Article
Care
Comment
5 min read

The healing touch in an era of personalised medicine

As data powers a revolution in personalised medicine, surgeon David Cranston asks if we are risk of dehumanising medicine?

David Cranston is emeritus Professor of Surgery at Oxford University. As well as publishing academically, he has has also authored books on John Radcliffe, and mentoring.

A doctor looks thoughtful will holding a stethoscope to their ears.
Photo by Nappy on Unsplash.

In 1877 Arthur Conan Doyle was sitting in one of Dr Joseph Bell’s outpatient clinics in Edinburgh as a medical student, when a lady came in with a child, carrying a small coat. Dr Bell asked her how the crossing of the Firth of Forth had been on the ferry that morning. Looking sightly askance she replied;  

 “Fine thank you sir.”  

 He then went on to ask what she had done with her younger child who came with her.  

Looking more astonished she said:   

“I left him with my aunt who lives in Edinburgh.   

Bell goes on to ask if she walked through the Botanic Gardens on the way to his clinic and if she still worked in the Linoleum factory and to both these questions she answered in the affirmative.  

Turning to the students he explained  

“I could tell from her accent that she came from across the Firth of Forth and the only way across is by the ferry. You noticed that she was carrying a coat which was obviously too small for the child she had with her, which suggested she had another younger child and had left him somewhere. The only place when you see the red mud that she has on her boots is in the Botanic Gardens  and the skin rash on her hands is typical of workers in the  Linoleum factory.   

It was this study of the diagnostic methods of Dr Joseph Bell led Conan Doyle to create the character of Sherlock Holmes.  

A hundred years later and I was young doctor. In 1977 there were no CT or MRI scanners. We were taught the importance of taking a detailed history and examination. Including the social history. We would recognise the RAF tie and the silver (silk producing) caterpillar badge on the lapel of a patient jacket.  We would ask him when he joined the caterpillar club and how many times he had had to bail out of his plane when he was shot down during the war – a life saved by a silk parachute. We would notice the North Devon accent in a lady and ask when she moved to Oxford.  

The patient’s history gave 70% of the diagnosis, examination another 20% and investigation the final 10%. Patients came with symptoms and the doctor made a presumptive diagnosis – often correct - which was confirmed by the investigations. Screening for disease in patients with no symptoms was in its infancy and diseases were diagnosed by talking to the patients and eliciting a clear history and doing a meticulous examination. No longer is that the case.     

At the close of my career, as a renal cancer surgeon, most people came in with a diagnosis already made on the basis of a CT scan, and often small kidney cancers were picked up incidentally with no symptoms. The time spent talking to patients was reduced. On one hand it means more patients can be seen but on the other the personal contact and empathy can be lost.  

Patients lying in in bed have sometimes been ignored. The consultant and the team standing around the foot of the patient’s bed discussing their cases amongst themselves. Or, once off the ward, speaking of the thyroid cancer in bed three or the colon cancer in bed two. Yet patients are people too with histories behind them and woe betide the medic, or indeed the government, who forgets that.  

With computer aided diagnosis, electronic patient records and more sophisticated investigation the patient can easily become even more remote. An object rather than a person.  

We speak today of more personalised medicine with every person having tailored treatment of the basis of whole genome sequencing and knowing each individual’s make up. But we need to be sure that this does not lead to less personalised medicine by forgetting the whole person, body mind and spirit.  

Post Covid, more consultations are done online or over the telephone -often with a doctor you do not know and have never met. Technology has tended to increase the distance between the doctor and patient. The mechanisation of scientific medicine is here to stay, but the patient may well feel that the doctor is more interested in her disease than in herself as a person. History taking and examination is less important in terms of diagnosis and remote medicine means that personal contact including examination and touch are removed.  

Touching has always been an important part of healing. Sir Peter Medawar, who won the Nobel prize for medicine sums it up well. He asks:  

‘What did doctors do with those many infections whose progress was rapid and whose outcome was usually lethal?   

He replies:  

'For one thing, they practised a little magic, dancing around the bedside, making smoke, chanting incomprehensibilities and touching the patient everywhere.? This touching was the real professional secret, never acknowledged as the central essential skill.'

Touch has been rated as the oldest and most effective act of healing.   

Touch can reduce pain, anxiety, and depression, and there are occasions when one can communicate far more through touch than in words, for there are times when no words are good enough or holy enough to minister to someone’s pain.   

Yet today touching any patient without clear permission can make people ill at ease and mistrustful and risk justified accusation. It is a tightrope many have to walk very carefully. In an age of whole-person care it is imperative that the right balance be struck. There’s an ancient story that illustrates the power of that human connection in the healing process. 

When a leper approached Jesus in desperation, Jesus did not simply offer a healing word from safe distance. he stretched out his hand and touched him. He felt deeply for lepers cut off from all human contact. He touched the untouchables.   

William Osler a Canadian physician who was one of the founding fathers of the Johns Hopkins Hospital in Baltimore, and ended up as Regius Professor of Medicine in Oxford,  said:  

“It is more important to know about the patient who has the disease than the disease that has the patient”.  

For all the advantages modern medicine has to offer, it is vital to find ways to retain that personal element of medicine. Patients are people too. 

Essay
Comment
Politics
10 min read

England needs a written constitution that defends against populism

A new resolution acknowledges what forges a sense of right and wrong.
A wide angle picture shows a king and queen on thrones before many people in ceremonial clothes.
The Opening of Parliament.
Roger Harris/House of Lords, CC BY 3.0, via Wikimedia Commons.

New Year is often a time for reckoning and resolutions. Nations, no less than individual persons, would benefit from such an annual reckoning with themselves.  

If in life we must always strive to find some Aristotelian ‘golden mean’, between recklessness and timidity so it is in the life of states and nations. Many countries have been brought into ruin by the excess of misdirected appetites and wrongly-ordered desires: demagogues inflaming the people; oligarchs seeking to turn the res publica – the ‘public thing’ – into their own personal fiefdom. Revolutions, corruption and public lassitude are the wages of such sins. Ultimately, it ends in the death of the state itself: the collapse of all legitimate authority into warring gangs, while refugees flee, if they can, to the borders. 

Many countries, conversely, go through their lives in cowed timidity, until they end up in an old age of regret, having never achieved their full potential. These nations do not necessarily collapse, but slowly decline – unable to reform themselves, locked in a vision of their past that was better than their present or any imaginable future.  

 England is at risk of both these dangers. On the one hand, a reckless reactionary populism, which has long laid dormant, but has been unleashed since 2016. It threatens to abandon all prudence and overthrow all restraint, to attack the civil service and the courts, to reject Human Rights, to corrode civic discourse, and to set aside all procedural propriety, until we end up sodden in the gutter of despotism. On the one hand, a persistent constitutional conservatism stands in the way of the necessary, long overdue, reforms which would breathe life and vitality back into an old, tired, country, and would give our institutions the strength to resist such destructive forces.  

Nations, like people, can experience decisive moments of what might be termed repentance. When they wake up in the gutter – their capital city bombed, their army disbanded, their people starving – they can turn from the paths which took them to that place, and find a newness of life, a new hope, embodied in a new constitutional order. This is what Germany, Italy and Japan did after 1945. They can also experience a kind of conversion, away from false principles to truer ones, as much of Central Europe did after the fall of the Berlin Wall.  

I am using theological language here to describe merely civic and political attitudes, which is always a dangerous thing to do. It would be a misreading of my intent if one were to conclude that I conflate a well-ordered polity with the Heavenly City. Nevertheless, a well-constituted polity, in which freedom and justice, peace and the common good, are not only treasured but actually – to some practical extent – achieved, is an inestimable blessing. We should strive to obtain it.  

A well-constituted polity is based upon the principle of ‘public government’. The state is a public entity, belonging to the public, in which public office is a public trust to be used for public ends, and where citizens in public life must be faithful stewards of the public good, for which they are responsible to the public. 

Democracy is our shorthand term for this arrangement, although it is a rather clumsy one. Democracy, properly understood, is not unlimited majority rule, nor the unconstrained rule of the person elected by the majority. It is, rather, a complex political system that combines representative and responsible government with civil liberties and the rule of law.  

Populism is a caricature of democracy. Populists attempt to undermine the barriers that restrain abuses of power. Their attempts to weaken the judiciary and civil service, sideline those who disagree with them, infringe fundamental rights, centralise power, and restrict public dissent, must therefore be seen as attacks on democracy. They put arbitrary power into the hands of particular persons. 

England’s position is not that of Germany in 1945. It might, in some ways, be analogous to that of Central Europe in the 1990s. Much of England today looks like I remember my first visit there then: the same grey faces, the same cheap clothes, the same visible effects of bad housing, bad food, and lack of opportunity. If anything, England is worse off, because at least those countries had hope of better days ahead. No one yet has imagined an English future better than its past.  

England has been let down by a failed ideology – that of neoliberal capitalism, which, as Dr Abby Innes points out, is every bit as rigid and doctrinaire as the official Marxist ideology of the former Communist states. England has been let down, too, by decades of corrupt, incompetent, short-sighted and careless government. The symptoms of misgovernment can be seen in England’s economic record, its social problems, its crumbling infrastructure and over-stretched public services.  Outside the Customs Union and the Single Market, England is isolated from its European neighbours.  The country is not living up to its potential.  

This should spur us to consider the weakness of English democracy. As currently established, the state often fails to serve the common good. The English do not live in a well-constituted polity with ‘public government’ as its foundation, but in a fiefdom-state that has been cut, privatised, deregulated into near oblivion.  

If it were only a matter of specific individuals, or of one party, the problem could easily be fixed. But the country has not only been let down by this government or that government, by this party or that Prime Minister. It is the system of government, the constitutional order as a whole, that has failed us. 

Restoring England’s hope for the future, its prosperity, and its quality of life, must begin, then, with the improvement of English democracy, and that with a refoundation of its constitution. This is hard to hear, because, as Mr Podsnap put it in Charles’ Dickens 1864 novel Our Mutual Friend, ‘We Englishmen are very proud of our constitution, Sir. It was bestowed upon us by Providence. No other country is so favoured as this country.' It is hard to admit that something is broken, when once it was so highly prized – indeed, so intrinsically bound up in England’s sense of national identity. 

The Westminster Model of democracy is not without its virtues. Its origins can be traced far back into English history. Yet it did not develop into maturity in England alone. Bagehot was carried around the world, read under palm and pine, and drilled into the ruling classes from Vancouver to Colombo. The Westminster Model owes much to Magna Carta and Simon de Montfort’s ‘Model Parliament’ of 1295, but it owes just as much to the developments of the Victorian age: (nearly) universal suffrage, political parties, manifestos, and the establishment of a permanent, professional and non-partisan civil service.  

The transformation of Empire to Commonwealth ended British rule, but not the British way of ruling. Westminster Model democracy had to be set down, of course, into a written, supreme-and-fundamental law, through which all the essentials were faithfully reproduced. If you want to discover the Westminster Model of democracy at its peak, read the constitutions of Belize or the Solomon Islands.

The rejection of written constitutions has been a prevailing English conservative principle since Burke. However, it leaves us defenceless against authoritarian reactionary populism. 

The irony is that those who are most comfortable with the imperial legacy are also those who are doing most to destroy public government at home. While fetishizing ‘The British Constitution’ and ‘Our Eight Hundred Years of Unbroken History’, the populist right rejects the principles and the values upon which that achievement rested. Just as they seek to create a pastiche of 1950s Britishness (absent of strong workers’ rights, strong unions, a generous welfare state, and publicly owned utilities and services), so likewise they seek to create a pastiche of the 1950s British Constitution, without the self-restraint, moderation, decorum, public service ethos, and high levels of social trust and cohesion, which made that system of complex unwritten rules work.  

The Blair-Brown reforms of 1997-2010 are a particular target of reactionary ire. The Human Rights Act mitigated, although it did not remove, the absolutism of Parliament. It gave the people who have little voice under a purely majoritarian system – ‘the weird, the wicked, the weak’ – a means by which to challenge the exercise of power. Devolution broke the prevailing English notion of British uniformity: it not only allowed Scotland and Wales to have a (muted) political voice and some (tightly constrained) freedom to craft their own policies, but also forced England into a reckoning with its own national identity. So far, this has played out mostly through the doubling-down on what the former Labour MP and scholar of English identity John Denham calls ‘Anglo-centric British nationalism’. The Tory – and Reform UK – constitutional agenda is obsessed with restoring the unlimited power of Parliament and of reinforcing the Anglo-centric British state. 

As we can see, from every NHS waiting list to every pothole in the road, the Anglo-British state is no longer working very well. It has all the vices of its past, and few of its virtues. A return to the pre-1997 status quo ante is impossible – it would be like trying to retake Hong Kong. Parliamentary absolutism tempered by the ‘good chaps’ theory is no longer a viable option. Either we must accept an untampered absolutism – which is the agenda of the reactionary populist right – or else we must deepen constitutional reform, and arrive at a new constitutional settlement which accepts that the British Imperial state, oriented to the needs of maritime imperial commerce, is over, and that an English nation-state, oriented to the common good of the ordinary people of England, is now needed.  

This entails a new, democratic, constitutional foundation. Small-c conservatives might baulk at this. The rejection of written constitutions has been a prevailing English conservative principle since Burke. However, it leaves us defenceless against authoritarian reactionary populism. Moderate, sensible, responsible conservatives should learn to think differently about written constitutions. Paradoxically, constitutionalism strengthens the state. By bounding and limiting state power, and providing a robust system of responsibility, accountability, and restraint, constitutional government actually enables the state to draw upon a deeper well of public legitimacy.  

What would English identity look like, if it were forged between the Channel and the Tweed, and not between the Nile and the Irrawaddy? What might an English constitution look like, and what values and principles might inform it?  

A constitution for England must recognise that England is a society of many faiths and none. It is, however, an acknowledgment that Christianity has forged and formed not only our institutions, but also our understandings of right and wrong. 

In addressing the last of these questions, the Christian tradition has much to add to the conversation.  

Christian theologians and political philosophers have spilled a lot of ink, in the past two millennia, on questions of good government, on the relationship between church and state, and what it means to be a Christian and a citizen of an earthly state.  

There seems to be an assumption – amongst both supporters and opponents of written constitutions – that a written constitution would have to be based on secular values. This stems, in part, from our ignorance of our own Westminster Model constitutional tradition. The constitutions of the United States and of France might be strictly secular, but the constitution of Antigua and Barbuda claims to be ‘founded upon principles that acknowledge the supremacy of God’, while that of Tuvalu explicitly refers to ‘respect for Christian principles’.  

This is not a bid for theocracy. A constitution for England must recognise that England is a society of many faiths and none. It is, however, an acknowledgment that Christianity has forged and formed not only our institutions, but also our understandings of right and wrong. To give all that up would produce an ethical vacuum in society, which will be filled only with ever more grotesque forms of exploitation.  

The cardinal ethical principle of constitutional democracy is a recognition of human dignity. At the origin and foundation of all institutions, and laws, and norms, we find ourselves having to cling to the fundamental command that Christians call the Golden Rule: ‘Do unto others as you would have others do unto you’. If we abandon that principle of human dignity, there is no solid ground on which to build a decent, well-ordered, democratic polity. Perhaps then we can build a new ‘Jerusalem’ in England’s grey and drizzly land. 

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