Dr. Kowaloff discusses aspects of appropriateness of medical care in an historical context much of which is rooted in the notion of "Do no harm". He identifies three sequential themes that inform the debate: 1) a historic debate within medicine to define the philosophical orientation and scientific foundation of medicine; 2) the rise of scientific medicine and the accompanying impulse for accountability and Quality Assessment; 3) the emergence of concerns of the lay public addressing patient autonomy and a redefinition of the Physician-Patient relationship.
By the 18th and 19th centuries, he points out, there were the competing "Heroic" and "Skeptic" schools of medicine. As the names imply, the Heroic school believed that in confronting disease one had to do something, even if of doubtful value, while the Skeptics noted that contemporary interventions were sometimes dangerous and it might be better to let nature heal. Over time the ancient admonition of "Do no harm" prevailed. As science and measurement became dominant in medicine, practitioners were able to make informed Risk versus Benefit decisions so that interventions were more likely to be beneficial than non-intervention.
In the mid 20th century the advance of science and technology led to the belief that medicine could bring miraculous benefits across a broad spectrum of illnesses. However, during the 50's the concept of iatrogenic illness began to be recognized. Although 5-8% of hospitalized patients sustained serious reactions to treatment it was believed that such harm was the price paid for receiving good care.
In the 1960's and 70's American society established a civil rights agenda and the concepts of self-fulfillment and self-determination. In this context and with the rising suspicion of institutions, the growing awareness of an iatrogenic burden gave rise to a backlash against the disproportionate authority and independence of physicians. This gave rise to the ethos of patient autonomy and the doctrine of informed consent arose. Standards of care, beyond sound science, had to encompass the individual patient's view of what constituted harm or benefit.
Then, in addition to personal values, the latter 20th century revealed economic realities that could challenge accessibility to high quality healthcare. Physicians were asked, for the first time, to consider resource utilization in decision making. Beyond avoiding harm to the individual patient, the physician had now to consider the healthcare resources of society as a whole.
Nevertheless, Dr. Kowaloff believes, that despite the increasing complexity and challenges to the role of a physician which he has recounted, we still continue to enjoy immense power to do good and assure the continued vitality of our healthcare institutions.