I’ve been listening on the radio to Merope Mills talk about a new rule that is being introduced into British hospitals following the death of Martha, her 13-year-old daughter, in hospital. https://www.bbc.co.uk/news/health-68348301 Merope felt that Martha’s condition was deteriorating, but the doctors reassured her and her husband that all was well. After Martha’s death Merope felt awful that she hadn’t kicked up enough of a fuss and had let her daughter down. She has campaigned for the introduction of the new rule that she and others think will save lives and mean her daughter had not died “in vain”. Her aspirations are noble and impressive, but it’s easy for good intentions to have adverse unintended consequences, particularly in complex systems like hospitals.
With the new rule patients will be able to ask for a second opinion from a critical care team available 24 hours a day every day of the year. The team will have to be staffed, and presumably at least one member of the team should be a consultant with long experience in critical care.
I’m a great believer that patients and carers must be listened to and that their experience of care is of paramount importance, but….
Martha was 13 when she died, and deaths of children are now relatively rare (at least in Britain) and seem unbearable. But the majority of people who die in hospital are elderly and often at the end of a long illness—from frailty, dementia, and cancer. When people die they deteriorate, as is to be expected. If everybody is prepared for the death this is fine and natural. Unfortunately because “the difficult conversation” has never been had and the words death and dying not mentioned, many patients and their carers are unaware that patients are dying until days or even hours before they die. Plus there are the relatives who arrive, perhaps from far away, shortly before patients die and feel that “everything must be done.” There are also family members who find it unbearable that their family member, perhaps a partner of 60 years, is going to leave them.
It’s easy to imagine that there could be a lot of requests for second opinions on those who are dying: “surely something can be done.” This gives rise to two risks. Firstly, the pressure to “do something” may be hard to resist, and even for the skilled working out who is close to death and who might benefit in some way from further treatment is not simple: the result might be that the suffering of patents may be increased from further ultimately futile treatment. We know already that there is a lot of overtreatment at the end of life, increasing suffering; and sadly so-called “curative” care (it’s rare that the treatment does cure) is increasing faster than palliative care at the end of life. The second risk is that skilled teams, a scarce resource, may be called away from caring for patients who could benefit from their treatment.
I hope that these risks will not come to pass. Indeed, Martha’s Rule might make it more likely that the “difficult conversation” will be held and that patients and their carers will be much better informed that the patient is dying and better prepared for their death. I hope so. I worry, however, that our society’s increasing discomfort with death combined with Martha’s Rule could increase suffering a well as cost and carbon consumption for the dying and those who love them. Let’s hope I’m wrong.
I think I’m healthy, but am I right? I’m tubby. My hair is white and thin and gone altogether from some parts of my head. I’m short sighted and astigmatic. My Achilles tendon aches at times, and when I get out of bed in the morning I hobble. I haven’t had my blood pressure measured for a while; nor my blood lipids. My prostate is, I suspect, large, but I haven’t had it examined. Nor have I had my prostate specific antigen measured. And my bowel has not been sigmoidoscoped. My genes have not been examined, but I suspect something dreadful lurks there. My mother is dementing as her mother did before her. I often can’t remember names. I don’t smoke, but I drink more alcohol than the Royal College of Physicians thinks wise—and I’m rather too fond of pies. I walk a lot, cycle often, and run occasionally, but I don’t exercise as much as I should.
So as I complete this paragraph I’m convinced that I can’t be healthy: I’m a mass of imperfections, and I’ve not bothered to discover the hypertension or latent cancer that may be about to carry me off.
But what is health? For most doctors that’s an uninteresting question. Doctors are interested in disease, not health. Medical textbooks are a massive catalogue of diseases. There are thousands of ways for the body and mind to go wrong, which is why disease is so interesting. We’ve put huge energy into classifying disease, and even psychiatrists have identified over 4000 ways in which our minds may malfunction.
Health for doctors is a negative state—the absence of disease. In fact, health is an illusion. If you let doctors get to work with their genetic analysis, blood tests, and advanced imaging techniques then everybody will be found to be defective—”dis-eased.”
Could we, however, have reached a stage when the concept of disease has ceased to be helpful? It was useful in the 19th century as fever was broken down into a series of conditions with different prognoses and treatments. Mary Tinetti and Terri Fried have argued in the American Journal of Medicine that thinking in terms of disease has become counterproductive.. “The time has come,” they write, “to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and non-biological factors, the aging population, and the inter-individual variability in health priorities render medical care that is centred on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment.” https://pubmed.ncbi.nlm.nih.gov/14749162/
Consider a patient called Lucy. She has heart failure, diabetes, asthma, and osteoarthritis. Her cardiologist treats her heart failure, her diabetologist her diabetes, her chest physician her asthma, and her rheumatologist her osteoarthritis. Her general practitioner holds the ring and writes her prescriptions.
But actually she’s not much interested in her diseases, and she’s not worried about dying. Indeed, if she could get to see her son in Australia one more time she’d welcome death: life has never been the same since her husband died. She needs a travel agent, not five doctors, but doctors are supplied on the NHS and travel agents aren’t.
I’m coming close to flippancy, but in a world where most of medicine is concerned with people with multiple chronic conditions combined with social and family problems health care must be person not disease centred.
So I’m not happy with health being defined as the absence of disease. Nor am I keen on the World Health Organisation’s definition of “Complete physical, psychological, and social wellbeing,”a state reached only at the moment of mutual orgasm, joked Peter Skrabanek. It’s a ludicrous definition that would leave most of us unhealthy most of the time.
My favourite definition of the moment is Sigmund Freud’s definition, which was never written down by him, of “the capacity to love and work.” You might be hours from death and still healthy because you can love and work. Freud selected love and work because these are the things that he regarded as most precious—and many, including me, would agree with him.
But if you’re a traffic warden rather than the inventor of psychoanalysis you may not be so keen on work. We are being led to the conclusion that we each must make our own definition of health—just as we each define “the good life.”
For you, it might be fast cars and fast women, whereas for me it’s being with my wife, drinking red wine, listening to Schubert, and writing blogs that probably nobody reads.
I was intrigued by what I read today in Peter Frankopan’s book The Earth Transformed: An Untold History about a 2019 big data study on the frequency of words used in almost 130 000 British television programmes between September 2017 and September 2019. https://wearealbert.org/editorial/wp-content/uploads/sites/6/2019/05/Subtitles-to-Save-the-World-Report-FINAL.pdf The researchers were interested in how frequently “climate change” and “global warming” were mentioned.
Frankopan introduces the results by sharing the statement produced from the 1988 Toronto Conference on Changing Atmosphere: human activities amount to an “unintended, uncontrolled, globally pervasive experiment whose ultimate consequences could be second only to a global nuclear war.” Global warming was predicted in the 19th century, but it was the late 80s before it emerged blinking onto the global agenda.
But how long has it taken to percolate through to broadcasters and citizens? The broad answer is a long time. Here’s Frankopan’s summary of the results of the study:
“ ‘Climate change’ and ‘global warming’ were mentioned 3,125 times and 799 times respectively. To put that in perspective, ‘gravy’ was mentioned 3,942 times, ‘cheese’ almost 33,000 times and ‘dog’ 105,245 times. In a follow-up report published in the autumn of 2021, climate change was mentioned marginally more often than ‘goldfish’, slightly less often than ‘Shakespeare’ and just over twice as often as the word ‘motherfucker’.”
My guess is that it would be different now and the phrases would appear much more frequently. A combination of the campaigning of Greta Thunberg and Extinction Rebellion and COP being held in Glasgow in 2022 pushed climate change up the agenda. And ironically the political attempt to make it a “wedge issue” may well have boosted it further. It seems to be second only to the cost of living as an issue in the forthcoming general election.
The study Frankopan quotes makes me think of other studies and of a film and a violinist. The studies, including one where I’m an author https://www.medrxiv.org/content/10.1101/2023.10.19.23297267v1 , have looked at how often health journals have published on climate change and health, the major threat to global health. Some journals published on the subject in the early 1990s, but many journals published nothing until well into the 21st century. Many still haven’t published anything. The number of articles on climate change and health began to increase rapidly in about 2006. This pattern may say something about the ecology of information with reports moving from science journals to health journals to the mass media.
The film I think of is, of course, the 2021 Don’t Look Up, which had more than the usual share of “Hollywod A-listers” and parodied the inability of broadcasters and politicians to respond to a planet hurtling towards earth. The film ends with the world destroyed and a few rich people (think Elon Musk and Jeff Bezos) arriving on another planet with one of them promptly eaten by a strange creature.
I have such respect for great writers that I believe what they write. I also believe fervently that “the truth is in the fiction” because only then can gifted writers write what they think without being constrained in what they write because of fear of offending somebody somewhere.
John Galsworthy was a great enough writer to win the Nobel Prize for Literature in 1932, and The Forsyte Saga is his masterpiece—and I think a great book. (As an aside, James Joyce’s Ulysses and T S Eliot’s The Wasteland, the two great works that are seen as the start of a new age and a new way of writing were both published in 1922. Yet ten years later the Nobel prize was give to a writer more in the Victorian than modern tradition. Most critics would rank Ulysses and the The Wasteland way above The Forsyte Saga, and I would as well.)
Respecting Galsworthy’s genius, I tend to believe the paragraph below that argues that all people of great age have at some time contemplated suicide. I’m 71 and have not ever contemplated suicide, or if I have I’ve forgotten it. But in 2024 71 probably does not constitute “great age.” Galsworthy died when he was 65.
In reading the paragraph think people not men and know that most middle class people are (or at least were when the 19th century turned to the 20th) Forsytes and that the two defining qualities of a Forsyte are “the power of never being able to give yourself up to anything soul and body, and the ‘sense of property’.”
“For all men of great age, even for all Forsytes, life has had bitter experiences. The passer-by, who sees them wrapped in cloaks of custom, wealth, and comfort, would never suspect that such black shadows had fallen on their roads. To every man of great age the idea of suicide has once at least been present in the ante-room of his soul; on the threshold, waiting to enter, held out from the inmost chamber by some chance reality, some vague fear, some painful hope. To Forsytes that final renunciation of property is hard. Oh! it is hard! Seldom – perhaps never – can they achieve it; and yet, how near have they not sometimes been!”
“Tarka the Otter” is a beautiful book, a long poem that allows you to come as close to being an otter as is humanly possible. But Henry Wiliamson writes in the book about other animals and birds in exquisite cameos, and the one below about curlews spoke to me. I particularly liked the line “In early summer the wild spirit of the hills is heard in the voices of curlews.” It took me back to May 2019 when I walked alone from Ravenstonedale to Kirkby Stephen and heard curlews cry on the top of the hills. Those magical moments have caried me through much.
“Within the moor is the Forest, a region high and treeless, where sedge grasses grow on the slopes to the sky. In early summer the wild spirit of the hills is heard in the voices of curlews. The birds fly up from solitary places, above their beloved and little ones, and float the wind in a sweet uprising music. Slowly on spread and hollow wings they sink, and their cries are trilling and cadent, until they touch earth and lift their wings above their heads, and poising, loose the last notes from their throats, like gold bubbles rising into sky again. Tall and solemn, with long hooped beaks, they stalk to their nestlings standing in wonder beside the tussocks. The mother-bird feeds her singer, and his three children cry to him. There are usually but three, because the carrion-crows rob the curlews of the first egg laid in each nest. Only when they find the broken empty shell do the curlews watch the crows, black and slinking, up the hillside.
Soon the curlew lifts his wings and runs from his young, trilling with open beak; his wings flap, and up he flies to fetch song from heaven to the wilderness again.”
A few weeks ago I wrote a blog that described my thought experiment on the dramatic steps we would need to take if we are to have the courage to declare war on the climate and nature crisis. https://richardswsmith.wordpress.com/2024/01/23/a-thought-experiment-what-should-be-our-priorities-when-we-finally-declare-war-on-climate-change-and-the-destruction-of-nature/ I drew comparison with the policies introduced when Britain declared war against Germany. But today I’ve been reading about a more recent and more directly relevant example of extreme steps being taken—this time not a declaration of war but the actions taken in the US to counter the shortage of oil that resulted from the Yom Kippur War in October 1973.
I’ve been reading about the Us reaction to the oil shock in Peter Frankopan’s monumental book—both in size and reach—on the importance of climate and its accompaniments (famine, pandemics, droughts, fires, floods, migration, and war) in the history of earth and humanity. The book is called The Earth Transformed: An Untold History.
Richard Nixon was the president at the time and made a speech to nation on 7 November, in which he said that the country was facing “the most acute shortages since World War II.” Dramatic action was needed: “we must use less energy – that means less heat, less electricity, less gasoline.” The US also needed to “develop new sources of energy.”
“It will be essential for all of us,” said Nixon, “to live and work in lower temperatures.” Lower “the thermostat in your home by at least 6 degrees [Fahrenheit].” This would be good for health, he’d been advised. Offices, factories and ‘commercial establishments’ were required to reduce temperatures by 10 degrees Fahrenheit.
Energy consumption was cut across “every agency and every department in government.” The school year was changed. “Unnecessary lighting” was stopped. People—in an unAmerican way—were encouraged to use public transport, and a speed limit of 50 miles per hour was introduced, a change that has largely persisted—perhaps because it saved lives and injuries as well as energy. ‘We must all co-operate to change,’ said Nixon.
Jimmy Carter became president in 1976 and worried about the cost of oil and gas. The US used more oil and gas than ever before in the summer of 1977, and Cater said that the country needed to “cut back on consumption, shift away from oil and gas to other sources of energy and encourage production of energy here in the United States.” He introduced a billion dollar programme “to hasten the shift from oil and gas to coal, to wind and solar power, to geothermal, methane, and other energy sources.”
In 1979 Carter installed solar panels on the roof of the White House and said: “In the year 2000, this solar water heater behind me, which is being dedicated today, will still be here supplying cheap, efficient energy…A generation from now, this solar heater can either be a curiosity, a museum piece, an example of a road not taken, or it can be just a small part of one of the greatest and most exciting adventures ever undertaken by the American people.”
In 2024 we know that it’s “an example of a road not taken.” The dangers of greenhouse gases causing climate change had been identified in 1979 but it was another decade before it began to arrive on the political agenda.
“The world,” said Carter in 1976, “has not prepared for the future,” while setting, writes Frankopan, “ambitious goals to insulate homes and new buildings, and to develop and expand solar energy.” These developments would “protect our jobs, our environment, our standard of living, and our future…We must not be selfish or timid if we hope to have a decent world for our children and grandchildren.”
Perhaps unfortunately Carter mixed his message on energy with moralising: “In a nation that was proud of hard work, strong families, close-knit communities and our faith in God, too many of us now tend to worship self-indulgence and consumption.” he said in July 1979. “Human identity is no longer defined by what one does, but by what one owns.”
This was not a popular message and contributed to Ronald Reagan winning a landslide in 1980 and introducing the neoliberal economic policies that have hastened the climate and nature crisis.
Reading on in Frankopan’s book I come to this sentence: “It was not just President Bush who realised that saying the right things about climate helped win votes while doing something about it lost them.” I fear that the Labour party came to the same realisation this week when abandoning its commitment to investing £28 billion a year in a Green Fund.
I’ve long wanted to see Ibsen’s play An Enemy of the People, and this week I did for the first time. The play, which is constantly performed and adapted, is arguably more relevant now than when it was first performed in 1882. It has a lot to say in a world of populism, environmental destruction, polarising social media, curtailments on free speech, and the suppression of whistleblowers.
Ibsen wrote the play as a response to people calling his play Ghosts (which by coincidence rather than design I saw two weeks ago https://richardswsmith.wordpress.com/2024/01/26/lives-and-a-room-full-of-ghosts/ ) degenerate, immoral, and scandalous. The hero (or antihero) of An Enemy of the People is a free-thinker who sees truths that the majority fail to see and is punished as a result.
My brother and I saw the first preview (that is, the first performance in front of an audience and before critics see it) of the new production that has Matt Smith, a well known actor from television and film, playing the hero Dr Thomas Stockman. The audience was younger than the usual London theatre audience, perhaps because Smith had attracted a different audience.
Before the play began we were told that one of the characters was ill and would have to be played by an understudy. “There’ll be nervous as hell,” said my brother, a stand-up comedian, playwright, actor. The first half did feel awkward even amateurish.
Dr Stockman has been appointed as the medical offer of the baths, which are beneficial for health and the main reason that visitors come to the town. The baths are vital to the economy of the town. Dr Stockman has become worried that far from being healthy the baths may be infecting people. He’s written an article for the local paper saying so. In the first act he receives scientific evidence that the waters do contain pathogenic bacteria. It’s now a scientific fact that the waters are dangerous. The baths must close. His brother, the mayor and chair of the baths committee, urges him to be cautious. He could destroy the economy of the town. In the two subsequent acts the editor of the newspaper comes under pressure and decides he won’t publish the article. Dr Stockman calls a public meeting to make his case.
After the interval the play resumed with Dr Stockman about to address a public meeting, and the play sprang into life. We, the audience, became the public. The house lights were turned up. The mayor spoke first, providing “context” and effectively telling the audience to disregard what his brother had to stay. Matt Smith then launched into a tour de force of a speech, moving beyond the problems of the baths being contaminated to arguing that the whole body politic was rotten. He spoke of inequality, poverty, climate change, consumerism, social media, the Post Office scandal (big roar of approval from the audience), Rishi Sunak, and other modern horrors. He condemned “the liberal majority” for failing to recognise truths and accept new ideas. At the end of this dramatic speech the chair asked the audience how many people agreed with Dr Stockman. Almost everybody put up their hand.
The chair of the meeting then asked people in the audience to say why they agreed with Dr Stockman. The audience was now part of the play. This could have been very good if people in the audience had spoken powerfully, but that didn’t happen when we saw the play. Nevertheless, the chair handled it well and us being both the audience and the public in Dr Stockman’s town added to the play’s impact..
Both my brother and I wondered how this modernised speech related to the original version, and I’ve found that in the original version Dr Stockman is often interrupted, concentrates on the issue of the baths, although he is clearly talking about more, and—most importantly—the audience is against him, calling him an enemy of the people three times. We did the opposite, seeing him as a hero, voicing what we felt.
I’ve found the original English version online, and there is, of course, overlap between it and the version delivered by Matt Smith. Much of it is below this blog, but here are some central points:
“The most dangerous enemies of truth and freedom in our midst are the compact majority. Yes, the damned compact, liberal majority—they it is!”
“The majority is never right. Never, I say. That is one of those conventional lies against which a free, thoughtful man must rebel.”
“I am going to revolt against the lie that truth resides in the majority. What sort of truths are those that the majority is wont to take up? Truths so full of years that they are decrepit.”
“And you shall hear this also; that free thought is almost precisely the same thing as morality.”
“Here in the town, since the whole compact majority is unscrupulous enough to be willing to build up the prosperity of the town upon a quagmire of lies and fraud.”
In the final act we learn that Dr Stockmann has been fired and his wife fired from her job as a teacher. They are facing penury and have a baby. But Dr Stockman’s wife’s father, the richest man in town, has bought up the shares of the bath at a low price as the price has been driven down by Dr Stockman’s complaints. The father gives the shares to Dr Stockman and his wife, and we are left wondering if they might be tempted to ignore the health hazard, promote the baths, and become financially secure.
Like others, I identify with Dr Stockman, the good and the bad. Like him, I am loud-mouthed, impulsive, attention-seeking, and quick to spot what’s bad. I also have many messages that people don’t want to hear. Many people must have had climate change in mind throughout the play, particularly during Dr Stockman’s marvellous rant.
We have known about climate change for at least 50 years, including its potential to make the planet uninhabitable for humans. But it was a message that people didn’t want to hear because it threatened their way of life and required changes they weren’t prepared to make. As in the play, it threatened as well the economy. People denied or disavowed climate change, but slowly the “liberal majority” has come to recognise its importance—but most probably too late. And still our response is inadequate.
An Enemy of the People is a great play with modern relevance. See it if you have the chance. Arthur Miller’s film version with Steve McQueen playing Dr Stockman can be rented or bought.
The essence of Dr Stockman’s speech in the original version:
“If anyone imagines, from what I have said here, that I want to exterminate these gentlemen [the establishment] to-night, he is mistaken—altogether mistaken. For I cherish the comforting belief that these laggards, these old remnants of a decaying world of thought, are doing this admirably for themselves. They need no doctor’s help to hasten their end. Nor, indeed, is it this sort of people that are the most serious danger of society; it is not they who are the most effective in poisoning our spiritual life or making pestilential the ground beneath our feet; it is not they who are the most dangerous enemies of truth and freedom in our society.
Yes, you may be sure I will name them! For this is the great discovery I made yesterday! (In a louder tone.) The most dangerous enemies of truth and freedom in our midst are the compact majority. Yes, the damned compact, liberal majority—they it is! Now you know it.
The majority is never right. Never, I say. That is one of those conventional lies against which a free, thoughtful man must rebel. Who are they that make up the majority of a country? Is it the wise men or the foolish? I think we must agree that the foolish folk are, at present, in a terribly overwhelming majority all around and about us the wide world over. But, devil take it, it can surely never be right that the foolish should rule over the wise! (Noise and shouts.) Yes, yes, you can shout me down, but you cannot gainsay me. The majority has might—unhappily—but right it has not. I and a few others are right. The minority is always right.
I am going to revolt against the lie that truth resides in the majority. What sort of truths are those that the majority is wont to take up? Truths so full of years that they are decrepit. When a truth is as old as that it is in a fair way to become a lie, gentlemen. (Laughter and interruption.) Yes, yes, you may believe me or not; but truths are by no means wiry Methusalahs, as some people think. A normally-constituted truth lives—let me say—as a rule, seventeen or eighteen years, at the outside twenty years, seldom longer. But truths so stricken in years are always shockingly thin. And yet it is only then that a majority takes them up and recommends them to society as wholesome food. But I can assure you there is not much nutritious matter in this sort of fare; and as a doctor I know something about it. All these majority-truths are like last year’s salt pork; they are like rancid, mouldy ham, producing all the moral scrofula that devastates society.
And you shall hear this also; that free thought is almost precisely the same thing as morality. And therefore I say that it is altogether unpardonable of the Messenger to proclaim day after day the false doctrine that it is the masses and the multitude, the compact majority, that monopolise free thought and morality,—and that vice and depravity and all spiritual filth are only the oozings from education, as all the filth down there by the Baths oozes out from the Mill Dale Tan-works! (Noise and interruptions. Dr. Stockmann goes on imperturbably smiling in his eagerness.) And yet this same Messenger can still preach about the masses and the many being raised to a higher level of life! But, in the devil’s name—if the doctrine of the Messenger holds good, why, then, this raising up of the masses would be synonymous with hurling them into destruction! But, happily, it is only an old hereditary lie that education demoralises. No, it is stupidity, poverty, the ugliness of life, that do this devil’s work! In a house that isn’t aired, and whose floors are not swept every day—my wife Katrine maintains that the floors ought to be scrubbed too, but we can’t discuss that now;—well,—in such a house, I say, within two or three years, people lose the power of thinking or acting morally. A deficiency of oxygen enervates the conscience. And it would seem there’s precious little oxygen in many and many a house here in the town, since the whole compact majority is unscrupulous enough to be willing to build up the prosperity of the town upon a quagmire of lies and fraud.”
The audience responds: “Enemy of the people! Enemy of the people! Enemy of the people!”
King: Good morning. This King Charles. I’m sorry to ring so early, and I’m sure that you’re surprised to hear from me. You’ll know probably that I’ve had cancer diagnosed, and by a strange coincidence while I was waiting in the hospital an aide brought to my attention the blog you posted yesterday about the meaning of cancer. https://www.physioupdate.co.uk/news/the-end-of-cancer-would-mean-the-end-of-humanity-concludes-richard-smith-in-a-startling-book-review/ As you may guess, I’m a man who likes to think about the big picture of everything, including cancer. That’s why I’m ringing you.
Richard: I’m honoured. The first thing I need to say is that I’m sorry that you’ve had cancer diagnosed. It’s always a shock no matter how much you might be expecting it. The second thing I must say is that my blog was based on a book Making Sense of Cancer: From Its Evolutionary Origin to Its Societal Impact and the Ultimate Solution, Jarle Breivik, a cancer researcher and doctor.The book is well worth reading, especially if you are interested in the big picture. Indeed, as you’ve put cancer in the spotlight—well, even more in the spotlight—you might recommend others to read the book. It hasn’t had the attention it deserves. You might also read and recommend The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, an oncologist. Your time will be much better spent reading them than listening to lots of witless witterings in the media.
King: I should have more time for reading. Do you mind me asking if you have had cancer?
Richard: Well, I have. and I haven’t. In a literal sense I have—because I had a basal cell carcinoma removed from my chest. https://blogs.bmj.com/bmj/2018/07/20/richard-smith-ive-got-cancer/ But nobody dies of a basal cell carcinoma, and my cancer was removed within a couple of hours of me having it diagnosed. You’ll know that when people think of cancer they think of the big cancers that can kill you—lung, pancreas, bowel, breast, and prostate. Would you mind if I was critical of you?
King: Not at all. A critical friend is the best kind of friend.
Richard: Well, I applaud you for letting the world know you have cancer. An announcement avoids the awful thing of some people knowing, some not knowing, and some knowing and not being sure whether they should do. It also dampens speculation and makes clear that there is nothing unusual about getting cancer: half of us will. But I think that you’ve made a mistake in not announcing the type of cancer. You will know that there are many sorts of cancers, all with different prognoses and treatments, and that they can be at different stages. By not announcing the type you’ve reinforced the misunderstanding that cancer is one disease. You’ve also left open the possibility that you might be either right as rain or dead in a few weeks.
King: I see your point, but you must understand that my advisers, a conservative lot, didn’t want me to say what I had at all. Others have made the same point as you, and we’ll have to think some more. Now, I know you’re not a practising doctor, but have you any thoughts on treatment?
Richard: My first thought is that you should not rush into anything. There is an exaggerated idea that days even hours matter when treating cancer, but that’s generally not true. Your treatment is likely to be a long haul, and you should take time to consider the best path. You are likely to come under pressure—from doctors, family, public opinion, and the media—to go for aggressive treatment. You might be thought a wimp if you don’t—oh, there’s another book for your reading list: Because Cowards Get Cancer Too by John Diamond. But aggressive treatment may not be the best treatment—even if your aim is to put quantity ahead of quality of life. You should talk with a range of doctors and with patients who have opted for different kinds of treatment. My guess is that quality of life will be more important to you than quantity, and you should make your decision accordingly. We know that many people are overtreated at the end of life and as a result spend much of the time they do have in the clutches of doctors, hospitals, operations, and drugs rather than out in the Scottish glens where I suspect you’d rather be.
King: Thank you for that. I’ve got to go in a minute, but I wonder if you’ve another big-picture thought?
Richard: Just one. I know that you have been concerned about the planet, the future of humanity, and justice far longer than most people—and you should think of your cancer in that context. There is a good chance that you will have treatment with very expensive drugs that will keep you alive far longer than would have been the case if you developed your cancer even a decade ago. That treatment will add to the damage to the planet. Most people in the world will not have access to such treatment. Indeed, many, the majority, don’t even have access to opiates and basic palliative care at the end of life. You’ll read in Jarle Breivik’s book how despite all the investment in cancer research and treatment we have more cancer than ever—because cancer is a disease of old people and it’s one of the ways we are programmed to die. Clearly a combination of ever more cancer and expensive, environmentally-damaging drugs is not sustainable for either the planet or sickness systems.
King: Well thank you. I hadn’t thought of that but will now. Bye bye.
We have an old dog we love, and my wife and I have been debating whether to take him to the vet. Will it be worth it, asks my wife. The dog is coming up to 13 (91 in “human years”). He has a large lipoma. Some of his teeth are bad. He may be a little deaf, and he doesn’t see well. He may have arthritis in his back legs, and we wonder if he’s demented. We’ve shortened his walks. He sleeps most of the day and still enjoys his dinner.
“What will the vet do if we take him,” wonders my wife. “If we get one of those young useless ones they’ll want to X ray him, do blood tests, and anaesthetise him to look at his teeth and possibly remove his lipoma. They’ll find other things, and before we know it, we’ll have spent £2000 and have a proposal for £5000 more. It isn’t worth it. Maybe we could take him to the old vet and simply ask if there’s anything that might make him more comfortable, but he doesn’t seem that uncomfortable. Let’s not bother.” Doesn’t the same go for human beings?
Vets have a financial incentive to order tests and complicate management. Doctors in Britain don’t have the same direct financial incentive, but they do have a financial incentive in that if doctors didn’t do lots of tests and interventions, we wouldn’t need so many doctors. This sounds outrageous, and I’m not suggesting that doctors are making a direct connection between having a job and doing more tests and making more interventions. Rather they are trained to “get to the bottom of things and sort them out.” They are not trained to think: “Is this worth it from the patient’s or society’s point of view,” although many doctors learn it with age. “Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate.”
I think of my father, dead for just over 10 years. He may have had value added by the warfarin for his atrial fibrillation in that he didn’t ever have a heart attack or a stroke. He died of renal carcinoma, and value was probably added by the bronchoscopy in that his chest mass might have been treatable. But his hospital admission subtracted value in that they stopped all his drugs and got him into an uncomfortable mess. We avoided the interferon that would have cost a lot and done no good. There was value in his terminal care, but it was in the people, the conversations, and the nursing—not any kind of medical intervention.
My mother is still alive in a nursing home with no short term memory. She takes no drugs, and no value was added by her MRI scan, her visits to the GP and the memory clinic, and her elaborate psychological tests—all of which she hated. Mostly, these expensive activities subtracted value, but there was bureaucratic value in that she was diagnosed as having dementia, which opened up various financial benefits. Value has, however, come from the carers who visited her when she was at home and the home where she now lives, but we have had to pay for all of that. It seems ironic to me that the bit with no (or negative) value is free, but we have to pay for the bit that does add value.
Although with medical care—for dogs and humans—it’s easy to do a lot and end up subtracting, rather than adding value, people across the world must value medical care because there is a very close correlation between the amount that countries spend on healthcare and their GDP. As we get richer, we spend more on healthcare. But what value do we think we are getting? Economic studies show that we are willing to pay huge amounts to fend off death for a few weeks, even if the quality of those weeks is horribly low. Most medical care costs arise in the last months of life, and the value seems to lie in keeping death at bay—or rather the perception that we are keeping death at bay. We know that people who move from “curative” (completely the wrong word) to “palliative” care often live longer than those who stay with “curative” care, which is not surprising in that many of the “cures” kill us. It’s the same logic that leads to death rates going down when doctors strike.
We can’t really know the value in fending off death in that we know not what we fly to; the dreams that may come give us pause. If you believe that you are going to fry or freeze in hell for all eternity, then there seems to be lots of value in fending off death for another few minutes; although mathematicians, and even a friend’s four year old, will point out that “eternity minus a few minutes” still equals eternity. If you believe in heaven, then there can be no value in fending off death. If, like most Britons, you don’t believe in either, then I can’t see the value in spending lots on medical care to fend off death. Death, I suggest, is a very value added state: profound peace at no cost, and not even any carbon consumption.
In contrast, there seems to be little value in a horrible old age, the curse of many. The mantra has to be that an “aging society,” some of it the result of medical care, is a good thing, but is it really? A politically minded friend, who is 51, says “assisted suicide will have to come as there won’t be the money or the people to keep us when we’re old.” My message to young doctors and vets is that it’s all too easy to spend a life working hard at medicine, and end up subtracting rather than adding value.
Tarka the Otter by Henry Wiliamson was published in 1927 and immediately admired by John Galsworthy, Thomas Hardy, and T E Lawrence. It has never been out of print, and Roger Deakin praises it in his fine book Waterlog, https://richardswsmith.wordpress.com/2023/12/14/the-joys-of-swimming-particularly-wild-swimming/ calling it “a great mythic poem.” It was the passage below from Waterlog that made me want to read Tarka the Otter, and I’m mightily pleased that it did.
“[Ted] Hughes [one of Britain’s greatest poets of the 20th century] had found and read Tarka at the age of eleven and counted it one of the great pieces of good fortune in his life. For the next year he read little else. ‘It entered into me,’ he said, ‘and gave shape and words to my world as no book ever has done since. I recognised even then, I suppose, that it is something of a holy book, a soul-book, written with the life-blood of an unusual poet.’ Hughes regarded Williamson as ‘one of the truest English poets of his generation’, although he never published a word of verse. Tarka had taken four years to write, and went through seventeen drafts. Williamson rewrote Chapter Eleven, which begins at the source of five rivers up on Dartmoor, thirty-seven times. He described the writing of those paragraphs to Hughes as ‘chipping every word off the breastbone’.”
I’m reading Tarka the Otter now and was arrested by the passage below. It’s about swallows not otters and exhibits perhaps more of the anthropomorphising that the book largely avoids, one of its main triumphs. Still I loved it, and you might too.
“On the fourth night of the otters’ arrival at Ram’s-horn duckpond, the swallows which settled among the reed-maces at sunset did not sleep. They twittered among themselves when the first stars gleamed in the water, for they had received a sign to leave the green meadows they loved so well.
They talked in the undersong voices – which men seldom hear, they are so soft and sweet – while clinging to the unburst heads of the reed-maces. They talked of white-and-grey seas, of winds that fling away the stroke of wings, of great thunder-shocks in the sun-whitened clouds under, of wild rains and hunger and fatigue to come before they saw again the sparkles in the foam of the African strand.
But none talked of the friends who would fall in the sea, or be slain in France and Spain and Italy, or break their necks against the glass of lighthouses, for the fork tailed birds of summer had no thought of these things, or of death. They were joyous and pure in spirit, and alien to the ways of man.”
Williamson fought in the First World War, and was, I’m sure, thinking of those who had been killed and maimed when he wrote the last paragraph.
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