Wendy and I were both struck by the measured tone of this week’s Parliamentary debate on assisted dying.

It’s a complicated topic. To me, the starting point is certainly that assisted death should be legal, but the practicalities are complicated. They are probably best left to people with more expertise than me.

It strikes me that the medicalisation of death complicates the picture. It is not obvious to me that it should be up to doctors to arbitrate on the processes surrounding the universal human experience of death.

It is, of course, appalling to contemplate that representatives of our state religion, in which only a minority of the population express a belief, will get a Parliamentary vote on the issue… but that’s hardly unique to this topic. It is absurd and unjust that bishops continue to sit in the House of Lords, and if this debate forces a re-examination of that issue, then that will be a welcome side effect.

I was particularly interested to read Richard Smith’s thoughts on this week’s debate, as a former editor of the BMJ who has spent much longer thinking about the topic than I have.

It’s not an original observation, but I’m of the strong opinion that the role of the doctor and the role of the priest are more closely related than many people realise. I think I’d have made a great priest, though I’m probably better paid as a doctor, and my atheism might have proven a barrier to the alternative.

This is perhaps even more true in public health than other specialties: I often ask people to do things which are to their own detriment—staying of work or isolating themselves—for the benefit of the greater good. The parallels with priesthood are inviolable.

When either role is done well, a large part—perhaps the majority—is listening. The act of simply listening while someone unburdens themselves provides a therapeutic benefit in itself—perhaps most of the benefit in many cases.

But, as Richard Smith reflects, this isn’t easy.

We interrupt because we mistakenly think people want answers, solutions. I’ve been making this mistake most days for 50 years.

Keeping quiet disguises the lack of solutions—but even with that impure motivation, allowing people to express themselves by keeping quiet provides a lot of therapeutic benefit.

The image at the top of this post was generated by DALL·E 3.

Richard Smith recently proposed banning the word ‘prevention’ in healthcare:

A few years ago, my friend Pritt, one of life’s instinctive radicals and iconoclasts, talked to me about “the deficit model of health.” At first, I didn’t grasp his point, but slowly I came to understand. What is being prevented? Sickness, of course. Prevention leads to health, which is the “absence of sickness.” Health is defined as a deficit, the absence of sickness. And who determines if you are sick? Doctors. If we stick with “prevention” then doctors will determine who is sick and who is “healthy” because they are not sick.

Like most radical ideas, this one took me on a journey. My instinctive response was to agree: I smiled broadly as I read, ‘Dying is healthy; living forever would be unhealthy.’

Of course, ‘we need a bolder and broader definition of health—something to do with resilience, adaptability, coping, interdependence, and relationships with others, our community, the planet, and nature.’

But then, I paused. I work in health protection. Most of my job is about ‘preventing’ illness. If someone is a close contact of a patient with a particular disease, then they may need antibiotics to prevent them from becoming unwell themselves. If there’s a high likelihood that a foodstuff in someone’s fridge was manufactured in a way which has introduced contamination, that food might be better off binned to prevent food poisoning. If a cloud of chlorine gas is rolling towards a housing estate, then the people must be evacuated to prevent them from choking to death.

And then I saw the point. To see my job as ‘prevention’ is precisely the sort of simplification that I myself often rail against. My job isn’t really to prevent people from becoming unwell: they can take as many risks and be as unwell as they damn well please. My job is really to inform them of the risk they face, help them to decide whether they want to act in light of that new information, and to support them to act if they wish to do so.

This is significantly different because—as I frequently find myself emphatically explaining to others—it can be perfectly rational not to act in response to a risk. This is especially true given that most actions generate side effects, which each of us will value differently. We don’t—and shouldn’t and mustn’t—compel people to act based on our assessment of the risk to their physical health, because there might well be other things that they value more greatly.

Banning the word ‘prevention’, even from an area of medicine that might seem to be entirely focused on it, would be enormously helpful in reframing what we do.

Richard Smith recently shared this editorial he wrote more than thirty years ago, on the subject of preventing whistleblowing. It seems entirely relevant to the present day.

I was particularly struck by this passage:

Most organisations eventually have to take tough decisions. Difficult choices, particularly over allocating resources, have long been part of working in the NHS. The choices will become tougher, and there may be more losers than winners. The fear that the losers will tell all to the media is what leads managers to reach for their gags. They make a mistake. Instead, they need to create organisations-be they hospitals or health authorities -where employees feel enough part of the decision making process not to need to blow their whistles.

You begin by letting everybody know what is going on. If the rhetoric is glossy brochures full of the word “quality” and the reality is elderly patients with pressure sores in back wards with peeling paint, then staff will become cynical and demotivated. They need to be convinced that the available resources are used fairly, efficiently, and effectively. The surest way to convince them is to involve them in decision making. The decisions that are made must be clearly and honestly communicated. Staff must have a chance to come back on poor decisions, and managers should not be afraid to reverse decisions that are wrong.

If staff understand the true circumstances of the organisation and feel that their views have been given serious attention then they will accept tough decisions. But if seemingly arbitrary decisions appear from nowhere then staff will be unhappy and one or two will contact the press. Managers who try to create a climate of fear will neither stop whistle blowing nor run an effective health service.

That second paragraph is remarkable: it is common sense, it has been clearly articulated for more than thirty years, yet it is seldom followed.

The difficulty so often seems to come at the point of involving people in decision-making. Frequently, efforts to do this appear as cynical attempts to justify decisions that have already been taken. This isn’t solely a problem in the health service: we can see similar cynicism, for example, towards the ongoing consultation about closing railway ticket offices.

If we choose to be as uncynical as possible, then it strikes me that this often boils down to poor communication. Smith talks about ‘glossy brochures full of the word “quality”’—and I think he’s right. Starting a conversation about funding cuts with rhetoric around ‘quality’ and ‘efficiency’ drives cynicism more than collaborative decision-making. Too frequently, managers fear being honest, and too often, managers choose not to be plain-spoken. You cannot have shared decisions if the people sharing in the decision have no idea what you’re talking about.