- The Black and white Medicine Show: How doctors serve and fail their customers by Donald Gould
Hamish Hamilton, 278 pp, £10.95, June 1985, ISBN 0 241 11540 X
In January 1936 when George V was dying, Lord Dawson, his physician, wrote on the back of a menu card: ‘The King’s life is moving peacefully towards its close.’ This message was broadcast to the world by the infant BBC. Shortly afterwards Neville Chamberlain wrote that Dawson had touched the hearts of millions all over the world. In the last fifty years the media, trading in the human-interest story, have been the beauticians of the medical profession. Open any newspaper any day and find a close-up of the man with an artificial heart, the proud mother of test-tube quintuplets or the bank clerk who got to the wedding in spite of his broken leg. Medical journalism is powerful stuff, and at its most deadly when it seems to cast faint shadows on the object of its appetite. In spite of such chapter headings as ‘The Medical Mafia’, Donald Gould’s book is no petard, cunningly placed to give sceptics entry to Asklepios’s temple. It is a vibrant device for keeping agitation alive at the frontiers but orthodoxy safe within. At the kernel of this book is the stuff of which Mills and Boon surgeons are made.
In one sense, orthodox medicine, as an intellectual package and as a profession, is a newcomer to the ancient bazaar of health dealers. Not surprisingly, its success, gained only in the second half of the 19th century, has provoked accusations of sharp practice, although even the best-directed criticisms have usually failed to find a vulnerable target. Quite how, without any obvious initial advantage, the modern profession did gain esteem and short-circuit its competitors is – thankfully – a question tricky enough to keep medical historians in employment. For instance, looked at symmetrically, there was virtually nothing in the 1840s to distinguish regular heroic practitioners from homeopaths, not in terms of the logic of their explanatory schema, the public support they were given, or their cure and failure rates. Yet homeopathy very soon felt itself pinched between practice and orthodox inflation.
Once self-styled scientific medicine came to run the health cartel the most percipient attacks on its authority have seldom come from those with shares in the monopoly. Doctors have been understandably quiet about their interests. Even their most strongly argued cases for medical reform have been for a shuffling of internal topography, not morphological collapse. A.J. Cronin’s The Citadel, which excoriated the medical profession of the Twenties and Thirties, was, ultimately, a melodramatic plea for a more scientific medical education. Paradoxically, the medical man who has produced the strongest case against his brothers has spurned the mantle of revolutionary. Thomas McKeown has long argued on epidemiological grounds that modern medicine cannot claim much credit for the shift in mortality and morbidity in the Western world.
Criticism of medicine which attempts to penetrate its vital organs has always come from outsiders. The Left, curiously, has been late in the fray, remaining content until well into the Fifties to regard medicine as an unmitigated if somewhat erratically distributed Good. The Labour Party remains devout in this faith. What serious left-wing thinkers have lacked in punctuality, however, they have made good by industry. Initially busying themselves with the medical profession’s role as mediator of the interests of Capital, as creator and monitor of a healthy proletariat, left-wing critics have recently struck a vein of epistemological ore. The questions are now not only, why did Rockefeller pour thousands of dollars into medicine, or, more generally, how does the profession manage sickness in a capitalist society, but how are the fundamental categories, health and disease, constructed? What, to borrow a phrase, is the political anatomy of the body? In the heady days of the Twenties when ‘the Great’, as London Hospital physicians were called, did their rounds they flourished their canes, exhibited their gold tie-pins and demanded that their poor patients call them ‘sir’. They gave extravagant dinners and patronised the arts: the young Henry Wood owed a good deal to the physician George Cathcart. If they were exceptionally well-connected like ‘Tommy’, Lord Horder, they bought their Rolls-Royces from former prime ministers. Where, historians are now asking, is the historical cunning which has joined economic power and pathological configuration?
The shape of disease in the medical eye has changed many times since antiquity. It has been, among others, fluid, alchemical, electrical, astrological and divine. Since the late 19th century it has been three-dimensional, co-terminous with organs and tissues deep in the body. Past shapes of disease seem foreign to us because we have estranged them. Putting them in the minds of their makers, we call them ‘imaginary’. The present shape we put beyond question, we put it in the ‘world’, we call it ‘real’. It is the shape of disease which permits the exercise of medical power, for liberation or control or both. The power must be appropriate to the shape – a leech makes no sense as a treatment for cancer. The Left’s inquiry into this maze of savoir pouvoir, which in addition to the young Marx has indebted itself to George Canguilhem and Michel Foucault, has by no means traversed all the routes to medicine’s heart. The Right, too, has probed the sources of its current quickening. The fervent Catholicism of Ivan Illich, for instance, has remorselessly questioned the medically unquestionable – the meaning of illness. For him, pain and suffering have been transmuted by medicine into merely physiological issues, they have been expropriated to the realm of the technical fix, where they are no more than things to be removed.
Donald Gould eschews all these approaches and bowls at the medical profession what seems to be flamboyant bodyline, which is about as nasty as you can get if you still want to go on playing the game. Gould is a doctor and a former editor of World Medicine – which, in his day, was a sharp thorn in the side of the medical heavies. Gould brings his journalism to his book, and the benefits are impressive: a racy format, anecdotes, reminiscences, and a frightening recitation of case-histories which he uses to lampoon medical self-importance. He has at his fingertips all those headlines which are only dimly-remembered horror stories for most of us: the Sheffield paediatrician who wanted to sterilise an 11-year-old, or the psychiatrist who had female hormone pellets implanted in sex offenders and then enlisted further surgical help to cut off their unwanted breasts. Gould unrolls the familiar catalogue of indefensible medical practices: over-prescribing, the carving-up of scarce resources, the farcical prolongation of life. He ridicules the carnival of heart transplants and upbraids the gushing enthusiasm of renal dialysers. He comes out strongly in favour of doctors not using clinical judgments to manipulate what are obviously moral issues. If women want abortions or sterilisations or whatever, it’s not the business of gynaecologists to refuse, as has been known to happen, on the grounds that unfortunate girls might be led into prostitution.
In an important sense, however, this is a trivial book. Behind its meretricious style more fundamental questions pass undetected and contemporary medical beliefs are rendered sound by a tactic which at times amounts to bullying. It may be the case, as he says, ‘that the entry of the chemical industry into the medicines trade has brought immense benefits in terms of lives saved and suffering,’ but it is brutal demagoguery to announce this as a truth which ‘nobody but a fool or a bigot would want to deny.’ Modern medicine cannot be defended simply by dealing out truth and science like rhetorical trumps every time its detractors hold an ace. Nor can everything that is not orthodox be hectored into oblivion by name-calling. To designate all other medical worlds irrational and bizarre is to appropriate the meaning of reason. Acupuncture treatment, Gould correctly relates, ‘consists of sticking needles into the skin’ at a number of points. Each point, he remarks, ‘represents a particular symptom or organ but bears no obvious relationship to the part concerned. Instead the points are placed along an imaginary network.’ This is not critical argument: it’s the equivalent of being in the ring with a fighter with lead in his glottis. Whether acupuncture has any merits or not, Gould’s yardstick is a Procrustean measure. Very few therapeutic interventions in Western medicine have any ‘obvious’ relation to the organ or symptom to which they are directed. Nor, to the uninitiated, is the mysterious labyrinth which connects our organs in Gray’s Anatomy a less ‘imaginary’ network than any which Borges might create.
Rationality is a slippery beast, quite likely to bite those who seek to cage it. Hippocratic physicians practised a medicine no less rational than ours today. Galen, prince of ancient physicians, was by any standards a penetrating thinker. In 1798 Edward Jenner, a hero in the pantheon of physicians, described the use of cow-pox matter to prevent smallpox. This piece of detective work remains a classic. Jenner’s observational powers are also testified to by his being the first to note that it is the newly-hatched cuckoo which dispatches to earth the other eggs in the nest. Yet, in a less well-known paper, Jenner described the use of the seton, a thread passed through a fold of skin producing chronic suppuration, to cure eye disease. In his experience, he said, the practice had ‘given sight to thousands’. Gould’s division of the world into ‘demonstrable facts’ and mumbo-jumbo or magic is worse than useless when trying to understand practices and deductions like these. It does not encourage us to understand the world in which such utterances had meaning. It is the language of Salem to silence argument by bellowing that ‘irrational beliefs are always dangerously corrupting.’
To be sceptical about the rational superiority of modern medicine, however, is not the same thing as arguing that we should gulp down any and every sort of potion we are offered. Instead, we should recognise that in medical matters what we think of as a rational choice is actually a dressed-up judgment of value. Gould, it could be said, recognises this. ‘There is an excellent case for having the proper doctors take a long hard look at the manner in which there [sic] dissident competitors operate with a view to adopting those features of their approach which are of patent value to their clients.’ Quite so, but who is to decide what values are important when we are dealing with something as personal as sickness? A mega-unit of penicillin in the buttock might have been a remarkably inappropriate way to deal with Job. Besides, doctors seem to have learnt very well from their competitors. Harley Street before the Second World War was a carnival of the sort of outlandishness usually associated with unregistered healers. Most successful consultants knew exactly what their private patients wanted – charm. Envy nicknamed one physician’s country seat ‘Bedside Manor’. In those days doctors practised something they called science by giving electrical shocks, and who was there to say it wasn’t? Such things no doubt were also of value to their clients.
In the end, Gould wants the doctors to go on deciding what’s good for us, what’s nice medicine and what’s nasty. There is a voice in popular journalism that can seduce us into believing we are engaged in serious debate, but this is diversionary, allowing the important words, ‘science’, ‘truth’, ‘reason’, to slip unnoticed across the border into safety, dressed in their common-sense usages – and common sense, as any anthropologist knows, is a highly sophisticated system for not talking about the sacred things at the heart of a culture. Gould’s voice is the language of closure tricked out in liberal cloth. The values which determine the form of medical practice, the meanings of sickness, suffering, pain, affliction and deformity, are what keeps the modern medical show on the road. To discuss these might be to end the performance.