Death by erosion

Paul Seabright

  • Medical Choices, Medical Chances: How patients, families and physicians can cope with uncertainty by Harold Bursztajn, Richard Feinbloom, Robert Hamm and Archie Brodsky
    Routledge, 456 pp, £12.99, February 1991, ISBN 0 415 90292 4
  • Examining doctors: Medicine in the 1900s by Donald Gould
    Faber, 148 pp, £12.99, June 1991, ISBN 0 571 14360 1
  • Some Lives! A GP’s East End by David Widgery
    Sinclair-Stevenson, 248 pp, £15.95, July 1991, ISBN 1 85619 073 0

Two of Britain’s largest remaining nationalised industries – the Church of England and the National Health Service – have recently acquired new bosses who have publicly declared that the Nineties will be a decade of major change. This has set me wondering what kind of reaction George Carey might expect if the plans he had in mind for his own organisation were at all like those being implemented under William Waldegrave. Capitation fees and evangelism budgets for individual priests? The chance for churches to opt out of diocesan control? A division between purchasers and providers so that a diocese can draft in the Jehovah’s Witnesses or the Wee Frees if it suspects that the fare in its own parishes is becoming a little dull? A small minority would no doubt welcome these along with other transatlantic innovations, but for most the sheer, well, commercialism of it all would provoke a delicious shudder of horror.

More Britons see a doctor regularly than go to church, but that is part of the problem. Doctors and priests once shared fairly equally the task of helping us to cope with the fact and fear of death, and of minimising the unpleasantness we might face before and, respectively, after the event. Although doctors also do much routine plumbing and maintenance work, the unpredictability and suddenness of illness means that their role as mechanics cannot be separated from their priestly function. The scope of the former role has grown through technological advance, while the need for doctors to exercise a priestly function has expanded as our hopes decline for an ultimate referral to the Great Consultant in the Sky (he opted out some while ago). When they act as our priests, doctors are expected to fight for us and to counsel us selflessly, certainly not to judge us or to treat us as costs in a function to be minimised. And if priests were all they had to be, running a health service on a shoestring, with less attention to management than to purity of vocation, would be an unexceptionable policy. But the priestly analogy breaks down once applied to the substantial resources that a modern health care system commands. This is partly the product of its own success: as death from infectious diseases has declined, so a sturdier population grows to an age where death comes by erosion rather than by conquest, and care of the sick is correspondingly more protracted and expensive. Partly it is the achievement of science in holding that erosion at bay: the technology of soul transplants has not changed much in two millennia (though Americans, as always, find the electronic media helpful), but many other bits of the person can be strengthened and supplemented with chemical or mechanical gadgetry. It’s a losing battle, but even postponement of defeat can feel like an achievement. And the greater ease of monitoring medical progress increases the temptation to intervene, to use newer and more expensive gadgets when the old ones fail, as inevitably they will. But partly the resources problem arises because much medicine is not a technological folie de grandeur: it consists of simple useful things like paracetamol and hip replacements and health visitors, things that genuinely improve people’s quality of life, but are always under threat from the claims of glamour medicine on one side and taxpayers’ meanness on the other. And when resources on this scale follow medical decisions, doctors become managers as well as priests. It’s not a role they can choose to forego: like speaking prose, they do it whether they acknowledge it or not. The current controversy over the NHS reforms is about how, not whether, that managerial role should be fulfilled.

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