"Rules are for the guidance of wise men and the blind obedience of fools."
–attrib. various1
An editorial in the JRSM by the formidable Dr McCartney, who tosses articles as lesser Jockettes do cabers, helped crystallise some bitter salts that have of late been swilling around the vague stream of consciousness that passes for Dr No’s thoughts. The gist of it is that doctors have had enough of being pushed about, demeaned, and generally told what to do, all of which are anathema to the professional mind. For GPs straining to meet Quality and Outcomes Framework targets, the doctor-patient centred consultation has become the government-contract centred consultation. Hospital doctors no longer manage or treat their patients, they protocol them through pathways, all too often watched over by guidelines of not so loving grace. Juniors no longer routinely strive for excellence; instead, they slavishly strive for ticks in boxes. All through medicine, the opportunity for individual, creative, effective and satisfying practise has been flattened under the weight of rules, guidelines, pathways, contracts and targets.
The doctors' strike, or ‘industrial action’, as the strikers prefer to call it, has happened. On the day after the longest day (2012 is a leap year), a smaller than expected number of striking doctors turned up for work sporting ARP style armbands declaring ‘I’m caring for patients’, which was a bit rich if you happened to be a non-urgent patient, and smugged their way through their day. As own goals go, it was a corker, more Rear Admiral Hamish McMayhem taking his entire fleet the wrong way up the Windward Passage, than a solitary cocoa bean going the wrong way up Bournville Boulevard. On the radio, you could hear Langho rubbing his hands with glee at the gift of anti-doctor propaganda, while the media at large took turns to shy coconut after coconut at the ‘my pension or your life’ protesters. If proof was needed that Dr No’s former colleagues had lost the plot, then this was that proof.
There is no doubt that the treatment ordered by the Court of Protection, and now to be forced upon E, a critically ill anorexic in her thirties, will be not only foul and burdensome, but intensive and extended too, perhaps for a year or more, providing she does not die in the meantime. For E, the treatment is likely to unspeakably foul, for she appears to have conflated the invasive nature of forced feeding, not to mention mechanical ventilation should that also be provided, with sexual abuse she suffered as a child. Moreover, the order for active treatment has been made at a time when E has already been admitted for palliative care, and started on the Liverpool Care Pathway, in the expectation she will die, and so represents an epic, even gruesome, volte-face, at a time when the patient was already settled on the glide plane to death. Can, we must ask, such a rude, and very likely futile, reversal ever be justified? Is it not, to use the old phrase, a clear case of striving officiously to keep alive, when common humanity calls for care and compassion in the face of the inevitable?