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Made to Measure?

Paul O’Mahoney

Can Medicine Be Cured? The Corruption of a Profession, by Seamus O’Mahony, Head of Zeus, 256 pp, €28.00, ISBN: 978-1788544542

This fiercely polemical book is surprising and dispiriting in equal measure. The layperson probably harbours certain ideas about the medical profession and the research and evidence that underlie it, believing that, whatever about chronic systems failures and the wicked problems of public healthcare resourcing and allocation, as a profession medicine is unfailingly scientific, rigorously empirical, honest, innovative, enterprising and, on balance, successful. It is very unlikely that such ideas will survive a reading of this book. It is not a hatchet job, and there is nothing in it that impugns the character of the medical staff member on the ward; but the reader will come away from it feeling that the full gravity of the judgement implied in its subtitle is warranted: that medicine today is, at its core, something corrupt.

It was not always thus. The public idea of medicine as progressive and successful has a solid enough basis, owing to still quite recent accomplishments in what O’Mahony calls the profession’s “fifty golden years”. O’Mahony’s own specialty is gastroenterology, and it is in reflecting upon a fiftieth anniversary conference of the British Society of Gastroenterology in 1987 that he roughly fixes the end of this golden age. Those fifty years saw, among other advances, the discovery of penicillin, kidney dialysis, effective treatment of tuberculosis, MRI and CT scanning, organ transplantation, endoscopy, in-vitro fertilisation, the end of smallpox and the discovery of the double helix of DNA. That the golden age did not or could not continue is down to a combination of factors, but prominent among them is the reorganisation of the discipline and certain crucial transfers of power. Advances were secured by the enormous expansion of medical research after the Second World War, with huge injections of public funding in the US and Britain, and the creation of new clinical teaching and research posts. With expansion, however, and especially with money, come ever the foreshadowers of corruption: more waste, more bureaucracy, more room for less qualified or diligent practitioners and the conflict between serving the public good and the chance of substantial private gain. From the founding of the NHS in 1948 until “sometime in the 1970s”, hospital consultants “enjoyed professional and academic freedoms that today’s beleaguered doctors can only dream of”. Those based in the great teaching hospitals “enjoyed almost complete professional and academic freedom. They answered neither to administrators nor to the general public”. In this climate, there were abuses of the freedom and power of the position, but the trade-off in terms of advances more than balanced the scales. Today, however, “[the] great teaching hospitals are now run by managers, and the consultants, though their number has increased dramatically since the mid-1980s, are collectively and individually without influence”. Power in medicine began to shift in the 1970s toward “Big Pharma”, and from the “teaching hospital clinician-aristocrats … to the new laboratory-based professional researchers, the Big Science Brahmins”. This power shift has not, for O’Mahony, been to medicine’s benefit; it has rather led to the creation of a “medical-industrial complex” whose inducements to dishonesty and array of perverse incentives all but guarantee its corruption.

O’Mahony qualified toward the end of ‑ and so just missed ‑ the golden age; he writes of how over the course of his career he has watched “the public’s disenchantment with medicine” and the emergence of the medical-industrial complex and the host of sectors which feed off it, from the medical food industry to health charities, an ever-expanding regulatory and audit function and “secondary parasitic professions such as lobbyists and management consultants”. His professional experience led to an apostasy which, rather than spurred by an anti-Damascene moment, was gradual, and the deeper for it. The author’s early-career experience as a medical researcher seems to have set the tone. “[My supervisor and I] never discussed anything as scientifically highfalutin as a hypothesis, a question: the main concern was to develop a new technique to generate data.” Ultimately, O’Mahony reports relief at abandoning research to return to clinical practice. “I could have advanced as a medical academic by the conventional route, but had a low tolerance for boredom and, although cynical, I was not quite cynical enough.” Of the products of that period of research, which included publication in one of medicine’s most esteemed journals, The Lancet, he concludes:

I achieved what I had set out to do, but it was a calculating, dispiriting business, and I produced little of lasting consequence. Although I didn’t add in any meaningful way to the body of scientific knowledge, I learned a lot about how medical research works. Few, if any, researchers were inspired by scientific curiosity; the senior academics I encountered were motivated mainly by things like promotion, grant money, publications and merit awards.

This senior academic “Brahminate” serves to perpetuate the dreadful situation, as its members sit on appointment and tenure committees, can game funding awards, and “[dole] out the grant money to each other”. O’Mahony concurs with the judgement of David Sackett, the “founding father of evidence-based medicine”, that: “Basic medical scientists have hijacked the granting bodies and have erected research policies that place greater value in serving their own personal curiosities than in serving the sick.” The final lessons of that early period as a research fellow: “Medical research was a byzantine game played by cynical careerists; data were more important than ideas; professorships were more important than patients.”

Placed together, the book’s two longest chapters, “Big Bad Science” and “The Medical Misinformation Mess”, lay out the charge sheet against modern scientific research in medicine. Medical research, particularly “Big Science” or “Big Data”, has always promised far more than it has delivered, and Big Science has in fact contributed little to medical advances; research and clinical trials, meanwhile, are in the midst of a “replication crisis”, where a huge percentage of trials either never are or cannot be replicated. The first issue medical research must face if it is to reform is “that the culture of contemporary medical research is so conformist that truly original thinkers can no longer prosper in such an environment, and that science selects for perseverance and sociability at the expense of intelligence and creativity”. O’Mahony quotes Bruce Charlton: “[the requirements of contemporary research are] enough to deter almost anyone with a spark of vitality or self-respect … Modern science is just too dull an activity to attract, retain or promote many of the most intelligent and creative people”. “Real scientists,” says O’Mahony, “tend to be reticent, self-effacing, publicity-shy and full of doubt and uncertainty, unlike the gurning hucksters who seem to infest medical research.”

The perverse incentives that drive research have resulted, almost inevitably, in confirmed cases of fraud, where researchers have falsified data. Meanwhile, the questionable metrics used to assess the “impact factor” of academic journals, and their startling proliferation, lead on the one hand to academics gaming the metrics, and on the other to more and poorer research seeing the light of day: “If your paper is rejected, send it to another journal and so on until one eventually publishes your work … most papers eventually find a home of greater or lesser prestige.” The Stanford statistician John Ioannidis showed in a famous 2005 paper, “Why Most Published Research Findings Are False” (by May 2019, it has been cited about seven thousand times), that medical research cannot stand over the vast majority of its claims because its methods are so flawed. The upshot of this is not only that the predicted successes of Big Science – such as the idea that completion of the Human Genome Project in 2003 would lead to the rapid elimination of many conditions – tend not to materialise, but also that the evidence for the efficacy of approved drugs (such as statins) is questionable: the benefit of taking them is not established in the majority of cases, and is often outweighed by the need to take other drugs to deal with the first drug’s side-effects (and so on, leading to a cascade effect and to widespread, unnecessary “polypharmacy” or the prescribing of multiple drugs, particularly among the older population).

While serious reform of the methods and culture of medical research is needed, O’Mahony also stresses the necessary limitations of medicine as a practice, insisting that it cannot hope to be entirely scientific in its processes or outcomes. He counsels a moderation of expectations. No one, O’Mahony says, speaks of “scientific physics” as if there were another kind. The very fact that people can speak of “scientific medicine” betrays something important: that everyday medicine as practised by frontline staff is not a science. “Science informs medicine, and medicine looks to science for answers, but they are radically different, often opposing activities.”

Lest one imagine that these views are eccentricities of O’Mahony’s, representing some axe the author has to grind, they are not: a formidable phalanx of eminent researchers, similarly despairing of the state of their discipline, is marshalled by O’Mahony to second his position. And the issues persist. In the April 2019 issue of Nature, Oxford professor Dorothy Bishop inveighed against what she dubbed “the four horsemen of irreproducibility”, writing frankly: “I think that, in two decades, we will look back on the past 60 years – particularly in biomedical science – and marvel at how much time and money has been wasted on flawed research.” (It is noticeable that Bishop’s timeline roughly concurs with O’Mahony’s setting of the end of the golden age.) Those “horsemen” (all four are covered by O’Mahony, who lists seven causes for the poor state of medical research) are low statistical power (use of sample sizes too small legitimately to support inferences drawn from the results, where, in addition, effects of unintentional manipulation of the sample are difficult to detect); “P-hacking” (only reporting results with statistical significance, which often requires narrowing focus after the fact so that insignificant results, and the original, broader context of the research, disappear); HARKing, or Hypothesising After Results are Known, which again involves dismissing the original context of the research in which original analyses were performed, to report on a surprising or exciting result and construct a paper around it; and publication bias, or the tendency of journals and other forums only to publish accounts of interventions or trials which show positive results, where negative or inconclusive results ought to be equally as important to the establishment of the efficacy of a drug or initiative. (As Bishop put it: “clinicians have realized that publication bias harms patients. If there are 20 studies of a drug and only one shows a benefit, but that is the one that is published, we get a distorted view of drug efficacy.”)

One requires no statistical or scientific training to understand that such practices are an abomination, an affront to the spirit of true scientific enquiry and unlikely to produce reliable evidence for very much. And one really must pause here to pass judgement: no one engaged in these practices should have a job in research. No one engaged in them, or condoning or facilitating them, should ever be entrusted with a position of influence, where their decisions might affect the destinies of others. They are, however, allegedly rampant (and the allegation issues from informed and prominent members of the medical-academic establishment); so prevalent, so normalised, are they, that they are at the root of the reproducibility/replication crisis in medical research. In the face of this, the conclusion to which one is forced is that contemporary medical research is, in very large part, perhaps in the majority, essentially a fraudulent enterprise, and pursued in the main by rather second-rate minds. This may shock the reader; it should.

With money driving medical research, rather than scientific curiosity or the desire actually to cure, the incentive is to produce drugs that alleviate symptoms of long-term conditions and which must be taken for years, even if the effects are minimal and the resources would be better spent elsewhere. The perversity of the predominance of commercial interests would be exemplified by the invention of new diseases to treat – O’Mahony devotes a chapter to recounting the creation of “non-coeliac gluten sensitivity”, a condition for which, he asserts, there is no firm evidence, but the “diagnosis” of which expands the customer base for the growing industry of gluten-free produce.

Channelling resources into the wrong things is not restricted to commercially-driven research. Inflated national health budgets are rife with waste and misdirection of resources. It is generally estimated that only ten to fifteen per cent of the health of a population is attributable to medical systems and treatments. More important for overall health are factors like sanitation, nutrition, adequate housing, control of pollution and levels of education. (In O’Mahony’s laconic summary, expanding health budgets leave less money for “housing, education, transport and (God help us) the arts”.) Ensuring better living and working conditions, and the quality of and access to education and employment, should be health priorities in a modern, Western society. In March 2019, RTÉ Television aired a three-part investigative special, Prescription Nation, which showed that prescription by dose of antidepressants had risen in Ireland by twenty-eight per cent between 2011 and 2017. One cannot but be reminded of one of the most shared pieces written by cultural critic Mark Fisher prior to his untimely death in 2017. Fisher identified the “privatisation of stress” as one of the great feats of modern capitalism. Noting that the most treated conditions by the NHS today were depression and anxiety, he contended that these conditions had been “privatised”, cast as the result of chemical imbalances and wholly endogenous. By insisting that the root of these conditions lay in the individual’s biochemistry, medical opinion provided a brilliant alibi for those objective arrangements within a modern capitalist society which made depression and anxiety their inevitable consequence. Insecure and precarious working conditions, lack of a safety net or of concrete prospects for advancement or security, must induce depression and anxiety. Health problems, especially mental health problems, are the attendants of what has been called “shit life syndrome” – the “condition” afflicting classes of people without status, recognition or prospects, professional or personal, as well as members of an often highly educated yet still downwardly mobile generation. By effectively making stress and anxiety private matters, dissociated from objective societal conditions, for Fisher, various elements of the system conspire to absolve themselves of their partial responsibility for the immiseration of a great portion of the population.

The unquestioned consensus that health budgets must rise year-on-year is evidence that demand cannot hope adequately to be met. In such a situation, rationing of resources is inevitable; but the wise and efficient distribution of resources is hampered by the political denial that rationing occurs. O’Mahony reverts in his discussion of rationing and resourcing to the analyses of the NHS in Enoch Powell’s brief and brilliant 1966 book A New Look at Medicine and Politics, a volume which ought to be required reading for anyone presuming to hold forth on the subject of public health systems or the scope of government obligation and power regarding healthcare provision. In a 1950 speech, Aneurin Bevan “envisaged the Welfare State as a two-way social contract between government and people”, and insisted that Britain would not have a “mature civilisation” until its citizenry could discuss, understand and tolerate denial as well as provision of services, and recognise that a system with limited resources had to make difficult decisions about who goes without. This mature citizenry, says O’Mahony, has not materialised; rather, “government and people collude in a mutual deception” that imagines that spending on a largely free service should rise indefinitely, while treating patients as informed consumers who have a range of choices. The latter idea, as O’Mahony shows, has been attacked by economists as a nonsense, because the medical patient simply does not resemble the informed consumer in a regular commercial marketplace; the lip service constantly paid to improved patient choice does nothing to address the fundamental fact of the system’s unsustainability.

If publics in Ireland and Britain have failed to live up to the kind of moral obligation implied in Bevan’s vision of the two-way contract between government and people, they have at the same time subscribed to what Richard Smith called the “bogus contract” between patient and doctor. This – remarkable in an era in which, as O’Mahony records, the status of and esteem for doctors has declined dramatically – is “based on patients believing that modern medicine can do remarkable things; that doctors can easily diagnose what is wrong, know everything it’s necessary to know, and can solve all problems, even social ones”. Doctors “know that these beliefs are childish, and that the contract is bogus”, but the medicalisation of life has encouraged people in these beliefs, even while they question doctors and expert medical advice and insist beyond reasonableness on being treated as equals in consultation about treatment.

The nature of contracts is changing of course in what the title of Shoshana Zuboff’s 2019 volume called “the age of surveillance capitalism”; increasingly, the individual is both the consumer and the product and volunteers data in return for a “free” service. The World Economic Forum in Geneva, via its founder Klaus Schwab, has for some time been pushing the line that we have entered the Fourth Industrial Revolution, where digital technologies will transform every aspect of our working, family and leisure lives, including healthcare. This is the era of “Digital Health”. There is little doubt of the transformative potentials of new technologies – for example, detection of disease from imaging and scanning will be done far better by machines than humans can manage. The zeal with which these developments have been greeted and promoted has, however, blinded people to the nefarious potentials of the new technology, particularly in data harvesting. Couched in positive rhetoric about empowering the individual, companies are harvesting genomic and other health data voluntarily handed over by consumers, which they are monetising by selling it on to Big Pharma companies. Insurers will no doubt be another interested customer.

The Orwellian dystopia is well under way: a US start-up called Miinome pays poor people cash for their genome. An American company called Exact Data sells lists of people with sexually transmitted diseases. The Carolinas Health System mines consumer credit card data to identify high-risk patients, though their purchases of alcohol, tobacco and other unhealthy items.

The embrace of digital health “also reflects a global societal shift towards neoliberal values of self-responsibility for health maintenance, along with a decline in state-provided health and social care”.

The beneficiaries of the new technologies, O’Mahony contends, have thus far overwhelmingly been members of the medical-industrial complex rather than patients. It is not sufficiently reflected upon that all of the data recorded by various fitness and activity-tracking apps and devices are stored, retrievable and marketable by companies. It is becoming more common for companies in the US to reward their employees for physical activity (it allegedly reduces absenteeism and makes people more productive). This is, for now, voluntary; but O’Mahony envisages the creep of such practices until they become normalised, and ultimately mandatory. Those who decline to have their activities tracked will be penalised with higher insurance premiums, until individuals face the choice of acquiescing to the monitoring of their activities or joining a new, uninsured underclass.

Anyone who has seen Errol Morris’s masterful, Oscar-winning 2003 documentary The Fog of War will remember that one of the “Eleven Lessons from the Life of Robert S McNamara” (its subtitle) is “Get the Data”. A fine precept, until radicalised unto perversity. The “McNamara fallacy” is a phrase coined by Daniel Yankelovich to describe an attitude that insists on measuring everything that can be measured, sometimes without solid rationale, and, crucially, disregarding whatever can’t be measured as unimportant. (One should also recall, in tallying the formidable McNamara’s peculiar follies, that he was also not averse to disregarding inconvenient realities supported by data, like the minimum standards of medical, moral and intellectual fitness required for military service. Short of fodder for the Vietnam war, McNamara notoriously initiated Project 100,000, revising the eligibility criteria for military service in the US by downgrading significantly the intelligence and medical fitness thresholds required for draftees, resulting in the mass recruitment of a class of soldier quickly dubbed “McNamara’s morons” or “the moron corps”.)

Data gathering and metrics have come to rule the modern medical establishment, but often with perverse consequences, as the gathering is done and the metrics are set by individuals who have neither sufficient understanding of clinical realities nor the requisite expertise in epidemiological or statistical methodologies. “Medicine is, and has always been, messy, imprecise and uncertain; the McNamara fallacy is the delusion that all of this complexity can yield itself to numerical analysis.” This leads to an overreliance on “crude metrics” and “the setting of arbitrary targets”. O’Mahony documents the emergence and, in his judgement, frankly calamitous career of a particular metric, the Hospital Standardized Mortality Ratio, whose use and abuse generated a number of scandals which rocked the NHS. Practice reviews later showed that the tyranny of the metric was leading to decisions in hospitals that served it rather than patients; it was later assessed to have yielded flawed data anyway, which could not be the basis of conclusions about quality of care. “It would be foolish to argue that metrics have no place in medicine,” O’Mahony acknowledges, “but over-emphasis on such metrics has distracted contemporary medicine from its true purpose. Numbers should be our tool, not our tyrant.” That they have become the latter within Britain’s NHS he attributes to the canny manoeuvring of a class of “pseudoprofessionals” who have realised that since the Thatcher reforms in the 1980s “the NHS has provided rich pickings for management consultants and other opportunists keen to ‘exploit the commercial potential’ of whatever fad is grabbing the politicians’ attention”. The modern “obsession with metrics in medicine is partly due to managerialism” which cleaves to “the delusion that generic business methods can be easily applied to the complexities of medicine” – or to the McNamara fallacy.

There is a still worse basis for decisions regarding the organisation of medical systems than poorly thought-out metrics, and this is sentimentality. As it has virtually every facet of modern society, so the dread, reason-defeating, reality-defying trap of sentimentality has captured medicine. It is hard to argue with O’Mahony’s feeling that the endless parade of awareness days which the calendar has now become is fatiguing and faintly ridiculous, and he gives the gimmickry involved in campaigns like the ice-bucket challenge, for raising awareness of motor neurone disease, short shrift. This eternal press for awareness has negative consequences: first, studies from as far back as the 1950s suggest the greater is the public awareness of something, the less likely individuals are to do anything about it. Second, it creates a crowded market of lobbying for public funds and inevitably fosters an unedifying competition that boils down to: “my disease is better than your disease”. One must tug on the heartstrings to loosen the purse strings of course, and this is all very well as far as it goes in soliciting charitable funds from the public. But emotional lobbying should not, O’Mahony insists, influence decisions on the allocation of state resources: need, and not sentimentality, should be the basis for such decisions, and the constant campaigning to raise awareness is a manipulative and counterproductive distraction. As O’Mahony records a psychiatrist colleague of his reflecting, perhaps “the politicians who publicly support suicide awareness campaigns and call for the provision of more counsellors, might better redirect their efforts to addressing poverty and unemployment, the main drivers of suicide”. The prime example of what O’Mahony calls “sentimentality-based medicine” is “Rory’s Regulations”, named for unfortunate twelve-year-old Rory Staunton, who injured his arm playing basketball and later died in a New York hospital from sepsis. In response, his father, who was a professional lobbyist, launched a large-scale awareness campaign resulting in protocols for screening and treating sepsis being implemented in all New York hospitals. “Bereaved people are regarded as having not only a special moral authority, but a medical one, too.” The upshot is not only that time-consuming protocols must be followed in all cases but that extraordinarily vague and wide-ranging “warning triggers” for sepsis now mandate treatments which, especially for elderly patients, are invasive and inappropriate. Experts in sepsis have revolted, insisting the protocols have not had any appreciable effect on patient outcomes and are contributing to the trend for making the healthy sick. That they were ever instated is a result of the indulging of sentimentality, where instead it might better have been explained that the admittedly tragic case of Rory Staunton was one of sheer bad luck. “How could you possibly question a man whose opening statement at a medical conference is ‘My heart is broken’? How could you possibly express doubts about the over-prescribing of antibiotics and inappropriate treatment of frail elderly patients to a man who pauses regularly during lectures to rein in tears?”

If there is one condition which competitors in the market for public and private monies dread going up against most, it is no doubt that which Siddhartha Mukherjee has called “the emperor of all maladies”. Richard Nixon’s 1971 declaration of war on cancer (though as O’Mahony notes, he never used that exact phrase) launched endless public campaigns promising better care and outcomes for cancer sufferers or even, routinely, and showing remarkable hubris and imprudence, a cure. (The latest front in what O’Mahony wearily calls this “never-ending war” is the so-called “Cancer Moonshot” programme in the US.) The war metaphor is hardly inapt; more than any other disease, the rhetoric surrounding cancer has savoured of the martial: sufferers are fighters, survivors “have beaten” cancer. Peter Bach, who like O’Mahony combines being a physician with an ability to write good prose that outstrips many professional writers (and who lost his wife to breast cancer), has long called for an end to or at least moderation of the “cancer warrior” trope. (It is perhaps refreshing that a May 2018 report by Macmillan Cancer Support, “Missed Opportunities”, suggests that the public generally, including those suffering from and survivors of cancer, are weary of this martial rhetoric, and, whether for information or in the soliciting of funds, would prefer factual statements to figurative enlistment in a war.) If it seems shocking or churlish to suggest money spent on cancer might better be directed elsewhere, this is because the realities of the matter (precious little return in terms of advances for colossal investment) are unknown; and of course, because sentimentality rules here too. “The medical-industrial complex is a very devious bully, fantastically adept at recruiting the general public: who could possibly be against more spending on cancer? What kind of monster could possibly question giving a dying person a chance, no matter how small?” The vast sums spent on cancer research have not yielded anything close to the promised improvements. Drugs which add minor increments to the end of life (and little enough improvement in its quality) retail for exorbitant sums, beyond the capacity even of a state to afford, yet it is difficult to be seen to decline to purchase them on the basis of cost. A small portion of the money spent on cancer redirected into better end-of-life care, for example, might actually benefit far more cancer sufferers. “As a society,” writes O’Mahony, “we have unquestioningly accepted [the cost of the war], believing that any advance – no matter how small – in this war of attrition is worth achieving. The cost, however, is too high, and the war is unsustainable.” The sentimental popular appeal of the cure for cancer, however, will no doubt ensure the demand for ever greater funding, which it is imagined better arms the grudgingly drafted warriors in their combat with the disease. “Populism doesn’t cure cancer, but it trumps justice, evidence and fairness every time.”

To criticise the prevalence or power of sentimentality in a field is never to suggest that sentiment ought to be evacuated from it entirely. O’Mahony laments the rise of a “target culture” where “metrics have become more important than patients” and identifies it as the source of the “unintended, unforeseen and perverse disincentivization of compassion”. The insistence that compassion is essential to treatment of patients comes in a chapter which condemns “the mendacity of empathy”, noting how a whole industry has emerged in medicine professing the necessity and assuring the teachability of empathy. “Empathy” has become a watchword of modern medicine, with its inculcation in doctors imagined to be the key to reform of the health services. The recommendations come, predictably, with a dubious claim to a scientific basis in neuroimaging. The jargon of “empathetics” is closely related, for O’Mahony, to what is called “medical humanities”, or “narrative medicine”. Narrative medicine began with courses which used classics of literature to teach medical students about aspects of the human condition in ways thought beneficial to their training (Tolstoy’s The Death of Ivan Ilyich was a favourite for prompting reflection on the existential woes of the dying). Such (minor) courses were originally taught by doctors with an interest in literature, but “the discipline was gradually annexed by professional humanities academics, chiefly because it attracted significant funding”. Much of what was taught in medical humanities subsequently became bewildering to doctors, as the usual practitioners and beneficiaries of intellectual imposture, epigones of thinkers like Foucault and Derrida, flocked to it. (Given his trenchant critique of the methods of medical science, it ought to be emphasised that O’Mahony reserves only contempt for that strain of “postmodern” thinking which asserts that science is just another narrative, with no more objectivity than any other field. The basis of his broad critique is not that any claim to objectivity is invalid, but that medical research is insufficiently scientific and fails to meet the rigorous criteria which real scientific enquiry imposes for validation of hypotheses. He is a confirmed partisan of scientific method, and appalled by phenomena like contemporary anti-vaccination campaigns.) “Narrative medicine, with its glutinous mix of virtue signalling, pseudo-biblical language and social justice agenda, is the dominant and unchallenged orthodoxy within the medical humanities.” One is reminded here of Harold Bloom’s complaint that humanities departments, under the political influence of the “School of Resentment” made up of feminists, deconstruction theorists and Marxists, were increasingly being stripped of real scholars and populated with “a pride of displaced social workers, a rabblement of lemmings, all rushing down to the sea carrying their subject down to destruction with them”. The growth of “medical humanities” has latterly become another lamentable example of the expansion of the academic space to accommodate mediocrity; if you have neither the clinical background to qualify as medical staff nor the capacity for the rigours of real scholarship in the human sciences these academic half-way houses can still provide a home and comfortable career in the university. Pushback against this trend came from four English medical students who questioned the increasing emphasis on “soft skills” in an article with the wonderfully polemical title “Hold My Hand While You Misdiagnose Me”.

O’Mahony writes: “Compassion and empathy are often used interchangeably, but they are entirely different qualities. One can be empathetic without being compassionate: psychopaths and bullies, for example, tend to be very skilled in divining people’s emotions. Similarly, one can be compassionate without being particularly empathetic, as good doctors often are.” The chapter is uneven, and one must demur on these points. Psychopaths tend to be radically deficient in empathy, but often skilled in mimicking it and counterfeiting emotions they do not feel. Some recent research suggests that true psychopaths are not devoid of emotion, but specifically lack negative or inhibitive emotions like anxiety, guilt, shame and especially fear. And though I agree it is possible to feel empathy without compassion, the converse is not true. The Latin compassio is a calque – a direct, morpheme-for-morpheme translation from one language into another – of the Greek sympathia: broadly “to suffer with”, to feel or undergo (pathein) with. Sympathy – which word one can substitute for compassion without loss – requires empathy, the ability to place oneself within what another is undergoing, whereas empathy does not imply sympathy. And “compassion” in fact has begun to be mobilised and monetised just as has empathy, exemplified in the Charter for Compassion promoted by the popular historian of religion Karen Armstrong; I am not convinced that, imagined as something taught or cultivated, it is any less of a con than is empathy. Compassion tends to be what one might call a vertical emotion, and is invariably directed downwards (as, say, envy is directed upwards); it is scarcely conceivable that one could feel great or enduring compassion for those much better off or more fortunate than oneself. A horizontal sense or emotion is solidarity; it can conceivably transcend differences in class, belief or status. Cultivated compassion is ambiguous, a potential substitute for and even a solvent of solidarity. At its worst, compassion ultimately degrades both its object, the one who inspires it, and the subject who suffers with them. At its worst, it is also an alibi; it allows one to “feel”, to “undergo”, rather than to act. Compassion (as passio or pathos) is by definition not active, which tells one that it can only be desirable as a prelude or spur to action. Such reflections however only serve to reinforce the sense that the peddlers of empathy training quite literally do not know what they are talking about.

Shortly after the publication of Enoch Powell’s book on medicine and politics, TE Utley, a particularly sharp journalist of the same political tribe as Powell, wrote: “Mr Powell, as his recent book on medicine shows, does not seriously believe in the possibility of reform. He thinks we live in the best of all possible worlds, and everything in it is a necessary evil.” There is similarly no sense in reading O’Mahony’s book that its main title might be answered in the affirmative. The impression is confirmed by a concluding chapter titled “The Mirage of Progress”. One cannot of course deny the boons brought to humanity by the progress of medical science, but, as with Paul Virilio’s observation that with each new technology a new kind of “accident” comes into being, from the car or plane crash to the nuclear meltdown, too little heed is paid to the negative potentials of medical advance. “Every new ‘advance’ in medicine is a genie that cannot be put back in the bottle. Big Science isn’t going to suddenly become thoughtful … Pharma isn’t going to develop a conscience in middle age. The medical misinformation mess is now a foetid swamp that may never be drained.” The need for it is obvious, but O’Mahony remains pessimistic about the potential for meaningful reform of the system.

 Too many have a vested interest in unreformed medicine continuing, so reform is very unlikely to happen by a societal consensus; we will have to be forced into doing it. What would force us?  The most likely events are economic collapse and a global pandemic of a new, untreatable infectious disease on a background of climate change and exhaustion of the earth’s resources by globalisation.

This grim conclusion does not, unfortunately in the context, make the prospect of reform in medicine unlikely. The Stockholm Resilience Centre “has defined nine boundaries that must be maintained to ensure a flourishing civilization. Five of these boundaries have been crossed: extinction rates, climate change, phosphorous and nitrogen cycles, land-use change and ocean acidification.” Exemplifying the misguided nature of modern medicine is the overprescribing of antibiotics (contributing to antibiotic-resistant bugs) and the underinvestment in the development of new forms of antibiotic because, in a research environment dominated by Big Pharma, they do not pay. (Teixobactin, discovered in 2015 and successfully synthesised in 2018, which offers hope of combating antibiotic-resistant bugs, was developed with the input of pharmaceutical companies; it remains some way from clinical application.) The unnecessary administering of antibiotics (to animals as well as to humans) meanwhile continues, despite its potentially disastrous consequences, and is one of the less-publicised aspects of “Rory’s Regulations”: “Paradoxically, sepsis awareness campaigns, which contribute substantially to overuse of antibiotics, may create a future where sepsis is untreatable.” What medicine is providing advanced Western populations is not impressive:

Despite its global dominance, the medical-industrial complex has given us meagre, feeble comforts at vast expense. Its chief concern is its own survival and continued dominance, and its ethos now is a betrayal of the scientific ideals of the golden age … Both [doctors] and our patients have been enslaved by the medical-industrial complex, and it is time we rebelled.

Rebellion against the misdirection of enormous resources and the appalling, multifaceted fraudulence that sustains the enterprise, might proceed from honest reflection on and assessment of our priorities, and rejection of a ruling thought that demeans humankind, cravenly clinging to life at all costs. “Medicine is now ruled by a very feeble philosophy that views man as a machine, concerned only with material comfort and survival into very old age. This philosophy … might be applied to ants and cows, but not to humans. We are made to struggle, to embrace dangers.” As O’Mahony insists:

We must surely have better, nobler ambitions than to survive into a frail old age. We are not a mere homo oeconomicus, or the bundle of diagnoses that is homo infirmus. Medicine is the bully that is stealing from education, from decent affordable housing, from the arts, from good public transport. Our ever-increasing spending on it is not giving us any greater comfort or joy.

This inability to rein in the excesses or redirect the priorities of the medical-industrial complex is largely a mark of the diminution of state power, the inability of political actors effectively to impose order on corporate action to the benefit of their people. The vanishing of the golden age is a consequence of political developments as much as anything else. Writes O’Mahony:

Strong societal forces will almost certainly ensure that the current consensus prevails. These forces include the commodification of all human life, the over-weening power of giant international corporations, the decline of both politics and the professions, the sclerosis of compliance and regulation, the fetishization of safety, the narcissism of the Internet and social media, but above all the spiritual dwarfism of our age, which would reduce us to digitized machines in need of constant surveillance and maintenance.

Whither medicine, society and humanity, then? The most famous ancient elaboration of the “golden age” is in Hesiod’s poem Works and Days. In this age, the earth bears bountiful fruit without the need for cultivation and man lives in the presence and as very nearly the peer of the gods. Hesiod’s own age, the iron age, utterly remote from these circumstances, is the nadir of a long decline; now, man must get bread from the sweat of his brow, on an earth where, with the abscondment of the gods, injustice thrives and corruption and dishonesty are rewarded, and where miserable death and countless ills stalk man daily. As far as the state of contemporary medicine goes, especially weighing the conditions which have permitted the unabated decline in the standards and integrity of research, we might well conclude that we are in something of an iron age. Behind O’Mahony’s pessimistic reckoning of our prospects, moreover, we might also discern our imminent entry upon a new age of iron, describing the temper or spirit of the times.

The calque compassio also passed into German, which rendered sympathia as Mitleid, which covers both “pity” and “compassion”. One cannot help thinking, in reading O’Mahony’s conclusions, of the greatest critic of Mitleid (as a perilous and degrading passion), the man who also exhorted, metaphorically, that one build one’s home on the slopes of Vesuvius – who so famously urged: “Live dangerously!” (Everyone knows of Nietzsche’s formula that “God is dead”; far fewer know that God died of his pity for mankind; similarly, the most perilous temptation for the character Zarathustra is precisely his pity for man.) The contemptuous description of homo infirmus reminds one of nothing so much as Nietzsche’s infamous portrait of the “last man” sketched in the prologue to Also Sprach Zarathustra:

The earth has become small, and on it hops the Last Man, who makes everything small. His species is ineradicable as the flea; the Last Man lives longest … Turning ill and being distrustful, they consider sinful: they walk warily … A little poison now and then: that makes for pleasant dreams. And much poison at the end for a pleasant death … They have their little pleasures for the day, and their little pleasures for the night, but they have a regard for health.

O’Mahony’s sketch of our difficulties represents a situation in which a Nietzsche might again, or in many cases for the first time, really speak to us. The ethos of the last man perhaps suits an era characterised by the decline of what Nietzsche called “the coldest of cold monsters”, the state (what O’Mahony labels “the decline of politics”). The waning of the nation-state in the face of its powerlessness to control flows of information or the movements of economic markets has long been predicted. One possible successor to the nation-state has been proposed by Philip Bobbitt as the “market state”. The market state would emerge in part due to the inability of the modern welfare state to sustain itself. The compact between state/government and citizen would no longer be power traded for protection and welfare, but power in return for guaranteeing the maximisation of opportunity. The vision appears in part as the fantasy of a Hayekian libertarian; but its arresting and grotesque aspect is how it ironically grants to so many left-leaning advocates what they campaign for: maximal equality of opportunity, blindness to race or class, refusal to impose a particular system of morality, a cultural levelling whose monstrous indifference abolishes every ethnocentric prejudice. Bobbitt himself professes not much to relish the transition he predicts. Of the nature of the market state he writes:

The market state is classless and indifferent to race, ethnicity, sex and sexual orientation; its yardstick is the quantifiable … If the nation state was characterized by the rule of law, the market state is largely indifferent to the norms of justice, or for that matter to any particular set of moral values so long as law does not act as an impediment to economic competition. Because market states are also indifferent to the values of loyalty, reverence for sacrifice, political competence, privacy and the family, they pose an important challenge to civil society: either these values must be supported without government backing or we will replace them with the values of the market, which seem largely to exalt entertainment and the accumulation of wealth … The market state says: give us power and we will maximize your opportunity (what you do with it is pretty much up to you). Not only will this bring an added ferocity to our politics, as different groups feel abandoned by government or their values betrayed, it will also pose the problem that it will be much harder to get the publics of such states to risk their lives and fortunes on behalf of a state that is no longer the champion of their cultural values … In the era of the nation state, the state took responsibility for the well-being of groups. In the market state, the state is responsible for maximizing the choices available to individuals.

Bobbitt has theorised the rise of market state since The Shield of Achilles (2002), but this particular vision of the “added ferocity” in our politics comes, appropriately enough, from a little book on Machiavelli, that marvellous purveyor of what Conor Cruise O’Brien called “ferocious wisdom”. O’Brien was contemptuous of “gentle Machiavellians”, a term he borrowed from his own, earlier denunciation of “gentle Nietzscheans”, a class for which he reserved an especial scorn, because Nietzsche – for whom Machiavelli was so much more important than the paucity of references in Nietzsche’s published work would suggest – was, if met, accepted and understood on his own terms, the most ferocious of thinkers. The popularised Nietzsche of his main American translator and interpreter Walter Kaufmann was one O’Brien recognised, correctly, as a decidedly domesticated beast, as he recognised that behind the artist-friendly Nietzsche of Kaufmann, who preached a gospel of self-creation, lay dormant the true, ferocious Nietzsche whose political force and potential awaited discovery and leveraging not by fringe-friendly dilettantes but by responsible, honest and powerful minds. Toward the wonderful close of his 1970 essay on Nietzsche, O’Brien forecast:

Each age, of course, re-invents the authors of the past … I suspect that we have not done with Nietzsche, any more than with Machiavelli, and that the fierce Nietzsche may be due for a revival. In part on intellectual grounds: the Nietzsche of the gentle Nietzscheans is a fake, and there are limits to the survival value of fakes. But there are also historical reasons why a Nietzschean ethic may come to recommend itself. The world by the turn of the century is likely to present some terrible aspects. The comfortable countries, assuming that they can keep their hands off one another’s throats, will be more comfortable, or at least more affluent than ever. But the poor world is likely to be drowning in an excess of its own population … The advanced world may well be like, and feel like, a closed and guarded palace, in a city gripped by the plague … As this situation becomes more obvious it is likely to generate its own psychological and moral pressures. The traditional ethic will require longer and larger doses of its traditional inbuilt antidotes – the force of hypocrisy and cultivated inattention combined with a certain minimum of alms. But there will also be minds, and probably some powerful minds, who will go in quest of a morality more appropriate to the needs of the situation and permitting, within the situation, both honesty and good conscience. Such minds may well turn to Nietzsche, reading him, not in the gentle adaptation, but for his bracing fierceness.

Fulfilment of this ominous and rousing prophecy rather feels overdue, as do the intellectual reckonings it predicts. Here perhaps are the deepest strata and most stirring implications of O’Mahony’s critique. Western medicine in its corruption is a microcosm of the civilisation which spawned it. The sorry state of medicine as presented is only a reflection and necessary consequence of the state of Western societies yoked to untrammelled capitalism and partisan politics, marked by spiritual dwarfism, mendacity and intellectual mediocrity; where everyday life and the individual’s worth have been economised, pride and greed exalted, excellence scorned and every degrading variety of sentimentality granted a global, “viral” audience, while the sustaining values and virtues of that civilisation from its inception – nobility, beauty, wisdom, courage, magnanimity, the sense of justice, above all moderation – have been subjected to ridicule and reduced to a parade of archaisms, with many quite literally dropping out of the modern vocabulary. The dismal prospect of a civilisation ordered wholly by the orthodoxies of the dismal science cannot inspire; nor, in view of the startling inequalities in health and wealth, worldwide and within advanced western societies, which any way one slices it constitute a rank offence against common humanity, and this before considering the rampant devastations of the Anthropocene, could anyone sensibly wager on that civilisation’s survival.

A moment’s reflection on the hard reckonings these accelerating trends are forcing into being, and there is every reason to imagine the rhetoric and narratives appropriate to the age must indeed savour of the “bracing fierceness” of Nietzsche. That rhetoric will best bolster, as O’Brien recognised, a Nietzschean ethic. O’Brien seems to envision only the beneficiaries and supporters, rather than victims and opponents, of the situation seeking refuge in Nietzscheanism; but the encroachment of Bobbitt’s “added ferocity” in our politics would well make Nietzsche and his bracing fierceness the lodestar of the faction in revolt. Indeed, it is precisely with the traditional left in abeyance, mired in the varieties of identity politics whose demands precisely the market state would satisfy, that the ferocious wisdoms of Machiavelli and Nietzsche – the former’s recommendation of judicious cruelty, of the instructive use of spectacular violence, the latter’s rhetoric of modern man’s degeneracy and insistence that a healthy and ascending society retains a capacity for cruelty – look due a resurgence.

The course we would seem set upon, doomed or redemptory, is toward the ferocity of Nietzschean politics. The prospect would rightly horrify many (Nietzsche’s was a mind that scorned the idea of the sanctity of human life, could countenance slavery under certain conditions and espoused eugenics without reserve); but none could deny the invigorating strain in Nietzsche, in no small part owed to the frank and terrible aspect he turns to the world in his writing; and there are those, not a few of them, who would today find inspiration in the recommendation of ferocity. If the necessary changes can, under present conditions, only be “forced”, in O’Mahony’s words, the alternative to awaiting catastrophe is precisely ferocity; and it must be substituted for compassion. Or, perhaps better put, ferocity and judicious ruthlessness must characterise the active face reflecting and proceeding from the feeling of compassion. Protest and persuasion evidently will not work, or they already would have. Change will ensue when it is ensured those who poison or pollute, who destroy lives through financial recklessness, who deceive and defraud, who corrupt public life by clientelism, who profit from exploitation or abuse, are called to a terrible account. Compassion with the victims of savagery, if it is real and deep, should spark punishment of the savagery’s perpetrators. When that savagery is perceived by enough minds as systemic, and they are minds which oppose but have been conditioned by it, and have marked well its success, the soil for the rise of a righteous Nietzscheanism becomes fertile.

Underlying the claims of O’Mahony’s book is an implicit call for, in the title of Powell’s volume, another “new look at medicine and politics”; contrary to O’Mahony’s hopes, but true to his analysis and predictions, one feels the quality of that look may be fierce rather than compassionate. Political Nietzscheanism is not a cheerful vision, and not long ago would have been unthinkable; now, it offers at least the possibility of intellectual probity, as well as the enticement to vigour and daring which the prevailing politics lacks. O’Mahony speaks explicitly of a societal consensus which must be broken rather than one likely to be reached, if reform is to be possible – and not only in medicine, but in politics, business and the academy, areas which similarly appear either impotent or corrupted, and to lack the capacity for moral and intellectual leadership. If it would otherwise take catastrophe or pandemic to shake us from the consensus that prevents our acting to prevent their arrival, the alternative of cultivating an iron spirit that breaks consensus and acts in good conscience begins to look like the last, best hope for combatting the myriad existential risks we now face.


Paul O’Mahoney lives and works in Dublin.



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