- Margaret McCartney, general practitioner, Glasgow
“Sooner or later there comes a point . . . when the physician realises that he can do no more than ease the terminal stages of life . . . Unnecessary investigations or surgical interference should be eschewed, and the doctor ought to concentrate on alleviation of distress rather than systematic treatment.” So wrote Trevor Howell, deputy physician and surgeon, of the Royal Hospital, Chelsea, in 1944 in Old Age: Some Practical Points in Geriatrics. I am in the habit of reading old medical textbooks, because sometimes they help to explain how we came to end up where we are. What they do not always explain is why.
The palliative care movement sometimes sells itself as something new and original—the idea that comfort can and should sometimes replace cure. Yet old books can also tell of common sense, of kind doctors seeing the person’s whole life in perspective as it draws to a close. In her book Iona Heath writes, “Despite the expensive pretensions of medicine, death remains the inevitable end of life, and is often unpredictable, arbitrary and unjust; yet it is seen more and more as a simple failure of medicine and doctors.” She goes on: “We talk all the time about preventable deaths—as if death could ever be prevented rather than postponed.” When did things go wrong?
All that modern medicine can sometimes offer is a change: from one cause of death to another, or one prognosis over another. Sometimes—often even—this is good. Yet both iatrogenesis and ageism exist; we dread complaints; and litigation as a possibility hovers. In our bruised NHS, general practice is being diluted and dissolved, and our profession is increasingly regulated. Is there much of a space left for the kind of meaningful, durable relationship with patients that allows for real, personal care towards the end of life?
Evidence based medicine, or at least the appreciation of the need for it, has done much good for health. Evidence based medicine, though, does not tell us how best to apply it compassionately and individually. The favourite form of distributing modern medicine is to apply evidence only once it has been cooked down to a protocol. The very favourite form of cost effective, modern medicine is then for the cheapest person capable of doing the job to apply it, and this is more likely to mean someone with advanced training in only a limited field. Such protocols, writes Heath, “regard patients as standardised units of disease. Such protocols have no way of accommodating the unique story of the individual—the particular values, aspirations and priorities of each different person and the way that these shift over time.”
The question then becomes how to be a doctor to the individual person while using and acknowledging the evidence and uncertainty that science presents to us. Some doctors attempt to accommodate the individual by abandoning evidence when it provides results that do not suit or instead parade pseudoscience as a remedy when it happens to appeal. Heath’s illumination is rooted neither in religion nor in the touchy-feely fluffiness of much of modern training in general practice. Instead she argues, often sharply, as a humanitarian. She argues for the general practitioner’s role in “acting as an interpreter at the boundary between illness and disease, and a witness to suffering.” As we are encouraged by a variety of vested interests to overdiagnose and overprescribe, to label everyone with risk factors, and to allow no one to be normal, no doctor can afford to stop thinking about what their role really should be.
This book is a work of practical and radical philosophy disguised as a medical textbook. Heath examines the function of pain, the worth of the “intensity of life, more than its length,” the need for trust between patients and doctors, the materialism of the market based healthcare system, the futility of much “health” advice, and the goodness possible within the given terms of the finite life. It is gold. Some of her conclusions are challenging, but if they cause the reader to think, that is surely worthwhile. Medicine has had a historical tendency to do first and think later, ignoring the need for humane concern in the rush towards unthinking intervention. Those who, like me, struggle with the political direction that general practice has been sent in will find themselves buoyed by Heath’s robust rigour. But it is those in government who really need to read this book.
Cite this as: BMJ 2008;337:a1024
Matters of Life and Death
Radcliffe Publishing, £17.95, pp 126
ISBN: 978 1846190964