In 1860 at a meeting of the Massachusetts’ Medical Society Oliver Wendell Holmes made one of the most celebrated comments in medicine. While noting that medicines, particularly opium, could help, he nevertheless made it plain that he thought that on balance medicines risked doing more harm than good. You can’t be much plainer than this:
“I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be better for mankind and all the worse for the fishes”.
Holmes’ note of skepticism marked a point at which medicine began to become scientific. Doctors began to distinguish themselves from quacks who dished out Mercury – also called quacksilver (see Pharmacosis: the day the music died). They began to grow into a role that had been sketched out for them by Philippe Pinel fifty years earlier:
“It is an art of no little importance to administer medicines properly: but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them”.
A century later regulators faced with the emergence of new drugs of which Holmes and Pinel would undoubtedly have approved, and aware of the risks these drugs might pose and the need for skepticism, and distrusting the public to be suitably skeptical, turned to doctors and made these new drugs available on prescription only.
Doctors who for centuries had being trying to push quacks and hucksters out of the medical marketplace were being offered the means to conclusively do so. You would only be able to get the drugs that really worked from your doctor.
But the bargain was Faustian. Few if any doctors seemed to spot that patients would no longer be the consumers of drugs. If by consumers we mean those who are the targets of pharmaceutical company marketing, then doctors were the new consumers. These new consumers moreover would consume by putting drugs into their patients’ mouths and so would consume without side effects. This was a win-win of which Mephistopheles would have been proud.
Recent estimates suggest companies spend over $50,000 per annum on marketing to each and every doctor in the United States – possibly considerably over $50,000. Despite this, there is not a single medical course on earth that teaches doctors about pharmaceutical company marketing.
Has this marketing done anything to erode the skepticism of doctors? In 1960 doctors rarely had patients on more than one drug at a time and the drugs that were used were for the most part only used for a limited course. Until the early 1990s, the recommendations for antidepressants were for a three-month course, now patients are told they are like insulin and will have to be consumed for life. Now an increasing number of every doctor’s patients are on 10-15 drugs indefinitely. Doctors in other words are consuming several thousand times more drugs than they once were. Left to their own devices few of a doctor’s patients would ever take 10-15 over the counter drugs at the same time for indefinite periods no matter what the supposed benefits.
There is no better symbol of what has happened than the use of drugs in pregnancy. Drugs are available on prescription only because we have every reason to think they will be riskier than alcohol, nicotine and other drugs we were prepared to let people manage for themselves in the 1960s. Now, pregnant women are skeptical of and avoid not just alcohol and nicotine but tea, coffee, uncooked meats and soft cheeses. Pregnancy is an area even quacks and hucksters steer clear of. But far from endorsing this skepticism, doctors cajole or frighten women into taking more antidepressants in pregnancy than any other drug, even though these come with greater risks of causing birth defects, miscarriages and learning difficulties in children than are linked to modest alcohol intake, nicotine, cocaine or most over-the-counter treatments.
When salt loses its taste it is useless. When doctors lose their skepticism they are worse than useless, they become dangerous.
Like Faust, doctors may be approaching their hour of reckoning. The world we are in is a world where medical art is not needed to get patients on medicines – this is now done by algorithm or checklist. This is also a world where prescription privileges have been extended to nurses and pharmacists who are cheaper to employ than doctors.
Doctors have become just one more element in the distribution channel for drugs, part of a juggernaut that is pumping people fuller and fuller of medicines. If Holmes were to return would he remark:
“I firmly believe that if doctors could be sunk to the bottom of the sea, it would be better for mankind and all the worse for the fishes”.
Can doctors save themselves? In Holmes’ day, except for metals like Mercury and arsenic the drugs of the time were rarely lethal in their own right. They did not kill as many children as were killed by diphtheria, or adults as died from influenza or tuberculosis.
Treatments now are far more lethal than they were in Holmes’ day and treatment induced injury has become one of the leading causes of death and disability. There has been one confirmed human drug disaster, the SMON epidemic in Japan, which resulted from the accumulation in fish of a modern drug, clioquinol. There are growing concerns about accumulations of other drugs in the fish we eat and water we drink.
Holmes’ and Pinel’s point remains that the greater art “lies in knowing when to stop or altogether to omit medications”. In many areas of consumption, personalized goods or services are branded as artisanal. Given that doctors should be offering professional discernment as a service and should be advocates for their patients and for possible non-consumption, may be doctors need to become p-artisans.
If they are to maintain prescription only privileges and a role for themselves in healthcare, doctors are going to have to come up with something extraordinary. They may even need to become a revolutionary class, partisans, who create a space that markets do not readily understand – a space where No is the operative word.
Or else it may be time to recognize the Faustian bargain medicine was offered in 1962 for what it was, and prior to being consigned to sleep with the fishes, depart stage left with a parting shot such as “So long and thanks for all the fish”.