The thought police take over the surgery

The message from medical journals is that the NHS is beyond criticism and reformers are motivated by economic self-interest

Features
(©BMJ)

Only other people have vested interests: we do not. The term is always one of disapprobation: no one is said to have a vested interest in doing good. It is not surprising, then, that we are infinitely better at spotting motes than beams.

A recent edition of the British Medical Journal recently had a cover story with the title The new politics targeting the nanny state. The accompanying artwork on the cover consisted of a Mary Poppins-type figure carrying an umbrella as the bulls-eye of a target (see above). The drift of the article inside was as follows: a number of Conservative Members of Parliament (some of them prominent and likely to be ministers) had either supported or been supported by the Institute of Economic Affairs; the Institute of  Economic Affairs received financial support from tobacco, processed food and alcoholic drink companies; therefore, future health policy is likely to reflect the vested financial interests of these companies rather than those of the public health as defined by experts without vested interests of their own.

No one could deny that large corporations have often resorted to intellectual and financial dishonesty in defending their interests. The large tobacco companies, for example, long sought to deny or minimise the harm done by their products. Pharmaceutical companies suppressed data from trials that were not flattering to their products. But this is not the same as saying that such companies are the only organisations with vested interests to defend, or indeed that they have no legitimate interests to defend or no interests that serve or coincide with the general good. The crudity of thought in the article in the BMJ  is worthy of that of 1970s polytechnic sociologists; the article could have been written by Mr Corbyn, if he had the literary ability.

The main rhetorical instrument of the article is insinuation. Thus we read about the Conservative MP Owen Paterson, who recorded a contribution of £84 from the IEA for travelling expenses to a conference in the US:

In 2014 Paterson, a former environment secretary, formed his own “independent centre-right think-tank” called UK 2020, set up “to produce a manifesto for the leader of the Conservative Party contesting the general election in 2020.” In 2016 it published its first report, written by Kristian Niemietz, the IEA’s head of political economy, which compared the NHS unfavourably with other national health systems. In a speech launching the report, Paterson questioned whether “a centralised state-run monopoly of healthcare is the best and only way to run a universal healthcare system that is fair.” Paterson has complied with parliamentary rules by declaring receipt of donations from his own think tank, which does not reveal its funders, but he had declined to say where its money comes from.

‘Whatever one’s view of the NHS, it is surely possible to criticise it on perfectly rational grounds

The implication is clear: the view that a centralised monopoly of healthcare might not be the best way to organise healthcare is merely an intellectual smokescreen for predatory commercial interests.

This is surely rather peculiar, and in a way sinister, as if criticism of the NHS were ipso facto heresy. But whatever one’s view of the NHS (for example that it is a curate’s egg), it is surely possible to criticise it on perfectly rational grounds. Study after study shows that its results in certain important fields are among the poorest in Western Europe; indeed, this is something that even its leaders accept, though they always attribute poor performance to lack of funds. To take only one comparison: when the NHS was founded, the health of the French or Spanish populations was markedly worse than that of the British, but after three-quarter of a century of the NHS, it was markedly better. To be sure, the health of a population is not determined only by its healthcare system; nevertheless, this cannot be depicted as a triumph for the NHS, nor can anyone who seeks the no doubt complex reasons for the reversal be simply characterised as a paid propagandist for commercial interests. It is possible, after all, that Owen Paterson received the funding because he held the views he did, rather than that he held the views he did because he received funding.

It is possible for everyone, of whatever point of view, to play the insinuation game. The British Medical Journal is at least as much the politico-ideological arm of the British Medical Association as it is a scientific journal (the balance between science and propaganda has changed completely within the span of my career). The BMA itself is paid for by the subscriptions of doctors, who in Britain probably receive at least 90 per cent of their income from public funds: ergo it is only natural that it should not only consistently seek ever-greater government intervention in the affairs of man, but place a preponderant importance on funding for health.

Perhaps that is the reason that modern doctors can see the consumption of tobacco and alcohol (indeed, of almost anything else) only through the lens of health effects. To most modern doctor-philosophers, everything, up to and including a meal, is either health-giving or health-harming, and it is the most important function of a government, under their expert direction, to promote the health and prevent the harmful. They are the Islamic fundamentalists of human welfare: their religion allows the healthy and forbids the unhealthy. They do not recognise any ambiguities. Vested interest for them arises only from the possibility of making a commercial profit: their own demand for control over ever more resources, or for ever more power to forbid, is purely and objectively for the good of humanity. As the BMJ puts it, concern has been “prompted” that the current Health Secretary might be “listening to the views of vested interests above those of the health community”. The “health community”—assumed to be of one mind, incidentally—has no vested interests, because its interests by definition cannot be vested.

The article (by no means the first of its type) seems to accept the vulgar Marxist notion that private economic interest is the only kind of sectional interest that there is or can be. According to this worldview, public institutions cannot develop an interest, nor can the desire for power play any role in human affairs independently of financial advantage. That is no doubt why the only kind of conflict of interests that have to be declared in scientific publications are commercial ones. It is true, of course, that such interests are the easiest to measure or expose: but what is easily measurable is not necessarily the most important, nor is the most important necessarily what is easily measurable.

Financial and moral interests are in any case sometimes ambiguous. The article says, in an unmistakable tone of self-righteousness:

The MPs Raab, Hancock and Truss, as well as IEA’s trustee [Neil] Record and life vice president Nigel Vinson, did not respond to requests from the BMJ to clarify whether they were even aware of the institute’s financial relations with BAT [British American Tobacco], which was part of an industry responsible for “the single largest cause of preventable deaths and one of the largest causes of health inequalities in England”.

But was the BMJ itself not aware that four-fifths of the price of a packet of cigarettes was tax, and therefore that the government was by far the biggest financial beneficiary of smoking, at least in absolute terms? True, the tobacco companies are almost entirely dependent on tobacco sales for their income, but if the government suppressed the sales of tobacco and alcohol altogether, as it is entitled to do and as the BMJ’s article would logically require it to do, it would lose approximately £30 billion in revenues, perhaps considerably more, in so far as large numbers of people would be thrown out of work and become liabilities of the state.  No government could possibly contemplate this, and it is therefore dependent on industries whose products the article characterises as “bad for public health”—as, of course, is the BMJ dependent, at least if its argument of guilt by association is accepted as valid. Would members of the BMA volunteer to donate approximately 5 per cent of their income to the government if it would prevent their patients from smoking or drinking? It is possible, I suppose, that they would, but if I know my colleagues in the profession they would on the whole prefer that other people sacrificed their 5 per cent to achieve this.

A sense of irony is another thing missing from the article. It is a curious fact that, in this country at least, an increase in health inequality between the richest and poorest decile, so often lamented by the BMJ, increased as public health campaigns against tobacco seemed to take effect. Because differentials in the rate of smoking between these deciles account for a considerable part of the health inequality, anything that more effectively persuaded the highest decile not to smoke than the lowest was bound to increase health inequality. Doctors were the first group in the population to give up smoking, being the first to be persuaded by the evidence (a refutation of the dismal idea that rational argument can have no effect upon human behaviour). Then came the rest of the educated class, and bringing up the rear social class V, the least likely to attend to logic and evidence—or alternatively that valued its own life the least.

I personally do not suffer any guilt feelings from a widened inequality caused by such a disparity in accepting the evidence, but others, who value equality of outcome more highly than I, do feel it, or say that they do. Since they can hardly advocate that the higher social classes start smoking more heavily in order to catch up (or is it down?) with the mortality of the lower classes, there is only one strategy left for them: more or less to tell the lower classes to stop doing what they are doing.

In view of the tobacco experience, whether they are likely to do as they are told is another question. The article in the BMJ  is outraged that some MPs oppose putting the precise calorific and other content on the packaging of foods, in an attempt to combat obesity. I don’t have any real quarrel with this idea except that it has a Canute-ish ring about it. The other day, for instance, I watched a fat slatternly mother in my local bakery try to force a cake on a child who clearly did not want one. Eventually, like some fanatical evangelist for obesity, she succeeded in making him eat it. If she had known how many calories the cake contained, would she have desisted?

On matters of public health I am not an ideologist, more a pragmatist. I do not think there is a simple principle that covers all cases. The trouble with libertarianism is that, as a matter of political reality, it cannot bring home to people all the consequences of their own conduct. The problem with nanny-statism is that it treats people as if they were minors, not really responsible for their own choices, and then is surprised when the faculty of making proper choices withers.          

I am not so much concerned that the views expressed in this article should be expressed (everyone is entitled to his opinions) as that there is not likely to be much debate about them. One has the impression on reading the medical journals—the New England Journal of Medicine, the Lancet, the Journal of the American Medical Association, the BMJ—that a kind of stifling pensée unique has overtaken or infected an important part of the medical world: a pensée unique from which it is increasingly harmful to a career to dissent.