An intelligent guide to medicine

Theodore Dalrymple, An Intelligent Person’s Guide to Medicine, Duckworth, 2001, £12.95.

The title of Theodore Dalrymple’s book has already raised hackles in the UK medical establishment. Reviewing the book in The Times, leading medical historian Roy Porter warned that ‘clever readers will resent the sense of being patronised’, and took offence at the complaint he attributes to Dalrymple that ‘we patients are incurably stupid’ (1).

In fact, both criticisms are unjustified and reflect an almost perverse refusal to engage with the key arguments of this remarkable book (whose title derives from its publishers, who are issuing a series of similar ‘intelligent person’s guides’). The chief executive of the UK Public Health Association has written an even more philistine review (2). But far from being patronising, Dalrymple displays a respect for the reader (and a prose style) unusual in contemporary medical writing. More importantly, he reveals a respect for the individual, especially one in a therapeutic relationship with a doctor, that is conspicuously lacking in contemporary medical practice (especially in the field of public health).

In the final chapter, Dalrymple discusses the ‘half medical, half pastoral’ role of the doctor in dealing with patients who present with addictions to alcohol or drugs, or other manifestations of existential distress. He insists that it is impossible to treat human unhappiness without ‘delving into moral matters’, dismissing the fashionable ‘non-judgemental’ approach as simply another form of morality (‘usually with a strong dose of self-congratulation into the bargain’).

With a subtlety that reveals long clinical experience as well as thoughtful reflection, Dalrymple explains how a doctor ‘must be a moralist, but not a moralist on all occasions’ and ‘not a moralising moralist’. The essential content of this moral code is the duty of the individual to weigh up the consequences of his actions and to take responsibility for them.

As Dalrymple puts it in one of his (numerous) aphorisms, ‘self-pity and self-deception are the great enemies of Mankind’. From the perspective of a doctor, it may be ‘necessary to undeceive to achieve change’, though this requires careful judgement and is sometimes impossible (Dalrymple repudiates the simplistic ‘one-size-fits-all’ formulas that emanate from the burgeoning world of medical ethics). The key point is that ‘the doctor accepts the patient as his moral equal by judging him by a common standard’.

Instead of absolving patients from responsibility, this approach rescues them from playing the role of victim, ‘a modern form of bullying sentimentality, far cruder than that of our Victorian forebears’. By contrast with the prevailing concept of a degraded individual subject to the compulsion of toxic substances (or indeed, toxic relationships), Dalrymple proposes restoring the notion of the self-determining individual. This approach restores some dignity to the individual and some hope for progress through the doctor-patient relationship.

Observing that ‘health is neither a necessary nor a sufficient condition of a good life’, Dalrymple accurately identifies the current preoccupation with health as a feature of an increasingly atomised and demoralised society. Though he is right that popular self-absorption with matters of health invites increasing state intervention in personal life, he neglects the crisis of confidence driving the medical and political elites towards a more intrusive role. This one-sided analysis invites Porter’s criticism that Dalrymple is merely ‘blaming the patients’ (though Porter also ignores the problems resulting from the establishment’s quest to restore its authority in society through intervention in health).

In the chapter on the question of how healthcare should be funded and delivered, Dalrymple offers a comprehensive – but not unbalanced – condemnation of state-provided healthcare. It is difficult to refute his judgement that ‘everyone who enters an NHS hospital is ipso facto a pauper’ and likely to experience depressing and degrading treatment.

And his view that there is no prospect of these deficiencies being remedied in the NHS as it is presently constituted has been abundantly confirmed by the experience of four years of New Labour reforms. But at the same time, it is difficult to share his conviction that some system of ‘dedicated healthcare savings’ accompanied by ‘public provision for the indigent’ could provide a viable alternative.

On a number of current controversies, Dalrymple takes a bold and independent line. At a time when the leading bodies of the medical profession have effectively surrendered the principle of self-regulation, he insists that independence of the medical profession is ‘a matter of the utmost moment’ and ‘the only way that doctors and patients can maintain a genuinely personal and therapeutic relationship’. He rightly regards the current drive to tighten bureaucratic control as a threat to excellence (which, contrary to the view of the UK minister of health Alan Milburn, ‘exerts more of an influence on medical practice than the dreadful’).

In face of the prejudices unleashed by the Alder Hey and Bristol reports, Dalrymple upholds medical paternalism, in the sense that it is the ‘inescapable duty’ of a doctor to ‘estimate what is in his patient’s best interests to know’. To deny that, in matters of medicine, the doctor, after long training and experience, very often knows best is ‘a position of pure irrationalism’. Informed consent, is, as Dalrymple rightly observes, a ‘pretty slippery’ concept.

It is difficult to do justice to the range of subjects covered in this short but substantial and controversial book. It is brimming with wit and insight and is fearless in challenging the orthodoxies and pieties of modern medicine. Nor does Dalrymple spare the commentators of the past. George Bernard Shaw’s much-quoted view that ‘all professions are a conspiracy against the laity’, he appraises as a ‘silly, shallow dictum, combining technical ignorance, adolescent cocksureness and intellectual dishonesty in equal measure’. Ivan Illich’s Medical Nemesis is dismissed as the work of ‘an egotistical philistine of limited historical imagination’; Peter Kramer’s Listening to Prozac, as a ‘fundamentally silly book’.

My main regret is that Dalrymple often fails to specify the more contemporary targets of his polemic (as, for example, in his critique of the proponents of ‘health inequalities’), with the result that they are allowed to evade and ignore his challenge.

This book is not entirely free of the misanthropic views that sometimes mar Dalrymple’s column in the UK Spectator. Historical pessimist he may be, but his critique of contemporary medicine contains more wisdom and intelligence than anything that has emerged from the pens of the ‘things can only get better’ school currently running the health service under New Labour.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

An Intelligent Person’s Guide to Medicine by Theodore Dalrymple is published by Duckworth, 2001, priced £12.95. Buy this book from Amazon (UK).

Read on:

After Bristol: the humbling of the medical profession, by Dr Michael Fitzpatrick

(1) The Times (London), 25 July 2001

(2) Health Service Journal, 25 August 2001