The felicific calculus of modern medicine: the survival of culture: III.

In May of this year, one of Britain's most wanted criminals, a man called Ronald Biggs, returned to Britain after thirty years of exile in Brazil. Now aged seventy-one, he was arrested on arrival and taken straight to prison. Biggs was one of the men behind the "Great Train Robbery" of 1963, whose daring astonished the country, and netted the robbers about $60 million in today's money. Biggs was caught and imprisoned, but he managed to escape to Brazil, a country with which Britain docs not have an extradition treaty. He decided to return after so long a period of exile because he was ill and impoverished (he had lived for years by granting interviews to British publications). He appeared to have calculated that the medical treatment in a British prison would be superior to that given to an indigent person of foreign extraction in Brazil.

On the day of his arrival back in Britain, a newspaper known nationally for the robustness of its views asked me whether I was prepared, as a doctor who worked part-time in a prison, to write an article to suggest that Biggs should be denied medical treatment while he was a prisoner. After all, he was a professional thief who had evaded, defied, and humiliated the British criminal justice system for many years; he had contributed no taxes to the exchequer, far from it, and now that he had returned home his incarceration would cost the British taxpayer a veritable mint of money. Plainly, he was not a deserving case.

I turned down the commission and promptly wrote an article in another newspaper of not dissimilar political bent to explain why Biggs should receive his treatment like any other patient. No doctor to whom he appealed for help could possibly say to him, "You are Ronald Biggs, you robbed a train and evaded justice for more than thirty years, and therefore I refuse to treat you." Indeed, it was the very unworthiness of the man that illustrated the strength of the medical profession's ethical commitment to treat individual patients irrespective of their moral qualities. A good man docs not receive better treatment from his doctor than a bad one: at least, insofar as it is possible for the doctor, himself a human being when all is said and done, to divorce his actions from his feelings.

This restatement of an elementary, principle of Hippocratic medical ethics called forth many vituperative letters from outraged readers. They said that if they were doctors, they would have no difficulty at all in letting Biggs die. On the contrary, they would do everything in their power to bring forward his well-merited demise. Hippocrates was a fool and a hypocrite: anyway, he had never existed. I suspect that if there had been a plebiscite at the time as to whether or not Biggs should be given medical treatment, a resounding majority, would have voted for withholding it, if not for outright euthanasia. This demonstrates that the Hippocratic ethic, like every other civilized cultural achievement, is not to be taken for granted; it has to be protected and defended, sometimes from majority opinion. Barbarism is a permanent temptation.

But there are threats to the Hippocratic ethical tradition that are far more serious and insidious than the gusts of anger that periodically sweep through the public like wind through a cornfield, leaving equally little trace because the memory of modern man is no longer than his attention span. Doctors have been expelled from the Hippocratic Garden of Eden (if they ever truly inhabited it) because they--and others--have eaten of the fruit of the Tree of Knowledge.

In the Hippocratic tradition, the doctor is the agent of the patient and of no one else. When a patient perceives he has an ailment, he visits the doctor. The benevolent doctor listens to the patient, examines him, and proposes a cure, if there is one to be had. The patient, grateful for the doctor's disinterested advice, pays him an appropriate fee for his trouble. The whole transaction is intensely simple and private: no one else need know anything about it. There are no ethical complications.

It requires very little knowledge of the conditions in which medicine is practiced nowadays to understand that medical ethics have become considerably more complex --that is to say, tense and controversial--than they were in the days of Hippocrates. To begin with, there are few Hippocratic patients any longer, those who are content to entrust or submit themselves to the wisdom and judgment of others: modern man finds that to do so in any circumstances whatever is an affront to his dignity, autonomy, individuality, and self-importance. Armed with a sheaf of raw information (and misinformation) downloaded from the internet, and unaware that right judgment is anything more than a matter of applying a simple algorithm to such information, the patient increasingly feels himself, rather than the doctor, to be the authority.