Hippocratic Oaths: Medicine and its DiscontentsBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7472.982 (Published 21 October 2004) Cite this as: BMJ 2004;329:982
Contemporary books on health and medicine tend to have an apocalyptic bent, predicting or insinuating medical disaster and incompetence on an epidemic scale. Tallis bucks this trend describing the incredible historical achievements of medical science, the tremendous scope of contemporary knowledge and organisation, and the dedication and talent of those who wear the white coats. When Tallis describes the achievement of nearly eliminating river blindness from west Africa, he is partly stating the obvious—blindness is bad and seeing is good—but this message of triumph is delivered so rarely that the arrival is surprising. Tallis is also explaining that while improvements in housing, sanitation, and so forth have certainly contributed to human wellbeing, the contribution of medicine was and continues to be large.
Atlantic Books, £19.99, pp 342 ISBN 1 84354 126 2
Tallis is no Dr Pangloss, however. Hippocratic Oaths is a rare gem for its optimism but it arrives alongside a justified anger at the state and trajectory of British medicine. While part one of the book champions the progress of medical science, part two looks at the current situation and part three examines an uncertain future. These latter two parts are much more disconcerting.
Driven by opportunist politicians, a series of scandals, and zealous patient groups and their media supporters, doctors now find they face opprobrium and monitoring that is neither reasonable nor necessary. The current distrust of doctors provides for a number of unfortunate complications. Patients will not, for example, tolerate being told that they must wait for a disease to progress before a diagnosis and course of treatment can be properly recommended. The result is premature diagnosis and unnecessary testing with ambiguous results. Meanwhile, the drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention.
Most corrosively, however, is that the distrust of medical professionals is breeding contempt for all that is associated with medical science. As Tallis states, “The default assumption that doctors are constitutionally disempowering, that all patients who meet all doctors… are disempowered by them is the profoundest imaginable expression of disrespect.” This disrespect encourages patients, alternative practitioners, journalists, and government officials to feel at ease in attacking the institutions of medicine and their practitioners, even to the point of absurdly and perversely undermining medical care. The “scandal” over pathologists collecting pathology samples at Liverpool's Alder Hey Hospital, for example, has caused the donation of tissue and organs for transplantation to fall precipitously, with obvious detrimental consequences for current and future patients.
The climate of distrust drives demands for reform and further documentation to ensure that doctors are doing their jobs and conforming to the rules. These demands, of course, only increase the obstacles to doctors being able to do their jobs effectively. Tallis notes in an aside, “Because every document that is generated by the Trust has to be checked against central guidelines, we have to document that our documents meet documenting standards.” But the problem is more than one of inconvenience. The Human Tissue Bill put together in the wake of Alder Hey provides for custodial sentences should a doctor use a piece of tissue not in accordance with instructions detailed in highly complex consent forms. To ensure legal use of their organs and tissue after death, critically ill children must, in some cases, complete consent. The inhumanity of such a discussion with sick children and the severe consequence of getting it wrong mean that most medical professionals will forego the possibility of research.
Not surprisingly, Tallis sees the future of British medicine being potentially very different from when he entered in the 1970s. The new medicine will be defensive and instead of “first, do no harm” the mantra of this new medicine will be “first, cover your ass and damn the harm.” The pressure on doctors never to say anything that might be misconstrued and never to perform any procedure that might have unexpected consequences lest they face litigation or miss some focus group inspired target will change doctors from professionals to service managers. The new breed of medic will be well trained in communicating but only able to provide formal, contractual services, from an agreed menu of options, as requested by the consumer patient. Creativity and imagination will be displaced by a system of smiling doctors working to protect their contractually defined interests rather than pushing against the indignities of disease. This is medicine with its professional soul ripped out, where, ironically, the doctor's fear of litigation and the unknown takes precedent over the health of the patient.
This is not to say that the book's end snuffs out the optimism of the opening. Tallis describes a better future for medicine, enabling a healthy long life instead of an unhealthy elderly existence. But he is clearly concerned that we will fail to deliver this future. It is remarkable how medical professionals, who perform such a vital social role, could have provided so little resistance to the multitude of attacks against their profession. Tallis demands rebellion “to lead medicine to the better future that science will make possible.”