Almost 20 years ago, I attended a meeting at the Department of Health in London and found that I was seated next to the late Professor Robert Kendall, at that time President of the Royal College of Psychiatrists. I didn’t really know him. He cut a rather austere, cerebral figure. He was friendly, but not exactly chatty. He had recently retired as Chief Medical Officer for Scotland, he had been an important researcher and he was a senior member of the medical establishment. At some point, a speaker was talking about iatrogenesis, harm caused by doctors. Kendall turned to me and said “You know, in retrospect, Ivan Illich was spot on”.
I was astonished. Ivan Illich was a priest turned postmodernist who caused a stir in 1976 when his book Medical Nemesis was published (click here to read a few extracts). The central thesis was that modern medicine makes the whole of society ill through a process of medicalization.
I first read the book when I was a medical student. Whilst I don’t agree with everything in it, I have returned to it frequently. As I became an experienced medical practitioner, it seemed more and more apposite, though I couldn’t say whether this was because Illich had been prophetic, or because I came to understand more about the limits to medicine. Illich’s ideas resonate in the work I am presently doing on long term, high dose opioid pain-killers prescribed for chronic non-cancer pain (for many people, the drugs make the pain worse, not better).
Health has become a commodity, purchased through healthcare, but technical intervention at an individual level only really offers symptom relief, not health, because treatment frequently carries a burden of adverse effects and dependency on professionals. It may keep you alive, but that is not the same as health. Or this is the argument. It is true of some conditions more than others.
At the time, Kendall’s positive appraisal of Illich seemed as surprising as the prospect of Melanie Phillips going on Radio 4’s The Moral Maze to say that she might have got it wrong about MMR. Later, when Kendall died, I read his obituaries and realised that his comment was by no means out of character. The lesson here is that assumptions about other people’s ideas are often wrong, sometimes in surprising ways.
I am not an eminent figure like Kendall, but I have to admit that I am a member of the medical establishment. I probably was already in that position twenty years ago. It greatly discomforts me to acknowledge it, but it is undeniable. I find it hard to imagine how I appear to younger colleagues and trainees. I don’t know if there is an apparent paradox over my advocacy of sets of ideas that don’t necessarily come as a package. I have some austere positions over professional matters, such as on proper boundaries in relationships with patients and acceptable standards of clinical practice. I am vocal about my strong awareness of the social origins of mental illness and my anger over the misery inflicted by welfare reform. It all seems absolutely consistent to me, but younger psychiatrists may find it surprising, as they have grown up in a world where neo-liberal economic ideas have been the orthodoxy.
In my more provocative moods I describe myself as a Marxist. This is partly true. There may be very few Marxist political parties these days, but I am based in a University school of social sciences, and Karl Marx was one of the fathers of social science. As a child, I grew up with intense discussion about Marxism over Sunday lunch and Christmas dinner. Three of my four grandparents were labour movement activists (there was shock and delight when we discovered years later that the last surviving grandparent, my grandmother who was married to a Marxist, had quietly voted Tory the whole of her life, but that is another story). Most of the other grown ups in my life had some form of strong left wing political conviction. In my family, Marxism didn’t mean the Gulag, or forced collectivisation or the Berlin wall. No one advocated Lenin’s political programme or tried to rationalise Stalin’s purges. Marxism was just a set of ideas, a major part of the way in which we understood the world. I didn’t realise how strongly this had influenced me until I started working in a social science environment and was described by other people as a Marxist. I am reluctant to see myself as an anything –ist, because it implies faith rather than a reliance on evidence and reason, but I can see why they say it.
I am someone in a position of authority who holds a sincere belief that it is a moral duty to question authority. I am a creature of the left. I will not disavow my continued attachment to socialism, which is really a set of values rather than a distinct political doctrine. Instinctively, my heart lifts when I see the Greek people defy the banks, just as at the same time I worry about what economic punishment may be inflicted upon them. Shamefully, a little part of me worries about my savings if economic instability follows.
When I arrived at medical school, I set myself the objective of getting through five years with my self-respect intact, which meant not calling the consultants ‘Sir’ and not pretending to be anything other than myself. I am now senior enough that my idiosyncrasies attract little or no comment. Of course, people on the right tend to suggest that it is in someway hypocritical to be socialist and to have money. This is a ridiculous position, which has no logic. Why should it be more honest for the wealthy to be on the side of the powerful? How exactly do politicians from privileged backgrounds occupy high moral ground when they attack the powerless?
We are living through an age of global revolution and counter-revolution. These are frightening times, as revolutions have unpredictable consequences. Conditions in Detroit, where nature is reclaiming a severely neglected city, and in Athens, where people have had enough of hopelessness, are unsustainable. No one can thrive in a society where there is severe inequality. This is a period when it is important for people in positions of influence to be clear about whose side they are on. We are perilously close to a position where opposing right wing economic orthodoxies is seen as unacceptable. So, although I belong to no political party, if I am pushed to say whether I am a socialist or I am not, I will say I am, unembarrassed. And as for Marxism, well it is an important intellectual tradition, and I will not disavow that either. In times like these, you just have to stand up for what you believe to be right.