The wrong life

Sir Simon Wessely is President of the Royal College of Psychiatrists. Together with Greg Smith, who works for the College, he wrote this excellent article about proposals to eliminate the payment of welfare benefits to fat people and people with alcohol problems. It is suggested that they will have their benefits withdrawn if they don’t accept treatment. We have to presume that it is believed that the treatment will work under these circumstances. Wessely and Smith conclude to the contrary: “…coercing people in this fashion is probably illegal, unethical, impractical and won’t save money”.

The most right wing government in modern history is flexing its muscles, trying on policies for size, and making proposals that would have made Margaret Thatcher wince. It is reasonable to suppose that this is just the beginning, and that policy attacks on the vulnerable will escalate. Some of these policies will not be implemented. Eye-watering proposals are sometimes used to manipulate public opinion to accept less draconian measures. Nonetheless, this regime has form when it comes to persecuting poorer people. Everyone working in the NHS sees the impact of the bedroom tax and the use of sanctions against claimants. It would be foolish to suggest that all claimants are virtuous or ‘deserving’, but the existing measures are unjust. They damage children and adults indiscriminately.

The prospect of further policies of this nature creates an interesting situation for Sir Simon, as the leader of British psychiatrists, as well as for less distinguished foot soldiers like me. In the foreseeable future we are likely to be told to do things that are unethical and plainly wrong, such as treating people under coercion in the absence of legal safeguards or adequate justification. For the first time in our lives, we may face a choice between our best interests and the best interests of our patients.

The Royal College of Psychiatrists has a proud history of confronting the unethical use of psychiatry, in the Soviet Union and elsewhere. It understands the importance of ethics and principles. On the other hand, it is a charity and it cannot become involved in party politics. Will its members be prepared to resist UK government policies that are plainly wrong? I don’t know the answer, but I am hopeful that they will, not least because the President of the College has made a prompt and clear statement of principle.

Psychiatrists are always at their best when they get alongside their patients. Exerting legal control over individuals, albeit temporarily, is something that is necessary but regrettable. Controlling people has adverse effects. It is a bad thing to do to another human being. It can only be justified within narrow constraints, under close ethical and legal oversight. Coercing whole categories of people is totally wrong.

What makes the proposals about the obese and the inebriated worse is that coercion only applies to poorer people. Fat people like me, with comfortable incomes, will face no compulsion. We can drink as much as alcohol as we want without molestation. The educated middle class have the highest per capita consumption of alcohol, but the physical and mental health impact of alcohol use is concentrated in the poorest section of the population.

It is sometimes argued that poor people make the wrong lifestyle choices, but it seems to me that they have lives that don’t fit with the values of privilege. They should choose to be born to wealth, public school and Oxbridge. David Cameron, Boris Johnson, George Osborne and, for that matter, Tony Blair had the foresight to choose such a start in life. Poor people are as careless about their antecedents as they are about their weight and their alcohol use. They opt for the wrong life; born without financial assets; in the unhealthiest parts of cities; and they get the wrong education.

For the most part, choice belongs to the well heeled and the well educated. At birth, there is no way of choosing a better life. I have experienced substantial social mobility in my lifetime, but it was an accident, not a choice. It was a consequence of the time and the place that I was born. Choice didn’t come into it. The window of opportunity started to open in 1945. It was wide open when I was born in 1956, but it had closed again for anyone born after 1980.

So we have a proposal for a ‘fat tax plus’. If it happens, most doctors will feel that it is wrong. Some will not resist implementation. They will argue that it makes no difference if psychiatrists resist, because policies get implemented anyway, and we’ll just get into trouble with our employers.

It is conventional to invoke the Third Reich at this point. This always seems like an excessive or melodramatic rhetorical ploy. If you read Robert Jay Lifton’s great book ‘The Nazi Doctors’, much of which concerns psychiatrists, it is obvious that people recognisably similar to me and my colleagues rationalised their involvement in atrocities on the basis that they were saving lives, not destroying them. The lesson is that anyone can drift into harming patients. You can only avoid it if you draw a clear line about what you are prepared to do, and where you will refuse to obey. I never took the Hippocratic Oath, but I stand by the opening statement: primum non nocere (firstly, do no harm). I believe that the vast majority of doctors do. It means that you have to resist doing things that you know to be wrong.

There is a link between the need for psychiatrists to resist what is wrong and the news that left-wing candidate Jeremy Corbyn is the favourite in the Labour leadership contest. I am not a member of the Labour Party, but I want Corbyn to win. Labour may not win elections with him in charge, but there is no point to Labour Governments when they have no attachment to any principle. Tony Blair won elections, but he was the key ally that assisted George W. Bush in the historic catastrophe of the Iraq invasion. Far better that an anti-austerity Labour Party leads public opinion outside of Government than it wins power by seeking the approval of the media’s neo-liberal zealots and xenophobes.

Wessely and Smith have made a good start. Psychiatrists should stand up for people who have the wrong life.