Take away their votes

Theodore Dalrymple says that bureaucracy is an increasingly poisonous menace, and must be curbed Everyone knows that it costs an immense sum to bring a new drug to market; and that the life of its patent being short, the pharmaceutical company doing so has to recoup its investment and make a profit very quickly by means of high prices; and that expenditure on research is always a gamble and no guarantee of eventual success.

Nevertheless, when all due allowances have been made, several pharmaceutical companies have been caught lately cheating in the most egregious ways. Their science has been more rhetoric than disinterested inquiry after truth: they have indulged in suppressio veri by disguising or denying the harmful effects of their products, and they have indulged in suggestio falsi by exaggerating the beneficial effects of their products. They have failed to publish research that found little or no therapeutic benefit from their products, while assiduously publishing that which did find such benefit, thereby perpetrating what in essence is falsehood, without actually lying. They have been ably assisted in this nefarious scheme by doctors who were effectively in their pay.

That is why general medical journals such as the Lancet and the British Medical Journal now insist upon declarations from the authors of the papers published in them of possible conflicts of interest that derive from the funding of their research. Even if this definition of conflict of interest is a somewhat narrow one, the development is welcome and necessary. And the pharmaceutical companies are now being forced at last to publish all the research relevant to their products, not only that which is of use in advertising and sales promotion.

Scandals continue to emerge. Not long ago the giant pharmaceutical company Merck lost 39 per cent of its share value on the discovery that it had withheld information about the increased risk of heart attack and stroke while patients were taking its new anti-inflammatory drug, Vioxx (upon whose success the success of the company in general, and the pay of the chief executive in particular, largely depended), thus laying itself open to countless lawsuits. One estimate is that Vioxx caused an additional 27,000 heart attacks in the United States alone. And it is alleged that Merck actually wanted to train its sales representatives in how to dodge awkward questions by doctors about the safety of Vioxx. Incidentally, there is one pharmaceutical sales representative for every five doctors in the United States.

The Vioxx scandal being only a few months old, the New England Journal of Medicine seems to have uncovered another even worse one. Last month it drew attention to the fact that a company called Scios was aggressively marketing a drug for intravenous use, Nesiritide, that cost $500 per dose and was without any clear advantage over far cheaper drugs for the condition — acute decompensated congestive heart failure — for the treatment of which it had been granted a licence.

The company thoughtfully provided doctors with a printed guide and a telephone helpline as to how to obtain payment from Medicare for the repeated intravenous infusions of the drug, for which there is absolutely no medical indication. (The payment to the doctor would be $619 per infusion, and the total cost to the American taxpayer $1,119.) Sales of the drug this year are expected to be about $700 million, double last year’s.

Furthermore, the drug is not totally safe. In so far as there is any scientific information, it appears that those who take it die more frequently than those who take a placebo. It seems to impair kidney function quite often, even when it does not kill. However, by the time all this catches up with the company, the shareholders (if they sell in time) and the executives will have made a packet.

I have long been uneasy about the relationship of the pharmaceutical industry to the medical profession. Small gifts, free meals, trips to beautiful foreign cities, all allegedly for educational purposes: is this the way a liberal profession should learn about what to prescribe and how to treat patients? I have known doctors whose proud boast it was to have visited every European capital and not to have paid a single penny for having done so. The doctors whom I most respect refuse all such blandishments.

You don’t have to be a ferocious opponent of market economics to think that the pharmaceutical companies should not take absolute control of our health services or medical research, however else they are arranged. In short order, the companies would have us taking even more unnecessary (and expensive) medication than we are already taking, to the benefit of shareholders, and even more to the benefit of those glorified bureaucrats known as executives, who are supposedly paid by results financial results, that is.

With the exception of those bureaucrats, we can probably all agree on this principle, whatever our political and economic philosophy. And with this agreement always in mind, let us now turn our attention to a matter of much graver significance and importance: the way governments are chosen. After all, it is not only shareholders and executives of pharmaceutical companies who have vested interests; there are many other ways of being self-serving than those used by commercial enterprises.

It is a very long time since the German sociologist Max Weber pointed out that bureaucracies soon develop interests of their own, and that while it is easy to increase bureaucracy, it is very difficult to reduce it. This difficulty arises precisely because bureaucrats become adept at defending themselves and their little empires. The sectional interests of bureaucracies, moreover, soon outweigh in importance any ostensible end they may have been set up to achieve.

If ever you needed empirical evidence of Max Weber’s thesis, you could hardly do better than observe British bureaucracies at work — or perhaps I should say at activity, since the word work usually connotes some kind of worthwhile production. Bureaucratic procedures have increased almost everywhere — education, the health services, the police force, housing and social work departments, the prisons, government ministries — to the point where they have supplanted the ostensible purposes of the various organisations in which they are employed. Thus we have more educational bureaucrats than teachers, more hospital administrators than hospital beds and (for all I know) more admirals than ships in the navy. At any rate, I should be surprised if the ratio of admirals to ships had not gone up in the last few decades.

The process under our present political dispensation is inexorable. Under it, all attempts to reduce bureaucracy increase it, and for a very good reason: bureaucrats are asked to decide their own fate. This is not to say that the individuals involved are bad people, but they are prey to imperatives greater than their own will; and they are generally miserable because they know that their life’s work is not merely useless but positively harmful and obstructive.

As an American senator once memorably said, you can’t get a hog to slaughter itself; but there is something even worse. Again under the present dispensation, all promises to improve public services amount to promises to create more bureaucratic sinecures, in the process buying the votes of those so employed, and of their dependents. The purchase could scarcely be more obvious if Gordon Brown went through the streets scattering £20 notes on election day. Incidentally, the expansion of bureaucracy (together with a desire to keep youth unemployment figures down) is the real meaning of the expansion of tertiary education: the creation of demi-semi-educated people to fill such posts. Meaningless education for meaningless jobs is the policy.

The solution is obvious. Just as we do not want pharmaceutical companies to decide what we should be prescribed, so bureaucrats and public employees should not be allowed to pass judgment on the government that employs them. The votes of those who derive more than half their income from public employ, and of all their dependents, should be withdrawn. Only thus can we have a genuine verdict on a government’s record; and only thus could a demand for better public services be translated into better public services rather than more bureaucracy and bureaucratic looting of the public purse.

Of course, I recognise the administrative and conceptual difficulties to which this might give rise. For example, in our increasingly corporatist state there are many enterprises, supposedly private, that actually depend wholly upon contracts from the public purse. If public services have been privatised, private services have been in effect nationalised, except for their ownership. There are many consultancies, operated by present or past employees of the public service, which in effect amount to the legalised malversation of public funds. However, to exclude employees of such ‘enterprises’ from voting would unduly complicate matters.

It is highly unlikely, of course, that the present government would adopt so eminently sensible a proposal as mine, mired as it, the government, is in the very corruption I have described. The nearest historical analogy I can think of is Peronism (we’ve certainly had our Evita): and Juan Domingo was John the Baptist to Tony’s Christ, announcing the coming of the Third Way.

No taxation without representation, demanded the American colonists; but it is surely time an equally important principle be accepted: that those who live off taxes should not have representation. Only then can the rottenness in the state of Britain be halted and, just possibly, reversed.