In an ideal world people would perhaps live such healthy lives that medicine would wither away. In this spirit, utopias are portrayed as realms where the ills of the world at large are ruled out both in principle and in practice.

Among the first genuinely preventive medical measures was the control of traffic into and out of municipalities hit by the plague, a policy that may have contributed to the eventual disappearance of that scourge from Europe.[1] In some cases visitors from plague-infected regions were temporarily confined on an island. A utopia might be envisioned as such an island writ large, except that in this case the quarantine secures against infection from the surrounding world instead of the other way around. Utopias are fantasies of prevention.[2]

The prevention imperative governs the original utopia, Plato’s Republic, where a policy of censorship or moral quarantine excludes all corrupting influences beginning with the Homeric myths and fables. Because anything a young person “receives into his mind . . . is likely to become indelible and unalterable, it is most important that the tales which the young first hear should be models of virtuous thoughts.” The young are to be kept not only from hearing but seeing and imitating certain things lest they grow up with deformed minds and bad habits. Here then is radical prevention. The Republic is designed not to reduce the incidence of degeneracy among the guardian class but to make such degeneracy impossible by shutting off the sources from which it springs. Similarly ambitious policies of exclusion are at work in other utopias, most notably, perhaps, the one responsible for the word “utopia” itself—More’s fantasy by that name.

Like the Republic, Utopia (a man-made island as it happens) represents an exercise in prevention. Utopia eradicates the very possibility of the division between rich and poor that is the shame and ruin of Europe, eradicates it by doing away with the source of the evil: money and private property. More than this, the desire for riches is rooted out of the islanders’ hearts by the conditioning regimen to which all are subjected, generation after generation, from an early age. (They are taught to despise gold, a lesson illustrated and enforced by the sight of slaves decked with the metal.) Besides, why would the good citizens of Utopia seek to amass treasure and lord it over their neighbors when they already have everything they want? In addition to ruling out the glaring evils that afflict a Europe split between rich and poor, the Utopian way of life performs a more subtle kind of prevention. It precludes, eliminates at the source, the oppressive anxiety that is an everyday condition in the world as we know it. Nature itself enjoins the Utopians “to lead a life as free of anxiety and as full of joy as possible, and to help all of one’s fellow men toward that end,”[3] and this dictate they take to heart. Citizens can be permitted to pursue their own pleasures in Utopia precisely because they are such easygoing beings—because the darker passions are virtually unknown to them. As two thoughtful commentators have written, Utopia

is not a rigorously regulated and repressive society whose constraints were dictated by fear. This is the feeling conveyed to later generations. Utopia was a society of do’s, not do not’s. . . . Perhaps the Utopians were low on the transcendental, esteemed commodiousness too much, but they lived in peace and tolerance. More set the tone for the utopia of calm felicity that dominated much of Western consciousness up to the end of the eighteenth century: a quiet, stable existence free from anxiety, marked by honest allowable pleasures.[4]

The Utopians are free from anxiety because the wisdom of their institutions has precluded it from occurring. By no means did the ideal of an anxiety-free existence die out in the eighteenth century, although neither did the Utopian ideal so dominate consciousness that it was spared satirical commentary and analysis.

In Johnson’s Rasselas the children of the Abyssinian royalty are confined in a Happy Valley surrounded by mountains on all sides—in effect, quarantined.

Here the sons and daughters of Abissinia lived only to know the soft vicissitudes of pleasure and repose, attended by all that were skillful to delight, and gratified with whatever the senses can enjoy. They wandered in gardens of fragrance, and slept in fortresses of security. Every art was practiced to make them pleased with their own condition.

Like More’s Utopians, the prince of Abyssinia lives a designed existence, surrounded with licit pleasures and shielded from the sources of anxiety. Quite as if Johnson were satirizing the Utopian ideal, however, in the case of Rasselas a prescribed existence serves only to breed the unhappiness it was intended to prevent. “When he looked round about him, he saw himself confined by the bars of nature which had never yet been broken.” In a Johnsonian paradox, the young prince is subjected to a prevention regimen so rigorous that it defeats itself. Happy Valley is at once utopia and dystopia, as indeed the ambition of managing human life in the name of prevention contains ominous as well as promising potential. As an illustration of the usage of “prevent,” the OED offers the sentence, “The idea is to prevent a crime, rather than wait for it to happen, by looking out for people who fit a suspicious profile.” Orwell’s Nineteen Eighty-Four can be read, just so, as a dystopian fantasy in which the Party identifies a suspect and nurtures, superintends, and crushes his rebellion against its own power, all in the interest of testing some fantastic, hubristic theory that crime can be rooted out—prevented—before it matures and manifests itself. If the ideal of prevention presides over utopias, the perversion of prevention presides over the supreme dystopia.

More’s Utopia, it is said, is a society of do’s, not do not’s. The ideal of a life free of the restraints and regulations of the world as we know it has inspired not only paper utopias but actual experimentation, most recently perhaps in 1960s when untold numbers of communes, cults, and co-operatives were launched in the name of human liberation. As I have argued, the language of the pop psychology movement now so fully institutionalized dates traceably back to the human-potential jargon of the 1960s.[5] In other words, it is utopian in spirit, and this being so, it is no wonder that it plays on and with visions of an alternative reality where people live lives of innocent enjoyment, free of self-reproach, anxiety and stress, in the manner of the original Utopians. Pop psychology inveighs continually against prohibitions—do not’s. Among the more radical aims of libertarian visionaries a generation ago was to bring up children communally, or in any case in such a way as to spare them the prohibitions and guilt that await anyone subjected to the hegemony of “society”—also a term of universal odium among pop psychologists. In theory, the lucky children would be the beneficiaries of radical prevention. Amid a society poisoned by false ideas and dying of its own way of life (much as Rousseau said), they would grow up healthy in mind and body.[6] The psychologists seek to extend similar benefits to those who had the misfortune to be born in society.

Afloat in our cultural biosphere is the notion that the tensions of modern life are very bad for both mind and body, with the implication that if only we led an equable, anxiety-free, uncompetitive existence like the Utopians we would enjoy better health. While marketed by the mass media, this proposition has also made its way into the medical literature. Recently, for example, a paper in Urology reported on the Prostate Cancer Lifestyle Trial, in which subjects already diagnosed with the disease but committed to watchful waiting rather than immediate treatment were assigned either to a control group or to “a 1-year intensive lifestyle change program,” including in addition to a vegan diet “stress management techniques” and a “1-hour weekly support group to enhance adherence to the intervention”[7] (all loosely reminiscent of the “temperate living” that renders More’s Utopians “liable to fewer diseases” than the rest of humanity),[8] to see if these measures had any preventive effect. Of 181 patients judged eligible for the study 93 participated, the reported reasons for the large percentage of refusers being “an unwillingness to make or not make the comprehensive lifestyle changes and/or a refusal to undergo periodic testing.” One suspects the deterring factor was an unwillingness to make, not an unwillingness to be barred from making, wholesale changes to one’s way of life. Like many or most men, those who declined to enroll in the PCLT may not have wanted to adopt a theoretically ideal behavioral regimen, and indeed may not have had the leisure to do so. How many are able to devote their life to avoiding stress? If the ideal of a frictionless existence has utopian echoes, an experiment in which half the eligible subjects decline to participate seems to be telling us something about the limits of the possible. Knowing they had cancer, the 181 potential subjects were presumably motivated.[9]

The paper reports that after one year the subjects in the experimental group showed a “significant” reduction in PSA (a biomarker associated with prostate cancer). In point of fact, their PSA declined marginally—by 4%, a figure that in any single case would be regarded as negligible, virtually within the margin of error of PSA testing.[10] Even if PSA is taken as a surrogate for the progression of cancer—and as the authors note, the very question of “what constitutes cancer progression” in patients like those in the PCLT has no conclusive answer—the PCLT provides less than compelling evidence that therapeutic rituals and dietary reform served to slow the disease. Although the experimental group did record fewer “prostate cancer-related clinical events”—in other words, underwent less treatment for the disease—two years after the trial, that is because the men in the group chose less treatment, perhaps in the belief that the behavioral regimen was itself a treatment. After all, the subjects in this study, unlike those in, say, the landmark Prostate Cancer Prevention Trial which ran from 1993 to 2003, were not blinded; they knew very well which group they were in. (The finasteride group in the PCPT showed a 25% decrease in the incidence of prostate cancer.) The authors themselves conclude, “the observed group difference in the incidence of treatment might not necessarily imply a group difference in cancer progression.” As in this case, some factor beyond the evidence seems to be driving interest in the theory that we can slow, arrest, or altogether preclude cancer by reforming our behavior. That factor I believe to be the utopian fantasy of a preventive way of life. The architects of the PCLT conclude that whatever the clinical effect of the “comprehensive lifestyle changes” in question, at least the experimental group by and large avoided the harms and expenses consequent on medical treatment for two years. According to More, the Utopians have less need for doctors than any other people.

Participants in the Prostate Cancer Prevention Trial underwent a total of some 1800 biopsies. No such hard evidence was collected in the PCLT, though the subjects’ reports of their own behavior was deemed evidence. (“Adherence consisted of self-reported diet, exercise, and stress management behaviors that were used to compute an index of adherence to the lifestyle program.”) The report, or avowal, is the enabling convention of utopian literature. As in More’s serio-comic tale, a traveler who stumbles on a wonderland tells the world of his discovery in the manner of a reporter, usually in language devoid of the convincing detail of good novelistic prose.[11] Papers on the PCLT give only the barest sketch of the behavioral regimen in question—“gentle yoga-based stretching, breathing, meditation, imagery, and progressive relaxation for a total of 60 minutes daily”—leaving a reader with little sense of what it really consists of.[12] What is “imagery”? Are we to believe that the 200,000 American men who stand to be diagnosed with prostate cancer this year will dedicate themselves to “breathing” in the hope of arresting the disease? At least the PCLT’s experimental diet, supplemented by vitamins C and E and selenium among other things, is specified to some degree. A few weeks after the paper was published, the SELECT Trial (Selenium and Vitamin E Cancer Prevention Trial) was halted when it was determined that selenium and vitamin E do not prevent prostate cancer. As for the diet itself, shortly after the initiation of the PCLT, published results of studies involving thousands of men showed that a vegetarian diet had no effect on prostate cancer mortality.[13]

Nevertheless, by its own logic the authors’ recommendation that “an intensive lifestyle program might allow patients choosing active surveillance to delay conventional treatment” (perhaps implying that the lifestyle regime represents unconventional treatment) could go much further. For if, as they believe, such a program shows promise for prostate cancer patients, would it not make sense to institute it well before the day they become patients, in other words preventively? Why not pre-empt the disease rather than simply waiting for it to happen? It is known to have a long latency period, after all. However, to follow a sort of quasi-religious preventive regimen for years on end would place men in the position of obsessively concentrating their lives on the prospect they want to avoid, which hardly seems the way of health. I believe the reason the PCLT is open to all these quarrels and criticisms is that while the study followed some of the protocols of a clinical trial, and while its results were reported in a medical journal, it was animated by a utopianism foreign to evidence-based medicine.[14]

No doubt it would be better to prevent a disease like prostate cancer than to treat it, if only we had means of prevention both safe and effective. But as interest in prevention grows—and prevention after all is on the frontier of medicine—it is important not to fall into utopian thinking. Prevention is so strongly associated with the utopian tradition, and utopian notions continue to exert such attraction, that even medical research may find itself drawn toward utopianism by a kind of gravitational pull. When utopianism does enter into medical reasoning it can only feed fantasy, as when the authors of the PCLT paper hold out the hope that certain mental and social practices can not only slow but, incredibly, actually “reverse” existing cancer. It bears remembering that utopia means nowhere.

Notes

[1] “Perhaps local and national policies of exclusion through quarantine and the cordon sanitaire finally worked.” Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: Norton, 1998), p. 238.

[2] Writes Chernyshevsky in What Is to Be Done?: Under the existing system the hardships visited on women are “inevitable. . . . It was exactly the same with smallpox in the days of old, before people learned how to prevent the disease.” That is, following the transformation of society into a utopia, the oppression of women will disappear. What Is to Be Done?, tr. Michael R. Katz (Ithaca: Cornell University Press, 1989), p. 197.

[3] More, Utopia, tr. Robert M. Adams (New York: Norton, 1975), p. 55.

[4] Frank E. Manuel and Fritzie P. Manuel, Utopian Thought in the Western World (Cambridge, Mass.: Harvard University Press, 1979), p. 134.

[5] Stewart Justman, Fool’s Paradise: The Unreal World of Pop Psychology (Chicago: Ivan R. Dee, 2005).

[6] See the utopian manifesto included in Wallace Stegner’s Angle of Repose (New York: Penguin, 1971), pp. 513-15. Stegner may have invented this document in part or in full, but in any case it captures the tune of the times very well.

[7] J. Frattaroli et al., “Clinical Events in Prostate Cancer Lifestyle Trial: Results From Two Years of Follow-Up,” Urology, e-publication ahead of print 2 July 2008.

[8] More, Utopia, pp. 61-62.

[9] Other studies of healthy-behavior programs report compliance rates of less than 5%. M. A. Moyad and P. R. Carroll, “Lifestyle Recommendations to Prevent Prostate Cancer, Part II: Time to Redirect Our Attention?” Urologic Clinics of North America 31 (2004): 306.

[10] The PSA of the control group rose by 6%. The paper by Frattaroli et al. also reports that after one year the serum from men in the experimental group inhibited a strain of prostate cancer cells at eight times the rate of the control group. The clinical significance of this finding is unknown to me.

[11] In and of itself, the sharpness and urgency of detail in Nineteen Eighty-Four signals an ironic departure from the utopian norm.

[12] A paper on a related study has subjects attending “a 3-day intensive residential retreat.” Exactly what the content of this experience was is left to our imagination. Dean Ornish et al., “Changes in Prostate Gene Expression in Men Undergoing an Intensive Nutrition and Lifestyle Intervention,” PNAS, June 17, 2008: 8373.

[13] T. J. Key et al., “Mortality in Vegetarians and Nonvegetarians: Detailed Findings from a Collaborative Analysis of Five Prospective Studies,” American Journal of Clinical Nutrition 70 (1999): 516S-524S.

[14] Reminiscent of the communitarianism of Utopia is the New Age conclusion of another paper on the PCLT: “A sense of belonging to something greater, along with all the lifestyle program components, creates a synergy that helps men [in group sessions] feel positive and optimistic. . . . There is less conflict in their lives and they value a sense of community.” C. Kronenwetter et al., “A Qualitative Analysis of Interviews of Men With Early Stage Prostate Cancer,” Cancer Nursing 28 (2005): 106.

Stewart Justman is Director of the Liberal Studies Program at the University of Montana.