‘Will it sting?’
‘Well, it might sting a bit, but you won’t mind too much.’
‘Well, actually, I would mind if it stings.’
Five year old being prescribed eye drops.
‘I THINK HE’S DEAD, DOCTOR’
The veins in the big farmer’s arm stand out like ropes and the
needle goes in easily. I release the tourniquet and begin to inject
the Diamorphine, a tenth of a millilitre at a time, watching the
tension, the pain and the sweat in his face. Listening to his
breathing. Feeling the pulse with my free hand. Feeling rather alone
at the end of the long road and the rough farm track.
‘You’ll feel better in a moment… Don’t worry…’
He opens his eyes and smiles a little.
‘It’s easing off a bit, I think.’
‘OK. Just rest back..’
I watch and wait for him to settle. Holding back half the syringe.
‘Could we have a bowl in case he feels sick please.’ His wife goes out
It is my weekend on duty and they are patients of one of the other
doctors in the rota. It sounded like a coronary on the telephone and
when I arrived it looked like one. It obviously felt like one.
I’m thinking what to do next. Whether to admit him to hospital or
keep him at home. I decide to be frank with him. He’s no fool, he’ll
want to know. ‘Now I think what’s happened is that you’ve had a
slight… Hang on… Damn!’
He’s not listening. His eyes are rolling upwards. Even as my hands
go to lift his chin he takes a convulsive unconscious inspiration,
stops breathing and begins to turn blue.
This is not my favourite pastime… I slap the centre of his chest
hard — worked once, but not this time. I make a space and swing his
heavy body on to the floor, stick a plastic airway from my emergency
bag over his tongue and begin to inflate his chest with my Ambu-bag.
No pulse — so I start cardiac massage as well. His wife is looking on.
What do I do next?
I suddenly remember my colleague who is on duty for the other
practice and who I know has a defibrillator in his car which we might
use to get his heart beating again. ‘Look, could you ring this number
and ask Dr Bethell to get here as quickly as possible.’ I know it is
stupid as I say it. He couldn’t possibly be here in less that twenty
minutes and we haven’t a hope of saving him after more than five. She
goes off anyway and I draw up some Adrenaline and inject it into his
heart. Nothing. He is turning bluer so I go back to the respiration
and the cardiac massage knowing that I am only doing it because I
haven’t the courage to stop.
And then I feel the gentle touch on my shoulder and the soft voice
of his wife, trying not to upset me too much, ‘I think he’s dead,
ALLOWED TO USE MY COMMON SENSE
I know that lady well now because she came on to my own list of
patients when my colleague retired. After her husband’s death she had
left the farm and moved to a smaller house. Now she keeps her new
garden as full of brilliant flowers as she used to keep the old one.
After the night of the great storm of October 1987 she told me that
she had lain there, alone in her bedroom, hearing the trees crashing
down onto her lawn, one after another. ‘I thought the end of the world
had come,’ she said, ‘I didn’t mind very much, I just lay there and
You don’t need to tell me the number of different ways I could have
treated her husband better, how much better equipped I could have been
or how much better trained for that particular eventuality. Nobody
could have felt these deficiencies more than I did. But her straight
forward, common sense brought home to me just how irrelevant, how
intrusive and how trivial such hi-tec interventions would actually
There is no correct answer to the problem of how far to push the
treatment of dying patients, the only answer is common sense. That’s
why heads of state get such an appalling deal at the ends of their
lives. Teams of the most distinguished doctors available are assembled
and while the whole world watches in horror they struggle to prevent
what is obviously inevitable.
Nobody, however senior or distinguished, can afford to be guided by
common sense when their actions are spotlighted on the media stage. So
Emperor Hirohito of Japan, President Eisenhower of the USA and General
Franco of Spain went through days and weeks of unnecessary suffering
because nobody had the courage to say the simple words, ‘I think he’s
When I die I hope that I will have a doctor who is free to use his,
or her, common sense. I know from numerous remarks made to me by
patients over the years that this is what other people want as well:
to be able to trust a doctor to weigh up the situation and treat them
as they would treat a member of their own family. No more. No less.
Most people are far more afraid of too much treatment at the end of
their lives than of too little and few expect their doctors to go on
saving them for ever. But they do expect them to use their common
sense. It is vital that we create a society which can respect such
final wishes of its members.
WHAT ROLE FOR THE INDIVIDUAL?
I have tried to give some impression in this book of the wonderful
cast of characters that peoples the world of one small town GP. I have
quoted some of the things they say in order to show the wisdom, love,
humanity of ordinary people, which the media phenomenon has somehow
misled us into doubting.
It is individual people who are important in life, with their
infinite variations, colours, strengths and failures. Yet, more and
more people are asking what role there is for them as individuals in
the impersonal, mechanistic society they increasingly live in. They
feel that there must be more to life than just being an anonymous
operative in a great machine, or an anonymous consumer, whose actions
can be reduced to a series of statistical norms.
What I have tried to do is to go beyond the simple statement of an
inner conviction. To express more than ‘just a feeling’ that without
the human aspects of life, life would not be worth living. I have set
out to show that there are excellent, logical reasons why society
needs the common sense and integrity of individual people in order to
sort out the tangle of proliferating technology that enmeshes us.
After we have dealt with the cold logic of the matter, those who want
to put the feelings back in again are free to join me in doing so.
THE CRUX OF THE PARADOX
Here we are at the crux of the paradox. We want to define clear
solutions to the problems we can see in the world. But as we do so we
progressively destroy the essence of life itself. It seems to be an
unavoidable rule that the precise definition of human affairs has the
effect of killing humanity itself.
To put it another way, society is faced with the following problem;
we understand the world we live in more completely than we have ever
done before, and yet we understand it less. The near total triumph of
our logical approach to quantifying and measuring and recording the
world looks like coinciding with our final destruction, by one means
or another, of that world. In other words, our logical approach to
life is threatening to bring our life to a logical conclusion. And the
irony is that our slide into the abyss will be understood and
explained and recorded like the greatest cinema epic there has ever
As Robert M Pirsig said in his wonderful book, Zen and the Art
of Motorcycle Maintenance:
‘…the crisis is being caused by the inadequacy of existing
forms of thought to cope with the situation. It can’t be solved by
rational means because the rationality itself is the source of the
As we hunt around, more and more frantically, for ways to describe
and control the world more and more perfectly, we find that the
problems don’t get less, they get more. Daily, we encounter the
consequences of our failed perception. And all the time the answer we
are seeking is there, not actually under our noses, but an inch or two
above and behind our noses.
I don’t want to get involved in the familiar argument about whether
or not our minds are machines. There can be no question that they have
qualities of subtlety and mystery which place them far beyond our
normal conception of what is meant by a machine. Whether the
capacities for self-awareness, passion and free-will are ultimately
explainable in solely mechanistic terms is beyond me, although I have
my view. But what I would say is that if our capacity for
understanding — this amazing ability which we take so much for granted
— to hold an imaginary model of the world, to constantly improve it by
comparison with experience, and then by applying something which we
call imagination, to test out future courses of action and future
possible developments — if this ability is the function of a machine,
that machine is like no machine that man has ever created.
The modern assumption is that we have machines and systems which
describe and therefore understand the world better than our minds
could ever do. We assume that we have improved enormously on nature.
But we are entirely wrong. Not only have we underestimated the
magnitude of the task we have undertaken, not only have we failed to
appreciate the power of our minds, but we have failed to see that the
absolute terms in which machines are compelled to operate are
incapable of describing life at all.
Machines are in their element when dealing with absolute terms;
they are enormously superior to us at, for example, performing
calculations. Computers, after all, compute. But when we extrapolate
from this, as many people do, to the assumption that they will be
correspondingly superior to us in understanding the world, we make
what is, ironically, a glaring error of logic. We forget that
performing arithmetic is hardly any more the purpose of a human mind
than making a wake is the purpose of an ocean liner. The purpose of
the human mind, which the evolutionary forces of millions of years
have operated to perfect, is to model the world. Brains only compute
as a by-product of their modelling; computers only model as a
by-product of their computing.
It is important to recognise that there is a fundamental inequality
in the comparison here. Ability in computing can be directly measured
and compared — indeed that is exactly the kind of thing that computers
are designed to do — so we know how much superior they are to us in
this respect. Ability in modelling, on the other hand, can only be
judged as an art form, and it is impossible to make absolute
comparisons. Nevertheless, when we consider the perfection of other
biological systems (you have only to think of the movements of an
Olympic gymnast) it seems very likely that the human mind is as nearly
perfect in its primary task of modelling the world as any machine
could ever be. So, even if we were to succeed in creating such a
machine, it would probably be very like a human mind. And we have
enough of these already. Or if we haven’t we know how to make more.
The automatic maintenance of the ocean of ideas which is our
conception of life is the purpose of much that is cleverest in our
minds. There are good reasons why these functions are automatic, and
therefore unconscious, and therefore forgotten. First, the ideas are
too large to fit into the window of consciousness all at once. And
second, their maintenance is too important to be left to the vagaries
of the will.
Just the same need for maintenance arises with the complex ocean of
ideas which defines a society, and exactly the same comments apply.
The ocean of infrastructure which underpins society is what really
matters, but it is unseen because society focuses its attention
exclusively on the beaches of innovation and change.
We are going to hear much more about maintenance in the future. The
concentration on the incongruent — the change — and the forgetting of
the ocean has reached its apotheosis in the disposable society, the
phenomenon of consumerism and the emphasis on surface rather than
depth. Greedily we gobble up goodies — our houses, our photograph
albums and our rubbish tips full of last year’s discarded toys. All
the exciting things of life are there on the edges of the ocean, the
surf washed up on the beaches.
As we romp along, drunk with the excitement of change, it is
gradually becoming more and more difficult for even the cleverest
people to ignore the compelling evidence that things are going wrong;
that the processes upon which society depends must, in the end, be
sustainable; that if we concentrate only on the beaches, the ocean
will die; that more and more of the effort of life must in future be
directed towards maintaining the artificial systems, technological and
organisational, which make our lives possible.
So that is why it is so wrong for people to give up and let others
do the job of trying to understand the world for them. Society’s
collective image of the world is nothing less than a summation of the
personal images of countless individuals. If people opt out of the
process of forming this image it will be formed by a smaller and
smaller and more and more specialised sub-group of individuals. This
sub-group will be distinguished principally by its certainty that it
is right — and therefore by the probability that it is wrong.
KEEP ON TAKING THE TABLETS OF STONE
While society needs the free minds of individual people, it must
also, of course, have rules and conventions, they are largely the
things that make a society. We can’t all choose the voltage of our
electricity supply or the side of the road we want to drive on. We all
have to subjugate our selfish, short-term interests in a host of ways
for the long-term interests of each and every one of the hierarchy of
groups we belong to; our families, our neighbourhoods, our
professional colleagues, all the way up to the world itself.
Enlightened self interest (which can be defined as allowing someone to
get out of a telephone box so that you can get into it), whether or
not it is ultimately the only human motivation, is certainly the only
way to live.
Society must have rules, individuals must have freedom. Defining a
rule always excludes a degree of individual freedom and somewhere a
balance must be struck. The point is that it is striking the balance,
not thinking up the rules,
which is the difficult bit. In the past the balance was achieved by
default, lots of rules which nobody took seriously — midwives weren’t
supposed to stitch but actually they often did, old people’s wardens
were supposed to follow the rules but actually used their common sense
etc, etc. Rules, we all knew, were made to be broken.
But now technology is being used to enforce the rules without fail
and the detached machinery of law is being used to impose penalties
without any understanding of the human reality. Computer systems are
par excellence machines for the carrying out of rigid rules. As they
become more established in our society there is a very grave danger
that they will impose standard procedures and rigidity to an
unprecedented extent. Many administrative and supervisory functions
currently performed by people could and probably will be taken over by
automatic audit systems. The important thing is that they should be
carefully designed to reflect the real objectives of what is being
done or entirely different objectives may be permanently built in.
This defining of objectives is a task in which ‘ordinary people’ must
become involved. It is absolutely vital that the narrow perceptions of
experts are not cast into tablets of silicone.
None of this is the ‘fault’ of computers. It was never the sword
that killed, but the man who wielded it. I have shown in my practice
that computers can encourage independence, individuality and
diversity. But there is a great danger that they will be used to
impose uniformity and constraints to an undesirable extent. It is up
to us to lay down the rules so that computers, and all other aspects
of management technology, are developed as liberating tools, not as
agents of constricting masters.
It is noteworthy that those people who are most thoughtful about
the application of rules and most troubled by pointless ‘stone checks’
are the very ones who are most realistic about their own limitations.
Perhaps this is because people who don’t think any rules matter aren’t
worried by foolish ones. A colleague in postgraduate GP education in
Wessex, Dr Roger Hillman, showed this with a study of how well
doctors’ real performance matched up to the rules they thought they
applied to themselves. He concluded that, ‘The only person who did
anything near what he thought he did, was the one who thought he did
If this is typical of people in other fields of life, as common
sense tells us it is, then it means that rules which are going to be
adhered to will have to specify minimum
standards. These minimum standards, furthermore, will be much lower
than the ideal standards which central controllers may think
desirable. And very much lower than those to which some individual
enthusiasts would otherwise undoubtedly aspire. Otherwise, the very
act of imposing the wrong sort of rules will kill the initiative of
those people who would previously have sought (sometimes
unsuccessfully) to reach far above them.
RULES FOR RULES
1 Rules should always be implemented properly so that they are
respected. If a rule has been made to be broken then it has been made
2 Rules must never, ever, be made for their own sake or for the
sake of change. It is never right, under any circumstances, for rules
to be created as a justification for the existence of the rule makers
or to satisfy their need for power, authority, status. Rule-makers
should be servants of society, not rulers of society; they should be
instruments of informed consensus.
3 Rules must always be practical — which means they will often be
far less stringent than we think ( — and enormously less stringent
than a specialist in the particular field would think.)
4 The number of rules must be kept to an indispensable minimum
which means there will be far fewer than we think ( — and enormously
fewer than the sum of all the recommendations of all specialists).
5 Rules should always be created and applied at the most peripheral
level of society possible. The best rules are imposed by the
responsible adult on himself and each step away from this ideal must
6 Rules should be SAFE MINIMUM BASELINES not IMPOSSIBLE IDEALS.
They should be foundations on which to build, not mountain-tops people
exhaust themselves struggling vainly to reach. People are best left
choosing their OWN mountains to climb.
7 Rules should be designed to set the limits of acceptable
behaviour, not to direct the details of behaviour.
The essential point is that rules can never describe life, they can
only set the limits.
THE BALANCED WAY FORWARD
We have seen that there are two possible ways for us to proceed.
One is the automated, mechanistic, defined way and the other is the
soft, instinctive, natural way. The first can’t cope with the
complexity of life and provides no reason for living; the second
leaves mankind blind, lacking in plan and vulnerable to all sorts of
So this is where we need human minds to make the balance. Enormous
opportunities to improve this balance are opened up by technology. By
producing a sort of summation of the thoughts and experiences of the
entire world, analogous to the image of the world contained in each of
our minds, we have the prospect of a new era of media scale
super-understanding and even of media-scale super-wisdom. But before
we can achieve that we have got to understand media scale
super-distortion and grow out of media scale super-selfishness.
Although many people now suspect that civilisation is rushing
towards the brink of a precipice, they have adopted the short term
solution of closing their eyes.
‘You worry too much, James, why don’t you have a drink.’
Others fix their eyes on one thing, typically the pursuit of their
own wealth, and exclude the worrying view ahead. Exclusion, remember,
is the enemy, the cop-out from life. The more closed the mind has
been, the more traumatic the eventual opening is likely to be, but we
have no alternative. We must all open our minds and let in things that
are not ‘our field’. Individuals in all walks of life have got to use
their minds to understand the enormously complex world in which we now
live. This is the duty of education in its broadest sense. Part of
that educational process takes the form of specialists making the main
truths of their disciplines accessible to generalists. I hope that I
have made it clear that in my book popularisation is a good thing.
Many of the most able scientists have shown themselves to be aware of
this need, and Stephen Hawking’s freshness and clarity in describing
advanced contemporary cosmology in the enormously popular
‘A Brief History of Time’ suggests that no subject is too difficult for lay
people to at least approach. We need specialists who can contribute
simplified models, which are consistent with the main truths of their
disciplines, to the common stock of ideas. They must watch so that
they can perform the necessary fine-tuning when they see errors in
people’s understanding of these models. And so must everybody else
watch and listen to them.
We need far more mutual respect in the world, with the generalist
part of each of us respecting the specialist part of everyone else and
vice versa. We must respect the whole system of rational thought which
is science and at the same time we must remember its limitations.
Mankind is absolutely committed to riding the tiger of science,
however great our misgivings at times may be. We are totally dependent
on the artificial systems that make our lives possible and if we try
to dismount mankind will suffer the usual fate of those who get off
Human understanding is not a game, it is not just an optional extra
in the modern world, a mere luxury which makes life richer, it is
absolutely essential for our survival. It is only human understanding
and common sense which can combine the hard, rigid world of logic and
scientific truth with the soft, vulnerable, inner world of human
feelings and passions to make a world which works and in which it is
worth living. It is time, I believe, to recognise the fundamental
imbalance in this equation, to recognise the fact that we are not
comparing like with like when we weigh up facts against feelings, and
to realise that if we don’t give back feelings their due, and soon,
the madness of society is going to get very much worse just as we
think we are finally getting everything perfect.
If people can be killed by kindness then certainly society can be
killed by progress. If you must sometimes be cruel to be kind, we must
sometimes go backwards a little in order to go forwards. The backwards
I have in mind is towards a respect for human values and for the
common sense and integrity of individual people. Backwards to the
personal, local scale where people feel they count and that what they
do or don’t do is likely to make a difference. We need a simpler
society, with fewer rules, not more. With a bias towards individual
freedom and diversity and away from restriction and uniformity. Most
of all we need to keep technology in its proper place, as the servant
of the individual person, not the master. To make use of its enormous
potential to enhance life. Whilst protecting ourselves from its
enormous potential to diminish and imprison us.
View of the World
The Distorted View of the Specialist
The Myth of the Ideal World
Everything in Life is Relative
The Ocean of Congruity
Nature Favours the Generalist