Accelerationâ proposed by the American historian Henry Adams, it is precisely at the moment that a scientific discipline is at its most apparently successful, as medicine was in the 1960s and early 1970s, that it will be approaching its apotheosis.
But there are also specific reasons why medicine should conform to this pattern of a Rise and Fall. First, it is limited to doing what is âdo-ableâ, and by the 1970s much of what was âdo-ableâ had been done. The main burden of disease had been squeezed towards the extremes of life. Infant mortality was heading towards its irreducible minimum, while the vast majority of the population was now living out its natural lifespan to become vulnerable to diseases strongly determined by ageing. Second, these age-determined diseases, which are far and away the dominant preoccupation of Western medicine, are of two sorts. Some, like arthritis of the hips and furred-up arteries, can be markedly improved with drugs and operations, while others, like cancer and the circulatory disorders, can be palliated though not postponed indefinitely. Thirdly, and very importantly, the rate of medical innovation was bound to decline because so many of its important discoveries had depended on luck. The bountifulness of nature in providing the extremely potent but entirely unanticipated antibiotics and cortisone is unlikely to be repeated, while sooner or later research chemists will find they are scraping the bottom of the barrel of chemical compounds that can be synthesised and screened for their therapeutic potential. And finally, medical research is, in Peter Medawarâs memorable phrase, âthe art of the solubleâ. As of this moment, it is not at all clear whether or how the last challenge left â the discovery of the causes of diseases like multiple sclerosis and leukaemia â is indeed âsolubleâ.
Now this contention that science has âreached its limitsâ has been expressed many times in the past, only to be repeatedly disproved. Famously Lord Kelvin, at the close of the nineteenth century, insisted that the future of the physical sciences was to be looked for in âthe sixth place of decimalsâ (that is, futile refinements of the then present state of knowledge). Within afew years Einstein had put forward his Theory of Relativity and the certainties of Lord Kelvinâs classical physics were eclipsed. Perhaps predictions about medicine âhaving reached its limitsâ will be similarly overthrown in the coming years. Perhaps, but the brick wall blocking further medical progress is solidly built, being no less than four layers thick. The readily do-able has been done, the chronic diseases of ageing have been ameliorated, the bottom of the barrel of lucky drug discoveries has been scraped and the causes of the common diseases of mid-life remain a mystery.
The epochs of the Rise and Fall of medicine do not just follow each other chronologically, but are dynamically related. The Fall from the late 1970s onwards is best understood as a set of false strategies by which the express train of medical advance, fuelled by the successes of the Rise, sought to variously hammer away at, pole-vault over, circumvent or undermine this four-layered brick wall impeding further progress.
The essence of âhammering awayâ is to do the same things but at greater intensity. We encountered this in Technologyâs Failings, with the excessive use of new investigative techniques for straightforward medical problems: an endoscopy for everyone with a stomach ache, a CT scan for everyone with a headache, and complex studies of urine flow for every male with symptoms of an enlarged prostate. The potential for expanding the use of these diagnostic techniques is virtually limitless, especially if the age group being investigated is pushed upwards to include those in their eighties and nineties. There was also considerable scope for hammering away
But there are also specific reasons why medicine should conform to this pattern of a Rise and Fall. First, it is limited to doing what is âdo-ableâ, and by the 1970s much of what was âdo-ableâ had been done. The main burden of disease had been squeezed towards the extremes of life. Infant mortality was heading towards its irreducible minimum, while the vast majority of the population was now living out its natural lifespan to become vulnerable to diseases strongly determined by ageing. Second, these age-determined diseases, which are far and away the dominant preoccupation of Western medicine, are of two sorts. Some, like arthritis of the hips and furred-up arteries, can be markedly improved with drugs and operations, while others, like cancer and the circulatory disorders, can be palliated though not postponed indefinitely. Thirdly, and very importantly, the rate of medical innovation was bound to decline because so many of its important discoveries had depended on luck. The bountifulness of nature in providing the extremely potent but entirely unanticipated antibiotics and cortisone is unlikely to be repeated, while sooner or later research chemists will find they are scraping the bottom of the barrel of chemical compounds that can be synthesised and screened for their therapeutic potential. And finally, medical research is, in Peter Medawarâs memorable phrase, âthe art of the solubleâ. As of this moment, it is not at all clear whether or how the last challenge left â the discovery of the causes of diseases like multiple sclerosis and leukaemia â is indeed âsolubleâ.
Now this contention that science has âreached its limitsâ has been expressed many times in the past, only to be repeatedly disproved. Famously Lord Kelvin, at the close of the nineteenth century, insisted that the future of the physical sciences was to be looked for in âthe sixth place of decimalsâ (that is, futile refinements of the then present state of knowledge). Within afew years Einstein had put forward his Theory of Relativity and the certainties of Lord Kelvinâs classical physics were eclipsed. Perhaps predictions about medicine âhaving reached its limitsâ will be similarly overthrown in the coming years. Perhaps, but the brick wall blocking further medical progress is solidly built, being no less than four layers thick. The readily do-able has been done, the chronic diseases of ageing have been ameliorated, the bottom of the barrel of lucky drug discoveries has been scraped and the causes of the common diseases of mid-life remain a mystery.
The epochs of the Rise and Fall of medicine do not just follow each other chronologically, but are dynamically related. The Fall from the late 1970s onwards is best understood as a set of false strategies by which the express train of medical advance, fuelled by the successes of the Rise, sought to variously hammer away at, pole-vault over, circumvent or undermine this four-layered brick wall impeding further progress.
The essence of âhammering awayâ is to do the same things but at greater intensity. We encountered this in Technologyâs Failings, with the excessive use of new investigative techniques for straightforward medical problems: an endoscopy for everyone with a stomach ache, a CT scan for everyone with a headache, and complex studies of urine flow for every male with symptoms of an enlarged prostate. The potential for expanding the use of these diagnostic techniques is virtually limitless, especially if the age group being investigated is pushed upwards to include those in their eighties and nineties. There was also considerable scope for hammering away
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