Desmond O’Neill: You don’t make peace with your friends

Desmond O'NeillIt is not often that I find myself quoting Moshe Dyan, but his aperçu that you don’t make peace with your friends has gained wide currency. In medical terms this might best be translated that our debates and advocacy are best shaped in dialogue where there is true opposition and dissent. I was reminded of this during the annual open week of the Royal College of Physicians in Ireland, called the St Luke’s Symposium after the physician evangelist.

A rather sleepy and inward looking institution until recent decades, under the dynamic leadership of the last president, John Donohue, maintained by his successor, John Crowe, the college has developed an open and engaged presence in Irish public life. The most concrete example is collaboration with the health services in directing clinical programmes, the first time that the Irish health services have worked with senior clinicians in this fashion.

The opening session of the St Luke’s Symposium, a public debate on ageing, could have been yet another episode of preaching to the choir between geriatricians, gerontologists, and the advocacy sector for ageing. Instead, in addition to a presentation on the Irish longitudinal study on ageing, the College invited a “motivational” speaker from the United States, the title of whose book, Younger Next Year, could be seen to encapsulate the unintentional and pernicious ageism of much popular commentary on ageing.

As it happens, it would appear that what the author, Chris Crowley, a retired lawyer from the United States, is promoting is a healthy lifestyle relating to aerobic exercise, diet, and social connectedness which would be likely to defer frailty, a goal with which we can all agree. However, much of his writing is couched in language which positions ageing as a) a phenomenon exclusively of later life, and b) something to be avoided and deferred so that the goal is to be “younger.”

This negativity towards ageing lies at the heart of the unhappy phenomenon of ageism, whereby we devalue the experience of ageing. In fact, ageing occurs throughout the life-span, and we understand failure to appreciate one’s stage in the process by terms such as “Peter-Pan syndrome.” Ageing, into later life, brings growth as well as loss, exemplified at the high end by the work of great artists such as Matisse or Louise Bourgeois, and in every day life by the exemplary safety record of older drivers, the group with highest level of illnesses which may compromise driving safety.

So, after his folksy and charming delivery, it was good that debate with the public afterwards allowed the geriatricians and advocacy representatives to emphasize that we shared his aspiration to defer frailty, but not ageing. In addition, the concern about gero-eugenic attitudes was raised, the concept whereby it is assumed that the only way to age successfully is through physical fitness, and that to be disabled is somehow a failure.

Therefore, successful ageing strategies must support the concept of adequate support – from preventive, through diagnostic and remedial, to prosthetic – for those affected by age related disability. A final message from the specialist in genito-urinary medicine on the panel on sexually transmitted diseases in later life added a suitably contemporary flavour to an excellent evening.

The other debate of the week, after sessions that included a packed and stimulating session on medical history arising from the college’s active Heritage Centre, was on pharmaco-economics. In this the college played a valuable role in a small country where doctors seem shy about expressing concerns about distortions of advocacy that are disruptive of equity and the common good, We rarely get a chance to pair the issues that on the one hand the newspapers pick up as “if it bleeds, it reads” health stories and on the other the thankless but necessary task of trying to formulate coherent and equitable policy.

The debate focused on value for money for high cost medications, and one side was Michael Barry, a pharmaco-economist who has undertaken sterling work in developing the discipline in a country which has traditionally had an unfettered free-for-all in access to medications, with most of the tab picked up by the state. The National Centre for Pharmacoeconomics, of which he is the clinical director, is one of the few islands of rational debate about value in healthcare in the Irish healthcare system.

On the other side was a highly vocal oncologist and member of the upper house of the Irish parliament, John Crown. His advocacy for new (and expensive) cancer medications was most recently marked by an attempt to pass a bill through parliament which would effectively make the Minister for Health personally sign off on any refusal to fund a new cancer medication.

This was seen as triply unfortunate by many: not only did it appear to use a national parliamentary position to advance issues from one’s own specialty, as well as undermining pharmaco-economic debate, but also seemed to try and change what should be a collective decision into a highly personalised one, i.e. “Minister X would not sign for the cancer medication for my daughter/wife/parent.. “The resulting Senate debates confirm Bismarck’s aphorism that laws and sausages are alike in that it is better not to see them being made – or as in this instance, not being made.

The college debate was lively, heated, and insightful. Eris, the goddess of strife and discord, made some appearances. One eristic contribution for which I have a strong personal dislike is that of doctors using the word “bureaucrat” is a dismissive and contemptuous fashion, without thought that the increasingly transparent walls of the domus medica often reveal unsavoury practices which are also vulnerable to lapidary assault.

However, at the end, I think that most of those attending could work out which approach best combined humanity, equity and the hard grind of supporting in equal parts the vocal and those without a voice. For this the RCPI is greatly to be commended, and if it continues to host true, serious, and occasionally contentious debate into the future, it will truly be living up to its stated aim to achieve optimum patient care and to promote health nationally and internationally.

Desmond O’Neill is a consultant physician in geriatric and stroke medicine in Dublin, and director of the National Programme Office for Traffic Medicine in the RCPI: the views stated are personal.