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I responded to the invitation to comment on this article with some diffidence. Firstly, the authors are to be congratulated for encouraging debate on an issue central to public health; namely the inherent conflict between the responsibilities of the individual and those of society.1 Secondly, I fully agree with the main thrust of the paper. Doctors must always be very vigilant about the roles that society tries to force upon them. In the century now closing there are plenty of historical warnings of where medical subservience to the demands of particular societies ultimately leads.2-5 Thirdly, as one who speaks no other language than his own, I am full of admiration for those who can argue difficult concepts in a second language. Some of the terminology that I would otherwise criticise may be no more than translation errors or linguistic misinterpretations.
Nevertheless, as the authors themselves agree, we are all ultimately responsible for our actions. In ordinary social intercourse we make judgements on the actions of others and attribute responsibility. We can no more “blame” illness on social or genetic determinants than upon an “act of God”. Ultimately we hold people accountable for their actions and there is no obvious reason why health behaviour should be an exception. One of the key worries about the human genome project is that it may well lead to a genetic fatalism, which makes individuals blame their genes for diseases that are multi-factorial in origin and for behaviours that are either tolerated with considerable reluctance or overtly punished by society.
The authors erect a series of “straw men”, which we can equally readily knock down. It is stated that society places more weight on changing individual health behaviours than upon environmental and social factors. This surely depends upon the pattern of disease in that particular community and the stage in the preventive cycle that it has reached. It is absurd to suggest that a poverty stricken woman from a developing country will be criticised for her failure to choose a healthy diet, when we all know that the most urgent priority is to provide her with a clean water supply. In the United Kingdom and most other developed countries environmental action to remedy infectious disease has received the necessary priority for the available resources although, as is so often the case, the level of investment is a constant matter for political debate. The problem now is that most of the common conditions that these countries wish to prevent, seem largely to be attributable to individual unhealthy behaviour.
Social inequality is indeed a major factor in the generation of illness, but while much can be done to reduce it and ameliorate its worst effects, no sustainable economic system has yet solved the basic problem. The biblical one offered to ancient Israel6 seems likely to do so (and has indeed been quoted during the current campaign to write off third world debt) but has never been wholeheartedly applied even in ancient Israel itself and certainly not in modern times nationally or internationally. The individual centred philosophy and the fragmentation of society prevalent in much of Western Europe, seem unlikely conditions in which to develop such an experiment now.
The authors tell us that we, “cannot demand that the general public accept every bit of news about risk factors . . .uncritically”. Is anyone seriously suggesting that we do? Epidemiologists identify apparent associations and, before they can be submitted to systematic analysis, the media have generated a political climate in which decisions are made on unreliable evidence. Charlton7 has warned public health doctors to avoid what he describes as the clinical imperative that demands that they are immediately required to “do something”.
Equally, is anyone seriously suggesting that individuals should change 218 separate behaviours, to reduce the risk of coronary heart disease? The reduction of smoking in the United Kingdom, with modest assistance from a more appropriate diet and greater exercise, is already leading to a welcome decline in mortality and morbidity. The statement that “health profit of most lifestyle adaptations is not very large—at the most one to a few years”, based apparently on two rather obscure references, defies belief. A follow up of British doctors over a 40 year period found that “those who stopped smoking before middle age subsequently avoided almost all of the excess risk that they would otherwise have suffered but even those who stopped smoking in middle age were subsequently at substantially less risk than those who continued to smoke”.8The reduction of smoking among British doctors has been associated with major changes in their life expectancy.
The authors are right to emphasise the role of social factors and of cultural mores in the generation of disease, but it is highly questionable whether they constitute extenuating circumstances that exempt individuals from responsibility for their actions. Ultimately each of us is accountable for our acceptance or rejection of the customs adopted within our own social group. It is patronising to imply that those in social class V are less likely to reject their cultural norms than those in social class I and II. Victim blaming for individual ill health is ultimately self defeating. It fails to solve the problem that it seeks to resolve and merely provides an excuse for political inactivity. Doctors normally respond to patients in need, without reference to their individual lifestyles. There have sometimes been worrying examples of doctors using adverse patient behaviour to control treatment. Usually the behaviour will have been shown actively to reduce the impact of the doctor's proposed treatment and, where there is evidence for this, it seems right to expect patients to play their part. Hippocrates said that recovery depended upon a combination of actions by the patient, actions by the doctor and upon favourable circumstances.
Ultimately people must make their own personal decisions and society must make it easier for them to take good health decisions. Unless both play their full part, the burden of illness and ultimately the cost of health care, will continue to increase.