HIPPOCRATIC OATHS. Medicine and its discontents. Raymond Tallis. 342pp. Atlantic Books. £19.99. 1 84354 126 2.
Raymond Tallis is a man unusual in modern medicine. His career has been devoted to caring for, studying, and advancing the health of older people in society.
But while working as a Professor of Geriatric Medicine at the University of Manchester, he has developed a parallel career -as philosopher, critic, poet and novelist -largely unknown to his clinical brother- and sisterhood. Indeed, important though his medical work has been, it is likely that his philosophy, and especially his philosophical anthropology, will leave a particularly indelible mark on human affairs.
But Raymond Tallis's mind is at present on other matters. For now he is mad.
Furious. Hippocratic Oaths is a compelling and unrestrained catalogue of his hates. Sometimes his anger is personal. Liz Kendall -"whom I would have had to invent had reality not done the work for me" -is a journalist who wrote an article for the Observer in 2002 entitled "How I fell foul of the NHS". Her encounter with a doctor left her "mortified", although the clinical result of her experience was, as far as one can tell from Tallis's account, entirely satisfactory. Tallis describes Kendall's "angry response" to the care she received, and points out the lesson she draws from her tale -that a failure of communication by the doctor, combined with the provision of limited information, will often leave the patient, irrespective of the outcome, feeling very unhappy indeed. Tallis uses Kendall's experience to quite devastating effect. Ms Kendall seemed to want nothing less than a "tutorial on the function of the gall bladder and the pathophysiology of gallstones". How dare she! Tallis continues with Kendall's account of the plight of older people in society. He singles out her use of the word "pensioner" as an example of ingrained prejudice against those who could surely not "have anything serious enough to justify blocking her own access to the GP". His mocking tone scores a hit -and hurts.
Beyond Ms Kendall, the hates seem endless. Multiculturalism (whose "sentimentality" disgusts him), New Labour ("distrust-fuelled over regulation"), Frank Dobson ("disgraceful"), the Conservative Party ("malign"), Kenneth Clarke (who "judged doctors' motivation by his own"), primary care trusts ("inexperienced and fragmented"), the humanities ("for whom empirical truths are treated with disdain"), Michel Foucault ("the patron Saint of postmodernist attacks on the professions"), the precautionary principle (a "recipe for paralysis"), alternative medicine ("a corrupting effect on clinical medicine") and Thabo Mbeki's policies on AIDS ("appalling").
But Tallis's loves have their place, too, in this unflinching defence of medicine's contribution to our collective well-being. John Diamond's sustained attack on complementary medicine was "lucid, passionate, and very funny". The late historian Roy Porter's magisterial history of medicine, The Greatest Benefit to Mankind, was a "masterpiece". Onora O'Neill's 2002 Reith Lectures, in which she set out a subtle critique of calls for transparency and accountability among the professions, was "brilliantly handled". And the sceptical environmentalist Bjorn Lomberg (who occasionally transmutes into Sven elsewhere in this tract of stubborn resistance to the easy criticism of the press commentariat) is quite simply "brave".
Yet Tallis wants to do more than sum up a career of accumulated frustration in a prolonged outpouring of spleen. He promises to "change forever the way you think about yourself, and your health". He wishes to challenge the "unthinking voices" and "hostile critics" who so debase the public's view of medicine with their "ill-informed" and "shallow" analysis. He writes that his arguments are "deeply personal", reflecting the "supremely serious calling of medicine".
Indeed, the splinter that has provoked his treatise is the "fear that medicine may be reaching the end of its course as a profession".
Tallis is keen to pour the undiluted virtue of doctors into the minds of his readers. Doctors have an "unbearable heaviness of responsibility". Their reluctance to disclose the reality of "occasional errors" is not only a "particular cross they have to bear" but also a reflection of their "demeanour of calm authority". When doctors make mistakes they feel "frightened, guilty, and alone". The generalized attacks they have suffered in recent years -in the wake of scandals at Bristol Royal Infirmary and Alder Hey, and after Harold Shipman's career of serial killing was revealed in all its horror -have made medicine far less attractive as a vocation. Academic medicine is now in "crisis".
Senior surgeons do not want to be operated on by surgeons who are in training today. Doctors have endured cycles of political interference unheard of in most other walks of life. Their status has been so eroded that they have become "supine . . . offering little or no resistance to these incursions".
The unremitting vilification that typifies so much of the practice of medicine today removes any incentive to investigate the causes of medical errors indeed, prevailing attitudes merely encourage concealment of mistakes. In place of commitment and self-improvement, doctors are being taught to think more about their work-life balance, a shift in perspective that Tallis abhors. He sees today's doctors as unwilling to work long hours and hesitant about doing unpaid work. This sensitivity draws doctors away from their professional responsibilities and towards the distractions of "birthday parties, school football matches, and domestic crises". This "emergent social ethos", he writes, "is hardly compatible with a life of caring for and worrying over others". And Tallis's analysis of the profession's state spills over into his more general assessment of medicine, whose demise he sees as imminent.
Tallis has worked in the National Health Service for his entire career. He now recoils from the creeping metamorphosis of the patient into the client or customer. He winces at the conversion of the NHS into a "shopping mall of medical care", turning the doctor into little more than a common vendor. The managerialization of the health service has silenced the doctor's voice of advocacy, eroded his intellectual leadership and blunted his role as a scientific pioneer. This "absurd ballet" of "endless navel-gazing" has meant that doctors have moved into the reductive business of chasing targets. The mystique of medicine is being lost. Notions of duty, honour and collegiality are being corroded. These virtues are being replaced by an insidious bureaucracy -he cites the sinister creation of a "document-control coordinator" in his own hospital -which is destroying the capacity of the NHS to look after patients safely and effectively. In his characteristically vivid way, Tallis likens these difficulties within the NHS to "driving blood down a furred-up vascular tree into atrophied organs". The result? That "dying, terrified, depressed patients will not get the doctors they need because a society whose overriding values are consumerist will not produce them". The introduction of competition into the NHS has killed patients.
The best parts of Hippocratic Oaths are those in which Tallis writes about his personal experiences as a doctor. In one utterly moving passage, he expresses the fear of any parent about the vulnerability of his children. He conveys his sense of empathy for the bereaved parent -the responsibility, grief, guilt and failure. But he uses his own understanding of patienthood to warn that simply because patients have often been through an intense emotional journey, that does not give them a uniquely valid right to criticize doctors for their alleged failures. Indeed, patients motivated by what they see as a doctor's error are potentially dangerous. Patients make mistakes just like their doctors. Their willing transformation into consumers suggests the idea that they are "essentially self-interested". This self-interest makes each patient the "direct or indirect enemy of every other patient". Tallis scorns the notion of the empowered consumer.
Tallis is right to argue that there is a sense of crisis within medicine. But it is not a crisis in the practice of medicine or within the system of our health care. The technical aspects of medical care improve steadily year by year.
Instead, the crisis lies within the profession itself. Levels of doctor discontent run high in most countries with advanced high-technology clinical care.
Why is there this pervasive decline in professional self-confidence among doctors?
Part of the answer, if one accepts Tallis's argument, is the acute loss in status that doctors have felt in recent years. Medicine is in danger of becoming "the first blue-collar profession". Doctors are now little more than tradesmen. The closure of the consultants' private dining room is a symbol for Tallis of the collapse in the doctor's personal authority. Journalists do not help. They must bear the greatest guilt for dulling the lustre of professional medical pride. Tallis cannot take seriously media whose only measure of success is sales. While he is careful not to damn all journalistic writing (Polly Toynbee and Nicholas Timmins are spared), he does credit print journalists in particular with fostering a culture of contempt for doctors.
But the darts thrown by the occasional journalist are only one very superficial symbol of a far more serious structural fault-line apparent in modern medicine.
Doctors now face patients who speak the language of rights. Instead of being enormously grateful for the advice and treatment they receive, patients demand their health rather than meekly enquire about it. This change has put doctors on a collision course with their patients.
Many medical practitioners still see their role as one of benevolent paternalism towards patients, rather than one of binding partnerships with them. And we can see why. The doctor will have what he will see as special knowledge and skills that the patient does not have. This puts him in a position to help someone if they are sick. If I break my leg, I must go to an orthopaedic surgeon to get it fixed; I cannot do it myself. I depend on the surgeon in an active and practical way to mend my broken leg; I am completely at the mercy of this person. To claim this surgical help as my right seems contrary to most of the rights I enjoy and take for granted in society today.
My right to freedom of expression does not demand anything from anyone else in the same actionable way that a claim to the right to health demands the care of a doctor. To argue the proposition that health is my right, and so that doctors have a duty to satisfy that right -and to be punished when they fall short of satisfying that right -seems to expose this rights claim to be the nonsense that it surely must be.
To argue that a doctor has a series of duties to the patient might also seem reasonable. The United Kingdom's General Medical Council talks incessantly about the duties of a doctor. But without attaching an equal set of duties to the behaviour of the patient -not to smoke themselves into terminal disease, for example -the anger directed at doctors who somehow fail to reverse ill-health seems, at best, rather unfair. In the spirit of equal partnership, the doctor might like to have the "right" to refer a patient to a General Public Council, alleging misconduct in the way the patient has abused his body and contributed negligently to his state of disability.
The point of this absurd scenario is simply to plead that the notions of rights and duties in medicine only take us so far -into the moribund territory of name-calling. The reason why we seem to have adopted the idea of health as a right rather than a privilege may be because we now put so little faith in trust. This seems to be Tallis's view, and he urges us to reject it. "We have to trust in trust", he writes; "suspicion has to end somewhere for any profession to continue to function."
Here, I part company with Tallis. The idea that trust in a doctor is some monolithic foundation stone that, if chipped away, risks bringing the entire edifice of medicine crashing down seems to me far-fetched. We need a far more nuanced analysis of trust in medicine if we wish not only to understand why doctors are so unhappy, but also to make them happier, in order, it is to be hoped, to make them better at what they do for us.
Trust requires belief in the person providing the care. Is the doctor someone who seems to put the interests of his patients before anything else? Surveys of the public show that people retain extraordinarily high levels of trust in their doctors. The public already trusts in trust at this personal level. A second component of trust concerns the confidence we have in the system of medicine being provided by the doctor. Do we believe that a drug prescribed to lower blood pressure is likely to be safe and effective? In this case, there is a series of trust relationships under scrutiny: with the pharmaceutical company that designed and manufactured the drug, with the regulator who licensed the drug, and with the scientist who recommended using this drug for high blood pressure. Despite the increasing attraction of complementary medicine, there is no evidence to suggest that society distrusts Western medicine in any serious or systematic way.
In one respect, however, we are probably more sceptical than we once were about what the doctor has to offer. This erosion of confidence is real, and concerns our inevitable state of dependence on the doctor when we are sick. The gap in knowledge between doctor and patient remains a wide one. Although patients can - and some do -become experts in their own conditions, this dependence naturally creates a sense of fear about one's future and the fact that one is now no longer wholly in control of that future. The patient has little choice but to share control over his life with the doctor.
Not unreasonably, this loss of autonomy can be unnerving. It is made all the more so by the Shipmans of this world. A reluctance to relinquish control without some deeper engagement with the doctor should not be surprising in societies where most people are better educated and more questioning about all forms of authority than they once were. Asking your doctor about what he is doing does not mean that you, the patient, have succumbed to Foucaldian critiques of the clinic. It does not imply a return to some quasi-medieval state of irrationalism.
It simply indicates that patients may wish to reset upwards the threshold at which they are willing to give themselves up to the power of the doctor.
Doctors would be wrong, in my view, to lament this loss of confidence. Less trust of this kind is a good thing. It suggests a desire among patients for more information -knowledge that, at its best, can help those same patients to take a more active and constructive part in their treatment. Doctors might be happier if they saw loss of trust as an opportunity to harness the greater interest patients now have in their care. Loss of trust could perform a useful service -to channel the anxiety created by a heightened awareness of dependence into a greater commitment to the therapeutic relationship with the doctor.
All of which presses the question: what is the ultimate purpose of this therapeutic relationship? As a humane doctor who has spent a lifetime caring for older people, Tallis is more sensitive than most of us ever could be to the positive possibilities of age. The old are today's underprivileged. Yet ageing offers hope, since "medicine can deliver on its twin aims of postponing death and reducing the burden of misery due to ill-health". The goal of medicine for Tallis is therefore "making the health span coterminous with the life span".
Older age offers "the possibility of a new kind of life beyond the traditional, sometimes unchosen narratives of ambition, development and personal advancement, and the biological imperatives of survival, reproduction and child rearing". This view has much to commend it. But it defines medicine according to a set of far too restricted coordinates: decrepitude and enfeeblement.
The therapeutic purpose of medicine has indeed been obscured amid the hoop-la of bedside technological wizardry. This absence of a shared understanding between doctors and society concerning the meaning of medicine seems to me the profession's most urgent predicament. One solution that I find attractive is to assert that medicine's primary purpose is to restore human dignity, an aim that would unite all doctors, irrespective of specialty or geography. The concept of dignity has a fine philosophical tradition. It suggests the idea of an individual's intrinsic moral and material worth, linked to a set of personally determined freedoms. Your unique dignity depends on you being able to fulfil your own particular needs and desires.
A doctor is there to help you do so.
In this way, a doctor's main role would be to restore the physical, psychological and social capacity of the sick person to allow him or her to live life in their own self-determined manner. Medicine would not be about returning the body or mind to an idealized state of normality. And it would not be error-free. Instead, medicine would be based on the more reasonable expectation that while sickness shortens the diameter of human possibility, medicine sets out to widen it. Such a purpose would give medicine a more humanistic and modest character, without lessening its scientific basis. That might be a rather good start for a modern medical oath, although I concede that Hippocrates -and, indeed, Raymond Tallis -might disapprove.
