Four legs good, two legs bad: sloganeering, everyone would agree, is not necessarily the best guide to policy. So when Tony Blair told us at a recent breakfast seminar at Downing Street that, with regard to the National Health Service, patient choice is good and medical paternalism is bad he was not so much enunciating a truth as launching a new and pernicious advertising slogan; all the worse because it contains an element of truth and thereby inhibits critical thought.
The NHS has long been dedicated to denying patients a choice of specialists: you get what you’re given, because beggars can’t be choosers. It is true that there is a theoretical right to a second opinion but, after you’ve waited 12 months to consult, say, an orthopaedic surgeon or a dermatologist, the last thing you want is to wait another year.
This lack of choice is the consequence of the way our medical services have for so long been funded and organised, and is increasingly irksome to a population that is no longer grateful, as good paupers should be, to receive any medical attention at all. But the proposal that the NHS will henceforth “put patients’ wishes first”, to quote a recent Guardian headline, would entail, in many circumstances, a total and unethical abrogation of medical responsibility. Consumer choice is an excellent thing in its own sphere, but in medical practice is an excellent thing only to a limited extent. There is no single or simple principle that will cover all cases, and to encourage patients to believe that they are but consumers in the department store of medicine is not merely foolish, it is wicked.
Under English law a patient has a right, so long as he has mental capacity, to refuse whatever treatment is offered him, however obviously that treatment may be to his advantage. He is even allowed to die as a result of his refusal of medical help, frustrating as doctors always find this. And few doctors would now oppose this fundamental principle.
But a right to refuse treatment on the grounds of personal autonomy does not translate into a patient’s right to receive whatever he wants. The doctor is not there to prescribe whatever pills the patient fancies, or to carry out surgical procedures at his whim. The doctor has an inescapable duty to consider what is in a patient’s medical interests – in other words, he must always be paternalistic. He must not do anything against the patient’s medical interests, however much the patient may wish him to.
Furthermore, it is simply not true that patients always want to be presented with a gamut of choices, among which they are ill-prepared to choose. One of the strongest weapons in any doctor’s armamentarium is the faith of the patient in his skill and benevolence. When a person is very frightened or very ill, he or she is often only too happy to hand things over to others. On the few occasions in my life that I have been seriously ill, the last thing I wanted was for the doctor in charge of my case to present me with endless lists of alternatives: I just wanted him to do his best for me and form his own judgement.
As a doctor myself, I know as well as anyone that doctors are but flesh and blood. Some make mistakes and a few are malevolent, but this does not make me mistrustful of their efforts or any more suspicious of their advice. And on the whole you don’t get the best out of people by insinuating that you’re watching them all the time because you don’t trust them.
The customer may always be right where department stores are concerned, but the patient is most certainly not always right. Moreover, the idea that patients need only a sheaf of information downloaded from the internet to enable them to decide what medical treatment they should receive is crude beyond belief.
This is not to say that patients should have no information, but the interplay between patients’ wishes and information on the one hand, and professional responsibilities on the other, is a good deal more subtle and complex than the “choice good, paternalism bad” slogan would suggest. Humankind differs widely in its ability or wish to bear reality.
Successive British governments have attempted to introduce commercial relations into medical practice: first, ignoring the manifold differences between keeping a shop and running a clinic; and, second, without introducing any element of genuine commerce into the proceedings.
Commercial relations without commerce are a recipe for disaster, for they encourage anger, bitterness, querulousness and disillusionment on all sides. The patient is persuaded that as the customer he is sovereign, but the doctor receives no monetary reward whatsoever for being treated not as a professional adviser but as a tradesman. To be a customer without the responsibility of paying for goods or benefits received is to be an egotist permanently resentful at not getting what you want immediately, which becomes the only criterion of satisfaction. To be a doctor constantly confronted by such customers is to wish to have chosen another career.
Underlying the changes wrought by successive governments is not an attack on authority (for, in a complex and civilised society, there must be authority), but a transfer or centralisation of authority. The doctor is no longer granted such authority on account of his knowledge and experience, even though his responsibilities constantly increase. Henceforth, it is not doctor who knows best, but Drs Thatcher and Blair who know best.
Theodore Dalrymple is a prison doctor