In his great novel Chance, Joseph Conrad describes:
‘… the trouble of transcendental good intentions, which, though ethically valuable, I have no doubt cause often more unhappiness than the plots of the most evil tendency.’1
In her Harveian Oration at the Royal College of Physicians, Iona Heath quotes Conrad in her critique of gung-ho surgery and of screening programmes which reveal ‘the seductive possibility of preventing disease ratcheting up good intentions and the wishful thinking which too often underpins them’.2 Unfortunately, the influence of ‘transcendental good intentions’ extends widely within today’s medical establishment, reaching even the President of the RCGP.
In his presidential address to the BMA, Sir Michael Marmot urges doctors to adopt the role of ‘community leaders’, in a crusade for fairness, equality and social justice.3 In his enthusiasm for doctors to take up the bedraggled Red Flag of Old Labour, Marmot does not seem to have noticed that this programme has been abandoned, not only by Labour, but by almost every social democratic party in Europe. Whether or not they have abandoned the aims of socialism, the parties of the left have in recent years conspicuously failed to attract popular support. This is presumably why it is necessary for doctors to proclaim themselves ‘community leaders’ by professional appointment rather than by democratic mandate.
Marmot has taken over from classical social democracy the combination of a maximum programme (the transcendental goal of socialism) and a minimum programme (the day-to-day quest for modest reforms). Thus he declares, in the style of Labour’s old ‘Clause IV’, a list of ‘policy objectives’ such as ‘to enable all children, young people, and adults to maximise their capabilities and have control over their lives’. But apart from promoting utopian fantasies, ‘what can doctors do’? Marmot recommends a practice in East London in which GPs ‘refer patients to services that help to tackle the social determinants of ill health — including welfare, employment, housing, and debt advice services.’ Of course, GPs have been writing to these agencies for years, but even the most apologetic supporter of Old Labour never expected them to tackle social inequalities.
Although Iona Heath reveals a familiarity with the world of medical practice that is entirely lacking in Marmot’s facile call for doctors to set the world to rights, she too succumbs to the notion that doctors should become lobbyists and advocates. She believes that ‘society should invest much more heavily in the early years of childhood’ and that doctors ‘should be … attempting to minimise violence and abuse, and promoting a more equitable distribution of wealth, hope and opportunity within society’.
The underlying assumption of these initiatives is the incapacity of individuals to raise their own children (or conduct their own lives) without expert guidance and direction. The inflation of medical authority implies the diminution of individual autonomy. Labelling the patient as the vulnerable, incompetent, pathetic victim of ‘structural’ (and domestic) violence is essential to the mission of the crusading, empowering, and supportive doctor-as-community-leader.
As Heath reminds us, patients have paid a high price for medical hubris in the past. If we follow the direction recommended by herself and Marmot, I fear that they may pay an even higher price in the future.
As this is my last column for the Journal, I would like to say a fond farewell to all my readers, especially to those who have written in response to my columns, whether supportively or critically, and to say thanks too, to the editorial team.
- © British Journal of General Practice 2011