Listen up folk !

Listen up folk !

Listen up folk ! Zog our tribal leader has kept us safe from harm these last months. he has protected us from wild animals who wanted to devour us. He has protected us from other tribes who wanted to kill us. He even protected us from ourselves when he lead us away from mistakes and disasters we would have made. Let us give our young women and food to the great Zog so he continues to protect us.

Listen up folk ! Our King Albert has kept us, his loyal subjects, safe for another year. He has protected us from King Zog who surely wished to invade and kill us. He has wisely guided us and avoided many a disaster that would otherwise certainly occurred without his wise council.  Without King Albert the barbarians at the gate would surely have entered our lands; killing our men, raping our women, and butchering our babies. So let us give thanks as we give our labour and produce to our monarch and prepare for another year.

Listen up folk ! The church has again saved us;  not just our bodies but also our souls. Our priests have guided us well in ensuring we do not fall prey to heathens at the gate. We know the pagans sit and wait for the chance to kill us and take our women and children. The warn us and protect us from the work of witches and demons. Thanks also to the clergy who, through their wise advice, have kept our souls safe. They warned us of our sins and saved us from eternal damnation and the pains of hell’s fire. So let us arrange a tithe to give a portion of our wealth to the Church so it may protect us for another year.

Listen up folk ! The government has lead us safely through another year. Without them no roads would have been built, no one would have cared for the poor, our children would have been uneducated and ignorant and doctors would not have attended to our sick. Without our ruling class we would have descended into savagery killing and raping our fellow citizens. So let us feel pride when we pay our taxes as we are protecting ourselves for another year.


Check who is taking your possessions, check who holds the power. This will let you know who is your enemy.


 

In Loco Parentis – the terrifying tale of Charlie Gard

In Loco Parentis – the terrifying tale of Charlie Gard

As a doctor I have found the unfolding tragedy befalling Charlie Gard and his family extremely upsetting to follow.  This poor boy and his family are butterflies being crushed on a wheel to press home a legal point, they are unfortunates being punished having committed no crime.

Let us firstly be clear what this case is not about. Despite protestations to the contrary this case is not about the best interests of Charlie Gard. The best interests of the child (1)  are clearly important and made paramount both in the UN Convention of the Rights of the Child (2) and in British Law with the Children Act of 1989 (3) . It is clear that all the parties involved in this debate are acting because they have the best interests of Charlie at heart. The doctors and hospital feel that they, by virtue of their knowledge, know what is best to do. His parents, through love and affection, also believe that they can see the best plan and hope for their son. Both are acting in the best interests of Charlie, this is not the problem. The problem is who decides what exactly are Charlie’s  best interests.

It has always been the case that the parents of the child decide what is in the best interest of the child. This is as it should be as it reflects the natural law and ensures that the people most attached to the child’s interest are those who act as the child’s guardian. There are very few circumstances when this can be changed and they depend upon proving that the parent is being either negligent or malevolent. Neither of these factors are in play here and, if anything, the parents have taken extraordinary steps to secure chances for their child, well over and above what many parents would have been able to do.

It is interesting that, at the 24th hour, Great Ormond Street Hospital has made an application to court to revise its plans (4) possibly starting to realise that the parents’ opinion may have been closer to Charlie’s best interests, than had their own opinion been. So in this difficult calculus of what is the best plan of action it appears that Charlie’s parents may have been the better judge all along.

While these arguments over the ‘best interests’ may mean that the parent disagrees with the medical team it does not mean that the parent can compel a doctor to do something they feel is inappropriate or wrong. But again this is not the case in this situation. Charlie’s parents have never asked GOSH or the NHS to undertake treatments they do no agree with. They have gathered together sufficient resources to enable Charlie to receive this treatment by doctors who believe it is, worth a trial, in the child’s interests. This should have been the end of the dispute. Charlie and his parents should have used their money to go and try this last ditch attempt, to catch this glimmer of hope.

GOSH and its staff, however, stopped this. Their court battle stopped the treatment and refused the parents the ability to move their child. In their paternalism they not only refused to help but also stopped anyone else helping. The thousands of people who collected money to help Charlie were thwarted by this as well as Charlie’s parents and the other hospitals and doctors who wanted to help.

I am a very old-fashioned doctor and I don’t fear paternalism per se. A desire to act like a father, is a a desire to be benevolent, guiding, helpful and wise. In itself not a bad thing. It becomes bad when it belittles another party and reduces their agency. When doctors worked in a professional relationship with their patients, the doctor’s paternalism would drive them to seek the best for their patient and was usually leavened by respect for the patient’s autonomy. This combination could be valuable when there were difficult scenarios – when the future was unpredictable and  the efficacy of plans of action difficult to assess. Much of the placebo effect of medical intervention depends on this aspect of the relationship and large parts of the benefit of of healthcare comes from this caring, guiding, advisory aspect of medical care.

There was always one very good safeguard against this paternalism becoming intrusive or  belittling, when the relationship was between doctor and patient, the patient could always terminate the relationship. If they felt that the doctor’s approach was wrong they had no need to continue to use them. This was a way to safeguard the patient and also a way in which the doctor would know that they had overstepped the boundaries and they could learn where paternalism started to erode patient autonomy. But in the NHS this is difficult. The patient can’t change their doctor without a great deal of difficulty. If they change they will probably be labelled a “difficult patient” which might mar relations with their next medical practitioner.

In addition, under the NHS the patient is no longer the employer of the doctor in the UK. The most important relationship for the doctor is the one with his employer – the state, the NHS – not the the patient directly. It is the state who pays his wages, sets his targets and assesses his performance and we know “he who pays the piper calls the tune“. In this scenario paternalism is largely unchecked and can be very dangerous. Paternalism, appearing kindly and wise, can mask actions that are not in an individual patient’s best interest. Rationing and refusal of therapy is hidden as medical advice and choices are withdrawn from the patient. Doctors often find, when working in the NHS, that their attempts to maintain professional standards and a focus on their relationship with the patient can cause them difficulties. They are made to feel as if they are being disruptive when they call for what is appropriate for the patient. They can be told they are jeopardising the budgets, failing to be a team player by not following the organisation’s line, and generally made to feel awkward if they behave in a manner that was formed by their vocation and training.

In this case paternalism seems to be being employed to sweeten a bitter pill. The state wants to end Charlie Gard’s life before all options that are available have been tried. Despite having seen parents act heroically and selflessly for their child, without an ounce of malice, they would prefer Charlie died rather than allowing the parents to try all they can do. But rather than admit this we are told that they are the wise and kindly people who know what they are doing, we are awkward and unruly children causing a fuss.

Well thank God for the fuss that Charlie’s parents have made;  it may not save Charlie but they will have opened the eyes of many people and might save future families from the horror that they have had to endure. They truly are a heroic family who deserve our support (5)

 

 

 

 


[1] https://en.wikipedia.org/wiki/Best_interests

[2] https://en.wikipedia.org/wiki/Convention_on_the_Rights_of_the_Child

[3] https://www.publications.parliament.uk/pa/cm201012/cmselect/cmjust/518/51807.htm

[4] http://www.telegraph.co.uk/news/2017/07/07/hope-charlie-gard-great-ormond-street-seeks-explore-new-evidence/

[5] http://www.charliesfight.org/

The fury and rage.

The fury and rage.

Before all the dead have been found, before anyone has been buried, and the left has started using them as fodder to make political points. Before we know the facts they are trying to create the narrative – this, in their eyes, was a fire caused by austerity and social inequality. The possibilities of criminal negligence, inadequate building regulations or of materials failure are all put out of mind, while they try and stir the flames for their “Day of Rage”.

I will certainly feel enraged if we discover that malevolence or negligence caused this tragedy. If people were sacrificed for short term gain then the fury will be real and justified. But I will also be enraged if this manipulated political fury allows the guilty to hide from responsibility. I fear the shifting the focus from the real task of finding our the causes of the fire, and the causes of the failure of systems to mitigate against the fire’s deadly effects,  to the task of scoring political points will obscure the truth and allow the guilty to escape.

There are likely to be, at the very least, lessons to be learnt on how to offer help and support to communities in the wake of tragedies like this. Knowing how to do this, and doing it, is more important than scoring a point against a Tory council.

The only bright glimmer of hope so far has been in the response of the local community. Local groups and charities have managed to get assistance to the victims very rapidly and with great skill. They have shown that individuals, working voluntarily, can outperform government agencies. Rather than being ashamed of this, as some commentators have suggested, we should celebrate this and consider how we could support this approach more generally.

 

Dodging a bullet ?

Dodging a bullet ?

The was a collective sigh of relief when Macron won the French election yesterday. There was a general feeling that a bullet had been dodged and normality has been restored. There have been some congratulatory reports that the French have turned the populist tide that had caused so much consternation with the Brexit referendum in the UK and Trump’s victory in the USA. But is this the case ?

It is clear that Macron won comfortably  by nearly 2:1. However, this misses a number of other factors. Firstly the turnout was poor  compared to previous French elections and there was the lowest turnout since 1969 and this as amplified by 9% of voters voting “Blank” finding themselves unable to support either party. Secondly, as was the case previously with Chirac, many voted for Macron, holding their noses, as they wished to defeat Le Pen rather then support Macron, and, thirdly, nearly 11 million French voted for the Front National. If one looks at the distribution of this vote it shows a clear divide in France between the more prosperous metropolitan areas supporting Macron and Le Pen’s support in the rural areas and ‘rust belts’. In addition to these problems there are the additional details that Macron has to form a government without the backing of an established political party which is unknown ground.

Then there is the problem of Macron himself. He presented himself as the outsider, the agent for change, the new broom. However, his background and policies are clearly those of the EU ‘business as usual” form. He had difficulties introducing these when he was the minister of the economy in  Hollande’s government. He has plans to reduce corporation tax, reduce  the number working in the public sector, promote greater EU integration and reduce the deficit. His policies will please companies and corporations and be regarded well, but are unlikely to be well received by those at the bottom. They will do nothing to improve the lot of those who currently feel disadvantaged and left behind. If the French economy  does not continue to grow, and grow substantially,  then those 11 million who voted for Le Pen will not have found a saviour in Macron and might find their numbers grow.

It is clear that the bureaucrats in the EU and the large companies and corporations who benefit from the EU (through rent seeking and stifling competition) feel they have dodged a bullet. However, it may be that they dodged this bullet by pushing a public sector worker in front of it, and it is in no way certain that the gun won’t be reloaded.

 

 

 

Kerosene is nothing but perfume to me.

Kerosene is nothing but perfume to me.

Many writers had commented that 17880067George Orwell’s “1984” had made its way back into the best sellers lists on Amazon and elsewhere. The general opinion was that the concerns with “fake news” and fears about the growth of the popularity of right-wing populist politicians had driven this resurgence of interest in a great classic. It is excellent that this book is being re-read as it is an excellent warning about the dangers of limiting free speech and a clear exposition of how those who control language and discourse also control thought and opinion. However, an interesting article suggested that this book was not the best guide to the recent events, to which we are witness, but rather another dystopian classic, Ray Bradbury’s “Fahrenheit 451″, held that distinction. It was for this reason I reread the book.

This book has not aged at all in the 55 years since it was published. It is still a fresh, fast-paced exciting read today and I can imagine if feels even more urgent now than it did then. It describes a frightening future when literature is banned, thought and discussion discouraged and, as an alternative, an overstimulating popular culture full of noise and movement is provided (with adjunctive psychotropic drugs as needed). In this future the duty of the fireman is to find and burn books.

Unlike “1984” in this future the  state has not forced these changes on an unwilling public but rather has promoted the changes as necessary and beneficial, as a means to protect a diverse community from distress and harm.

‘Now let’s take up the minorities in our civilization, shall we? Bigger the population, the more minorities.’

‘It didn’t come from the Government down. There was no dictum, no declaration, no censorship, to start with, no! Technology, mass exploitation, and minority pressure carried the trick, thank God.’

‘Coloured people don’t like Little Black Sambo. Burn it. White people don’t feel good about Uncle Tom’s Cabin. Burn it. Someone’s written a book on tobacco and cancer of the lungs? The cigarette people are weeping? Burn the book. Serenity, Montag. Peace,’

It was also seen as a way to ensure the avoidance of distress of all. Choice requires decisions and decisions can be difficult and promote conflict, best to avoid them. Any discomfort, no matter how integral to the human condition, could be used as an excuse to restrict choice and action.

‘You can’t build a house without nails and wood. If you don’t want a house built, hide the nails and wood. If you don’t want a man unhappy politically, don’t give him two sides to a question to worry him; give him one.’

‘Funerals are unhappy and pagan? Eliminate them, too. Five minutes after a person is dead he’s on his way to the Big Flue, the Incinerators serviced by helicopters all over the country. Ten minutes after death a man’s a speck of black dust. Let’s not quibble over individuals with memoriams. Forget them. Burn them all, burn everything. Fire is bright and fire is clean.’

Indeed in this nightmare of a future all we need is pleasure and fun and just enough knowledge to allow us to be productive.

‘School is shortened, discipline relaxed, philosophies, histories, languages dropped, English and spelling gradually neglected, finally almost completely ignored. Life is immediate, the job counts, pleasure lies all about after work. Why learn anything save pressing buttons, pulling switches, fitting nuts and bolts?’

‘So bring on your clubs and parties, your acrobats and magicians, your dare-devils, jet cars, motorcycle helicopters, your sex and heroin, more of everything to do with automatic reflex.’

This is a libertarian novel, one which clearly promotes the individual over the group, one which warns against conformity, no matter how enjoyable, and promotes responsibility and cooperation with our fellows. There is no wastage in this novel, each page carries the story forward, either adding to the adrenaline rush of the chase or offering interesting and challenging insights into our society. We are often warned that if we ignore history we may repeat our mistakes and this is true. But when we also have warnings as clear as this, about our future dangers, we really have no excuse if we end in trouble.

‘But remember that the Captain belongs to the most dangerous enemy of truth and freedom, the solid unmoving cattle of the majority. Oh, God, the terrible tyranny of the majority. We all have our harps to play. And it’s up to you now to know with which ear you’ll listen.’

Did you see this about Donald ?

Did you see this about Donald ?

I am sure many others, like me, have found their timelines on facebook and twitter awash with jokes at the expense of Donald Trump. Joke about his character, his hair, his colour, his spelling ability and so on. Some are funny but most are simply attempts at humiliation. The audience for these jokes is obviously other like-minded  people and they serve as a way to share unhappiness with the present situation and to rail against this.

It reminded me of when I was a junior doctor and would share black humour with my comrades. We made jokes about dreadful things, and in dreadful taste, in an effort to show to ourselves and each other that we shared and appreciation of the predicament. It fostered camaraderie and developed support at a particularly stressful time in our career. We knew this and found it useful. However, we never mistook it for a strategy to improve things. It was a coping strategy not a mechanism for change. Increasing experience and knowledge, union activism, and political change were the things which improved things (partially), not our black jokes.

I can therefore understand why some people make jokes about Trump. It helps them cope and to identify themselves to other fellow ‘sufferers’ so they may develop a sense of community and lessen any feelings of isolation. But is it wise in the world of politics, and, more importantly, could it be counter-productive ?

Though many wish to go back to the thirties to look for historical similarities which might help us understand Trump this is unnecessary. We barely need to go back 10 years and can look at the story of Silvio Berlusconi, the infamous Prime Minister of Italy, who despite many obvious failings also has the distinction of being the longest serving Prime Minister of Italy as well as the most controversial.

In an article in the  New York Times Luigi Zingales considered how this pompous, brash, and at times corrupt man could remain in power for so long. One reason seems to have been the failure of the opposition to him to take him seriously, and the tendency of the opposition to focus on his personality rather than on politics. As with Trump, there was no shortage of attempts to bring down Berlusconi with humour and ridicule. Unfortunately, while this made the opposition feel good about their ability to create stinging puns, and confirmed their prowess in the cartoon, it did nothing to unsettle him and may have strengthened his position.

Mr. Berlusconi was able to govern Italy for as long as he did mostly thanks to the incompetence of his opposition. It was so rabidly obsessed with his personality that any substantive political debate disappeared; it focused only on personal attacks, the effect of which was to increase Mr. Berlusconi’s popularity. His secret was an ability to set off a Pavlovian reaction among his leftist opponents, which engendered instantaneous sympathy in most moderate voters. Mr. Trump is no different.

 

And ..

The Italian experience provides a blueprint for how to defeat Mr. Trump. Only two men in Italy have won an electoral competition against Mr. Berlusconi: Romano Prodi and the current prime minister, Matteo Renzi (albeit only in a 2014 European election). Both of them treated Mr. Berlusconi as an ordinary opponent. They focused on the issues, not on his character.

We need to debate the issues and politics with Donald Trump. We need to show what needs to be done and warn against what should not be done. We should not allow ourselves the distraction of the option of an easy joke or a zippy one-liner. We must ignore what he looks like, must ignore his bluster and style and focus on what he says and does. It is easy to debate the wrongs of protectionism in the economy, the wrongs of religious prejudice, the wrongs of nationalism and the wrongs of cronyism. If we do this we will possibly avoid the danger of just talking amongst ourselves and might, hopefully, win round others to our views so that four years do not become eight.

Will it never end ? Quebec’s terrorist attack.

Will it never end ? Quebec’s terrorist attack.

Another atrocity, six innocent men gunned down, while at their devotions, 19 others injured and 5 remain in a critical condition. Again we are witness to innocent people, slaughtered as thy try to get on with their lives and again we know that wives have been left widowed and children fatherless for no reason.

This time, it seems highly likely that a young man with right-wing nationalist views (Alexandre Bissonnette) is responsible for this horror. If it is he, we will no doubt discover that he, like Dylan Roof and  Omar Mateen and many others before him, was a warped young man unable to tolerate those he disagreed with, unable to tolerate those different to him. It is no surprise that these people choose their targets by features which mark out their group as different to his group; the white supremacist attacking those performing their religious duties while the jihadist identifies those participating in banned activities.

Terrorists from both groups are much more similar than they would like to imagine, both see themselves as warriors defending their group against the others or avenging wrongs done by the other group. While these are extreme members of their groups, this tendency to see politics and life in terms of groups is a major problem. It does not matter if the group is defined by religion or race, nation or class, heritage or any other  tribal banding, viewing the world in this manner distorts our society.

Humans are intrinsically social animals. We don’t survive in isolation and instinctively seek out our fellows. Despite what dystopian films and novels may tell us, in good times and bad we band together to cooperate, help and trade. We find ways to be with others that is mutually beneficial. It is important to recognise that xenophobia and fear of others is commonest in people who have little contact with other groups. When we have to opportunity to mix and mingle we find ways to make this benefit both ourselves and the others and fear quickly dissipates. When we are left to our own devices we create an emergent order which is beneficial to all. This only goes wrong when we are grouped and ruled.

This is not simply the old story of “divide and rule” but rather “categorise and control“. When we are encourage to see ourselves as members of groups ( American, Christian, Black, Lesbian, Working Class, Welsh, Jewish, Islamic, Aryan, etc) we are encouraged to see the differences we have with others. We are encouraged to view others as being not only different but wrong and potentially threatening. We are encouraged to feel under threat and in need of protection. And in responce to this perceived threat, there are usually a group of people (politicians, clergy, kings,  inspired leaders, etc) who will guard us and look after our interests. These are the people who benefit from this grouping, they now hold the power (and usually a great deal of the wealth) as they control how we may and may not interact to preserve our group. All their power comes from controlling spontaneous  activity by individuals  and disappears if people are allowed to interact freely.

Once in our groups we are encouraged to view all problems in terms of this. It leads to partisan and transactional politics. Our group is always right, the other always wrong. Our problems come from the malevolence of the other group. While watching the coverage of Quebec I noticed on social media the cheerleaders of each group swinging into action. Those on the alt-right ecstatic when it looked as if a muslim might have been involved (erroneously), the progressives cock-a-hoop at having another timely white nationalist terrorist just in time for the fight with Trump about closing borders. Our politics have descended into this. We are unable to discuss issues without this being along the lines of our group identities. This means we fail to develop and change as quickly as we might otherwise be able.

The Quebec tragedy will end up being defined as a battle between those fearing islamophobia and those fearing islamofascism. Left to their own devices, followers of different faiths would cooperate happily and beneficially. When they are individuals they find a way to coexist in a way that benefits all, it is only when they are pushed into groups that hatred such as this arises. It is leaders who lead us down these dark alleys of discrimination and violence.

Remember the men who lost their lives in Quebec, remember them as real people like you or I, remember them as fathers or sons like you or I, remember them as individuals.  Don’t think that their religion makes what happened to them explicable in any manner, nor does it explain their murderer’s actions.  Don’t force them into a group and don’t let yourself be forced into a group. When we stay as individual units we remain individually responsible and recognise that we have the same rights as everyone else. Maintaining this is our only hope of preventing future tragedies. The first step in murder and maltreatment is making the victim an exemplar of a group rather than an individual. The second step is removing our own individual responsibility by passing it to a higher authority.  Don’t be pushed to take these dangerous steps.