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138 pp. Price £12.95 ISBN 0-7156-2973-5 (h/b)
London: Duckworth .
The book forms part of a series called The Intelligent Person's Guide — to ethics, philosophy, culture, and so forth. Most of these guides are designed as route maps, but when the publishers chose Dr Dalrymple to contribute the volume on medicine, they knew very well that they would not get a route map but something quite different—a witty polemic written from a decidedly non-politically-correct standpoint. Those who have been amused or infuriated by Dalrymple's columns in magazines and newspapers will not be disappointed: this is vintage Dalrymple, grumpy, iconoclastic, well informed and immensely readable.
He starts with three main premises. The first is that ‘health’ is a Humpty Dumpty word (it means what I say it means) and is thus indefinable. The second is that healthcare is not a right but a good, to be marketed like cars or holidays. Finally, all arguments about the relative virtues of healthcare systems do not amount to very much because they all get it roughly right (or wrong) in the end. We remain well or get ill and die, whatever the actions of politicians or the distribution of gross national product. For example, much fuss is made about the inferior services for cancer and cardiovascular disease in the UK compared with other European countries, but as these diseases account for two-thirds of deaths in all of these countries yet life expectancy across them is almost the same, the impact of such alleged differences cannot be as great as is claimed.
So far so good, but inconsistencies begin to creep in. If we cannot define health, then all discussion of healthcare systems becomes idle. There is nothing surprising in the fact that, although we in the developed world are getting steadily ‘healthier’, at the same time the number of doctors is rising and they are busier than ever. We are simply dying of other things, albeit rather later and more expensively. Diphtheria and polio have been replaced by cancer and heart failure—risks from which we were in the past protected by our youth. The hard-nosed pragmatic Dalrymple drops his mask from time to time. Thus on page 44 we are told that ‘no-one has a right to health care’. Fine fighting words and well supported by arguments too complex to be set out in this review. But three pages later we are told that ‘no one would want to see a society in which the ill were denied help... humane kindness, decency, solidarity and sympathy demand that we succour the sick’. However, the corollary of a right is a duty, and if it is our duty as kind humans to succour the sick, then surely the sick have a right to expect it of us. That leads us on to define who is sick and who is not, and here Dalrymple is as confused as are the rest of us in exploring the grey area that lies between medical illness and social distress. Most doctors would agree that the persistent self-multilator (Munchausen syndrome) who staggers from hospital to hospital simulating life-threatening crises and submitting himself to repeated operations must be by any sensible definition mentally ill, with a condition that one day may be treatable. Dalrymple would see this as a moral problem, and one which the patient (or delinquent) should be asked to face.
Dalrymple is superb on the potential charlatanism of ‘alternative’ medicine and on the capricious inequalities in the National Health Service. He has some rather beguiling prejudices. For example, there is a quite unexpectedly ferocious attack upon dermatologists—surely one of the gentlest and least harmful of all specialties. The book is full of dilemmas and paradoxes of which most of us are well aware, but is notably thin on solutions. The arguments for and against abortion and euthanasia are set out with brilliant clarity—a better exposition than most of us have ever read—but when it comes to suggesting answers Dalrymple shies off. There are several inaccuracies: for example, he tells us that the overall percentage of GNP spent on health is the same in the UK as in France or Germany, and that most cancers are incurable. So, when we are assured that the symptoms of opiate withdrawal are no worse than a dose of `flu, we don't entirely believe him. It would be reassuring to have some footnotes or a list of references to back these assertions—though as a prison doctor he must know about such things.
Therein lies the problem. Dalrymple's clinical experience is dramatically different from that of the average doctor in the NHS. His typical patient is a sullen, tattooed, heroin addicted football supporter with a history of childhood abuse, who has revenged himself on a series of vulnerable women whose children he has fathered and abandoned. That such people exist in sizeable numbers is beyond dispute, but hard cases make bad law, and to start from such a standpoint tends to narrow one's argument. We all agree that, although it is not possible for a doctor to like all of his patients, he is nonetheless professionally obliged to swallow his prejudices and treat them with equal honesty and compassion. But when you dislike all of your patients this must become very difficult to achieve.
One is left with the impression of a very intelligent doctor who is skilled in diagnosis but somewhat weak on patient care. Many of us would rather consult a doctor who had something to offer, however imperfect, than one who reiterated our problems and told us to snap out of them. But the book (or perhaps pamphlet?) deserves to be read by anyone seriously interested in helping the sick, because it challenges many of our assumptions.