Is There Conflict Between Standard and Preventive Medicine?

I sometimes wonder whether the recently announced smoking ban in HUD dwellings in the USA, as well as the smoking bans proliferating in the grounds of NHS hospitals in the UK, set up stresses within the organisations involved.

After all, it seems reasonable to suppose that the people who work in HUD – Housing and Urban Development – are very likely to have the best interests of their residents in mind, whether or not they do a very good job about it in terms of keeping their housing stock in good repair, well lit, crime free, with working lifts, and so on. How are such people likely to feel when they are instructed to police smoking in their properties, forcing smokers out onto the streets, and in addition fining them and perhaps even evicting them? Doesn’t that contradict the whole ethos of public housing, which is to provide shelter for even the poorest members of society?

The same question may be asked about the doctors and nurses working inside the NHS hospitals in which draconian smoking bans are now multiplying. Doesn’t it contradict the whole ethos of medicine to force patients, often with drips and catheters, to walk hundreds of yards outside these hospitals to enjoy a smoke? How do surgeons who have just operated on patients, sewn up their incisions, and wrapped them in bandages, feel when they see the same poor fellows limping slowly out of the hospital grounds? None too pleased, I imagine.

In the UK, as best I understand it, these smoking bans don’t originate inside the hospitals themselves, but in central government – perhaps the Department of Health, or maybe even the WHO. And the doctors who work in these government organisations appear to mostly be non-practising doctors who, despite their medical qualifications, prefer to work in preventive medicine, trying to stop people getting sick in the first place, before they ever arrive in hospital, by enacting smoking bans, alcohol bans, dietary restrictions upon the general population.

It is in the nature of preventive medicine to try to prevent well people becoming sick, just as it is in the nature of standard hospital medical practice to try to make sick people well. And usually, once patients have have been discharged from hospitals, little or no further interest is taken in them. Or at least that has been my experience. But the preventive medical practitioners, who want to prevent the well from becoming sick, are essentially only interested in well people rather than sick people. Which is why they are always demanding smoking bans, alcohol bans, and any number of other public health measures to be enacted on people who are for the most part perfectly well.

And because of their opposite points of view, standard best medical practice (trying to make the sick well) would seem to be in conflict with standard best preventive medical practice (trying to prevent the well getting sick).

If nothing else, preventive medicine medicalises the whole world and everybody in it, whereas standard medicine restricts itself entirely to people who are sick, ignoring those who are well. So a standard medical practitioner in a war zone will restrict himself to simply treating people who have been injured by bombs or bullets. But a preventive medical practitioner in the same war zone would wish to prevent people getting injured by bombs and bullets in the first place, and would try to stop the war – perhaps by enacting gun controls, and denormalising military culture, and so on. The preventive medical practitioner must become, in effect, a politician (if he isn’t one already).

And if preventive medicine is concerned with preventing well people becoming sick, what interest should it have in the sick people inside hospitals? If preventive medicine and standard medicine operate in separate domains – the well and the sick – when someone becomes sick and enters hospital, shouldn’t they fall wholly within the remit of standard medicine – the care of the sick – for the duration of their stay, and only be returned to the jurisdiction of preventive medicine – the care of the well – when they have become well again? That is to say, what business does preventive medicine have inside any hospital? Surely it should restrict itself to the community of the well outside the hospital gates? Once someone enters a hospital, are they not testament to the failure of preventive medicine to stop them from smoking, drinking, eating, fighting wars, or whatever else made them sick?

These, and other similar considerations, suggest to me that standard medical practice and standard preventive medical practice must in many cases be in conflict with each other. And this should result in protests – and perhaps even resignations – by doctors and nurses inside hospitals against the incursion of preventive medicine inside them.

But that’s just my guess, as a distant outsider looking in. I don’t know any doctors. I’ve hardly ever known any during my entire life. My closest approach was perhaps with the antismoking Dr W, in whose house I once lived, and who has since become for me the personification of the bureaucratic busybodying preventive medical ethos, even though he is long dead now. Has anyone ever spoken to any doctor who is practising medicine inside a hospital, and asked them what they think of hospital smoking bans?

In this respect it’s interesting that Donald Trump seems set to appoint Dr Ben Carson to run HUD. I wonder what side of the fence this neurosurgeon belongs to. Is he one of those standard medical practitioners who merely want to make sick people well, or is he one of the preventive medical practitioners who want to prevent well people becoming sick? It may completely determine his attitude to smoking bans in HUD dwellings. Or perhaps there is no conflict at all between these radically different approaches to medicine, and I’m only imagining one?


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22 Responses to Is There Conflict Between Standard and Preventive Medicine?

  1. Juliet 46 says:

    Airports have smoking rooms. Why can’t Hospitals have smoking rooms too, for both patients and staff? Coulldn’t pubs be classified in the same way as supermarkets? Large pubs, over a certain square footage, could have an air conditioned, segregated room, away from dining area (but warm and cosy in winter – let’s call it a “Snug!” for sake of argument…).
    Small bars and pubs – let them and their patrons choose.
    I’m not a smoker, my husband is, but for me it’s a no-brainer. Let the paying customer decide.

  2. prog says:

    Notice that they decided to suspend industrial action ‘for the sake of patients’? I believe the real reason was that they were rapidly losing public sympathy, knew it, and decided to cut their losses. It was always about them.

  3. Bones says:

    I feel that many areas of modern medicine have lost compassion. This was once the overriding quality needed to become a doctor or nurse. It has now been relegated to bottom of the list.
    My mother was a nurse trained in the 1940’s primarily on the ward not university as is today. Granted medicine has become more technical but there is much that can be picked up on the ward from seniors that have learnt through experience.
    Whilst my mother didn’t smoke she often lit a cigarette for patients who were unable to do so for themselves, i.e. showing compassion.
    It is my experience that many doctors are particularly gullible because they are book learned and believe ‘experts’. Their view is that people in general must be compliant. One of the worst things that they can put on patients’ notes is “non-compliant”, that is “won’t do as s/he is told” or “doesn’t listen” or “has own opinions”. Most believe in man-made climate change.

  4. Jay says:

    Well, I’m sure the standard doctors must detest the preventive doctors when the latter insist on resources being used to invite the worried well for screening for diseases the symptoms of which they show absolutely no sign.

  5. Rhys says:

    Bit off-topic here, but one of the biggest health problems in US public housing is mould. Especially in New York. So many people there are having problems because of it.

    Why the hell aren’t they working on cleaning up that (because that can really mess up people’s breathing) instead of this idiotic proposed smoking ban?

  6. waltc says:

    A few yrs ago someone found and shared a link to a nurses’ website where they chatted among themselves and revealed that they HATED smokers–thought patients who snuck a smoke should be instantly evicted from the hospital. Scum. And if eviction made them worsen or die, it was their fault, not the fault of the policy. Many, tho not all, doctors now believe that smokers don’t heal well from surgery and tangentially believe that whatever it is that ails them, they “brought it on themselves” a nd are therefore less worthy of treatment than are the “innocent” victims.

    Smoker hatred is so rampant, smokers are per se so thought to be “wrong” and so harmful to others, that –at least from the HUD comments–the public housers feel fully justified in wanting to ban them. As for Carson, I think Audrey posted something that might indicate he’d be more sympathetic, but who knows if he’d be willing to face the firestorm (“he wants to kill children!”) that would follow from undoing the housing ban.

  7. Rose says:

    Shaming of the charity vultures: RSPCA and British Heart Foundation fined for snooping on donors’ wealth after Mail exposé
    6 December 2016

    “Both charities were also found to have used unscrupulous firms to find out more information about donors and to have been sharing personal data with other organisations – putting them at risk of fraud.
    The penalties could open the floodgates for thousands of donors to sue the charities for misuse of their private information.”

    “The British Heart Foundation obtained Col Rae’s details from a data firm. They also bought a list he was on from another charity. They contacted him 32 times by post between 2008 and 2015 and phoned him twice even though he had not consented to being contacted.”

    So what do they do with all this money?

    British Heart Foundation

    Fags over family? Smoker’s choice sparks hate from loved ones
    February 27, 2013

    “Nearly a third of smokers surveyed admit their children or family hates them smoking and a quarter enjoy smoking less nowadays because they feel more guilty about it.”

    “The data showed money matters often prick the conscience of smokers; as just over a third said they feel guilty about the amount they spend on cigarettes and a similar number stated they avoid thinking about it.”

    “Our Associate Medical Director, Dr Mike Knapton, said: “These figures reveal the emotional burden smokers endure by feeling guilty about the impact their addiction has on family life and their finances.”

  8. jaxthefirst says:

    It’s something that I’ve often mused over – this ability for people from all walks of life to completely abandon all of their professional integrity (i.e. their objectivity) when, and only when, it comes to smokers. Doctors and nurses will willingly perform operations to the best of their ability and, showing extraordinary levels of self-control and professionalism, provide the best of medical care towards sex criminals, murderers, paedophiles, alcoholics, grossly obese people, heroin addicts, self-harmers, suicidal people, anorexics, extreme sportspeople, drunk drivers, reckless drivers and drunken town-centre brawlers, only ever refusing medical care when one of those conditions has a direct impact upon the outcome of the treatment, and always stoically insisting that “care for the patient must be the priority, over and above any personal feelings we might have about what that patient might be, or might have done.” But the moment someone admits to smoking tobacco, no matter whether that’s just occasionally and no matter how otherwise healthily they might live their lives, and no matter how much they might need that treatment, all those professional standards fly out of the window and all these so-called medical “professionals,” suddenly seem to feel able – in the most unprofessional way possible – to allow their personal prejudices to massively influence decisions which, in any other circumstances simply wouldn’t get a look-in.

    And it’s not just the medical profession, either. There are lawyers aplenty who will willingly devote hours of their professional time and expertise to defending people who are, quite frankly, rogues and cads of the very worst variety, on the basis that it is vital that even habitual or violent criminals must have access to decent legal representation within any system the aim of which is to ensure that justice is served; but the moment a client comes along who has been persecuted in some way purely because they smoke, all the high-minded principles of “all being equal in the eyes of the law” fall by the wayside and lawyers head for the hills. Similarly, otherwise well-intentioned, even kindly, employers don’t seem to bat an eyelid when it comes to treating their smoker employees like naughty children to be punished or humiliated or worse and will happily mete out harsh disciplinary action against smokers whilst treating much more serious misconduct cases in a far more measured and reasonable way.

    This inability to control smoking prejudice goes right down the line. I remember, not so long ago (pre-ban), staying at a little bed & breakfast guesthouse where the very jolly landlady stated proudly that she honestly didn’t mind what people did when they were staying at her guesthouse (we had booked the room because it was a dog-friendly place, so that’s where the conversation had started). “As far as I’m concerned,” she announced, “I accept everyone for what and who they are and people can do whatever they want when they’re here. As long as they don’t upset the other guests or smash up all the furniture, then what they do when they’re in their room is OK by me.” And guess what the first thing was that I saw when I walked into our room? Yep, a prominently-placed “No Smoking” sign on the mantelpiece! So much for “I accept everyone!” The level of denial was so obvious it was almost laughable. I think it might have been at that point that I started mentally adding the words “except smokers” in my head whenever I heard anyone saying the word “everyone” or “everybody” or “all our customers/clients/visitors” etc!

    It seems to be so endemic that I’ve long thought that anti-smoking, as the only currently permissible – nay, State-supported – outlet for bullying, is in fact encouraged as a kind of release-valve for all sorts of other, currently-suppressed, prejudices which it is no longer socially acceptable to admit to. Perhaps, inside every anti-smoker, whether they’re one of the Big Cheeses in Tobacco Control, or just one of the spiteful little internet commenters (or a nice, but deluded B&B landlady who proudly labelled herself as “a true libertarian”), there actually lurks a raging racist, a horrified homophobe or a spittle-flecked sexist!

    • Tony says:

      Yes. It’s like or perhaps is, mass hysteria. Fomented by the anti-smoking industry.

      • Tony says:

        I should add that we are blamed for the loss of a billion lives which is more than any of the worst and most evil mass murderers in history. And we continue to offend.

      • Frank Davis says:

        And I think it’s an hysteria which is being quite deliberately whipped up. We’ve all read about those nazis who used to grab cigarettes from smokers’ mouths. I think they’re trying to create a society in which everyone is a little nazi who’ll do exactly that. No need for no smoking signs everywhere: an army of little nazis will not only grab cigarettes out of smokers’ mouths, but beat them up as well.

        This is the society they are trying to create – one in which mass bullying takes place on every level. Smokers are just the start of it. The same will apply to any and every other disapproved activity. And their role is to be the remote instigators of this reign of terror, with no blood on their delicate little hands.

  9. Tony says:

    I’d suggest that ‘standard’ medicine works, at least after a fashion, whereas ‘preventive’ medicine does not. But more importantly, ‘standard’ medicine is hard work for the medic whereas ‘preventive’ medicine is more about politicking than actual work.

    A bit like at management level in business where some get very little done and like it that way. It means their incompetence remains hidden and gives them time to indulge in company politics.

    Unfortunately such people often rise to the top and end up causing great damage to the business. Others can resent them but tend to be too busy to do anything about it.

    • Frank Davis says:

      I’d suggest that ‘standard’ medicine works, at least after a fashion, whereas ‘preventive’ medicine does not.

      That’s a good point. With ‘standard’ (I wish I had a better word. Classical? Clinical?) medicine, you find out very rapidly whether it’s worked or not: the patient either recovers, or they don’t, very often in a matter of hours or days. But preventive medicine has time scales of decades or even longer. The expected improvements in health due to stopping smoking, drinking, eating, etc, lie in the distant future. So there’s no immediate way of knowing whether it works or not. It’s an act of faith. What is being proposed may in fact be extremely damaging, but we’ll only find out in a few decades.

      And much the same applies with global warming/climate change. That also is ‘preventive’ medicine, but on a planetary scale. The results of our preventive measures will not experienced tomorrow, or next year, or even next decade, but in the next century. Only then will we find out what life will actually be like in a “carbon-free” world. And I suspect it will be horrific.

      • Joe L. says:

        Not only is there a nearly immediate result with ‘classical’ medicine, but that result is also easily quantifiable (e.g., has the disease/condition improved, remained the same, or worsened).

        However, with preventive medicine, the ‘results’ are ‘measured’ by the presence of (or continued absence of) a disease/condition that was previously absent. This, coupled with the fact that the ‘results’ take decades to materialize (and the fact that it is impossible to control a multitude of other variables over that long of a duration), excludes ‘preventive medicine’ from being repeatable, and thus also from being scientific. It’s snake oil, plain and simple.

        • jaxthefirst says:

          A fine example of this “precautionary principle,” and how it is used by the elites/establishment/politicians to wield ever-greater control over people was given in the three-part documentary “The Power of Nightmares,” shown about 10 years ago (surprisingly) on the BBC and the winner (or at least in the top three of the “best documentary” competition shortly afterwards. Not specifically about smoking, but it does do an excellent job of pointing out how the “precautionary principle” can be applied to pretty much anything that politicians want to apply it to, and also why it is so often wrong, based on hysteria and, usually, does more harm than good which, eventually, people do rumble (being as it’s the people who are usually affected by that harm).

  10. Roberto says:

    The issues you mention: the difference between standard old medicine and “preventive” medicine meddling with lifestyles, are discussed in the book “The Tyranny of Health: doctors and the regulations of lifestyle”, by M Fitzpatrick London: Routledge 2001, ISBN: 0-415-23571-5. Fitzpatrick focuses on developments in the period between the late 1980’s and early 2000’s in the UK, but his analysis is more or less valid for other developed countries. Fitzpatrick argues that the obsession we see (since the late 1980’s) to regulate lifestyles (or to “medicate” life) by the medical profession is a consequence (not a cause) of the politicization of medicine. His thesis is that the the post cold war demise of traditional ideologies motivated a symbiotic relation between the political establishment (more the liberal than its conservative part) and the bureaucracy of medical profession. Health (understood in terms of zero risks and longevity) became for the political class a sort of new political ideology, so medical bureaucrats were recruited (or self recruited) to utilize health related lifestyle issues as a form of social control.

    However, Fitzpatrick’s analysis only covers the emergence and maximal prominence of this process in the early 2000’s (the Blair’s government), which coincides with western politics becoming completely dominated by globalization. Perhaps, this medical tyranny on lifestyles and its forced “medication” of all aspects of life is one of the factors behind the current anti-globalization reactions in the western world (Brexit and the election of Donald Trump). Perhaps the pendulum may be starting to swing back, perhaps we may see the reversal of the busybody politicized puritan medicine into medics who gave health advise and information but did not use state power to coerce patients into changing lifestyles.

    Hopefully, Ben Carson will veto the HUD smoking ban. Yes, tobacco controllers and most of official medicine will scream “.. horror … shock … wants to kill the children..”, the democrats may use this as a political weapon. Yet, Carson has expressed opposition to government meddling on every aspect of private life. He has a lot of elements to win this political fight: he can argue that it is very cruel to force senior HUD residents who smoke (something that is legal) to be forced to endure long walks under freezing temperatures for a cigarette. This is a cruel as banning alcohol or harassing gay people or minorities. Carson should stand firm on this and Trump should support him. It could be a good opportunity for all to see if he and Trump are men of principles.

  11. waltc says:

    OT: Noel Coward once wrote a song called “Alice is at it again” Well, Bloomberg is (at it. again. Or still).

  12. Rose says:

    With standard medicine you get obvious and reasonably immediate results with visible and recordable successes and failures. With preventative medicine any successes are so far off in the future that the possible results can only be calculated and and if the theory is wrong from the start any failures that begin to show up can still be argued and will most likely happen after your retirement.

  13. Rose says:

    The arrogance of preventive medicine

    “Preventive medicine displays all 3 elements of arrogance. First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy. Occasionally invoking the force of law (immunizations, seat belts), it prescribes and proscribes for both individual patients and the general citizenry of every age and stage. Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.

    Although one could level these same accusations against the “curative” medicine delivered to symptomatic patients who seek health care, the 2 disciplines are absolutely and fundamentally different in their obligations and implied promises to the individuals whose lives they modify. When patients sought me out for help with their established, symptomatic diseases, I promised them only to do my best and never guaranteed that my interventions would make them better. Although many of my interventions had been validated in randomized trials, the need to intervene in rapidly advancing, life-threatening disorders forced me to use treatments justified only on the basis of past experience, expert advice, and the first principles of physiology and pharmacology.

    But surely the fundamental promise we make when we actively solicit individuals and exhort them to accept preventive interventions must be that, on average, they will be the better for it. Accordingly, the presumption that justifies the aggressive assertiveness with which we go after the unsuspecting healthy must be based on the highest level of randomized evidence that our preventive manoeuvre will, in fact, do more good than harm.”

  14. prog says:

    Of course, a healthy diet has long been claimed to ward off illness, though some people have become totally obsessed with what they believe or have been told is good, potentially to the detriment of their health.

    Funny thing is, that we sometimes hear about people, including kids, who eat nothing but (say) cheese or chips etc and, on the face of it at least, appear to be perfectly fit. Not quite the same as this, but the Irish poor once thrived on little more than potatoes, milk and the occasional herring sometimes supplemented by what they could forage. But, as tragically proven in the mid-19th century, it seems the potato was the major crucial element.

  15. I agree with this… I’ve always thought a doctor’s job was to make sick people better, or more comfortable. When a doctor is doing THAT, they’re doing their actual job. When they’re telling you to never eat bacon because bacon “causes” heart disease, they’re stepping outside the bounds of what we’re paying them for. Which brings me to another point, which is that everyone (including doctors or at least some doctors) seems to have forgotten that the doctor works for the patient. When you’re at the doctor’s office, YOU are supposed to be the boss. Not the other way around!

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