Time Past

Tuesday, March 5th, 2013

Theodore Dalrymple looks back:

From time to time, for reasons that I cannot explain, an episode returns to me from when I was almost sixteen. I was hitch-hiking in Scotland with a French friend; it now seems almost incredible that two boys of such an age should have been allowed by their parents to fend for themselves in this fashion, when communications were so much more difficult. We had a tent, and camped by the side of the road wherever we were when night fell. It wasn’t comfortable – tents in those days were not the suburban home from home that they are now – and many a time the rain leaked through the canvas because we had touched it on the inside, which meant that we lived in a state of chronic dampness. We thought nothing of it.

In those innocent days, it never crossed our mind that those who picked us up might harm us, or the minds of those who picked us up that we might harm them. When we arrived late one night in a northern English industrial town and could find no accommodation we went to the police station where we were allowed to stay overnight in the cells; in the morning the police brought us bread and tea. How gentle the world seemed then, when people trusted one another!

This is a reminder that wealth and its consequent increased range of consumer choice (which have increased enormously since then) are not the same as freedom tout court: youngsters today do not have the freedom that we had, when no one thought it was negligent of parents to allow us to do what we did. Whether the anxiety of parents that would prevent them from allowing children to do as we did is objectively justified by the condition of the world, or whether the manacles are mind-forged is beside the point: an important freedom has declined greatly.

There’s more to that story. He concludes that paternalism has its place — which leads him to this story:

I have an example in my own family history of a surgeon who acted in a way that would now be deemed ethically reprehensible, and perhaps even actionable, but which seems to me to have been in the very highest tradition of his profession. His name was Cox, and I don’t know whether he is still alive: by now he would be very old. I thanked him insufficiently at the time.

I was in Africa when I telephoned my mother (by no means the easy thing to do then that it is nowadays). She was about to go to America on a visit, but she told me that she had been bleeding intestinally. I told her she must abandon her visit and see a surgeon at once, which she did.

It was cancer; she underwent an operation within the week. I returned home before the operation.

My mother said that she wanted nothing hidden from her; she wanted to be told everything, and made me promise that I would hide nothing. She exuded a kind of pride in her own rationality.

After the operation, the surgeon spoke to me. Whether he was franker with me than he would have been with a son who was not a doctor I do not know; but he told me that, while he had excised all the cancerous tissue that he could see macroscopically, histology demonstrated that my mother’s prognosis was very bad. There was an eighty per cent chance of recurrence within a year.

I told the surgeon that my mother had made me promise that I would tell her everything. The surgeon said that, on his estimate of my mother’s character and personality, this would not be a good idea. He advised me against this course of action; and since he was clearly a man of experience and integrity, I took his advice.

My mother asked me, when she had recovered sufficiently from the operation, what the surgeon had said. I told her that, as far as he could see, he had cut out all the cancerous tissue. This was the truth, but of course not the whole truth, and I rather dreaded further questions, to which I might have to reply with outright lies: and I might not prove to be a very convincing liar. My mother was perfectly well aware that removing all cancerous tissue to the naked eye was not the whole of the matter, but to my surprise – and relief – she enquired no further. Despite her protestations beforehand, she did not want to know everything.

In the event, she lived another nineteen years without recurrence and relatively free of anxiety about her cancer because the surgeon had ‘cut it all out.’

I was very impressed by the surgeon. It seemed to me then, and seems to me still, that he had acted as the very model of a fine medical practitioner. He was technically accomplished, it goes without saying; the operation went smoothly, with no avoidable complications. But more than that, he had given consideration to my mother as a person, as a human being; and on the basis of limited acquaintance with her – at most, a few examinations in the clinic – he had come to a shrewd and, I believe, accurate assessment of what was best for her, better indeed than my assessment. Surgeons are often accused of being brash, mere technicians without human subtlety, but this was certainly not the case with him.

From the standpoint of modern medical ethics, he committed two cardinal sins: he broke medical confidentiality and he was not entirely truthful with his patient. If he had acted in accordance with modern precepts, or obsessions, he would have done neither; with the peculiar result that, if he had acted ethically, he would have acted worse.

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