6 EVERYTHING IN LIFE IS RELATIVE
Almost nothing is absolute in life — but absolutes are being used to attempt to describe our lives.
‘Oh Tim’s OK. There’s nothing wrong with Tim!’
Young wife’s response on being asked in passing about her blind, diabetic husband.
‘Did you win?’
‘No — we were up against the Under Elevens’
In cowboy films people are ‘absolutely good’ or ‘absolutely bad’. This is a conventional simplification which is absolutely unlike real life.
It is easier to watch a streetful of young men being killed by a glint-eyed household hero if you have first been persuaded that they are all baddies. Somehow the fact that they may also be daddies doesn’t seem to occur to the avid audience, but in real life it would.
The closer you get to real life, the more complex and subtle it seems, the further away, the simpler.
Almost nothing to do with people and life is absolute, nearly everything is relative. Nature cannot, by definition, be ‘perfect’ and most of the problems of real life have no ‘correct’ solution. It is therefore hardly surprising, indeed it is inevitable, that nature has equipped our minds with powerful mechanisms for making judgements on the basis of things that are not absolute but relative. In recent years mankind has increasingly attempted to use machines to imitate and improve upon the workings of the human mind. One of the results of this has been to reveal, as never before, the size of the problems that the human mind solves with so little apparent effort. Here is an example.
One of my personal projects in our health centre has been the construction of a general health screening questionnaire. The idea is that the patient has his height, weight and blood pressure measured and that he then sits by himself at a computer and answers a series of questions.
There were a number of novel features of this system (which is what made it fun to design) especially the fact that the report was addressed to the patient himself with the clear implication that it was his life and his choice about whether he followed the advice given. The point I want to discuss here is the difficulty of defining the advice that I was programming the computer to give.
Consider a section on drinking. There is no problem about getting the computer to ask for information on daily intake of pints of beer/cider, glasses of wine/sherry and singles of spirits. From this it is easy to work out the units of alcohol consumed in a week. (A unit of alcohol is defined as a glass of wine, a half pint of beer or a single of spirits.) Thus for each patient you get a nice clear figure expressing their alcohol consumption.
OK, what do you do next?
If you are absolutely opposed to all alcohol consumption there is no problem. In fact you only need to ask one question, ‘Do you drink alcohol… Yes or No?’ If they say, ‘No’, give them a good mark. If they say, ‘Yes’, give them a roasting.
But I don’t find it as easy as that. While I recognise alcoholism as one of the most destructive conditions that anybody can suffer from, and a common one at that, I also know that moderate drinking is very nearly universal, great fun and is almost certainly slightly advantageous to health. Where do we draw the line?
We are helped by the experts because for once they broadly agree. There is a reasonable consensus amongst them (at the moment) that the upper limit of acceptable drinking is twenty one units a week for a man and fourteen units a week for a woman. This gives us a starting point for our computerised advice. Twenty one units for a man will earn a stern but friendly rebuke: ‘The upper limit recommended for a man is twenty one units per week, therefore you are drinking too much… Try to cut down.’
The chap who scores twenty units (by drinking, say, a glass of wine less per week) scrapes into the category below. He is told, ‘Your drinking is in the upper part of the acceptable range; don’t let it creep up’, and he goes off to celebrate.
If somebody drinks twice the magic upper limit — forty two units or more — he gets a real telling off, ‘You are drinking Far Too Much… Get help with your drinking’. Wow! Worth keeping to forty one units to escape that!
The real problem comes at the division between, ‘You appear to have no problem with alcohol’ and, ‘Your drinking is in the upper part of the acceptable range… don’t let it creep up.’ Shall we set the division at half of the magic number, at two thirds, or where?
Well the answer is that there is no logical way of making such a distinction. It is a matter of balance, a matter of judgement. We do it all the time. But try to make a computer do it and you find out what a subtle business it is. Compared with the human mind computers will always be clumsy and unsubtle, and no programming revolution that is remotely conceivable, even incorporating the magic of ‘fuzzy logic’, will enable them to approach our sophistication in making value judgements.
Finally, before getting too hung up on the mathematics of these distinctions, have another look at the figures they are based upon. To start with, the recommended drinking limits are picked more or less out of the air. There can be no scientific justification for claiming them to have a validity better than plus or minus fifty percent, not least because they are changed from time to time. On the other side of the equation, the figures entered by the patients are themselves only the grossest of estimates, even when entered honestly. (Any sensible person ought to be very sure what is going to be done with figures about their drinking habits before entering them honestly into any computer.)
So here we have another example of the mystical power that we attach to figures simply because they are figures.
JUST NOT THE RIGHT WAY TO MEASURE THE SIZE OF PROBLEMS
For a period of ten years or so I had a patient who was terribly crippled by rheumatoid arthritis. Both legs had been amputated and she had gradually accumulated complications including a severe stroke. Her intelligence was as high as it had always been but her speech was gradually becoming more difficult to understand. She typed by holding a padded stick in both forearms.
She once asked me what on earth the point of her existence was and I replied that she was the person who made everybody else feel better by being relatively worse off than any of them. Which, in a sense, I believed to be true (you’ll never carry conviction when you say things like that if you don’t believe them yourself). Anyway, it amused her at the time and I think it kept her going for a little.
If a patient has been ill for a long time he or she will be grateful for any form of relief (although, naturally, sometimes indignant that it was not provided earlier). If the illness is only just beginning and although the doctor may know that he is saving the patient from suffering, and even from worrying about the possibility of that suffering, the patient is often not particularly grateful and is more preoccupied by the side-effects, real or imagined, of the treatment. This is why syringing ears (and restoring hearing at a stroke) is so much more satisfying than treating high blood pressure (and turning people who feel fit and well into patients requiring regular medication and supervision, who all too often feel ill).
Almost everything in life is relative. We all know that happiness has surprisingly little to do with physical health. Some of the most miserable people are perfectly well physically and appear to have everything that they could wish for. The various joys and cares that people have seem to bear no relationship to any measure of absolute importance. An old lady may lavish as much thought and care on her tiny garden as a Dowager on a vast estate. The loss of a dog can disturb one man as much as the loss of a battle disturbs another. I have seen more than one full-blown bereavement reaction to the loss of a budgerigar.
I dare say that the problems worrying the Minister of Health as he sits at his desk in the morning have about the same relative importance to him as the problems that I have to face as I sit at mine. One of us may be dealing with millions of people and the other individual people. In absolute terms it seems clear that to one of us the problems must be millions of times bigger than to the other. But our instincts tell us that that just isn’t the right way of measuring the size of problems.
ABSOLUTE QUANTITIES DO NOT CONSTITUTE TRUTH
Take physical fitness as another example. To appreciate fitness to the full you have to know what it is like to be really unfit. My advice to anybody who wants to keep up exercise over a long period of time is to spend a decade or so early in life at a rock-bottom level of unfitness, as I did, and then find out what you have been missing. That gets you out on the cold mornings! Appetite is the same of course. It is so relative that when you are full you find it hard to imagine hunger being even slightly unpleasant. And tiredness. If you spend much of your time feeling mentally tired there is nothing in the world like relaxing when physically exhausted.
All our perceptions are expressed in these kinds of relative terms. After spending a day traveling high up in a mini-bus, when we get back into our familiar car it seems very low. When we hear a compact disc recording for the first time the clarity is almost overwhelming; a month later we hardly notice it. A child who has never known kindness will be amazed by a smile. And yet we persist in thinking that absolute quantities and measurements are what constitute truth.
THE NEED FOR SLIPPAGE
General practice is full of problems which have no absolute and correct answer. This is what makes it seem to be a woolly, vague and inherently less valid discipline than a restricted specialist field within which certainties can be seen to apply much more directly. But general practice is a much better model of life than is any medical specialty. Life is full of woolly uncertainty. By undermining our respect for, and confidence in, the mechanisms by which we cope with this uncertainty we are making it very difficult for people in the real world to live their lives.
That is why it is so important to make a coherent, logical defence of the generalist approach, in spite of the paradox that the generalist approach itself is ultimately illogical.
The modern understanding of life contains a fundamental inconsistency. On the official, media scale we treat life as though it is a machine, which can be analysed, defined and controlled precisely. And yet, our unspoken instincts tell us that life is nothing of the kind, it is infinitely subtle, flexible and relative.
Real people, operating on the personal scale are forced to live with life as it actually is. Thus individual working teachers, nurses, social workers, doctors or whatever have no alternative but to accept that life is a series of messy compromises.
Society as a whole is now being confronted with that reality for the first time, because for the first time it has the machines and the systems which it thinks it can use to control life at the individual level. So the hidden cop-out is being revealed. The shabby posture of media scale society has been to rely on individuals for the slippage upon which life is utterly dependent. And yet, when instances of that slippage are exposed on the media stage, the individual is ruthlessly sacrificed.
By permitting slippage within the National Health Service, GPs act, in a sense, like the cut-throats whom the outwardly noble Macbeth secretly employed to do his dirty work for him. We follow our personal judgement, educated as it is, rather than the rules we are nominally meant to follow. Thus we provide the essential discontinuity on the logical road which, in an increasingly litigious world, would otherwise lead every patient with a headache to the brain scanner.
In order to do this we have to take a series of more or less carefully balanced risks, all expressed in relative terms. In other words we use common sense. But if society continues to denigrate this process and begins to expect perfection, as judged by the false perceptions of the media scale, then doctors are not going to let themselves be rewarded in the way that Macbeth rewarded his servants. We will eventually be forced to work to rule and not to life, in order to defend ourselves. And society will be the poorer. For however detailed the rules, any attempt to live by them is inevitably doomed to failure because the kinds of problems we deal with do not have logical solutions. And in any case, as I have already said, the complexity of the rules which would be created in the attempt would be self-defeating.
At the moment the move towards ever more central supervision throughout society is gathering pace as quickly as the necessary technology becomes available. But ironically, as a direct consequence, the need for slippage in society is becoming more and more apparent. After all, the more refined the method of counting you use, the more clearly it reveals inconsistencies. It is already quite obvious from a personal perspective that technology and rules are a poor substitute for common sense. The question remains how long it will be before this becomes obvious from the media scale perspective as well, and how far things will have deteriorated by then.
GENERALISTS MUST LIE
This brings me to the answer to a question which has troubled me for much of my life. A remark which a teacher once wrote on one of my history essays, ‘He who generalises… generally lies!’.
I’m sure the remark was fully justified as it was applied to my essay but ever since I have been worried about its wider implications as a criticism of the entire generalist approach.
The answer, however, is this: ‘Yes. Generalists must lie. Controlled lying, or slippage, is the only means we have of coping with the complexity and the uncertainty of life.’
The slippage which our minds permit, the subtle distortion of the literal reality of the world, is not a failing but a necessary strength.