management, it seems to be mere instrumental for ‘better service quality’.
Self-management, in this sense, does enlarges patient’s and people’s autonomy in relation to clinicians. But it does not, however, enlarges our autonomy towards sickness itself. In the discourse of self-management and projects alike, there is a strong emphasis on the feasibility of living healthy and a control over one’s life: it is a (liberal) matter of taking one’s responsibility. Topics such as frailty of human life, the tragedy of certain situations (for example in the sector of youth care and mental health care) are underexposed. Terms as ‘quality improvement’ and ‘self-management’ may be nothing but hollow phrases in these situations and often promise
a utopia, whether organizational or medical, which alienates us from our ability to independently relate to pain, sickness and death. The art of living, Seneca once wrote, lies not in getting rid of tragedy, but in relating to tragedy. It is what Heidegger mentioned: ‘only a god can save us now.’ And perhaps he was right.
Though this all seems very abstract, there is an important and practical policy issue. What I would like to see is that in European policy making, whether political, technological or medical, we need a more modest and humble attitude: no big promises of better quality, but a sense for frailty and uncontrollability of human life. And perhaps some more openness to different conceptions of health, rather than only the technical and modern one (in The Netherlands, for example, homeopathy is considered by many to be quackery). This might open the way for reflecting on the meaning of being healthy or unhealthy, instead of an absolutisation of health itself. This might, on its turn, have impact on our
discussions on overtreatment, iatrogenesis and even cost reduction.