‘Societies get the doctors they deserve’ writes Raymond Tallis in Hippocratic Oaths, his important new analysis of ‘medicine and its discontents’.1 As an experienced clinician — he is professor of geriatric medicine at Manchester — Tallis is intimately familiar with the realities of contemporary medical practice in Britain. As the author of a number of critiques of fashionable irrational philosophies (such as postmodernism), he is well qualified to appraise the bleak ideology currently permeating the National Health Service.2 He offers an acerbic assessment of the current crisis of the medical profession.
Over the past 20 years, doctors have been disparaged as paternalistic and authoritarian. In common with other professions, their claims of commitment to public service have been dismissed as a disguise for venal self-interest, and their professional organisations exposed as monopolistic cartels against the consumer.3 Under New Labour, in particular, the medical profession has been subjected to the full rigours of market-inspired reform and modernisation. Doctors have been smitten with ‘the triple-edged sword of transparency, accountability, and regulation’. In an increasingly fractious relationship, the ‘demonised doctor–perpetrator’ now confronts the ‘canonised patient–victim’. The assumption that doctors are untrustworthy, nurtured by a series of scandals, has encouraged a process of political interference in medicine that is likely to prove wasteful, corrosive and destructive.
As Tallis observes, ‘an aggressively consumerist society will breed defensive consumerist physicians’. Furthermore, as he perceptively points out, ‘ “defensive medicine” is much worse than it sounds’. It is ‘a desperate euphemism for a profound corruption in the doctor–patient relationship’, ‘a betrayal of the professional ethos’, that implies abandoning paternalism for ‘something much worse — inhumanity’. The Hippocratic principle ‘First do no harm’ is supplanted by the new ethical imperative: ‘First cover your ass and damn the harm’. It is ironic that the principle of informed consent — which has become something between a dogma and a fetish for contemporary medical reformers — will be undermined by this process, as patients will not know the primary reason for the intensive programme of investigations and interventions to which they are subjected.
The medical profession has offered little resistance to the drive to deprofessionalise doctors. While commitment and continuity of care have been undermined by trends towards shift working, part-time working, and the abandonment of out-of-hours responsibilities, doctors have appeared more concerned about their work–life balance than with defending professional autonomy. The dumbing down of medical education and training, and the intrusion of third parties — insurance companies, government agencies, lawyers — into the doctor–patient relationship have contributed to the degradation of the profession. As medicine is transformed from being a calling into a business, a new generation of doctors faces a future of slavishly following protocols, and a working life of clock-watching and box-ticking.
Professor Carol Black, president of the Royal College of Physicians, recently expressed concern that the growing proportion of women doctors might lead to a decline in the professional status of medicine.4 Tallis offers an interesting aside relevant to the ensuing controversy over the ‘feminisation’ of medicine. He notes that, despite the increasing numbers of female consultants and GPs — with their widely acknowledged superior qualities of empathy — and despite, too, the formal training of medical students and junior doctors in communication skills, complaints about failings in this area have continued to grow. The key issue here is not the sex of the doctor, but the inherent difficulties of the doctor–patient relationship, ‘the incommensurability of the personal experience of illness and the scientific understanding of it’. However, whether a doctor is male or female, the real threat to professional values arises from the shift away from taking genuine responsibility for the welfare of the patient, towards the formal discharge of contractual obligations towards a customer.
In the same spirit in which he has championed the ideas of the Enlightenment against theories that disparage reason and diminish human subjectivity, Tallis challenges today's doctors to take a stand against the current onslaught on professional values. Although a staunch opponent of pessimism, he warns that the cost of failure may be high: ‘The doctor as intellectual leader, as clinical pioneer, and as advocate for the patient and the service, as the midwife of the future as well as the servant of the present, may well become a thing of the past.’
- © British Journal of General Practice, 2004.
