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A Medical Paradox: Curative versus Preventive Medicine

J. F. BROCK

SUMMARY
A familiar medical contrast is presented as part .of a modern medical problem. The problem it reflects is the relative importance of preventive and curative services for medical practitioners, which is already, or will shortly resolve itself into, a dilemma of whether medical men should stress preventive medicine to the possible detriment of curative medicine. It is submitted that the solution to both problem and dilemma should be sought against the background of history and philosophy, where they are seen to be expressions of an eternal paradox - that of the relative value of the individual in relation to the family, group, or community. If the submission is valid, then the answer to the problem is not a purely medical exercise, nor is the dilemma purely a 'doctor's dilemma'. The paradox, being eternal, is not soluble in our time, but the community must, on the urging of the medical profession, find a 'a public consensus general solution to the problem for our time'. This must be followed by public demand for a parliamentary solution - 'decision-making ex consensus'. It is argued that although the latter programme does not come easily to democracy, it can be achieved through public consensus if action is taken by the leaders of thought in appropriate categories. Initiative must be exercised by the medical profession, but public consensus can only be achieved in consultation with the leaders of all learned professions, civil servants and legislators. It must then be presented fairly and without bias to the public. In the meantime, the medical profession must formulate its own 'medical consensus' and the doctor must resolve his personal dilemma according to formulated law, public or medical consensus or, in the last resort, according to his conviction and conscience. This method of solving a problem will almost certainly be applicable to other and more recent medical problems such as the population explosion, selective abortion and euthanasia.

S. Afr. med. l., 50, 1327 (1976).

Medical ethics is faced with many philosophic problems, of which three are at present being widely examined by the profession and by intelligent laymen, lawyers, clergy
Department of Medicine, Groote Sehuur University of Cape Town J. F. BROCK, n.M., F.R.C.P., Emeritus Hospital and

Paper presented at a meeting of the Adler _Museum of the History of Medicine Johannesburg, on 23 October 197,. After ha'ving submitted this paper for publication, I saw a rel'ly by MooreH to an article by Mahler15 entitled Health A of Medical Technology. This reminds me that I am not alone 10 my anxiety about tbe future of Hippocratic medicine.

and politicians. They are the problems of population explosion, of elective abortion and of euthanasia. They overlap, but are distinct from an older problem to be di cus ed here. Daily, as one look out from the windows of Groote Schuur Hospital, one pictures the great problems of indifferent health, sickness and unnapptness resulting from malnutrition and defectlve nygiene among the dwellers in the Cape Flats townships, while in the hospital, large resources of public money and personnel are being poured into OUI salvage activities for the elderly and infirm, our intensive care wards and units for cardiac, respiratory ana metabolic resuscitation, and in other divisions of the hospital for trauma and abortion. The alternatives in the subtitle, of course constitute an oversimplification because both are good and neither necessarily excludes the other. However, recent rapid developments are so demanding, expensive and competitive that a choice of emphasis is necessary for the immediate future. This problem of choice is thought about by many intelligent laymen and is most vigorou Iy discussed and debated among medical and other university students. It is not easy to decide which of the two services, preventive or curative, should be given preference by the medical profession. To the modern university student, whose idealism is half formed, there can be little doubt that the medical profession should do 'the greatest good to the greatest number of sick people'. Preventive medicine must be put before curative medicine, even if the result is a population explosion so great that after the latest decade the amount of food available per capita is less that it was in the previous decade. But the ordinary university student has not yet appreciated the anguish of the young mother to whom a single dying child (or husband) is more deserving of the informed, unhurried, and expert attention of the medical profession than any impersonal group of malnourished si um-d wellers. Here the paradox begins. The core of the 'curative versus preventive' problem in our present structure is that medical personnel appear to have insufficient time, and that there are insufficient funds and public resources to meet the obvious and growing needs in both fields. Many doctors are troubled by this; their consciences ask which need is greater, and to which need they should devote their time and skill. Some have found a way out of 'doctor' dilemma' through pecialisation in either clinical or public health practice or in curative or preventive medicine. Tho e doctors who elect to remain in clinical practice, whether it be private or in titutional, follow the age-old Hippocratic ethic and distribute their time, knowledge, ability and resources to individual patients according to medical need. The others, who pursue careers in public health and preventive medicine, try to distribute their talents and the public funds tbey control so that

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the greatest good i achieved for the greatest number of the community. But this pragmatic solution for the doctor's conscience merely hifts the problem back to the community, repre ented in theory by the voter, but in practice by civil ervants and politician. In outh Africa our political y tern provides an effective way of dodging the problem. It gives most of the responsibility for subsidising clinical practice to the Provincial Council, while dividing the respon ibility for providing funds for preventive medicine between local authorities and the Republican Government. Gbody can ee what i really happening through this moke-screen, and the problem is not even appreciated, much le tackled, so the pragmatic answers applied by the medical establishment and by community government erve only to bury the real problem under the carpet. If we dig it out, does it constitute a dilemma? One definition of a dilemma is 'a position which leaves only a choice between equally unsatisfactory alternatives'. In tbis ense it may become a dilemma, since, if the limitations are accepted as real, preventive medicine can only be set forward at the expense of curative medicine. Are the limitation real?

THE ROLE OF PHIWSOPHY

In another study' I expressed the view that any doctor who had spent a lifetime trying to help the sick must, through his experience, have been forced into some sort of philosophy. He must have contemplated what JuIian Huxley' referred to in his question 'What are people for?" In other words, he must have become a medical philoopher. I urged a younger generation of medical graduands to attempt consciously to formulate a medical philosophy. I have come to believe that our dilemma represents one of the great problems of our age and arises from the central paradox of our medical and social philosophy. It is worth while to look at the nature and definition of a paradox. The word comes, of course, from the Greek 'doxa', meaning opinion or dogma, and the prefix 'para', meaning 'beside' or, better perhaps, 'over against' in a comparative and competitive sense. A classical paradox of theology and metaphysics is the assertion or sentiment that God is omnipresent, omnipotent and infinitely loving, and yet does not intervene miraculously to cure the pain and suffering of his children. Philo ophers and theologians have written many treatises on how to solve or dodge thi paradox, but most of us have found our own answer in one of 4 ways: (I) to deny the existence of God (atheism or humanism); (2) to escape the paradox by calling ourselves, after tudy and thought, agnostics; (3) to escape the paradox by ignoring the evidence the lazy way - or (4) to find a satisfactory answer through religious concepts of free choice and of the educative value of pain and uffering. Of the dictionary definition of a paradox, I should like to quote one; 'a tenet or proposition contrary to received opinion'. The paradox I have chosen to examine may be et out in the following fashion in terms of this

definition. One 'received opinion' or dogma contained in the Hippocratic Oath as further developed through JudeoChristian philosophy, may be tated: 'Individual human life is infinitely valuable and no effort or resource should be spared in the attempt to rescue it from death or harm.' This 'received opinion' ha been, within and without the medical profession, the root of some of the greatest acts of heroism in the history of man; acts which involved endangerment or even loss of personal life in an attempt to salvage an otherwise doomed individual. Within the medical profession, since at least the time of Hippocrates, its corollary has been that a doctor must set aside the welfare' of himself and his family, without counting the cost, to answer a call for urgent medical service, under all circumstances and at all times, unless he believes that he is already engaged on an even more important professional service. In the modern days of scientific medicine, it has developed further to mean that expensive diagnostic and investigatory services, and eventually curative services, must be applied without estimation of the cost. The paradox is immediately obvious when a seemingly contrary tenet or proposition is put in such terms as the following: 'It is the duty of a doctor to devote his time and the available physical and other resources which he commands in his community, to do the greatest good for the greatest number of people.' In my opinion, this proposition is often necessarily a directly 'contrary tenet' to 'received opinion' deriving from the Hippocratic Oath. The onus may therefore be on each medical practitioner, according to his conscience, to decide whether this apparently contrary assertion is or is not valid. I have used the words 'may be' because there are some who feel that the decision is too difficult, and that doctors must be rescued from their dilemma by a resolution of the community: I shall later contend that the community must resolve and that Parliament must choose, but that the medical profession must first stimulate consensus.

mSTORICAL PERSPECTIVES
I have no pretensions to being a formal medical historian, but since I am interested in the evolution of trends and concepts, I like to sec a problem against the perspective of history. Reviews in standard textbooks of medical history leave one with the impression that the practice of medicine in Sumerian, Babylonian, Egyptian, Indian and Chinese cultures varied quite considerably, but that its approach was largely clinical or curative. Hebrew culture probably went furthest in the direction of community prophylaxis or public health. For example, Leviticus in the Old Testament has been referred to as 'the first textbook of public health'. Early Greece borrowed from her neighbours in Asia Minor, and one of her philosophers, Empedocles, while practising as a physician, is reported to have checked an epidemic (presumably malaria) in his home town by draining a swamp and fumigating the houses. The Golden Age of Greece brought Hippocrates (born 460 BC), whose oath is still part of the graduation ceremony of medical students. His name and those of his daughters, Hygieia and Panacea, have dominated Western medical practice for nearly 2500 years. I have

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vi ited Co, the Greek Island on which he wa born, and where he practi ed and taught under the famou plane tree which is alleged to be 2 500 year old. For those who are not historians, a delightful novel entitled The Torch' gives a fascinating perspective of the life and times of Hippocrates. Hippocrates has dominated the thoughts of Western medical practitioners so much that I spent some time studying hi writings. What is known as the Hippocratic Corpl/s consists of a large number of books attributed to Hippocrates himself or to the writings of his pupils. I have used particularly The Medical Works of Hippocrates, translated by Chadwick and Mann.' These writings convey the plea that the physician should study the entire patient and his environment, and should view disease with the eye of a naturalist. Nevertheless, most of the titles of the chapters are clearly directed towards clinical medicine. Some have titles which suggest an approach to preventive medicine or public health. They include 'A Regimen for Health', 'Epidemics' and 'Airs, Waters and Places'. However, when these chapters are perused, it is clear that they are directed at the daily habits and activities of individual men. The regimen is for individuals, and not for communities. 'Airs, Waters and Places' is concerned with climatology, and its objective is to help individual people to adjust themselves to the vagaries of climate and surroundings, and there is little, if anything, about what the community or the State Government could do to make their climate more healthy, e.g. by draining marshes. In that particular respect Hippocrates seems to have been behind rather than in advance of his predecessor, Empedocles. evertheless, it is no wonder that, under the leadership of this intellectual giant, Western medicine was oriented largely or entirely towards clinical practice until the early 19th century.

A NEW EMPHASIS
Even then, the new emphasis came not to any important extent from the medical profession, but rather from humanitarians, and it started as part of a more general humanitarian philosophy in Britain. Jeremy Bentham (1748 - 1832) was known both as 'the utilitarian philosopher' and as the 'father of modern preventive medicine'. As a philosopher, he insistently preached the doctrine of 'the greatest happiness of the greatest number'. His views are et out in his Introduction to Principles of M orals and Legislation." His work was intensively followed up by a lawyer, Edwin Chadwick (1800 - 1890). He was a friend of Jeremy Bentham, and put pressure on the Government to apply the latter's humanitarian philosophy under the name 'The Sanitary Idea'. He succeeded in persuading the Government to appoint a Sanitary Commission in 1839, and this led to the establishment of a general Board of Health in 1848.' Time was not ripe for radical reform, and the Board was dispersed 10 years later. evertheless, Chadwick's enthusiasm was undiminished, and before the end of his life he was rewarded for his persistence. These two reformers were supported in Britain by Thomas Southwood Smith (1788 - 1861), a physician at the London Fever Hospital. He implemented the farsighted

request of Jeremy Bentham that hi body hould be di ected ' 0 that mankind may reap ome mall benefit in and by my decease'. Smith wrote a book entitled The Philosophy of Health," in which he empha i ed the importance of national health. He upported Chadwick on the General Board of Health, and his de cription of the prevalence of preventable icknes among the poor illustrated the need for the Board' activities. These three pioneers were followed by a famou London medical trio, William FaIT (1807 - 1883), John Snow (I8131858), and Sir John Simon (1816 - 1904). These three men all, presumably under the impetus of the health philosophy of Bentham, Chadwick and Smith, devoted their lives in quite eparate ways to the common idea of preventive medicine. Farr had little formal education, and spent most of hi life in the office of the Registrar-General in London, although he had ome short experience in medical practice." He devised and published a book on the classification and nomenclature of diseases, which is still the basis of vital statistics. John Snow, before the bacterial origin of disease had become known, pointed out that cholera in London was water-borne, and made hi famous remark about the communal pump in Broad Street. John Simon systematised the advancing knowledge and became Medical Officer to the General Board of Health, and later Medical Officer to the Privy Council. His book English Sanitary Institl/tions (1890)" summarised the me sage of the trio. In the rest of Europe an outstanding figure was Max von Pettenkofer (1818 - 1901), a pupil of Von Liebig. In 1866 he founded the Institute of Hygiene at Munich, and investigated the relation of soil and atmosphere to health, particularly in relation to the prevailing cholera epidemic. He fell slightly out of line in that he did not accept the views of Koch regarding the role of organisms in disease. In the United States, the city of Boston and the state of Massachusetts led the movement under the impetu of Lemuel Shattuck, a bookseller and publisher with a keen interest in social welfare. Medical visitors to Boston will know Shattuck Street, which is almost the heart of the Harvard Medical School. Lemuel was appointed to a Sanitary Commission to survey the State of Massachusetts, and edited the Report of Massachusetts Sanitary Commission 1850.' Most of his suggestions were adopted and public interest was awakened. Boards of Health were ew Orlean established, the first being instituted in in 1855.

John Ryle
For a few years before I came to the Chair of Medicine in Cape Town I was Assistant Director of Research in Medicine at the University of Cambridge. My chief there was John A. Ryle, a member of that gifted family which in three generations gave Britain a leading bi hop, an apostle of atheism, a humanist physician, a philo opher and an astrophysici t. Before his appointment as Regiu Professor of Medicine at the University of Cambridge, John Ryle had achieved great distinction as a physician at Guy's Ho pi tal and a a leading con ultant in London. His book The 'atural History of Disease" is till a model of de criptive clinical medicine and of the art of

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a consulting physician. In 1938 I left his department to come to Cape Town, and when I next saw him in 1948 he wa Profes or of Social Medicine at the Univer ity of Oxford, and author of a book published in 1948 Changing Disciplines - Lectures on the History, Method and Motives of Social Pathology." I quote two paragraphs from one of his chapters, headed 'Prevention or Cure?': 'For a very long time we have accepted the old adage 'Prevention is better than cure'. In our new era the belief in it - for of its truth there can be no doubt - must be made ever more manifest in our research and its directives and in our teaching. The most conspicuous interest of the student ten or twenty years hence will, I hope, no longer be in the rare or difficult and too often incurable case, but in the common and more understandable and preventable disease. M ay the daily questions on his lips become not 'What is the treatment?' but What are the causes?' and 'If preventable, then why not prevented?' . . . (my italics). 'The training of the doctor, which began with observations on and the care of the sick individual, is due now for a great forward stride. Observations on whole communities, whether great or small (or on appropriate samples) and improved health provisions for them, must henceforword become The prior objective.' (My italics.) How much progress has English-speaking medical science and practice made towards these objectives? Has it indeed accepted them? My impression is that there has been wide acceptance of them as ideals and, to a lesser extent, as educational principles. There has even been some attempt to apply scientific inquiry to them. I refer to scattered attempts to apply mathematical statistics to morbidity and mortality trends, to new ideas about human ecology in the prevention of pollution and to attempts to apply economic principles of cost/ benefit analysis to alternative programmes for prevention and treatment. These trends are very scattered, tentative and unrelated. But even at this early stage, I see some signs of an unhealthy overswing of the pendulum. In pursuing this line of thought I have rearranged and partly rephrased his two quoted paragraphs as follows: 'For a very long time we have accepted the old adage 'prevention is better than cure'! In our new era the belief in it - for of its truth there can be no doubt must be made ever more manifest in our research and its directives and in our teaching. The most conspicuous interest of the student ten or twenty years hence will, I hope, no longer be in the rare or difficult and too often incurable case, but in the common and more understandable and preventable disease. The training of the doctor, which began with observations on and the care of the sick individual, is due now for a great forward stride. Observations on whole communities, whether great or small (or on appropriate samples) and improved health provisions for them, must henceforward be an educational objective as important as the diagnosis and treaTment of the sick individual. May the daily question on the studem's lips become WhaT is The diagnosis?' 'What are the causes?' 'If prevenTable, Then why noT prevented?' and 'What can be done to cure or

relieve This patient and those who are close to him?' (My rearrangement and italics.) I like to believe, from close personal knowledge of John Ryle, that he would agree with this rephrasing. This is, I think, clear when the underlined sections in the original quotation and in its rephrased version are compared with each other. What I have tried to do, in essence, is to avoid the implication that preventive services must have prior attention and must be regarded as more important than the Hippocratic ideal of the diagnosis, cure or alleviation of the sick individual and his immediate family. I knew Ryle as a man of compassion who would save no trouble nor underrate this latter objective. This belief stands out in every page of The Natural History of Disease, and I do not believe that he retracted one iota from what he wrote in this book when he wrote Changing Disciplines.

THE MAKINGS OF A DILEMMA

Life is full of paradoxes, such as the classical one of good and evil. Mostly they remain unsolved as general problems, but one facet of a general problem impinges at a particular time on the individual or the community and demands decision and action. It then constitutes a dilemma. I submit that this is the point we have reached in our medical paradox. Why has this dilemma been precipitated in the 1970s? This question deserves a whole lecture on what has happened in the quarter-century since the end of the Second World War. It can only be summarised here in 3 sections: I. 'Death control', through community hygiene, health education and effective modern drugs, has been effectively applied to a high proportion of the world's population. But its necessary counterpart, birth control (better called family limitation), has been accepted by only a small proportion of the same population. The result is the 20th century population explosion. 2. The success of 'death control' has prompted a new worldwide approach to preventive medicine. Starting through the UN agency WHO, this has spread to national public health departments and resulted in a worldwide demand for more public health medical officers. 3. In the same quarter-century, a wave of technological sophistication has swept into curative medicine. This wave has pinpointed diagnosis by machines and physicochemical tests. It has made previously incurable conditions amenable to cure or worthwhile salvage, but it has done so at enormous cost in terms of finance and of multiplication of hospital doctors in intensive care units. I submit, therefore, that we have a dilemma on our hands which is only a '1970 facet' of an eternal paradox. How do we approach the problem and solve the dilemma?

THE PROBLEM OF MEDICAL RESPONSmILITY FOR PUBLIC EDUCATION

The individual doctor can make a personal choice between a career in clinical or public health medicine, but hili responsibility does not end with his personal choice. He has to lead the public, the community and, eventually, Parliament, to an ability to solve the problem on a national basis.

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to be exposed and analysed, until eventually Parliament is faced with a dilemma which demands decision. In respect of exposure, we already have a position in which, as a result of urbanisation, the deleterious effects on health of poverty and unhygienic slums have become glaringly obvious. As a result of population pressure, the additive effects of undernutrition and malnutrition are to be seen everywhere. It takes no effort of imagination for the public to see the connection between lack of hygiene, slum housing and malnutrition. They can see it around them in every poor district; the correlated differentials in infant mortality, morbidity from 'social diseases', and life expectation respectively between the races and social groups are evident. The Poverty Datum Line is a concept familiar to most intelligent city-dwellers, and its relationship to sickness is apparent. The public conscience has been aroused and from many sides demands are being made for public medical prevention. In the developing nations, the example of the British social and medical reformers of the late 18th and early 19th century, from Chadwick to Simon, is being renewed. This is powerfully supported by United Nations agencies such as WHO, FAO and Unicef. The connection between cause and effect is now generally appreciated. We no longer need a John Snow to demonstrate the cause and effect relationship of the parish pump and the cholera epidemic. For the same reason, the public now has to recognise that the solution to the problems of slums and sickness is no longer a strictly medical matter - it is a matter of economics, education and politics. This is a point of the utmost importance, but there is no time in this talk to develop it properly. We are concerned here with the duties and responsibilities of the medical profession. Where do these begin and end in the modern context? How do medical practitioners individually, and collectively as a medical profession, educate the public? Firstly, medical men must be responsible for the collection of facts in their field of expert knowledge. Jeremy Bentham and Edwin Chadwick gave the impetus to knowledge of the relationships between poverty and disease, but it required a medical man, John Snow, to show that the water of the parish pump in Broad Street, London, was the cause of a cholera epidemic, even before the existence of bacteria had been discovered. Secondly, they must be pace-setters in health education and in persuading legislators to apply its lessons. Sir Edwin Chadwick, a lawyer, persuaded the British Government to appoint a Sanitary Commission in 1839, but it lapsed and would have died, had Southwood Smith, a physician, not reformulated it as a General Board of Health. Lemuel Shattuck of Boston, a medical man, spread the doctrine throughout the United States. In 1866 Max van Pettenkofer founded the Institute of Hygiene in Munich. Finally, Sir John Simon Medical Officer to the British General Board of Health systematised (1890) the new trends in his book English Sanitary Institutions.' Later he became Medical Officer to the Privy Council, and showed what a medical man could do to shape the legislative programme of public government. The pattern was set for a new breed of medical administrators.

Public Health Doctors

These are the men who must interpret to legislators and administrators, whether they be central or local, the need for and the steps to be taken towards an evolving preventive medical service. However, they must be fully a ware of the paradox which we are discussing, and they must not wing the pendulum of legislation and administration too far or too rapidly so that the central importance of individual diagnostic and therapeutic services is allowed to deteriorate. This objective can partly be met if the teachers of preventive medicine regularly attend the medical faculty boards and subcommittees of their local univer ities. An important link at the top in our country is the ex .officio membership of the South African Medical and Dental Council which is bestowed upon the Secretary for Health (our Chief Medical Officer). Preferably, his two senior assistants should regularly attend meetings of the Council. Tn addition, hi representatives should play their part in the activities of local branch Councils and meetings of the Medical Association. At congresses of the Medical Association there should regularly be plenary sessions aimed at keeping the profession generally aware of trends in government health and sickness policy. This is asking a lot, but a reciprocal interest in the problems of community and preventive medicine must be expected from clinicians. Unless regular and intimate contact is maintained between this new breed of medical administrator and the leaders of clinical medical practice, they will be inclined to resolve the paradox in favour of 'the greatest good to the greatest number of people'. To maintain a lasting sense of the value of Hippocratic tradition is difficult for a man who is not in daily clinical practice. One aspect which is relevant is the appropriate terminology for distinction between what is referred to throughout this talk respectively as curative and preventive medicine. In a recent address at the Jubilee Congress of the Medical Association, the Secretary for Health I quoted as using the following words when referring to Health Services: 'The service will have to succeed in establishing and maintaining the optimal balance between the preventive, the curative, the health-promotive and the rehabilitative components of a comprehensive health service.''' This quotation expresses an entirely logical and desirable objective, but ignores the point that individual curative medicine is thousands of years old, whereas the other 3 components are new competitors for personnel and funds. Therefore, to avoid ambiguity, I am using the following words and terms as defined: 1. Medicine or medical services denote tho e activities applied or directed by medical graduates (registered medical practitioners); 2. Curative or individual medicine denotes those medical services applied to sick individuals for their diagnosis, cure, rehabilitation or symptomatic relief. When it attempts to see the individual's sickness problem against the background of family and community we call it comprehensive medicine, provided that it is applied primarily to the individual.

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3. Preventive medicine denotes those medical services which direct the promotion of health and the prevention of illness in communities. It has been called public health, environmental medicine, social medicine and more recently, community medicine. At the moment I am concerned with the inevitably emerging competition for service and national funds on behalf of preventive medicine, to the possible detriment of curative medicine. A great deal can be done in the future to relieve the burden of work falling on the public health doctor by training health assistants, health nurses and other classes of medical aUXiliaries. This should enable him to shepherd his specialised training into the direction and planning of programmes. At the same time, it will ease the financial burden of preventive medicine and its threat to the resources available for curative medicine. Likewise, in the curative field, the doctor's time can be saved by other types of medical auxiliaries, so that he is able to continue to give his personal medical attention to the sick individual for whom it is so vitally needed.

The Importance of the Sick Individual

If I am right that so ardent and expert a clinician as myoid teacher John Ryle missed the importance of this medical paradox when he became Professor of Social Medicine, then clearly we must beware. In reflecting on this possibility, I have become more than ever convinced that the undergraduate programme of medical education must remain common ground for all intending medical practitioners, whatever their postgraduate speciality may become, and whether the latter be oriented towards individual or community medicine. Only thus can the importance of the clinical approach to diagnosis and treatment of the individual be retained in the minds of those who proceed to postgraduate studies in community medicine. My conviction implies that in correcting the too exclusive concentration of medical education, during the first half of the 20th century and throughout medical history, on the wards of the hospital, we must not swing the pendulum to a point where there is any doubt in the student's mind about the infinite importance of the 'sick soul'. I use this term deliberately at this point in the argument, not in a religious or theological sense, but in the psycho-emotional sense that distinguishes a person from an animal. However, I shall not repeat it, but will talk of the 'sick individual'. As a side-thought, one may reflect that the increasing number of married medical students in our modern medical schools may be important in preserving the 'importance of the sick individual', because it is often in marriage that the student relearns the forgotten priorities of the parental home where the claims of the individual child are always important. Here he tends to outgrow his adolescent enthusiasms for political answers to the plight of mankind.

a 'blue-print for decision and action is a taxing task which will certainly go wrong if the 'principles and priorities' are ignored. In my opinion, certain decisions must be made before a programme of action can even be outlined. Consensus must be reached on toe rightness or wrongness of applying certain logical developments arising from scientific technology to our HippocraticJudeo-Christian principle of the infinite value of each individual. Must heart transplants be provided for all those threatened by progressive heart failure, or kidney transplants for all those affected by progressive renal failure? I think that decision has already been made in the negative, by general agreement that quality of life is more important than quantity of life, and that heroic measures for the extension of a disabled life will only be offered to those who are likely to enjoy, and be enjoyed, in their extended lifespan. I submit that this decision has been made, and is already being applied. A difficult decision which must soon be resolved by consensus is whether there may be selective termination of pregnancy when prenatal tests declare that the fetus will not be capable of 'meaningful' independent existence. Virtually everyone is agreed in the case of monsters and severely demented persons. But what about Down's syndrome (mongolism) in its varying degrees, the severity of which can only be assessed after birth? Can we say that persons with the mildest degrees of Down's syndrome are incapable of meaningful existence? Here there is no consensus, because science teaches us little, if anything, about the content of meaningful existence. That is a philosphic and ethical topic often tinged with theology. while sectarian religion or humanism lend controversy in which consensus becomes difficult. I contend, however, that there are degrees of this and other congenital defects which we could define. I believe we must do this. H exceptions are to be defined, there must be some improvement in machinery. At present they are defined by the well-tried method of consultation between doctors, close relatives and selected colleagues. It has worked well in the sphere of early selective abortion on strictly medical indications. The latter is now legal in this country, but the machinery will require some more generally acceptable legal standing in the near future. How many and what classes of people are to be consulted, and who takes the final decision in the absence of a consensus? Should neonatal resuscitation be withheld from the infant who is obviously severely malformed? What physical supportive steps are to be offered to those who are approaching or already at the end of purposeful physical existence? Who turns off the pump and at what point in, for example, the progress of a patient with irreversible traumatic brain damage, who has to be maintained on an artificial respirator? I believe tbat these problems will easily be solved if we agree on tbe decisions which have already been taken and applied by consensus. That consensus is, I believe, expressed in the frequently quoted Thou shalt not kill, yet need'st not strive, officiously to keep alive'. It seems easy now, but it was difficult when it first became a problem for decision.

CONSENSUS AND DECISION

I believe I have now given my personal answer philosophic principle to my medical paradox. To fill
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The Curative Limb of the Paradox

We have cleared the air lightly if we agree that the traditional dogma of the infinite value of the individual has acquired some definable exceptions. The application of scientific technology has already reduced some of the traditional implications of the dogma to absurdity, e.g. the maintenance of artificial respiration for an individual with irreversible brain-damage when there i no meaningful life. Other advances in scientific and medical technology will certainly force us into the recognition that other traditional implications are wrong, e.g. that the recently fertilised ovum or even the early fetus is an 'individual'. Nevertheless, to me, the dogma of the infinite value of the individual is one of the highest expressions of our civilisation and of our medical idealism. It has served us well since before the days of Hippocrates. It is a source of compassion without which there is no satisfactory medical practice. That scientific advances should show up some of its tacitly accepted implications as out of date, does not destroy the dogma. But it does demand its revision in certain respects, as for example, in the acceptance of definable exceptions to its applicability. In discus ing the nature of a paradox I quoted as a 'received opinion' or dogma the proposition that 'individual human life is infinitely valuable'. I am now proposing the addition of a few words so that the dogma becomes 'individual human life, with certain definable exceptions, is infinitely valuable'. The contrary tenet of 'the greatest good for the greatest number' is now less clearly contrary, and we may be on the way towards a solution of our paradox 'for our time'.

CO CLUSIO
Although 1 cannot pretend to have resol ed the paradox. I have suggested some way in which the apparent competition between preventive and curative medicine for national funds and medical personnel can be relieved. These mea ure depend upon a medical consen us between all branches of the medical profession and continued mutual understanding and respect between its curative and it preventive wings. I believe that a recapitulation of principles and priori tie upon which a con ensus can be based will al 0 erve as a summary of my an wer to thi particular medical paradox.

Principles and Priorities

I. The historic 'dogma' of the infinite value of the individual must be reaffirmed again and again by the medical profession and supported by the community. Its emerging threat to engulf our resources can be neutralised by defining exception . 2. The comparatively new speciali ed group of public health practitioners or practitioners in preventive medicine must support their curative or clinical colleagues in this first principle and must help to develop machinery for medical consensus on principles, priorities and exception. 3. They must, as the mouthpieces of the medical profession to government and parliament, analyse the problem of curative versus preventive medicine, and so formulate a public consensus. 4. This consensus must recognise that the provision of most of the requirements for health such as food, housing, hygiene and general education. is a matter of good government upon which preventive medical services can build through medical education. Doctor should not have to spend their specialised time urging government to provide these physical necessities. 5. Both the curative and the preventive medical services can be diluted with specially trained medical and health auxiliaries so that the long and expensive training of the medical practitioner can be used where it will always be most needed, namely in the direct or indirect care of the infinitely valuable individual in the context of his home and community.
REFERENCES
I. Brock. J. F. (1971): Unpublished data. 2. Huxley, Sir J. ill Wolstenholme, G .. ed. (1962): Man alld his Flit "re. 14th Ciba Foundation Annual Lecture. London: Churchill. 3. Pollard. A. H. (1972): Med. J. Aus!.. 2, 1025. 4. Penfield. W. (1961): The Torch. London: Harrap. 5. Chadwick. J. and Mann. W. . (1950): The Medical Works of Hippocrares. Oxford: Blackwell Medical Publications. 6. Bentham. J. (c. 1775): Collected Works of Jeremy Bell1ham. edited by Burns, J. H. and Hart, H. L. A. University of London: The Athlone Press. 7. Chadwick. E. (1842): The Sanitary Conditiolls of the Population 0/ Great Britain. Edinburgh: University Press. Southwood Smith. T. (1847): The Philosophy of /-lealrh. 3rd ed London: Cox. 9. Simon. Sir J. (I 90): English Sanitary Institutions. USA: Johnsoll

The Preventive Limb of the Paradox

Can the apparently insatiable demands of this other limb of the paradox be scaled down? I believe that they can be. Such necessary action as the provision of nutritious food, housing, hygiene, etc. is in no ense a medical responsibility. The shortages are determined by our socioeconomic system, which in turn depends on our politics. The programme of preventive medicine should rightly begin only after all the physical, educational and other needs of the whole population have been provided. It should then be the task of preventive medical services to ensure through health education their proper use, i.e. consumption of the right kinds of food, control of population pressure. the application of the principles of cleanliness and hygiene. This is largely a task for non-medical personnel acting under the direction of preventive medical practitioners. The latter shoMld not have to spend time trying to persuade the government that the population or any part of it needs more or better food. The requirements of millions of people of any class or colour are laid down in tables of nutrients which are easily translated into those foods which the country can most easily grow or rear. This should be the work of agronomists, not of medical practitioners. Unfortunately our preventive medicine practitioners will for a long time have to keep up the hue and cry against bad government. Similar arguments apply to housing. hygiene and general education.

10. Shattuck. L., Banks. . P. and Abbot!. 1. Unpublished d31a. 11. Ryle. J. A. (1936): Nfllural History of Disease. London: Humphrey Milford. 12. Idem (1948): Challgillg Disciplines. London: Oxford Universiry Press 13. De Beer, J. (1975): South Africall Medical Post, March, p. 4. 14. Moore, F. D. (1976): Lancet, 1, 3. 1-. Mahler, H. (1975): Ibid., 2, 29.

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