by Theodore Dalrymple (February 2013)
There are some people whose imagination and emotions are stirred more by the past than by the future, and I am among them. We to whom time the past is more important than any time to come are not world builders, we improve nothing; on the other hand, we seldom destroy anything. We tend to pessimism rather than to optimism, or at any rate to expectations that are not extravagant; supposedly imminent solutions to life’s problems, after all, seem never to arrive, and disillusion is more common than fulfilment of promise. A disappointment anticipated is a disappointment halved; pessimists are therefore happy in the long run, or happier than optimists.
When, as sometimes happens as I get older, I lie awake at night unable to sleep, my mind returns to episodes from my past. As to the future, I can seldom think further ahead than the next article I am to write. I can dwell for any length in my sleeplessness only on the past.
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.
My friend and I were in a remote part of Scotland where sheep were grazed. We had been given a lift by a newlywed couple on their honeymoon. As we drove round a corner on a hill, there was a sheep by the side of the road that had been severely injured in a collision with a previous vehicle (few and far between in these parts). The sheep’s guts had spilled out of its open belly, but it was not dead; it was still kicking convulsively if feebly.
The bride let out a cry of distress; she asked her young husband whether he had seen the sheep that was still alive. He said that he had seen the sheep and that it was dead. Then he turned to me and said, ‘It was dead, wasn’t it Theodore?’
I too had seen that it was alive; it took me a fraction of second to realise that the husband was not making an enquiry into truth, but trying to reduce his wife’s clearly mounting distress.
‘Yes, it was dead,’ I said.
This calmed the bride, who concluded what she wished to conclude, that she must have been mistaken. And immediately afterwards I felt a great pride: pride that the groom, clearly an educated and intelligent man, had felt sufficient confidence in my intelligence and savoir-faire to ask me (at my age!) his question and that I would appreciate its real significance. How mature and sophisticated I felt, how proud that I had passed the test and come up to his expectations!
I have replayed the incident in my mind many times since, perhaps because it was the high-point of my psychological acuity. But there are other reasons too. I often wonder what happened to that young couple whose path I so briefly crossed. Their love was young and tender; the groom’s protectiveness towards his bride would now, perhaps, be unfashionable, but seemed to me then (and now) to spring from unselfconscious love and a plain sense of duty. They were young and just starting out in life; they would now be in their early or even their middle seventies. I remember hoping at the time that their love would survive, because my own life at the time had been so singularly lacking in tenderness, so completely loveless; and that if it did survive it would be reassurance that lovelessness was neither inevitable nor the normal state of mankind (for it is easy for young people to suppose that their experience of life is all the experience that life can afford).
This tiny episode was also important because it taught me, very vividly, that the truth, or rather telling the truth, was not always a virtue, that other considerations might trump it morally. Kant, of course, would have said that I was wrong not to tell the truth about the sheep; but this seemed to me then, as it has seemed to me since, only to show that Kant was mistaken. I had enough insight even at that age to appreciate that telling the truth in such circumstances might easily spring not from a disposition to truthfulness based on an ethical principle, but from sadism, a pleasure in causing dismay for its own sake.
It also taught me the inescapable necessity for paternalism in human relations: not, of course, on every occasion, or invariable, but sometimes, on occasion, as suggested by judgment. As a doctor I have never forgotten this, though paternalism has become almost a dirty word in medical ethics. There must, of course, be a presumption in favour of truth-telling, but like almost any other principle it much not be made into a categorical imperative or, to put it more crudely, a fetish.
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.
I assume that the surgeon, who is a hero to me, acted differently according to his assessment of the clinical situation confronting him: that breaking medical confidence and untruthfulness by omission were not fixed principles with him that he applied in every case. But this is surely very unlikely.
Instead, his understanding of the requirements for human decency was much more sophisticated than that of modern medical ethics. He understood that people generally live in a social situation, not as isolated beings, and that it is sometimes right for relatives to know more about an illness than the ill person him or herself. And I am sure that he knew that truthfulness can descend into indifference to suffering or even to sadism. To try to force people to know what they do not want to know can be cruel, and often ineffective into the bargain.
I thought of the couple in Scotland again last night and what became of them. They are forever fixed in my memory because of that one episode. It is surprising how egotistical memory is: if I met the couple again I would be surprised to discover how they had aged, as if my memory of them had preserved them from all change ever since. Not long ago the distinguished actor, Marius Goring, died; I had seen him at Stratford as Angelo in Measure for Measure more than forty years earlier, when he was middle-aged, and I was almost outraged to discover that forty years later he was not as I remember him in his burgundy velvet tunic, but was 85 years old. My having seen him was thus not as important to him as it was to me.
But when I recall the couple in Scotland, I still feel a certain pride at my moral intuition.
Theodore Dalrymple's latest book is Farewell Fear.
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