Richard Smith asks: Is medicine as excessive as the banks?

Richard Smith Is medicine, like the banks, falling into excess? I asked myself this question at the end of last year as I read about the death of Faith Williams, the conjoint twin who died 23 days after the operation to divide her from her sister, Hope, who died during the operation. Does it really make sense to be doing such operations in an overpopulated world where millions of children continue to die each year for lack of basic facilities and treatments costing pence?

This is a question that many must ask themselves privately, but it’s almost indecent to ask it publicly.

Could I stand face to face with Faith and Hope’s parents and the dozens of surgeons and nurses who have cared for them and say “That was disproportionate, a dreadful waste?” I doubt I could, and it would be even more difficult to say it to the parents of girls who had survived such an operation and were now happily going to school.

Similarly I don’t say it to friends who have undergone treatments costing tens of thousands of pounds to keep them alive for extra weeks. And perhaps if and when I arrive at such a point myself I’ll want my days or weeks in intensive care.

But I do feel that such heroics show medicine losing touch with reality—just as the banks did with their 100% loans to NINJAs (no income, no job, no assets). And British society seems to accept the general idea of a limit with the National Institute for Health and Clinical Excellence being reluctant to support treatments that cost more than £30 000 per quality adjusted life year. (On these criteria, if Faith and Hope had managed to survive for 60 years each then treatment costing £3.6m would have been justified, although I wonder about the “quality” of those days.)

The cost is the first — but probably not the most important — problem with an operation like that to separate Faith and Hope. A team of 20 operated for 11 hours, and Faith then spent 23 days in intensive care at a cost of probably at least £500 a day. The cost was probably not more than £25 000, but would have been much higher if both twins had survived but been severely disabled.

Many people find it unacceptable to talk about life in terms of money, but they perhaps forget that money is simply a measure of resources—and we live in a world of finite resources (even though we are all inclined to forget that, especially when hundreds of billions are being spent to bail out banks). Money spent on A cannot be spent on B, C, D, or E. The £25 000 could have been spent on clean water, sanitation, immunisation, and oral rehydration therapy for children living in poverty in Africa or South Asia and saved probably more than a 100 lives. Or it could have been spent on very unglamorous activities—like carer support or incontinence services—and made unbearable lives bearable.

But a deeper question is whether such highly complex surgery distorts health care? Lip service is paid everywhere—by governments, health policy experts, doctors, and nurses—for a shift from treatment to prevention, but it doesn’t happen. And it doesn’t happen for very human reasons: confronted with a child dying of meningitis and a malnourished child, people give their attention and resources to the dying child. Doctors cannot do otherwise when presented with such a choice, but medicine and health systems could choose to shift attention, prestige, and resources away from high tech surgery to low tech prevention. But they don’t.

A still deeper problem with medicine’s excesses is that its “crack troops” (medicine is shot through with military imagery) are engaged in glamorous struggles to ward off death. Yet ironically, as the National Audit Office report made clear, people in Britain die so badly because of an inability to recognise that death is part of life. There are much worse things than being dead, and, for me at least, death gives life a narrative and a meaning. But, as Ivan Illich warned 30 years ago in Limits to Medicine, medicine’s vain attempts to abolish pain, sickness, and death have actually left us less able to cope with those inevitable parts of being human.

Competing interests: I can’t see anyway in which either my finances or even my reputation (apart from that of being an awkward bugger) are going to benefit from this piece — but maybe that’s just lack of imagination.