Hippocratic Oaths

Medicine and its Discontents

Raymond Tallis

• Publisher: Atlantic Books
• Year: 2015
• ISBN:
  9781782396512
• Topic: Medicina
• Subtopic: Salud general

Contents

Acknowledgements

A (Very) Personal Introduction

PART ONE
Origins

1 The Medicine-taking Animal: a Philosophical Overture

2 The Miracle of Scientific Medicine

3 The Coming of Age of the Youngest Science

PART TWO
Contemporary Discontents

4 Communication, Time, Waiting

5 Power and Trust

6 Enemies of Progress

7 Representations and Reality

PART THREE
Destinations

8 ‘Meagre Increments’: the Supposed Failure of Success

9 The End of Medicine as a Profession?

10 ‘Everyone Has To Die Sometime’

Envoi

Notes

Index

Acknowledgements

This book owes its existence to the enthusiasm and encouragement of Jacqueline Korn of David Higham Associates, my agent, and of Toby Mundy of Atlantic Books. Toby it was who suggested the title of the book. Many thanks to both of you.

I am even more indebted to Louisa Joyner for her brilliant editorial work. Her eye for detail, combined with her clear understanding of the big picture, has resulted in countless suggestions that have dramatically improved Hippocratic Oaths from the original manuscript. Louisa, I can’t thank you enough. Louisa’s work has been complemented by the superb copy-editing of Jane Robertson, to whom I am enormously grateful for much judicious textual liposuction, vital structural changes, an intelligent scepticism that has tempered some of my more passionate outbursts, and an unremitting attention to important minutiae.

Finally, thanks are due to my secretary, Penny Essex a) for putting up with me not only during the period of gestation of Hippocratic Oaths but also for wonderful support over the preceding decade and a half and b) for chasing up many elusive references often on the basis of vague and/or misleading information.

1

A (Very) Personal Introduction

Nothing could be more serious than the care of ill people, nor more deserving of intelligent discussion. Few topics attract such media coverage; the National Health Service is never far from the top of the political agenda; and most people regard good health – and access to first-class care when they fall ill – as supremely important. It is, therefore, regrettable that discussion of medicine – of medical science, of clinical practice, of the profession itself – is frequently ill-informed. Comment is often shallow, even when it is not riddled with errors of fact, interpretation or emphasis. Reactive, piecemeal and disconnected from the big picture, much analysis lacks historical perspective and ignores the complex reality of medical care.

Notwithstanding all the books, column inches, air-time and screentime devoted to it, therefore, the practice of medicine remains virtually invisible. Hippocratic Oaths, which contemplates the art of medicine from a broad perspective while not losing sight of the details, aims at making medicine more visible. This is worthwhile not only because scientific medicine is one of the greatest triumphs of humankind; but also because illness is potentially a mirror, albeit a dark one, in which we may see something of what we are, at the deepest level. Making medicine truly visible may cast some light on the greater mystery of what it is to be a human being. That mystery is the starting point of this book.

Medicine, objectively, has never been in better shape. Its scientific basis, the application of this science in clinical practice, the processes by which health care is delivered; the outcomes for patients, the accountability of professionals, and the way doctors and their patients interact with each other – all have improved enormously even during my thirty years as a practitioner. Yet the talk is all of doom and gloom: short memories have hidden the extraordinary advances of the last century. The danger is that endless predictions of crisis may become self-fulfilling by making the key roles of doctor and nurse deeply unattractive. This would be a disaster, given that further progress will require more, not less, medical and nursing time.

The curious dissociation between what medicine has achieved and the way in which it is perceived originates outside of medicine itself. While medical practice is continuously improving, it has not kept up with patients’ rising expectations. Many things are much better than they were, but few things are as good as people have been led to expect. Changes in patients’ expectations reflect changes in the world at large. What is more, there is a tension between the consumerist values of society and the values that have hitherto informed medicine at its best; values that have driven its gradual transformation from a system beleaguered by fraud, venality and abuse of power¹ to a genuinely caring profession whose practices are informed by biological science and underpinned by clinical evidence.

Hippocratic Oaths does not pretend be a comprehensive account of medicine or even of its current troubles. I have aimed at depth rather than breadth. I examine the institutions of medicine and their present discontents in a series of essays – in some cases prompted by particular events or personal experiences. The book is a triptych: the large middle section deals with present discontents. It is flanked by panels that deal, respectively, with the origins and the destination of the art of medicine.

Though many of its reflections are cast in an impersonal form and address matters of public interest, Hippocratic Oaths is deeply personal. I believe that medicine is in danger of being irreversibly corrupted. This threat comes not from within (where its values are struggling to survive) but from society at large. The most serious dangers emanate from those for whom the moral high ground is a platform for self-advancement, many of whom have never borne, or have been willing to bear, the responsibilities that weigh on the daily life of practitioners. The unthinking voices of those who have a shallow understanding of the real challenges of medicine (and an even shallower appreciation of its achievements) will make patient care worse not better. Their influence already threatens to bring about a disastrous revolution in the values and attitudes of health-care professionals: if we are not careful, the patientas-client will receive service-with-a-smile from a ‘customer-aware’ self-protecting doctor delivering strictly on contract. If the current debased public perception is not challenged, medicine may become the first blue-collar profession, delivered by supine, sessional functionaries. This will not serve the longer term interests of people who fall ill.

Everyone agrees that we need to rethink medicine; in particular its relationship to society at large. This book offers an introduction to that rethink. We need to take a long view and to unpeel the layers of second-order discussion that takes so much for granted and has hidden the reality of a deeply human, and humane, profession. Only on the basis of an appreciation of what has been achieved, and a better understanding of the ends, aims and ultimate limitations of medical care, shall we be able to begin an intelligent examination of the present discontents and the future path; and arrive at a clearer understanding of what might be expected of medicine and of those who deliver medical care.

This book is dedicated to two of the many admirable people I have worked with in my thirty-two years in the NHS. Mohendra Gonsalkorale has been a consultant colleague for sixteen years. His many patients and colleagues, including myself, have benefited from his energy, cheerfulness, clinical expertise and wisdom, moral support and conscientiousness. Bill Sang is a manager whose ability to keep the larger vision in view while attending to the small details has been an inspiration. It is such people who keep the NHS afloat despite the misguided interventions of those many ill-informed individuals who wish to ‘save it’. However, neither Mohendra nor Bill would agree with everything in the pages that follow: both would be more philosophical about many of the things that cause me to bite the carpet. But they share my passion for public service and for the supremely serious calling of medicine – a passion which, over the years, has prompted them to work all the hours God made and some He has not thought of yet.

Perhaps this book should have another dedicatee: the students of Manchester Medical School, which still attracts the best and brightest. It is upon such people that the future of medicine will rest. If their sense of medicine as a calling is not destroyed, they will be doing their best for sick people in the dark hours when the hostile critics of the profession are chattering away at their dinner parties or safely tucked up in bed.

PART ONE

Origins

1

The Medicine-taking Animal: a Philosophical Overture

Medicine-taking has roots in many different quarters of individual and collective human consciousness. Swallowing a safe pill makes sense only in the context of a recognized system of knowledge and belief, which encompasses many things: the significance of the suffering that prompts the search for relief; the structure and function of the human body and the means by which they may be changed; and numerous sciences, such as organic chemistry, pharmacology and industrial chemistry. What is more, it is part of a tapestry of social arrangements ensuring the dissemination of expertise in the prescription and administration of medicines, involving the division and sub-division of labour, the development of institutions, the creation of numerous forms of material infrastructure, and networks of agreements based on trust or contracts. The least-considered therapeutic action draws on fathomless aquifers of implicit knowledge, understanding, custom and practice.

In the next chapter, I will sketch the long journey that led us to this point where humanity began to pop its pills. For the present, I want to focus on the beginning of the journey. While whatever it was that made us takers of medicine sits at the heart of the difference between ourselves and animals, the science which gives scientific medicine its efficacy comes from seeing sick persons as if they were stricken animals. There is therefore a paradox: as medicine-takers we are not organisms but complex selves; but the effectiveness of the medicine we take is owed to a view of ourselves as organisms.¹ If we are to place medicine and its present discontents in perspective, and understand both its achievements and its limitations, we must bear this paradox in mind: medicine’s triumphs are rooted in a biological understanding of sickness while the science, the art, the humanity of medical care is a supreme expression of the distance of humans from their biology.

Humane, scientific medicine is a (very) recent manifestation of the special nature of a creature who, uniquely among sentient beings, has knowledge. Knowledge – articulated or propositional awareness formulated into factual information and abstract general principles – is utterly different from the sentience that all conscious animals (including human beings) possess. Medical expertise is a peculiar development of knowledge: it is directed upon the body of the knower, who is in the grip of the least mediated form of awareness, namely bodily suffering. It is hardly surprising, then, that truly scientific medicine is less than a hundred years old. It h...