Quality of Life

A Post-Pandemic Philosophy of Medicine

Robin Downie
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 Sir Kenneth Calman

Foreword
One of the most rewarding aspects of being a Chancellor of a university is to be
part of the tradition of graduation ceremonies where young men and women,
from widely different backgrounds, are awarded their degrees. The ceremony for
the medical student graduations is of special interest. In front of their family and
friends, they stand and recite a version of the Hippocratic Oath. It is a powerful
ceremony as the graduates set out their standards for their future practice in
medicine.
One question raised in this book is whether or not this is an appropriate
process in the twenty-first century, and in the midst of a most powerful
pandemic. Perhaps a new approach should be taken, so much has changed. Team
working is now crucial for good clinical practice. Professional groups in a wide
variety of subjects in addition to medicine have a major part to play in caring for
patients. How do they all fit together, and have they all had experience of
learning about such a wide range of issues? The medical curriculum has changed
and the role of quality in clinical practice has been redefined. At the same time
quality of life has become more relevant, and what does that mean anyway?
Quality of life is a difficult concept and is linked to the related topics of
happiness, choice and living standards. How do we define them, measure them
and improve them? Even that short sentence leaves many questions open for
debate, questions which this book discusses. Another facet of this relates to a
real problem in the pandemic: who should be actively treated, and who not? This
is a common problem in clinical practice, but the pandemic has given it sharper
focus because so many individuals are involved. How am I going to choose
when we recognise that not everyone can be cared for in the same way? What
can a deeper knowledge of philosophy add to our understanding of such difficult
issues affecting real people?
These issues have raised the question of the role of the arts in health, a role
which is seen by many groups as particularly relevant, including an All-Party
Parliamentary Group on Arts, Health and Wellbeing. In the old days, it was
common for those wishing to study medicine to obtain an arts degree first, but
that is unusual now. Does the change to an exclusively science-based education
also change the way we think about those who are unwell, and what about
ethical issues raised by the change? How are they to be approached, and can
philosophy offer guidance?
I first became part of these discussions almost 40 years ago. I was involved
with the teaching of medical ethics to medical students and my fellow teacher
was Robin Downie. In this process I learned a number of things and the first was
that philosophy was more than medical ethics. Second, my own thinking on
quality of life began to change. I was at the time a professor of oncology and
such issues were at the heart of the care given to individuals. Third, it was clear
that the students enjoyed being involved in the debates and had much to
contribute. Finally, I discovered the role of the arts in caring for those whose
quality of life needed improving.
The inspiration of these thoughts began when we occasionally introduced
literature to the medical ethics teaching process, using stories, poems, books.
They enjoyed this and, as a consequence, we set up a programme of classes with
the broad title of Literature and Medicine. The students were inspirational to
listen to, and their comments and views on the readings were revealing. They
showed how medical students, whose work was grounded in science, used these
occasions to open up a range of questions and allow discussion of broader issues.
They had so much to contribute. This initiative continued in many forms and
other medical schools and organisations developed an interest.
A particular issue, relevant to many of the subjects raised, was how best to
communicate with patients and the wider public. The use of the arts opened up
new opportunities and methods of helping with these difficult issues, and shone a
new light on quality of life, its meaning and ways of grounding it in practice. In
addition, the wider impact of philosophy added extra dimensions to the care of
patients and the public.
The current pandemic has opened up a range of new opportunities. As
mentioned earlier the team approach was crucial in improving health and caring
for individuals. The ethical basis of this care was generally dealt with in different
settings, and not necessarily together. The scientists involved had probably not
considered these issues fully, but here they were at the centre of a process of
care, and with a significant role. The broader aspects of public communication
became critical. How do you communicate if you don’t have all the answers?
How can you tell the truth, and use words like ‘safe’? These are not new topics,
and philosophers over the ages have tackled them. We can learn much from that
experience.
This book integrates many of the thoughts noted above, and many more. It is a
book for its time which can help in improving health and quality of life for all
and encourage wider debate.

Sir Kenneth Calman

KCB DL FRCP FRCS FRSE FRCGP
Former Chief Medical Officer of Scotland and England
 Preface
I have learned a great deal about how medicine works from joint writing
ventures with doctors, and from being a member of many medical and
government committees concerned with assorted medical policy questions. And
I shall make full acknowledgement and reference in the text to what I have
learned from these cooperations. Moreover, I am second to none in my
admiration for the skills and dedication of the doctors, nurses, social workers,
care workers and many other professions working in health care. Nevertheless,
in all these interesting joint ventures it was always the medical point of view that
prevailed, even if sometimes I had reservations. I therefore thought it might be
of philosophical interest if I addressed some fundamental questions about
medicine, but from a philosophical perspective. There is a need for this as we
enter the post-pandemic period.
The fundamental questions I shall address are important because answers to
them affect the future direction of medicine, the kinds of treatment we shall all
receive, and the kind of social arrangements we might be willing to accept.
Apart from these practical considerations the questions are in themselves of
philosophical interest because they raise issues such as: how scientific is
medicine? Can the complex ethical problems of medicine be resolved by the
limited concepts of ‘medical ethics’? Have the problems of growing up been
medicalised and turned into mental health problems? Is consumer choice in
medicine consistent with the belief that medicine is a ‘profession’? Can health be
improved without a more equitable distribution of resources and a greener
environment?
Questions of the above kind and many others to be discussed lead to one
which underlies them all: what is the basic aim of medicine? We might
immediately think that the basic aim of medicine is to cure our diseases. But that
will not do. Doctors assist with childbirth, ease the suffering of the dying, offer
advice on diet and a host of other issues. Moreover, concepts such as ‘disability’,
‘mental illness’ and even ‘disease’ have elements not captured in a purely
scientific approach. Many doctors therefore prefer a wider aim—to improve
quality of life —and a great deal has been written on this as the aim of medicine.
But the problem with the medical approach to the idea of quality of life is that it
is distorted by the illusion that it can be treated as a purely medical idea and
measured on a scale 1–10. I wonder how I might feel if I were to see my case-
notes and learn that my quality of life was 6. I reckon I might feel as readers of
the Hitchhiker’s Guide to the Galaxy feel when they learn that the meaning of
life is 42! Quality of life is a rich non-numerical concept with a social and
[1]

environmental side to it and requires to be explored in a much broader way.

Medical practice is governed by codes of ethics. Yes, but what is taught and
practised is medical ethics, or ethics from a medical point of view. But hospitals
and general practices are microcosms of society as a whole—with heightened
tensions. Dealing with the problems which arise requires more than learning up
regulations from official bodies such as, in the UK, the General Medical Council
or the British Medical Association. And the idea which has prevailed among
teachers of medical ethics for several generations that the many and complex
problems arising in medicine can be covered by only four principles peculiar to
medicine reflects the inward-looking nature of medical ethics and is totally
unrealistic. What more is needed and how can that ‘more’ be taught and
encouraged in practice?
I shall suggest that the arts and humanities can have a helpful input. They can
provide a supplement to the standard teaching approaches to ethics and
communication in the clinic. And they can have a critical function in offering
philosophical discussion of specific issues such as: informed and voluntary
consent for treatment but ‘presumed’ consent for removing organs; the rights (if
any) to assisted suicide; the tensions between patient choice, consumer choice
and medicine as a profession. But they can also examine more general
philosophical issues such as the scientific basis of medical treatments; the need
for a community-based political philosophy to support public health medicine
and the GP practice of ‘social prescribing’. Above all, philosophy can explore
the connections between health, a greener environment and quality of life.
It is not easy to change or modify doctors’ approaches to their profession. A
reviewer of a book I once wrote with a medical colleague on medical education
said that trying to change medical education is like trying to move a graveyard.
This is unfair since medical schools have modified their curriculum and
introduced methods such as ‘problem-based’ learning. But what has not changed
is what I shall call the ‘ethos’ of medicine. The ethos was shaped at the origins of
modern medicine in the Greek world and its structure is still recognisable in the
present day in medical schools and in the practice of medicine. The ethos is
characterised by four firmly held beliefs: in science; in medical ethics; in
medical practice as self-contained; in professional solidarity. It is the ethos or
strong sense of identity which makes medicine inward-looking. The ethos is of
interest both philosophically and as an important factor in determining what is
encouraged or frowned upon as medical treatments.
There is, for instance, an ‘arts in health movement’ which has the blessing of
an All-Party Parliamentary Group but it does not receive recognition in the
evidence-base of medicine, presumably because it is not based on science. It has,
however, been shown to be effective for some disorders. And what is known as
‘social prescribing’, or the GP prescription of ‘treatments’ such as joining a
walking group or community choir, can be more effective for many mental
health problems than pills or ‘counselling’. Moreover, the remedies of social
prescribing are non-addictive whereas the dangers of anti-depressant pills and
similar are now being recognised. But social prescribing cannot be evaluated by
the methods preferred by the scientific ethos, such as randomised trials, so again
it cannot go into the medical evidence-base. A philosophical critique of the
current ‘scientific’ methods of evaluating proposed treatments is therefore
desirable and timely.
In sum, my hope is to discuss some fundamental philosophical questions
about medicine and to make some suggestions for modifications in its present
approach. Firstly, I shall offer a critique of medicine considered as applied
science, and governed by the ethics of consumerism. Secondly, my positive
suggestions will be directed towards the contribution which the arts and
humanities can offer to medical ethics and communication with patients, and the
need for a community-based concept of quality of life in which a greener
environment is a central feature. Many of these remedies involve working not
top-down on the community but alongside the care sector and the various other
community and environmental agencies concerned with our health. This will go
against the self-contained nature of the medical ethos, and the medicalisation of
health. But community involvement in health matters will take us to a much
more satisfactory idea of quality of life than the current medicalised one. A
philosophy directed towards that end may help to move the graveyard.
What gave me the courage, as a layman, to risk rejection or mockery from the
medical profession was the opening of a short story by H.H. Munro (‘Saki’)
called ‘The Lumber Room’. This passage will be at the back of my mind when
medical critics tell me (as they will) that I have got it all wrong.
The children were to be driven, as a special treat, to the sands at Jagborough. Nicholas was not to
be of the party; he was in disgrace. Only that morning he had refused to eat his wholesome bread-
and-milk on the seemingly frivolous ground that there was a frog in it. Older and wiser and better
people had told him that there could not possibly be a frog in his bread-and-milk and that he was
not to talk nonsense… The dramatic part of the incident was that there really was a frog in Nicholas’
 basin of bread-and-milk; he had put it there himself so he felt entitled to know about it. The sin of
taking a frog from the garden and putting it into a bowl of wholesome bread-and-milk was enlarged
on at great length, but the fact that stood out clearest in the whole affair, as it presented itself to the
mind of Nicholas, was that older, wiser, and better people had been proved to be profoundly in error
in matters about which they had expressed the utmost assurance.
1 Adams, D. (1979) The Hitchhiker’s Guide to the Galaxy.
 Dedication and Acknowledgements
This book is dedicated to the many doctors with whom I have collaborated in
previous books and articles and from whom I have learned as we sat together on
many committees. In particular I am indebted to Sir Kenneth Calman, for
contributing a foreword and for our collaboration on many writing and teaching
projects. I have also had profitable collaborations with Professor Jane
Macnaughton, Dr Fiona Randall, Dr Andrew and Professor Carol Tannahill, Dr
Bruce Charleton, Professor Carl Elliott, Professor Raanon Gillon, Professor
Brian Hurwitz, Professor Kenneth Boyd, Dr Emma Storr and Professor Sheila
McLean. They will agree with some of what I say—because I am using their
ideas—but they may disagree with what I have done with these ideas. I have
blended them in various way and shaped them into a philosophical structure
which I hope will fit the changed medical and social circumstances we find
ourselves in after the pandemic. Whether or not that structure is convincing I
must leave to the judgement of my former colleagues and future readers.

Robin Downie
Department of Philosophy
The University or Glasgow
December 2020
 Introduction
The philosophy of medicine is a path less trodden than other branches of
philosophy. Writings on medicine, when they are not technical, usually consist of
anecdotes by doctors or complaints from patients. Yet medicine offers a rich
field for philosophers willing to take a little trouble to examine what goes on in
medical practice. There is scope for conceptual analysis—what are we talking
about when we speak of negative or positive health; for the philosophy of
science—how ‘scientific’ are randomised trials or mathematical models; for the
philosophy of social science—can a doctor–patient relationship be ‘measured’;
for moral philosophy—the whole area of ‘medical ethics’; for political
philosophy—can the medical aim of improving quality of life be improved
without a more socially equitable society? I shall examine medicine using all the
preceding philosophical disciplines.
Philosophy can be descriptive in the sense of trying to create an understanding
of a given subject-matter, how it hangs together at a given period, or it can be
revisionary, by trying to suggest possible improvements or changes of emphasis.
My approach will be both descriptive and revisionary. From the descriptive point
of view I shall try to create an understanding of what contemporary medicine is
aiming at, and why there is medical resistance to a change of approach. The
resistance stems from what I shall call the ‘ethos’ of medicine, an ethos which
has its roots in the Greek origins of medicine and is continued and enhanced by
the present inward-looking nature of medical education. As a revisionist I shall
suggest what the changes in emphasis should be. A fresh look at the future
direction of medicine is desirable if medicine is to be fit for the new sort of post-
pandemic society which is emerging. It is the role of philosophy to begin that
discussion. What I offer is no more than a beginning which others may be able to
modify or develop.
Western medicine more than other professions has a strong sense of identity,
which derives from its ‘ethos’. The ‘ethos’ originated in the Greek world and has
been built up over millennia. Its nature and its good and not so good effects for
patients will be examined in detail in subsequent chapters, but briefly the ethos
has four main elements: a belief in science as the sole evidence-base for
diagnosis and treatment and social science as the basis for communication; a
belief that a code of ethics should govern these; an emphasis on the centrality of
the medical consultation; an all-pervading solidarity with those in the profession.
Those four elements profoundly affect the development of students throughout
medical school and are reinforced by the solemnity and dedication of a medical
graduation. They shape the identity of a doctor, determine the approach of the
profession to treatments and patients, and create a resistance to suggestions for
change, or at least to those suggestions which are made from outside the
profession.
The benefits of the ethos for both patients and doctors are considerable.
Patients benefit from treatments which are the result of scientific research and
tests; they are protected from exploitation by the many updates and
developments in the ethical regulations issuing from official bodies such as the
General Medical Council and British Medical Association. In general, patients
have the assurance that doctors are uniquely concerned with their interests.
Doctors also benefit in that they have the support of their colleagues in what is
often a stressful career with long hours. Moreover, the ethos gives them a respect
and status in society which is not accorded to other professions. Surveys
frequently place medicine at the top end of public esteem.
Nevertheless, the ethos also creates some disadvantages for patients. The
belief in science has come to dominate what is thought appropriate as treatment,
to the extent that some doctors see medicine as an applied science. ‘Follow the
science’ has become a familiar slogan during the Covid-19 pandemic even
though scientists sometimes differ in their predictions or recommendations. In
any case, not all the ills of patients are best treated by scientific remedies.
Patients present with many clinical problems and some of these might be
ameliorated by community activity, such as joining a gardening or dancing
group, rather than by means of pills. Remedies of that non-medical kind have
been recommended by both ‘arts in health’—an All-Party Parliamentary Group
—and by the GP movement known as ‘social prescribing’, as well as by the
many and various community arts groups round the country. But such remedies
are not recognised in the scientific evidence-base of medicine. Indeed, such is
the belief in science that even public health medicine is dominated by
mathematical modelling; and social scientists have come to dominate the
teaching of what are known as ‘communication skills’, even though it is very
doubtful if there can be a scientific approach, an expertise, in human
relationships.
It is interesting that the ancient Greeks realised that there can be successful
non-scientific ways of approaching patients. Existing alongside the School of
Hippocrates there was the School of Asklepios. Whereas Hippocrates and his
present-day followers hold that treatments involve external intervention—pills or
surgery—the followers of Asklepios believed that healing must come from
within the patient. It is appropriate that the serpent of Asklepios still coils round
the staff which is the emblem of the Royal College of General Practitioners. I
shall suggest in Chapter 2 how this strand in Greek medicine has an important
place in the contemporary world. Science-based treatments are often but not
always the optimum remedies for suffering humanity and it is an illusion of the
age that there can be a science of human relationships, although (as I shall
suggest) there can be non-scientific ways of coming to understand the
complexity of human relationships.
The ethos rightly stresses the importance of ethics in regulating medical
treatment, and medical schools nowadays make discussions of ethics a part of
the curriculum. But what is taught is medical ethics, or ethics from a medical
point of view. Indeed, for many years the idea has prevailed among teachers of
medical ethics that the complexity of our lives as moral beings can be distilled
into four principles peculiar to medicine. It is arguable that the advocates of
these principles may have made the ethical practice of doctors worse than it
otherwise would have been. The principles are: non-maleficence, an odd
neologism. It seems a strange way of saying: first do no harm. The second
principle is ‘beneficence’, which is easily confused with ‘benevolence’. But
doctors are not being ‘benevolent’ or ‘beneficent’; what they do for a living is to
offer treatments which they believe are best suited to their patients’ problems.
The third principle is: respect the patient’s autonomy. But this has led to the
erroneous belief that doctors must do what the patient requests. Moreover, the
ambiguity of the phrase ‘respect the patient’s autonomy’ has been an important
factor in the rise of consumerism in medicine. As I shall argue (Chapter 6),
consumerism destroys the whole idea of medicine as a profession. The fourth
principle is that of justice, but it is not clear whether this means justice to the
patient or the health budget, and certainly does not include reference to equity in
the distribution of resources for health.
The central point to be made about medical ethics is that life in hospitals or
general practices is a microcosm of the myriad circumstances of ordinary life
with added intensity, as is seen in the many difficult decisions and stresses of life
in hospitals during the pandemic. Doctors may need to make life or death
decisions, deal with frightened patients, with angry relatives, with overbearing
managers, with distressed colleagues, and still perhaps manage to have a family
life. There are therefore philosophical questions concerning: what to do—or the
optimum way of reaching morally sound decisions; concerning the manner or
the adverbial side to morality—when, how and how much to communicate
decisions; concerning how to identify and deal with bad practices—the critical
side to morality; concerning how to become a person who makes sound
judgements—the self-development side to morality. Coping with these wide
areas of ethical concern requires much more than learning up four principles.
Additionally, in the post-pandemic world there are many moral/ethical problems
which arise in public health medicine, problems which require an enlargement of
the characteristic individualistic ethics of clinical medicine. How can medical
students and doctors become familiar with these concepts?
I shall suggest that exposure to the arts and humanities can be a method of
drawing attention to the many and complex ways in which human beings and
communities interact. Stories, paintings and other arts and humanities distil the
essence of the ways in which people interact, and philosophy can offer a critique
of the scientific basis of medicine and the social and political context in which it
operates. Medical training and practice inevitably require a narrow focus, but
understanding human interaction and community dynamics requires a broader
focus. In sum, what the arts can contribute to is the development of sound
clinical judgement which, despite the prevalence of algorithms, remains an
essential requirement of a good physician or surgeon. Moreover, the arts and
[1]

humanities raise awareness of the manner in which wider community interests

can be affected by medical decisions. Medical decisions and treatments can
affect not just the individuals concerned but their families and their
communities.
The ethos further assumes as basic the one-to-one consultation. For example,
the Declaration of Geneva states: ‘The health of my patient will be my first
consideration.’ Yes, but there are problems with the two words ‘my patient’. First
of all, the idea of ‘my patient’ grates a little if we consider the range of
professionals who may be involved: the scientists in the background, the nurses
and many others who act at the bedside. Health care is now delivered by teams
and the doctor does not own the patient. Moreover, health care does not stop at
the hospital door. Many health workers in the community may be involved.
Secondly, the Declaration was written before costs in health care became so
central. To say that the health of ‘my’ patient will be my first consideration slides
over the economic side to a given treatment. Despite the rhetoric of politicians
not every patient can receive what is perhaps their optimum treatment.
This takes me to a fundamental philosophical assumption of the ethos: it
assumes the political philosophy of liberal individualism. The one-to-one
consultation is the foundation of medical practice and is central to the ethos. But
it is important to point out that the huge improvements in health have not come
about via one-to-one medicine but via public health medicine, and, as the
contemporary pandemic has made all too clear, the comparative neglect of public
health medicine has left the UK and other countries underprepared for
pandemics. Yet public health medicine receives about one tenth of the resources
of clinical medicine and is not ranked so highly in public esteem. Moreover, the
health of the public requires more than even public health medicine on its own
can offer; it requires the support of the care sector. Yet the care sector is a very
poor relation of the NHS in terms of both the salaries of the carers and public
esteem. The Covid-19 pandemic has made clear the practical need for bringing
the care sector into the remit of the NHS.
The fourth and final aspect of the ethos is solidarity. Students are chosen to
study medicine in terms of excellence in the scientific aspects of the school
curriculum and in tests set up by medical educators. Interviews are conducted by
doctors who naturally favour candidates like themselves. Students are then
educated or trained together in medical school; their friends are mainly from
medical school and solidarity is re-enforced by year clubs. This has huge
benefits for doctors in that it leads to support in a stressful career, but it can lead
to a closing of ranks and a cover-up when things go wrong, and it creates a
resistance to criticism or suggested changes coming from outside the
professional ethos.
My argument is based on the underlying philosophical assumption that health
is a wider concept than the freedom from disease of individuals; it extends
beyond the focus of clinical medicine, public health medicine and the care sector
(however important they may be) and requires an input from many agencies,
including those concerned with a green environment. To put the point differently,
doctors say that their basic aim is to improve quality of life. But the medical idea
of quality of life is of something individualistic which can be supplied by
doctors and is quantifiable on a scale one-to-ten. To regard quality of life in this
way, however, is to make a category mistake. ‘Quality of life’ is not a descriptive
first-order quality such as pain or depression. Indeed, it is not a ‘quality’ at all. It
is a second-order, all-things-considered, value judgement on first-order
descriptive qualities such as mobility, freedom from pain, general welfare and
social relationships. It must not be narrowed down to ‘health-related’ quality of
life, which is not a coherent idea. Quality of life has many non-medical aspects,
such as equitable relationships among the members of a community, the
provision of material and cultural goods and a green environment. This was
recognised in the WHO 1947 definition of health which stressed not just the
absence of disease but social and mental well-being.
Perhaps the thesis of the whole book can be summarised in terms of an
analogy from grammar. ‘Health’ has traditionally been understood as a noun
referring to a condition or state of affairs which individuals can possess and
which can be protected by vaccines and repaired by surgery. More recent views
have not rejected this approach but have supplemented it, suggesting that health
can additionally be seen as an adverb—a style of living, or a way of qualifying
the active verbs of living. This is exemplified in the health promotion approach,
and has become prominent in advice on how to live if we are to avoid infection
by Covid-19. But Covid-19 has also highlighted the need for a third way of
looking at health. The need is to see health as a relational predicate. Health is a
state of individuals but it is also a way in which people relate to each other in
communities and the environment. The narrow ‘on-a-scale-of-1–10’ medical
view of quality of life must be enlarged to admit a fresh approach in which
people and professionals relate to each other on an equitable basis in greener
communities. Philosophy as a revisionary activity can make a case for this
approach.
1 A detailed discussion of clinical judgement can be found in: Downie, R.S. and Macnaughton, J. (2000)
Clinical Judgement: Evidence in Practice, Oxford: Oxford University Press.
 Part 1.
Medicine and Science:
A Philosophical Critique
 Chapter 1
Medicine as

Applied Science
The Hippocratic School

Hippocrates was a Greek physician who was born around 460 BC. He and his
School were dedicated to investigating the rational, scientific basis of medicine,
an approach which is the foundation of modern medicine. The central doctrine of
the Hippocratic School is that every disease has a cause which can be discovered
and is curable, and that this knowledge is generalisable. His scientific approach
ignores the individuality of patients and concentrates on what diseases have in
common. For example, Hippocrates writes: ‘Every phenomenon will be found to
have some cause’ or ‘Each disease has a natural cause and nothing happens
without a natural cause’. This belief is the foundation of western, scientific
[1]

medicine, expressed nowadays in the slogan ‘evidence-based medicine’.

Medicine has been profoundly influenced by this tradition, to the extent that it is
sometimes seen as an applied science. Science is the dominant value in the
medical ethos at the moment, and is the inspiration behind the algorithmic
approach to patient care which I shall discuss later (pp. 21–2). Indeed, I hope to
show how a belief in science has affected the other elements in the doctor’s
approach to patients, not always in a beneficial way. Consider first the
connections between science and medicine.
Science is relevant to medicine in five different ways. Firstly, from the
[2]

Greeks to the present day there have been investigations into the normal and
pathological workings of the body, carried out by sciences such as anatomy,
physiology and biochemistry. Secondly, there are observational/statistical studies
which report such matters as changes in birthweight or life expectancy over a
period. Thirdly, there are qualitative studies which might be concerned, for
example, with the interaction between doctors and patients. Fourthly, there are
randomised clinical trials, and fifthly, more recently mathematical modelling has
appeared on the scene. Are these different sorts of research equally scientific?
The subjects in the first group—anatomy, physiology, biochemistry, pathology
—are clearly sciences. They satisfy the usual criteria for science in that they are
observational, reductionist to the factors being researched and experimental.
Their results are quantifiable, generalisable and frequently offer causal
explanations. They are therefore objective in the sense of being independent of
personal bias. And, importantly, they provide understanding of the normal and
pathological workings of the body.
The second category is more doubtfully scientific. Observational studies may
record quantitative changes, such as death rates in social or occupational groups
or geographical areas, but such studies belong more to the category of natural
history than to science. This of course is in no way to denigrate their importance
—facts must be known before causal explanations are attempted.
Thirdly, qualitative studies are even more doubtfully scientific, being based
very much on the interpretation and value judgements of the researcher. They are
certainly observational—for example, observing doctor–patient interaction—but
attempts to generalise them by making the qualitative quantitative will actually
reduce their value. For example, if something is quantitative, or measurable,
there must obviously be factors to be measured. But in measuring, say, ‘patient-
centredness’, the factors selected for measuring, such as the making of eye
contact or the angle of the chair, simply reflect the views of the researchers, and
may even get in the way of a positive doctor–patient relationship. Some patients
may feel embarrassed at being stared at! The reductionism necessary for
quantification makes such studies misleading. [3]

The fourth sort of research—randomised trials—is regarded as the ‘gold-

standard’ of medical research and is the kind of research most often reported in
the press. But is this the ‘gold-standard’ of science? Are randomised trials
observational, reductionist, experimental, quantifiable, generalisable and
objective or independent of personal bias?
They are certainly observational and quantifiable, and they are reductionist in
that they set out to test discrete factors, such as the efficacy of a given drug. But
they cannot fully satisfy the generalisability criterion in that they are concerned
only with statistical probabilities. More importantly, there may sometimes be
questions about how the volunteers for the trials are chosen, how the trials are
financed (perhaps by pharmaceutical companies with vested interests) and how
their results are evaluated and promoted (perhaps by paying doctors to carry out
evaluation). In other words, there may be doubts raised about the objectivity
criterion, a necessary condition for scientific respectability.
Moreover, there are limitations to the relevance of knowledge gained from
randomised trials to clinical practice—limitations which stem from the statistical
nature of randomised trials. It does not follow from the fact that a drug has been
efficacious in 65% of cases that it will be efficacious with a given patient.
Indeed, it might be harmful, or the patient having been told the side effects might
refuse consent to it. In other words, randomised trials are not the be-all-and-end-
all of clinical medicine, even if they are the begin-all.
Clinical medicine claims to be ‘evidence-based’, but the evidence of
randomised trials compares unfavourably with that of laboratory science or that
of a court of law. But perhaps it does not matter whether randomised trials are
truly scientific provided they produce useful knowledge. The problem is that,
whereas the information from randomised trials may be worthwhile, its uncertain
scientific credentials do not warrant the use of the term ‘gold-standard’ in
referring to them, thus encouraging clinicians to urge them on patients. From the
point of view of a sceptical critic that is a disadvantage.
More recently mathematical modelling has become prominent as a scientific
approach to epidemiology. It may well have been transferred from its use in
economics and its mathematical nature may appeal to those who stress the
scientific side to medicine. It has not been conspicuously successful as a tool in
economics because its initial assumptions are doubtful—that people behave in a
rational self-interested way. Likewise in epidemiology assumptions must be
made about how infections are likely to spread. But these are assumptions
whereas medicine insists it is evidence-based. What are offered are models of
what might happen rather than hard evidence. They may have a role but over-
reliance on them can be misleading.
Moreover, what is ‘modelled’ is only one type of phenomenon; for example,
the spread of a given disease such as Covid-19. But there are many different and
equally serious health problems which afflict society at any given time, and there
are many other economic and social problems. To base a political policy solely
on the findings of mathematical modelling may therefore be misleading. To
‘follow the science’ requires listening to many other voices, including other
medical voices and economic ones, not just those of epidemiology.

The Use of Human and Animal Subjects in Research

A different set of issue can limit the scientific aspects of medical research: the
ethical problems which can arise over the use of human subjects, and more
especially the use of animals in research. Beginning with human subjects of
research I shall discuss two specific issues which arise over the use of human
subjects in a trial or other experimental procedure.
 The first of these has received a great deal of attention—it concerns eligibility
to enter a trial. This is usually established by local research ethics committees
(LRECs), although sometimes national committees examine fundamental or
more controversial issues, such as the Warnock Committee. LRECs have been
[4]

in existence since the early 1990s, and it is not likely that research from an NHS
or other research group would be published without LREC approval. The
membership of such committees has been much discussed and there are detailed
arrangements for their procedures, but since it is generally accepted that they do
a good job I shall not comment further, but note that membership bias can affect
decisions of LRECs.
The second issue involves what is known as therapeutic research. Therapeutic
research is required when there are two or more possible treatments and
clinicians are not sure which provides the optimum benefit so they set up a trial
to enable them to decide. We can stipulate that at the beginning of the trial there
is no clear evidence of the superiority of either treatment A or treatment B. The
methodology in this case would suggest that patients could be randomly
assigned to each arm of the study without violating the basic ethical rule of not
harming. If by the conclusion of the trial it emerged that clinicians could be 90%
certain that treatment A was superior to B, they would have a persuasive
scientific outcome. The difficulty, however, is that clinicians could have drawn
the same conclusion at some earlier point when, say, they were 65% certain of
the outcome. But trends can reverse themselves so 65% would not be acceptable
scientifically. The Hippocratic or scientific influence might therefore lead
researchers to continue with the study, but the majority of clinicians faced with
the figure of 65% would be persuaded to switch to that treatment, despite its lack
of scientific credentials. My point in this example is that there can be tension
between the Hippocratic or scientific strand in the doctor’s identity and the
ethical strand to provide the best possible care.
Turning now to the use of animals in medical research we find a very different
sort of tension between the scientific and the ethical strand in medicine. Many of
the developments in health care have been researched initially on animals.
Animals have also been used for non-medical purposes, such as testing
cosmetics, but in the contemporary moral outlook the non-medical uses of
animals are widely condemned so I shall not discuss them.
In medical research animals have been used for four main purposes: the
testing of new drugs; the study of basic mechanisms of body function in health
or disease; the testing of hypotheses about physiological or pathological
processes; the transplant of animal organs or other tissues into human beings
(‘xenotransplantation’). Can these uses be justified?
It can be argued against the use of animals that they are living, sentient beings
and, since they have no say in the matter, they should not be used for
experimental purposes. In support of this we can imagine a piece of science
fiction. We can be invited to imagine that the human race is invaded by hostile
aliens from outer space. They discover that a medical problem common in aliens
can be cured by removing organs from human beings. The aliens decide to do so.
They have the power to do so, and of course they are acting from the highest
motives: to benefit the suffering of fellow aliens and to cause minimum suffering
to the human race, which indeed might benefit from the research involved. Have
the aliens a case? The case is similar to the one used to justify research on
animals to benefit human subjects.
For those readers who prefer something less fanciful there is the direct moral
appeal, if not argument: that it is wrong to inflict pain on any living creature
even for good motives, such as the search for cures for human health problems.
In opposition to this position that it is morally wrong to use animals in
medical research it can be argued that we must balance the suffering caused to
animals with the benefits to humans, and sometimes to animals themselves.
Moreover, it can be pointed out that those who do use animals in experimental
work follow clear guidelines laid down by the Home Office (in the UK). These
include the use of as few animals as possible; the use of animals for specific
purposes only; avoidance of pain or discomfort; proper safeguards for their use.
Of course, while there are safeguards in place it is less clear that there are
sufficient inspectors to ensure that the rules are being followed.
[5]

Apart from the ethical considerations there are also scientific arguments
against the use of animals for research purposes. For example, it can be argued
that it is because animals are not human that results obtained from them are not
reliable. What seems to be successful in a mouse population might have serious
side effects in the human population. Moreover, there are fears that the processes
involved in obtaining animal organs, such as those from pigs, for transplant into
humans involve disturbing methods. Xenotransplantation has not yet been
[6]

successful but the techniques involved in the attempt to avoid human rejection of
the pig organs—such as injecting the pig with human genes and creating a new
species of transgenic pig—can stir up a deep-rooted human fear, like the ancient
Greek fear of hubris. Or it can be a reminder of the original temptation in the
Garden of Eden: Ye shall be as gods. [7]
 There are two very general cultural movements which are beginning a social
resistance to using animals for experimental purposes, or otherwise interfering
with their natural lives. One is the fear of plagues, of the creation of new viruses
which may jump from animal to human. The mechanisms of this are not fully
[8]

understood, but the fear exists and there is speculation about the causes of recent
plagues, including Covid-19. For the ancient Greeks hubris, trespassing over
natural boundaries, leads to nemesis or catastrophe. The second cultural
movement is a more positive celebration of the environment, and a growing
recognition that we are one animal species among others with whom we must
share the planet. The likelihood is that in the post-pandemic era the use of
animals for human purposes will decline partly for the two reasons I have just
suggested, but also because science will find more accurate, less controversial
and cheaper ways of serving the purposes for which animals have hitherto been
used.
In conclusion, then, there is genuine science, or many sciences, at the basis of
medical practice but also much guesswork and judgement—a central concept I
shall return to. Moreover, the medical sciences are not exempt from ethical
scrutiny, a point accepted in the medical ethos.
Underlying this complexity it is possible to identify two views of the aim of
science. One view—the dominant view of funding bodies and perhaps the
general public—is that the aim of science is to control nature for human benefit.
An extreme version of this view is provided by the seventeenth-century
philosopher Francis Bacon (1561–1626) when he says that: ‘Truth and utility are
here the very same thing.’ This is an extreme version of the view that what lies
behind science is utility.
[9]

Without going as far as Francis Bacon, the aim of funding bodies generally is
to promote what they regard as ‘useful knowledge’. The importance of science
on this view is an importance internal to medicine; science is important to the
extent that it informs medicine, and other areas of political significance. But an
alternative view is that the primary purpose of science is to understand nature,
including human nature. In terms of this alternative view of science randomised
trials, apart from their failings in objectivity and generalisability, do not
contribute to the primary purpose of science—which is to offer an understanding
of nature. If science is seen as an attempt to understand, randomised trials are
really natural history rather than science in the full sense. Of course, it might be
said that these aims are not incompatible—to control we must first understand.
This is true, so even from the point of view of a funding body science as the
understanding of nature must surely be encouraged. How can science, including
medical science, help us to understand nature?

Scientific Understanding

The idea that true understanding of events and of people can be provided only by
one or more of the sciences begins with Plato. Plato’s view is that real
understanding comes from having insight into the blueprints, the timeless
patterns, which make things as they are. In our day the task of discovering such
patterns has been taken over by the natural and social scientists. We might say
that scientists are attempting to trace order, or repeatable patterns, in the apparent
randomness of what we observe. These patterns can be anything from the orbits
of the planets to the typical development of a tumour. We could put it another
way by saying that one way in which the sciences provide understanding is by
demonstrating that events, and indeed pieces of organic and inorganic matter, are
not endlessly different or individual but can be classified into types.
The beginnings of scientific classification can be found in Aristotle, who
distinguished the types into ‘genera’ and ‘species’. For Aristotle, to understand is
to be able to classify, to be able to show that there is order in the apparently
random; and the more developed the science the more refined will be the
systems of classification. Whereas the terminology has changed a little (say, in
botany), Aristotle’s approach to the scientific understanding of the world is still
accepted, especially in medicine.
The same kind of account can be given of the behavioural sciences. They
attempt to provide understanding by tracing patterns in human behaviour. There
has been less success here because of the complexity of human behaviour, and
the ethical and practical problems which arise through any attempt to experiment
on human behaviour. Nevertheless, the principle is the same: the behavioural
sciences, like the natural sciences, attempt to provide understanding through
tracing repeatable patterns, such as the types of behaviour shown in, say, bipolar
disorder, or indeed by a person who is dying.
There is a second, although connected, way in which the sciences try to give
us understanding of the world, and that is through discovering the underlying
causality of the patterns. For example, an early botanist might have observed that
insectivorous plants, such as butterwort, typically grow in boggy terrains. The
more modern biochemically-minded botanist could explain the pattern by
establishing that a boggy terrain is deficient in nitrogen and that the plant obtains
nitrogen by ingesting insects. Thus the pattern is explained in terms of an
underlying causality. Once again the same is true of behaviour patterns. An early
scientist, such as Hippocrates, noted the behaviour patterns which are typical of
epilepsy, say, and a modern scientist would try to explain such patterns in terms
of the underlying causality of the brain.
There is a third feature of the scientific approach which we might term
‘reductivism’. The term is used in a variety of ways, but what I have in mind
here is the tendency to treat the phenomenon to be explained in isolation from its
total context. The origins of this tendency can be seen in early modern physics
where the laws of moving bodies, for example, are investigated and established
in isolation from other factors such as air resistance. To the extent that the
behavioural sciences model themselves on the natural sciences this tendency is
also found in them. The reductivist tendency is encouraged because reductivism
makes it easier to assign numbers to the phenomena being explained, and
numbers give the appearance (often deceptive) of objectivity and rigour.
A fourth characteristic of scientific understanding concerns the scientific
attitude—one of detachment, emotional non-involvement with what is being
investigated. This characteristic can best be identified if we take an example.
Suppose a psychiatrist is interviewing a patient and the patient becomes angry
and abusive. The response of the psychiatrist will be detached in the sense that
she will not take personally anything said, but rather will see the anger as the
result of causal forces the patient cannot control; the anger will be seen as a
symptom. Suppose now that the same psychiatrist later in the day encounters
anger from the Chief Executive of the hospital trust. Let us say that she has
parked her car in the Chief Executive’s space. In this case she will respond
differently, perhaps with indignation—‘There was no other space and I was
called in urgently to see a case’—or perhaps with embarrassment—‘I’m sorry I
just didn’t notice that it was exclusively your space’. But, however the
psychiatrist responds, the general nature of the response will be essentially
different from that which she offers to the patient. Some philosophers have
contrasted the ‘objective’ attitude, when we respond to deeds and words as if to
the effects of causes, with the ‘reactive’ attitude, when we assume that deeds and
words have a human meaning and are to be taken at their face value as parts or
ordinary human interaction. We might say that the distinction is between the
[10]

scientifically or technically or professionally detached, where the interest

terminates in the phenomenon in question, and the humane where there is a
deeper resonance involving human feelings.
 Some Limitations of the Scientific Approach

If these four characteristics (there may be others) are typical of a scientific

approach to nature and to human beings it will follow that there can be
reasonable reservations about the Hippocratic element in medicine, to the idea
that medicine is an applied science. Firstly, randomised trials do not deliver the
objective evidence they often claim; the understandable desire to be immediately
useful may get in the way of real scientific understanding. Secondly, the desire to
quantify may actually distort useful qualitative information about patient
behaviour. Thirdly, the evidence-based information available to the doctor must
be delivered to the patient not with the detached manner of a scientist but in a
humane manner. Of course, medical educators may argue that they are well
aware of this and can use the social sciences to teach the appropriate manner in
courses on communication skills. I shall discuss communication skills in more
detail later (pp. 52–3) but simply note here that being able to communicate
sometimes bad news in a humane manner is not just a learned skill like how to
carry out a blood test, but springs from a human concern for suffering or for the
worries of a patient.
In addition to these points it is important to stress that the ‘useful’ side to
medical science is developing in a new direction with the increasing
employment of algorithms. Consider the following extract from a book
concerned, among other matters, with the way in which we are increasingly
organised into networks so that each person is only a small step in a huge
network of algorithms, and it is the algorithm as a whole that makes the
important decisions. The author takes the specific example of hospitals and
writes:
Think about a modern hospital, for example. When you arrive the receptionist hands you a standard
form, and asks you a predetermined set of questions. Your answers are forwarded to a nurse, who
compares them with the hospital’s regulations in order to decide what preliminary tests to give you.
She then measures, say, your blood pressure and heart rate, and takes a blood test. The doctor on
duty examines the results, and follows a strict protocol to decide in which ward to hospitalise you…
Specialists analyse the results according to well-known statistical data-bases, deciding what
medicines to give you or what further tests to run. The algorithmic structure ensures that it doesn’t
really matter who is the receptionist, nurse or doctor on duty. Their personality, political opinions
and momentary moods are irrelevant. As long as they follow the regulations and protocols they have
a good chance of curing you. According to the algorithmic ideal, your fate is in the hands of ‘the
system’, and not in the hands of the flesh and blood mortals who happen to man this or that post.[11]

This is an example taken from US experience, but something similar is no doubt

increasingly being advocated in the UK, especially in the budgetary constraints
of the post-pandemic world. But is algorithmic-based treatment always in the
best interests of patient?
There is a persuasive argument for claiming that the most satisfactory result is
likely to emerge from following the algorithm. For example, let us imagine that a
GP is interviewing a patient. She comes to the conclusion that the symptoms
indicate a certain condition and treatment. Now an experienced GP may have
seen 50–100 similar cases. But the algorithm indicates that the symptoms should
be fed into the computer. The computer contains information on 5 million cases.
Hence a more accurate diagnosis and treatment will emerge. But where is the
responsibility here? The individual responsibility is that of the GP or consultant
who followed the proper procedures, and presumably a computer programmer is
responsible for correctly programming the data, but the data come from
innumerable sources. These sources amount to collective wisdom; they will
[12]

express the best evidence-base for the ailment in question.

But does this collective wisdom always lead to the optimum treatment for a
given patient? It may be that a given patient has a strong preference for a
different treatment or a fear of the offered treatment. In such situations the
‘placebo effect’ may be worth recognising, and of course a patient has the right
to refuse consent to any treatment. The reality is, however, that the doctor may
ignore her own judgement on this and go with the algorithm, for the reason that
there will always be a strong defence in law to the effect that ‘I did what the
protocol instructed’. In other words, the responsibility lies with the ‘system’,
with collective information.
The development of an algorithmic approach to patient care thus seems to
involve the development of the idea of medicine as an applied science. In other
words, computerised diagnosis and treatment seem to involve an erosion of
individualised care based on a doctor’s clinical judgement.
Recently there has been a move—based on science—towards discovering
ways of individualising treatments, and thus avoiding the charge that algorithms
do not take into account the factors which may affect individual patients. This is
currently an important research area and if successful will certainly improve the
efficacy of treatments. The underlying research is into the sequencing of the
human genome. The hope is to achieve what enthusiasts regard as a medical
revolution based on the four P’s: prediction, prevention, precise diagnosis,
personalised intervention. Genomic Medical Centres are based round the
country.
‘Personalised medicine’ as it is called is seen as the cutting edge of medicine,
but it is in its infancy, and its costs are considerable. It certainly represents a
complete medicalisation of health, and keeps health firmly in the hands of
scientific medicine. But ‘prevention’ or ‘personalised intervention’, for example,
are surely not just medical ideas. They involve issues of lifestyle, living
conditions and the whole sad subject of multiple deprivation. In the post-
pandemic world, it is important to avoid the hard sell of the ‘scientific’ side to
medicine as the answer to all our health problems. Medical judgement requires
to be broadened as health depends as much on social factors such as equity in the
distribution of resources and a green environment as on sequencing the genome.
It might also be said that there is certainly scope for discretion concerning
ways of communicating and managing the patient—the ‘adverbial’ side to
treatment, concerning in what manner, when and how much to communicate to a
given patient. But even here courses on ‘communication skills’ have the effect, if
not the aim, of stereotyping doctors’ responses to patients. They convey the idea
that there is a universalisable, teachable and learnable skill in communicating.
Hence, it might seem that the scope for individual initiative and therefore
responsibility is increasingly limited, even in matters such as communication.
But communication is not like a skill in checking heart rhythms. Doctors are
endlessly varied in their personalities and so too are patients. There cannot be a
science of the endlessly varied and particular. Of course, there are elements
common to any consultations, such as not using technical words, not speaking
too quickly and repeating the message. But this is common sense rather than
social science. Nevertheless, the Hippocratic or scientific element in the ethos—
to the effect that what is worthwhile in medicine can be generalised or even
quantified—has tended to distort even this side to medical practice. I shall
develop this point in Chapter 3.

Non-scientific Research

The study of medical history can suggest ways of looking at medical research
other than that of current medical orthodoxy, the ‘gold-standard’ of randomised
trials; it can offer a wider historical perspective on research. For example, Sir
James Mackenzie, working as a GP in the first half of the twentieth century,
regarded general practice, rather than hospitals or laboratories, as the proper
place for clinical research. He carried out pioneering work in cardiology in
Burnley, London and in the St Andrews Institute for Clinical Research. A study
of his work—its successes and failures—can suggest new ways of looking at
medical research.[13]

Research has also shown that performing music can result in surprising health
improvements. For example, singing has been shown to lead to improvements in
chronic obstructive pulmonary disease (COPD) and to the enhancing of mental
health and well-being. Choral singing is especially effective for depressions. It
[14]

was also encouraging to hear on the radio that GPs in Shetland have been
recommending walks by the sea as a therapy for depressions. And massage
seems to be effective in releasing white cells to counter pain. Such therapies, as
well being effective, are also much cheaper than standard medical treatments.
Non-medical treatments are further discussed in Chapter 11.
Now, it is true that many doctors may grudgingly recognise these treatments—
but they will be labelled as ‘alternative therapies’. Such labelling is patronising
and dismissive. One can ask: alternative to what? A crude answer is alternative
to pills with uncertain side effects. Defenders of medical orthodoxy might prefer
the answer: alternative to a scientific approach. But it must be stressed that
medical science has goals internal to medicine; doctors are interested in reliable
warrants for effective clinical intervention rather than scientific purity. If such
‘alternative’ therapies can be shown to be effective they should be part of
mainstream medicine. In other words, the evidence-base of medicine requires to
be widened. It is not unreasonable to be a little sceptical of the scientific
monopoly, the narrow focus of medical research.
More generally, many doctors see medical solutions to all the problems of life,
and have encouraged the public and governments to do likewise. Thus, mental
illness, disability and drug addiction are usually understood by doctors and the
public as medical problems when in fact there may be other approaches to them.
Perhaps organising festivals, pageants or firework displays, clearing the litter
and improving the appearance of and access to buildings may improve the health
in a deprived area more than funding another GP. A doctor who can look beyond
his prescription pad might be able to suggest other remedies.
The point here is best expressed via the term introduced by Edward de Bono
—‘lateral thinking’. His main point is that we tend to see the world in terms of
certain patterns or groupings. The person with a disposition to lateral thinking is
the person who can break away from familiar patterns and discover new ways of
looking at things. Intellectually, lateral thinking may emerge as a sceptical
disposition towards received opinion and routine. There is a fair amount of
received opinion and routine treatment in medical training, practice and research,
but the arts can sometimes suggest alternative ways of approaching problems. I
shall develop these points in Chapter 11.

Conclusions

Medicine is moving in an increasingly scientific direction and there is no doubt

about the enormous benefits which have accrued to patient care. Nevertheless
there can be doubts about how scientific in the end medicine can be. It deals with
human beings in their enormous variety and complexity. Science gives us
understanding of the many patterns to be found in events and processes
including, to a limited extent, the patterns of human behaviour. But
understanding of that kind does not touch the meaning of the patterns, whether
of disease or human emotion. Many doctors are aware of this and therefore stress
the importance of the individual consultation. But there is a danger, as I shall
suggest in the next chapter, that the individual consultation has itself become
medicalised. The post-pandemic world provides an opportunity for resetting
priorities in medical research and the ways of tackling the ill-health of
individuals and communities.
1 Lloyd, D. (1983) Hippocratic Writings, Harmondsworth: Penguin, p. 29.
2 I am indebted to Professor Jane Macnaughton for these ideas. See Downie, R. and Macnaughton, J.
(2007) Bioethics and the Humanities, Abingdon: Routledge-Cavendish.
3 Downie, R.S. and Macnaughton, J. (2000) Clinical Judgement: Evidence in Practice, Oxford: Oxford
University Press.
4 Warnock, M. (1985) A Question of Life, Oxford: Blackwell.
5 Montgomery, J. (2001) Health Care Law, Oxford: Oxford University Press, pp. 353–55.
6 Fox, M. (2006) Exposing harm: The erasure of animal bodies in healthcare law, in McLean, S.A.M. (ed.)
First Do No Harm, Aldershot: Ashgate.
7 Genesis, 5:3.
8 https://www.worldsciencefestival.com/2014/12/eight-animal-plagues-wreaking-havoc-right-now/.
9 Bacon, F. (1620/1872) Novum Organum, Devey, J. (ed.), London: Bell, Bk. 1 sect. 124.
10 Strawson, P.F. (1962) Proceedings of the British Academy, vol. XLVIII.
11 Harari, Y. (2016) Homo Deus, London: Harvill Secker, pp. 160–61.
12 Susskind, R. and Susskind, D. (2015) The Future of the Professions, Oxford: Oxford University Press.
13 Macnaughton, J. (2002) The St. Andrews Institute for Clinical Research: An early experiment in
collaboration, Medical History, 46, pp. 549–63.
14 Clift, S. (2011) Singing, wellbeing and health, in MacDonald, R., Kreutz, G. and Mitchell, L. (eds.)
Music, Health and Wellbeing, Oxford: Oxford University Press.
 Chapter 2
Medicine as

Inner Healing
The Tradition of Asklepios

The Asklepian tradition is also Greek in origin and is older than the Hippocratic
tradition. The two traditions flourished together and were not seen as mutually
exclusive. Asklepios is a shadowy figure in Greek thought. He was believed to
[1]

be the son of the god Apollo (the god of healing and the arts) by a mortal
woman. The Asklepian tradition stresses healing, but in the context of our
acceptance of our mortality. The temples of Asklepios, which were the centres of
healing, contained harmless serpents (coluber longissima). It was thought to be
the mystical hypnotic gaze of the serpent which was healing, and the fact that
serpents change their skin was also a symbol of healing. Moreover, the
atmosphere of the temple and the quiet repose and dreams of the patients were
important in the healing process, for the healing comes from within the patient.
[2]

There is an important contrast here with the Hippocratic tradition of modern

medicine where the emphasis is on external intervention.
The Asklepian tradition, of the healing gaze of the serpent and the changes
coming from within the patient (as in changing one’s skin), translates well into
some aspects of the modern medical consultation. In a sense the gaze
corresponds to the doctor’s attention to the patient, to the careful waiting and
listening, and to acceptance of the particularity of the patient as a unique and
important person in the context of our knowledge of our humanity. An approach
of this kind is not manipulative and does not threaten the patient’s integrity.
Healing derives from the careful application of medical knowledge while
constantly attending to the patient.
Dr Marie Therese Southgate, who was Deputy Editor of the Journal of the
American Medical Association, brings out the nature of the Asklepian tradition
by means of a comparison between the approach of the doctor and that of the
artist. She argues that both have a common goal—to complete what nature
cannot bring to a close. This is done, she suggests, by paying attention: ‘If we
are attentive in looking, in listening and in waiting, then sooner or later
something in the depths of ourselves will respond.’ This approach is drawing
[3]
attention to the mystique of a medical consultation and ascribes to the doctor an
almost shamanic quality, corresponding to the hypnotic gaze of the healing
serpents. In more down-to-earth terms doctors have a high status in western
society and are respected and deferred to. Doctors are aware of this status and
see it as part of the medical inheritance. Patients also benefit from this shamanic
quality. Writers have traditionally made fun of doctors, portraying them as
pompous and self-seeking, but sick patients at a consultation can feel they are
handing their burdens and worries to someone else who has their best interests at
heart. This can result in an uplifting of their mood. The placebo effect of the
consultation is an important element in it. It will be a considerable loss to the
healing process if in the financial constraints of the post-pandemic world the
face-to-face consultation is replaced by Zoom.
The insights of the Asklepian tradition and their valuable contribution to the
ethos of medicine require some further explanation. There are three points which
are relevant to a medical consultation from this point of view: concerning the
manner, the diagnostic insights, the ethics.

The Asklepian Manner

The manner consists of quiet waiting and listening, concentrating attention on

the patient. At this point medical educators influenced by the evidence-based,
Hippocratic tradition may say: ‘We know this, we do it already, and it is taught
in courses on communication and listening skills.’ There is indeed a vast
literature on communication skills, but does this literature really express the
manner of the consultation as hinted at in the Asklepian approach, or does it
rather distort human communication? The very term ‘communication skills’ is
itself the give-away in that it suggests that there are generalisable skills which
are teachable and learnable and therefore widely applicable. Perhaps there are,
but they are unlikely to extend much beyond such matters as avoiding technical
terms, not speaking too quickly, repeating the message and so on. These things
are of course of the first importance because a common patient criticism of
doctors generally is that they are deficient in such matters. Nevertheless,
attempts to have a complete reduction of communication to a set of discrete
skills is bound to fail. As I remarked in Chapter 1 (pp. 233–4) patients and their
problems are too varied and doctors and their personalities are too varied for any
reductionist approach to work. Indeed, interaction with patients may be
adversely affected if trainee doctors are encouraged to inhibit their own natural
responses and substitute consciously adopted trained responses. Human
communication will become a manipulative technique.
The problem arises because there is an attempt to use the approach of
Hippocrates (in the disguise of social science) in an area of human experience
for which it is not suited. The Asklepian tradition has become distorted because
it is being interpreted in terms of the protocols, training courses, questionnaires,
scales and measurements which have become dominant in the Hippocratic
tradition at the present time. A recent scientific study argues: ‘The concept of
communication skills is inherently reductionist inasmuch as it proposes that
complex behaviour such as conducting a consultation or building a relationship
can be atomised into component skills.’ The authors conclude that, granted the
[4]

uncertain dynamics of consultation, good communication must be inherently

creative. I shall develop this point in more detail later (pp. 52–3).

Narrative Understanding

Turning now to diagnostic skills, I agree that they are mainly the prerogative of
what I am calling the ‘Hippocratic approach’ of modern medicine rather than the
Asklepian approach. Diagnostic skills involve knowledge of the whole battery of
evidence-based tests, scans and techniques and algorithms, which are essential to
contemporary medical practice. Nevertheless, patients themselves may have
things to say which are relevant to a sound diagnosis. I suggest that there is a
form of understanding distinct from that provided by science and social science.
It is known as narrative understanding, listening to the patient’s story. [5]

Something will always be missing if our behaviour is understood entirely in

terms of the assumptions of the Hippocratic model, from the outside, as it were.
A similar problem is faced by anthropologists attempting to understand a
primitive society. It is not adequate for them simply to describe the behaviour;
they must see the meaning of this behaviour in a way of life. Similarly, to
[6]

understand a patient a doctor must understand the meaning of the behaviour for
the patient. This is the context in which the idea of narrative has an important
role. An understanding of meaning requires close attention to the patient’s
unfolding story. It is in this way that narrative understanding can complement
scientific (Hippocratic) explanation. Indeed, in some branches of medicine such
as general practice or psychiatry, narrative understanding may even, sometimes,
bring about an improvement, if the GP or psychiatrist is able to suggest that the
patient’s unfolding story is open to another and less destructive meaning. To
achieve the understanding which supplements Hippocratic explanation the
doctor must search for meaning in the patient’s story rather than make a vain
attempt to share feelings. Consider this search for meaning in more detail.
I argued (pp. 19–20) that scientists enable us to understand the world by
discovering patterns which can sometimes be explained by an underlying
causality. Patterns are atemporal and, as it were, they structure space. An
example is the double-helix which is the pattern of the DNA molecule. How can
we understand something if not by discovering the kind of pattern into which it
fits or its causality? One possible way is in terms of a type of formation other
than a pattern—namely, a sequence. Whereas patterns may be said to structure
space, events and human actions follow each other in time. This gives us a
sequence, and a sequence structures time. This suggests another type of
understanding: we can be shown how a person’s action might fit into the unique
sequence which is their life. For example, we might ask why Mr A, who lives
next door and is known to dislike gardening, has spent all weekend working in
his garden, and we might come to understand when we are told that he is putting
his house on the market and thinks it will sell better with a tidy garden.
The first point in this explanation is that we can now see the action in the
sequence of events and actions which constitute Mr A’s life. Secondly, there are
explicit and implicit references to individual and social purposes and values,
such as selling houses and keeping gardens tidy. These are familiar to us and for
that reason the relating of Mr A’s actions to them helps our understanding.
Thirdly, because such purposes and values are ones which those who are in a
certain social context can share, and with which they can have a sympathetic
identification, understanding is thereby deepened. Fourthly, the story of Mr A
implies a variety of standpoints. There are hints of curious neighbours, perhaps
disapproving of the untidy garden, of speculation about Mr A’s motivation and
so on. Our understanding involves a complex mixture of individual purposes,
social norms and contrasted viewpoints. In a word, it is holistic.
The obvious way to develop insight into these individual purposes, social
norms and contrasted view points is via literature. Writers or at least good
writers have the ability to present the complexities of life as lived in an
approvable and condensed form. There is therefore a case for making short
courses on literature available to medical students. But other arts can be of
assistance in other ways. It is of the essence of the medical consultation that the
doctor should be alert not only to what the patient is saying but also to other
details of their manner and appearance. This is where the concept of attention is
central. Of course, most doctors are aware of this and indeed must be able to
give a concentrated attention to be able to carry out even simple tasks like
checking a pulse rate. But attention of that kind is the attention of a scientist
dealing with an instrument; it must be detached and impersonal. To carry
attention of that kind over to attending to a patient is to omit the element of
humanity which patients value in the consultation. But what other kind of
attention can there be? Here it is helpful to draw analogies with other arts, such
as painting or music. They too have a role in supplementing the approach of
science.

Paying Attention

Apart from their intrinsic value, the skills involved in painting or music are
transferable to other disciplines; especially they are able teach a way of
cultivating a particular kind of attention which differs from the detached
attention of the scientist. One way of identifying this kind of attention is to take
the example of the attention we give to a painting, or even that of the attention
which an artist might give to a person or landscape he/she was about to paint. As
some readers will be aware, the Journal of the American Medical Association
(JAMA) publishes prints of paintings on its front cover. M. Therese Southgate,
who was Deputy Editor of JAMA, writes about the relevance of painting to the
practice of medicine. In her Preface to The Art of JAMA she writes of her belief
that deep affinities exist between medicine and the visual arts. She goes on to
suggest what some of these are: [7]

Firstly, they do share a common goal: the goal of completing what nature has
not. Each is an attempt to reach the ideal, to complete what is incomplete, to
restore what is lost. Secondly, the practitioners of each have something in
common. The first is observation, keen observation. Even more important than
the first because it determines the quality of the first, is the necessity of
attention… Attention does not seek anything, nor does it impose itself on what is
before it. It simply waits in a state of readiness to receive; what it receives is the
truth of the object before it. In the end, both art and medicine are about seeing:
one looks first with the eyes of the body, next considers with the eye of the mind,
and finally, if one has been attentive enough, one begins to see with the eye of
the soul. If we remain in this vision, are patient enough and still enough, we
begin to hear as well, somewhere deep in the depths beyond where words are
formed… It is in this same wordless language of the human spirit that the
physician sees not just a disease nor even a patient but the person. It is in that
moment that healing begins. Paradoxically, the healer is healed as well. That
perhaps is the art of medicine.
The above passage brings out eloquently that it is not the feelings of the
professional which are important but concentrated, involved attention. Just as the
artist tries to see things as they are and ignores her feelings (if any) so the doctor
should concentrate on the patient for what the patient is—a unique individual.
A similar point is persuasively made by the psychiatrist Jonathan Green. He [8]

argues that works of art ‘carry their cultural power by being ways of embodying
states of mind’ and that ‘inferring mental states is not only a core psychiatric
skill but also one we exercise in looking at art’. In a telling image he says: ‘The
painting sucks in attention to itself’, or as the French philosopher Merleau-Ponty
puts it: ‘[art is] the act of bringing truth into being.’ My gloss on this is that, as
[9]

far as medicine is concerned, the attentive act must be both Hippocratic and
Asklepian. A good example of this, and an illustration of the way paintings can
be used in the teaching of communication in medicine, is provided by the
portrait of ‘The Doctor’ by Sir Luke Fildes which hangs in the Tate Gallery. A
lot can be learned from the concentrated attention of the doctor in the foreground
and the parents in the background. A painting can have a direct emotional impact
in the way a lecture on ‘communication skills’ cannot. Perhaps an analogy from
a different kind of art might reinforce the point I wish to make.
A musician giving a performance must concentrate on, give a full and engaged
attention to, the music. A successful performance may evoke emotions in an
audience, but the performer must remain in control of whatever feelings he or
she may have, otherwise he or she might lose the place in the music! The
attention, the listening with both the physical ear and the inner ear, takes
precedence over any emotion. In a similar way, the attending doctor directs
his/her gaze towards the patients, and is totally receptive to what the patient is
communicating. This way of learning what the patient needs is both more
effective and more humane than imposing structured interviews from the
outside. It is in terms of this analogy from the arts of painting and music that I
am interpreting the Asklepian notion of the healer’s hypnotic gaze.
Granted that I have provided an outline of what I am calling the ‘Asklepian’
approach, and granted that I am in no way belittling the Hippocratic or evidence-
based approach, the question arises as to whether and if so how the two
traditions might be combined. Can we unify the insights of both traditions? Can
the attention of the artist be combined with Hippocratic, scientific attention?
 Combining the Hippocratic and Asklepian traditions: Martin Buber

A striking example by Martin Buber suggests how this might be done. The
twentieth-century philosopher/theologian introduced a new phrase into the
language. In his most famous book, he speaks of the ‘I–Thou’ relationship.
Buber contrasts that relationship with what he calls the ‘I–It’ relationship. In the
I–It relationship we see an object, or perhaps another person, in terms of
causality or function. Most obviously we are in an I–It relationship with a thing
we make use of for some practical purpose, a hairbrush, say. We can also be in
an I–It relationship with another human being. This is not necessarily a bad
thing; we all must make use of each other if social life is to continue. But we are
in an I–Thou relationship with a friend, if we appreciate each other for what we
are, and questions of instrumentality are not in the forefront of our minds. The
question Buber raises is whether it is possible to combine the two attitudes. This
is precisely the question of whether we can combine the Asklepian mode of
attention with that of the scientific mode of Hippocrates. Buber discusses the
question in terms of a striking image: [10]

I consider a tree. I can look on it as a picture; still column in a shock of light,

or splash of green shot with the delicate blue and silver of the background. I can
perceive it as movement; flowing vein or clinging pith, suck of the roots,
breathing of the leaves, ceaseless commerce with earth and air and the obscure
growth itself. I can classify it in a species and study it as a type in its structure
and mode of life. I can subdue its actual presence and form so sternly that I
recognise it only as an expression of law, of the laws in accordance with which
the component substances mingle and separate. I can dissipate it and perpetuate
it in number, in pure numerical relation. In all this the tree remains my object,
occupies space and time, and has its nature and constitution. It can, however,
also come about, if I have both will and grace, that in considering the tree I
become bound up in relation to it. The tree is now no longer It. I have been
seized by the power of exclusiveness. To effect this it is not necessary for me to
give up any of the ways in which I consider the tree. There is nothing from
which I would have to turn my eyes away in order to see, and no knowledge that
I would have to forget. Rather is everything, picture and movement, species and
types, law and number, indivisibly united in this event. If I face a human being
as my Thou, and say the primary word I–Thou to him, he is not a thing among
things, and does not consist of things… nor is he a nature able to be experienced
and described, a loose bundle of named qualities. But with no neighbour and
whole in himself, he is Thou and fills the heavens.
This passage is both obscure and inspiring. The details of its meaning can be
passed over, since for our present purposes it is making four main points. Firstly,
it is stressing the importance of accurate observation, and observation with a
variety of dimensions concerned with type, number, law, composition, forces in
opposition and so on. If we apply the analogy to the context of health care we
can interpret it as saying that there is no substitute for a careful and accurate
diagnosis of the patient’s symptoms and underlying disease, and this
(Hippocratic) concern must take priority. Secondly, this (Hippocratic) kind of
observation can change into a particular kind of attention directed specifically at
this object or person. ‘I become bound up in relation to it… I have been seized
by the power of exclusiveness.’ This is the Asklepian moment. Thirdly, the
observation and the particular kind of attention are compatible: ‘to effect [this
attention] it is not necessary for me to give up any of the ways in which I
consider the tree.’ Fourthly, this kind of attention is at the same time a
recognition of the value of this unique individual: ‘If I face a human being as my
Thou… he is not a thing among things…’ This is the ethical moment. In short,
Buber is saying via this example that the I–It and the I–Thou relationships can be
unified. The Hippocratic, scientific, observation of symptoms is compatible with
Asklepian attention to the unique value of the patient we are attending.
It is important to stress that Buber is not saying that the I–Thou relationship
should always replace the I–It relationship. There is a temptation to interpret
Buber in this way, especially at a time when phrases such as ‘patient-centred
care’ are common. Buber is claiming that the kinds of attention indicated by the
[11]

terms ‘I–Thou’ and ‘I–It’ are not exclusive. This is surely of the first importance
in a medical consultation. ‘Patients are persons.’ ‘Yes, but they are still patients
and must be subject to Hippocratic as well as Asklepian attention.’ Moreover, ‘I–
Thou’ or Asklepian attention may but need not be given a spiritual interpretation.
As Buber goes on to say after the passage quoted: ‘I encounter no soul or dryad
of the tree, but the tree itself’ (p. 8).
There is one further question which must be answered. I am maintaining that
the Hippocratic or scientific attitude is compatible with the special attention of
the Asklepian attitude. But how can both exist at the same time? How can a
patient at one and the same time be observed with detached scientific attention
and the engaged attention of the Asklepian attitude? The answer is that there
seems to be a problem here only if we think of the situation in terms of a
misleading image. If we interpret the attentive gaze of the doctor as being like
that of a searchlight which is either on or off then we might think that there was
a problem. But a better image (to continue with lighting) is with the varied and
coloured lighting of a disco. Human beings are capable of switching among a
range of technical attitudes and a number of human attitudes. It is this facility
which makes it possible for the professional–patient relationship to be both
technical and human, or Hippocratic and Asklepian. This is difficult to achieve
—it requires experience, maturity and an engaged attention. The arts and
humanities may assist with the identification of the relevant kind of engaged
attention, and provide some practice in developing it. As Buber put it in the
passage cited: ‘There is nothing from which I would have to turn my eyes away
in order to see, and no knowledge that I would have to forget. Rather is
everything, picture and movement, species and types, law and number,
indivisibly united in this event.’
[12]

In a similar way, our understanding and appreciation of a painting as a piece

of art is increased by a knowledge of the technicalities behind its creation—the
mixing of the colours, the use of perspective and so on. So too our appreciation
of music is enhanced by some knowledge of its construction, its form, its
contrapuntal textures and so on. It is only when attention to technicalities
becomes dominant that the artistic experience is extinguished. Balance and
proportion are everything. In a similar way the attention of the doctor must be
balanced.

Professional Attitudes

There are further points to be made about the doctor’s attitude. Consider the
difference between an ‘objective’ and a ‘reactive’ attitude. An objective attitude
is one which might be appropriate for a psychiatrist to adopt towards at least
some patients. To reuse an example from earlier, if a patient becomes angry or
abusive then the psychiatrist will understand such behaviour in terms of the
causality of the patient’s disorder, and will not take it personally. This objective
attitude can be contrasted with the reactive attitude which we adopt towards our
friends and colleagues. We engage with them and assume that they mean what
they say and do. Should the attitude of, say, the GP or other clinician be more
like that of the psychiatrist or more like that which we adopt in everyday life?
The answer is that either may sometimes be appropriate (or sometimes
inappropriate) but flexibility is required and flexibility requires judgement (see
pp. 53–5).
 In a consultation in any specialty it may sometimes become apparent that what
the patient is saying or doing is the outcome of some quirk of personality or bad
incident from the past. The adoption of an objective attitude may then be
appropriate. The danger here is that of stereotyping or fixing people. There is a
temptation to think, ‘He obviously would behave like that—he’s from a broken
home’. This kind of pigeon-holing can make encounters easier in any walk of
life, but it oversimplifies human relationships.
By way of contrast, it may well be in order to adopt a reactive attitude with
some patients who would respond well to this. For example, it might be
desirable or appropriate to enquire about family events. Some medical or nurse
educators will want to say that we should always adopt the reactive attitude and
remind us that ‘patients are persons’. I have already touched on this in discussing
Martin Buber. Patients are certainly persons but they remain patients. In other
words, the doctor is in a role-relationship with them, and comments which might
be appropriately directed to a friend may be inappropriate if directed to a given
patient. This of course is a delicate matter. Sometimes, with some patients,
informal questions about the family might be helpful but a degree of detachment
should remain, otherwise the consultation may not work. That at least is my
experience as a patient, and it is similar to my experience of tutoring university
students. Perhaps the point could be put as follows, although there is a danger of
sounding glib: in a professional capacity one is not a friend although one may
befriend. In other words, perhaps the standard attitude should be one with a
degree of personal detachment, displaying a concern but not one which goes
over the top.
There is another problem about the professional attitude. It is sometimes said
that the doctor should be ‘non-judgemental’. What does that mean and is it
[13]

appropriate? It might be said that the doctor’s job is to find out what the patient’s
worries are and to go along with what the patient wants as a remedy. We might
call this the laissez-faire interpretation of non-judgementalism. Clearly, the
doctor should not go along with the patient’s wishes if these are not in the
patient’s medical interests. I shall discuss this issue in more detail later (pp. 91–
2). For example, this may mean not prescribing the antibiotic the patient wants,
or refusing to certify the patient as fit to drive or unfit to work. A second
interpretation of non-judgementalism is that the doctor should not form a
judgement about the patient’s character or actions. Well, doctors are moral
agents like the rest of us and it may difficult not to form a moral judgement. But
this does not mean that the doctor should necessarily express a judgement to the
patient. Sometimes of course—for example, if the patient is abusing his partner
who is another patient—expressing a view may be necessary. How it is done, of
course, is important.

Conclusions

Science is essential for an accurate diagnosis and suggested treatments; the

Hippocratic tradition underpins present-day medicine. It is the first element in
and foundation of what I am calling the ‘ethos’ of medicine. This has had mainly
good consequences for patients even if a belief in the ‘gold-standard’ of
randomised trials may lead doctors to urge treatments on patients which may
sometimes be inappropriate. Indeed, there can occasionally be doubts about the
scientific credentials of certain aspects of medicine. ‘Evidence-based medicine’
does not always have the scientific certainty of laboratory medicine. Moreover,
there are successful medical treatments which are not based on science although
they may be based on non-scientific research. I shall develop this point in
Chapter 11.
The contrasting tradition is that of Asklepios. It is an approach emphasising
quiet listening and waiting. Of course, the Asklepian element clearly has much
greater importance in some branches of medicine than others. There is also a
question as to how it can be cultivated. Perhaps for some doctors it can’t be. This
is not necessarily a fatal weakness. As I suggested, there are many areas of
medical practice which are largely technical, and a technical area might suit
some doctors. But if there are elements of the Asklepian attitude in a given
doctor’s personality, then some exposure to some humanities might develop it. It
is obviously important in general practice, psychiatry and clinical medicine
generally, but less important in surgery and impossible in pathology. I shall
develop the role of the arts and humanities in later chapters. Here I shall simply
note that the Asklepian tradition can be distorted if it is interpreted in terms of
taught courses on communication skills. Patients easily sense the doctor’s
attitude, whether it is brisk and dismissive (conveying that there are many more
patients to be seen) or (worse) one developed from a course on communication
skills.
1 Hart, G. (2000) Asclepius: The God of Medicine, London: Royal Society of Medicine.
2 Mitchell-Boyask, R. (2008) Plague and the Athenian Imagination: Drama, History and the Cult of
Asclepius, Cambridge: Cambridge University Press.
3 Southgate, M.T. (1997) The Art of J.A.M.A, Boston, MA: Mosby.
4 Salmon, P. and Young, B. (2011) Creativity in clinical communication: From communication skills to
skilled communication, Medical Education, 45, pp. 217–26.
5 Greenhalgh, T. and Hurwitz, B. (eds.) (1998) Narrative Based Medicine, London: BMJ Books.
6 Winch, P. (1967) The Idea of Social Science, London: Routledge.
7 Southgate, M.T. (1997) The Art of JAMA, Boston, MA: Mosby, Preface.
8 Green, J. (2009) Form and mental state: An interpersonal approach to painting, Advances in Psychiatric
Treatment, §5, pp. 137–45.
9 Merleau-Ponty, M. (1962) Phenomenology of Perception, London: Routledge, p. 76.
10 Buber, M. (1923) I and Thou, Smith, R.G. (trans.), New York: Continuum, pp. 7–8.
11 Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First, Maidenhead: Open University
Press.
12 Buber, op. cit., p. 7.
13 Stalley, R.F. (1978) Non-judgmental attitudes, in Timms, T. and Watson, D. (eds.) Philosophy in Social
Work, London: Routledge & Kegan Paul.
 Part 2.
Medicine and Ethics:

A Philosophical
Critique
 Chapter 3

The Complexity of Ethics

The idea that the practice of medicine should be governed by ethics is part of the
ethos of medicine and was given its first formulation in the School of
Hippocrates. Medical ethics has developed over many centuries and has been
influenced by religious traditions. For example, the Good Samaritan in the New
Testament is held up as an example of a physician who cares for his patients
regardless of danger or cost. Medical ethics has greatly developed in the period
since 1945 and the vast majority of doctors in the contemporary world see ethics
as central to their role. Medical law has also developed. But the regulations of
medical law and ethics cannot cover all aspects of ethics, especially what I have
termed the adverbial side to ethics—the manner and extent of medical
interventions and wider environmental concerns. The principles and the manner
both require discussion.
There are several issues requiring preliminary clarification. First, and
surprisingly, there is some ambiguity in the minds of patients, doctors and the
general public as to what is meant by the term ‘medical ethics’ or ‘health care
ethics’ or ‘bioethics’. Indeed, the subject has been taught as if ethics were a
purely medical subject, something cut off from ordinary right and wrong.
Secondly, basic criticisms can be made of some of the central approaches to
what is taught as medical ethics. For example, its emphasis on individual patient
autonomy may have created confusion and been one factor in the rise of patient
consumerism (see Chapter 6). Thirdly, there are what may be termed two levels
of medical ethics: that of the problems facing clinicians, and that of issues which
are more properly discussed as matters of public policy into which official
bodies such as the BMA, GMC, the Royal Colleges and similar bodies in other
countries will have an input. In this chapter I shall be concerned with the first
two issues, which have a bearing on clinical ethics, and in Chapter 4 and 5 with
some matters of public policy.

The Ambiguity of the Term ‘Ethics’

The term ‘ethics’ is frequently used simply as a synonym for the term ‘morality’.
An ethical issue or problem in this sense is just the same as a moral issue or
problem. There is a tendency to use the term ‘ethics’ for the moral issues which
arise in professional contexts, but there is no difference in meaning. For
example, the question of whether coronary pulmonary resuscitation (CPR)
should be attempted on a patient at the request of relatives when the
professionals are clear that it will be unsuccessful can be termed either a ‘moral’
issue or an ‘ethical’ issue; there is no difference in meaning. Public and
journalistic uncertainty on terminology can be seen when an issue is described as
‘ethical or moral’ —if uncertain then hedge your bets!
Secondly, the term ‘ethics’ can refer to the codes and guidance which are
issued by professional bodies, such as the General Medical Council and similar
bodies in other countries. Such guidelines are drawn up by committees which
attempt to bring professional practice into line with certain aspects of the general
social morality and law of a given society in the light of the current state of
medical research and practice. The ethical guidelines and advice coming from
such bodies have a quasi-legal status, in the sense that a practitioner acting in
terms of these guidelines would have a robust defence against legal action. But
they cannot replace individual moral (ethical) responsibility in the first sense.
Thirdly, ‘ethics’ can refer to that branch of philosophy called ‘moral
philosophy’. The ancient Scottish Universities and Oxford and Cambridge have
chairs of moral philosophy, but nowadays chairs with that subject-matter are
likely to be called chairs of ethics. ‘Ethics’ in this sense is detached from
practical concerns. One of its aims is to generate theories about the moral or
ethical life in the first sense. In other words, they are what might be termed
‘second order’; ethics or morality in the first sense is their subject-matter. What,
if anything, can be achieved by theories in moral philosophy? This is a question
worth asking because some medical specialties require knowledge of ethical
theories as part of their training.

What can Ethical Theories Achieve?

Some medical ethicists regard it as helpful to use the terminology of ethical

theories—words such as ‘autonomy’, ‘deontology’ and ‘utilitarianism’—on the
grounds that they provide a helpful vocabulary for discussing ethical problems. [1]

There are two problems about the use of philosophical terminology in practical
decision making. The first concerns which piece of terminology is the right one
to apply? Should the language of utility or autonomy or beneficence be
dominant?
 The second difficulty is even more serious. It derives from what may be called
‘language drift’. For example, a term such as ‘autonomy’ is widespread in the
discourse of health care ethics. But what does the term mean? It has been taken
from the moral philosophy of Kant, where its meaning is quite different from
that which it has acquired in health care ethics. The word ‘autonomy’ combines
two Greek words—‘nomos’ meaning a law and ‘auto’ meaning self. Thus, for
Kant, to be ‘autonomous’ is to be self-governing or to be willing to see the basis
of a moral decision as a rule applying to one’s self and everyone else alike. To
put the point in an oversimplified way, for Kant a decision must be reasonable to
be autonomous. But in health care ethics Kant’s precise meaning has become
confused. Some health care professionals speak of a ‘right to autonomy’, others
of ‘enhancing autonomy’ and most take ‘the patient’s autonomy’ to mean
whatever the patient happens to want. In other words, the term now means the
reverse of what Kant meant by it. This drift in meaning has had consequences,
not all desirable, for patients and the doctor–patient relationship. It suggests that
medical ethics, as commonly taught in medical schools, can sometimes have
consequences which distort the common sense moral attitudes which students
may have before they enter medical school.
The cognate word ‘respect’ has also slipped. For Kant the object of ‘respect’ is
an autonomous person, and persons are to be ‘respected’ (he sometimes uses the
word ‘reverence’) because, unique in creation (he thinks), we have the ability to
stand back from our own wants and act reasonably, with consideration for all.
But such is the slippage of language that in medical ethics ‘to respect the
patient’s autonomous decision’ just means to do what the patient wants. And
such is the power of corrupted language that many working in health care
believe that they are morally obliged to do whatever the patient wants. There are
therefore dangers in language drift or, to change the metaphor, in the back-
seepage of philosophical jargon. Indeed, a case could be made for saying that the
teaching of ethical theories in courses on health care ethics has actually been
harmful because it has introduced a number of badly understood terms which
simply distort the sound judgements which health care professional might
otherwise have made. This creates scepticism about the value of teaching ethical
theory to medical students.
Turning to the guidance in official codes, protocols or flow charts we can see
that it is necessarily simple and rule-like, and it cannot cover every ethical
eventuality. The Hippocratic tradition in ethics has of course been restated in
updated versions such as the Declaration of Geneva, adopted as the Code of the
World Medical Association in 1968. In recent times codes have been made more
specific by medical law and the quasi-law issuing from the GMC in the UK and
similar bodies elsewhere. Ethical regulation is of course of central importance
for a clinician but it by no means covers everything of relevance because what it
offers is medical ethics, or ethics from a medical point of view. But ‘ethics’ is
just a professional name for ordinary right and wrong, and right and wrong, good
and bad, extend well beyond the boundaries of medicine.
An influential attempt to connect the ethical problems of medicine with the
broader sphere of morality was made in a book entitled The Principles of
Biomedical Ethics by Tom L. Beauchamp and James F. Childress. They argued
[2]

that all the complexity of ethical (moral) problems in medicine can be resolved
by the use of only four principles peculiar to medicine: non-maleficence (don’t
harm), beneficence (do some good), autonomy (respect the patient’s decisions)
and justice (treat patients fairly). Their book has exerted a dominant but largely
unfortunate influence on the teaching of ethics to medical students.
For example, there are problems about how to use the four principles. As
premises from which, with clinical details, a moral decision can be deduced? If
only moral problems could be dealt with so easily! As I pointed out above some
medical ethicists argue that the four principles offer a vocabulary for discussing
moral problems in medicine. But we do not need a special medical vocabulary
for discussing moral problems; our ordinary moral vocabulary developed over
centuries seems adequate. In any case, the vocabulary offered has a bizarre ring
to it: ‘Non-maleficence’ is an odd neologism, and ’beneficence’ is easily
confused with ‘benevolence’ and ‘respect for autonomy’ is downright
misleading, since it has encouraged many in health care to think they must do as
the patient requests. Most obviously, there is no reason to impoverish our
discussions by restricting moral concepts to just four. For example, sometimes a
doctor may need to stand up to a manager, or an angry relative. Qualities such as
courage, equanimity, tact, honesty or patience may be needed—even humility
when things go wrong.
Moreover, moral or ethical decisions require much more than the application
of general principles; detailed investigation will involve the balancing of
conflicting considerations, or will require an all-things-considered judgement
(see pp. 53–5). I have already discussed some features of the Hippocratic
tradition, the tradition which is dominant at the moment. It will be remembered
that this scientific approach ignores the individuality of patients and instead
concentrates on what diseases have in common. It is assumed that diseases
follow a pattern, the causal laws of which can be discovered. When they are
discovered, treatments may be devised and applied regardless of the individual
experience of illness and disease. But even in ethics the Hippocratic tradition is
dominant, in its stress on general principles to be applied regardless of the details
of individual cases. The humanities can offer a different approach.

Ethics and the Humanities

The arts and humanities have no clear identifying criteria but most commonly
they are thought to comprise histories, philosophy, literatures, drama and film,
visual arts and music. Their methods are imaginative, analytical, critical or
investigative, and they provide insight into human motivation and relationships.
And let us not be too high-minded or purist to forget that they can also provide a
lot of enjoyment, and can be fun to be involved in as musicians, readers, actors,
dancers, artists or audience. They can have a bearing on medicine in a number of
different ways. They can have a supplementary function and a critical function.
The emphasis in this chapter will be on their supplementary function and in
Chapters 4–7 on their critical function.
The humanities can supplement the teaching of clinical ethics in two main
ways: by suggesting a method of analysing and reaching solutions in difficult
cases, and by providing an understanding of what I have termed the adverbial
side to ethics, the how, how much and in what manner side. Consider first ways
of analysing and reaching decisions in medical ethics. How should doctors
reason in complex moral situations? Good advice was given to Harry Potter
faced with the task of fighting a dragon: play to your strengths. In Harry’s case
his skill was on his broomstick at the game of Quidditch. For doctors their
strength is in observing or obtaining by tests the medical details of specific cases
with the aim of reaching a treatment decision. Helpfully, there is a closely
analogous way of discussing the moral details of cases. This type of reasoning
follows the very ancient tradition of casuistry. The word ‘casuistry’ has bad
associations, but it just means ‘case-based’ reasoning, and it should have an
appeal for doctors in that, as the term suggests, it is the kind of reasoning used in
cases when doctors are seeking a diagnosis and treatment.
Casuistry, historically, became associated with special pleading. As such it
was totally rejected by many writers of the eighteenth century, such as Adam
Smith. Oddly enough, although Adam Smith rejects casuistry as a method of
[3]

moral reasoning, he is happy with an activity he calls ‘natural jurisprudence’,

which is for all the world like a legal version of casuistry. Indeed, it would not be
an exaggeration to say that English and American common law are casuistic in
their method of case analysis. So what are the characteristics of this method of
reasoning, whether we call it casuistry or natural jurisprudence?
It was introduced as a way of reasoning in medical ethics as a result of the
experience noted by Stephen Toulmin and Albert R. Jonsen. They both served on
the US National Commission for the Protection of Human Subjects of
Biomedical and Behavioural Research, and they noted that agreement could be
reached on specific substantive points by members who held very different
religious and philosophical theories of life. Out of this experience they were
encouraged to return to this ancient method of moral reasoning called
‘casuistry’, i.e. a method based on attention to the details of specific cases. They
explain casuistry as:
the interpretation of moral issues, using procedures based on paradigms and analogies, leading to
the formulation of expert opinion about the existence and stringency of particular moral obligations,
framed in terms of rules or maxims that are general but not universal or invariable, since they hold
good with certainty only in the typical conditions of the agent and circumstances of action.[4]

Their explanation requires to be explained! The first characteristic is that there

must be total immersion in the details, the particularities of a given case and its
setting. Albert Jonsen calls this the ‘morphology’ of the case. For example,
before reaching a decision it would be important to know the expectations of the
interested parties, whether these expectations were reasonable in the context,
what the institutional policies, if any, might be, what the history of the case was
and so on.
Now, of course, the morphology of the case will be investigated against a
background of moral rules and principles. But it is too simple to say that the
pressure of these rules and principles will shape the structure of the case. It is
just as likely that the rules and principles will be interpreted in terms of the
particular case in hand. It is all very well to parade ‘respect for the autonomy of
the individual’, but how is this principle going to be interpreted in a case where
the main party involved is a self-destructive individual who is also the provider
for a family? Whose autonomy is being considered? Are there other moral
principles, such as a regard for holding a family together, also involved? In
complex cases a whole range of moral considerations must be identified and
sifted before a reasonable moral judgement can be made. This process of
interpretation involves an integration in which the facts are interpreted in terms
of rules and the rules are interpreted in terms of the particularities of the case.
Jonsen calls this the ‘taxonomy’ of the case.
The word ‘taxonomy’ is helpful here. The Greek work ‘taxis’ means the
drawing up or ordering of soldiers in battle lines. Just as the best troops might be
marshalled at a certain point so it is important in moral reasoning to have
paradigms or clear examples where there will be no dispute. For example, in the
controversy concerning when medical treatment might be withheld or withdrawn
we might begin with the maxim that it is always wrong to give medical treatment
to a dead body. Moving out from that paradigm we might ask in what way a
permanent vegetative state is like that of death. These comparisons and analogies
then suggest that some forms of treatment, perhaps artificial nutrition and
hydration for a limited time, might be appropriate but not others. The point about
the term ‘taxonomy’ is that it helps to make clear that the given case is not
unique. It has similarities and dissimilarities to a paradigm case. An ultimate
practical judgement about what to do will therefore not be based on a deduction
from a principle but on how the principle might appear in the morphology of the
total circumstances in comparison with other cases. This is very similar to
reasoning in matters of ‘natural jurisprudence’ or the common law.
Jonsen uses the term ‘kinetics’ to describe the third feature of casuistical
reasoning. He uses the term to indicate the way in which one case or a set of
circumstances imparts a kind of moral movement to other cases. The metaphor
suggests that reasons can be more or less ‘weighty’ or that there may be
‘balancing considerations’. This ‘it all depends’ approach does not fit easily with
ethics since the time of Kant, or indeed with a system of medical ethics based on
four principles. A true Kantian would take the line that ‘Lying is always wrong’
but the casuist would want to know the bearing the lie had on the ‘community of
trust’ which is the underlying justification for truth-telling. Perhaps the lie was a
‘jocose’ lie, or perhaps it was part of a good story which was true for the most
part.
In order to illustrate Jonsen’s terminology and to contrast it with the Kantian
approach let us take an example from Kant:
Suppose, for instance, that someone is holding another’s property in trust (a deposit) whose owner is
dead, and that the owner’s heirs do not know and can never know about it. Present this case even to
a child of eight or nine, and add that, through no fault of his, the trustee’s fortunes are at their
lowest ebb, that he sees a sad family around him, a wife and children disheartened by want. From
all of this he would be instantly delivered by appropriating the deposit. And further that the man is
kind and charitable, while those heirs are rich, loveless, extremely extravagant spendthrifts, so that
this addition to their wealth might as well be thrown into the sea. And then ask whether under these
circumstances it might be deemed permissible to convert the deposit to one’s own use. Without
doubt, anyone asking the question will answer ‘No!’—and in lieu of grounds he can merely say: ‘It
is wrong!, i.e. it conflicts with duty’.[5]
Kant has reached his conclusion by simple deductive reasoning:
It is wrong to steal;
Taking someone’s deposit is a case of stealing;
Therefore one ought not to take the deposit.

But a casuist would want to be immersed in the details of the case: how much
was the deposit? What were the conditions of the trust? What was the trustee’s
relationship with the owner (private or professional)? What was the relationship
of the owner to the relatives? And so on. This is the morphology of the case.
Then the casuist would want to line up cases of stealing, cases of saving from
starvation, cases of the presumptions of friendship, etc. This is the taxonomy.
Then he would consider how this particular case in these particular
circumstances could be balanced against other such cases. This is the kinetics.
Casuistry, interpreted in this way, seems a possible method of moral reasoning.
Just as a clinician will seek a treatment which is likely to succeed in a given case
so the same clinician wearing an ethical hat will try to decide what is the morally
right decision in this particular case after a survey of all the relevant details. The
current method recommended by many ethical textbooks—deducing moral
conclusions from a mere four principles or using their highly unclear vocabulary
(‘maleficence’, ‘beneficence’, ‘autonomy’, ‘justice’)—seems by comparison
inadequate and confusing, if not positively harmful.

Matters of the ‘Small Morals’

Moral issues can also arise over small matters and here again the humanities can
offer insights. Small matters do not involve life and death but they can affect a
doctor’s relationship with a patient. The seventeenth-century philosopher
Thomas Hobbes speaks of ‘matters of the small morals, as when a man may pick
his teeth’. Teeth-picking at the consultation is perhaps not a common patient or
[6]

doctor complaint, but there are other small matters which can affect a patient’s
morale, such as a pleasant manner or a little friendly conversation. Of course, it
can be the patient who is rude. A GP friend tells me that she has had patients
interrupt a consultation because they must answer their mobiles. It is a matter of
the ‘small morals’ how this can be dealt with.
Perhaps ‘small morals’ are just matters of etiquette and not morality proper.
Perhaps, but there is a fine line between etiquette (let’s call it courtesy or good
manners) and morality proper. Both involve sets of rules and conventions which
have evolved to assist the smooth running of society. Rules of etiquette, or good
manners, can of course change more easily and vary more widely in different
cultures and social settings than rules of morality. For example, the practice of
shaking hands has been affected by Covid-19, and it is a matter for individual
judgement whether first names should be used or not. The wearing of ties is also
a sartorial convention, perhaps on the way out. But that again is a matter of
judgement.

Communication

The arts and humanities are also highly relevant to providing an understanding
of human communication. They offer what I termed the ‘Asklepian’ approach. In
other words, the humanities bring out that human communication is not mainly,
or at all, a matter of ‘skills’ but rather of being a certain kind of person, rather
than someone who has mastered a technique. Importantly, there is the matter of
how much and in what manner information should be communicated to the
patient. This is not a mechanical matter of exercising ‘communication skills’.
Good communication is a creative matter expressing the doctor’s own
personality and awareness of the patient’s reactions. Similarly, the ethics of the
situation requires sensitivity. I have known junior doctors being instructed ‘to
consent’ the patient, as if ‘to consent’ were a transitive verb with the patient as its
object!
Codes of ethics or GMC guidelines certainly contain sound ethical principles
but such principles may be less important than a humane attitude. It is the
attitude of the doctor which above all is the essential factor in shaping a practical
judgement. Nowadays in internet communications to official bodies we are
required by ticking boxes to establish that we are not robots. It is essential in
matters of practical judgement in health care that medical or nursing
practitioners make it clear that they are not robots. And this time it cannot be
done by box-ticking. How can it be done? If it can be done at all, and perhaps
some doctors by nature and personality can do it and others cannot, my
suggestion is that the arts and humanities can help a little for at least some
students and practitioners.
For example, a study of doctors’ communication to patients with breast cancer
provides an illustration. It emerged that patients wanted a relationship with the
doctor in the sense that they wanted to see each other as individuals: ‘The
perception of being regarded as an individual was communicated in several
ways. Non-verbal cues included eye-contact, smiling and touching. The most
common strategy was brief conversation unrelated to disease.’ The ability to do
[7]

this requires the doctor or nurse not just to have technical skills of a Hippocratic
kind but to be a particular kind of person. As J.S. Mill says: ‘It is important not
only what men do, but also what manner of men they are that do it.’ Whether
[8]

we regard this as a matter of morality or not is something for philosophers to

discuss. It is certainly important.

Professional Judgement

The supplementary contribution of the the arts and humanities to medicine may
be summed up if we say that they can help to develop professional judgement.
What is professional ‘judgement’, why is it especially needed at this point in
history, and how can the arts and humanities assist its development?
I have noted (pp. 21–3) the increasing use of treatment protocols and
algorithms in diagnosis and treatment. But if they become dominant then
medical treatment will become a mechanical matter—the Asklepian element will
be lost entirely. Some doctors, the technocrats, may welcome this, but I suggest
that a great deal would be lost from the medical consultation. Some critics might
say that the missing element is emotion, but emotion is passive. Others say that
what is required is ‘empathy’, a term which has become the Japanese knot-weed
of the times. What is required is the development of something active and
[9]

outward-looking—clinical judgement. Feelings may come into the picture, but

[10]

only as a component of an all-things-considered-judgement. What then is

judgement?
The eighteenth-century Scottish philosopher Thomas Reid defined a
judgement as an assertion made with some evidence, or for good reason, in a
context of uncertainty. There can of course be bad judgements when the
[11]

evidence is defective. For simplicity I shall use ‘judgement’ to refer to good

judgement. There are two basic types of judgement: theoretical and practical. A
theoretical judgement is an assertion about what is probably true or correct, and
a practical judgement concerns what we ought to do. In both cases there must be
some evidence or reasonable considerations determining the judgement,
otherwise it is not a judgement but a guess. In both cases the context must be one
of uncertainty. We do not judge that 2 + 2 = 4 because we know it with certainty.
Theoretical and practical judgements are of course linked in that our judgement
about what we ought to do may be grounded on what we believe to be the case.
 A professional judgement is one made in a professional context and it may be
either theoretical or practical. The uncertainty derives from the professional
context and the evidence or relevant considerations derive from the professional
knowledge and skills. The uncertainty in the professional context may concern
diagnosis and treatment, but also the question of how the patient views the
diagnosis and suggested treatment. There is clearly enough uncertainty to satisfy
the first criterion for the need for judgement. The evidence and good reasons
derive from the evidence-base and the experience of the doctor or other health
practitioner. But while these factors may be sufficient to ground a theoretical
judgement, they are not sufficient to ground a practical judgement about what
ought to be done. And, as I have argued, health care is not applied science; it is
pre-eminently practical, and its judgements must be humane. What are the
factors additional to the theoretical ones which should ground a judgement about
what ought to be done?
The main factor is a particular sort of understanding, a sort of understanding
which the arts and humanities can help to cultivate. Indeed, perhaps the main
contribution the arts and humanities can make to judgement in medicine is to
provide a kind of understanding which is different from, but complementary to,
that provided by science. We can think of this kind of understanding as ‘holistic’.
It is a type of understanding which can be illustrated by stories, such as those
offered by a biographer or a historian or a novelist. As I have already discussed
(pp. 30–2), it is sometimes called ‘narrative’ understanding because it is the sort
of understanding which we can obtain from a story. Perhaps as a result of a
degree of scepticism about the current emphasis on ‘evidence-based medicine’,
there has been a new awareness that patients’ stories about themselves, their
anecdotes, can be relevant to their diagnosis and treatment. Indeed, it can be
maintained that it is in terms of our stories about ourselves, and also our
emotions and future projects, that our very identity as persons consists.
The identity of a person, it might be argued, is more like that of a drama than
like that of a material object. To maintain this is really to maintain two points:
that we have a serial identity through time, and that we have an individual
identity. Just as the play Hamlet has a serial identity through time, and a different
one from Macbeth, so we all have our own unique identities unfolding through
time.
Scientific understanding is required for optimum treatment but so too is the
kind of understanding which can be cultivated via the arts and humanities.
Together they can result in an informed and humane professional judgement.
 Personal Development

My central theme in this chapter so far has been that the arts and humanities can
contribute to the actual practice of medicine via the concept of balanced and
humane judgement in clinical practice. I would like to suggest how they can also
contribute to the long-term personal development of doctors. A noticeable
feature of medical training and practice is that it is highly focused and clearly
useful to society. Every code of ethics stresses that the doctor must above all
provide a service to others, and every aspect of medical training is practical and
goal-directed. The demanding and prolonged nature of medical training coupled
with the tiring and often emotionally draining nature of patient care may leave
time for little else, resulting in the diminishing of a doctor’s personality. This is
where the arts and humanities can offer a remedy.
The nature of the remedy emerges when I admit that many practitioners of the
arts and humanities would be uncomfortable with my attempt in this book to
suggest how their subjects may be useful in medical education. For them the arts
and humanities are simply worthwhile for their own sake. One of Aristotle’s
criteria for the highest good is that it must be completely useless. This sounds
[12]

comic to modern ears. But Aristotle is surely right. Whatever is useful is useful
for a given end, which itself may become a means to a further end. Hence, there
will be a never-ending chain of means and ends unless we find activities which
are not ‘useful’ but rather are worth pursuing just for their own sake. The arts
and humanities can be included with pure science among these worthwhile
activities. But, of course, not all activities worthwhile for their own sake need be
grand. Sports or indeed conversations can also be worthwhile for their own sake.
Perhaps medical education could be improved if medical students were given
more time to mix with other students and just be ‘students’ rather than
specifically ‘medical students’.
Simply by being worthwhile for their own sake, the arts and humanities can
broaden the outlook and enrich the personality of a doctor. This is important
throughout a career but also in retirement. Having retired from an absorbing
career, many doctors think: what now? Seeds sown in medical education may
finally mature and new interests can develop.
Personal development can be furthered by the arts but it should be noted that it
can also be furthered by an interest in pure science. I pointed out in Chapter 1
that science as taught in medical training necessarily has goals internal to
medicine, but pure science has goals internal to itself—as a way of
understanding the universe and its creatures. In that way it is educative. As
simple illustrations of science depicted as a broadening or educative pursuit I can
point to the TV programmes of Sir David Attenborough or Professor Brian Cox
or Professor Jim Al-Khalili or Dr Hannah Fry. What shines through their
presentations is their belief that the sciences they enthusiastically explain and
expound are among the glories of the human mind.
It is also worth issuing the warning that the humanities themselves are not
necessarily humanistic or educative. For example, a historian of the French
Revolution if asked what it taught about social equality or democracy might well
reply, ‘I am not interested in that kind of question. I am just interested in the
documents and facts.’ A historian with that approach is trained rather than
educated. The sad truth is that many arts subjects have become infested with
jargon and are inward-looking, and consequently fail in their basic humanising
function. Nevertheless, the arts and humanities can make a contribution to the
development of professional judgement and to personal development.

Self-reflection

Doctors have a high status in society and are rightly highly respected for the
work they do. It is therefore not surprising that some doctors sometimes are also
seen as pompous and self-important. Indeed, as I shall discuss in Chapter 7,
some institutions representing medicine actually wish to convince us that doctors
are altruistic simply by doing their day-job. But literature can provide an
antidote to self-importance, can hold up a mirror for self-reflection. It is true that
some doctors in literature come out well—such as the doctor in Macbeth who
sees limits to what medicine can do—or Dr Lydgate in George Eliot’s
Middlemarch. And the experiences of Dr Andrew Manson in The Citadel by A.J.
Cronin are said to be important influences on Aneurin Bevan and the founding
of the NHS. More recently the medical soap opera has glamourised the doctor.
[13]

In opera doctors hardly ever come out well. Sometimes they try
[14]

manipulation or threats in an absurd attempt to marry beautiful young women, or

they arrive at the death bed of heroines and appear useless. Throughout my
discussion, I have been praising the approach of Asklepios, the demigod of
medicine, but most shaming of all, even he came to a bad end. There are various
accounts of the story, but it seems to be agreed that he over-stepped the mark
when he brought back from death a patient whom Zeus had decreed should die.
According to the Greek poet Pindar, ‘Gold glittered in his hand’ (same old story)
and Zeus destroyed both with a thunderbolt. The myth does not make it clear
[15]

whether Zeus was annoyed at the introduction of private medicine, or whether it

was a punishment for hubris—the attempt by Asklepios to continue life beyond
its ordained length. Either way the myth can produce good discussion about the
limits, if any, to what medicine should attempt. The days of the god-like medical
consultant are no doubt long gone, but a reminder of human limitations is
worthwhile. The humanities can offer a gentler and perhaps more effective
critique of medicine and its practitioners than the ‘in-your-face’ arguments of,
say, Ivan Illich. [16]

Conclusions

In this chapter I have suggested how the arts and humanities can supplement
what is already in the curriculum, namely, ethics and communication. They can
offer historical or philosophical perspectives and suggest new or alternative
approaches to existing courses on the curriculum. Above all they can encourage
creative but critical thinking on evidence, a humane approach to patients and the
development of clinical judgement. And they have a contribution to make to the
doctor’s personal development. As the country takes stock of itself in the past-
pandemic period there is an opportunity for medicine also to consider its
approach to patients.
Some issues in medical ethics are matters of public policy and they also
require examination in the new era we are entering. In the next three chapters I
shall discuss some public policy issues. The discussion will involve the critical
function on the humanities especially represented by philosophy.
1 Gillon, R. (1994) Principles of Health Care Ethics, Chichester and New York: John Wiley and Sons, pp.
xxi–xxx.
2 Beauchamp, T.L. and Childress, J.F. (1994) Principles of Biomedical Ethics, 4th ed., Oxford: Oxford
University Press.
3 Smith, A. (1776/1976) The Theory of Moral Sentiments, Bk VII, Oxford: Oxford University Press.
4 Jonsen, A.R. (1991) Casuistry as methodology in clinical ethics, Theoretical Medicine,12, pp. 295–307.
5 Kant, I. (trans. 1974) On the old saw: That may be right in the theory but it won’t work in practice, in
Leites, E. (ed.) (1988) Conscience and Casuistry in Early Modern Europe, Cambridge: Cambridge
University Press.
6 Hobbes, T. (1651) Leviathan.
7 Salmon, P. and Young, B. (2011) Creativity in clinical communication: From communication skills to
skilled communication, Medical Education, 45, pp. 217–26.
8 Mill, J.S. (1859) On Liberty, London: Collins, Chapter 3.
9 Macnaughton, J. (2009) The dangerous practice of empathy, Lancet, 373, pp. 1940–41.
10 Downie, R.S. and Macnaughton, J. (2000) Clinical Judgment: Evidence in Practice, Oxford: Oxford
University Press.
11 Reid, T. (1785) Essays on the Intellectual Powers, Essay 6. Of Judgment, Indianopolis, IN: Library of
Liberal Arts.
12 Aristotle (1971) Nicomachean Ethics, Bk. 1, Oxford: Oxford World’s Classics.
13 Cronin, A.J. (1937) The Citadel, London: Gollancz.
14 Robertson, J.S. (2012) Doctors in Operatic Medicine, Glasgow: Scottish Opera.
15 Edelstein, E. and Edelstein, L. (1998) Asclepius: Collections and Testimonies, Baltimore, MD: The
Johns Hopkins Press.
16 O’Mahoney, S. (2016) Medical nemesis: 40 years on: The enduring legacy of Ivan Illich, Journal of the
Royal College of Physicians of Edinburgh, 46, pp. 134–39.
 Chapter 4
Consent and

‘Presumed Consent’
Who Owns My Body?

The aims of doctors are liable to constraints of various sorts. All treatment, with
exceptions such as accident and emergency treatment, requires the consent of
patients. Doctors may be sure that what they are proposing is in the best interests
of given patients, but they are still constrained by the requirement to provide
information on their proposal and obtain the consent of the patients in question.
No doubt this can sometimes seem burdensome to a busy doctor, and doctors are
not always good at explaining—they would rather get on with the treatment.
Moreover, such is the fear of being labelled ‘paternalistic’ that doctors are now
discouraged even from giving advice on treatment. Their official responsibility is
limited to that of providing information. But this is surely odd. The doctor will
have had much more experience of treatments and their outcome than the
patient. It does not therefore seem unreasonable or paternalistic for the doctor to
offer advice. In this respect at least the ethos—which stresses the best interests
of patients—seems to lead to good health care outcomes. After all, the patient
can refuse what is offered. But no doubt the doctor feels restricted in what, if
anything, to recommend by the menace of the lawyer. In view of the issues
around consent it will be helpful to offer a brief survey of the history and nature
of the doctrine of consent. This is the first topic for this chapter.
A second topic which is currently being discussed by doctors, governments
and the public is that of ‘presumed consent’ for organ donation. Granted the
decades of medical, legal and public discussion which it has taken to enlarge the
ethos to enable the doctrine of free and informed consent to become accepted
and be embedded in law, it seems on the face of it irrational for doctors to argue
for a view of ‘presumed consent’ which undermines the accepted doctrine. The
explanation for this apparent irrationality concerns the shortage of organs for
transplant. The solution—with public and some political support—is to enable
transplant surgeons to ‘presume’ consent for organ ‘donation’. Is this an
irrational extension of the doctrine of consent as free and informed?
 A third controversial issue arises over consent when a patient is deemed to
lack the capacity to make a free and informed decision to accept or to refuse a
treatment. Acts of Parliament in both England and Scotland cover this situation.
Nevertheless, there can be difficulties of interpretation, both of the symptoms
and the Acts of Parliament. When a decision about capacity is required it should
not be based on a purely scientific assessment (the Hippocratic approach) but
one based on an ‘all things considered judgement’—a concept previously
discussed (pp. 52–5).
Fourthly, there can be problems over the consent or refusal for a specific
category of patient—young children. In these cases, parents may argue that they
are better placed to decide what is in the interests of their children than doctors.
This can impose an unwelcome constraint on doctors who are clear that what
they are proposing is in a child’s best interests.

Models of Consent

The concept of consent probably entered ethical discourse via common law ideas
of bodily integrity and assault. It is normally reckoned to be an assault on bodily
integrity if one person touches another without consent. That idea passed easily
into medical ethics. Nevertheless, it is against a background of the (confused)
idea of patient autonomy that consent tends to be discussed. [1]

It is not difficult to see the connections between the general concepts of

dignity and autonomy and the more specific concept of consent. In the course of
providing health care it is necessary to examine patients, carry out investigations
and provide treatment. Each of these has a direct effect on the patient’s body and
mind. Hence, so long as the patient is able to make such choices, consent is
necessary if we are to respect autonomy and dignity. It is also important in
palliative care and more widely to note that consent is also required before
pursuing interventions such as ‘counselling’, aimed at alleviating mental distress
or suffering. There can be various models of consent, which have a bearing in
different ways on concepts of dignity and autonomy. It may be a help in
understanding the present situation to review these.
Firstly, consent as simply being told what is going to be done is much too
weak a notion. Such behaviour is regarded as paternalistic and is an affront to
personal dignity (as well as an assault). Secondly, consent as just agreeing or
acquiescing to a treatment proposal may still be too weak an idea to count as
consent in a treatment context. Consent in everyday contexts does not require the
spelling out of details, a point I shall discuss later (p. 64), but in health care
many details are required. How much information is required is an interesting
and much-discussed question which is not relevant here. The point in this
context is simply that consent in health care is stronger than agreement or
acquiescence; we have a right to know what is going to happen to our bodies.
But of course there may be a range of treatment or care options which are
possible and the dignity-autonomy combination gives us a right to choose among
them with help from the physician. This suggests a third idea of consent as joint
investigation. Consent as a joint investigation with the physician is probably the
best model. It combines respect for the patient’s dignity and autonomy with
respect for the consulting physician’s dignity and professional autonomy (an idea
frequently overlooked in this kind of discussion). The dignity of both doctor and
patient is respected then in joint investigation of the best treatment for this
patient.
Nevertheless, there is a fourth model of consent which has been gaining
ground: we can call it consent as patient choice. There is of course no problem
about patients choosing among alternative treatment options offered: this is
model three—consent as ‘joint consultation’. However, we are dealing with
something quite different when we consider the situation in which patients
request or even demand a treatment which the professionals judge is not in their
best interests. Examples of such demands might occur in a GP’s surgery when
the patient insists on a prescription for an antibiotic for a sore throat. Or they
may occur in the hospital where the patient, or more likely the relatives, require
the continuation of life-prolonging treatment or resuscitation attempts when the
doctors are convinced that such demands are not in the best interests of the
patient because they are most likely to cause net harm, or simply that they will
not succeed. What we have in this model is a consumerist interpretation of
consent. This is an approach which will alter the entire ethos of health care, and I
shall indicate considerable scepticism about it in Chapter 6. At present, however,
it is sufficient to note that consent as joint investigation is a constraint on
medical intervention which is to be welcomed by patient and doctor alike.
My only reservation concerns the ambiguity around the idea of ‘joint
investigation’. In an investigation there are usually findings, but who is to
evaluate them and suggest the one which might be optimum in a given case? The
doctor has the experience and is in by far the best position to evaluate the
options. Nevertheless, as I noted above, many doctors might be reluctant to
make positive suggestions. As I said, one reason for this is fear of litigation if the
treatment doesn’t work, but another is the doctrine of ‘non-judgementalism’ (p.
38). Nevertheless, we expect professionals to offer advice fearlessly and it will
be an abdication from a traditional professional role if a doctor is unwilling to do
so. Of course, how this is done, the ‘adverbial’ side of the consultation, is
crucial. The obtaining of free and informed consent is a central and robust
doctrine of medical ethics and it will be a sad day if it is weakened. But this
seems to be what is happening over the recent demand for ‘presumed consent’
for organ donation.

‘Presumed Consent’ for Organ Harvesting

The term ‘consent’ illustrates the problems of stipulative definition (by x I shall
mean y), especially those stipulative definitions which take a word from ordinary
language. ‘Consent’ is a common idea in ordinary life but as a central term of
medical ethics it is given a specialised meaning. As I have pointed out, a patient
is not deemed to have consented to treatment unless he/she has been given full
information on the possible treatments, their side effects and the chances of
success. Moreover, the consent must be entirely voluntary. Obviously, the doctor
will have had much more experience of the problem and its treatment than the
patient. But, as I said above, in theory at least doctors are not encouraged to
advise in case it is considered that they have compromised the patient’s free
choice. Such an account of consent may or may not be an improvement on the
alleged paternalism of earlier generations of doctors, but it is the present
position.
To bring out the difference between consent in ordinary contexts and consent
in clinical contexts consider the following example. Suppose I invite you to meet
me for a drink after work and you reply, ‘Thanks, see you at the door at 6pm’.
As far as ordinary language and conventions go you have consented, and if you
do not show up around 6pm I have a moderate grievance. It will not do if you try
to defend yourself by saying, ‘You did not inform me how long the date would
last, whether we would be drinking coffee or gin and tonic (far less the kind of
gin and the kind of tonic!)’. But information of that kind and much more would
be required for a valid consent in the contemporary clinical context. Nor is it
simply in trivial contexts that the ordinary notion of consent can be seen at work.
If you say ‘I do’, in a certain context you have consented to marry me—indeed,
you have married me—even if you are not at all well informed about what you
are letting yourself in for! The point in all this is not necessarily to criticise the
use of ‘consent’ in bioethics but to point out that unnecessary disputes arise
when a term is taken from ordinary language and given a more precise sense
than it usually has. A real-life example of a bad situation which arose as a result
of the weasel-nature of the word ‘consent’ concerned the retention of tissue after
autopsy.
It was alleged that, around 1999–2000, pathologists and clinicians had
retained the organs and other tissues of children after autopsy without obtaining
full consent from the parents of these children. Many pathologists argued that
they were acting in terms of the law then current—the Human Tissue Act of
1961. In terms of this Act a pathologist or other professional ‘lawfully in
possession of the body of a deceased person’ could proceed with non-statutory
autopsy and research, but only if ‘having made… such reasonable enquiry as
may be practicable… he has no reason to believe’ that any surviving relative of
the deceased objects to the body being so dealt with. In other words, the
pathologists were required to ask parents and relatives if they objected to the
organs or tissues of a deceased child being used for research. If the parents said
‘We don’t object’, they were deemed to have consented. And as far as ordinary
language goes, they had consented. But as far as the language of current
bioethics goes, they had not consented, because in bioethics consent is nowadays
logically tied to full disclosure of all relevant facts. In this context medical
practice in the past was not joined up with the more recent view from
bioethicists, who unfairly in my opinion censured their predecessors.
The same problem—of consistency when words in ordinary language are
given stipulative meanings—has arisen over the idea of ‘presumed consent’.
Consistency is central to logic, indeed to communication of all kinds.
Inconsistency can lead to conclusions which have ethical implications. Here is
an example of this. It involves a letter to the BMA News Review and the reply to
it from the Chairman of the BMA Medical Ethics Committee. The letter to the
News Review from Dr Michael Jarmulowicz runs as follows:
Is the BMA medical ethics committee suffering from schizophrenia? It fully supported the cries that
there must be consent to take tissue for post-mortem histology but is now promoting the idea of
presumed consent for transplantation. Can someone explain the point of principle that I seem to
have missed? Doesn’t logic demand some consistency? Why should a pathologist deserve
condemnation for removing a diseased, non-viable heart after death without consent, while a
transplant surgeon will be allowed to remove a healthy, viable heart on the assumption that the
patient would have wished this?[2]

BMA Medical Ethics Committee Chairman Michael Wilks responded:

Logic demands consistency between like issues. There are fundamental differences between the
 retention of organs for research and the removal of organs for transplantation. The primary
difference is that there is considerable knowledge and support within society for transplantation—
the latest official survey shows 90 per cent support for transplantation—the same is not true of
research. There would be widespread publicity to ensure that the 10 per cent who did not wish to
donate could register that objection. The justification for this different approach is explored in the
BMA’s parliamentary briefing (www.bma.org.uk). [3]

He refers us also to a more sustained paper on the topic by English and

Somerville. [4]

Michael Wilks seems to have missed the point of the objection. Of course
‘logic demands consistency between like issues’, and of course research is
different from transplantation. And no doubt the public may favour
transplantation (perhaps because they have not been told the details of the
procedure—information is another condition of consent). But these points are
neither here nor there. The ‘like issues’ are those of consent, and in the case of
research we are told that it is unethical to remove tissue without full consent but
in the case of transplantation it seems to be ethically desirable to remove tissue
merely on a presumption of consent.
‘Presumption’ would not even meet the ordinary life meaning of consent—‘I
just presumed you would want to join me for a drink!’ The relevant point is
whether the bioethical conditions for consent were satisfied, not the use which
will be made of the tissue or organ. On this matter the BMA committee is clearly
inconsistent, and the inconsistency has serious ethical implications. And the
same is true of the more sustained defence offered by English and Somerville.
This is a current issue because the Welsh Assembly has introduced, and (as I
write) the Scottish Government is minded to introduce, the idea of ‘presumed
consent’. I am not arguing against a doctrine of ‘presumed consent’, far less
arguing against organ transplantation, but I am pointing out inconsistency in
official policies and public attitudes. Public attitudes can move from one position
of absolute certainty to another if enough emotion has been generated. But
irrational emotion also generates bad consequences!
As a secondary issue it is worth pointing out that it is a contradiction in our
use of words to speak of presumed consent for a ‘donation’. Donations, whether
of books to Oxfam or of tissue and organs, must be freely given. That is what the
word ‘donation’ means. For example, suppose someone says to a friend, ‘I put
your name down for a £200 donation because I presumed you would want to
donate!’ Nevertheless, despite the abuse of language it is a fair prediction that
the word ‘donation’ will remain: ‘presumed consent to organ harvesting’ would
not be a vote winner. [5]
 These are just two of many possible examples of ways in which bad logic and
inconsistency can have serious ethical consequences. Weak logic encourages us
to lump together what is logically distinct, or to separate for doctrinal reasons
what are in effect in the same logical category, such as consent for organ
removal whether for research or transplantation. Apparently neutral definitions
may sometimes conceal value judgements with important implications for
practical medical policy. Logic requires the occasional challenge to received
opinion, and familiar words such as ‘consent’ can conceal confused policies.

Consumerism in the Sale of Body Parts

Medical students are sometimes supportive of the idea of consumerism in

medicine, especially those students who have been led to believe that patient
autonomy means doing what the patient or the general public wants. In that kind
of context it is possible to raise with them the question of the voluntary sale of
bodily organs or other bodily parts. Consumerism requires buying and selling
based on fair, free and informed contracts so what if anything is wrong with a
patient wanting to sell an organ such as a kidney? The first response is that such
a sale is illegal. OK, but it could be legalised. Other students say that it puts the
donor at risk and surgeons should not put a patient at risk even to benefit another
patient. But although there are risks, as with any surgical procedure, in the hands
of a skilled surgeon the risks are minimal and the benefits for the recipient of the
kidney are considerable.
Another common argument is that it involves exploiting the poor for the
benefit of the rich. But that need not be the situation. The price must be right and
decided by some impartial judge. Moreover, the recipient need not be someone
who is rich—in the UK the NHS could set up a system to distribute the organs
according to need. More positively it could be argued that a poor family should
not be deprived of an opportunity to bring financial relief to their children.
Parents often donate a kidney for the benefit of a child and this is praised as
altruism. So why is it not also altruistic for a poor family to make the sacrifice
for much needed financial assistance?
It was common and acceptable in the nineteenth century for poor women to
sell their hair. Yes, but it will be said that hair is renewable but a kidney is not.
While this is true it is not a decisive argument. People can live a long and
vigorous life with only one kidney. The final argument I have come across is that
the tissues or organs sold are not necessarily safe; they may be infected. Those
using that argument can point to the considerable harm that was done to patients
by the use of blood purchased from overseas. This is true but it indicates a
serious failing on the part of the doctors who used contaminated blood without
rigorous checks.
The conclusion I wish to draw from this is that even when the students
admitted that their arguments against the sale of organs were not convincing they
were still unhappy about the idea. I pointed out that there could be a contract
drawn up with a fair price and witnessed, and the operations carried out by
competent surgeons for the benefit of donor and recipient. In the words of the
‘four principles’ approach the contract exemplified beneficence and autonomy
on the part of the donor. So what’s wrong? Why should the students be uneasy?
The answer is that there is more to morality or ethics than the rights and duties
specified by principles.
In order to bring this out I shall discuss a short novel by Graham Green
entitled The Tenth Man. The story begins towards the end of the Second World
[6]

War in occupied France. The Nazis have taken hostages and when the French
Resistance attack the Nazis or blow up some installation the Nazis require that
some hostages be shot. The Nazis do not care who is shot so they leave it to the
hostages to make that dreadful decision for themselves. After some arguing the
hostages draw lots. The hostage who draws the short straw is a rich lawyer
called Chavel. He offers to sign a contract making over all his wealth and
property to anyone who will be shot in his place. A poor man called Janvier
agrees. A legal document is drawn up and signed in front of witnesses and the
Mayor of the town. Janvier is duly shot, and that concludes the opening chapter
of the short novel. The rest of the novel concerns the life of the former rich
lawyer Chavel after the war.
The novel has many interesting and surprising twists and turns. But what is
important for the argument of this chapter is that Chavel does not feel good
about himself; he feels guilty, and tries to conceal his identity. Yet, if we confine
our attention to a morality of rights and duties, what has he done wrong? No one
was in the least forcing Janvier to agree to this contract, and he was motivated to
assist his (twin) sister and elderly mother.
In terms of the ‘four principles’ approach no one can be faulted. In the
situation we can note ‘beneficence’—Janvier is intending to assist his family
—‘autonomy’—he is making a free and informed decision—‘justice’—there is a
free and witnessed contract. It might be said that the first principle is ‘non-
maleficence’ or, in clearer English, ‘first do no harm’. Yes, but people sometimes
harm themselves for the sake of others—it is called ‘self-sacrifice’.
The question is: why should Chavel feel guilty about entering into this
contract? There seems to me to be no reason in terms of the moral framework of
rights and duties, or the ‘four principles’. It might be argued that what Chavel’s
subsequent behaviour and feelings exhibit is really fear of how others might see
him. There is something in that, but the outcome of the story—and I won’t spoil
it for readers!—seems against that interpretation because he wishes and succeeds
in making some restitution. In sum, even if medical ethics is typically discussed
in terms of rights and duties there seem to be a number of moral concepts
outside this framework. They would include concepts such as shame, honour,
self-sacrifice, self-respect and others. None of these on their own settle the
question of a market in organs but they bring out that some moral problems
cannot be settled in terms of rights and duties. In the post-pandemic world
doctors and their teachers should be aware of the wide range of moral concepts
needed to cover the complexity of real-life situations. Literature can be of
assistance here.

Consent and Incapacity

Problems of consent arise again when a patient is disabled. In many cases

consent can be applied in standard ways. Even if patients are in a wheelchair or
are blind there is no reason why they will be unable to receive the appropriate
information and agree or not to the proposed treatment. If there is a problem it
may be because relatives urge the patient to accept (or refuse) a treatment for
non-clinical reasons. A more serious problem arises, however, when the
disability concerns the mental capacity of the patient. Indeed, there are several
problems. [7]

Firstly, someone lacking mental capacity to give consent may already have an
advance statement refusing certain treatments in certain conditions, and
indicating their wishes and values. This situation might arise when a person
foresees that he/she may be overtaken by incapacity, such as dementia, and takes
the legally recognised step of writing an advance statement or living will.
Problems with this can arise if the wording is ambiguous and open to more than
one interpretation. For example, the statement might say that its writer, if lacking
capacity, does not wish life-prolonging treatments, but does wish symptom
control. But some treatments appropriate for symptom control may also have the
effect of prolonging life. Again, doubts may arise about the validity of the
document. When was it written? Was it signed and witnessed? There has been a
tendency for doctors to look for loopholes, especially when the document is
refusing life-prolonging treatment. Doctors’ doubts about following the
instructions on advance statements may be fear of subsequent litigation or an
ingrained desire to prolong life or, cynically, a dislike of being told what not to
do. The latter two points illustrate pressures from the ethos.
Secondly, the person lacking capacity may have appointed in advance a
relative to consent or refuse on their behalf. The assumption is that the relative
will know the wishes and values of the person lacking capacity. Here there can
be problems if relatives disagree, and the attorney or tutor dative may not want
the responsibility of refusing life-prolonging treatment even if it is known that
that would have been the preference of the patient.
Most commonly there will be no advance statement and no one appointed to
take decisions. This situation is covered by the Mental Capacity Act in England
and Wales and the Mental Incapacity Act in Scotland. These provisions stipulate
that when a patient lacks capacity decisions are to be made by the physician in
the best interests of the patient. Ethical problems can arise here if the physician
disagrees with the relatives on what are the best interests of the patient. There
are problems because it is never clear in this context, or more widely in health
care, what counts as ‘best interests’ (see pp. 92–3), and whether the best interests
of a person disabled in the sense of lacking capacity are different from a person
with capacity. Is ‘best interests’ to be given a medical interpretation—the ethos
would suggest this—or an interpretation based on the patient’s wishes which
may be different from the medical interpretation.

Parents, Children and Doctors: Who Should Decide?

It is a common view that parents have a right to make health care (and other)
decisions on behalf of their infants or young children. Of course, there can be
disputes about the appropriate age at which children can and should be allowed
to make their own health care decisions. I shall not enter into that dispute.
Indeed, I shall not query the basic position that, at least in most circumstances,
parents have the right to make health care decisions on behalf of their infants or
young children. My problem concerns the basis of that right. Is the basis that the
parents know the best interests of their children?
Competent adults can of course make their own decisions to accept or reject
health care. Infants and young children are not competent to make such
decisions, but why is it thought that their parents should decide for them? After
all, adults who are not competent have decisions made for them by the health
care team, unless the courts have appointed a proxy decision maker or the patient
has left and advance directive or appointed a proxy decision maker with legal
powers. But parents are not appointed in this way and yet it is assumed that they
have the authority to decide for their children. Why?
An argument for parental authority in decision making might be based on the
claim that children have a right against their parents to have their best interests
safeguarded and that there is therefore a reciprocal duty laid on parents to make
health care decisions on behalf of their children. In more detail this argument
rests on two premises: that young children do not know their best interests, and
that parents do. Presumably the underlying assumptions are that constant and
close proximity will provide the knowledge, and bonds of kinship and love will
provide the motivation.
This argument might need to be qualified a little. Parents may have several
children and this may modify the attention they give to a given child or to each
other or to their possible careers. But the obvious and stronger objection is that it
is contestable that a child’s best interests are best served by parental as
contrasted with paediatric decisions. This objection really follows from a more
general objection: duties serve the interests of others, and if these interests can
be as well or better served by B as by A then the duties are transferable. In this
kind of case the duties would be transferable to the paediatrician. Hence, if we
are to maintain that it is parents who have the necessary authority to make
decisions on behalf of their young children, that authority must be based, not on
a child’s best interests, but a prior parental right to do so. To assert the existence
of this other parental right is compatible with allowing that the state may
intervene when parental decision making goes wrong. But, if it is not exclusive
knowledge of a child’s best interests, what gives the parents this priority right to
make health care decisions on behalf of their under-age children?
One way to ground this prior parental right would be to depict it as a species
of property right. But this approach suggests that if a child is to be seen as
parental property the parent may dispose of it at will. This would indeed be a
very unhappy conclusion but it does not follow from the idea of a property right.
For example, works of art can be someone’s property, but disposal of them is
modified by legal and moral considerations. Nevertheless, it remains true that
there is a repugnance in the contemporary consciousness to the idea that parents
have a property in their child. ‘This is my child’ can never mean ‘I have a
property in this child’. The ‘my’ here does not indicate an ownership
relationship.
The dilemma here seems to be this. Rights safeguard interests so we must ask
what interests are safeguarded by parental decision-making rights. If we say the
interests are those of the child then the right is grounded in the contingency that
others, such as doctors, can better promote the interests of the child. But if we
say that parental interests are furthered then we seem to be back with the
ownership view. The way ahead may be to find some interests of the parents
other than property interests which can be promoted by parental rights of
decision making.
A possible answer is that parenting itself is the interest protected by a parental
right of decision making. After all, if parental decision making is in some way
blocked—say, if the child is taken out of the charge of the parents and placed in
care—then it is not thought that the child’s interests will suffer; ex hypothesi, if
the child is taken into care the presumption is that its interests will benefit.
Rather it is the parents’ interests which suffer if their rights of decision making
are blocked. This argues for an interest in parenting as such. If we think of the
right to parental decision making as derivative from the value of parenthood, we
have distanced it logically from the idea of the child’s best interests, although no
doubt it will most often be true that the child’s best interests will follow from the
value of parenting.
On the other hand, basing the argument on the vocabulary of rights and duties
may be misplaced. From the point of view of parenting and the complexity of
values involved in it, the idea of rights and duties as the motivation for carrying
out its many activities seems inappropriate. The parent/child relationship seems
rather to be an example of an ‘intimate relationship’, the many subtleties of
which are not captured by the quasi-legal vocabulary of rights and duties.
The nature of an ‘intimate relationship’, especially a familial one, is explored
by Ferdinand Schoeman. He writes that ‘the relationship between parent and
infant involves an awareness of a kind of union between people which is perhaps
more suitably described in poetic-spiritual language than in analytic moral
terminology. We share ourselves with those with whom we are intimate… This
makes for non-abstract moral relationships in which talk about the rights of
other, respect for others, and welfare of others is to a certain extent irrelevant.’
[8]

It is typically within such intimate relationships that human beings find meaning
in their lives. Important among such intimate relationships is that between
parents and children. Ministering to the needs of children and nurturing them in
a context of security from external intervention is an experience that parents
value for their own sake. To say that parents have a right to make decisions on
behalf of their children is not then to say that these are rights against children.
Rather they are rights against external bodies, such as the state, which might
interfere with the intimacy of family relationships. Moreover, to stress the
importance of intimate relationships in the family is quite compatible with
stressing that parents ought to listen to paediatricians, and indeed their own
children as they mature and develop their own views on their best interests. Here
again, as in the ‘Tenth Man’ story discussed above, we have a situation which
requires a wider moral vocabulary than that of rights and duties.
There are, however, two issues which require more discussion: they concern
the parent who demands inappropriate treatment for their child, and the parent
who refuses on behalf of their child treatment which might be appropriate.
Strong parental love can lead a parent to demand treatment which the doctors
think inappropriate, perhaps because the chances of success are remote and/or
the treatment is very unpleasant, such that an adult might refuse it. Sometimes
doctors may go along with parental demands even when they have only a tiny
chance of success. This may be when the press picks up the case and describes
the child as ‘courageous’ and implies that the doctors are heartless or concerned
with the costs. But the press may be unaware or unconcerned about the child’s
suffering, likely in the end to be futile. And the futile suffering which may be
inflicted on the child will waste precious resources. The public and the press
easily forget the opportunity cost. If one child is receiving a large amount of
precious resources there is less left in the allocation for other children who might
benefit more. The rights of parenthood are not absolute. The NHS is based on
compassion, yes, but also on equity, as I shall argue (pp. 38–41).
The other side to the coin concerns the parents who refuse beneficial or even
life-saving treatment on behalf of their child. Here there is a lack of symmetry
between adults deciding for themselves and adults making surrogate decisions
on behalf of their children. Adults are fully entitled to refuse even life-saving
treatment, but it is not at all obvious that they have a right (legal or moral) to
make such refusals on behalf of their children. In such cases the law may
intervene, and there have been difficult cases in the UK and the US. Two
familiar types of case concern Jehovah’s Witnesses who wish to deny their child
life-saving blood transfusions, and parents who learn that their neonate is
[9]

seriously brain-damaged. Legal judgements in such cases have not always been
consistent. Nevertheless the Master of the Rolls in re J. (1990) made some
worthwhile suggestions. He stressed that decisions must be made from the
[10]

point of view of the patient, and attention must be directed especially at the
quality of life of the patient. Discussion must take place with the parents, and
any decision must concern only withholding or withdrawing treatment and not
with terminating life. In other words, if death occurs it must be from natural
causes. These points are helpful but they have problems, such as knowing the
point of view of a brain-damaged neonate, whose future quality of life can only
be poor.
These problems are not common but it is not unreasonable that doctors,
managers, the courts and the general public should be involved since they
involve questions of public policy. In other words, a joined-up service is
desirable. For the most part, however, parents and their children should be left to
discuss and make their own decisions in the intimacy of family relationships.

Conclusions

‘Consent’ is central to medical practice and medical ethics. A consensus on the

doctrine has been reached after decades of discussion, and it is now part of
health care law. There are of course exceptions to the requirement to obtain
informed consent, but there are not many and they are obviously of a common-
sense nature, such as treatment for someone unconscious after an accident. But it
seems to this patient that the years of discussion on this are to be thrown aside to
obtain organs for transplant. No matter how desirable it is to increase the number
of organ donors it is quite morally wrong to ‘presume’ that someone has
consented because he/she has not signed an opt-out register. Populist demand
should not drive health care policy. ‘Presumed’ consent is a contradiction, and a
‘donation’ requires that something be freely given, not taken without conscious
consent.
There are difficult problems in evaluating the consent or absence of it in the
case of a patient who lacks mental capacity. Humane judgement is needed here.
The highly emotional problems of parents with a very ill child require the utmost
sensitivity. But it may not always be in a child’s best interests to be subjected to
further treatment which the doctors judge to be clearly futile. When disputes
between parents and doctors are not resolved, the courts will become involved
and will base their decisions on the child’s interests rather than those of the
parents. The courts are reluctant to get involved in such situations but
nevertheless handle them with compassion.
 The discussion of these different issues concerning the ownership of the
human body has brought out the need for doctors to widen their moral
vocabulary beyond that of ‘principles’ and rights and duties. Medical students
may often have these wider insights and it may be their instruction in ‘medical
ethics’ and the ethos of their education which has narrowed their perceptions and
moral vocabulary. Perhaps the post-pandemic world will be an opportunity for a
reappraisal and widening of the vocabulary of medical ethics.
1 A more detailed discussion of consent can be found in: Randall, F. and Downie, R.S. (2007) The
Philosophy of Palliative Care, Oxford: Oxford University Press, pp 59–62.
2 Jarmulowicz, M. (February 2002) British Medical Association News Review, p. 7.
3 Wilks, M. (February 2002) British Medical Association News Review, p. 7.
4 English, V. and Somerville, D.A. (2003) Presumed consent for transplantation: A dead issue after Alder
Hey?, Journal of Medical Ethics, 29, pp. 147–152.
5 The issues of presumed consent are discussed in more detail by Randall, F. and Downie, R. (2012)
Misguided presumptions, Clinical Medicine, 12 (6), pp. 1–4.
6 I owe this argument to Carl Elliott (1995) Doing harm: Living organ donors, clinical research and The
Tenth Man, Journal of Medical Ethics, 21, pp. 91–96.
7 These problems are discussed in detail in Randall, F. and Downie, R. (2006) The Philosophy of Palliative
Care, Oxford: Oxford University Press.
8 Schoeman, F. (1980) Rights of children, rights of parents and the moral basis of the family, Ethics, 91, pp.
6–19.
9 An excellent treatment of the ethical problems arising from the Jehovah’s Witness issues can be found in
a novel by Ian McEwan entitled The Children Act (2014).
10 In re J. (a minor) (wardship: medical treatment) (1990), case, 3 All E R 930: [1990] 6BMLR 25.
 Chapter 5
Ethics in Public Policy
Two Controversies

Assisted Suicide

An extremely controversial area in health care concerns treatment at the end of

life, and in particular the area loosely identified as involving assisted suicide or
euthanasia. The language of rights is often used in discussions of this problem
for the simple reason that most moral problems are nowadays presented in the
language of rights, the language of consumerism. I have already pointed out the
confusions and distortions of ethical issues when moral discussion is confined to
the language of rights. On the face of it indeed it does not seem very appropriate
to speak of a ‘right’ to die, for the obvious reason that we do not need a right to
die—we are all going to die anyway whether we like it or not! Dying is a matter
of bodily causality, not of rights.
Perhaps, however, what people may (sometimes) mean by a ‘right to die’ is a
right to be allowed to die. It is sometimes argued that doctors prolong treatment
when it is no longer doing much good. For example, a patient may be offered,
and perhaps pressured by doctors and relatives to accept, yet another course of
chemotherapy with a 15% chance of prolonging life for six months. But
treatment with an 85% chance of failure coupled with toxic side effects may not
be a good option. It is in this kind of context that patients may say that they have
a right (to be allowed) to die. But such a right already exists. Patients may
lawfully refuse or withdraw their consent for even life-sustaining treatment. This
should be more widely known. Again, if what is meant is a right to be assisted in
dying then that is what those in palliative care try to do. Just as obstetricians and
midwives assist in birth so the skills of palliative care assist in making the
process of dying as humane as possible. Perhaps skilled palliative care should be
more widely available but there is already a right to it under the NHS.
But the core intention of those who use the misleading phrase ‘a right to die’ is
to claim that there should be a right to be assisted in committing suicide. What
kind of a right would this be? There is already a right to commit suicide, in the
sense that it is no longer a criminal offence to take your own life. The Voluntary
Euthanasia Society (or Exit) and similar bodies have publications suggesting
effective ways of doing this with minimum unpleasantness to self and others.
This kind of right is what we might call a ‘right of action’ or a freedom; it is a
right in the sense that it is not wrong, legally at least, to commit suicide. But a
right to assisted suicide cannot simply be a right of action because, in the nature
of the case, others must be involved to assist. We might think of this as a ‘right
of recipience’, in the sense that others have a reciprocal duty to assist with the
implementation of the right. Who would be the ‘others’ in the case of assisted
suicide?
The widespread assumption is that it must be doctors who will assist. But that
is quite against the ethos, even in its earliest statement in the Hippocratic Oath.
On the other hand, those in favour of requiring doctors to assist with suicide
argue that doctors are involved in treating the patient, and will know the
prognosis. Assisting with suicide could be seen as the final terminus of end of
life care.
But there are real problems with that argument. Firstly, the transition from
treatment that provides a life-prolonging benefit to supplying or administering a
lethal dose of medication seems a switch to something of a different order. The
BMA and GMC in their guidelines to doctors say that all treatments must aim at
a health benefit, and death is regarded as an ‘adverse incident’. An ‘adverse
[1]

incident’ could hardly be the aim of any treatment. Secondly, most doctors in
recent nationwide surveys are in fact (and for many reasons) against involving
themselves in assisting suicide, so legislation may founder on this. Thirdly,
reports from soldiers sometimes say that killing the first enemy is difficult, but it
gets easier once the inhibition against killing is broken. Do we want our doctors
to break their inhibitions?
If these points are accepted does it follow that any legislation to decriminalise
assisted suicide must (perhaps ought to) founder? It will founder only on the
assumption that doctors must be the ones assisting. But why make that
assumption? Administering a lethal dose is not a difficult procedure. It could
easily be carried out by a technician with a short training. The assessment of the
competence of a patient to make the decision, and to probe into the risks of
pressure or financial benefit by the family, are more for lawyers than doctors.
Indeed, if we are speaking of a right to assistance then lawyers more than
doctors are the ones to investigate and defend rights.
The main argument for legalising assisted suicide is now not mainly the
‘unbearable pain’ argument (if there is unbearable pain something has gone
wrong with the medical treatment) but the ‘control’ argument. People, especially
those with degenerative diseases, very reasonably want to control when and how
they die, and they connect this with the idea of dignity. What is meant by
‘dignity’?
Kant identified dignity with autonomy because by ‘autonomy’ he meant not
only that people are self-determining but more importantly that they are self-
governing; they can act as universal moral law-makers; to be autonomous is to
be able to stand back from one’s immediate desires and consider others as
equally members of a kingdom of persons regarded as intrinsically valuable. In
other words, Kant’s conception of autonomy encompasses justice and the rights
of others as well as liberty. For Kant, then, dignity consisted in the possession of
these abilities. There are various problems with Kant’s position on this but for
present purposes the problem is that he restricts dignity to the ability to exercise
rational choice.
Yet perhaps it is unfair to Kant, it misunderstands his historical context, to say
that he ‘restricts’ dignity to autonomy. The point may rather be that in Kant’s
historical context, towards the end of the eighteenth-century Enlightenment, he
was concentrating on just one element in the wider concept of dignity. It was
important at that time to assert the importance of the side of human nature which
is represented by a desire for a say in how we are governed, and by a reluctance
to be pushed around by external authorities. Kant is thinking here of political and
religious authorities, which were the threats to individual liberty at that time. In
the nineteenth century J.S. Mill, in his essay On Liberty, is asserting the liberty
of the individual against ‘the tyranny of majority opinion’; the external threat is
social rather than political. (It is arguable that the ‘tyranny of majority opinion’
[2]

nowadays threatens many areas of our lives, even the language we use.)
The general point is that when some aspect of human nature is threatened
people reach for one of a range of concepts to defend themselves. Sometimes it
is ‘freedom’, sometimes it is ‘equality’, sometimes ‘human rights’, and
sometimes it is ‘dignity’. I am suggesting that ‘dignity’ does not name a property
which human beings have, but rather it is a term suggesting how human beings
should or should not be treated in a given social or individual context. It is a
concept lacking precision, but if it is to have other than rhetorical force dignity
(or indignity) claims must have some sort of foundation. Can a foundation be
found, despite the variety of contexts in which the term is used? Is there a basic
dignity which is universal?
Basic dignity must rest on basic human nature as a foundation. Dignity or
indignity claims arise when some of the many aspects of our basic human nature
are being neglected or abused. For Kant, the basis of human nature is its
autonomy (understandable in his context). But although this is a thin conception
of basic human nature it can still ground a large number of dignity or indignity
claims. For example, granted that people are rational, self-determining and self-
governing, it will be an affront to their dignity to lie to them, to delude them, or
to fail to consult them. But there are many other aspects of basic human nature
as well as rationality. Human beings are mind–body unities; they are sentient as
well as rational. Human beings have a strong dislike of physical pain, they have
a desire to cover their bodies, and a desire for privacy when engaged in various
bodily functions. Whether these desires are universal or simply enormously
widespread is a question I shall leave to one side. Certainly, they extend well
beyond western civilisation. For example, patients waiting in public places for
clinicians to see them and clad only in inadequate paper gowns may well claim
that their dignity has been violated, or patients who are not brought bedpans in
good time may similarly feel that they have been degraded. Paradigmatically,
patients who are in ‘total pain’, like Ivan Illich in Tolstoy’s story, are robbed of
[3]

their dignity.
Conceptions of dignified or undignified treatment still apply to people when
they are semi-conscious or comatose. Indeed, the idea of ‘basic human nature’ as
a base for claims of dignity or indignity still apply to a dead body. This is a
deeply-rooted human idea which can be found at the centre of Sophocles’ play
Antigone. In the play, Creon, the ruler of a city state, has decreed that the body of
Polyneices should be left outside the city walls to be eaten by vultures. His sister,
Antigone, argues with Creon, to the effect that there is a higher law, a law of
nature that we can all recognise, which rules that even the dead should be treated
with dignity.[4]

Whereas it is reasonably easy to see what constitutes respect for dignity when
we are dealing with the rational aspects of human nature (e.g. truth-telling and
consent) and also for the bodily function aspects (pain relief and privacy
mainly), it is less easy to know what will be considered a dignified treatment of a
dead body. Here there are cultural differences and we need to draw a distinction
between ‘basic dignity’ and ‘cultural conceptions of dignity’. This will apply
especially to the treatment of a body after death. The concept of dignity can be
therefore be understood as follows. Respecting dignity requires certain basic
forms of behaviour and treatment which we can all understand because we are
all human. In addition, there are certain cultural or personal beliefs which we all
may have about what dignified treatment of behaviour amounts to.
 I am now in a position to answer various questions about dignity. Can it be
defined? If by definition we mean a set of necessary and sufficient conditions
then it cannot be defined. In particular it cannot be restricted to the ideas covered
by self-determination or autonomy. Rather there are a range of contexts relating
to features of our basic human nature where it might be ‘in gear’ as a concept. If
relatives attempt to keep the truth from a patient, this is an offence against
dignity for it implies that a person is not able to face up to fundamental truths
about themselves, and if we are rational, competent adults we have a right to
know these fundamental truths. Again, it is an offence against dignity if we are
not given a measure of privacy for basic bodily functions, or not given adequate
pain relief. Does dignity stretch beyond these basic contexts? Yes, the concept is
to some extent culturally conditioned. It may be difficult from our own intuitions
to know what a member of another culture might regard, say, as the dignified
care of a body after death. This does not require a questionnaire, but a courteous
discussion.
There are, however, a number of limitations in the use of the concept. As Ruth
Macklin points out: ‘A pervasive problem with the concept of dignity is that it is
used to defend and justify diametrically opposed actions or practices.’ She cites
[5]

the example of voluntary euthanasia. In discussions of this vexed topic

proponents but also opponents of voluntary euthanasia sometimes build their
case round the concept of dignity. The moral here is that playing the dignity card
cannot be used to settle high-level controversies such as assisted suicide.
Certainly, in some contexts people may assert that their dignity requires that they
control the manner and the time of their dying. As Ruth Macklin maintains, this
is a common argument used by those advocating the assisted suicide or
voluntary euthanasia argument.
But human dignity can also be seen in those who accept their fate and bear it
with patience. This point is movingly made by the seventeenth-century poet
Andrew Marvell, who describes the behaviour of King Charles I at his
execution: [6]

He nothing common did or mean

Upon that memorable scene,
But with his keener eye
The axe’s edge did try;
Nor called the Gods, with vulgar spite,
To vindicate his helpless right;
But bowed his comely head
Down, as upon a bed.
Perhaps the best summing up of palliative care and its attitude to assisted suicide
is provided by Samuel Johnson:
If the changes we fear be thus irresistible, what remain but to acquiesce with silence, as in the other
insurmountable distresses of humanity? It remains that we retard what we cannot repel, that we
palliate what we cannot cure.[7]

Genetics

Genetics is now a rapidly developing and highly technical area of medical and
general science. I shall discuss only its bearing on disability and in particular its
bearing on two main medical procedures: pre-natal screening diagnosis (PND)
and pre-implantation genetic diagnosis (PGD). In the case of PND, potential
parents who are at risk of giving birth to a child with a disability arising from a
genetic defect may request that the embryo in utero be checked for the presence
of defective genes. Risk factors here may include family histories of such
disorders or perhaps age, as the likelihood of some disabilities, such as Down’s
syndrome, increases with age. The genetic procedures may involve a slight risk
of damage to the embryo or causing an abortion. If a genetic defect is
discovered, the only remedy at the moment is abortion. For that reason, some
potential parents would not wish PND even if at risk.
To avoid the distress of abortion, many parents at risk prefer PGD. The
embryos can then be tested in vitro for a range of disorders before being
implanted. The ethical issues here arise for those who hold that life begins at
conception, for the procedure will involve the discarding of defective embryos.
In cases of PND in which the result indicates future disease or disability it is
clear that it is the woman who gives or withholds consent on whether to abort
the pregnancy. This is presumably on the grounds that a woman has a right to
control what happens to her own body. In cases of PGD it is less clear who has
the right to control what happens to the fertilised ovum in the laboratory in a
petri dish. It can be argued, however, that if the couple are sufficiently informed
about the procedures of IVF and PGD they have consented to entrusting their
gametes to the scientists and clinicians for the purposes of the procedures and
these procedures may involve the destruction of embryos which are not
implanted.
Some people consider abortion wrong for whatever reason, as they would say
that it involves the killing of a potential person. I shall not take up the much-
discussed general issue but examine three charges sometimes made when
abortion is carried out specifically because the child when born will in some way
suffer from a disability.
The first charge is that to abort or not implant because the child when born
may have a disability is to imply that disabled people now alive do not have
lives worth living. This conclusion does not follow. From a parent’s perspective
it will certainly be preferable if a child is not disabled. There are many obvious
reasons for this preference, such as the lives of their other children, their own
lives and careers and the funding of support services. And if this preference
leads them to choose to abort the foetus in utero or to refuse the embryo in vitro
then that is their choice. It casts no adverse reflection on existing people who are
disabled or on parents who choose otherwise.
The second possible charge is that reproduction is a gift and that any form of
selection or manipulation turns the child into a commodity. In other words, the
argument is that it is wrong to choose traits of an offspring, no matter how well-
intentioned the aim might be. In reply we might argue that if what is proposed
[8]

is simply screening for aneuploidy or serious Mendelian disorders then the

objection, however sincerely voiced, seems to exaggerate when it suggests that
clinicians or scientists are turning a child into a commodity.
But the charge of manipulation can be restated in a way which constitutes the
third objection I shall consider. The third accusation levelled at PGD is that the
manipulation involved is at least the first step towards a policy of eugenics, a
policy which, as practised in Nazi Germany, advocated the killing of persons
who are disabled and other groups held to be ‘degenerates’. The interesting
feature of this criticism is that it moves the argument away from the
unanswerable questions which arise in the standard abortion debate about the
moral status of the embryo, to a controversy on selecting embryos for different
indications. Here we must distinguish between medical and non-medical
indications. Medical indications may be the identification of genes suggesting
the likelihood of late onset conditions, such as Alzheimer’s disease. Parents may
well wish to avoid the birth of a child with this future. Non-medical indications
may be such matters as intelligence or beauty. This is beyond the reach of the
science at the moment, but if possible in the future it would certainly count as
eugenics. So too would the desire of some deaf parents to have a deaf child (see
p. 117).
Before leaving the topic of genetics, I shall note some arguments in favour of
PGD. Firstly, PGD offers the alternative of screening embryos in vitro rather
than foetuses and thus it avoids the psychological problems of abortion.
Secondly, many couples who are at risk of conceiving an embryo liable to
diseases such as Tay Sachs, sickle cell, or cystic fibrosis may choose not to
attempt a family to avoid having a child with a disorder. PGD offers the
possibility of a conception which will result in a child without such disabilities.
These issues are highly controversial and decisions about their development
and application require the involvement of an informed public, an involvement
which must include the scientists but requires wider consultation. Wider
consultation should be a watch-word for post-pandemic medicine.

Conclusions

I have sketched some of the arguments in two out of many ethically

controversial areas in public policy—assisted suicide, and genetic issues. There
are obviously other areas of controversy as medical treatment advances. A
critical understanding of these controversies brings out that ideologies can
interfere with clear thinking. For example, a doctrine such as ‘Human life is
sacred’ can lead to burdensome and futile treatment being continued on the
mistaken grounds that if it is stopped or removed the doctor is intending to kill
the patient. Or the slogan ‘Playing God’ can impede valuable research and
treatment in genetics. Or ‘Follow the science’ puts science and scientists on a
pedestal they may not wish to stand on. What is needed for the future of
medicine is wide public discussion on these and similar issues.
1 BMA (1999) Withholding and Withdrawing Life-Prolonging Treatment, London: BMJ Books, p. 1.
2 Mill, J.S. (1959/1969) On Liberty, Warnock, M. (ed.), London & Glasgow: Collins, p. 129.
3 Tolstoy, L. (1983) The Death of Ivan Illich, Harmondsworth: Penguin Classics.
4 Sophocles (c. 492 BC) Antigone, Harmondsworth: Penguin Classics.
5 Macklin, R. (2003) Dignity as a useless concept, British Medical Journal, 327, pp. 1419–20.
6 Marvell, A. (1650) An Horatian Ode upon Cromwell’s Return from Ireland, in The New Oxford Book of
English Poetry, Oxford: Clarendon Press, pp. 329–33.
7 Johnson, S. (1755) Dictionary of the English Language, Harmondsworth: Penguin Classics.
8 Kass, L.R. (2000) Triumph or Tragedy: The moral meaning of genetic technology, American Journal of
Jurisprudence, 45, pp. 1–16.
 Chapter 6
Consumerism
and Medicine
From Ethics to Political Philosophy

Patients and Consumers

Consumerism has been a growth movement since the Industrial Revolution and
it rapidly developed in the twentieth century. The movement emphasises that the
free choice of consumers should affect the choice of manufacturers on what is
produced and by that means orient the economic organisation of society. In
contrast, a policy of offering health care free at the point of need was outlined in
the Beveridge Report of 1942 and adopted by the British Government as the
NHS in 1946. The consumerist movement and the NHS have both become very
popular with the public. It is therefore not surprising that successive
governments from the 1980s have made attempts to marry the two. The aim is to
improve the NHS by introducing consumer choice while keeping the service free
at the point of delivery. The hope is that the introduction of consumer choice will
both increase patient/ service-user satisfaction and improve efficiency. Although
the idea of this marriage derives from right-wing free market assumptions,
governments of a more left-wing persuasion have made no serious effort to
reverse the trend to a consumer-based NHS. [1]

The general public, however, remains suspicious of what is seen as the

privatisation of a public service, and the health care professions remain critical
or indeed hostile to consumerism in health care; as I shall show it is contrary to
the basics of the ethos. Moreover, despite the hope of improved efficiency, costs
continue to rise. There are many reasons for these adverse effects but my
argument will be directed at a conceptual misfit between a publicly funded
service free at the point of delivery and the free market assumptions of consumer
choice. I shall consider three areas of conceptual misfit: the incompatibility of
patient choice and consumer choice, confusions over the term ‘best interests’,
and the centrality of equity in a publicly funded service contrasted with its
absence in a consumerist free market. If the post-pandemic world is to be one
with a fairer distribution of resources then consumerism in medicine must be
resisted.
 Choice

The word ‘choice’ is familiar in ordinary language where it overlaps and in some
contexts is interchangeable with words such as ‘decide’ or ‘pick’. For example, a
conjuror might equally say ‘Choose a card’ or ‘Pick a card’, and looking at a
holiday brochure we equally choose or decide where to go. Nevertheless, it is
possible, without too much artificial stipulation, to build up a model of choice as
the term is used in ordinary language. First, a choice must be free from external
constraints or pressures. This bald statement requires of course to be qualified.
Friends urge us, advertisers persuade us and many other constraints affect us, so
that in a given context it might be debated how free a choice really was.
Nevertheless, it is not really contentious that a genuine choice requires some
degree of freedom. Second, there must be at least a few alternatives, as in a
chocolate box. Third, there must be a minimum of information: the diagram on
the chocolate box lid might be adequate for that choice but the choice of a car
would require much more information. Without the appropriate amount of
information we are picking rather than choosing. Finally, we must take personal
responsibility for the choice. If we don’t like what we have chosen, our friends
say ‘It was your choice’. These conditions of choice in ordinary language—
freedom, alternatives, information, responsibility—helpfully spell out the
acronym FAIR, and I shall use the acronym as a convenient short-hand way to
refer to the model of choice we accept in everyday life.
The ordinary conception of choice—FAIR—enters medical practice via the
term more commonly used in health care—consent. Consent to medical
treatment is now a foundation principle of medical ethics. I have discussed
consent in Chapter 5, but as a brief reminder consent has two main roots: the law
of battery—that it is a legal offence for one person to touch another without
consent—and the ethical idea that we all have a right of self-determination with
respect to our bodies. I pointed out in Chapter 5 that ‘consent’ as used in medical
law and ethics differs from the way the word is used in everyday speech. If you
ask me to meet you for a drink after work and I say ‘OK’ I have in ordinary
contexts consented to go for a drink. You are not required to spell out what we
will be drinking. In other words, ‘consent’ in everyday contexts is just a matter
of freely agreeing to what is proposed—it meets the first condition of the
ordinary sense of ‘choice’. But in the medical context the doctor must also
suggest possible alternatives and provide adequate information—conditions 2
and 3 of ‘FAIR’. The fourth condition—responsibility—is shared: the doctor
takes responsibility for the alternatives, the information and the action plan, and
the patient takes responsibility for choosing an offered action plan. In other
words, the preferred medical model for consent simply adopts FAIR with the
extra proviso that the responsibility for the final choice is shared.
[2]

But consumer choice has conditions additional to those stipulated in FAIR,

and if consumer choice is to enter the NHS then these additional conditions must
be present. It will emerge that these conditions are at variance with medical law
and the traditions of medicine. The first of them is competition. From the time of
Adam Smith competition has been regarded as a necessary condition of a free
market and therefore of consumer choice in that market. Consumerism requires
competition of two sorts: between the consumers of goods and services and their
suppliers; and among the suppliers of services. Successive governments from the
1980s have tried to introduce competition of both sorts to the NHS.
Consider first the attempt to introduce competition between consumers
(patients or ‘service-users’) and suppliers or providers (GPs or hospitals). To
create competition in this context, league tables have been published, showing
such results as waiting times, operation success rates and so on. The
measurements involved are often disputed, but even if we leave that aside league
tables do not help the vast majority of patients. For example, the elderly who
make up the majority of patients may not have the skills or energy to investigate
league tables, but must rely on advice from their GP; those who require urgent
care via emergency services have to use the nearest service; and in general if you
are ill you lack the energy to get involved in competition. Choice overload can
cause the debilitating effects of bewilderment and high levels of stress and
anxiety. Genuine competition between patients and providers is an illusion. [3]

Turning now to competition between different providers we encounter another

kind of problem. The foot soldiers of the NHS are the doctors and nurses who
serve the patients. But the process of their education and tradition has a
solidarity that is quite contrary to the ethos of competition, a theme I shall
develop (pp. 95–6). From the start of medical education students are taught
together and share a curriculum which is largely similar for all students, and
even extra-curricular activities reinforce the ethos by informal student societies,
such as ‘year clubs’. Such factors play a role in inculcating a sense of loyalty
even in the earliest years, and in later years ways of relating to patients and other
health workers even in other institutions becomes part of medical
professionalism. The professional ethos of medicine is quite inimical to the
individualism of commercial competition.
 It might be objected to this point that, whereas medical professionalism may
be incompatible with institutional competition, it is in fact the managers and
chief executives of hospitals who will manage the competition. While this is
true, its truth creates another problem for competition in the NHS. The problem
is that managerial attempts to encourage a competitive spirit among doctors, say
by stressing the importance of meeting targets, can create disharmony between
management and medical staff. The medical ethos is concerned with patient care,
rather than targets. This is by no means just a theoretical risk. It is not
uncommon to hear of a culture of bullying in hospitals and attempts to intimidate
whistle-blowers. This is obviously bad for staff morale, and what is bad for staff
morale will obviously be bad for patients.
This suggests that since consumer choice requires competition to be added to
the sense of choice (FAIR) which underlies joint decision making in medicine
then consumer choice sits in tension with medical practice. Patients are able to
decide whether they prefer Tesco or Waitrose but the evaluation of league tables
is much harder and sometimes impossible. Moreover, the traditional ethos of
medical education and its resultant professionalism is quite inimical to that of
competition. But competition is not the only problem which arises for consumer
choice in the NHS. Two further problems concern the alternatives for choice and
the locus of responsibility.
In FAIR, the alternatives are displayed, for example, on the lid of the
chocolate box, and in the development of this in a medical situation the
treatment alternatives are outlined by the doctor. In other words, the number of
possible choices is limited. But the choices of consumerism are not constrained
in this way. If one shop does not have the product another might, or the
consumer can go online and have the commodities of the world available. There
are no limits to the number of alternatives and it is the consumer who is the
dominant figure. Current political policy is to develop a version of this enlarged
idea of competitive consumer choice within the NHS. The hope is that if one
hospital cannot offer the treatment or care regime then perhaps another can. If
medical research suggests that a treatment is not adequately tested or cost-
effective then the consumer ethos encourages patients to write to the newspapers
or their MP and it is likely to be made available. Indeed, there is general protest,
sometimes extending to outrage, if a cancer treatment is judged not to be cost-
effective and therefore not provided on the NHS. The underlying problem here is
that of equity for the NHS, which I shall discuss later (pp. 138–41, 178–9). But,
in addition to raising problems of equity, the extensive alternatives of consumer
choice also raise problems about the locus of responsibility in a medical
situation.
In FAIR and its extension to joint decision making, the locus of responsibility
is clear: the doctor has responsibility for offering the choices and carrying out
the one chosen by the patient. But on a consumer choice model the patient might
say: I have read about a certain treatment on the internet and that is the one I
want. In other words, the patient can widen the range of choices. Doctors of
course are not infallible and perhaps after consideration the doctor might agree
with the patient’s preference. But the doctor might judge that the patient’s choice
is not cost-effective or not tested, and refuse to grant it. Where does the
responsibility for choice lie? To illustrate the problem here let us take an
example.
Suppose I wish to purchase a computer and explain to the retailer that it is for
word-processing, emails and other simple tasks. The shop assistant suggests one
or two models, but my eye alights on one with a spectacular screen-saver, and I
say that I want that one. The assistant patiently explains that that model is
complex and is really for scientific purposes. I insist and put my money down.
The shop assistant, having provided adequate information, has no duty to refuse
the sale. But if, after a week of despair, I return it to the shop, the seller has no
duty to take it back. Some retailers might of course accept a return out of
customer goodwill but they have no consumer duty to do so. The point is that
having been given adequate information the purchaser carries the responsibility
for the choice. But this situation does not apply in medicine. In law it is the
doctor who carries the responsibility. In other words, the locus of responsibility
in the two contexts of consumerism and medical professionalism are
incompatible.
The UK and the US seem to differ on this issue. In the UK the Court of
Appeal ruled that the courts could not require a medical practitioner to offer a
treatment which the practitioner thought was contra-indicated. Lord Justice
[4]

Balcome went as far as to say: ‘[he] could conceive of no situation where it

would be proper to order a doctor to treat a patient in a manner contrary to
his/her clinical judgment’ (re J., a minor, 1992). On the other hand, in a survey
of the literature in the US it was claimed that doctors will almost always
continue treatment if requested by patients or relatives even if they regard it as
futile (Paris et al., 1993). This view was supported by many US ethicists
throughout the 1990s. Thus, Veatch and Spicer maintain that a physician is
obliged to supply requested treatment even if the the request ‘deviates
intolerably’ from established standards or is in terms of the doctor’s judgement
‘grossly inappropriate’. I do not know what Veatch and Spicer mean by saying
[5]

that a physician is ‘obliged’ to supply ‘grossly inappropriate’ treatment. Such an

obligation seems in direct conflict with the moral duty of a physician. Indeed, it
is in direct contradiction to the claim by US medical authorities that doctors are
‘altruistic’. This equally extreme claim is discussed later (p. 102). Certainly, the
position reported by Veatch and Spicer is in accord with the consumerist maxim:
‘The customer is always right.’

Best Interests

It is often said that one merit of a consumer-based system is that it enables

patients to achieve their own best interests. The assumption here is that patients
know their own best interests whereas in the NHS doctors decide what is in the
patient’s best interests. In support of this assumption it can be pointed out that in
the FAIR model of choice as it applies to medical decision making it is the
doctor who offers the treatment choices in what the doctor decides is the
patient’s best interests. But there is a confusion here that arises from an
ambiguity in the concept of ‘interest’, an ambiguity between a psychological and
a normative sense. ‘Best interests’ in the psychological sense refers to choices
arising from what people actually want to have. ‘Autonomous choice’ is usually
interpreted in this way as a choice expressing what the patient wants. But ‘best
interests’ in the normative sense refers to what a patient ought to have, whether
or not he/she in fact wants the offered treatment. For example, it might be in a
person’s best interests in the normative sense to take some exercise or cut down
on sugar but he/she might not want to. As we say to the relative reluctant to
accept the treatment, ‘It’s for your own good’.
Now in the framework or value-base of consumerism the psychological and
the normative senses will run together, for a person’s best interests in such a
framework or value-base is simply the satisfaction of his/her wants. The
essential self is a consumer. But in the framework or value-base of medicine the
psychological and normative sense of ‘best interests’ are quite separate, and the
doctor’s professional duty is to offer treatments from the normative
interpretation of ‘best interests’. This normative view will have two components:
a duty to promote the health of patients where possible, and an awareness of the
safety and cost-effectiveness of treatments. Of course, the patient is entitled in
law to refuse the doctor’s offer of choices based on this normative view of best
interests, even in cases where life-prolonging treatment is involved. But the
central point is that the psychological sense of ‘best interests’ expresses the value
base of consumerism while the normative sense expresses that of medical
professionalism.
In view of the rise of consumerism and its popularity with both governments
and electorates, it is not surprising that governments have tried to introduce
consumer choice into health care. The question which arises is: how does this
affect the values of the traditional professions and especially medicine?
There are crucial differences between medicine and the market. Patient choice
and consumer choice are logically different in their structures. If the issues seem
abstract I must stress that an understanding of them is crucial to the survival of
medicine as a profession, as distinct from a consumer service. There are of
course good arguments for preferring a consumer-based medical service to one
based on professional values—such as stressing the importance of looking after
your own health—but the attempt to combine the two leads to confusion. It is
rather like an attempt to combine incongruent triangles.

Conclusions

I have argued that joint decision making, which is currently the preferred model
in the NHS, represents a development of the everyday conception of choice
which I encapsulated in the acronym FAIR. It is fully compatible with the
medical ethos and the idea of medicine as a profession. The consumerist model
of choice, however, adds elements not present in either FAIR or joint decision
making: competition, a wider range of alternatives and a change in the locus of
responsibility. Moreover, a consumerist view of best interests—‘My interests are
to get what I want’—may conflict with medical values—‘The patient’s best
interests are expressed by the attainable medical good.’ Underlying all these
conflicts is the problem that a consumerist free market system does not require
the principles of equity and utility which are essential in a publicly funded
system such as the NHS. Of course, a consumerist system has merits—such as
stressing individual responsibility for health care—and it may therefore be
preferred by some societies. But the attempt to combine a consumerist system
with one which is publicly funded will give rise to tensions and contradictions.
As I said earlier, it is rather like the attempt to combine incongruent triangles.
This incongruity does not work to the benefit of patients, and doctors in a
changed post-pandemic world should reject the encroachment of consumerism
into medicine.
1 I have developed the critique of consumerism in medicine in Downie, R. (2017) Patients and consumers,
J. R. Coll Physicians Edinburgh, 47, pp. 261–65.
2 Randall, F. and Downie, R.S. (2010) End of Life Choices, Oxford: Oxford University Press, Chapter 1.
3 Bate, R.G. (2005) British Medical Journal, 331, pp. 1488–89.
4 Re J. (a minor) All England Law Reports 1992; 614. For discussion see Kessell, R. (1992) British judges
cannot order doctors to treat, Hastings Centre Report, 22, pp. 3–4.
5 Veatch, R.M. and Spicer, C.M. (1992) Medically futile care; the role of the physician in setting limits,
American Journal of Law and Medicine, 18, pp. 15–36.
 Chapter 7
Medicine,
Professional Solidarity

and Other Occupations

Solidarity and Medical School

The fourth element in the medical ethos or the identity of the doctor is a strong
sense of solidarity. But challenges can arise over professional solidarity even
though many doctors would see it as a positive feature of the profession. In the
original version of the Hippocratic Oath there is a stress on treating and
supporting colleagues in the profession. In the contemporary world this stress is
continued through medical education. From the start of medical education
students are taught together and share a curriculum which is largely similar for
all students, and even extra-curricular activities reinforce the ethos by informal
student societies, such as ‘year clubs’. Such factors play a role in inculcating a
sense of loyalty even in the earliest years. This loyalty is directed partly towards
the institution and its members, but also towards medicine itself. In later years,
ways of relating to patients and other health workers even in other institutions
becomes part of medical professionalism. This strong sense of collegiality has
many good aspects: modern medicine is highly complex and requires
contributions from many specialties, and it can be demanding in terms of the
hours required and its emotional impact. Hence, support from colleagues can be
very helpful. Consider the nature and origins of medical solidarity.
Selection for medical schools involves a rigorous process. Candidates are
required to have very good results in all high school subjects, but especially
science. They must also have been involved in voluntary charitable work, and
other non-academic activities. Most medical schools also require applicants to be
interviewed. This kind of process is no doubt essential for the admission of
appropriate candidates for what will be a rigorous course and a demanding
profession. But it inevitably has the result that there is a certain sameness in the
candidates chosen. The qualifications for entry are roughly the same and the
interviewers are likely to be from the medical faculty and will tend to favour
applicants like themselves. After admission, the medical students will follow
more or less similar courses, laid down in the UK by the General Medical
Council. The courses will be taught by other doctors and assessed by doctors.
The students will socialise mainly with other medical students and will belong to
year clubs. Throughout the entire course the idea (entirely valid) that they are a
privileged group and must be dedicated to the service of patients will be
reinforced, culminating in many cases in the taking of an updated version of the
Hippocratic Oath.
The advantages of this are obvious: a rigorous training designed for the
treatment of disease and dedication to patients, coupled with the support of like-
minded colleagues is mainly good. But from a patient’s perspective, there are
two disadvantages. The first can be simply stated: the admission and training
process make for a certain similarity in the personality and approach of doctors.
But patients are different from each other. No doubt diseases can have a
similarity in symptoms and progress, but it is patients who have diseases and
there can be marked differences in the way patients react to their problem. A
standard approach may not always work. In general terms medical education can
be criticised for a failure to encourage, far less cultivate, individuality. I shall
later offer a detailed discussion of individuality and independence of mind (pp.
172–3). Current medical training is directed to an evidence-based approach
which can produce a scientific cast of mind. But a scientific cast of mind, while
it may be necessary, is not sufficient from the perspective of a patient, as I
suggested in my discussion of the Asklepian element in medical identity. The
evidence-base must extend beyond science. Scientific understanding requires to
be supplemented by other sorts of understanding.
The second disadvantage of medical training is that collegiality may lead to
the covering up of errors in diagnosis and treatment, an issue I shall discuss in a
later section of this chapter. Just as the military, the police and politicians have a
tendency to close ranks when faced with hostile criticism, so doctors can become
defensive and look inward. Criticism can be seen as ‘doctor bashing’.
Nevertheless, the idea of medical solidarity is the unseen basis for the common
idea of medicine as a profession. A post-pandemic philosophy of medicine must
offer a wider or more inclusive idea of health care professionalism, of which the
medical input is only one factor. The issue to be considered first is that of the
nature of a profession.

Definitions and Evaluative Criteria

The first difficulty in defining a profession concerns the sort of definition which
would be helpful. There is a large sociological literature on the professions, but
sociologists tend to identify professions in terms of criteria such as: five years of
training; a code of ethics; an annual conference; remuneration by fees or salary
rather than wages; and so on. Now it might be possible to define a profession
using such criteria, but they do not really advance our understanding of why a
profession might have a valuable contribution to make to the community, or why
professional decisions typically involve judgements of value. I shall therefore
suggest evaluative criteria as a basis for a definition. But, as we shall see, these
criteria have implications which are contentious if they are regarded as
constituting the necessary and sufficient conditions which a strict definition
would require.
The first of the evaluative criteria is that a profession must be a learned
occupation; it has a basis of knowledge and skills. This is perhaps the criterion
which, historically, would originally distinguish a profession from other
occupations; the schoolmaster, the clergyman, the doctor, were the main scholars
of an earlier epoch. But now many occupations have a basis in knowledge and
skills and so this criterion can be no more than necessary to distinguish a
profession; it certainly is not sufficient. Secondly, medicine, like all professions,
offers a public service to clients, patients, students or similar categories. In more
detail, this service is offered, thirdly, through a special relationship, a connection
involving both a legal tie and an appropriate attitude. The legal tie is decided by
the governing body in conjunction with the law, and the attitude is largely
constituted by a strong ethical influence.
A fourth feature of the professions is that professional leaders have a moral
duty to speak out on matters of public policy as it affects their profession. For
example, judges have a duty to speak out on matters of sentencing and the law
more generally, doctors on matters of health policy, teachers’ leaders and vice-
chancellors on matters of education, and architects on housing policies, planning
permission, conservation and the like. Governments do not always like this.
There has been a tendency for governments of both the right and the left to resist
the influence of the professions, seeing that influence as a kind of threat to their
own political positions. Campaigns against the professions are easy to mount
with support from the media, for there have been high-profile scandals which
encourage public opinion to turn against the professions and depict them as
‘elitist’ and monopolistic and lacking ‘diversity’.
If the professions are to be a reliable source of independent advice, they must
be self-regulating. This is the fifth criterion which an occupation must satisfy to
be a profession. Yet it is increasingly difficult for any profession to satisfy this
criterion. Most professions are dependent for finance on governments or large
pharmaceutical companies. I have already indicated some doubt about the
influence of pharmaceutical companies on the ‘gold-standard’ of randomised
trials (Chapter 1). As far as research grants go, if you pay the piper, you want to
call the tune, and this is precisely what governments have increasingly been
doing. They impose targets, curricula and policies, all with a political agenda in
mind. To resist external bullying, courage is needed—an underestimated moral
value of great relevance to the professions, but not usually discussed in courses
of ‘medical’ ethics.
It is often argued against the self-regulatory nature of professions that they
must be ‘accountable’. Yes, but accountable to whom? Professions typically
have governing bodies concerned with discipline, education and ethics. These
governing bodies have lay members, and lay members can bring an
independence from the professional ethos. Of course, there is a danger that lay
members will tend to go along with the views of the professional representatives.
But the alternative to self-regulation is government interference via appointed
managers. The general public and the media respond favourably to political
assertions to the effect that the professions must be accountable. But it is not so
widely realised that this largely amounts to a managerial/governmental takeover,
with its attendant targets and highly-paid bureaucracy. Hence, it is to be hoped
that the professions will have the courage to hold on to self-regulation, and to the
right to comment on government policies. It is good for a society if there is a
measure of political pluralism (an issue taken up in Chapter 12 on
‘communitarianism’). The professions can be one source of basic political
values.
Finally, not only must a professional have knowledge and skills, offer a public
service through a special relationship and be self-regulating, a professional must
know when, how and how much to exercise the skills. For example, the skilled
surgeon may be able to carry out the complex operation, but s/he must decide
whether the operation ought to be attempted. This kind of decision is of a
different order; it involves judgements of moral value. What is the balance of
risks and harms? Has the patient consented to the risks? What are the long-term
prospects of recovery? And so on. This complex mixture of the technical and the
ethical ideally requires that the surgeon be broadly educated, as well as
technically skilled. I shall therefore make education in humane values the final
and essential criterion for a profession. Education of this broad kind is necessary
to inform professional judgement, a concept central to my entire analysis, as I
argued in Chapter 3.
This final criterion of education in humane values requires some expansion.
What are the differences between being trained to have skills, and being
educated in humane values? This, of course, is a large topic on its own, but a
[1]

few points can helpfully be made. Firstly, the person educated in humane values
has a broad cognitive perspective and is able to see the significance, for
example, of social work, teaching, medicine or the law, in a total way of life.
Secondly, the person of humane education has a continual curiosity about the
world, a desire to develop the skills throughout a working life, and connectedly
is aware of the standards of work which must be satisfied. Here we have the
familiar idea of a ‘professional job’ or a ‘job well done’. Thirdly, the idea of a
humane education embodies the idea of ethics. It is possible to be trained to pick
pockets, as in Dickens’ Oliver Twist, but a humane education is necessarily
directed to worthwhile ends. I have already mentioned the Hippocratic wish to
reduce ethics to the application of a few principles. But here I am stressing the
idea of standards of behaviour, of ‘being professional’ in one’s approach to a
client or patient or student. Fourthly, the broadly educated person has a
flexibility of mind which enables her/him to see things in a variety of ways.
A good analogy which brings out the nature of the fourth attribute of the
educated person is given by the twentieth-century philosopher Ludwig
Wittgenstein. His example is a fly in a glass bottle. The fly buzzes against the
glass and cannot escape, but there is no stopper in the bottle. If the fly changed
direction, it would fly straight out. The person of flexible mind is the one who
[2]

can show the fly the way out of the bottle! The point here is that there tends to be
a grey uniformity about professional education: nowadays it is forced into the
mould of aims and objectives, powerpoint presentations and bullet points. No
doubt there are merits in this, but the price is stereotyping and a suppression of
individuality. Suppression of individuality affects not only personality but also
the creativity which leads to innovative research. The educated professional
must have the ability to think differently. As J.S. Mill puts it in his essay On
Liberty: ‘[human nature] is not a machine to built after a model… but a tree,
which requires to grow and develop on all sides, according to the tendency of the
inward forces which make it a living thing.’ Professional education must avoid
[3]

the idea that one size fits all. If the first requirement for a profession is a base of
knowledge and skills, the final requirement is that the knowledge and skills must
be developed in a long-term programme which includes broad and ethical
perspectives on the profession and its skills and does not stifle individuality. I
shall discuss this important point in more detail later (Chapter 11).

Family Resemblances

So far I have suggested five criteria which an occupation must satisfy if it is to

count as a profession: knowledge and skills; a public service provided via a
special relationship; a duty to comment on matters of public policy; professional
self-regulation; a broad framework of values stemming from a humane
education. Now these criteria seem plausible enough, but if we regard them as
constituting a definition—a set of necessary and sufficient conditions for an
occupation to count as a profession—we are faced with some implications which
are likely to be unpalatable to many who consider that they are in professions.
This is the point in the argument which might be considered contentious. For if
we regard the criteria as constituting a definition, we have ruled out as
professions at least the following occupations: civil servants, bankers, the armed
forces, journalists, plumbers, the police, scientists, writers, musicians, actors,
airline pilots, estate agents, politicians, care workers and so on. There may be at
least two independent reasons they could be ruled out as professions, despite the
fact that they offer a valuable public service. The first is that they do not offer
their service via a special relationship, and the second is that at least some may
not satisfy the first and the final criteria: they may lack a sufficient knowledge
base and they may lack the broad educational framework.
There are two possible approaches to this implication of the criteria. The first
is to accept the implication and say that many occupations offer a public service,
and professions are a subset of these; they are those public service occupations
which have a more developed knowledge base and/or offer the service through a
special relationship. The list would obviously need to include medicine and
dentistry. The other approach, perhaps preferable, is to drop the idea of a strict
definition, of being ‘absolutely clear’ (as politicians say) about what we are
going to mean by the term ‘profession’, and say instead that we are dealing with
a range of occupations which have a ‘family resemblance’. Members of a large
[4]

family do not all have the same features, but they have a number of features
which, as it were, overlap, and enable us to recognise someone as belonging to
that family. This approach follows from the point that occupations develop over
the years: some become professions, and others may cease to be such if the
public no longer needs the service. For example, surgeons or dentists are now
clearly in professions but it was not always so.

Occupational Motivations

Many doctors wish to claim that their professional motivation is altruism,

whereas that of business or consumers is commonly said to be self-interest.
Indeed, it is interesting to note that even in a society such as the US where the
values of consumerism are dominant (see pp. 91–2), medicine continues to hold
on to traditional beliefs about itself: that the profession in its aims and practice is
uniquely benevolent, indeed altruistic. Consider the following characteristic
claims:
Medicine is one of the few spheres of human activity in which the purposes are unambiguously
altruistic.[5]
Or:
Altruism is the essence of professionalism. The best interest of patients, not self-interest, is the rule.
[6]

These and similar claims by other medical bodies in the UK are made by these
bodies about themselves—not always a reliable guide to realistic assessment.
Indeed, doctors in literature until halfway through the twentieth century—until
the arrival of the medical soap opera—tended to be portrayed as comic or even
as grasping, as for example Chaucer’s Doctour of Physique. There is certainly
room for some scepticism about such claims. We patients, whether we are
plumbers or schools-crossings ladies, feel we help others too (for much less
money).
There are of course benevolent or indeed altruistic doctors. For example, some
doctors work in dangerous situations, or work beyond or outside the call of duty,
and most will communicate with their patients in a caring manner and show
concern for their patients as appropriate. During the Covid-19 crisis many
doctors were tirelessly working round the clock along with their colleagues in
nursing and the care sector. But these are contingent, if highly desirable, ‘add-
ons’ to the relationship. The essence of the medical relationship requires only
that the object of the doctor’s attitude should be a health benefit for the patient.
In any case, the intention to confer benefits is not exclusive to the doctor, for
all those who work in the division of labour aim to create or confer some kind of
benefit through their work, whether it be baking bread or repairing a burst pipe.
As Aristotle tells us at the opening of the Nicomachean Ethics, all activities aim
at some good—the medical art aims at health, the art of shipbuilding at making a
vessel. It is simply a confusion to extrapolate from this neutral sense of ‘good’
[7]

or ‘benefit’ to a moral sense. If all those who confer benefits on us by means of

the division of labour are to be called ‘benevolent’ in the moral sense then the
word ‘benevolent’ will be emptied of its suggestion of the morally praiseworthy.
Certainly doctors aim at a good for patients and for society, but plumbers also
aim at a good. Indeed, systems of sanitation may have led to a greater public
health good than medical prescriptions.

Collective Cover-ups

When things go wrong, as they often do, the values and attitudes—the ethos—of
both medicine and management can lead to the covering up of serious failings in
an attempt to preserve the reputations of both the medical profession and
management. When it emerges that adverse incidents have been covered up,
scepticism and worry among patients can be created as to how much has been
covered up. There has certainly been increasing public concern about the
covering-up or non-disclosure (as it is often called) of medical errors. In the US,
for example, the Institute of Medicine reports that there are perhaps over a
million preventable adverse events each year. It suggests that of these ‘adverse
events’ between 44,000 and 98,000 led to the deaths of patients.
These figures seem startling, but a note of caution should be recorded here.
The Institute defines a medical error as ‘the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim’. But that is
[8]

a counter-intuitive definition of an error. If I plan to meet you at 8pm for dinner

and I am prevented from getting to the intended restaurant because of a transport
breakdown then that’s very unfortunate, but I have not made an error. Indeed, it
is not uncommon for most of us—and no doubt especially within the complex
world of clinical medicine—to have rational evidence-based plans which for
unforeseeable reasons do not work. Sometimes, for example, the standard,
evidence-based antibiotic might not clear the infection because an unknown
strain of bacteria has appeared. These failures are hardly errors. As Robert Burns
puts it in his poem To a Mouse:
The best-laid schemes o’ mice an’ men
Gang aft agley,
An’ lea’e us nought but grief an’ pain,
For promis’d joy.[9]

Burns is not suggesting that the mouse has made an error! The mouse has simply
discovered, as we all do, that ‘stuff happens’ and things don’t work out as we
had intended.
Nevertheless, there are areas of health care in which there are justifiable
concerns about non-disclosure. These usually concern poor care, sometimes
amounting to negligence. The areas most often involved are in care homes or
mental institutions. According to an article in YouGov: ‘One in six British adults
knows of someone whose poor treatment by the NHS has been covered-up—and
majorities support sacking, prosecuting and removing the pensions of staff found
to be involved.’ Even allowing for some populist exaggeration from the people
[10]

questioned in this survey, there is no doubt that cover-ups are of public concern.
There are several reasons why cases of poor treatment might be covered up.
The first concerns the collective values of medicine which encourage the closing
of ranks. There is a smooth transition from the sharing of attitudes and a spirit of
solidarity to a conspiracy of silence. The second is a legitimate desire not to
upset the patient, especially when nothing can be done to put things right. The
third, perhaps the most important, concerns fear of litigation. From the doctor’s
point of view there may be a fear of disciplinary action which could extend to a
loss of licence to practise.
But even from the management point of view there may be incentives to cover
up. For example, the phenomenon of the ambulance-chasing lawyer is common
enough and patients and their relatives can easily be persuaded that they have
been badly treated and are entitled to financial compensation. Indeed, in the UK
even if the courts find in favour of the hospital and not the patient costs are
likely to be awarded against the hospital. Hence, hospitals may settle out of court
because this is cheaper. Again, hospital managements may not want the bad
publicity which comes from admitting to failures in care. At the very least this
would weaken their position in a competitive market. Hence, hospitals and their
doctors for different but understandable reasons are inclined to play down
significant adverse incidents. Collective attitudes here combine to work against
good patient care.
Despite these understandable collective concerns, however, the evidence
seems to be that patients are less upset if there is disclosure of errors, provided
that the disclosure is done in a compassionate way. Legal liability is another
[11]

matter. Nevertheless, the American Medical Association’s Council on ethical

and judicial affairs states: ‘Concern regarding legal liability which might result
following truthful disclosure should not affect the doctor’s honesty with a
patient.’ It is of course easy for patients to single out doctors for this kind of
[12]
blame, and the media never fail to report medical mistakes. But doctors might
reasonably point to the covering-up of disastrous errors in banking and other
occupations for which individuals are not usually made to pay.

Professions, Trades, Crafts and Caring about What You Are Doing

I have suggested that there are family resemblances between the professions
narrowly conceived and broadly conceived. I now wish to suggest that these
resemblances extend also to those engaged in other occupations not usually
considered professions. Indeed, some patients prefer the attentions of helpers,
such as those from voluntary societies, who are not in ‘professions’. The concept
of a ‘profession’ for some patients can carry the undesirable baggage of the ‘top-
down’ and patronising. Moreover, despite the well-publicised medical stress on
medical ethics, members of other occupations also adhere to standards. Many
craftsmen and tradesmen would refuse to carry out work they regarded as
dangerous or aesthetically unpleasing. For example, the garage mechanic would
be unwilling to alter a car engine for a teenager on the grounds that to increase
its potential for speed would be dangerous. Moreover, the ideals of a ‘job well
done’, of high standards of work and behaviour being satisfied, are ones which
can extend to trades as well as to traditional professions. The idea that the
traditional professions have a monopoly of ethics is simply self-deception; after
all, Jesus was a carpenter. An excellent description of a desirable and an
undesirable professional attitude, and its accompanying ethics, is provided by an
account of motorcycle maintenance which would be regarded by professionals as
a trade. In his novel Zen and the Art of Motorcycle Maintenance, Robert Pirsig
describes the attitudes implicit in technical manuals and in his experience of
some mechanics as a ‘spectator’ attitude. He writes:
These were spectator manuals. It was built into the format of them. Implicit in
every line is the ideas that ‘here is the machine, isolated in time and in space
from everything else in the universe. It has no relationship to you, you have no
relationship to it…’ And it occurred to me that there is no manual that deals with
the real business of motorcycle maintenance, the most important aspect of all.
Caring about what you are doing is considered either unimportant or taken for
granted.[13]

Doctors, dentists and others in health care may well care about what they are
doing, but so do musicians, mechanics, plumbers, bus drivers and others who
serve the public. The traditional health care professions require to loosen up and
work more with others in a post-pandemic world. This is especially true of
medicine. If the traditional professions have a weakness, shared with academics
and politicians, it is a self-importance which takes the form of looking inward
rather than outward.

Conclusions

Traditionally, the professions have been seen as distinct from both commercial
occupations and trades. But increasingly this distinction has become weaker.
During the Covid-19 pandemic the devotion of doctors has been matched by
carers who have given devoted service for a fraction of the financial reward. As
a result, they have risen considerably in public esteem. There is no question that
many doctors have worked tirelessly at personal risk throughout the pandemic,
and those who have done so can fairly be judged as ‘altruistic’ or going beyond
duty. Likewise, some doctors have worked in dangerous areas of the world and
put their lives at risk. They too are altruistic. But moral praise in such cases is
legitimately deserved because of their personal sacrifice, not for the reason that
they are doctors. Certainly, doctors aim at a good—the well-being of their
patients—but that is simply a definition of their job description and not moral
praise. In the same sense nurses and carers aim at a good but that similarly is just
what they do for living even if many exceed their duties in difficult
circumstances. The most important message, however, is that doctors must
recognise and work not just with occupations ancillary to medicine, such as
nursing, but also with the arts and other community agencies. These agencies
and their suggested remedies should not be kicked into touch as ‘alternative’.
Many are successful enough to be mainstream and in the evidence-base, an issue
to be discussed further in Chapter 11.
1 Calman, K.C. and Downie, R.S. (1988) Education and training in medicine, Medical Education, 22, pp.
288–91.
2 Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell, para. 309.
3 Mill, J.S. (1859) On Liberty, London: Collins, chapter 3.
4 Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell, paras. 65–75.
5 Editors (2000) Looking back on the millennium, New England Journal of Medicine, 42, pp. 42–44.
6 American Board of Internal Medicine (1998) Project professionalism, Philadelphia: American Board of
Internal Medicine, 5.
7 Aristotle (1971) Nicomachean Ethics, Ross, Sir D. (trans.), Oxford: Oxford University Press, p. 1.
8 Institute of Medicine (2000) To Err is Human: Building a Safer Health System, Washington, DC:
National Academy Press.
9 Burns, R. (1785) To a mouse, in Poetical Works by Robert Burns, London: Collins, p. 115.
10 Dahlgreen, W. (2013) Yougov, [Online], https://yougov.co.uk/news/2013/ 06/23/one-six-britons-know-
ups-personally.
11 Wu, A., Cavanaugh, T., McPhee, S., Lo, B., Micco, G. (1997) To tell the truth: Ethical and practical
issues in disclosing mistakes to patients, Journal of Internal Medicine, 12, pp. 770–75.
12 Institute of Medicine (2000) To Err is Human: Building a Safer Health System, Washington, DC:
National Academy Press.
13 Pirsig, R. (1974) Zen and the Art of Motorcycle Maintenance, New York: The Bodley Head.
 Part 3.
Medicine as

Self-Contained:
A Philosopical Critique
 Chapter 8
Medicine
A Multi-Professional Approach

On first impression it might be said that there is no problem about the aims of
clinical medicine: the aims are to fix whatever medical problems we happen to
suffer from. But a moment of consideration will suggest that patients require
many more services. For example, doctors are expected to prevent diseases
occurring in the first place, to promote fitness, to ensure safe delivery of babies,
to offer advice on contraception, to treat depression and a host of related mental
illnesses, and to deal with disability. Indeed, many patients and the general
population think that doctors should also assist with suicide at the end of life.
Awareness of at least some of these assorted medical aims is recognised in the
1946 definition of health.[1]

Health is a state of complete physical, mental and social well-being, and not
just the absence of disease and infirmity.
This definition suggests that there are two aspects to the aims of medicine: a
negative one concerned with the removal of unwanted states such as disease and
infirmity and a positive one concerned with well-being. I shall discuss the
positive aims of medicine in Chapter 11, but in this chapter I shall examine ideas
of disease and disability. It will emerge that both have elements which doctors
cannot manage on their own. Clinical medicine is not self-contained; teamwork
is required, and in many cases wider community involvement. Take first the idea
of disease. Disease and illness are terms as old as human life but nevertheless
both doctors and patients can have different ideas about what counts as disease
or illness. Doctors identify and treat diseases, but what is disease?

Illness and Disease

Illness is a less technical notion than disease. Any of us can know when we are
physically ill; mental illness is more of a problem, as I shall discuss in the next
chapter. The kind of things which are relevant in physical illness are overall
upsets of the system—not wanting to eat, feeling abnormally hot or cold, having
headaches, feeling chronically tired, aching all over and so on. We are all
familiar with symptoms of that kind so illness seems less puzzling than disease
and we don’t worry about definitions. Disease is a more technical notion.
Scientists seek the nature, causes and treatments of specific diseases, but what is
disease itself?
There are two main strands in discussions of disease. I shall call them the
[2]

biological and the sociological. In terms of the biological strand, ‘disease’ is a

scientific, descriptive term and diseases are discovered and classified by various
biological sciences, such as biochemistry, physiology and anatomy. The origin of
this approach to disease can be found in the ancient Greeks. For example, the
biologist-philosopher Aristotle sees the task of the biologist as that of
discovering the repeatable features of nature and then of classifying the
phenomena in terms of genera and species, as was discussed in Chapter 1. In a
word, biological science is taxonomy. This way of thinking enters the early
modern world through the seventeenth-century physician Thomas Sydenham
(1624–89), and the eighteenth-century botanist Carl Linnaeus (1707–78). These
influential biologists believed that it was possible to classify, not only plants and
animals, but also diseases, into genera and species. According to this approach,
types of disease can be discovered, and they exist independently of human
interests. They would be identified in terms of various malformations, irregular
growths, genetic irregularities and so on, which lead to the malfunctioning of an
organ or a bodily system. In terms of this type of definition, diseases exist as
independent entities and can be studied independently in laboratories.
Such a view is very plausible in general outline and is currently very much
alive. It has been given new strength with the rise of genetics and the popular
belief that there is a ‘gene for’ every human ailment, and a vaccine against many
diseases. Nonetheless the biological view has limitations which emerge when we
examine the second approach to defining disease—the sociological.
The sociological view has a negative and a positive side. Negatively, it finds a
range of problems in the biological view. Its exponents point out that there are
some phenomena which are regarded as diseases by some social groups but not
by others. For example, there is a range of conditions associated with ageing,
such as failing vision or hearing, or stiffness in the joints. Value judgements and
cultural norms are the factors which determine whether these are diseases or not.
From the biological standpoint they are statistically normal. A similar sort of
problem concerns the fact that some conditions might count as a disease in one
context, but not in another. For example, colour-blindness might seem a disease
in many contexts, but colour-blind individuals can identify camouflage with
greater success than colour-visual individuals. Here one might imagine an
environment where the capacity to spot camouflage maximises one’s own
chances to survive.
More positively, the sociological approach invites us to see disease in terms of
the impairment of human function taken as a whole. In the biological approach
disease is associated with failings in organs or parts of the body, but in the
sociological it is thought to apply to the whole human organism. From the
sociological perspective, human beings are diseased if they cannot function
normally, where ‘normal’ is interpreted in terms of the norms of a given culture.
‘Disease’ (‘illness’ or ‘disability’), they say, characterises a life as a whole, as it
is acted out in a given society, and the terms apply only derivatively to an organ
or part of the body. The stress in the sociological approach, then, is on the
evaluative nature of the concept of disease, and the values of a given culture. For
example, in some cultures obesity might be ranked as a disease but in others it
might be seen as a sign of affluence or status. Diseases, for the sociological way
of thinking, are not discovered, and they have no timeless, absolute definition.
Rather they are defined by the values, norms and social expectations of a given
society. This approach has merits and clearly fits some of the ways in which we
speak of disease. To some extent diseases and their treatments are matters of
fashion—an idea made fun of long ago by Bernard Shaw in The Doctor’s
Dilemma.
Nonetheless there are also real problems with the sociological line. Briefly, I
shall mention two difficulties. First, science can identify particular, anatomically
located diseases. These are attributable to specific organs or systems, and not to
the person as a whole. For example, someone might have diseased lungs and be
dying in a palliative care unit, but overall, as a person, he/she might experience
the well-being of someone who has made peace with friends and family and is
ready to go. So a diseased bodily part can exist alongside overall health and
well-being. Secondly, there is general agreement in the medical sciences about
what biochemical or physiological states should be viewed as healthy and what
viewed as diseased. It is true that in many cases there might be dispute at the
margins. For example, there might be dispute as to whether a given cholesterol
level is too high. But nevertheless there is agreement that certain levels indicate
disease and others are entirely normal. This seems to suggest that disease
language is at least mainly scientific, and a non-evaluative definition would
therefore be appropriate.
We seem to have reached an impasse. The biological and the sociological
approaches are plausible in their criticisms of each other, but neither has a fully
persuasive positive theory. The solution might be to look for a new approach. A
new approach might be to drop the whole idea of defining ‘disease’ and
substitute the idea of ‘clinical problem’. In developing this line, we might say
that language can misguide, and concepts by their very character can misdirect
us. Disease-concepts have been distorted on the one hand by the assumption that
they name things in the world in a value-free fashion, and on the other hand by
the assumption that they are purely human value-constructs. The new suggestion
is that we should simply bypass questions of definition and see disease-concepts
instead as goal-directed notions. What are the goals? It might be claimed that
they are the goals of medicine. These we might characterise in general terms as
the attempt to prolong life, where that is worthwhile; to free us from pain; and to
minimise impairments to everyday function. Certain physiological and
anatomical states are likely to impede the achievement of these important human
goals in any environment. Obvious examples are the major cancers and heart
diseases. They will therefore constitute cross-culturally recognisable diseases.
However, other states of affairs, such as the failings of age, will count as
diseases in some societies but not in others.
Looking at the situation more broadly we might say that it is an error to try to
define the nature of disease. Different sorts of answer may be appropriate for
evolutionary biology and for clinical medicine. The concern of doctors and
patients is with clinical problems. Now, if clinical medicine is focused on
resolving clinical problems connected with prolonging life, minimising pain and
improving impaired everyday functioning, then it will allow with equal propriety
as clinical problems: lung cancer, schizophrenia, the pains of childbirth,
unwanted fertility and unwanted sterility, as well as difficulties like appendicitis
or stiff joints. That list contains some problems which are classic diseases, others
which are conceptually borderline and others which don’t fall under the heading
of ‘disease’ at all. The point is that clinical medicine is interested in reliable
warrants for useful medical interventions, and the question whether something is
or is not a disease then becomes irrelevant. As a warrant for medical intervention
I suggest that clinical judgement and the patient’s consent are more reliable
guides than biological disease-taxonomies or definitions.
This approach has certain merits for both patients and clinical medicine in that
it sidesteps the philosophical problem of definition. But the ‘clinical judgement’
approach throws open medicine to inputs from wider non-medical community
agencies. The British Medical Journal ran an issue on ‘non-diseases’. The [3]
editor listed the top 20 non-diseases, which included boredom, baldness,
freckles, jet lag, unhappiness and road rage; more recently we can add addiction
to gambling and too much sex. From a narrowly medical point of view a merit of
the disease-entity approach is that it can stop clinical medicine being forced to
take over all the ills of life. The clinician can say: where there is no underlying
pathological condition there is nothing for clinical medicine. Yes, but from the
patient’s perspective there may still be a need for help or advice, and this where
wider community services have role.
Patients of course may prefer to have their conditions identified with a
disease-name. Armed with a disease-name, patients have a socially and legally
validated defence against employers; a possible claim against insurance
companies; immunity from ordinary social claims and conventions; and indeed a
nameable alien entity against which they can be said to ‘fight’. Hence, the
popular, and perhaps also the scientific, belief in disease-entities and viruses may
be stronger than that in clinical judgement, especially granted the new faith in
vaccines. Many members of our obese population feel relief at the suggestion
that there may be a ‘gene for’ obesity! But this belief suggests the need for more
effective health promotion rather than a search for miracle pills. The general
public, encouraged by the medical profession, may accept the ancient Greek idea
of biological disease-entities, despite its drawbacks, and the search to identify
disease-entities and to find a pill or vaccine to fix them is still the preferred
approach of medicine but it may not be the only or the best route to community
health and well-being.
Perhaps an analogy might help to clarify this complex situation. Diseases can
be compared to weeds. Weeds are genuine plants, but if these plants are growing
in the wrong place, or there are too many of them, or they kill other plants, or
they are multiplying too rapidly, the plants become weeds. Patients are like the
owners of gardens, and clinicians are like gardeners. Together they decide which
plants or diseases to try to eradicate, which they can only restrain and keep in
check and which should be left alone. Moreover, gardeners have jobs not
connected with deciding what are weeds and what should be done about them—
jobs such as watering and planning for a flourishing garden. In a comparable
manner, health carers have jobs not directly concerned with disease, but rather
with encouraging fulfilling lifestyles. Questions of definition are therefore not
always helpful, and can mislead by pointing research in the wrong direction.
Clinical problems are not always solved by clinical means; the attainment of
health requires a wider approach than that provided by a concentration on
diseases and their remedies.

Disability

A similar conclusion emerges if we examine another aspect of the negative side

to health—the removal of infirmity or disability. ‘Disability’ is a term
[4]

frequently used in the context of the NHS and more widely. But what is
‘disability’? Before trying to answer that question, we must first face the
objection that there is no such condition. For example, it has been said that
people can be ‘differently abled’. That might mean that if you are blind you will
develop other senses, such as hearing, to a higher degree than the sighted
population. This is common among blind musicians. Some associations for the
deaf have taken a different line and argued that the difference between those who
can hear and those who are deaf is a cultural one, that there is a ‘deaf culture’.
[5]

They point to their sign language and the shared experiences which go with a
shared language and take this as evidence that they are simply culturally
different rather than disabled. Other groups again use terms such as
[6]

‘challenged’—visually challenged, intellectually challenged and so on—or they

might speak of ‘learning difficulties’. Others again might argue that if the groups
in question encounter problems in their daily lives the problems are created by
society and social arrangements which do not facilitate their lives, for example
by providing adequate ramps and other appropriate provisions.
Arguments of the above kind can be developed and made more plausible if a
distinction is drawn between ‘impairment’ and ‘disability’. It can be argued that
people might be physically impaired but are disabled only if society fails to offer
facilities and services which will counteract the disability. In terms of this
approach, ‘impairment’ is an individual concern but ‘disability’ is a social
concern.
It is easy to understand and sympathise with what lies behind all such attempts
to redescribe what is commonly known as ‘disability’. They show a laudable
desire to get away from the harsh terminology of the past, and to stress that the
groups in question are human beings with human dignity. Nevertheless,
disability is real and redescription will not change its reality. This bedrock must
be agreed if government agencies are to be persuaded to create arrangements and
the public to pay taxes to enable disabled groups to have worthwhile lives.
But to claim that disability is real is not to say what it is, and there are
formidable problems in deciding what it is. To bring this out I shall examine the
most recent definition known to me which is offered in the Equality Act. [7]

A person is disabled according to this Act if he or she has ‘a physical or

mental impairment’ that has a ‘substantial’ and ‘long-term’ negative effect on the
person’s ability to ‘carry out normal day-to-day activities’. The Act defines
‘substantial’ as ‘more than minor or trivial’—an unhelpful swapping-of-words
type of definition. Guidance produced by the UK Government’s Office for
Disability Issues gives the example of taking much longer than it usually does to
complete daily tasks like getting dressed. By ‘long-term’ it means 12 months or
more, and the guidance gives the example of a breathing condition that develops
as a result of a lung infection. ‘Progressive conditions’, or those which get worse
over time, count as disablement, and there are special rules about recurring or
fluctuating conditions such as arthritis. Some conditions are not covered by the
definition. We are told by the guidance that these include addiction to non-
prescribed drugs or alcohol.[8]

This definition and the covering explanations raise some interesting questions.
The definition uses the word ‘normal’, a weasel word if ever there was one. It
glosses ‘normal’ in terms of ‘completing daily tasks like getting dressed’, but for
many people their daily tasks include much more than that. We might therefore
ask: normal for whom and according to whose standards? We are told that a
‘progressive condition’ or ‘one that gets worse over time’ can be classed as a
disability. Old age seems to fit this kind of progression, and of course ‘age
discrimination’ is often condemned alongside disability discrimination. Again,
colour-blindness might be thought by some to be a disability; it would make
impossible some kinds of ‘normal’ life. But it is be excluded as a disability.
Surprisingly, HIV infection, cancer and multiple sclerosis are ‘automatically’
covered by the Act. It is easy to see why multiple sclerosis is included, but
someone with HIV infection or some cancers may well be able to carry out
normal daily activities, but they are ‘automatically’ included. On the other hand,
addiction to non-prescribed drugs or alcoholism is excluded. But some addicts
and alcoholics are likely to have extreme cravings which have a substantial and
long-term effect on a ‘normal’ life. The Act stresses that disability concerns
‘effects’, such as difficulty in performing daily tasks, rather than underlying
causes. But alcoholism and drug addiction may have serious effects on a
‘normal’ life, and cancer is not an ‘effect’ but an underlying condition. The main
difficulty with the 2010 Act is that it tries to give a definition, or a set of
necessary and sufficient conditions, for disability, but is then obliged for
political, financial or other reasons to include certain conditions which do not
seem to fit the definition and to exclude others which do seem to fit.
It might be helpful to look back at the problems which arose in the previous
section over the definition of disease. I tried to show that biological and
sociological approaches have problems and that a pragmatic approach might be
more helpful. Transferring this pragmatic approach to disability, I suggest that if
someone has a physical or mental condition such that the person would benefit
from some assistance then the assistance should be provided. But what sort of
assistance?
There are two answers often given to this question. One is to the effect that
what is needed is medical assistance, that disability is a clinical problem
affecting some individuals. This is often called the ‘medical model’ of disability.
The other answer is that disability may not be a problem at all, or, if it is, it is a
social problem requiring social rather than medical solutions. This is known as
the ‘social model’ of disability. But setting up the medical and the social models
[9]

of disability as if they were exclusive alternatives is misleading. It is easy to

select conditions which would support either point of view. Some conditions
may require or benefit from constant medical attention, medication for clinical
depression or the like, while others, say a person in a wheelchair, require ramps
and good equipment for getting around. This suggests that a joined-up approach
will work best. Indeed, there are large and developing industries of
bioengineering or biotechnology which sit midway between what is medical and
what is infrastructure improvement, such as electronic devices which assist
communication.
I draw from these considerations that ideology, whether from the medical or
the disability lobby, can interfere with good care and well-being. More generally,
the treatment or care for either disease or disability, and (as I will suggest in the
next chapter) for mental illness, require a joined-up service. My argument will
culminate in Part 5 with the suggestion that a total community involvement in
the post-pandemic world is required to create an optimum quality of life for
sufferers from disease, disability or mental illness. In the meantime, I shall
examine the role of teams in supplementing a purely medical intervention.

Teamwork

Nowadays, whether in hospitals or in general practices, health care is delivered

by multi-disciplinary teams. In hospitals a team will have members from several
medical specialties and at different levels of training, but also and importantly it
will have nurses, social workers and perhaps chaplains and others such as
physiotherapists. From a patient’s perspective the hope is that the collective
wisdom of teams will result in better care for the patient than treatment from an
individual, no matter how well skilled. A general practice is likely to be a scaled-
down version of this. Often GPs will have areas of special expertise and they
will also be assisted by nurses and social workers. ‘Assisted’ is perhaps a weak
term, for there are highly qualified nurse practitioners who may make their own
decisions. And of course there are community nurses and others loosely attached
to a general practice. The relationship between assorted district and community
nurses, midwives and others and GP practices and hospitals is an arcane area into
which I have not the knowledge to venture. But the general conclusion is
obvious: teams with assorted knowledge and skills must surely be very
advantageous for patients, in view of the complexity of issues around diagnosis,
treatment, care and after-care. Although I shall not question this conclusion in
any fundamental way, it may be of interest to indicate a measure of scepticism
about some aspects of it.
One question might seem to have an obvious answer: what is the aim of the
team? The obvious answer is: to benefit patients. And certainly all teams will no
doubt claim that they are patient-centred, and most teams are likely in fact to be
patient-centred. But we live in a time of shortage of staff and resources. It would
not therefore be unreasonably sceptical to wonder if perhaps sometimes some
teams are more management-centred than patient-centred. This change could
happen without the team members becoming fully aware of the change. The
ethos in the hospital might be one where the saving of resources dominates. This
could result in team policies such as too early discharge, which are not in
patients’ best interests.
The morale of a team will obviously depend partly on leadership, and the team
leader is likely to be the most senior medical consultant. When medical
educationists speak of communication and listening skills, they are thinking of
patients as the recipients of these alleged skills, but it is just as important that the
leader should be willing to communicate with and listen to the team members,
and should encourage team members to share their views with the whole team.
No doubt the days of the dictatorial lead consultant are largely over, but we still
sometimes read newspaper reports of bullying in hospitals, although these
reports are more often about management than lead consultants. A current
general difficulty with teams arises from the reality of hospital staffing—it is not
always easy to maintain a full-strength team and there may be frequent changes
of staff recruited from agencies. Staff changes can get in the way of creating an
esprit de corps, and may indeed lead to poor morale.
There can be further grounds for concern if we consider weekends. Senior
staff may not be available, but the conditions of patients can deteriorate at
weekends. It is therefore important that senior consultants really are at the ends
of telephones. Harassed junior staff can make mistakes at weekends or indeed at
other times. This can give rise to the practice of scapegoating. In order to
preserve the reputation of a team or hospital it is tempting for its members or its
senior leaders to point the finger at a given individual when in fact the
responsibility should be shared by the whole team or organisation.

Responsibility

But what does it really mean to say that responsibility should be shared by the
whole team? Can there be collective responsibility? This is a large philosophical
topic, but it is of interest to look at different models of collective responsibility.
In the first sense a number of professionals who are individually responsible for
their practice operate together as a group. We might say they have aggregate
responsibility for the entire group of patients they serve. In other words,
collective responsibility here is simply the sum of individual responsibilities. In
a second sense there may be group discussion with input from different
professionals but the decision in the end is taken by the team leader, usually the
medical consultant, in the light of the advice received. We could think of this as
hierarchical responsibility. True collective responsibility is to be seen when after
input from assorted professionals there is a consensus about the decision to be
taken. We could think of this as multi-professional responsibility and it is a
genuine kind of collective responsibility. If the decision turns out for the best, the
team as a whole can share the praise. Of course, multi-professional responsibility
may not be practicable in many situations; the doctor in charge of the patient
may well decide perhaps after discussion with the ward sister. In the end it is the
doctor who carries the legal responsibility.
A problem inherent in the idea of team responsibility is that of confidentiality.
Confidentiality as been stressed as a necessary ethical requirement since
Hippocrates. Does everyone in the team need to know everything? A team as a
whole cannot be collectively responsible if some members, perhaps for good
reason, do not know all the facts. Of course, with the advent of technology,
government surveys, research inquiries and similar sharing or patient records,
patient confidentiality may be a lost cause.
Conflict can happen within teams. For example, there may be disagreement
about continuing or terminating treatment, and this can occur within the team or
between the team and the patient or the patient’s relatives. There is no solution to
this other than to hope that points of view are listened to respectfully. It is worth
stressing here that patients cannot (legally) force the doctor to provide a
treatment anymore than a doctor can (legally) force a patient to accept a
treatment.
‘Conflict’ may be on one side of the coin but on the other is ‘cosiness’. Teams
can be inward-looking and more concerned with their own welfare than that of
the patient. Indeed, this can lead to the problems of cover-up (pp. 103–5). But,
despite the occasional sceptical doubt, well-led and harmonious teams in
hospitals or general practice are very much of benefit to patients. It is important,
however, to be realistic about teams and discussion. Hospitals and general
practices are busy places and there is pressure both to decide on treatment and to
beat political targets. Hence some kind of balance between individual and team
decisions must be struck. The point is made in two different statements by
Clement Attlee. In a comment to Winston Churchill he said: ‘A monologue is not
a decision.’ But in a speech at Oxford he said: ‘Democracy means government
[10]

by discussion, but it is only effective if you can stop people talking.’

[11]

Traditionally teams were thought to consist of doctors, nurses, social workers

and other ancillary staff. I shall argue in later chapters that teams must be open to
others, such as artists and many others not traditionally thought to be
appropriate. This is where the idea of ‘social prescribing’ is relevant. Professor
Helen Stokes-Lampard, Chair of the Royal College of General Practitioners,
welcomes social prescribing, but introduces an interesting metaphor. She
suggests that the doctor (she is thinking of GPs) is like the conductor of an
orchestra who can bring in a variety of instruments, but remains in charge. It is
the GP, as conductor, who joins up the assorted players in health care. I shall
discuss social prescribing in more detail in Chapter 11, and simply note here that
it suggests a medical recognition that health, especially the positive health
recommended by the WHO, requires a wide community input.

Conclusions

The problems of clinical medicine are usually considered to be exclusively the

task of medical science to solve and construed as the problems of devising
treatments for our diseases and disabilities. And indeed perhaps these are the
main problems. But reflection on these concepts brings out some confusion as to
what they are, and whether it is entirely up to doctors to deal with disease and
disability. Teams are essential, and these teams should helpfully include
members other than those in the health professions. A complete medicalisation
of health must be avoided. This fuzziness round the concepts which are usually
thought to define the aims of clinical medicine is even more pronounced when
we move to mental illness and positive health.
1 World Health Organisation (1946) Constitution, New York: W.H.O.
2 I am indebted to Engelhardt, H.T. (1984) Clinical problems and the concept of disease, in Nordenfelt, L.
and Lindahl, I. (eds.) Health, Disease and Causal Explanations in Medicine, Dordrecht: Reidel.
3 Letters to the editor (2002) British Medical Journal, 324, pp. 912–14.
4 Downie, R.S. (2015) Disability and health care: Some philosophical questions, in Ferguson, P.R. and
Laurie, G.T. (eds.) Inspiring a Medico-Legal Revolution, Farnham: Ashgate.
5 Padden, C.A. and Humphries, T.L. (2005) Inside Deaf Culture, Cambridge, MA: Harvard
UniversityPress.
6 Levy, N. (2002) Deafness, culture and choice, Journal of Medical Ethics, 28, pp. 284–85.
7 Equality Act (2010), s. 6 (1).
8 Equality Act (2010): Guidance, at p. 15.
9 Oliver, M. (1996) Understanding Disability: From Theory to Practice, Basingstoke: Macmillan.
10 Williams, F. (1961) A Prime Minister Remembers, London: Heinemann, chapter 7.
11 Attlee, C. (1957) Speech in Oxford, as reported in The Times, 14 June 1957.
 Chapter 9
Mental Illness
Moods and Medicalisation

When we turn to mental health and illness we encounter a range of very complex
problems. The classification of types of mental illness is controversial, but for
present purposes I shall suggest some broad categories into which it may be
possible to fit the many technical names for types of mental illness. Psychiatrists
may point to omissions, or have a different way of categorising, but any method
is to some extent open to challenge and what I propose should at least be easily
recognisable. Even if my classification of mental illnesses does not fully accord
with current terminology, my main thesis remains intact: that mental illness, at
least in many cases, is social or cultural rather than purely medical, and requires
social, cultural or community-based remedies. This is not of course to deny that
there are mental illnesses with genetic or other physical causes. In any case,
mental illness can be an overwhelmingly bad experience for the sufferers
whatever its causes.
As a preliminary I should note that just as there are some critics who deny that
disability is a real category so there are some who deny that there is a real
category of mental illness. The name most associated with the denial of mental
illness is Thomas Szasz. He argued that the proper concern of medicine is
[1]

physical illness, and since we cannot usually point to physical causes of mental
illness the idea of mental illness is a myth. Adequate arguments against this
position would require discussion of an age-old problem in philosophy—
Cartesian dualism between mind and body. Such arguments have considerable
philosophical interest but they would take my present concerns down a different
route.
It should be stressed, however, that the influence of the medical ethos is
powerful over the broad area of mental illness and it has affected public and
political perceptions. It has led to the view that negative mental conditions, such
as loneliness, depressions or even too much sex, are mental illnesses and require
medical treatments. I won’t deny the existence of these and many other
unfortunate and sometimes debilitating mental conditions but I will cast doubt
on the common view that it is helpful to classify them as illnesses, requiring
specifically medical treatment. Indeed, it may be positively unhelpful to those
who have such conditions to classify them as ‘illnesses’. If we are once labelled
as ‘mentally ill’ we may come to view ourselves in a way which will not be
conducive to recovery. This is not at all to deny that there are real illnesses
which can be classified as ‘mental illnesses’, or in older language as ‘diseases of
the mind’. I shall therefore accept the reality of at least some conditions called
mental illness, although I shall cast doubt on claims regularly made in the media
that most of us suffer mental illness at different periods in our lives, as if mental
illnesses were like bad colds which we might expect to have every year or so.
Claims of that kind are particularly unfortunate when applied to children and
young people.
But accepting the reality that there are many cases of mental illness, I must
face the problem of how they can be classified. We frequently hear the term
‘mental illness’, but what counts as mental illness? I shall suggest that there are
some broad categories into which cases of mental illness can be classified,
whether or not these categories fit the ones used in psychiatry does not affect my
argument.

A Classification of Mental Illness

Psychiatric research into mental illness is of course ongoing and the situation is
complicated by the fact that some psychiatrists treat or are involved with cases
of distressing circumstances which are not exactly mental illness. For example,
difficulties in a marriage don’t amount to mental illness but psychiatrists may
sometimes be expected to assist, although this may be more common in the US
than in the UK and Europe. Again, poor mental capacity is sometimes a concern
of psychiatry, but it is hardly a case of mental illness. Many people with limited
mental capacity, such as those suffering from Down’s syndrome, are happy and
well-adjusted to their circumstances, and can make a genuine contribution to
community life. This is hardly of medical concern.
From the point of view of my argument, I suggest that there are three broad
strands or ways of classifying mental illness. Perhaps there are more than three
categories and there are certainly sub-categories, but the three I identify are
sufficient for my argument.
First, mental illness can be seen to involve deviant or sick desires, some of
which operate as compulsions. Extreme mood swings from elation to depression
is a second category of mental illness. Mental illness, thirdly, can manifest itself
in delusional beliefs or behaviour. A few preliminary points should be noted
about my suggested categories. They are not tightly bounded in that the
categories may affect each other. For example, a mood swing to depression may
affect what, if anything, someone has a desire to do. Indeed, in extreme cases of
clinical depression the desire to go on living may be extinguished by the
depression. Moreover, and this is important, in many cases there is a sliding
scale from beliefs or moods we all might have from time to time to pathological
states. For example, it is not uncommon for people to believe that they are
cleverer/more attractive/more popular than in fact they are. This is delusional but
it is hardly mental illness. Again, we all have mood swings, but to label a period
of low spirits ‘mental illness’ may not be helpful. If we come to attach a label to
ourselves we may well come to act out what is on the label; we turn a normal
episode of living into a pathological state. I shall return to this theme. Note also
that there are other conditions which may be treated by psychiatrists but don’t fit
easily into my three categories, such as addictions or Asperger’s syndrome.
My first broad category of mental illness which I have loosely called ‘deviant
desires’ is the hardest to sort out conceptually (and no doubt also in the clinic).
An important problem in this category becomes more obvious if the word
‘abnormal’ is substituted for ‘deviant’: ‘normal’ and ‘abnormal’ are weasel
words, for they are grounded very much in cultural attitudes which change, and
may include simple eccentricity or indeed moral wrongdoing. Some
psychiatrists, at least in the past, have been happy to categorise all deviant
desires, immorality and eccentricity included, as examples of mental illness.
Consider the following: ‘It should be stressed that all failure to comply with the
rules of the game, and indeed all anti-social behaviour… is evidence of some
psychological failure in the conduct of life.’ By thus construing any ‘deviant’
[2]

behaviour as the product of illness, a spurious air of objectivity is given to what

is largely culture-relative, and it denies responsibility for action to those
regarded as wrongdoers, not bad but mad. The extreme of such a view was to be
found in the old Soviet Union where psychiatrists treated as mentally ill those
who criticised the regime. Even in the West we have a shameful history of
attempts to treat homosexuality as ‘deviant’ and indeed criminal behaviour. It
might as well be argued—perhaps it has been—that, since most students pass
exams, failure is a case of deviant behaviour, so the student should visit the
counsellor rather than the library!
Nevertheless, there do seem to be desires which are in themselves sick or
deviant to an extreme degree, such as a desire to torture children. But it must be
stressed that being sick is not necessarily the same as being immoral. Some
people seem to have a desire to have a healthy limb amputated. This is
sick/deviant but not morally wrong because it is not harming others, a common
criterion for what is morally wrong. (Whether surgeons should go along with this
desire is another matter.) On the other hand, the desire to have an affair with
your colleague’s spouse may be morally wrong but it is not sick. If we think of at
least one strand of mental illness in terms of sick or deviant desires there will
obviously be a spectrum from harmless eccentricity through to harmful
antisocial behaviour. Moral and legal wrong will kick in at some point in the
spectrum, a point decided by cultural attitudes. The need or not for treatment is a
matter for psychiatric judgement (pp. 52–5).
A complication in this account of deviant desires is that some may be
powerful enough to be classified as compulsions to act in certain ways. Indeed,
those who wish to have a healthy limb amputated often portray this as a
compulsion, to the extent that if a surgeon is unwilling to assist then they suggest
they will put their limb on a railway line. More commonly in this subset of
compulsive deviant desires we find such problems as obsessive neuroses
manifesting themselves in actions which the patient cannot help doing, such as
those of the compulsive arsonist or gambler, or checker that the taps are turned
off.
Compulsion is of course an excusing condition derived from Aristotle and
recognised by the law. Persons will be excused from responsibility if, but only if,
either they did not know what they were doing or, if they did, they were unable
to stop themselves—they were ‘compelled’ to act. Courts of law accept these
‘excusing conditions’ but encounter difficulties when they are faced with the
psychopath. The psychopath both knowingly and willingly carries out his
frightful acts. In other words, the psychopath meets the conditions for moral and
legal responsibility. What is wrong with the psychopath is not that he is mentally
ill because he is compelled by his desires or doesn’t know what he is doing; it is
that what he wants to do is sick or deviant. But since he knows what he is doing
and is not compelled to act, the courts will argue that he can be held responsible
for the evil he carries out. But he (usually a ‘he’) may still need psychiatric
treatment because his desires are ‘sick’. I do not know how successful such
treatment is.
A second strand in the idea of mental illness has come to prominence recently,
and that concerns extremes of mood, such as bipolar disorder or clinical
depression. The clinically depressed person loses all interest in what is going to
happen to him/herself. In other words, the category of clinical depression will
become a case of loss of capacity to decide anything. A severely depressed
person does not have sick or deviant desires, but rather is void of any desires—
nothing matters.
There is tendency in medicine to take over certain words and give them a
meaning which is more specific, or more technical, than they have in ordinary
language. An example of this is ‘consent’, which I discussed in Chapter 4. In the
present context, ‘delusion’ is such a word. In the literature of psychiatry, a
‘delusion’—my third category of mental illness—is necessarily an example of
mental illness. This linguistic takeover must be resisted. In pub gossip we might
easily say of an absent friend, ‘Poor guy, he thinks she still loves him. He is
totally deluded.’ If true this is very unfortunate but it is not mental illness, and it
is very different from the poor guy thinking he is Napoleon. In the category of
‘delusion’, as in my other suggested categories of mental illness, there is a
sliding scale from the wishful thinking or daydreams we all have to what is
indisputably mental illness. There is a separate ethical question as to whether it
is always necessary or kind to shatter someone’s delusions. Perhaps we all need
some as buffers against reality. As the poet T.S. Eliot said: [3]

Human kind
Cannot bear very much reality.

It might be said that what is common to these three strands in mental illness is
that they are states unwanted by the sufferer. But this is not plausible. Many of
those with sick desires, such as the psychopath, are perfectly content with their
states. It is the rest of us who do not want them. And, as I have suggested, some
delusions help us to get through the setbacks of real life. It has been said ‘The
truth will make you free’. Perhaps, but it doesn’t always make you better able to
cope. Indeed, not all physical diseases/illnesses are unwanted by the sufferers.
Someone might want a skin rash if it gets him out of the army or off work and on
to benefits.
I suggest that there are two lines of continuity affecting the categories of
mental illness, at least the categories I have identified as mental illness. One
continues from mental illness through eccentric behaviour to the ordinary swings
in mood which affect us all. No doubt there are also branch lines here. The other
line of continuity raises much harder philosophical and scientific questions
between mental illness and physical illness; these questions concern the mental
or physical causation of mental illness, and answers range from early upbringing
to defective genes. They are interesting and important questions but beyond the
scope of this analysis.
 Nevertheless, two matters are raised by these lines of continuity. First, when is
a worry or a dip in mood a mental illness? As I have already said, startling
claims sometimes appear in the media, that one in five of us at some time
experience mental illness, or two out of five children have mental health
problems. Really? Life can be a rough business and certainly some children are
bullied at school or on the internet, but it may be unhelpful to construe these
setbacks as mental health problems. This kind of labelling may actually be
harmful. The medical ethos is here unhelpful and it has infected public
perceptions. The solutions, if any, to such issues may be social rather than
psychiatric, and my suggestion here is the same as my central thesis—that the
joining up of assorted services, including non-medical ones, may here be the
way forward. The second matter which arises out of my suggested lines of
continuity concerns treatment. Granted a problem of mental illness, how should
it be treated? There is not likely to be a consensus of psychiatric opinion. Some
will favour drugs or other physical interventions (the Hippocratic approach)
whereas others may favour talking cures (the Asklepian approach), or broader
social prescribing.
There are also problems of language and public attitudes. In terms of language
it is clear that names have to keep changing to keep ahead of public prejudice.
Support groups have a right to fight prejudice in whatever way they can, and
suggesting more acceptable names may be one way. For example, Wordsworth
wrote an insightful and moving poem called ‘The Idiot Boy’, but the language of
the title would be frowned upon nowadays. Even milder terms such as ‘mental
handicap’ are not in current use. The preferred term seems to be ‘a person with
learning difficulties’. But this can work to the detriment of some groups or some
within labelled groups. No doubt it is preferable to some to speak of ‘learning
difficulties’ rather than ‘handicap’, but ‘learning difficulties’ diminishes the
problems of those within the group who cannot talk or understand, cannot feed
themselves and are incontinent. Similarly, it is misleading to call everyone with
psychological problems ‘mentally ill’. Hard realities will not go away by a
change of name and a hard reality can actually be created by an inappropriate
labelling. Inappropriate labelling could also have dreadful consequences. I once
heard a psychiatrist say that Van Gogh was clearly mentally ill and that
nowadays he would have been cured by being pumped full of anti-psychotic
drugs! The anti-psychiatry movement clearly has a case.
Public attitudes are a serious problem for the whole area of mental illness. The
public in general believes that mentally ill persons are dangerous. Media
reporting emphasises violence and tends to be sensational. But violence, while it
sometimes happens, is rare. Moreover, the public is encouraged to categorise as
mental illness what might just be a stage in growing up, or a social problem. The
internet with images of a desirable appearance is responsible for some of this,
but so too is the growth of counselling services which are widely seen as
necessary for young people, and all of us, if we are to cope with the many
setbacks of life. When services such as counselling are set up there is strong
encouragement from those employed in them for the rest of us to make use of
them. But when young people make use of them they begin to think of
themselves as mentally ill. Counselling is therefore a practice which can give
rise to scepticism. If young persons have ‘mental illness’ in their records it won’t
help their self-esteem or even their job prospects. What is ‘counselling’?

Emotional Problems and Counselling

Counselling is like ‘caring’ or ‘befriending’—no decent person would want to

attack it. And, indeed, my intention is not exactly to attack it but to cast doubt on
the idea that there can be such a thing as ‘professional skills’ counselling. First it
is necessary to draw a distinction between two kinds of activity which might be
called ‘professional skills’ in counselling, for one is genuine and the other highly
suspect.
The genuine skills are what we might call ‘contextual’. For example, when a
student fails an examination a head of department or adviser of studies will want
to interview the student to enquire if there were special reasons, whether the
course was too hard or otherwise unsuitable, and will give advice on resits or
alternative courses. In many areas of life—genetic testing, adoption or mortgage
defaulting—this kind of counselling takes place. It has a knowledge-base
appropriate to its context and its skills derive from this; it is not transferable to
other contexts, and it may be directive. Of course, it is up to the recipient to
decide whether to take the advice offered, although sometimes there may be no
option.
A subset of contextual counselling is what we might call ‘experience-based’
counselling. This takes place in the many self-help groups which exist at present,
such as cancer support groups, bereaved parent groups, ex-servicemen groups
and the long-established Alcoholics Anonymous. These are groups of ordinary
folks who can help and support each other because they share experiences and
misfortunes. This kind of counselling is successful precisely because it is not
professionalised, and the members of the group have had the experiences in
question.
The more dubious kind of counselling is what we might term ‘free-floating’. [4]

The idea is that there are universally applicable transferable skills which can be
acquired from professional courses and which enable their possessors to have
insights denied to the uninitiated into the human soul and every problem of life.
As professionals, the practitioners must be detached from those they term
‘clients’ and also be non-directive.
The trouble is that no such esoteric skills exist, and the attempt to pretend that
they do represents one of the many facets of the widespread movement to
professionalise ordinary human relationships and experiences. Of course, if
someone has a period of prolonged depression, say after a bereavement, then
he/she may need some sort of help. Most often, however, what is needed is a
friendly chat or a cuddle. I remember taking part in a seminar on helping
bereaved parents at which the paediatric staff admitted that the person best at
helping bereaved parents was the ward maid. Had she attended counselling
courses? Highly unlikely. She was a warm, compassionate human being, no
doubt with kids of her own. Consider the following advice from a consultant in
palliative medicine: [5]

The ability of one person to lend strength to another (not just in medicine, but also in the way a
good leader does, for example when men or women face possible death in some kind of threat or
disaster) is a mystery that nobody entirely understands. But, for my money, in medical situations—
especially advanced cancer—just being natural and friendly has a lot to do with it. Look at the way
some hospital cleaners and porters boost the morale of frightened patients. Do they have special
understanding, spiritual inspiration, or powers of leadership? Not usually. How many
communication and counselling courses have they attended? None. They are just natural and
relaxed, with friendly good humour and no awkwardness or embarrassment…

Or again:
Professional friendship is not quite the same as ordinary friendship, but much that applies still holds
true. A friend is warm and welcoming at each meeting. A friend pays small compliments. A friend
has at least some idea of how the patient feels; some idea of what she has been going through;
understands how her moods may vary… A really supportive friend does not go over the top
emotionally, but is always concerned; doesn’t stay too long; knows when to be silent; doesn’t ask too
many questions. A doctor should follow suit.

To all this it may be objected that not everyone has friends, neighbours or
relatives they can turn to. This is certainly true and it partly explains the
presence in GPs’ surgeries of patients with non-specific pains and worries. GPs
have sometimes been criticised for lacking the skills to deal with such patients,
and they have been pressured into referring them to counsellors. This is unfair
both to GPs and to patients, for there is no such thing as an expertise in human
relationships. The fact that counselling is a growth area is a sign of three things:
that we live in a fractured society which has lost the sense of a shared
community; that for every human ailment there is an expertise to put it right; that
it is always ‘good to talk’.
Having said that, I should modify it a little by repeating what I said above—
that schools at least should have someone available, such as an experienced
teacher, to whom pupils can turn for advice or a friendly chat, but who will not
professionalise the conversation. Rather than a policy of employing professional
counsellors in schools it might be preferable if an experienced and approachable
teacher could be available for pupils who have problems. No doubt there are
some school pupils who have serious mental health problems and who should be
referred for professional help, but I believe the current practice of labelling
problems of growing up as ‘mental illness’ problems is not helpful to young
people.
The Scottish Government is planning to invest many millions of pounds in
employing more counsellors in schools, and no doubt other administrations in
the UK are doing the same. I suggest that this is a mistaken policy. The money
should be spent on improving sports facilities, introducing film and camera
clubs, dancing clubs, drama groups, instrumental teachers, school orchestras,
rock bands, brass bands, choirs, school gardens, talks from role models and so
on. These create cultural and social interests that can last a lifetime, but they can
also be seen as health alliances. Health, and especially mental health, is best
approached by some positive, looking outward, type of activity. If there is a
pervading mental health problem of some young people it is narcissism—too
much concern with how they look or what others think of them. Counselling
may encourage this self-obsession.
My suggestion is not that young people, and the rest of us, should snap out of
it; rather it is that we should snap into other things outside ourselves. This is
where joined-up help is highly necessary. The great tennis player, Sir Andy
Murray, and his (almost as great!) brother, Jamie, were both present at Dunblane
Primary School when Thomas Hamilton murdered 16 children and their teacher
th
on March 13 1996. The Murrays knew Thomas Hamilton, had attended his kids’
club, and had given him lifts in their car. After the murders and his parents’
divorce, Sir Andy said he had a lot of anxiety which he bottled up. But he coped
by throwing himself into tennis. Perhaps that is a better way of coping than
facing one of the many counsellors who descended on Dunblane.
 Conclusions

Psychiatrists have various complex ways of classifying mental illness, and the
causal connections between mental illness and the body is a complex area which
has not yet been satisfactorily explored. I have therefore suggested a way of
classifying mental illnesses which enabled me to highlight a conclusion which
will be further developed in Chapter 11 and 13—namely that many of the
unsatisfactory mental states we all have from time to time may be better
ameliorated by non-medical means. To say this is of course by no means to go
down the Szasz route and deny the reality of mental illness, but it is to point to
the need for non-professional solutions to many of life’s problems. This point of
view requires to be stated in the post-Covid world.
1 Szasz, T. (1961) The Myth of Mental Illness, New York: Secker and Warburg.
2 Rees, J.R. (1947) Mental Health and the Offender, London: Clarke Hall Fellowship, p. 6.
3 Eliot, T.S. (1936) Burnt Norton pt 1, in Four Quartets, London: Faber and Faber.
4 Counselling is discussed in much more detail in Randall, F. and Downie, R.S. (1999) Palliative Care
Ethics, Oxford: Oxford University Press, chapter 10.
5 Brewin, T. (1996) The Friendly Professional, Bognor Regis: Eurocommunica Publications, pp. 74–79.
 Chapter 10
Public Health Medicine and Health Promotion
Bridges to the Community

Public health medicine and health promotion/education are prime examples of

branches of medicine which by their very nature must join up with communities
in order to achieve good health outcomes. And indeed most of the enormous
health benefits of the last centuries have been brought about worldwide by
assorted improvements in public health. Yet public health medicine is the poor
relation of health services in terms of funding and public esteem. There are many
reasons for this, such as the assumption of the medical ethos that medical
practice requires individual consultation; a public dislike of ‘paternalism’ which
appears in popular media as accusations of ‘nanny-state-ism’; the popular appeal
of silver-bullet cures, vaccines and miraculous surgery. How should the contrast
between clinical medicine and public health medicine be drawn?

Clinical Medicine and Public Health Medicine

Clinical medicine is concerned with individuals whereas public health medicine

and health promotion are concerned with populations. To bring this out, I shall
contrast the interventions typical of clinical medicine with those of public health
medicine. It should be noted here that I am using in this discussion the definition
of public health accepted by the UK in the Acheson Report:
Public health is the science and art of preventing disease, prolonging life and promoting health
through organised efforts of society.[1]

Assuming this definition, I can contrast the approach of clinical medicine with
that of public health medicine. The clinician is typically in a one-to-one
relationship with a patient who has requested an interview because of a felt
problem. The clinical imperative is therefore that something must be done
including the giving of advice. Public health specialists, on the other hand, do
not have specific patients with whom they are in a special relationship, and have
received no request from a patient. It could be said that the public health
specialist responds to a collective cry from individuals in a community when
some medical problem occurs which affects a large number of people in a
locality. Examples might be outbreaks of food poisoning or infectious diseases,
or currently the outbreak of a pandemic. But here, again, there is no continuing
relationship between the specialist and the affected group of individuals and
therefore no opportunity for those individuals to express their views on the
public health response. The public health specialist therefore is making a
judgement about what it is in people’s interest to have, whether they have
requested it or not, and dealing with populations, groups or societies rather than
individuals.
The ethical consequences of these features are that public health generates
problems concerned with issues such as paternalism and individual rights, which
are broadly (i.e. non-party) political in their implications. It follows that for any
specific intervention—legislation for clean water, a programme of immunisation,
restriction on smoking in public places or the large-scale lockdown of
populations—the necessary precondition of implementation is that it will
improve the health of the public; and this improvement must be objectively
demonstrable. According to this approach, effectiveness must be established by
scientific means, such that all rational and competent judges can agree on the
facts. The most common technique for establishing effectiveness of this kind is
through the discipline of epidemiology, in which clear and certain conclusions
may not always be obtainable, as has been evident during the Covid-19
pandemic. The importance of having measurable objectives for programme
management and evaluation has been recognised in some official documents.
See, for example, the Report of the Department of Health, The Health of the
Nation.[2]

Justice and Utility

Public health interventions require to be supported by two main ethical

principles: justice and utility. In this section I shall examine a number of contexts
in which these principles create the ethical framework for public health policies.
But I shall first offer a short outline of the principles.
Justice sometimes means observing the rights of individuals and sometimes
that patients are all equally entitled to shares in the distribution of health care.
The latter emphasis is particularly important for public health. Indeed, it is
arguable that justice in the sense of equity raises the most important of the
ethical issues for public health. There are variable levels of health between
countries, and within countries there are marked differences in health which can
be correlated with differences in distribution of resources. [3]

In discussions of justice it is important to distinguish ‘equity’ and ‘equality’.

The distinction can best be described in this context by looking at those factors
which can influence health and health care. It is possible to divide inequalities
into those which are unavoidable, and hence where questions of equity do not
arise, and those which might be avoided and thus raise issues of equity. Let us
look at some examples. In discussing the examples, we must always remember
that what is ‘unavoidable’ at one point is history becomes ‘avoidable’ at another.
Firstly, natural or biological variations such as age, sex, race and genetic
background could be considered as factors which cannot be changed and thus
any inequalities related to them are unavoidable. For example, older men have a
higher incidence of heart disease than younger men, a clear example of an
inequality. But no one would consider this related to inequity, except to the
extent that we have neglected risk factor reduction in the elderly.
Secondly, lifestyle and behaviour, if freely chosen, can result in inequalities in
health. As an example, cigarette smokers have a higher incidence of lung cancer
than non-smokers. This is an inequality, but to the extent that it is created by
choice, it is not inequitable. Indeed, selective uptake of health promotional
initiatives by middle-class groups could even increase inequalities in health but
could not be considered as unfair, unless it could be established that health
promotion is selectively targeted towards these groups.
Thirdly, lifestyle and behaviour, if not freely chosen, and which results in poor
health, is likely to be considered as avoidable by society and thus unfair. A
behaviour chosen through a lack of resources, housing conditions, overcrowding,
dangerous working conditions, exposure to environmental hazards or lack of
adequate public health response would be examples of this. Disabled people
often suffer unfairness (inequity) which compounds their already unequal health.
Fourthly, inadequate access to health care or other public services might be
inequitable if the cause were avoidable. For example, financial considerations
which resulted in a failure to use public transport might be one such factor.
Another might be lack of access to information about services due to learning or
language problems, or the information not being available. This lack, or inequity,
could lead to inequalities of access because of the restriction of choice and
opportunity.
In summary of this discussion of the principle of justice, we can say that those
examples bring out that equity is about fairness and implies that everyone should
have an opportunity to attain his or her full potential for health. Inequalities exist
in health and health care. Some of these are unavoidable, and thus could not be
considered unfair or inequitable. Others are avoidable. It is this latter group, in
which the inequalities are inequitable, to which further attention might be
addressed.
In discussion of public health, the principle of utility must also be stressed—
maximising the benefits for the populations involved. In the old formation it tells
us to seek the greatest happiness of the greatest number. As such the principle of
utility says nothing about how the greatest happiness should be distributed: an
aggregate of utility A might be greater than an aggregate of B, but we might still
give our moral approval to the situation which produces B rather than A, on the
grounds that in B the benefits are more fairly distributed. Thus, there must be a
balance between the ethical principles of justice and of utility.
Some people may argue that prioritising or rationing, while it raises important
policy issues, does not raise ethical issues. The assumption of this position is that
ethics in medicine concerns only the face-to-face situation, a view presupposed
in the ‘four principles’ approach. This view is inadequate. Questions of the
supply and fair distribution of resources are matters of ethics, and, as I have said,
the general ethical principles which are relevant are those of utility and justice.
Ethical problems of prioritising arise in the area of health service provision. The
level of provision of health services is of considerable importance particularly in
relation to the balance between hospital and primary care, the use of resources to
develop effective interventions and the ability to deliver public health measures.
The infrastructural organisation and management are all important.
In recent years in Britain the government has been laying emphasis on
Primary Care as the central plank of the National Health Service with the policy
of a ‘primary care-led health service’. This approach was thought to have clear
advantages for a publicly funded service in that the care provided by general
practitioners was considered to be much cheaper than hospital care. Additionally,
it makes sense to provide as much care for patients locally near their own homes
by doctors whom they know and who know them. But the financial aspects of
this policy clearly depend on the assumption that the remuneration for GPs is
less than that for hospital consultants, and that assumption may not be true. But
at least Primary Care Trusts or Health Boards now have real muscle in
influencing the development and scope of services provided by hospitals. The
idea is that GPs know their patients and know what services they need; therefore,
as the slogan goes, ‘the money follows the patient’.
Funding, however, has been slow to follow this change of emphasis. This has
led to a debate about the allocation of resources between primary and secondary
care. The NHS in Britain works on the basis that each person must come through
their GP to get access to expensive secondary care resources. The assumption is
that GPs are aware of the limited nature of these resources and will refer wisely
and equitably. The government and health service planners recognise the crucial
position of GPs as gatekeepers of NHS resources and have attempted to redress
the balance of power through past and future proposals to improve the status of
general practice within the NHS.
Even if we ignore the details of this policy, financial and otherwise, it is
possible to be sceptical about the whole approach, if that is intended to improve
the health of the whole community. The approach assumes it is by means of the
treatment of individual patients that the health of the nation is to be improved.
But this approach ignores the underlying causes of the main health problems of
the nation. These causes are mainly social—poverty, ignorance, exploitation by
the food industry and so on. I shall pick up on these ideas in Chapter 11–13.
Public health and measures such as those discussed below are likely to have
more impact on the nation’s health than making more GP appointments
available.

Prevention, Avoidance and Protection

There is sometimes confusion between prevention, which is the abolition or

reduction in the incidence of the disease; avoidance, which is keeping clear of
risk factors; and protection, which may limit the spread of disease, say by
vaccination (the current hope in the battle against Covid-19). For example,
public health policy may encourage the prevention of malaria by swamp-clearing
programmes and thus aim at the elimination of the source of the disease; or
travellers may be prevented from catching the disease by avoiding certain
geographical areas; or they may be protected against it by being given tablets.
All these practices are loosely called ‘prevention’. Of course, the categories will
sometimes overlap. For instances, immunisation or vaccination programmes,
which are really protection programmes, may lead to a reduction in the incidence
of a disease, or even to its elimination, as in the case of smallpox. But this
overlap does not always occur. The compulsory wearing of seat-belts is often
regarded as a preventive measure. But it does not prevent accidents; only good
driving and safer roads and vehicles do that. It gives a measure of protection
against accidents.
 It might seem that there is no need to provide any ethical justification for
prevention: it is self-evidently a good thing. While this may be true, the general
public and governments do not always act as if it were so; rather, it seems that
much more money goes in the direction of health care than of prevention.
Moreover, the general public often has an attitude of scepticism towards many
preventive measures, and even more towards what is now called ‘health
promotion’, using terms such as ‘nanny state’. There is a worrying anti-
vaccination campaign on the internet which may affect the uptake of the Covid-
19 vaccinations. Prevention as a general policy therefore requires some
justification.
There is an economic justification, that prevention is usually cheaper than
care; a medical justification, that some diseases are probably not completely
curable so their occurrence should be prevented: and an ethical justification, that
prevention avoids the pain, misery and grief of disease. It is also possible to
include the economic and medical justifications in a wide sense of ‘ethical
justification’. As I shall suggest, however, this general ethical justification of
prevention does not always apply to specific areas of prevention, and even when
it does there are those who argue that the benefits of prevention can be
outweighed in some cases by the ethical costs. Let us look as some examples.
Take the fluoridation of local water supplies. From the 1930s it was noted that
there was a correlation between the levels of fluoride in the drinking water and
levels of dental caries. This suggested a preventive policy of introducing fluoride
where the level was low. There were objections, on the grounds of undesirable
side effects, such as Down’s syndrome and more recently cancer. But a Working
Party in Britain found no evidence for such claims, and other scientific groups
have reached the same conclusion. The ethical objection remains, however, that
adding fluoride to the water supply can count as compulsory medication, and as
such it is a violation of individual rights as laid down in the UN Declaration of
Human Rights. Rights, of course, are not inalienable and can be overridden
when the survival of the public requires it. But it is doubtful if the prevention of
dental caries can count as a justification for ignoring rights. Note that there is
really no solution to this dispute. One position or the other must be overruled.[4]

It is interesting to speculate that, despite the anti-vaccination misinformation,

the current public enthusiasm for a vaccination against Covid-19 may encourage
the uptake of other programmes which are in decline, such as the MMR
programme. At lot may turn on the success of the Covid-19 vaccines.
 The Ingredients of Public Health Medicine/Health Promotion

The Acheson Report definition of public health (quoted above) like the WHO
definition makes it clear that public health medicine must not only prevent
disease but promote health. The literature of the new public health, and
especially health promotion, tends nowadays to have a complex view of the
concept of health and to distinguish various elements within it.
The first of those is often called ‘negative health’, or the absence of ill-health.
Ill-health itself is a complex notion comprising disease, illness, handicap, injury
and other related ideas. These overlapping concepts can be linked if they are
seen on the model of abnormal, unwanted or incapacitating states of a biological
system. I have already discussed some of the problems in the concept of disease
and related ideas in Chapter 8–9, and I shall discuss some of the problems in
what is called ‘positive health’ in Chapter 11. ‘Positive health’ disappears into
other good states such as happiness and therefore requires a joined-up approach
for its implementation.
But there is a third idea which health promoters see in the concept of health—
that of ‘fitness’. Fitness in its most obvious sense refers to the state of someone’s
heart and lungs. To be fit in this sense is to have a place on a scale ranging from
being able to climb stairs or run for a bus without getting out of breath to being
able to run a marathon or climb Mount Everest. Fitness can also be used in a
related but broader sense, which we might call ‘sociological’ as opposed to the
‘heart and lungs’ sense. In the sociological sense of fitness, a person is fit for
some occupation or job. This means that people have the necessary health to
enable them to perform the job or task adequately without, for example, too
many days absent from work.
Can we link the absence of ill-health and the presence of well-being in a
single concept of health in the manner of the WHO definition? This is not a
rarefied question because it affects the legitimate scope of health education. If
well-being is a component in the concept of health, then clearly health education
has a much wider remit than it would otherwise have.
One important factor influencing this question is that ill-health and well-being
cannot be related to each other as opposite poles on a linear scale. This approach
has been tried by some theorists but it is not satisfactory, for it is logically
possible (and not in fact uncommon) for someone to have poor physical health
but a high state of well-being—as in the case of a terminally ill patient in a
hospice or specialist care unit who is supported by caring staff and loving friends
—or a good state of physical health but poor well-being—as in the case of
someone who has no diseases or illnesses but lacks friends, a job, interests.
[5]

The fact that health (the absence of ill-health) and well-being cannot be
related on a linear scale must raise the question of whether they are two
components of a single concept or two related but different concepts. My own
view is that it may be preferable and less confusing conceptually to think of
them as two overlapping concepts rather than as a single concept with two
dimensions. Thus, the feeling of well-being that a person has after an
invigorating swim can be fairly described as a ‘glow of health’, but the well-
being or satisfaction that a person has after listening to a piece of music,
watching a good film or just playing an enjoyable game is less obviously related
to concepts of health, and more obviously related to concepts such as
‘enjoyment’ and ‘happiness’. Again, the well-being that is created by moving
someone to better housing is more obviously related to concepts of ‘welfare’
than to that of health. My conclusion then is that, while the concepts of health,
well-being and welfare overlap, they are distinct and cannot be combined in one
concept. Once again, the need for joined-up approaches is necessary. Public
health medicine/health promotion like clinical medicine must reach out to wider
community agencies for beneficial outcomes.

Imperialism and Commercialism

But whether we think of health as a single multi-faceted concept, or as a

narrower concept which overlaps with related concepts such as well-being and
fitness, there are still two charges sometimes levelled at health promotional
activities—that they are unethical in that they are ‘imperialistic’, and that they
‘commercialise’ health.
Those making the charge of health imperialism might argue that what in
health promotion terms is ‘positive health’ is really just a name for a range of
states which are as easily or better seen in other ways. For example, ‘well-being’
might be said to be just another name for happiness. Again, the idea of ‘fitness’
might be said to be a technical one, relative to specific ends, such as playing in
the Premier League, but not one with an important bearing on health. Mental
illness may satisfy some of the criteria for illness although, as discussed in
Chapter 9, even that has been disputed, but positive mental health might be said
by critics to be a concept which attempts to annex the territory of the well-
adjusted to that of the healthy. For example, mental illnesses, such as depressions
or obsessions, are incapacitating in a manner similar to that of physical illness,
but to stress positive mental health might be seen as simply making a value
judgement in favour of the conventional or the well-balanced as opposed to the
eccentric.
In reply to this sort of objection, it is helpful to introduce the concept of health
alliances. There are certain activities which are indisputably health promotion,
but there are many others with which health promotion can form alliances, such
as walking groups, book clubs, community centres, community choirs, youth
orchestras in deprived areas and so on. If health and health promotion can be
seen in this logically and practically flexible way, then the charge of imperialism
can be avoided. I shall discuss these initiatives in more detail in Chapter 11 and
13.
The second ethical objection to health promotion is that it attempts to bypass
autonomy and to sell health like a commodity. In this it might be said to
resemble the advertisements for unhealthy products which it is opposing. In
reply to this argument, I question the premise that autonomy (as the term is used
in the medical discourse) is something which everyone in fact possesses. People
can be victims of all sorts of social processes and be lacking in power. This is
obvious in the developing world. As such countries become more affluent, so the
consumption of unhealthy products will increase with consequential long-term
adverse health effects.
Another example concerns breast milk substitutes. All health authorities are
clear about the value of breast feeding for the mother and the baby. However,
considerable pressure was brought to bear on mothers in developing countries to
use breast milk substitutes. Not only would this be more expensive, but the
health benefits of breast feeding would be lost. International action was required
to deal with this issue. The WHO resolved that states ensure that there be no free
or subsidised substitute, which would affect breast feeding practice. This may
seem to be merely a political compromise, but it may nevertheless be an
effective way of implanting an ethically defensible position.
In view of the political and commercial power of the anti-health forces in
society, health must be presented in as attractive a way as possible or health
education will fail totally. If health educators confine themselves strictly to the
rational, critical approach to education, then it is preferable to depict health
education as an element within a larger health promotion movement concerned
with health advocacy, legislative change, fiscal reform and the mobilisation of
community interests, as well as education narrowly conceived.
 ‘The Organised Efforts of Society’

The tension between the ethical requirement to be person-respecting in methods

and the practical necessity to be effective is addressed from an interesting point
of view in the literature of self-help groups. The growth of self-care groups
concerned with every conceivable malady and involving both the sufferers and
their relatives has been a notable development during the last decade, as I
discussed previously (p. 132). These movements avoid the charge of paternalism
commonly still made against every branch of health care, including health
education. Apart from ethical considerations, self-care movements seem to be
effective within their limits, although they may benefit from a professional
health educator to advise and facilitate. Advising and facilitating is indeed an
important role for health education. They are part of the communitarian
approach to health that I shall advocate in Chapter 11–13.
Public health medicine, according to the Acheson Report definition, must
obtain its results ‘through the organised efforts of society’. How is this slogan to
be interpreted, and what ethical issues arise from the interpretation? Is it just a
metaphor to speak of ‘society’ bringing about health? One obvious answer to this
question is that to speak of ‘society’ bringing about health is a roundabout way
of referring to our elected political representatives. I shall therefore begin by
looking at the role of the state in health care, concentrating on health legislation.
First, a person’s right to exercise autonomy may be legitimately curtailed by
health legislation when he or she is suffering from certain sorts of infectious
disease or mental illness such that the interests or health of others are liable to be
harmed. There is no difficulty about the acceptance of this restriction in general
terms; the problems arise over the more detailed application. For example, there
was a debate about the nature and extent of the restrictions which should be
placed on sufferers from AIDS, although with more successful treatment this has
largely subsided. Again, it is controversial how far those who are mentally ill
should be detained against their will, or what sort of treatment they should have
if they are detained.
Pressure for legislation is generated as more becomes known about how
diseases are transmitted. For example, the dangers of ‘passive smoking’ are now
appreciated, and other sorts of environmental pollution are now known to cause
or exacerbate diseases such as asthma. There is therefore a case for curbing the
freedom of both individuals and corporate bodies, such as car manufacturers and
other industries, in the name of the autonomy of other individuals. This issue is,
of course, a source of much political debate. Some countries have banned
smoking in many public places, and various ‘watch-dogs’ keep a close eye on
the consequences of the operation of the nuclear power industry. The pollution of
our streets from unhealthy fuels is currently a political issue. Although there can
be political debate about application of the ‘preventing harm to others’ idea, the
general principle is clear and acceptable.
The dangers for the transmission of Covid-19 are widely recognised, and, on
the whole, accepted by the general public. Indeed, in the early stages a total
‘lockdown’ was accepted even though it brought large-scale economic and
personal hardship. But for such massive interference with liberty to be widely
accepted, the general public must be convinced that it is a necessary measure,
and one applied in a fair manner. The governments of the UK were required to
work through the community rather than on it, a repeated message of this
chapter.
These problems become more acute when we consider the international
dimension of health. In a developed country like the United Kingdom,
international aspects have several implications. The first relates to
communicable disease, and with the ease of transport now the possibility of
transmission to different populations becomes ever easier. Movement for
business, leisure or migration of populations is occurring on a scale as never
before. The great plague, cholera and influenza epidemics of the past, and AIDS,
tuberculosis and malaria in the present, show just how vulnerable the world is to
such infections. There have been worldwide worries about avian influenza and
the possible transmutation of the Covid-19 virus into a form even more deadly to
human beings. As a consequence of these worries there have been draconian
limitations on travel. But this is nothing new. The introduction of quarantine in
Italy and France, in the fourteenth century, was one of the earliest attempts to
control infections, and there is still ethical justification for certain sorts of
boundary control for health reasons.
The need for international legislation is apparent also if we consider
environmental issues. These issues are very wide, from the international outcry
against the radioactive release in Chernobyl to worries about carbon emissions
and the pollution of the seas with plastic. Environmental problems regularly
cross international boundaries and require international cooperation for
programmes of ‘sustainable development’.

Legislation for Positive Health

My discussion of public health and health promotion has been concerned mainly
with the negative or preventive side. Has the state any justification for using
fiscal policy for passing legislation to promote positive health or well-being? A
strong argument for maintaining that a government does have a duty to promote
positive health can be found in the preamble to the Constitution of WHO (1946),
which asserts that there is a right to positive health. In ambitious terms it states:
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every
human being without distinction of race, religion, political belief, economic or social condition.[6]

If this is a fundamental right, then presumably there is a correlative duty laid

upon governments to implement it. In other words, acceptance of the WHO
Constitution commits states to health and welfare policies. How far such policies
can be implemented no doubt turns on the wealth of the country, but there can be
no doubt that wealthy western nations are committed to implementing fiscal and
legislative policies to enhance positive health.
To argue that there is a duty on governments to promote health for its own
sake still leaves some questions unanswered. Supposing there is such a duty, can
it be implemented other than at the expense of individual autonomy?
It is easy to slip into the error of regarding all legislation on the model of the
criminal law—as restrictive prohibition backed by sanction. But this is an
oversimplified way of looking at some health legislation. For example,
legislation may require public bodies to make provision for the disabled. This is
more aptly seen as positive creation of new opportunities than as negative
prohibition. There are legal requirements on factory owners to restrict unpleasant
pollutants, and on car manufacturers to ensure certain safety standards. Indeed,
there is an enormous range of health legislation with a positive slant. Whereas
this may diminish the freedom of some groups in society, it certainly extends the
freedom of the majority. A central argument in this chapter is aimed at
countering the widespread view, held by individuals and governments, that
health is a function of individuals. I wish to suggest that it is best seen in
community terms. We are in fact social beings and members one of another and
therefore require a health service joined up with wider community agencies to
meet the wide variety of our needs.
If we think of ourselves as social beings, then health legislation is not
removing our individual autonomy but rather enhancing it. In improving the
general quality of life, legislation can add to our autonomy. This is obviously the
case if we consider the example of provision for the disabled, but it is true also
of anti-pollution legislation and many other types of health legislation.
 So far in this section I have been concerned with the role of the state and
health legislation. But there is much more to the ‘organised efforts of society’
than legislation. Let us state the five principles which the WHO sees as the basis
of health promotion:[7]

1. Health promotion involves the population as a whole in the context of their

everyday life, rather than focusing on people at risk for specific diseases.
2. Health promotion is directed towards action on the causes or determinants
of health.
3. Health promotion combines diverse but complementary methods or
approaches, including communication, education, legislation, fiscal
measures, organisational change, community development and spontaneous
local activities against health hazards.
4. Health promotion aims particularly at effective and concrete public
participation.
5. While health promotion is basically an activity in the health and social
fields, and not a medical service, health professionals—particularly in
primary health care—have an important role in nurturing and enabling
promotion.

How are we to interpret phrases such as ‘concrete public participation’? What is

the ethical importance of this approach?
One way of making sense of this idea is to think of society not in terms of
individuals who make it up, but in terms of the institutions, practices, customs,
political arrangements and social class relationships which give structure to the
society. From this point of view, people are related to each other by the
structures of their society, and indeed part of their identity is created by these
social structures. We could then evaluate a society in terms of the way in which
its social structures tend to produce health in the people who belong to that
society. Just as we sometimes praise the ‘atmosphere’ in a school or hospital as
one of well-being, so the social structures of an entire society might be said to
make for or detract from health or well-being. I develop this idea in my
exposition of the philosophy of communitarianism in Chapter 12–13.
Some theorists with firm attachments to individualism might prefer to
understand what I have said as referring to health determinants rather than health
itself. For example, they might agree that a society with marked social class
gradients and corresponding gradients in the distribution of ill-health is one with
a tendency to create ill-health in individuals. Thus, in terms of this approach, if
we speak of an ‘unhealthy society’ we are simply speaking metaphorically about
the determinants, such as poor housing and diet and so on, that have helped to
produce poor health states in individuals. Other thinkers might be prepared to
extend language and to maintain that it is not a metaphor to characterise social
relationships and structures as being themselves unhealthy. It is perhaps self-
indulgent to pursue this theoretical question here, but it is certainly one way of
making sense of the phrase ‘the organised efforts of society’, in the Acheson
Report, or ‘effective and concrete public participation’, as the WHO principle
puts it.

Conclusions

It is often assumed that ethical problems in medicine are the prerogative of

clinical practice, and that the problems of health medicine are those of public
policy and legislation. But I have tried to bring out that the policies advocated by
public health medicine do indeed raise ethical issues of a basic kind involving
principles of justice, utility and individual rights. Moreover, these familiar
ethical concepts must be supplemented by some which are less familiar. If the
collective goods which are promoted by public health medicine are to be
achieved, the methods must involve the development of community identity and
awareness. In other words, public health medicine, to be effective in an ethically
acceptable manner, must seek health alliances with other community
movements, and some of these are helpfully arts-based movements. These
movements will contribute to an improved quality of life for communities in a
post-pandemic world.
1 Acheson Report (1988) Public Health in England: Report of the Committee of Inquiry into the Future
Development of the Public Health Function, London: HMSO.
2 Department of Health (1992) Health of the Nation: A Strategy for England, London: HMSO.
3 Calman, K.C. and Downie, R.S. (1997) Ethical principles and ethical issues in public health, in Oxford
Textbook of Public Health Part 1, Oxford: Oxford University Press.
4 Report of the Working Party on Fluoridation of the Water and Cancer: A Review of the Evidence (1985)
London: HMSO.
5 I am indebted here and throughout this chapter to: Downie, R.S., Tannahill, A. and Tannahill, C. (1996)
Health Promotion: Models and Values, Oxford: Oxford University Press.
6 WHO (1946) Constitution, New York: World Health Organisation.
7 WHO (1984) Health Promotion: A Discussion Document on the Concept and Principles, Copenhagen:
WHO.
 Part 4.
A New Philosophy:
Post-Pandemic Medicine and
Community Involvement
 Chapter 11
Social Prescribing, Positive Health and

the Role of the Arts

Terminology

In the preceding chapters I have indicated how the solidarity of the medical
profession, its ethos, has affected important aspects of medical treatment, the
doctor–patient relationship and medical professionalism. In particular, I have
drawn attention to the ways in which the ethos can create a resistance to
suggestions which do not come from medicine itself. But there are various new
movements in the air, such as ‘social prescribing’, which might enlarge the
evidence-base of medicine. Social prescribing can be effective, and sometimes
more effective than pills, for at least some types of ill-health. The arts and
humanities have a contribution to make here.
In the area of doctor–patient interaction also the humanities can offer
alternative approaches. They can cast doubt on the idea that there are special
‘skills’ of human interaction which social science can teach. There is no such
thing as an ‘expertise’ in human relationships, as I have argued. Indeed, even in
spheres where there is expertise, such as taking blood pressure or estimating
cholesterol levels, the question may often arise as to what action to take in the
light of the results. And that question cannot be answered purely by science. It
requires a consideration of the results in the context of a given patient’s
circumstances and views. Education for an all-things-considered humane
judgement requires a broadly educated doctor. It is therefore worthwhile to
consider what the arts and humanities can offer both the evidence-base of
medicine and medical education. This is to take up again one of the themes of
Chapter 3.
In view of the various ways in which the arts and humanities can have a
bearing on medical practice and education, it may be helpful to begin by making
a few distinctions. The ‘medical humanities’ movement relates mainly to
medical education. In the long past medical education had a basis or at least a
starting-off point in the humanities. For example, a knowledge of Latin was
often required for entrance to medical school. Indeed, in Scotland it was
common for entrants to medical school to have a general arts degree. But from
the 1950s the sciences became the preferred route to medical school entrance.
The stranglehold of science was a little loosened in 1993 when the General
Medical Council liberalised the medical school curriculum to allow what were
then called ‘Special Study Modules’—five weeks of intensive study of whatever
a medical school could offer. There was strong encouragement for arts and
[1]

humanities modules to be included. And, indeed, some medical schools offer the
opportunity for medical students to study for an intercalated degree in medical
humanities. Despite this, anecdotal evidence suggests that medical humanities
modules are not encouraged by deans, and in some medical schools medical
students maintain, rightly or wrongly, that they are more likely to get good
hospital placements if they have a solid medical science-based curriculum.
Moreover, good science results are usually required for entrance to medical
school, although some medical schools may admit mature students with broad
experience. In the next section I shall examine in more detail what the arts and
humanities can offer in medical education, despite the negative views of some
medical deans.
A second common employment of the arts in medicine is concerned not with
medical education but with ‘treatments’, although some enthusiasts would not be
happy with the word ‘treatments’, perhaps fearing that the word ‘treatment’
medicalises what they are trying to do. But certainly those in the various
movements concerned with using the arts are all in different ways attempting to
improve or enhance health by non-medical means.
The broadest of the non-medical approaches to health improvement is what is
loosely called ‘social prescribing’, although once again some supporters of the
movement would be unhappy with the traditional medical associations of the
word ‘prescribing’. Nevertheless, even if the source of the prescription is the
doctor, usually the GP, what is prescribed is not what would traditionally be
considered ‘medical’. Social prescriptions might vary from joining a community
choir or a walking group or community gardening to learning to dance or trying
creative writing or painting and drawing, or being referred to someone who
could advise on debt. In other words, the prescription is issued in a traditional
way by the GP but what is prescribed is not what would traditionally be
considered ‘medicine’. With a helpful expression Dr Helen Stokes-Lampard
makes the point by saying that the GP ‘orchestrates’ the social prescription
according to the needs of the patient and the available local resources.
[2]

Having said that a GP can be the issuing source of a social prescription, it

must also be stressed that there are other arts and health movements which are
not dependent on GP prescriptions for their activities. One such is ‘arts therapy’.
Arts therapists of one or another kind must be registered with the Health and
Care Professions Council and are accredited forms of therapy using the arts as
the vehicles of their therapy. They have their own codes of ethics and must
belong to the relevant professional bodies, such as: British Association of Art
Therapists; British Association of Drama Therapists; British Association of
Music Therapy. The arts therapy movement long pre-dates ‘social prescribing’,
and several institutions of higher education offer degree courses in assorted
therapies. Professionals registered by the Health and Care Professions Council
can initiate therapies without going through a GP. It is therefore a second and
distinct movement concerned with ‘treatment’ in a broad sense.
A third movement is known as ‘arts and health’. It differs from the arts
therapy movement in that the practitioners in ‘arts and health’ are not trained as
‘therapists’ but rather wish to retain their identity as visual artists, musicians or
creative writers. They wish to work alongside patients with the aim of improving
or enhancing health and well-being, perhaps especially but not exclusively
mental health and well-being. The movement received a boost with the
publication in July 2007 of an All-Party Parliamentary Group Inquiry on Arts,
Health and Well-being. It was entitled ‘Creative Health: The Arts for Health
[3]

and Wellbeing’, and received collaboration from King’s College, London, Guy’s
and St Thomas’ Charity and the Royal Society for Public Health. The National
Alliance for Arts, Health and Wellbeing provided the Secretariat and project
managed the inquiry. The funding of the groups involved the Paul Hamlyn
Foundation, Wellcome and the Arts and Humanities Research Council. Support
from these assorted groups meant that this was a centrally important report.
Among its 10 positive conclusions it recommended that the NHS and the Social
Prescribing Network should incorporate arts on prescription into their
commissioning plans, that the education of clinicians and public health
specialists should include modules at undergraduate and postgraduate level on
the contributions the arts can make to health and well-being. In other words, it
recommended a widening of the evidence-base of medicine. It further
recommended that Research Councils should fund research into the efficacy of
the arts for health and well-being, and that bodies such as the National Institute
for Clinical Excellence should examine the evidence for the efficacy of the arts
in the provision of health care.

Social Prescribing and Conventional Treatments

What can social prescribing, including the use of the arts and humanities, offer
by way of treatments which might be supplements or substitutes for more
conventional treatments? The answer is that they can have an impact on health at
various stages. I shall suggest that they can have a useful role at every level of
medical treatment: primary care, including its concerns for prevention or health
promotion; secondary care; and in long-term recovery programmes. Moreover,
although their beneficial effects on mental health are the ones most discussed, I
shall argue that for certain problems of physical ill-health they can also play a
part. I noted above that the arts therapy and the arts in health movements can be
involved independently of GP ‘orchestration’, to use Dr Helen Stokes-Lampard
useful term, but I shall begin by discussing social prescribing, which may
include but is wider than arts-based ‘therapies’.
A GP has often to interview and ‘prescribe’ for patients who are up against the
many problems created by our fractured society. These are problems such as
loneliness created by social isolation, or depression or boredom masquerading as
a medical problem, or anxieties caused by debt or obesity. It is an urgent
question how far the typical medical school provides training or education to
help with such problems. But as far as present concerns go it seems to me that
these are cases for social prescribing. Indeed, in cases such as those mentioned
above, pills might make matters worse. What is necessary for such cases is that
the GP should have the broad judgement (see pp. 52–5) to recognise cases of that
kind, and also to be aware of the many community services which might be of
assistance. This is where medicine must be joined up to other local organisations
which might be anything from walking groups, classes advising on diet, advisers
on debt or community gardening or singing.
Having noted some of the contributions to health made by the various arts and
community groups, I must sound a note of pessimism. In earlier chapters I
emphasised the need for equity in the distribution of wealth. Unfortunately, in
the UK there is a huge gap between rich and poor, and deprived areas often have
multiple problems of drugs, unemployment, debt and violence. No amount of
social prescribing can solve the problems thrown up by a broken society. As I
write, it has emerged that once again the Nordic countries, such as Finland, have
a very high level of satisfaction with life. They also have a very narrow gap
between rich and poor.
Many readers may have sympathy with the view that GPs are in a position to
make use of social prescribing because they meet such a wide variety of
problems. But what role can social prescribing or the arts and humanities have
on secondary care? Can they set bones or remove a kidney stone? No, but they
can make a contribution to other physical conditions. According to the WHO
about 64 million people worldwide suffer from chronic obstructive pulmonary
disease (COPD). There seems to be evidence that this problem can be eased by
singing. Plausible claims are also made that dancing can assist the 145,000
[4]

people in the UK suffering from Parkinson’s disease. According to a report in

The Guardian newspaper:
English National Ballet has been running a Parkinson’s programme for 10 years and has hubs in
Ipswich, Oxford, Cardiff, Liverpool and London. Initial research with Dr Sara Houston from the
University of Roehampton showed a series of 12 weekly dance classes improved balance and
stability. And a new study led by Dr Judith Bek at Manchester University’s ‘Body, Eyes and
Movement Laboratories’ suggests dance classes can help people with Parkinson’s to tackle everyday
domestic tasks more effectively.[5]

Social Prescribing for Mental Health

An encouraging report on this was published by NHS Scotland entitled: Social

Prescribing for Mental Health: Guidance Paper. The report is directed at GPs
and is concerned specifically with mental health. It states the position of the
Royal College of General Practitioners Scotland as follows:
The RCGP Scotland supports social prescribing, defined as a range of approaches to linking people
to non-medical sources of support. This aims to identify the 30–40% of GP consultation time where
the patient could benefit from involvement in services and community groups to complement their
medical treatment. The signposting of the possibly wide range of opportunities and interventions to
suit the person’s needs wold include, for example, debt or relationship counselling, alcohol and/or
drug interventions, and social and self-help groups.[6]

At a further point the paper recognises that social prescribing has been used with
a number of different ‘client groups’ and draws on a wide range of community
services. The paper mentions a wide range of services such as ‘arts and cultural
activities, green space, debt advice, physical activity and leisure, bibliotherapy,
learning, volunteering, housing advice, benefits, employment and legal advice’.
In other words, social prescribing can be used as a possible remedy for many of
the problems of life, problems which can indeed have an impact on health,
especially mental health. Of course, social prescribing requires that a GP be
aware of these services and has both the judgement to know when it might be
appropriate to ‘prescribe’ them and the knowledge of what is available locally.
This kind of judgement and knowledge is not usually part of medical education.
There are now many models and schemes of social prescribing. One of the
oldest is the Bromley by Bow Centre in London. The scheme uses link workers
who help patients to access a wide variety of local sources of support. Support
may include anything from legal advice to swimming. But there are now many
such schemes in the UK.

Arts Therapies and Arts in Health

It must also be remembered that, while social prescribing can include GP

prescriptions for some sort of involvement in the arts, the arts therapy and arts in
health movements exist independently and are not dependent for their existence
on being prescribed. In the Report of the All-Party Parliamentary Group on Arts,
Health and Wellbeing Inquiry social prescribing is not considered—the inquiry
concentrates specifically on what the arts can contribute to health and well-
being. The inquiry quotes and discusses many examples of the benefit of the
[7]

arts for a variety of health and human problems. For example, it discusses how
dancing or playing a musical instrument can boost brain function and help to
delay the onset of dementia. It refers to a testimony from a woman whose
husband had been diagnosed with terminal cancer. She explained to the Director
of Grampian Hospitals Arts Trust how the terminal diagnosis had taken away her
sense of self, purpose and role in life:
Yet in the midst of this suffering lies the Artroom. An oasis of positivity and fulfilment providing a
different purpose… It is a place where the self is rediscovered and allowed to flourish.

Or Dr Jane Povey GP, Director of Creative Inspiration, Shropshire, writes:

At least one third of GP appointments are, in part, due to isolation. Through community resilience
programmes creative arts can have a significant role in enabling wellbeing in communities.

There are very many similar testimonies to the effectiveness of social prescribing
the therapeutic value of the arts, but the medical ethos requires more rigorous
evaluation. I shall discuss evaluation in a later section.
[8]

Positive Health

I began my attempt to acquire a critical understanding of the aims of medicine

by looking at what the WHO regards as ‘negative health’—the absence of
disease, illness or disability—but if we turn to what they regard as ‘positive
health’ there is even more room for a joined-up service. Images of disease,
illness, mental illness, bereavement and death are common in literature, but
images of health are more difficult to find. The reason is that health does not
have a clear identity of its own. The experiences of disease and illness are
intense and have a certain duration. Thus, they can become objects of attention
in their own right and easily generate a rich variety of images. Being healthy, on
the other hand, might just be a way of saying that we are not ill or diseased. If
so, the lack of literature on health is not surprising, because there is nothing to
write about. Medical practice seems to support this view of health, in that when
treatment restores us to health it is really just removing disease or illness. Even if
we say that positive health involves some biological balance or equilibrium, we
still do not have a concept that is likely to be a focus for a writer’s attention. For
when we are in this state of bodily equilibrium—when we are healthy—we do
not notice our health but concentrate on other matters. Health is, as it were,
transparent, whereas illness and disease are opaque—our attention is fixed on
our disease or illness. Health easily escapes the attention of writers because it
lacks the identity of illness or disease. For what has come to be known as
‘positive health’ is a concept in perpetual disguise. It is conceptually impossible
to distinguish positive health from other states such as well-being, happiness,
exhilaration, fitness or vigour. In other words, we shall not find many images of
positive health unless we look for them under other descriptions or in other
guises. But these other guises tell us a great deal about health, just as we can
learn a great deal about someone by noting the clothes they wear. It is therefore
on some of the many guises of health that I shall concentrate, and also on the
conceptual company that health keeps, such as beauty and youth. [9]

In whatever guise it appears, health is regarded as a value, for it frequently

appears in lists alongside other values, as in phrases such as ‘healthy, wealthy
and wise’. The following anonymous verse about the four-leaf clover is typical:
One leaf for fame, one for wealth
One for a faithful lover,
And one leaf to bring glorious health,
Are all in a four-leaf clover.

The health that is thought to be valuable or worth having, however varied its
images, is usually more than the absence of disease or infirmity; it involves
being well in a positive way. But there is a huge variation of opinion about what
this ‘being well’ consists of. The only thing that seems to be agreed upon by
writers is that there is no single state that is ‘being well’.
For example, the quiet life of honest toil is much promoted in literature as the
life of true health and well-being. Oliver Goldsmith (1730–1774) writes in The
Deserted Village:
 A time there was, ere England’s grief began,
When even rood of ground maintained its man;
For him light labour spread her wholesome store,
Just gave what life required, but gave no more;
His best companions, innocence and health;
And his best riches, ignorance of wealth.[10]

More typically, images of health are presented in terms of youth and vigour and
beauty—as can be seen in advertisements for patent medicines.
There seems to be widespread agreement from the time of Plato to the present
that diet and exercise (rather than health care or doctors) are the determinants of
health. John Dryden (1631–1700) is another example of this tradition: [11]

Better to hunt in fields, for health unbought.

Than fee the doctor for a nauseous draught.
The wise, for cure, on exercise depend;
God never made his work, for man to mend.

But literature has its health cynics, such as James Thurber (1984–1961):
Early to rise and early to bed makes a male healthy and wealthy and dead.[12]

The same emphasis on the variable nature of states of health can be found in the
nineteenth-century writer/philosopher Nietzsche: [13]

For there is no health as such, and all attempts to define anything that way have been miserable
failures. Even the determination of what health means for your body depends on your goal, your
horizon, your energies, your drives, your errors, and above all on the ideals and phantasms of your
soul. Thus there are innumerable healths of the body and… the more we put aside the dogma of the
‘equality of men’, the more must the concept of a normal health, along with a normal diet and the
normal course of an illness, be abandoned by our physicians. Only then would the time have come
to reflect on the health and sicknesses of the soul, and to find the peculiar virtue of each man in the
health of his soul: in one person’s case this health could, of course, look like the opposite of health
in another person.

Maimonides (1135–1204) is another philosopher who distinguishes between

physical and mental health, and goes on to tell us what mental health consists of.
For example, he writes of the two perfections of man: [14]

Man has two perfections: a first perfection, which is the perfection of the body, and an ultimate
perfection, which is the perfection of the soul. The first perfection consists in being healthy and in
the very best bodily state. His ultimate perfection is to become rational in actuality.

But not everyone agrees that the well-being of the mind or soul consists of the
exercise of rationality. George Herbert (1593–1633) sees it as virtue: [15]

Only a sweet and virtuous soul,

Like seasoned timber never gives;
But though the whole world turn to coal,
Then chiefly lives.
Others see mental health (and indeed physical health) as a balance of elements:
‘Whatever dies was not mixed equally.’ John Donne (1572–1631) is here
[16]

writing of love, but he is using an idea of health that goes back to the Greeks.
Indeed, the notion of mental health as expressed through a ‘balanced personality’
is still current in psychiatry. But others again see mental health as an extreme.
For example, William Blake (1757–1827) in ‘The Marriage of Heaven and Hell’
represents some aspects of this point of view: [17]

Energy is Eternal Delight.

Or:
The road of excess leads to the palace of wisdom.

In the case of Richard Wagner (1813–1883), his ‘normal’ state is one of

‘exultation’, as a letter to August Roeckel dated 26 January 1854, shows:
In order to become a radically healthy human being, I went two years ago to a Hydropathic
establishment; I was prepared to give up Art and everything if I could once more become a child of
Nature. But, my good friends, I was obliged to laugh at my own naiveté when I found myself almost
going mad… When I think of the pain and discomfort which are now my chronic condition I cannot
but feel that my nerves are completely shattered: but marvellous to relate, on occasion, and under a
happy stimulus, these nerves do wonders for me; a clearness of insight comes to me, and I
experience a receptive and creative activity such as I have never known before. After this, can I say
that my nerves are shattered? Certainly not. But I must admit that the normal condition of my
temperament—as it has been developed through circumstances—is a state of exultation, whereas
calm and repose is its abnormal condition. The fact is, it is only when I am ‘beside myself’ that I
become my real self, and feel well and happy.[18]

It is noteworthy that there is also a tradition that sees our mortal life as highly
unsatisfactory. Bodily health, which sustains that life, is correspondingly
described paradoxically as a kind of sickness. Shakespeare’s disillusioned Timon
of Athens is a good example: [19]

My long sickness / Of health and living now begins to mend, / And nothing brings me all things.

Again, when Socrates (469–399 BC) drinks the hemlock, which is his
punishment for speaking the truth, Plato (428–348 BC) reports in the Phaedo
that Socrates asks for a sacrifice to be made to Asklepios. The point here is that
he wishes to give thanks to the demigod of health for his recovery from the long
sickness of life.
This brief survey shows that the imagery of health is richer than at first it
seems. It has emerged that health is a multi-faceted concept and cannot be
pinned down in a single definition; any attempt to do so will lead to a distortion
of human values, a matter of considerable ethical significance for it involves
forcing one ideal of the good life on us. Outside exact sciences, definitions such
as attempted definitions of health can have ethical implications because they can
suggest particular ways of perceiving patients and treatment policies, and these
in turn lead to ways of spending health resources. But definitions cannot settle
ethical issues and, in the guise of neutrality or objectivity, definitions often
conceal ethical positions which have no more claim on us than other positions.
That is especially true of mental health. The image of a young person glowing
with positive physical health after a swim is attractive, but the idea of someone
glowing with positive mental health is repulsive! I shall develop this point when
I discuss independence and individuality if mind (pp. 171–3). The general point
which emerges is that positive health is multi-faceted and if it is to be enhanced
—and enhancing it will have a bearing on ill-health—then many agencies must
be involved; medicine and especially general practice and psychiatry must join
with wider cultural bodies.

Evaluation

The NHS Scotland paper on social prescribing for mental health, already
discussed, touches on the topic of evaluation. The paper notes that there is a
strong theoretical basis for social prescribing, on the grounds that ‘connecting
people with appropriate local sources of support can potentially lead to
improvements in levels of mental wellbeing, greater sense of control, heightened
ability to cope with life, increased confidence, improved wellbeing, increased
purpose in life, heightened personal aspirations, increased personal drive etc.’
Yes, that indeed sounds a ‘strong theoretical basis’, but does it work in practice?
The paper claims that ‘there is promising evidence that social prescribing can be
effective’ in some of the ways mentioned above, but admits that the existence of
a ‘range of different approaches and limited good quality evaluations makes it
difficult to draw firmer conclusions at present’ (p. 7). A conclusion of that
generally positive kind is typical of many similar reports of both social
prescribing and of the use of the arts in a health context. But it certainly does not
satisfy those looking for a more rigorous evaluation.
A more typical medical examination of the effectiveness of social prescribing
can be found in a paper with the discouraging title: ‘Social Prescribing: Less
Rhetoric and More Reality. A Systematic Review of the Evidence’. The review
[20]

of the evidence for social prescribing involved accessing nine databases in the
UK from 2000–2016 for relevant studies. The data sources included the
Cochrane Database of Systematic Reviews and the NHS Economic Evaluation
Database. The authors reported that the quality of the evidence was poor. The
randomisation process was misunderstood in two of the studies considered, and
the studies did not meet a key inclusion criterion of Cochrane. In the discussion
it is noted that: ‘Most of the evaluations of social prescribing activity are small
scale and limited by poor design and reporting. Missing information has made it
difficult to assess who received what, for what duration, with what effect and at
what cost.’ It concluded: ‘Social prescribing is being widely advocated and
implemented but current evidence fails to provided sufficient detail to judge
either success or value for money. If social prescribing is to realise its potential,
future evaluations must be comparative by design and consider when, by whom,
for whom, how well and at what cost.’ While the study does not establish that
social prescribing is ineffective, it does stress the need for more rigorous testing
to enable social prescribing to reach its potential.
This evaluation of social prescribing follows the rigorous method typical of
the evaluation of new drugs. In other words, it is in accord with the medical
ethos, with an emphasis on the importance of ‘measurement’. For example, it
states that ‘Primary outcomes of interest were any measures of health and well-
being and/or usage of health services’. But, whereas it is no doubt possible to
count ‘usage of health services’, it is not at all clear how health and well-being
are to be ‘measured’.
Moreover, the paper touches on many different aspects of social prescribing.
For example, the paper states that social prescribing ‘is being widely promoted
and adopted as means of dealing with some of the pressures on general practice’,
or ‘as a way of making general practice more sustainable’. Perhaps it is, but
these can surely not be the most important reasons for promoting social
prescribing. As the authors suggest, it must above all lead to some improvement
in mental or physical health, as a primary outcome measure. Again, the authors
recommend that future evaluations ‘must be comparative by design’. I think they
underestimate the difficulty of this. For example, suppose a patient presents to a
GP with depression or similar mental health symptoms. After a few questions it
emerges that the patient has money problems, and his/her ‘prescription’ is to be
put in touch with Citizens Advice or some local organisation which can help
with debt. The patient’s state of mind improves. What is that to be compared
with? Putting the patient on anti-depression pills? And ignoring the long-term
consequences of the pills for addiction?
Or a GP judges that a patient who frequently turns up with vague symptoms is
just lonely and puts him/her in touch with some community or befriending
group. What is the relevant comparator? There are many different possible social
prescriptions and it is not easy to see how the usual Cochrane-type evaluations
will work.
And that brings out the difficulty in the evaluation of social prescribing. To
approach the problem of evaluation in this context with the scientific mind-set
which is typical of the medical ethos is to miss what is important about social
prescribing. Someone who acquires new friends, new interests, new skills, is
going to feel a lot better about his/her life but it is not easy to see how that can
be captured in ‘measures of health and well-being’. How do you evaluate
prescribing visits to dieticians for patients who are obese, visits to financial
advisers for those in debt or joining in a community project for those who are
lonely? Who are the comparators? How would randomisation work? There was a
spoof article in (I think) the BMJ some years ago. In the article it was pointed
out that there is a widespread belief that if you have to jump out of an aeroplane
you are more likely to survive if you have a parachute. But the evidence for this
belief is anecdotal. No randomised tests have been carried out!
The general point is that it is not at all clear how you can set about evaluating
common sense. In defence of orthodoxy it must of course be stressed that
doctors are rightly anxious to protect patients from ‘quacks’. Hence, there is
need for an evaluation of non-orthodox treatments, if they are to be allowed into
the evidence-base. Perhaps it is important to stress here that the relevant word is
‘evaluation’ rather than ‘measurement’, and not all evaluation need involve
randomisation or comparators.
I was once confronted by a medical dean who demanded to know how I would
‘measure’ the benefit to medical students of reading novels or viewing certain
plays. I replied that I would try to answer that question if he told me how he
would measure the benefit to medical students of studying anatomy. He replied
with incredulity that it was just common sense, that the the benefit was obvious.
Yes, I said, but you used the word ‘measure’. My general point is that someone
who asks how to ‘measure’ the benefit of the arts not only does not understand
the arts but does not understand measurement. Evaluation is not the same as
measurement. Aristotle comments that it is a mark of the educated person to look
for exactitude no more than the nature of the subject permits.
Nevertheless, some points can be made, even though they will not satisfy
enthusiasts for the Cochrane database. Will social prescribing relieve pressure on
GPs? Presumably the patient must first visit a GP before such a prescription can
be issued, although if the social prescription is successful there will be fewer
repeat visits to the GP. Will social prescribing save money? Since social
prescribing takes many forms it is not easy to be sure on this, but since the
prescription will often be to contact voluntary organisations it is likely that
overall it will be. More importantly, from a patient’s point of view how
satisfactory is social prescribing likely to be? What are called ‘measures’ of
health and well-being are pretty crude instruments, reflecting the medical
obsession with numerical measurement. But some points can be made. First, the
social prescription—say, to join a gardening group—might lead to a feeling of
individual achievement and the development of skills. Nowadays, person-
centred health care works to put the individual and their experience at the centre
of care. In other words, the contemporary emphasis is away from the stress on
symptomatic similarities and towards individualised differences. But standard
‘Cochrane-type’ evaluation stresses systematising, the search for outcome
patterns or case histories. But this kind of ‘bolt-on’ may be quite inappropriate.
More generally, the arts have a far-reaching potential to enhance the quality of
people’s lives and to contribute towards maintaining or regaining health and
well-being. That was the conclusion of ‘The Kingfisher Project’—a writing in
health and social care project set up in Salisbury in 1999–2002—with Dr Fiona
Sampson as the leader of the project. The participants included patients on a
spinal injuries unit, Salisbury Hospice, a secure psychiatric unit, an acute
orthopaedic ward, a stroke unit, a surgery and group of day-centre attendees. In
other words, the participants represented patients with a wide range of health
problems. There seems to have been a positive response to this writing project. [21]

The participants reported the following benefits:

increased self-esteem and confidence;

a sense of achievement;
entertainment and reduced boredom, providing an ‘escape from the ward’;
humanising influence: ‘people treated as people, not just as patients’;
stimulated memories (stroke patients) and mental activity generally;
a developing sense of companionship on the wards—opening participants
up both to each other (helping develop friendships) and, significantly, to
staff, sometimes resulting in a clearer understanding of patients’ symptoms
and experience of life on the ward;
bringing like-minded people together and developing a sense of solidarity.
The above are just a few illustrations of many arts and health initiatives which
are working successfully around the country and, in general terms, some of the
benefits. There are many more arts in health initiatives around the UK as can be
illustrated by a search of the internet. They should be adopted into mainstream
medicine and the medical evidence base. Medical and nursing education requires
to be more receptive to fresh initiatives in the new post-pandemic era.

Educating for Social Prescribing

Medical and nurse educators are of course aware of the importance of what is
variously called personal and professional development, or continuing medical
education. Broadly speaking, we might say that the reason for this emphasis in
medical education at all levels is an awareness on the part of medical
educationists that doctors and nurses must not only be up-to-date with the latest
scientific information, but must also be able to think for themselves, or to have
minds of their own, to enable them to translate the many and conflicting claims
of evidence-based medicine and government initiatives into humane treatment
for individual patients.
Yet there is an important ambiguity in the idea of having a mind of one’s own
which can distort programmes of personal and professional development, and
health care education more generally. The ambiguity can be brought out if we
distinguish two different ideas which might be implied by having a mind of your
own: independence of mind and individuality of mind. Independence of mind is
shown in the kind of support or justification which a person might offer for a
belief. In more detail, independent-minded persons can exhibit three qualities.
Firstly, their beliefs, medical or otherwise, are based on evidence or argument.
This sweeping statement must of course be qualified and developed. Different
types of evidence are needed in difference sorts of situation, and sometimes, if
the matter is very technical, we ourselves may not be able to state the evidence,
and may need to rely on the word of experts. But even here we may be able to
assess whether the person really is an expert in that field, or whether the
‘evidence’ is really just ideology or pharmaceutical hard-selling.
Secondly, independent-mindedness requires an ability to understand what we
claim to have in our minds. For example, suppose someone is told that the
structure of the DNA molecule consists of a double-helix. How does that person
make this statement his/her own? The claim would need to be understood in
several different senses. Thus the person would need to understand some
concepts of biochemistry and of mathematics and how they might be linked, and
also the wider context and significance of the claim. Understanding here is
something we can have more or less of, and to the extent that we have it we are
more or less independent-minded.
Thirdly, we are independent-minded if we are critical of the evidence or
argument for a belief. For example, we may come to hold that the evidence for a
proposed treatment is insufficient, or of the wrong kind, or that the side effects or
the cost of the treatment have not been mentioned. Critical appraisal of
appropriate evidence is indeed one of the characteristics common to any
academic discipline, and typically goes on at lunchtime meetings in hospitals
and postgraduate centres.
From the above brief account of what it means to be independent-minded it
will be clear that in the context of health care the person of independent mind
has the excellent characteristics which belong to what I have called the
Hippocratic approach. Let us turn now to individuality of mind.
Individuality of mind concerns differences in the content of people’s beliefs,
rather than in the rational basis or evidence for their beliefs. It concerns their
imaginations, their intuitive abilities and their sensitivity. The beliefs of an
independent mind purport to be well-founded, whereas those of a mind with
individuality purport to be distinctive, unusual, original, challenging,
idiosyncratic, imaginative, intuitive or sensitive. Individuality can be shown in
many ways: for example, it may be shown in an unusual direction of interest.
The person with the individual mind may know about unusual or less commonly
known things, and this can be shown as much in the sciences or medicine as in
the arts. Again, individuality of mind can be shown in a great depth of
knowledge in some areas. This kind of specialised knowledge is often dismissed
by saying ‘He knows more and more about less and less’. But a highly
specialised direction of knowledge and skills is desirable in medicine and other
areas. As a gesture towards allowing individuality of mind to develop, the
medical curriculum in the UK now allows Special Study Modules (SSMs) in
which students can follow their interests in science, medicine or the humanities
through short periods of in-depth study which may lie in unusual directions of
interest.
A third aspect of individuality of mind can be shown in a variety of ways.
Perhaps it is best expressed by the term already introduced (p. 25), ‘lateral
thinking’. The main point made by de Bono is that we tend to see the world,
[22]

including the areas of it which constitute our professional lives, in terms of

certain patterns or groupings. But these are only some of the many possible
patterns or groupings. The person with a disposition to lateral thinking is the
person who can break away from the familiar patterns and suggest new ways of
looking at things, or non-routine ways of behaving. Intellectually, lateral
thinking may emerge as a sceptical disposition towards received opinion and
ways of doing things. Lateral thinking is required to break through the defences
of the medical ethos.
What are the connections between independence of mind and individuality of
mind, and personal and professional development or continuing medical
education? The classic text which guides us here is J.S. Mill’s essay, On Liberty.
I have already quoted from Chapter 3 of this essay, in which Mill tells us that
[23]

the end of man is the highest and most harmonious development of his powers to
a complete and consistent whole. These powers are developed by pursuing ends
which are rich and complex and therefore suitable for bringing out the
potentialities within us. In more detail, Mill argues that we all have what he calls
a distinctive human endowment, which can be developed. The qualities which he
thinks make up this endowment are: the human faculties of perception,
judgement, discriminative feeling, mental activity and even moral preference
which are exercised only in making a choice. It might be said that these qualities
are distinctive of what can be called the generic human self. These qualities, Mill
holds, can be developed, and it is incumbent on us as human beings to develop
them. It is my claim that developing this endowment and developing
independence of mind are one and the same, and are one essential component in
personal and professional development.
Individuality of mind by contrast is concerned with the development of at
least some of those qualities and interests which are peculiar to a given person.
However, the development of those idiosyncratic qualities will make use of the
generic features of the human endowment, the features on Mill’s list, but will
turn them in a direction unique to a given individual person. Mill argues for this
in a second and complementary strand in his thinking. When the second strand is
uppermost, he stresses the importance of the conscious choice of objectives
which express authentically one’s own uniqueness as a person. According to this
strand in his thought, it is important to be oneself as opposed to conforming to
custom. A custom may be a good one, he says, but ‘to conform to custom merely
as custom does not educate or develop [in a person] any of the qualities which
are the distinctive endowment of a human being’.
Independence of mind and individuality of mind will both find their ultimate
justification in self-development (or personal and professional development), but
in different ways: independence of mind leads to the development of our
distinctively human endowment, the generic aspects of the self, whereas
individuality of mind leads to the development of our personal uniqueness, our
individuality, the idiosyncratic aspects of the self. These two aspects of
development are necessary and sufficient for total self-development. One aspect
can be seen as the Hippocratic side to health professionals, and the other the
Asklepian side.
Now it is reasonably clear in general how independence of mind can be
developed in the health care professions. The process will be one of reading
journals, attending courses on the latest treatments and the basic science behind
them, and above all learning to exercise one’s critical abilities. This is the
Hippocratic side to medical education.
The development of individuality of mind represents the Asklepian side to
medical education and it is much harder to achieve. But, if social prescribing is
to be a successful component of medical education, the development of
individuality of mind must be encouraged. It will develop the flexibility and
imaginative insights which can lead to prescribing for patients which is
appropriate for their unique situation. But in many ways individuality is
discouraged, and certainly what I have termed the ethos, the climate in which
health care professionals operate, is not friendly to individuality of mind.
Consider, for instance, the sameness of presentations with their overhead
slides and powerpoint presentations. Indeed, it is amusing to an outsider that at a
time when medical educationalists are emphasising the importance of
communication and listening skills, the professionals themselves seem unable to
give or follow a talk without constant visual aids! The result is a dreary
sameness. The teachers of any subject we remember are the ones with the
individual or even the eccentric approach; they enrich our imagination as well as
developing our knowledge. Anecdotes and enthusiasms are more memorable
than bullet points, just as watching, talking and listening to a patient are more
therapeutic than harassment with assessment scales!
The Asklepian side to patient care is important and must be re-stated and
cherished in health care. The British Medical Journal contains very affectionate
‘Portraits from Memory’. The portraits celebrate the enthusiasm, the
compassion, the eccentricity of physicians and teachers from the past. But I have
not read any which celebrate the use of ‘powerpoint’ or the making of eye
contact! The need for the fresh initiatives which come from a mind with
individuality is particularly important in the post-Covid world. Individuality of
mind is necessary for both patient care and medical research.

Conclusions

In this chapter I began by distinguishing a number of overlapping terms, which

refer to different movements within health care and medical education. The term
‘social prescribing’ has come to be used, especially in the context of general
practice, for the suggestions a GP might make for the benefit of a patient but
which are not at all traditionally ‘medical’. GPs are faced with all the problems
of society, but such problems may present as ‘medical’ or ‘mental health’
problems. GPs must have the skills and judgement to diagnose the underlying
causes which may be anything from loneliness to debt. And they must have the
local knowledge to refer the patient to the appropriate community agencies.
Some of these may involve arts organisations. But the arts can have a role in
enhancing health and well-being independently of a social prescription. GPs, and
other doctors, must be educated to be aware of the wider possibilities offered by
the arts and other community-based and non-medical remedies. Standard
medical prescriptions will often be the appropriate ones to offer a patient, but the
doctor with individuality of mind will be able to judge when a different kind of
prescription is required.
1 General Medical Council (1993) London: General Medical Council.
2 kingsfund.org.uk/audio/video/helen-stokes-lampard-social-prescribing.
3 https://www.culturehealthandwellbeing.org.uk/appg-inquiry/
Publications/Creative_Health_The_Short_Report.pdf
4 Clift S. (2011) Singing, wellbeing and health, in MacDonald, R., Kreutz, G. and Mitchell, L. (eds.) Music,
Health and Wellbeing, Oxford: Oxford University Press.
5 https://theguardian.com/society/2018/nov/05parkinsons-disease-and-dance-it keeps-me-alive.
6 NHS Scotland (2016) Social Prescribing for Mental Health: Guidance Paper, Edinburgh: NHS Scotland.
7 https://www.artshealthandwellbeing.org.uk.
8 See for example: http://artshealthandwellbeing.org.uk/what-is-arts-in-health.
9 Downie, R. and Macnaughton, R.J. (1998) Images of health, The Lancet, 351, pp. 823–25.
10 Goldsmith, O. (1869) The Deserted Village, Masson, J. (ed.), London: Macmillan.
11 Dryden, J. (1700) Epistle to my honoured kinsman John Driden 1. 164, in Kinsley (ed.) (1956) Collected
Works, Oxford: Oxford University Press.
12 Thurber, J. (1939) The shrike and the chipmunks, The New Yorker, 29 April.
13 Nietzsche, F. (1967) The Joyful Science, New York: Vintage Books.
14 Maimonides (1963) in Pines, S. (trans.), Chicago, IL: Chicago University Press, p. 82.
15 Herbert, G. (1972) Virtue, in Gardner, H. (ed.) The Oxford Book of English Verse, Oxford: Oxford
University Press, p. 257.
16 Donne, J. (1970) The good morrow, in Allison, A., et al. (eds.) The Norton Anthology of Poetry, 3rd ed.,
New York and London: Norton.
17 Blake, W. (1951) The marriage of heaven and hell, in de Selincourt (ed.) Selected Poems of William
Blake, Oxford: The World’s Classics.
18 Wagner, R. (1965) The Musicians’ World: Letters of the Great Composers, Gal, H. (ed.), London:
Thames and Hudson, p. 290.
19 Shakespeare, W., Timon of Athens, Act V, Sc. 1.
20 https://bmjopen.com/content/7/4/e013384.
21 Sampson, F. (2004) A case study: The Kingfisher Project, Creative Writing in Health and Social Care,
London: Jessica Kingsley Publishers.
22 De Bono, E. (1990) Lateral Thinking, Harmondsworth: Penguin Books.
23 Mill, J.S., op. cit., chapter 3.
 Chapter 12
Communitarianism
A Post-Pandemic
Philosophical Foundation

Aims of Medicine

Currently, the usual aim of medicine has been subsumed under the heading of
‘improving health’ or improving ‘quality of life’. No one could argue against
these as slogans—indeed I shall adopt an enlarged conception of quality of life
as an optimum aim for medicine—but there are two problems with the aim as it
is currently being implemented. Firstly, the implementation has been
overwhelmingly in terms of what we might call (without intending to sneer) the
pills and surgery tradition of medical treatment. It is true that what is called
‘alternative’ medicine has been given some grudging acceptance, but the root
problem is that many of the ills of life, such as obesity, depressions or self-
harming, have been medicalised and therefore medical or ‘professional’
solutions have been suggested, such as surgery for obesity or pills for
depression. There may, however, be other more effective approaches to them.
For example, as I have argued, group singing can have beneficial effects on
sufferers from depression. My point here is that ‘medical’ research should be
broadened to look at ways of improving lives without the use of pills or
‘counselling’. These ways are to be found in community activities, such as those
which can be recommended by means of social prescribing.
The second problem with the current implementation of the aim of improving
health or quality of life is that it has been given a narrow individualistic
interpretation. Public money, government rhetoric and public attitudes have
mainly been directed at the never-ending increase of spending on clinical
medicine. But the ‘improvement of health’ on a population basis will not come
about by this route, and the expenditure will swallow up the entire budget. Is
there a solution? Well, ‘solution’ is an over-optimistic word. But it may be that
some of the problems in the current aims of medicine could at least be mitigated
if the emphasis were to be moved from clinical medicine to public health
medicine, and more especially to a more equitable, joined-up, community and
environmental approach. In the next section I shall place these points in a new
philosophical framework. This framework is a logical extension of that of the
original NHS, and can be contrasted with the liberal, individual consumerist
framework in which health policy in the UK is currently struggling.

Communitarianism: An Outline

The framework of my argument, or its foundational theory, is communitarianism

—the view that communities rather than individuals or the state should be at the
centre of our value system and, as I shall add, that the idea of ‘community’
should be extended to include the natural world. Unlike theories such as
utilitarianism or liberalism, communitarianism does not have a clearly defined
identity, but it does have some key themes. There are two main strands in the
theory: a stress on equity in the distribution of resources (a stress which is
present also in other political theories) and a stress on the essentially social
identity of individuals and communities. As a way into communitarianism I shall
revisit the principles of utility and equity, which I have touched on in other
contexts in the book (e.g. in Chapter 3 and 10).
An important principle which ought to guide but not wholly determine public
policy is utility, or the maximising of benefit for the majority of a population.
This general principle turns into specific economic tools such as cost/benefit
analysis or quality-adjusted life years and is presented to the public as ‘value for
money’. But it is obvious that this ought not to be the only guiding principle. For
example, suppose a doctor is faced with a patient who might benefit from an
expensive drug. In terms of maximising benefit to the community at large it
might be better to ignore the needs of patients with that kind of condition and
spend the resources on those whose need is less severe but who might benefit
more. But this policy seems wrong in that it ignores the rights of individuals to
equal consideration. No one ought to be regarded simply as expendable for the
sake of the good of others.
This notion of ‘equal consideration’, however, needs more examination. In
some contexts, the demand for equal consideration is simply a demand for
consistency of treatment between one person and another. In other words, it is a
demand that people be treated in accordance with a rule which can be
formulated. But the demand for consistency seems to clash with the more
personalised side to casework in the NHS; general rules conflict with the
uniqueness of individual situations. On the other hand, patients are keen to
demand consistency and criticise anything which smacks of a ‘post code lottery’.
Consistency seems to be a necessary condition for the distribution of medical or
social benefits to patient groups if such distribution is to be seen as fair. But
consistency is certainly not sufficient for fairness. After all, a principle such as
‘Never spend time with anyone who is disabled or alcoholic’ could be applied
consistently. To get nearer the moral principle of equal consideration we need
some way of deciding on justified differences in treatment.
The principle usually invoked here is that of equity. Equity is not the same as
equality, since it requires not only that like cases should be treated equally but
also that unlike cases should be treated unequally. Equity presupposes a criterion
for justifiable differences in the way people are treated. In the context of illness
or disease this criterion will be need (although in other contexts criteria such as
merit, or ability to benefit, might be relevant).
But this analysis highlights the problem of what is to be meant by the term
‘need’, a term which is easy to pass over since it is so familiar in this kind of
discussion. A ‘need’ arises from a desire or an aim to reach a certain goal; that
which is needed is instrumental for attaining the goal. But what is the goal in
health care? Some economists propose a very wide goal, and define need as a
‘capacity to benefit’. According to this definition, people ‘need’ from health
[1]

and social services anything that might benefit their health and well-being. But
that would include good housing, lack of deprivation, rewarding employment
and so on. Patient groups might well say, ‘Yes, that is what we do need!’ But
there is the problem of resources and their allocation not only for health groups,
but also for other areas requiring spending from the public purse, such as
education, defence and the arts. It is therefore arguable that ‘capacity to benefit’
is too broad a definition of need.
The American ethicists Beauchamp and Childress suggest a narrower
definition of ‘need’ as ‘that without which one will be fundamentally harmed’. [2]

This provides a minimum level for the relief of needs. But it must be
remembered that the US takes a much narrower view of what the state should
provide by way of health and welfare benefits than would be acceptable in the
UK.
In view of the problems in providing a precise definition of ‘need’ it might be
preferable for those in health care to drop the idea of a ‘needs assessment’ and
concentrate on specific goals: the alleviation of pain and discomfort, the
restoration or maintenance of function and the prolongation of life of a human
quality. But even with specific goals, controversy will remain. In the context of
[3]
scarce resources, we shall probably never be free of disputes about both
government policies and ‘post code lotteries’. The implication of all this is that
there is really no escape from some form of rationing, whatever politicians may
say, or whatever is their preferred term—‘prioritising’ or the like—or preferred
method of rationing.
But, however imperfect these attempts at prioritising may be, they have the
merit that they attempt to incorporate some conception of equity in the
distribution of a public good such as health care. On the other hand, in the pure
form of a free market consumerist system of health care, equity and utility do not
feature at all. Treatment alternatives are the choice and responsibility of the
individual patient; the principles of utility and equity are simply not relevant
because health care is a choice for the consumer rather than a public good.
Basically, you would get what you paid for. There would of course be legal
principles covering such matters as safety and redress over negligence. But it
would be up to patients—who are now health care consumers—to compare
insurance companies and work out the package which best and least expensively
implements their choices, and up to insurance companies to work out which
packages are likely to be the most profitable for them. The principles of utility
and equity are totally irrelevant to this kind of system, but are essential for the
working of a publicly-funded system of health care. No doubt a case can be
made for each sort of system, but the attempt to combine systems with
incompatible logical structures will lead to confusion in policy and public
perception. I discussed this issue in Chapter 6. But, as far as communitarianism
is concerned, equity and utility are basic principles.
The second and distinctive strand in communitarianism is its emphasis on the
social nature of life. Whereas liberals stress that individuals are the originators of
all value, communitarians see value as rooted in communal practices. As a
theory it is influenced by certain strands in Marxism but would disassociate itself
from historical determinism or centralised state socialism. Normative theories in
moral philosophy can be distinguished as strongly normative which prescribe
how we ought to live and weakly normative which simply describe norms. There
are elements of both in communitarianism.
The theory makes a strongly normative claim—that social life will be better
if, for example, health care and welfare are seen collectively and delivered as
public rather than individual goods. But communitarianism also makes
descriptive or indeed metaphysical claims—for example that its description of
the self as embodied and embedded in historical and cultural values is more
accurate than the abstract, atomistic liberal view of an a-temporal self. Whereas
the top value of liberalism is individual autonomy, and the vocabulary of its
moral discourse is based on individual rights, the communitarian would stress
values such as trust, solidarity, mutuality and friendship, concepts which by their
nature require others to participate.
Communitarianism in the post-pandemic world would also stress that an
enlightened sense of community would see humans as one element in the wider
community of nature. In the view of a communitarian, the liberal idea that
human beings are uniquely the objects of respect in nature and can legitimately
dominate it must be enlarged: we are part of the much wider community of all
living things. My argument is that if this very general philosophical idea can
permeate and direct medical research and treatment in the post-pandemic world
it will lead to a more sustainable concept of human health.
The communitarian would certainly condemn values imposed top-down, as in
late Marxism, but would also argue that a society based on the consumerist
values of individual autonomy will in the end become bankrupt—literally so as
is happening with the NHS and its individualistic view of health care. By way of
contrast, the communitarian will argue that the cultivation of the values of
intersubjectivity will lead to political practices which will realise viable public
goods, and they would argue that goods such as health care and welfare are
public goods.
The tradition of liberal individualism can be traced back to the Enlightenment
and one interpretation of Kant. Its contemporary defenders include utilitarians
and rights theorists such as John Rawls and Ronald Dworkin. The tradition of
[4] [5]

communitarianism, on the other hand, can be traced back to Aristotle. There is

also a version of it in Adam Smith’s The Theory of Moral Sentiments in which
the role of ‘sympathy’ is urged as the creator of intersubjectivity in communities.
[6]

Another eighteenth-century writer who contributed to the development of

communitarianism was Edmund Burke (1729–1797). Burke believed that
[7]

society depends on what he calls ‘prejudice’, that is, on instinctive feelings of

love and loyalty. He rejected the central place which revolutionary thinkers had
given to reason and the idea of natural rights. Basically, he seems to be arguing
that communities are held together not by enlightened self-interest but by the
feeling that we are members one of another; communal feeling is everything and
reason insignificant.
A more recent writer on communitarianism is Alasdair MacIntyre. He writes
in opposition to the radically individualistic view of the self that is its own
source of valuation (so-called ‘autonomy’ again) because it has ‘no necessary
social content and no necessary social identity’, but only ‘a certain abstract and
ghostly character’. MacIntyre is arguing for the cultivation of the social virtues,
[8]

which require a form of human community with its traditions and collective
memories. It is the community which is necessary to complete the life of the
individual.
This type of view has found acceptance among at least some feminist writers.
They argue that individualism puts a premium on autonomous self-reliant
individuals who exercise power to protect themselves from competitors in the
pursuit of self-interest. Societies with such assumptions have dominant males
with subordinate females. In contrast, some feminists are exploring the nature of
communities which stress caring, reconciling and relationships of
interdependence. For example, Carol Gilligan argues that men evaluate moral
thinking with hard and fast rules impartially imposed. An example relevant to
my concerns in this book is the ‘four principles’ approach in medical ethics, the
idea that doctors must aways respect the patient’s autonomy, or do what the
patient wants. She wants to replace the abstract, impersonal principles approach
to morality with one in which ‘values of care and connection, salient in women’s
thinking, imply a view of the self and the other as interdependent and of
relationships as networks created and sustained by attention and response’. [9]

Gesellschaft und Gemeinschaft

Another approach to the issue I am attempting to identify by the contrast

between individual liberalism and communitarianism was given one kind of
treatment in a distinction introduced by the German sociologist F. Tönnies. His
[10]

distinction was between a Gesellschaft and a Gemeinschaft, and it can be

explained if we translate the distinction as one between an organisation or an
association, such as a business or other commercial or official enterprise, and a
community, such as may be found in a country district which has traditional ties
with the soil. In a commercial association the individuals involved have nothing
in common apart from their interest in a specific commercial aim. If that aim is
achieved there is nothing holding the group together, other perhaps than their
hope of another similar commercial aim. A community, in contrast, is held
together by many bonds such as a common language or dialect and a common
religion, which are likely to be deep and complex.
But the original distinction by Tönnies is perhaps simplistic. Any
organisation, however commercially orientated, is always liable to become more
than a mere association of persons for a specific objective. Additional interests—
say, involving sports and recreational activities—are likely to constitute the
growing points for a Gemeinschaft. Traditional industries, such as coal-mining,
steel-making, ship- building or agriculture, provided a focus for complete ways
of life which dominated the basic attitudes of sections of the population. And the
disruption of this, such as in coal mining or steel-making, can produce a deep
distress which is not adequately explained simply in terms of loss of earnings.
There are two strands to the communitarian movement, an academic and
practical. The academic strand has been developed by philosophers such as
Michael Sandel or Charles Taylor. They argue that the self is embedded in a
[11] [12]

culture and that contemporary liberalism cannot account for the complex social
relations that all individuals in the modern world are part of. They reject the idea
of universal moral values, especially individual autonomy. In particular they
argue against the influential liberal theorist John Rawls. His well-known ‘veil
[13]

of ignorance’ cannot be used as the basis of a theory of justice, they claim,

because the idea of an abstract individual choosing in a veil of ignorance does
not make sense, even in principle.
The leader of the more practical side to communitarianism is Amitai Etzioni. [14]

His main thesis is that, while autonomy and rights are values, they cannot take
precedence over the common good. This practical approach stresses informal
social controls rather than state coercion or market pressures. Its practical
influence extended even to President Obama. His book The Audacity of Hope
argued for the notion of a common good and for community-building rather than
identity politics.
The breakdown of a sense of community can be deleterious to the
personalities of the people involved. They become ‘alienated’ from the societies
to which they nominally belong. Marx sees the alienation of the worker from
his/her work as the inevitable consequence of the capitalist form of economy.
Now we need not in this context consider whether he is correct in his claim that
alienation is the inevitable consequence of the capitalist form of economy, but I
can make use of his concept of alienation to identify at least one aspect of the
real need people feel to be emotionally involved in their community and its
social structures.
It is in this context that it is helpful to introduce the concept of a ‘culture’, a
term favoured by communitarians. The term is often simplified to refer just to
the arts and humanities. A culture in the proper sense—that of the anthropologist
—is a way of life in which the total activities of a society, including the arts, the
sciences, health care, technology and care for the natural environment and other
species, are integrated and create for the participants a life of emotional
significance as well as rational organisation. It is the aspect of the integrated life
that I wish to stress in this brief exposition of the moral philosophy of
communitarianism. [15]

There are many objections to communitarianism from the individualistic

perspective of liberalism. For example, critics might argue that communities are
authoritarian and suppress dissent. Behind this criticism there lurks an old-
fashioned view of communities, such as traditional villages geographically cut-
off with a limited range of values. But in the contemporary world people are
members of many communities and have many sources of attachment, but there
can still be an underlying set of core values.
It should be noted that the communitarian will stress informal social controls
rather than top-down state-imposed controls. There are many convincing
empirical examples of this. For example, the wearing of seat-belts and the
decline of smoking are examples which suggest that communal controls work
better than coercion by the state. It is certainly the case that monolithic
communities can result in conformism, but in the modern multicultural world
communities are varied, overlap and interact. It is of course true that an
expensive public good such as health care requires some central state control to
ensure standards and this requires some degree of societal unity. But my
argument is that the successful delivery of health care must involve working
with these varied communities and using their many resources rather than
imposing top-down approaches.

Health as a Community Good

What implications does communitarianism have for the concept of health,

especially if its stress on social justice is noted? It might be argued that health is
just a brute fact about individuals. Certainly, our health is causally affected by
our genetic inheritance, and that is a brute fact about which little can be done (at
the moment). But our individual health is also affected by health care, and health
care is certainly affected by social justice. For example, if the health of a given
population compares poorly with that of a wider population, there is a prima
facie case for investigating the adequacy of the health care provided.
But health is also and predominantly affected by health determinants, such as
the standard of housing, environmental pollution, employment and similar
factors, and these are matters of social justice, which a communitarian approach
might help to improve. Moreover, the connection between health care and health
determinants is not sharp. Thus, it is by no means clear whether such matters as
the provision of community centres for the elderly members of the community,
facilities for those who are disabled and rehabilitation centres for addiction
problems are health care or health determinants. And what of nursery facilities,
meals-on-wheels and similar? There is therefore a clear causal link between
health and both health care and health determinants. But I wish to argue,
controversially, that the link between health and health determinants is also
conceptual; health is not just a property of individuals but also of social
relationships and social structures. This claim requires some expansion.
I have argued that persons are essentially social; it is our nature to be citizens.
Our positive health is therefore continuous with the quality of our social
relationships. This is implicit in the WHO definition of health (p. 111). But
‘social relationships’ and ‘social structures’ are simply alternative terms for what
are normally regarded as health determinants—housing, employment, leisure,
green spaces and cultural facilities. In other words, the distinction between
health and health determinants is by no means clear-cut, and we can think of
health as being experienced through social relationships. Indeed, we speak quite
naturally when we say that the atmosphere in a school or a community is one of
well-being. Perhaps this point is most dramatically made in the example of a
well-run and humanely administered hospice. We can say that well-being
pervades its atmosphere—it enables its inmates to live until they die—regardless
of the fact that its inmates, from the point of view of negative health, are
terminally ill. In such an institution the social relationships and social structures
can properly be said to express well-being.
I have not denied that health can be seen as a property of individual persons—
our genetic inheritance ensures that that is the case—but my argument has been
that health is also a social concept and as such it is affected by social justice. The
NHS at the moment is largely targeted at individuals, at the kind of ill-health that
can be cured or ameliorated by operations and pills, and the social dimension of
health is very much the poor relation. It is true that public health medicine exerts
some influence, as does health promotion/education, but by far and away the
greater emphasis is on the treatment of individual persons by doctors.
Cultural and environmental activities are not thought to have any bearing on
health at all and are the first to be cut by governments or local authorities. But it
is by participation in such activities that we come to experience well-being; they
give meaning to our lives and the perception of meaning is basic to the
experience of positive health (p. 222). I doubt very much if Beethoven would be
best pleased to have his music described as a health determinant! But it is the
case that being enabled to appreciate his music, for example, or being able to
live in a green environment with good houses and attractive public parks, are
among the factors which make human life worthwhile and give it meaning.
To depict health in this way, to stress it has a social aspect, implies a change of
emphasis in funding, indeed a change in social attitudes. At the moment funding
is overwhelmingly for the individualised NHS. The NHS at its inception in 1947
represented a fair shot at introducing a measure of communitarianism, but it was
not enthusiastically received by doctors and it has not been backed-up by similar
measures. Moreover, such as it is, its values are slowly being eroded by neo-
liberal policies, such as the introduction of consumerism into patient choice (see
Chapter 6). I have stressed that this is not a textbook of political or social
philosophy, although my arguments have been underpinned by a philosophical
position. But my hope is that even this very brief account of communitarianism
may at least suggest that there are other ways of delivering health care than
through the present individualistic, autonomy-consumerist-based NHS.
The NHS is a religion substitute for voters, and the political fear is that the
failure to continue injecting large amounts of cash into it will be seen as a kind
of political blasphemy. But only structural change will solve the problems
inherent in our health care system. Limits must be set on what the NHS should
provide and much more should be spent on greening the environment and other
community-based agencies. There are often complaints about the bureaucracy of
Brussels, but it is surpassed by the top-heavy, overpaid and sometimes bullying
bureaucracy of the NHS. The ethos of current management with its stress on
competition and top-down values is quite alien to the communitarian spirit
present at the inception of the service.

Conclusions

In this conclusion I shall try to pull together the disparate strands of

communitarianism to provide at least some schematic clarity. The theory is
asserting that we have a social nature and that that nature requires communities
for its realisation. An appropriate moral structure for communities is one in
which values such as trust, befriending, caring, etc. are more dominant than
abstract general principles. In terms of wider values, a community should offer
facilities of many kinds, such as good housing, nurseries, a green and attractive
environment, sports facilities, libraries, drama groups, opportunities for children
to learn musical instruments, churches, schools without league tables and
hospitals without targets. These and many other features and facilities are what
constitute the identity of sustainable community life, and a community life
enables the fulfilment of the life of individuals. To describe in this way the
identity of a sustainable community is also to describe health determinants, and
to make the case for saying that health is a community good.
In claiming that health should be seen as a community good I am asserting
three theses: a conceptual thesis—that health cannot be separated from other
concepts with community roots, such as welfare, or well-being or (to anticipate
my next chapter) quality of life; a causal thesis—that flourishing communities
will lead to the decrease of many of the health problems of contemporary life;
and a financial thesis—that too much of the health budget goes to funding
treatments for the immediate health problems of individuals and not nearly
enough to removing the underlying causes of these problems in dysfunctional
communities.
The three theses could be expressed in a slightly different way. Either some
problems, mainly but not exclusively lifestyle problems such as depression or
obesity, should no longer be seen as medical problems, or the evidence-base of
medicine should be considerably enlarged to include community-based
treatments such as choral singing, group walking, creative writing and many
similar. The welfare state was founded, as it were, to orchestrate the help which
members of communities can give to each other, but it has now become detached
from communities and has become a monster which is eating up our entire GDP.
To say that all the NHS needs is more money is simplistic; it needs radical
change in its emphases. I am sceptical of this happening because the public has
been conditioned to believe in a traditional medical way of treating every human
ill, and governments will not win votes by challenging this approach. But I hope
it has been worthwhile to state the outline of another approach, an approach for a
post-pandemic world.
Whereas doctors, policy-makers and many patients may not be familiar with,
or sympathetic towards, the moral philosophy of communitarianism, they will all
be familiar with a concept widely used in health care and familiar in other
contexts in everyday life—that of ‘quality of life’. Indeed, many doctors, aware
of the limitations of medicine to bring about ‘cures’, would see the underlying
aim of medical practice as more modestly that of improving quality of life. I
shall develop this approach and enlarge it with some of the broader approaches
to quality of life which are to be found outside medicine. This will enable me to
avoid two distortions of ‘quality of life’: a narrow individualistic understanding
of it, and the typical Hippocratic desire to measure it in a pseudo-scientific scale.
My hope is that my enlarged concept of quality of life will enable me to express
in a very different and non-philosophical way the moral philosophy of
communitarianism.
1 Edgar, A., Salek, S., Shickle, D., et al. (1998) The Ethical Q.A.L.Y., Haslemere: Euromed
Communications, p. 4.
2 Beauchamp, T. and Childress, J. (1994) Principles of Biomedical Ethics, 4th ed., Oxford: Oxford
University Press, p. 330.
3 Randall, F. and Downie, R.S. (2006) The Philosophy of Palliative Care, Oxford: Oxford University Press.
4 Rawls, R.J. (1971) A Theory of Justice, Oxford: Oxford University Press.
5 Dworkin, R. (1985) A Matter of Principle, Cambridge, MA: Cambridge University Press.
6 Smith, A. (1976) The Theory of Moral Sentiments, Oxford: Oxford University Press.
7 Burke, E. (1790/1968) Reflections on the Revolution in France, Harmondsworth: Penguin Book.
8 MacIntyre, A. (1981) After Virtue: A Study in Moral Theory, Notre Dame, IN: Notre Dame Press, pp. 30–
31.
9 Gilligan, C. (1986) Remapping the moral domain: New images of the self in relationships, in Heller, C.,
Sonsa, M. and Wellbery, D.E. (eds.) Reconstructing Individualism, Stanford, CA: Stanford University Press,
pp. 240–42.
10 Tönnies, F. (1887) Gemeinschaft und Gesellschaft, Loomis, C.P. (trans.) (1956) Community and
Association, New York: Dover.
11 Sandel, M. (1998) Liberalism and the Limits of Justice, 2nd ed., Cambridge: Cambridge University
Press.
12 Taylor, C. (1989) Sources of the Self, Cambridge, MA: Cambridge University Press.
13 Rawls, J. (1971) A Theory of Justice, Oxford: Oxford University Press.
14 Etzioni, A. (2001) The Monochrome Society, Princeton: NJ: Princeton University Press.
15 Anyone interested in examining communitarianism in more detail might like to look at: Mulhall, S. and
Swift, A. (eds.) (1996) Liberals and Communitarians, Oxford: Oxford University Press.
 Chapter 13
Quality of Life
A Reinterpretation
For A New Age

Quality of Life as Currently Used in Medicine

The term ‘quality of life’, despite the frequency of its current use in both
ordinary conversation and medical papers, has appeared comparatively recently.
In Medline, a medical index, there were no entries at all under ‘quality of life’
for the period 1961–65. But in the four-year period 1996–2000 there were an
astonishing 12,749, and there must be many more by now. Moreover, the term is
also used in many other contexts. For example, newspapers from time to time
rate cities or even countries according to the quality of life they offer. This wider
use, not recognised in medical papers, is nonetheless important for broadening
the aims of medicine and improving health, while minimising the health budget.
I shall first note briefly some of the contexts in which the concept is used in
medicine, and the confused way in which it is used.
The idea of ‘quality of life’ has occasioned a great deal of theoretical literature
in medical journals. But it is always used in an individualistic, ‘health-related’
way. This fatally limits the concept, but the limitation enables doctors to
‘measure’ it on a scale 1–10. Indeed, it is unlikely that it would have been
allowed into the Hippocratic medical vocabulary unless it could be depicted as
something ‘measurable’.
A typical example can be found in a study ‘to determine the association
between symptoms and depression in patients with advanced cancer’ carried out
by Professor Mari Lloyd Williams et al. The study includes a table detailing the
following items, each of which receives a score: pain, mood, breathlessness,
physical movement, general quality of life, and tiredness. In their Hippocratic
[1]

desire to give the appearance of objective science by using a numerical scale, the
doctors have missed a simple point of logic. It is that ‘general quality of life’ is
not an item like the others. The others—pain, mood, breathlessness, physical
movement, tiredness—are descriptive or factual qualities, identifiable by
observation or medical diagnosis. But ‘general quality of life’ is not identifiable
in that way and ought not to be a separate item on the same list. It belongs to a
different category and is consequential on the others; it is an evaluation arising
from the others.
The mistake of placing quality of life on the same list as the objective factors
such as pain, depression, etc. amounts to what philosophers call a ‘category
mistake’. To illustrate what is meant by a ‘category mistake’ let us suppose that
[2]

someone from the University of Glasgow (with the image the university’s spire
in his mind) is taken by a friend to visit the University of Oxford. He is shown
all the colleges and says to his friend: ‘I really enjoyed seeing the colleges but
you haven’t shown me the university.’ But of course the University of Oxford
just is the sum total of the colleges. In a similar way, ‘quality of life’ is the
outcome of other qualities or is consequential on them but it is not on the same
logical level as the other qualities.
Some doctors say that what they are concerned with is ‘health-related’ quality
of life (although Professor Mari Lloyd Williams et al. speak of ‘general quality
of life’). But the idea of a specific category of ‘health-related’ quality of life is
not a coherent idea. Certainly (as I shall shortly argue) health is an important
factor in a quality-of-life judgement, whether made by the patient or the doctor,
but it is not a special type of quality of life. It is one factor on which people
place a variable weight in their all-things-considered judgement of their quality
or life. For example, someone may be dying and therefore would obviously have
a zero score in terms of health. But the person may have had a good life, be
surrounded by family and be comfortable and well cared-for in a hospice. Such a
person may rate their quality of life highly, for the reason that quality of life is
not itself a quality at all but an all-things-considered evaluation of qualities. As I
shall suggest, the qualities to be considered for health extend well beyond the
remit of medicine, although of course medicine has a part to play.
But even if doctors avoid the category mistake of regarding ‘quality of life’ as
itself a quality, they tend to see the concept in individualistic terms. A typical
context would be one concerned with the withholding or withdrawing of
treatment. For example, consider the following typical case. ‘This patient of
mine aged 75 is in the terminal stages of Alzheimer’s disease. Her quality of life
is nil, and she has been like this for five years. Her husband is aware of the
situation and his health is declining through cardiac causes and stress. Recently
this lady developed an upper respiratory infection and was febrile.’ Is it ethically
acceptable to withhold medication in this case?
In this example the doctor clearly thinks that the ethics of the decision to
withhold treatment turn on the question of the quality of life of this particular
patient. Doctors of course recognise their limited use of the term and often
restrict their usage, as I said above, to ‘health-related’ quality of life. But in this
chapter I shall argue that quality of life cannot meaningfully be restricted to
health in the sense of the absence of disease or illness. Indeed, as I have already
argued (Chapter 11), ‘health’ is a much more complex term than just the absence
of disease.
If it is to serve as an aim, which will serve to broaden our ideas of health and
remove them from individualism to a wider community-based idea of health,
then we must look to the other contexts outside medicine in which the term is at
home. For example, there is currently important discussion of the extent to
which quality of life in cities is marred by pollution or too many cars. Or there
may be debate over whether the quality of life of a society requires the existence
of wildernesses, or subsidised arts, or improved architecture. I shall suggest that
these wider considerations move the concept away from individualism and
enable us to see the aim of medicine as more helpfully holistic—concerned with
community values including the wider community of the environment and its
creatures.
I am not arguing, of course, that doctors should ignore the health problems of
individuals, but rather that the health of individuals is intrinsically connected
with that of their communities and environment. This is not to say that doctors
should alone try to manage these wider matters. My point is that doctors should
work with many other professionals in community and environmental
programmes. There is currently a political move to join up clinical and welfare
programmes. This is where social prescribing is important. My argument will be
that true and lasting health requires even further mergers, for community health
is inextricably tied to wider political and cultural values such as equity in the
distribution of wealth, the improvement of education and the built environment,
the preservation of the countryside, the encouragement of sports and other
leisure facilities and the cultivation of the arts.
It should be clear from these contentions—and the discussion of positive
health (pp. 162–6)—that problems in medical and wider social decision making
or questions of quality of life overlap with those of happiness, welfare, the
environment and even of what constitutes a meaningful life. But what exactly is
the relationship among these concepts? Are they all synonymous? For example,
are the components of a meaningful life the same as those of one of good
quality? Or are some components or subsets of others? For example, are well-
being and welfare parts of a life of good quality? Or are some of the concepts
rivals? Is a happy life a rival idea to one of good quality? Some great historical
figures, such as Van Gogh and Beethoven, had lives of superlative quality, but
perhaps neither of them had lives which were either happy or healthy. These
questions call for an answer if we are to have any sort of systematic
understanding of ‘quality of life’.
If I were a Hippocratic social scientist enquiring what factors make up a good
quality of life for individuals, I would answer this by issuing a social survey
resulting in a statistical document with tables broken down into age, social class,
political preference (and nowadays no doubt sexual orientation). I shall try a
different approach—following the example of Plato—and attempt to answer the
question by developing a Greek myth.

The Myth of Sisyphus: Essential Human Nature

In Greek mythology, Sisyphus was King of Corinth and was known as ‘the
wily’, which is why some stories describe him as the father of Odysseus. For
reasons not entirely clear, Sisyphus fell into disfavour with Zeus. One version of
the story is that Zeus abducted Aegina, daughter of the river god Aesopus.
Sisyphus knew the whereabouts of Aegina and disclosed them to Aesopus on
condition that Aesopus would set a river running through Corinth. Zeus was
enraged and sent down the god of death, Morpheus. But Sisyphus succeeded in
binding Morpheus in chains, and nobody was able to die. Finally, however,
Morpheus was released and Sisyphus was sent to Tartarus, a particularly
unpleasant region of Hades. In Hades his punishment was that he had to push a
boulder up to the top of the mountain and when he had just reached the summit
the boulder would roll to the foot, creating huge clouds of dust which obscured
the light. Coughing and cursing, Sisyphus had to repeat the procedure through all
eternity. Many writers have taken this to be the paradigm of a life of poor
quality.
I shall now develop the myth to bring out some points relevant to my
discussion of the nature and identity of good qualities of life. Let us suppose that
the demigod of medicine Asklepios (whom we have met before) comes down to
a medical school to brush up his skills. He attends the ethics class (ignores the
four principles approach) but knows he should be the patient’s advocate, so he
pleads with Zeus to allow some changes to be made to the punishment. Zeus
grants these.
 Asklepios first arranges that the boulder will no longer cause huge clouds of
dust. As a result, there are improvements to the lungs of Sisyphus and his health
improves. Has his quality of life also been improved? Clearly it has. We
therefore have one obvious factor in a good quality of life—physical health.
Secondly, Asklepios arranges for some friends to visit Sisyphus to comfort him,
wipe away the sweat and so on. Has his quality of life been improved? Yes,
loneliness diminishes quality of life and friends improve it. Thirdly, Asklepios
persuades Zeus to transfer the place of punishment from the fearful environment
of Tartarus to a Scottish mountain. He is still pushing the boulder, but in
beautiful scenery. Once again, there is an improvement; environment is
important in quality of life. Fourthly, the myth stresses the pointlessness of
Sisyphus’ activity—a meaningless task with no end. But let us suppose that
Asklepios manages to modify the punishment further, so that Sisyphus now
carries up different boulders and eventually succeeds in building a cairn, or even
a shelter, at the top of the mountain. The activity now has a point, a minor
creative purpose, a meaning. Immediately we can say that there has been an
important improvement in quality of life. Work must have a purpose that
workers can recognise as worthwhile. Fifthly, let us suppose that Sisyphus is
allowed the occasional remission from his punishment—he is given every
second weekend off or the like, during which period he can do other things.
Once again we have an important factor in a good quality of life—some leisure
and the possibility of varied activity.
Finally, and most controversially, let us imagine an essential change. The
original punishment was to go on through all eternity. Suppose that Asklepios
pleads with Zeus about the everlasting nature of the sentence, and Zeus says,
‘Okay I will allow him to die after one more year!’ Does this improve his quality
of life? Opinions might differ here. Some people might say that life is good
whatever the quality. Indeed, if the life of Sisyphus has been improved under the
headings just mentioned, some people might say that it cannot possibly
constitute a further improvement that this life will come to an end. Others might
say that, whatever its quality, human life is by its very nature a transient affair.
Indeed, it might be argued that a necessary condition of life’s having meaning, or
that what makes the very idea of good quality possible, is that death comes to us
all in the end; death supplies the framework or the parameters within which we
can talk of meaning and quality. I shall assume the latter position for the moment
because it enables me to bring to a close one particular type of analysis of
‘quality of life’. I shall call it the ‘essential human nature’ model of quality of
life.
This model has the following features. It assumes that a life of good quality
can be described under a number of headings: health, friends, environment,
creativity, leisure, an inevitable end. But three qualifications must be made of
this picture. First, a life might be said to have a good quality, or a reasonable
quality, even if not all the above elements are present. Secondly, there may be
other similar headings which I have omitted; the headings are not necessarily
exclusive. Thirdly, the headings must be interpreted in a flexible manner. For
example, health is not an all-or-nothing matter, and some people stress their
health more than others do. Again, for some people their creativity is in their
employment and for others it is found in their leisure. Again, for some people
friends are important while for others it might be a partner or children. But, with
sympathetic interpretation of the headings, we have a plausible model: a life of
significant toil with death the signature of its completion.
The life of good quality is here synonymous with the meaningful life, the
valuable life or the worthwhile life. It therefore emerges from this development
of the Greek myth that the quality of life of an individual, in this case the
unfortunate Sisyphus, involves factors other than physical health. Some of these
factors are social, requiring the presence of other human beings, and others
require a green environment. In short, even if we are thinking simply of the
quality of life of the individual, some social, community and environmental
elements must be present.
Why is this model plausible? The answer is that it taps into an important and
widespread set of assumptions about human life, assumptions which go back to
Greek mythology and are still present in all of us. They are that we all have
something that can be called an essential human nature; that that nature can be
developed or realised or educated, granted the appropriate conditions; that
friends, a community, a good environment are all necessary and are inseparable
from the idea of health. These assumptions, originally Greek, passed into
Christian thought, where they were reinforced by the idea of God creating
human beings in the divine image, that is, with an essential nature, which is
social. We are members one of another. It should be obvious, however, that even
at the level of the individual the qualities identified are more than traditional
medical prescribing on its own can deliver. In contemporary terms, welfare
should be joined to health care and leisure activities, and a green environment is
also needed. Social prescribing has a role to play here. Many doctors, perhaps
especially GPs, are becoming aware that their role must be extended and joined
up with community services.
Despite the plausibility of the essential human nature model as so far
described, it is open to serious objections, each of which can give rise to a
different model of the quality of life. The first objection is based on the
happiness model of quality of life.

Happiness or Well-being

A criticism of the ‘essential human nature’ model is that it does not mention the
happiness or well-being of Sisyphus. According to this criticism, people’s
quality of life is solely their happiness or well-being. But what is meant here by
the ambiguous terms ‘happiness’ or ‘well-being’? For the Greeks, human nature
has a certain structure, and happiness consists in developing the structure, or in
acting in ways which express the form of that nature. Aristotle speaks of
‘eudaimonia’, a term which is usually translated as ‘happiness’ but really means
‘living well and doing well’. It would follow from Aristotle’s view of happiness
[3]

that the life of Sisyphus, improved in terms of the modifications suggested by

Asklepios, would count as a happy one because his essential human nature is
being developed and realised.
But there is a second view of happiness—and it is the dominant one in
contemporary culture—which we can call the ‘nice feelings’ sense of happiness.
The historical origins of this widespread view are in the writings of Jeremy
Bentham. According to this view, we are happy if we are in certain states or
[4]

moods in which pleasant feelings dominate. These moods have many variants or
subsets, such as exhilaration, rapture or just contentment, but common to all are
subjective feelings of pleasure.
In the first model of quality of life described above, a person must undertake
activities which express and develop the human self and these activities will
constitute happiness in Aristotle’s sense. But in the second model (that of
Bentham and contemporary popular belief), a person cannot be happy without
the predominant experience of nice feelings or at least feelings of contentment.
No importance on this view is attached to the origins of the feelings. For
example, let us return to the myth of Sisyphus and imagine that Asklepios
(having brushed up his knowledge at medical school) puts Sisyphus on a course
of pills—prozac or the like. We are to imagine that Sisyphus is still undergoing
his original punishment of pushing his boulder up the dusty mountain to be faced
eternally with the futility of what he is doing. The myth describes him as
groaning and cursing the gods. He is then put on the pills and as a result he
becomes euphoric and brimming with nice feelings which totally divert him
from the unending futility of his activities. Has his quality of life been
improved?
I once asked a group of (somewhat bewildered) GP trainees this question and
they all raised their arms to vote that his quality of life had been improved by the
pills. The elderly trainer teaching them immediately burst out: ‘Anyone who
thinks that is going out of my practice!’ This produced a reconsideration of the
issues. He had got the point that I was telling them a kind of political/social
story. In the deprived part of town where the practice was situated, a common
type of patient was a single mother living in damp housing who becomes
depressed and turns up in the GP’s surgery. The temptation is obviously to put
her on a course of pills. The GP trainer pointed out that all this would do would
be to turn a depressed woman into a pill-addict. His solution was to get in touch
with a women’s support organisation, to ring the council and urge help with the
damp housing and so on. The trainees then replied: ‘But that’s social work.’
Right, and my point is that help for that patient and thousands similar does
require a joined-up service. Her health will not be improved by doctors on their
own, although social prescribing may be the first step towards improvement.
What is required is a multi-professional team and (as I shall shortly suggest) a
more equitable distribution of resources. But, if ‘quality of life’ is just happiness,
and happiness consists of nice feelings regardless of their causation, then the
prozac (or whatever) has indeed vastly improved her quality of life. And it
would follow that the quality of life of Sisyphus, and indeed of all of us, might
be improved if there were a drug which enhanced our feelings regardless of the
grim reality of our actual situations. It is simply the patient’s feelings which have
changed, and only for a short period until addiction kicks in.
It is easy to see in this how doctors can be described by sceptical patients as
‘agents of social control’. They are providing opiates for the masses which blind
the poor to the reality of their social situations. There is plenty room for patient
scepticism about the ‘just prescribe a pill’ culture in medicine. Nevertheless, it is
often said that your quality of life is just how you happen to be feeling. This
view of quality of life is a rival to the first model, for it ignores self-
development. Indeed, self-development, which involves effort, might interfere
with the nice feelings.
It is sometimes argued that pills can help patients get out of the grip of
depression, and then they can get back to more positive ways of living. Perhaps,
but the trouble is that the second part of this prescription does not usually take
place; there is nothing beyond the pills, and indeed many patients find it very
hard to free themselves from the addiction caused by the pills. In conclusion,
then, the ‘nice feelings’ view of happiness may be the dominant contemporary
view, but I have argued that it is not a serious rival to the ‘essential human
nature’ view of quality of life. This is not to be a kill-joy but simply to contrast
the transient and possibly self-destructive nature of pill or alcohol induced ‘nice
feelings’ with the more lasting view of quality of life as the development and
expression of our essential human nature.

Choice

A fundamental objection can be levelled at both the self-development and the

happiness view of quality of life. It might be said that it is up to individuals
themselves to decide what is a good quality of life for them. According to this
view, quality of life is a matter of individual choice. The individual is the source
of all value. The origins of this objection can be found in the philosophy of Kant,
and the Enlightenment more generally. The objection is that my description of
the life of Sisyphus, even as improved by Asklepios, lacks one important
ingredient, some would say the vital ingredient, for a life of good quality—
choice. Sisyphus is compelled to push his boulder and the modifications of his
punishment are all arranged on his behalf by Asklepios; he himself is totally
without any choice. For Enlightenment thinkers this would be a fatal flaw in
both the significant toil model and the happiness model.
In a historical/political context Asklepios would be seen as an ‘enlightened
despot’ such as Joseph II or Maria Theresa, and in a medical context he would be
seen as exercising ‘benevolent paternalism’. Even such thinkers as the
existentialists, who reject most enlightenment assumptions, would still insist on
the central importance of choice. And the more extreme ‘post-modernists’, who
reject all enlightenment assumptions, would still hold on to individual preference
as expressed through choice as the most important or indeed the only factor
making up a good quality of life.
How plausible is this objection and the alternative it offers? In general terms,
for most people the framework of life, the boulder-pushing, is thrust upon them.
If there is freedom or autonomy, it is within the framework which our situations
in life, our heredity and environments, have determined. In terms of the myth,
Sisyphus might decide which route to take up the mountain or what to do on his
day off, and so it is for many people; we cannot really choose our lives.
Nevertheless, let us develop further the idea of choice or autonomy as the
central quality which makes life valuable. Supposing Zeus decides to release
Sisyphus after many years of punishment and gives him a sum of money to help
him back to ordinary life. Sisyphus proceeds to spend this money on whatever is
the mythological equivalent of gambling machines, lottery tickets, scratch cards
and so on. Let us say he is successful, and makes a large income from gambling,
invests it in tax-havens and buys fast cars, brothels and dodgy casinos. Has his
quality of life been improved from the point at which he was pushing boulders to
build shelters at the top of a pleasant mountain with his friends and so on? If it is
said that the single most important factor in quality of life is an individual’s own
preference expressed through choice, then it must follow that this life does have
a better quality than the other, because to be a realised self is just to be able to
choose. This is the post-modern view of quality of life; agents are the only
authorities on their own quality of life. Some politicians and others who see
consumer choice as the fundamental value of life may be willing to accept this
implication of their view of quality of life, but I hope doctors will not.
But this criticism is persuasive only if choice is thought to be the only or the
supreme determining factor in a good quality of life. If the ability to choose is
regarded not on its own but rather as one attribute of our essential human nature,
then a more balanced view of the role of choice emerges than is provided by the
philosophy of existentialism or the more familiar consumerism. After all, we
pass judgements on choices: good, wise, prudent, unfortunate or ill-informed and
so on. J.S. Mill expresses a view on what our essential human nature consists of.
He calls it our ‘distinctive endowment’ and it contains choice. He writes: ‘…the
human faculties of perception, judgment, discriminative feeling, mental activity,
and even moral preference, are exercised only in making a choice.’ In other
[5]

words, choice may be a necessary condition for a life of good quality but it is not
sufficient. In a life of good quality, we express our human nature by means of
choice. Choice is a means for delivering good quality; it is not in itself that
quality.

Society and Material Needs

All three models of quality of life so far discussed, especially the second (the
happiness model) and the third (the individual choice model) can be criticised as
being too individualistic. Even if, as I have suggested immediately above, we
combine them into a single model after the manner of J.S. Mill, we are still left
with a model which is individualistic. But I wish to argue that it is inadequate—
economically, politically, culturally and even in terms of human nature—to base
an account of quality of life simply round the individual. The communitarian
argument of Chapter 12 stressed both the social nature of human beings and the
need for equity in social arrangements.
Consider material needs. A community requires education, housing, transport,
unemployment benefit and a clean environment as well as health care. All of
these will affect quality of life and are financed by taxation. This raises the
issues of who should bear the burdens of taxation, and of the opportunity costs.
How much should be allocated to health as compared with other claims on the
budget? The material satisfactions of the future lay a claim on the political
spenders of the present.
Another major factor essentially quality of life in all its aspects is the
environment. First of all, the environment is a major determinant of health,
estimated to account for almost 20% of all deaths in the WHO European Region.
For example, poor air condition is linked to premature death, cancer and long-
term damage to respiratory and cardiovascular systems. In 1989, WHO/Europe
became concerned about the growing evidence of the impact of hazardous
environments on human health. It therefore initiated the first ever environment
and health process, towards a broad primary prevention public health approach
to facilitate policy-making. Since then there have been several WHO
conferences in Europe. For example, in 2008 the WHO held a large conference
out of which came the WHO Parma Declaration on the Environment and Health.
More recently there has been a WHO initiative from the Czech Republic,
published as the Ostrava Declaration on the Environment and Health. The fact
that these initiatives are Europe-wide brings out that there is an international
dimension to quality-of-life considerations. No doubt the WHO also has
worldwide concerns for the impact of the environment on health. Moreover,
there is a temporal dimension to this. Society and its environment continually
evolve through time, and the actions of one generation have a bearing on those
of another. An underlying topic central to all these concerns is equity in the
distribution of material resources.
If we accept these arguments critical of individualistic accounts of quality of
life then two points emerge. First, questions of the quality of life cannot be
separated from issues concerning the satisfaction of material needs. Moreover,
the satisfaction of needs must be based on the principles of equity and utility,
including environmental concerns. I have discussed equity and utility in several
contexts because they are central to quality of life. Scandinavian countries
frequently emerge well from surveys of quality of life, and it is noteworthy that
compared to the UK they have a much greater degree of equity in the
distribution of resources and greater environmental concerns. Secondly, the
arguments above stress human interrelatedness. The quality of life of one person
has a bearing on that of another, and in health care in particular huge costs are
potentially and actually involved. The emphasis in health care should be moved
from its current individualistic bias to that of the quality of life of a society. And
of course the practice of medicine has a central role in this wider conception.

Society and Culture

But there is more to the quality of life of a society than health care, welfare and
social provision, no matter how equitably distributed. There is also what we
might very broadly call the culture of a society—its architecture, science, public
gardens, wildernesses, its consciousness of its history and heritage, its political
cartoons, the accessibility of its art galleries and concert halls to the general
public and so on. What is necessary for the quality of life of a society is that its
members should recognise that there are two different ways in which quality of
life can be promoted. One is through health, welfare and related goods, and here
we should not be individualistic but thoroughly community- centred and
egalitarian. As long as we confine ourselves to this, however, we are acting as if
health and material satisfaction are the only goods. But there is another side to
quality of life which involves the promotion of ideals which are impersonal, yet
are nevertheless essential to the dignity of a society and its flourishing through
time. Indeed, they constitute an essential element in our social identity. The
quality of life of a society from this perspective adopts the position that some
qualities are better than others, regardless of what is democratically chosen at a
given point in history.
For example, the environment is a major health determinant not only for what
I have been calling ‘negative health’ but also for positive health, for human well-
being. There are various aspects of this. Most obviously there is a widely
recognised need for green spaces in cities and the preservation of the countryside
in the face of destructive methods of agriculture. Many farmers are now
returning to the eco-friendly methods of agriculture of their predecessors. Going
along with that there has been an increasing recognition of the fact that we share
the planet with many other creatures, and that we have a duty to halt as far as is
possible the decline in living species which human habitation has caused. We are
part of the living environment and our well-being is tied up with that of the other
creatures with whom we share it. Education is finally creating in young people
an awareness of our dependency on other species. Our positive health is
fundamentally tied up with that awareness.
In sum, I am arguing that, while doctors must be concerned with the
individuals who turn up in the clinic, the overall aims of medicine cannot be
realised without the cooperation of other non-medical professionals. They
require heightened activity from public health medicine/health promotion and
social prescribing. Individual health as a concept has a validity, but true, lasting
and economically viable health is a community goal. It is best expressed through
the several aspects of ‘quality of life’—concerned with the essentially social
nature of human beings, with their material needs, their environmental concerns
and their cultural aspirations. Medical education has an overwhelmingly
individualistic bias—aimed at helping the sick or injured individual. Obviously
much of this is necessary. But this individualistic and narrowly focused bias can
have unfortunate consequences: for costs, for individuals and for communities.
Unfortunately, there can also be problems which arise from attempts to
implement a community-based approach to health. These problems are
illustrated in a striking way in a play by Henrik Ibsen called An Enemy of the
People.[6]

‘an Enemy of the People’

An Enemy of the People was first performed in 1883. The ethics of public health
does not seem a likely subject for drama, yet the play succeeds in making us
vividly aware of the central ethical problems of public health and health
interventions more generally—the problems of freedom of information, of being
allowed to publicise problems of health in a society in which anti-health forces
—the forces of vested interest—conspire against the truth. It also highlights the
manner in which a popularity-seeking media can manipulate public opinion for
their own ends.
The central character in the play is Dr Stockman, who is the doctor in charge
of the Baths. The doctor had the idea that the creation of Baths would bring
tourists and some prosperity to the small town in which the Baths are to be
situated. This has proved true and when the play opens the doctor is popular in
the community both for the creation of the Baths and for his medical work
among the townspeople. Unfortunately, for reasons of cost, the Baths have been
located below a tannery, against the doctor’s advice. The water flowing into the
Baths has become contaminated by effluent from the tannery. In Act I the doctor
receives conclusive scientific proof of the contamination of the water and the
resultant danger to public health. He proposes to publish his report, which has
been enthusiastically received by the local newspaper editor.
The mayor of the town is the chairman of the Baths committee. He has vested
interests in the Baths and tourism; argues that the doctor’s scientific report is
exaggerated (fake news); that the town will lose its tourist appeal; and that he as
the chairman forbids the publication of the report. He sacks the doctor. The
newspaper changes sides and will not publish the report, and at a public meeting
the mayor and the editor and their supporters turn the people against the doctor
who is declared an enemy of the people.
Perhaps the central point for the argument of this chapter is made by the editor
of the newspaper in Act II. Dr Stockman is portrayed as in many ways a simple
character, dedicated to scientific truth. The editor does not dispute the scientific
truth of the doctor’s report but says: ‘You’re a doctor and a man of science, and
to you this business of the water is something to be considered in isolation. I
think you don’t perhaps realise how far it’s tied up with a lot of other things.’
This is a huge ethical problem for public health medicine, as has been very
apparent in the epidemiology versus economics controversies during the Covid-
19 pandemic. The ‘truth’ has to be implemented in a complex social and
economic situation, one in which uncertain epidemiological information is pitted
against employment and other economic and legitimate interests such as
individual freedom and human interaction. In other contexts there can be conflict
between support for political party funding from dubious vested interests such as
the tobacco or sugar industries and values such as population health and
democratic control. And of course political decisions are always affected by that
most changeable of all factors, public opinion. In turn, public opinion is affected
by newspapers, television, popular public figures and other influences, which
may themselves be affected by vested interests, such as the views of newspaper
owners.
Out of this ethically confused situation the play leaves us with two ethical
problems for public health medicine. One is the priority which should be placed
on the truths and values of public health, and the other is how to present these, to
communicate them to a public which may have more immediate concerns such
as employment.
It is true that no amount of improvement in public health regulation or social
conditions is a substitute for people taking responsibility for their own health and
that of their neighbourhood. On the other hand, it is entirely unrealistic to expect
individuals on their own, say in deprived areas or circumstances, to take full
responsibility for their own health and well-being. Assistance, advice and
leadership are required, and it is this that social prescribing and the health
promotion movement aims to provide. My argument has been that professional
help in community development is best carried out on a multi-disciplinary basis.
It is not simply a matter of health care provision. For example, health
education/promotion officers must work alongside social work services, local
churches, arts and sports organisations and the general public. The danger to be
avoided is the one in which the delivery of health care has fallen. It is rightly
criticised for using top-down methods, and over-emphasising the magic bullets
of medical research, algorithms and mathematical modelling, often reported in
over-optimistic ways by the press. This criticism, which was given its most
trenchant formulation by Ivan Illich, is that health care workers and the whole
context of health care have become ‘over-professionalised’. [7]

Medicalisation

There are three connected aspects to this. The first is what we might call the
medicalisation of ordinary experience. We have been encouraged to think that
every human anxiety, discomfort or misery is a medical or related problem.
Where in the past people might have thought that sleeplessness is something that
you can treat yourself, that anxiety or grief are to be shared with a friend or
neighbour, or that discomforts are to be put up with until they go away, we now
turn to the doctor for a pill. Going along with the medicalisation of experience
there is secondly the complementary belief that for every ailment there is an
expert to help. Those in the health care business have not discouraged either of
these beliefs, and constantly warn of the dangers of not consulting the doctor on
time, of not going for screening, etc. Now a new generation of specialist health
promoters appear on the media with the high-pressure selling of remedies such
as ‘mindfulness’. And schoolchildren are encouraged to think that if they are not
happy they have a mental health problem and need ‘counselling’.
The outcome of all this takes me to the third and most important point. The
medicalisation of ordinary experience plus the rise of the ‘expert’ has had the
result that people have lost confidence in their own abilities to take care of their
own health in particular and their own lives in general. Ordinary people have
come to feel that they do not have the expertise needed to help with family or
similar difficulties. As a consequence, many people have lost the feeling that
there is a moral need to have any concern for one’s neighbour; ‘they’ can now be
expected to do everything. The substantial scepticism I have expressed in these
three issues all point in the same direction: the delivery of health care has had a
tendency to sap individual freedom by removing our sense that we are in control
of our health.
The cure for all these ills is the same. Those involved in health care must
abandon their professional isolation and work through the community rather than
on it, in order to make improvements with the community rather than on it. To be
fair there are many signs that this is beginning to happen. There has been a
growth of self-help from the familiar Alcoholics Anonymous groups to the many
types of parents’ groups concerned with education, bereavement and every sort
of childhood disease. The growth of such self-help movements should be
encouraged and informed by those in professional health care. Here again social
prescribing and activities such as community arts have a role. One of the five
principles of health promotion identified by the WHO is that ‘health promotion
aims particularly at effective and concrete public participation’ (p. 150). The
post-pandemic world provides an opportunity for this kind of ‘reaching out’ to
develop.
Indeed, for adequate health care, for the reduction of negative health, i.e. of
disease and illness, and the promotion of positive health or well-being, we
require not just that we should be served by authorised representatives with the
rights, duties and skills of the health care professions; not just that these
representatives should cooperate in teams for our total health; for wholeness or
well-being we require that we should all see ourselves as members of a
collectively responsible society. In other words, the members of the health care
professions must be assisted by our own striving to become members one of
another. This view of society depicts it as a community with a communal good
not entirely reducible to the individual goods of the persons who make it up, and
indeed also includes the good of our environment and the creatures with which
we share it. In other words, it is a communal view of society which is
importantly different from liberal individualism. Or, for those who want to hang
on to the idea of the ‘individual’, the same point could be made by saying that
these individuals are citizens, or individuals with social responsibilities and a
social well-being.
To the extent that there is exclusive emphasis on the state delivery of health
care to individuals, there is an invitation to see health as a commodity supplied
by the state. The same is true if we think of health as a commodity bought by
private health insurance. But health is not in any sense a commodity. Health and
well-being are in the end a set of relationships among citizens.
As D. Beauchamp wrote:
Collective goods are ultimately a set of relationships among the citizens of a community,
relationships in which the community as a whole participates to obtain desired benefits. These
collective goods include aggregate states of welfare or well-being, including declining rates of
disease and premature deaths; efforts to limit the resources society devotes to personal health
services; shared and common access to a good like medical care to foster the sense of community
and membership in the group itself. And finally, there are those highly important collective goods,
shared or common beliefs and values.[8]

It is clear that we can add a legal system to Beauchamp’s list, and in particular
one designed to stimulate social responsibility. Indeed, it is plausible to suggest
that the increasing government intervention on drunk-driving issues has
encouraged a greater social awareness about the dangers of alcohol more
generally, and thus an increasing sense of community and individual
responsibility. In a similar way, legislation designed to assist disabled persons
can also increase a sense of community responsibility for those groups. And so
too environmental legislation and green ‘targets’ can make us aware of our
dependency on a clean environment, and the interdependency of all living
creatures on the planet.
Health alliances have been shown to be helpful in developing community
awareness, such as that between health promotion services and community arts.
Several projects have taken place and have had favourable evaluations, such as
the Bristol Area Specialist Health Promotion Service report on projects
involving photography, the visual arts and drama. Again, for many years
[9]

Bromley by Bow has mounted ongoing community arts and health projects. [10]

The central message from these and similar projects all over the country is that
disease and ill-health cannot be eradicated by narrowly medical means; they
must be tackled in a community context with the approval of the community. In
other words, medicine needs health alliances. The arts are a vital and ethically
acceptable ally, and GPs can have a role in directing patients to them. The
ancient Greeks recognised this when they made Apollo god of both medicine
and the arts.
The usual models of health are medical or sociological, but since the
inspiration for this book came from the humanities—literature, philosophy,
history—it might be appropriate to sum up my views by repeating my analogy
from grammar. In my Introduction I used terms from grammar as a metaphorical
condensation of my argument. Now at the end of my main argument I shall
repeat the analogy in the hope that it will carry the message of the entire
argument.
Health can be seen, and traditionally was seen, as a noun—referring to a state
or a commodity which individuals could possess and which could be protected
by vaccination, impaired by disease and restored by surgery or pills. I have not
rejected this as a way of understanding health but have added to it by referring to
more recent ways of looking at health. According to these more recent health
promotion or lifestyle ways of looking at health, health is an adverb—referring
to a style of living, a way of qualifying the active verbs of living. But I want to
suggest that health can also be seen as a relational predicate—that health,
especially positive health or well-being, can be seen as a set of relationships in
which the community as a whole participate to obtain mutual benefits, benefits
which include a decline in ill-health, and the enhancement of well-being through
the shared values of citizenship and a green environment.
Health care certainly requires a scientific evidence-base, but it must also be
open to wider approaches to evidence which reflect the many ways in which
human beings express themselves through the arts, and relate to each other in
communities. Communities are no longer the inward-looking gossipy places they
once were; rather they intersect and criss-cross in our lives and are sources of
multiple values. In the end we are part of a wider global community and can be
affected by wider global concerns and values. The pandemic has at least made
that clear. It has also made clear the dangers of exploiting the wider community
of living creatures. When we try to exploit the natural environment and its
creatures, nature will hit back, something that Covid-19 and other recent
pandemics have demonstrated. The health care slogan of ‘respect for persons’
requires to be supplemented to respect for the living environment. Such an
approach would indeed offer the best possible quality of life. Sisyphus would be
well-satisfied with that.

Conclusions

In Chapter 12 I outlined a philosophy of health care alternative to the current

neo-liberal, individualistic approach, namely, communitarianism. Health care has
been a stand-alone institution without the back-up of other more broadly-based
institutions, and it has had to bear the burden of all the ills of society.
Consequently, it has been much criticised for its failings even though its doctors
and other health workers have reached the level of exhaustion. And its
expenditure is at breaking point. It is in the interests of medicine, although it is
contrary to the ethos, to reach out to a much wider community-based range of
supporting agencies. These will include the arts but also many other agencies.
This will both ease the burden on medicine narrowly conceived and improve the
health and well-being of the population.
In Chapter 12 I outlined the philosophy of communitarianism as an alternative
to liberal individualism as a plausible philosophy of medicine for the post-
pandemic world. As a more vivid way of stating my argument I developed the
concept of quality of life—already in common use both in medicine and more
widely. I suggested five different ways of looking at quality of life: as an
individual life of self-development; or one of subjective feelings of well-being;
or one of autonomous choice unconstrained by other considerations; as a social
life in which there is an equitable distribution of health and welfare; and as a
social life in which the service of ideals of the good life are promoted alongside
health, welfare and a green environment. The conclusion of this investigation, as
it affects the main theme of my argument, is that ‘quality of life’ is a many-
faceted concept which might incapsulate the aims of medicine in a more
satisfactory way than ‘improving the health of individuals’. A truly healthy
society is one in which medical services are integrated with social and welfare
services, and in which these integrated units form health alliances with self-help
groups, community associations, cultural and sports facilities, a green
environment and (importantly) all are equitably funded. Doctors and especially
GPs as social prescribers can be facilitators here.
1 Lloyd-Williams, M., Dennis, M. and Taylor, F. (2004) Prospective study to determine the association
between physical symptoms and depression in patients with advanced cancer, Palliative Medicine, 18, pp.
558–63.
2 Ryle, G. (1947) The Concept of Mind, London: Hutchinson’s University Library.
3 Aristotle, Nicomachean Ethics, Book 1, 4–12.
4 Bentham, J. (1876) The Principles of Morals and Legislation, Oxford: Oxford University Press.
5 Mill J.S. (1859) On Liberty, London: Collins, chapter 3.
6 Ibsen, H. (1883) An enemy of the people, in Henrik Ibsen: Plays Two, London: Eyre Methuen.
7 Illich, I. (1976) The Expropriation of Health, New York: Pantheon Books.
8 Beauchamp, D. (1987) Lifestyle, public health and paternalism, in Doxiadis, S. (ed.) Ethical Dilemmas in
Health Promotion, Chichester: John Wiley.
9 Hecht, R. (ed.) (1996) I Talk Now, Bristol: Specialist Health Promotion Service, Central Health Clinic
Bristol.
10 Bromley by Bow Centre Annual Report (1995–96), London: Bromley by Bow.
 Chapter 14
Values, Meaning

and Health
A term used throughout the book has been ‘value’. Values have been ascribed to
morality, to science, to consent, to community and, above all in this book, to
health. But what is ‘value’?
When a question of values arises, it is common for suggestions to be made as
to what, for example, are democratic values or British values, and it will be said
that toleration is a value or freedom of the press is a value. Answers of this kind
were discussed and rejected long ago in Plato’s Dialogues. The Dialogues
usually begin by raising questions such as ‘What is knowledge?’ or ‘What is
justice?’ and initially the participants provide answers such as ‘The doctor has
knowledge’ or the ‘Captain has knowledge of navigation’ or ‘The lawyer has
knowledge of justice’. By means of his questioning, Socrates brings out that,
while such answers are correct as far as they go, they do not answer the
questions of what knowledge itself is or what justice itself is; they simply tell us
who has knowledge of a particular kind or who enacts justice. In a similar way,
when politicians or newspapers tell us, no doubt correctly, that democracy or
press freedom are among our values, we do not have even the beginning of an
answer to the question: what is value? Moreover, the latter question cannot be
answered by sociological surveys or phone-in votes; it is an underlying
philosophical question.

Types of Value

To pose the question ‘What is value in itself?’ may cause what Wittgenstein calls
‘mental cramp’, for not only do we not know the answer, we do not know how to
set about getting an answer or indeed what is going to count as an answer.
One way in to this question is to consider the occupation of professional
valuers whose job it is to value items. In other words, we have moved from the
question ‘What are values?’ to the more manageable question: what is it to value
something? The move takes us from the noun ‘value’ to the verb ‘to value’. This
breaks the cramp because we can answer the question by considering what, for
example, the presenters on TV programmes such as the ‘Antiques Road Show’
do, or we can consider what estate agents do when they value our houses. What
they mainly do is to suggest the money an object might fetch at an auction, or
perhaps what its insurance premium might be, or what a likely sale value might
be. We can call this value in exchange.
But there are some commodities which have no exchange value but are
nevertheless of vital importance to our lives. For example, air is essential for our
lives but it has no exchange value. We can think of this as use value. Some
commodities might have both a use value and an exchange value. For example,
money itself has an obvious use value but it also has an exchange value when we
hand some money over to make a purchase.
But exchange and use do not exhaust the types of value. Returning to the
‘Antiques Road Show’ we can note that some exhibitors agree that the objects
they display have no exchange value or use value but are of vital importance or
significance to themselves or their families. Such objects have an intrinsic value.
Letters or photographs come into this category. It is reasonably clear what
exchange or use values are but what is an ‘intrinsic value’?
We might try to answer this question if we draw a contrast between means and
ends. Some things or activities are valuable as a means to something else. For
example, practising scales is a means to becoming a good performer on a
musical instrument. But other things or activities are valuable as ends, or for
their own sakes, or intrinsically—for example being able to play a musical
instrument. So we could say that, while a job might be a means to a good life,
life itself is valuable as an end, or intrinsically, or for its own sake, and not as a
means to something else. Now this is clear as far as it goes, but it can be taken
further with help from Aristotle.
Aristotle begins his account of the good life by drawing a distinction between
types of activity. Many activities are useful because they are a means to other
[1]

ends or activities, and these in turn can lead to further ends or activities.
Aristotle’s example is that of bridle makers whose activities are useful, or are a
means to a further end such as horsemanship, and this in turn might have been
useful in Greek warfare. But his central point is that the chain of means and ends
must stop somewhere otherwise nothing can even be useful. The useful (use
value) depends on there being some one or set of ends which are valued just for
their own sake, or are of intrinsic value, otherwise there is no meaning to be
attached to usefulness.
Aristotle argues that there is one ultimate end, but we need not follow him
there. There is no reason why there should not be a variety of ends of intrinsic
value or worthwhile for their own sakes. Aristotle put this paradoxically by
saying that ends of intrinsic value must be totally useless. Students used to find it
amusing when I said that what is valuable for its own sake, or is of intrinsic
value, must be totally useless. But Aristotle is surely right on this. Unless there
are ends, objectives or activities which are worthwhile just for their own sake or
are of intrinsic value, nothing can even be useful. What is useful is useful for an
end or objective and if this chain goes on indefinitely then the idea of the useful
loses its meaning; it is not heading anywhere.
The idea of ‘intrinsic value’ suggests exclusively high-class pursuits, but
games or sports can be included in the category of intrinsic value. Sports tend to
be promoted by governments as being good for your health—in other words, as
being useful for a further end. No doubt that is true but surely the basic point of
sport or games is that people enjoy them for their own sake. The arts of all kinds
and at all levels are other examples of activities valuable for their own sake.
Music can be useful to provide the rhythm for dancing or to disguise lulls in the
conversation, but surely, whether it is Count Basie or Mozart, music is just
worthwhile for the kind of thing it is or for its own sake. Pure science again is an
activity valuable for its own sake. Governments encourage science as an activity
useful for the economy. Again, no doubt this is true of at least some sciences.
But consider TV programmes such as those presented by Sir David Attenburgh
which simply celebrate the wonders of nature. They enable us to see the sciences
as of endless interest in and for themselves.
If we turn to relationships between people, we find that they too can have a
use value and an intrinsic value. We make use of others all the time because
social life requires a division of labour. I discussed this in Chapter 2 when
quoting from Martin Buber (pp. 32–7). At a more personal level also we make
use of each other—we borrow ladders, take in parcels and so on. But friendship
or family relationships are also of intrinsic value. Indeed, one of problems most
talked about during the pandemic has been the difficulty in maintaining personal
and family relationships; they give life its meaning.
One of the worst aspects of human history has been the way in which human
beings have been seen as having an exchange value, as in the buying and selling
of human beings via the institution of slavery and its more recent manifestations
in people trafficking.

Value Itself
So far, then, I have begun the answer to the question—what are values? —by
distinguishing between use values, exchange values and intrinsic values or
values for their own sake, and suggesting that both individual things and
relationships can exemplify the three basic types of value. But I have still to
address the question of what value itself is, or what these three basic types of
value have in common in terms of which they are values. Are they objective
properties of things, or do they simply express our attitudes to things?
Plato developed one type of theory which depicted values as existing
objectively. His theory of ‘Forms’ is a complex and inspiring version of an
objective theory. Basically the ‘Forms’ are the blueprints, the essences, of all
existing things. In his dialogue Republic he argues for a supreme Form which he
calls the ‘Form of the Good’. Just as the light of the sun sustains all things so the
Form of the Good provides value to all things. Plato’s theory is easily given a
religious interpretation. In a thinker such as St Augustine, for example, Plato’s
Forms become the creative thoughts of God. [2]

Whatever can be said in interpretation and defence of Plato—and a lot has

been—his theory does not appeal to common sense. The common-sense
criticism is to ask what kind of things these Forms are. They certainly have no
existence in our everyday world, although values have. So we are back with the
question: ‘what are values?’
To answer this question I shall return to the starting point. I suggested that the
cramp-inducing question ‘what is value?’ could be approached by moving from
the noun ‘value’ to the verb ‘to value’. But if we ask ‘what is it to value
something?’, rather than ‘what is a value?’, we can suggest an answer. To value
something is to prefer it, or to choose to have it, keep it, preserve it, enjoy it, in
comparison to other things. In other words, the essence of value is not an entity,
however inspiring, but rather it is the familiar activity of choosing in preference.
It might be objected that, described in this way, valuing is depicted as
essentially comparative—we are choosing something in preference to something
else—whereas simply having values does not seem to involve comparisons; we
just have values without any comparison. But we can accommodate the apparent
non-comparativeness of having values in terms of the comparative notion by
saying that a person’s values are those things which for their own sake are
preferred to everything else. Thus, if appreciating music is among a person’s
values, he/she will, given a choice, sacrifice other activities to listen to or
perform music, unless another value gets in the way.
This account of valuing can be developed and made more plausible if we
distinguish between two distinct ways in which something might be valued
intrinsically or chosen in preference to other things, or for its own sake. For
example, suppose a reserved person takes a lot of pains to keep his doings to
himself. We might say that privacy is one of his values. But there are two
possibilities here. He might say that he personally likes privacy but is happy for
others to be more open. Alternatively he might disapprove of those who are quite
open and willing to chat about their own affairs; and indeed he might bring up
his children to set the same store by privacy as he does. Again, someone who
values thrift for its own sake might either simply like to be thrifty as a matter of
temperament, or he may approve of thrift and condemn others who are
spendthrift.
This suggests that among what is valued intrinsically or for its own sake we
can distinguish what we can call ‘liking values’ from what we can call ‘ideal
values’. Liking values are, well, just those values which someone personally
happens to like, possess or enjoy for their own sake. For example, someone
might say: ’After a hard day at the office/ or looking after patients/or teaching
kids, I like nothing better than watching a good murder on TV.’ Watching a
diverting TV programme would be for this person an intrinsic value of the liking
variety. Again, playing football may be an intrinsic value but it is so because
many people just happen to like or enjoy playing or watching football.
On the other hand, ideal values have two characteristics which liking values
do not. An ideal value possesses an appeal which may be universal and is
certainly widespread. Moreover, it has the additional feature of what we might
call ‘depth’ in that it derives from an essential feature of our nature as human
beings. For example, if we consider the worldwide phenomenon of people
appreciating or performing music, we can plausibly maintain that music has a
universal appeal; and while music has uses it can also have the depth to qualify
as an ideal value. This is also obviously true of the graphic arts—cave drawings
to Banksy tell of their universal appeal, and Leonardo to Rembrandt of their
depth.
Importantly, human relationships also can have an ideal value. As I remarked
earlier, relationships can have a use value. For example, a professional
relationship, say between doctor and patient or tutor and student, has a clear use
value. But the relationship of friendship, while it might have a use value (helping
out with baby-sitting), is fundamentally an ideal value. The need for friendship is
universal and it derives from a basic and profound feature of human nature.
Indeed, human relationships based on love offer the supreme examples of
intrinsic values of the ideal sort. They have a universal character and are
grounded in the depth of our human nature.
Ideal values may sound like moral values but there is an important difference.
They can sound like moral values because there is an overlap—some ideal
values such as courage or truth-telling are also moral values—but ideal values
are not identical with moral values because there is a difference in subject-
matter. Moral values are mainly involved with human welfare—that is, they
have a use value (as I shall explain in the next section). Ideal values on the other
hand cover a much wider area than welfare concerns; they are not mainly
directed at preventing harm or producing benefit, but rather with being a certain
sort of person. As ideal qualities of the human spirit they have an intrinsic value
with depth and a universal appeal. This is also true of our appreciation of the
arts, science and the wonders of nature, as noted earlier.
The argument so far can be summed up by saying that values are most easily
understood as choices in preference, and that they can be subdivided into
exchange values, use values and intrinsic values. Intrinsic values can themselves
be subdivided into liking values and ideal values. Ideal values have the qualities
of universality and depth. There may of course be a sliding scale between liking
values and ideal values.

Morality and Value

Nietzsche’s dramatic saying is often quoted: God is dead—everything is

allowed. But while the claim is high in drama it is equally high in silliness.
Nietzsche would have been the first to object if another philosopher had stolen
his book and passed it off as his own. Whatever else can be said about morality,
it has a clear use value. A moment’s reflection on human beings, our physical
and psychological natures, our vulnerability to each other and the environment,
brings out that if we are going to survive, far less prosper, we need rules of social
harmony and cooperation. These have evolved through family experiences, tribal
experiences and slowly extended to larger societies as legal systems developed.
The existence of such rules and their evolution has nothing at all to do with
whether God is dead or not. Of course, things do not always work smoothly:
tyrants seize power, superstitions emerge and vested interests can prevail over a
common good. Nevertheless, it remains obviously true that morality has a
central function in enabling any society to survive and prosper by encouraging
social harmony and cooperation.
 But there may be more to be said. People sacrifice themselves for others. For
example, mothers will give up careers to look after a sick child; doctors and
teachers will show great courage by working in dangerous parts of the world;
politicians will endanger their career by speaking the truth (although that is rare).
What we admire in this sort of behaviour is more than the use value of devotion,
courage or truth-telling: morality also has an intrinsic value of the ideal sort.
Indeed, while honesty may be the best policy, that is, it has a use value, it is also
plausible to say that the person whose honesty has the motive of policy is not
really an honest person. True honesty has an intrinsic value, and an intrinsic
value of the ideal kind.
Morality, then, can have an intrinsic value as well as a use value. But, whether
we think of it as having a use or an intrinsic value or both types, the values are
relational. Morality is essentially interpersonal. It involves our impact on each
other; the manner and quality of our interpersonal relationships. Hence whether
its value is use or intrinsic or both that value is relational.

Health, Community and Value

It might be said that health cannot have an exchange value. Certainly, as in the
case of morality, it is stretching language to suggest that people can actually
exchange their health for another good. Nevertheless, people can sacrifice it for
another good. For example, someone might be warned that if they return to some
dangerous part of the world they are likely to die. But for some people bringing
aid to others, say, is more important, is to be chosen in preference, to protecting
their health. The intrinsic value of a perceived moral duty may trump the claims
of health. But sacrifice is not the same as exchange.
Health obviously has a use value. Some degree of health, or lack of ill-health,
is necessary for the majority of activities in everyday life. Admittedly, there may
be circumstances where someone is glad of ill-health as the lesser of two evils,
as when it exempts him/her from unpleasant or dangerous duties. But ill-health
even in these circumstances is regrettable given the possibilities that it cuts off. It
is not, then, controversial to ascribe a use value to health.
But can health be valued also intrinsically as an end? It can, but the analysis
here is complex. Health can be valued as an end, or for what it is in itself, firstly
because sickness is painful or uncomfortable. This point can be amplified if we
recall the glows of health which accompany full health and contrast them with
the miseries which accompany ill-health. Health can bring a contentment with
life. There is, however, what we might call a limitation in depth if health is
valued for this reason, viz. its agreeable nature contrasted with the miseries of ill-
health. In terms of the distinction drawn earlier, it is a liking value rather than an
ideal value.
But it is also possible to value health not just as a liking value but as an ideal
value to be sought after, so that people who cherish health are to be approved of
and people who squander it (unless for another intrinsic value) are to be
disapproved of. It is perhaps a biological or teleological or purposive idea of
how our species is meant to be that catches our imagination. This idea is partly
an aesthetic, of a design with which we ought to conform.
There are connections between health and beauty. For example, the film stars
of the 1940s–1960s can seem less beautiful now if they are shown with a
cigarette in their hand. Contemporary viewers may find themselves thinking of
the condition of the film stars’ lungs or the smell of smoke round them. Indeed,
people can see conditions of themselves as ugly simply because they see them as
unhealthy. There are various ways of explaining this idea of health as an ideal: to
seek health as an intrinsically good end might be said either to show respect for
the claim that we are made in God’s image, or to show respect for the marvellous
way our species has evolved.
Of course, for many doctors and others working for our health these ideas may
seem abstract and unhelpful. For them, health is valuable simply because it is
useful and its absence painful, i.e. it has a use value and a liking value. But, even
if we do not go with the argument to place an ideal value on health, I have still
said enough to make it an important use value. Some activities or states of the
person which have a use value are more important in society than some with an
intrinsic value. For example, farming has a use value rather than intrinsic value
but it is clearly of great social importance.
Health, then, can be seen as having simply a use value or as having an
intrinsic liking value or as having an ideal value. But, however it is seen, its
value, like that of morality, is relational. While it is true that disease or illness
may be the misfortunes of individual people, it has been the thesis of this book
that health, especially positive health or well-being, involves relationships
among people. We are biologically and psychologically social by nature and it is
through society that our health must be sustained.

Meaning and Health

The myth of Sisyphus can be seen as presenting the paradigm of a meaningless
existence—it involves an activity with no point but continuing endlessly. One
important modification of the life of Sisyphus took place when Asklepios (in my
enlargement of the myth) was allowed to leave his boulders at the top and build
something with them. His activities then acquired a creative purpose, and his life
could be seen as worthwhile (pp. 196–7). Meaning in that sense of worthwhile or
creative activity is important also for health, whether of the individual or the
community. There has recently been an increase in the number of suicides,
especially among young men. No doubt there are many reasons for this, but one
reason certainly is a feeling of being worthless, of lacking any goals worth
pursuing or relationships worth sustaining. Indeed, most people at some time ask
themselves questions such as the following: what does my life add up to? Have I
ever done anything really worthwhile? Answers to this question have a bearing
on health.
They have a bearing on health in that there is no obvious reason to preserve
your health if you have nothing outside yourself to live for. If your job is
uninteresting, if you do not have the education (or the money) to develop
interests outside your job, if your relationships have failed, if you have become
trapped in addictions, then health promotion campaigns are not likely to appeal.
Indeed—and I have made this point in several different ways—health promotion
campaigns are likely to fail, paradoxically, because they concentrate on health.
Rather they should concentrate on providing the contexts in which people have
an incentive to preserve their health. In other words, they should offer the
possibilities for people to pursue worthwhile activities. The emphasis should be
on the provision of facilities for sports and cultural activities in a decent
environment. This follows from the philosophy of communitarianism, or a
developed concept of quality of life.
What are the factors which make a life seem meaningful? The issues are
partly conceptual: certain factors make a life count as meaningful. Someone
whose main activities are gambling and spending the proceeds on himself might
have an exciting or enjoyable life, but it hardly counts as a meaningful life. I
brought this out in the discussion of the ‘choice’ model of quality of life (pp.
200–2). The factors are partly empirical or experiential: the adoption of certain
purposes causes people to feel that their lives are meaningful. For example,
someone who trains for and obtains a job may feel that her life is meaningful,
and experiences like falling in love or sharing an interest with a friend can also
cause us to feel that our lives are meaningful. The factors are partly moral: for
we morally approve of the meaningful life and withhold the term ‘meaningful’
from lives which lack certain purposes or qualities. An embezzler might be very
skilful, but we would not call his life meaningful.
Granted the acceptability of this three-aspect analysis, we are left with the
question of what sort of activities give people the feeling that their lives are or
have been worthwhile or meaningful. It is obvious, but perhaps should be stated,
that to be meaningful is not the same as to be profound or socially important.
Ordinary activities and relationships are what are likely to constitute a
meaningful life. These simple activities can be said to comprise the final
fulfilment of a human life. As I pointed out in a previous chapter, J.S. Mill, in
analysing what self-development consists of, argues that we all have what he
calls a ‘distinctive endowment’. The qualities which make up that distinctive
endowment are: ‘the human faculties of perception, judgement, discriminative
feeling, mental activity, and even moral preference which are exercised only in
making choice.’ Now many of the simple purposes and activities which we
[3]

have mentioned can be seen to fall into Mill’s list, but arguably the most
important and, as Mill suggests, the one which is common to all of them, is the
ability to make a choice. The consciousness that, however sick one is, one
retains some marginal control over one’s life, is one important factor which can
make the end of a life seem worthwhile.
The ability to exercise some marginal control over one’s life, to exercise some
choice, is often depicted as important to the idea of human dignity, as I have
argued. But I am emphatically not going down the path of many, perhaps the
vast majority, of those in health care ethics, who make choice an essential factor
for human dignity. The idea of informed, rational choice, of consent and refusal
of treatment, is of course important in health care ethics, and I have stressed this,
but it is not essential for human dignity; it is just one of the ways in which
dignity can be shown. Even when there are no choices possible, human dignity
can be shown in an acceptance of the inevitable. The poet Andrew Marvell
expressed this in his account of the death of Charles I (see pp. 82–3).
It is not easy for many people to find meaning in their employment. This has
been a recurring theme in the critique of industrialisation. A common type of
criticism has been directed less at the division of labour than at the sub-division
of labour. Gone are the days when workers could look at the great ship being
launched and think, ‘I made that’. Meaning can of course be found in
relationships with family and friends. But communities outside this confined
circle are important too. Not everyone can play in the local football team but we
can get satisfaction from being aware that a football team is there.

Conclusions

My argument in this section—and in the book as a whole—has been that a

community—its varied social, cultural, sports activities and environment—can
provide the context in which its members can pursue worthwhile or meaningful
activities. And in pursuing these worthwhile activities they are ipso facto
pursuing health. Doctors can be facilitators in these pursuits, and in the post-
pandemic world they have the opportunity to join with many others in the
community to do so.
1 Aristotle (1971) Nicomachean Ethics, Ross, Sir D. (trans.), Oxford: Oxford University Press, Book 1.
2 Plato, Republic, 6, 509.
3 Mill, J.S. (1859) On Liberty, London: Collins, chapter 3.
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