DEATH BY DOCTOR

A.M.Daniels wonders

why people live longer when doctors go on strike

IN GENERAL I try not to kill my pa- tients, whatever their moral failings or my personal inclinations. And as a rule, with one or two exceptions, I have succeeded in this (for a doctor) modest aim. My consci- ence is clear: when the great Medical Audit in the sky is held it will be found that for every patient I have consigned to an early grave there have been a hundred, perhaps more, I have saved from the same fate.

I am under no illusions, however, that this favourable balance is due to an excep- tional medical skill on my part. My skill, I should say, is about average. Nor am I one of those who believe that only doctors who have undergone precisely the same training as myself are of any value. On the con- trary, I believe that all the doctors of developed countries — and many unde- veloped ones too — are trained to approx- imately the same standard.

Bearing all this in mind, it therefore comes as something of a shock to me that whenever the doctors in countries like Belgium or Israel go on strike, the death rate not merely fails to rise, but shows a marked tendency to fall. (The doctors usually resume work before anyone real- ises this.) What, 1 ask myself, are the doctors of Belgium and Israel doing, that when they withdraw their services people live longer?

Reviewing my own brief and interrupted career, several possibilities come to mind. I have on many occasions been asked by close relatives to kill my patients, when there was no immediate chance of their dying without ,my assistance. Usually, these requests have been entirely under- standable, if not laudable. Of all the agonies I have seen endured, none equals that of the spouse of a demented person, to whom he or she may have been married for 50 years, but who is now reduced to a dribbling, incontinent, incoherent shell of a former human being, who fails even to recognise his or her partner of a half a century. A high proportion of requests to murder have come from people who wish to retain memories of their spouse other than washing their clothes and their sheets soiled ten times a day.

A high proportion, but not all. Occa- sionally one is asked to bump off a merely inconvenient relative. I remember one lady whose psychopathic husband indulged in playful tricks like trying to push her from the fourth floor window during Christmas lunch at her daughter's flat.

'Can't you kill him, doctor?' she asked. 'Everyone would be much better off with- out him.'

I looked into her eyes and saw that she was quite serious.

'I'm sorry,' I said, 'but that service is not available on the National Health.'

'Can't I go private, then?' she asked.

If any of my patients are reading this, they will be relieved to know that I did not even make inquiries as to fees.

But even supposing my Belgian and Israeli colleagues are always more accom- modating in this respect than am I, re- quests to kill one's patients are not suffi- ciently common to exert the previously mentioned statistical effect on mortality rates when doctors go on strike. Some other explanation must be sought.

There is, of course, the matter of suicide. Requests for information about how best to commit it are by no means uncommon, but doctors are often chary of revealing professional secrets.

'Will these kill me if I take them all at once?' asked a lady to whom I had just handed a prescription.

'No,' I replied.

'Not even with a bottle of whisky?' 'No,' I replied.

'Well, they're no bloody use then,' she said, handing back the prescription.

However, even if Israeli and Belgian doctors positively encourage their patients to commit suicide and give them the wherewithal to do it, I do not think the 'Was it wise to give money to a middle-of- the-road party?' statistical anomaly is fully explained. The explanation, I believe, lies far deeper.

It appears I have been deluding myself about the number of lives I have saved. Medical historians have proved beyond reasonable doubt that the great improve- ment in life expectancy that industrialised countries experienced in the 19th and early 20th centuries had,little or nothing to do with medical advances. Since then, medical knowledge and expenditure have increased geometrically, but life expectancy only arithmetically. Indeed, there seems to be an inverse relation between the number of doctors in an economically developed country and the infant mortality rate.

But at the same time there remains a totally refractory differential in the mor- bidity and mortality between the higher and the lower social classes, if anything all the greater since the creation of the unified National Health Service. It seems, there- fore, as though medical services (other I than those devoted to prevention and public health) are not important determi- nants of the level of health of a population. So it is scarcely surprising that when doctors go on strike the result is less than catastrophic. It is more surprising that left-wing publicists, dutifully appalled at the difference in health between richest and poorest, invariably end up demanding more health services for the poorest, de- spite their record of failure.

And this leads me to other slightly subversive thoughts. When I was a student I worked in my vacations as a porter in a hospital. Without boasting, I may say I did the work that it normally took three men to' do — not by superhuman exertions, but merely by working steadily and con- tinuously, as presumably I was paid to do. It seemed to me then, in my naivety, that British workers had the same attitude to their work that I had as a schoolboy to my homework: namely, it was to be avoided at all costs, even if the subsequent need to make excuses rendered life wretched. The work itself was not devoid of interest, and after all it is possible to do even hospital portering well or badly. But men preferred to sit around all day with bad consciences, drinking endless cups of tea and playing cards in dark corners.

Therefore, when I hear the screams of outrage at any proposed cut in the Health Service budget — the heartlessness of the minister etc etc — I take it all at less than face value. Since its inception, the labour costs of the National Health Service have risen from under 50 per cent of the total to over 80 per cent. But since jobs are sacred, and the high priests of the unions have the

power to enforce sanctity, any cut in expenditure has to come from the decreas- ing proportion of the budget that is actually spent on the patients. Cui bono? I ask myself. The National Health Service is (or has become) an

elaborate and costly ruse to disguise the full extent of unemployment. For once, the unions and the Government have preciselY the same interests at heart.