Change in care?

Part 2: Social Prescription or Medical Proscription?

This is part two of a four-part blog series, entitled Social Prescribing, a panacea or another top-down programme?

Part 1: Social Prescribing, a panacea or another top-down programme? 
Part 3: The Importance of Asking
Part 4: We Don’t Have a Health Problem, We Have a Village Problem.

This week’s blog focuses in on the ethical role of the doctor in supporting people to have a good life at the center of community, and argues that that role cannot be fulfilled through prescription or referral but through relationship building, advocating for pathways to citizenship, and ending the medicalization of socio-economic and political issues.

Because I will be comparing terms such as prescription and proscription, not to mention genuine participation and liberation, I’m going to start the post with a few working definitions:

Prescription:

  1. an instruction written by a medical practitioner that authorizes a patient to be issued with a medicine or treatment.
  2. a recommendation that is authoritatively put forward.

Proscription:

  1. the action of forbidding something; banning.
  2. condemnation or denunciation of something.

Participation:

  1. the action of exchanging gifts, skills and passions with others.
  2. the act of engaging with others in valued social roles and contributory civic efforts.

Liberation:

  1. the action of setting someone free from imprisonment, slavery, or oppression; release.
  2. freedom from limits on thought or behaviour.

Introduction: First do no harm (Primum non nocere)

When thinking of the Hippocratic Oath, most quote the well-known dictum: “First do no harm” (Latin: Primum non nocere)”. Interestingly those words don’t appear in the original text: https://en.wikipedia.org/wiki/Hippocratic_Oath#Text_of_the_oath although the phrase: “I will utterly reject harm and mischief” does. My sense is we really need our Doctor to engage in more mischief making, if not outright heresy, while at the same time as doing no harm to the people and communities they serve. As I’ve argued previously in In Praise of Medical Heretics and in Search of More we need more doctors like Dr. Robert Mendelsohn, a self-proclaimed medical heretic and author of books with titles which reveal his antipathy towards medical hegemony, like Dissent in Medicine-Nine Doctors Speak Out. In Dissent in Medicine he revealed the following:

“In the late 1960s, my patients began to return to me with the diseases that I had previously created. The first group of patients were the ones with cancer of the thyroid gland, because, when I was trained at Michael Reese Hospital as a pediatric resident, I learned that the proper treatment for tonsillitis was X-ray therapy. Together with hundreds of other doctors, I prescribed X rays for the tonsils. This led to an epidemic of tens of thousands of cases of thyroid cancer. The second group of patients had permanently yellow-green stained teeth from tetracycline given for the treatment of acne. The third group were the DES sons and daughters. When I was a medical student at the University of Chicago, I participated in the DES experiments in which we gave women that female sex hormone diethylstilbestrol in a fruitless attempt to prevent miscarriages. It didn’t work, but it did leave us a generation of sons and daughters with tumors and malformations of the reproductive organs…
When I first recognized those events in the late 1960s, I thought that perhaps that was all past history in medicine. Doctors today must have learned from their mistakes…
But, when I look today at diagnostic ultrasound, immunizations, environmental pollution, amniocentesis, hospital deliveries, allergy treatment, and practically everything else in medicine, it is obvious that doctors haven’t changed at all. They are simply making a different, new set of mistakes.”

The proscription against doing harm is at the heart of medical ethics, and is beautifully captured in the modern version of the Hippocratic Oath (see annex 1 below for the full version). Mendelsohn was the very embodiment of an ethical doctor, as well as being honest to a fault, he believed his primary role was to ensure he did nothing to displace the health producing capacities of people and their indigenous communities, in other words he was more engaged in medical proscription, than prescription.

He also understood the power he had as a nationally respected Pediatrician in protecting the health producing capacities of local communities. Marion Thompson, the president of La Leche League International, credits him as a central figure in supporting the movement to flourish across 87 countries around the world. He supported the movement by engaging in rear guard action against the naysayers in the formal healthcare systems, both as a medical authenticator of the health producing value of breastfeeding and as the chief heckler of anyone from the medical compact who attempted to undermine or devalue the efforts of this mother-led, lay person movement.

Proscription/Prescription

The 1964 version of the oath frames the dual and related functions of the doctor as a) ethical medical prescription and b) proscription. Ethical medical prescription is a legitimate function because a doctor has the keys to the ‘medicine cabinet’, so to speak, and hence the authority to prescribe necessary medicines for biomedical issues. {Medical} Proscription is equally if not more important because with that authority comes the responsibility to not prescribe anything from the ‘medicine cabinet’ that may cause harm.

The role of Gapper

Mendelsohn teaches us about a third role, which may be described variously as the role of the ‘border hound’, ‘line-backer’, ‘centennial’, ‘heckler’ or ‘gapper’, take your pick. These roles, only make sense when we recognize that society is composed of two distinct domains, an institutional domain, governed by legal, contractual and administrative norms (bureaucracy), and a community domain, where citizens associate for their own purposes in more covenantal than contractual terms and where people matter for themselves. While these two domains occupy the same space, they are fundamentally different, and perform different functions when it comes to learning, justice, safety, and wellbeing. Some social policies and the institutions that implement them, respect these differences, and work to keep the two domains in the right relationship with each other, and assign each their appropriate functions.

Most institutional advocates however do not respect the integrity of the community domain, their primary agenda being to treat perceived problems with institutional solutions; not to defend community capacities. In the process communities lose the capacity to perform the functions that were and still are in principle their birthright. Within this frame, the role of the ethical professional is to occupy the gap between these two domains and to challenge any colonial/imperial impulses of bureaucracies, hence opening more space for communities to grow and become more powerful and health creating. When understood in these terms the role of the doctor is critical to community and individual wellbeing, and their impact can stretch well beyond their surgery.

Medicine is currently going through a great transition from the science of treating sickness to the science and art of health creation. Increasingly savvy doctors, allied health professionals and Community and Voluntary Sector (CVS) are recognizing that they cannot unilaterally produce health; that in fact health is not a product to be dispensed by professionals and consumed by ‘the sick’.

In UK, “Social prescribing”, as defined in last week’s post is being put forward as evidence of this transition. However before advancing along these lines we must ask: ‘is “Social Prescribing” the correct term to use to describe health creation?’ Or more specifically does this term properly describe and value the process by which a doctor enables one of her/his patients to make the journey towards interdependence at the heart of community life? In answer to these questions, I believe the term ‘Social Prescribing’ is a misnomer for three reasons:

  1. The word “prescription” does not accurately describe what impactful doctors with the support of link workers are doing to broker people back into interdependent relationships or to support them to maintain existing bonds;
  2. In some instances the practices of social prescribing have become too oriented towards referral and signposting, in part because prescribing is by nature programmatic and insufficiently relational.
  3. The doctor has authority over the medicine cabinet, but has no real authority over associational life in modern communities, and hence needs the support of allies.
In sum the word “prescription” does not describe what impactful doctors do.

Freirean critique of prescription

Paulo Freire’s ‘banking’ concept of education describes a critique of the traditional education system, where students as treated as containers into which educators must put knowledge. As banking is to pupils, social prescribing is to patients.

To explain: Freire, building on the banking critique, asserted that one of the basic levers of power between the oppressor and the oppressed is “prescription”. In his ground breaking book Pedagogy of the Oppressed he states a:

“pedagogy of the oppressed must be forged with, not for the oppressed, whether individual or people, in the incessant struggle to regain their humanity. One of the basic elements between the oppressor and the oppressed is prescription”.

Of course, an ethical doctor would never intentionally seek to oppress a patient, but Freire’s analysis of ‘prescription’, presents a critique not of individual behaviours, but of social norms. Social norms across human societies routinely promote some to valued positions, while others are relegated to devalued roles.

Whenever a doctor sits across from a person whose personhood has become devalued, there is an imbalance of power, since few are more socially valued in general society than doctors. Not to acknowledge this in the first instance is to risk breaching the doctors covenant (annex 1) with the people he/she works for: first do no harm.

The alternative to prescription or banking is liberation, which situates the doctor in the role of ‘alongsider’, the role of participation or citizen advocate, not prescriber, but proscriber and heckler extraordinaire.

So, is a doctor a social prescriber or a participation advocate?

In pursuit of a good life: beyond prescriptions referrals, and activities

With respect to Social Prescribing practitioners who refer to social activities, thinking about people in terms of what social activities they may wish to engage in is certainly better than leaving them languishing in isolation, with limited connections to the wider community and few if any valued social roles. Yet one activity per week is not the same as having a good, satisfying life that goes with the rhythm of the seasons. Where one engages in many activities which change with the natural rhythm of things, from day to day, week to week, month to month, session to session, at special times of the year like: holidays, birthdays, through life stages, and significant life events such as one’s first job, finding a life partner, having a child and so on. Referring people to social activities within a community is simply addressing the symptoms of a social ‘dis-ease’ and ought not to be confused with a process that genuinely creates pathways towards satisfying and enriching life experiences.

This is not about finding people roles within the context of a programme, or activities but within the context of a society: most human-beings want to have some status and good reputation. People will never belong when they are just dropping in. People who are socially isolated, are not deficient in social activities per se, but in opportunities to contribute their gifts and receive the gifts of others outside of contract or exchange of money. Which is to say, they’re primarily missing reciprocal connections that create a sense of belonging and self-belief in their own gifts, skills and talents. That said before we can support people who are isolated to grow pathways to a satisfying life, it is critical that we know what some of the obstacles out there are.

The harsh reality is that certain qualities and conditions are profoundly devalued, such as:

  • Oldness
  • Addiction
  • Having physical/intellectual/cognitive impairments
  • Living on low income

 

Doctors know better than most, that when people are devalued because they embody these life qualities and life conditions it has life altering consequences for their wellbeing, which include:

  • Rather than being seen as a whole-person with an identity, a nature of one’s own, hopes, preferences, etc. they become seen as their condition.
  • This then leads to a deficit orientation where other people can’t see the capacities or the potential of the person. They do not for example see how the person communicates but simply that they are “non-verbal” which too often is code, for “non-communicative” or “non-responsive”.
  • When people solely focus on a person’s deficits they assume that person needs to be in special places with other special people, supported by qualified people who can look after them. In this way, labelled people often end up being rejected from mainstream society and segregated into such special places, where the opportunity to experience socially valued roles, in society at large, are foreclosed on.
  • The net effect of this rejection is a distancing from neighbours, neighbourhoods and community life, being put apart and sometimes away, either physically or socially, in what some have aptly called: “Service-land” and others “Apartheid”.
  • Another part of this mindset is that people get cast into negative roles, such as not being fully human, alien, treated as objects, viewed as objects of pity or a burden, some adults are put into the role of perpetually being children (e.g. a Child Psychologists/Psychiatrist tells parents of a child with intellectual learning differences: ‘your child will never function beyond the developmental age of a 7 year old, and so parents are “trained” to spend their son’s or daughter’s lifetime treating them as children).
  • Another negative role that is regularly assigned to labelled people is the role of ‘client’, people can literally lose their identity and be referred to not by name but as clients, or service users. Thereby defined by what they are in relation to the service system, and not what they are in themselves or as they relate to family, friends and community. More humanising labels that professionals could use might include: people I work for, people I support/serve, citizens.

 

These kinds of role perceptions act as powerful barriers to the meaningfully participation of labelled people in community life. Worse still people who are assigned limited role expectations are regularly subjected to all kinds of discrimination and abuse. Practices such as prescribing, referral, or signposting run a high risk (albeit inadvertently) of further reinforcing such devalued and demeaning role perceptions and limiting expectations. Hence to avoid further compounding such oppression and to begin to address these barriers the oppressor and the oppressed must first accept that the oppression is real and then be prepared to do something about it, while simultaneously believing in the potential of abundant and welcome community.

Next week (third blog in the series) we will get practical and look at how a doctor with the support of neighbours, allied professionals in the Public Sector and the Community and Voluntary Sector, can work to support someone to live well with Dementia in their home and in their community. We will also highlight the fact that the doctor cannot do this alone, they need support.

The fourth and final blog will propose a makeover for Social Prescribing; outlining an alternative framework that emphasises participation, community building and the importance of the ‘Good Life Conversation’.

Key message of the blog: Supporting people to create pathways towards a good life is not about prescriptions or referrals, it is about walking alongside people in their life’s journey. A doctor can’t do that alone, but they can advocate for greater participation and ensure that social issues are not medicalised, and community efforts are not devalued.

Cormac Russell

“I believe it is time to state clearly that specific situations and circumstances are “sickening,” rather than that people themselves are sick. The symptoms which modern medicine attempts to treat often have little to do with the condition of our bodies; they are, rather, signals pointing to the disorders and presumptions of modern ways of working, playing and living.” – Ivan Illich

References :

  1. PEDAGOGY OF THE OPPRESSED by Paulo Freire. New York: Continuum Books, 1993.

Annex 1: Modern version of Hippocratic Oath.

Modern version of Hippocratic Oath:
I swear to fulfill, to the best of my ability and judgment, this covenant:I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

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5 Comments
  • Hugh
    Reply

    So, trying to connect someone with a service that could help them, at home, is a bad thing… Are all services bad now? Can’t we “refer” someone to a volunteer friendly visiting program, for example, that helps people get connected to their neighbours?
    How did we get to this?
    A referral can be a suggestion to try a different service or product. A trusted clinician doing this at a moment when someone is particularly motivated just seems like a good idea.
    A referral is not the same as a “prescription”.
    An “advocate “is fine too, I just don’t know why the result of an advocate’s action can’t be to refer someone to a program that could help them, and get them connected with someone at that program.

    August 20, 2017 at 3:06 am
    • Hi Hugh, thanks for your comments. Sorry you had so much hassle posting. That was a glitch nothing more. Appreciate your point of view, and I’m pretty sure you’re right that there’s some really good practice and intentions underpinning SP. The perspective I’m aiming to advance is that Residents in association with each other have an irreplaceable set of functions when it comes to health, for which there is no medical proxy. Professionals must tread carefully when operating in asymmetrical power relations. I don’t think this is too radical a position to hold, but respect the fact it’s not everyone view. I simply don’t accept that services alone produce health. It is my concern that good community development efforts are struggling while SP seems to be yet another initiative, which is bypassing community. Holding up efforts on the ground. Anyway I hope you read the remaining blogs and appreciate your comments. BW Cormac

      August 21, 2017 at 7:13 pm
  • Hugh Bornio
    Reply

    I have tried to post comments. Each time I do, it gets deleted. Is this a mistake. Feels like your ‘inclusive, bottom up’ approach is a lot of hot air.

    HB

    August 21, 2017 at 3:01 pm
  • Meg Wright
    Reply

    I think there is a real need for all people to be respected and recognised for their skills and talents rather than what they cannot do. People will need services at various points in life, but in my experience they thrive when they can participate in the service rather than merely receiving. I know that is not for everyone, some people may want a referral, service then go home. But we must be open to a more inclusive form of approach at supporting health and well-being. Loved the blog Cormac

    August 21, 2017 at 8:42 pm
    • Many thanks for your kind words Meg. I’m chuffed that this resonates with your lived experience and values. BW Cormac

      August 22, 2017 at 9:11 am

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