Friends in Low Places
The Final Chapter of Friends in Low Places
"Thank you for everything you did, and your team"
"It’s a funny thing, they were all very good, but he kept asking for Doctor Willis."
It was one of the shocks when I got back to work after my six-month sabbatical. Only a month earlier (I was told) he had gone in for tests for a stomach pain and the exploratory operation had found pancreatic cancer spreading right through the organs of his upper abdomen. There was no possibility of removing it and they had just closed up the incision knowing he was dying. Now at home - because he had hated it in hospital and his wife had insisted - already in the last stages. On a syringe driver. Nurses going in several times a day. Night nurse most nights. Everything nicely under control; the team in full swing. The National Health Service at its best.
I offered to do the visit that was due on that first Monday I was back, drove the five miles in the sun, found the front door open and walked into the empty hallway. "Hello…", I called.
"Come on up, please." The familiar voice from the landing – she sees who I am as I come up the stairs. I take her hand and we just look at each other for a moment. Then she shows me in.
"It’s Doctor Willis, dear… come to see you"
I don’t do anything. Really. Nothing to do. Bring up a chair and sit there, thinking, remembering, saying something. "What a beautiful airy room. With the sun streaming in from the common like that. I’ve hardly ever been here, have I? Your garden is superb."
He had been so pleased with his new hip, before I went away. When he had finally got it. After all the waiting. After I’d written to say how bravely he was putting up with the pain, asking the consultant to give him some priority, saying how much he wanted to get back to a little golf. The National Health Service at its worst.
Then I think of the rest of the long, long saga. All the years since they moved to the area and joined my list. We always got on well. He had a lot of problems with different joints, and a maddeningly-difficult gout which would never do the right things with what should have been the right treatment. Old friends, really. Open up his notes on my knee and write something. Just for the record.
"Have you finished the book, then?" He looks thin, and incredibly older. Incredibly the same.
"Well not quite, but I think I’m getting somewhere. I’ve had a brilliant time."
His wife sees me looking at a striking photograph on the wall, "That’s one of his."
"Really? It’s superb." I look back at him and I can see he is pleased.
"The next room is full of his photographs."
"Really, can I see? I never knew"
Full of his photographs it is, and cameras, and boxes of equipment. All the walls covered with portraits, girls’ faces mainly. Superb . "He got known and he took everybody, he just loved doing it." Easy to see why he got known. Some amateur! I look back into his room on my way to the stairs.
"Your photographs are superb". Definitely the thing to say.
Next day he is sinking fast and two days later he is dead.
A month later she is here to see me in surgery, as she promised. Telling me how busy she is, sorting everything out. All the things she has to do. How the house seems so empty.
"I thought I might get a dog."
"Yes, that’s a wonderful idea. You must get a dog. Something alive in the house."
She hesitates after opening the door, looking back.
"Come again if I can help. Yes, get a dog…"
It almost seemed that it was meant for me to get back three days before he died. Of course it wasn’t really. But I’m sure he would have understood the point, he was certainly one of the hundreds of patients with whom I explored these ideas in my consulting room over the years. And now, as I try to picture us talking there, I fancy I can remember him commenting on my own photographs on the walls. Yes, I’m sure I can.
The point I’m so sure he would have understood is this; none of this counts. None of it registers on the ‘performance indicators’ of the new way of doing things. To the official mind none of this matters. It is completely invisible.
And yet you know, I know, he knows, his wife knows, my wife knows, everybody knows, that these human things are really the things that matter most in the end. That is the extent of the gulf, that is the scale of the problem. The two cultures. The two sides of the world. Each oblivious to the other, permeating each other utterly, yet hardly interacting at all. Like neutrinos, elementary particles that stream through space and straight through the heart of our planet, hardly affecting it, or being affected by it, in the smallest degree.
As I give this chapter its final form, I am oppressed by the intractability of the problem I am addressing. At work I find respected friends and colleagues, almost without exception, regarding increased regulation and control of doctors as inevitable. "We don’t like it, but that’s the way its going", is what they say. "He who pays the piper calls the tune." And from so many contemporaries, seeing themselves as the lucky ones, those awful, cop-out words, "Roll on retirement."
And the executive, meanwhile, so far from seeing the problem, has only just begun. It sees regulation, without any shadow of self-doubt, as the very embodiment of progress. It want lots and lots more of it.
The National Health Service Plan of July 2000 talks of "arms-length control" and then says, "Doctors, therapists and nurses will increasingly work to standard protocols". It talks about "earned autonomy" and then explains that this means "green light organisations" having fewer of the new official checks than "red light organisations", with "yellow light organisations" somewhere in between. A hospital manager friend tells me that they are already being audited to death and that he seriously doubts the capacity of the system to accommodate the apparatus of additional procedures now proposed.
And so the thing goes on. And everybody can see the problem, and nobody can see the problem. We are being sucked into the vortex. And there is a feeling of real anger, of real grievance, as I see the way the humanity of good people is being usurped and squandered. But the devil of it is that I can see both sides of this, and so can we all. It is more important than ever to answer the question I started with; how on earth can two such vastly different views of life be reconciled?
Part of my answer is that the official view simply does not accept the validity of the kind of evidence it ought to be taking into account.
When Radcliffe Hall was accused of obscenity for her book, The Well of Loneliness, George Bernard Shaw and a number of other great literary figures of the day came forward to defend her at her trial. But they weren’t allowed to speak. The judge ruled their evidence inadmissible – he said they weren’t competent to talk about obscenity (presumably one of his own areas of expertise) – and that was that. Their famous voices remained unheard.
It is the same when we try to articulate the front line view of life, in which relative values and feelings are of such importance. The official mind can only register the measurable, the fixed. Some of the most important considerations, which we take into account automatically in our personal judgements, are inadmissible evidence on the official scale. Evidence that doesn’t follow the rules. Evidence not submitted on the necessary form. Evidence that doesn’t count. In vain do we protest that that is exactly the point; please listen; we are talking here about things that can’t be counted. The system is completely blind to the problem. It is shouting at everyone else, but the official mind can’t see it at all. The scattered voices, Lesley’s and mine amongst them, remain unheard.
And although we can all see it from both points of view, when we have to choose one of the points of view as a basis for our actual decisions, however strong our instincts and our feelings to the contrary, when we are operating in the official side of life it is the hard, fixed, quantified point of view which wins. No contest. No discussion. The other course cannot possibly be justified. Because the other course is not, by its very nature, open to justification.
The question is how to obtain some sort of purchase, some sort of leverage; how to connect. That is the reason I have dwelt so obsessively on the subject of authority. Little of what I am saying is new. These things are the common currency of daily conversations, probably all over the world. But on the official level, all over the world, they are utterly discounted. They do not register at all. We are not just speaking a different language, but a different kind of language. Vainly do we hammer on the bolted shutters of ‘their’ minds.
Oliver Cromwell expressed his frustration against the perennial arrogance of the official view in his vivid sentence, "I beseech you, in the bowels of Christ, think it possible you may be mistaken.". Not the words I would have chosen myself, but I share the sentiment exactly. Think it possible, that is the key. Think it possible that we are not simply dealing here with ideas which are being abused or applied with too much enthusiasm, think it possible that the ideas are fundamentally misguided. Quite simply wrong.
Take that apparently knock-out saying, "He who pays the piper calls the tune". Think it possible for a moment that the conventional meaning is nonsense.
It seems to me that anyone employing a piper would be a fool to tell him what to play. Pay him well, by all means, though it would be sensible to do that afterwards. But for goodness sake let him choose his own tunes. I counsel this most strongly, come to think of it. And as for trying to operate his lungs, his mouth and his fingers like a puppet – do I need to spell out the stupidity of that? Well, yes, come to think if it, in this context perhaps I do.
There we are, isn’t it amazing. Coup de grace to own goal in an instant. The conventional meaning revealed as an empty mantra, by a moment’s scepticism. If you are paying a piper you leave the guy to get on with it in as much freedom as you can possible devise. You know it makes sense.
I have a dream, which is expressed in George Eliot’s line:
"If we had a keen vision and feeling of all ordinary human life, it would be like hearing the grass grow and the squirrel’s heart beat, and we should die of that roar which lies on the other side of silence."
My dream is that the world will begin to listen to the scattered voices; the curtain will lift and the deafening roar will be heard at last.
In a nutshell, I think we have got it wrong about the nature of reality. We need a new understanding which is simply more sophisticated than hitherto. Major new modes of perception have always needed new frames of understanding. Few changes in history have equalled the one our generation has experienced. It would be surprising if our old models were adequate to faithfully reflect our new, fabulously-enhanced perspective. And while we continue to use the old models the madness will continue.
We have raised our gaze, and this applies in a thousand ways. It is as though the optician has given us seven league contact lenses, acting like immensely powerful binoculars, and forgotten to tell us he has done so. Thus equipped, we clump our booted feet amongst the eggshell problems of our daily lives, our eyes fixed on what we assume to be a higher view.
We see before us a magnificent, horizonless vista of what we assume to be reality, but it is in fact an highly-artificial construct, generalised-up from unimaginably small elements, which are chosen at best at random and all-too-often because they are unusual. And without the background, subconscious appreciation of the whole picture which we take for granted in our unaided perception, generalisations from the exceptional and incongruous (ie scare-stories, headlines) give us a distorted and corrupted picture.
But not only do we use technology in this way to extend our view but society as a whole uses it to construct models from that information. The tools include words, statistics, mathematics, computer spreadsheets, photographs, clay. And just as technology corrupts the information we receive, it also corrupts the model of reality which society holds in common in its ‘overmind’.
Some of the corruption results because the overmind unwittingly amplifies the failings the natural mind. Characteristics which are mere peccadilloes on the personal scale are blown up into massive distortions and illusions when translated to the artificial model. The lure of the new, the fixed, the absolute. Our inability to judge the relative importance of finite risks. Our inability to call off the endless hunt for perfection. The overmind resembles a patient with obsessional compulsive disorder, performing endless checking rituals, yet without the insight which so often accompanies, although notoriously it does not help, this crippling complain.
Equally importantly, the overmind unwittingly lacks the strengths of the natural mind. In particular the phenomenal power of our natural minds to model the whole of our experience and to keep it in constant interaction with the infinitesimal fraction which will fit into our conscious attention at any particular time, is something which has no counterpart in the artificial overmind at all.
Front line generalists recognise this better, perhaps, than most, because it is our job to deal in wholes. So many of the things we see as unchallengeable sense when we view them one part at a time, jump out as obvious madness, like the hidden images in the stereograms which enjoyed a vogue some years ago, when we let our eyes go out of focus and see the whole.
So, here is another linking feature which goes some way further to solving our puzzle; it is that in each case the madness is only apparent when we look at the whole, and is completely invisible when we look at its parts. This makes the madness invisible to an overmind which prides itself on basing everything on its clever reductionist tools.
So, we are wrong ascribe to our senses and minds the characteristics of machines, and we are wrong to ascribe to machines the characteristics of our senses and minds. But that is not enough. If it had all been as simple as that I would have written a much simpler book. It wouldn’t have needed any poetical allusions, that’s for sure. Something much deeper, much more radical, is needed to complete this puzzle. Something like this:
We pride ourselves on being rational animals, but when we look closely we manifestly are not. But, in spite of our assumptions to the contrary, our irrationality is more of a strength than a weakness. Indeed our irrationality is essential. The time has come to stop being apologetic for it.
Because, although we assume that we live in a rational world, when we look closely we manifestly do not. Our minds have evolved in response to that reality. Our problems arise when we pretend that reality is rational, or as Penrose puts it, ‘computable’, and that our minds ought to be rational in order to model it properly.
Looked at this way, the rationality into which not only computers but all the machines and systems of rules we can ever construct are irrevocably locked is making our problems much, much worse. Because, while we use machines and systems more and more to model reality, they are in fact incapable of doing this with the reliability and accuracy which is what we believe to be their unique strength.
It is hard to imagine a better setting in which to model this clash (between art and science is one way of putting it) than general practice. Battling through a busy surgery, saving lives with both hands, as we say, every patient having more and more problems however deeply we look and every problem having more and more layers of complexity, it is as obvious as anything could be that we are doing something which is beyond computation. Bits of it are, of course, but the whole thing, never.
But this truth is very far from obvious to the outsider. The outsider is enthralled by the power and the sophistication of his new modelling tools and he knows that every aspect of our work that he looks at could be done better by using them. He sees it as only a matter of time before our entire role will be reduced to a formula and every situation we deal with will have a single, correct answer.
In the past this was a theoretical question of no practical importance, but now the tools are with us to make it a very practical question indeed. The new tools have forced a confrontation with the problem and the cracks are opening wide. Say ‘Ah’.
The failure of the architects of the Millennium Thames footbridge to predict that it would wobble dangerously when people walked across might perhaps have lessened the confidence, but there is little sign that it has. Here was a carefully-planned structure, made of materials whose physical properties are known with great precision, which was presumably designed using the most sophisticated computer simulations available, by people who knew exactly what they were trying to prevent - a wobble when people walked across it. And in spite of all this they got their answer completely wrong. The bridge was closed for an indefinite period one day after its opening.
At the same time in another part of London the Department of Health was pressing on with its program of audits, protocols and information systems with the promise that it will eliminate error in the unimaginably greater complexity of the health provision of the entire nation. Hubris entirely undiminished.
It may be true to say that every bridge failure, every aircraft crash ought to be preventable. Though even that is questionable and in the case of boats at sea it is generally accepted that freak waves, with massively-tall, vertical, breaking faces will occur capable of sinking a boat of almost any size. Such monsters are described as non-negotiable Human things are different. Not just quantitatively but qualitatively. Not just in extent but in kind. Every death is not preventable in medicine. Good deaths are amongst our most tangible successes.
Our generation has experienced a change in view comparable to the ones which led to the Copernican revolution, the Darwinian revolution, Relativity and Quantum Mechanics.
We have started using new tools which have brought a revelation that something doesn’t fit. The record we are so diligently assembling simply doesn’t make sense. Because it is being composed of corrupted data being compiled in a corrupted way. And, just as might be expected, the first people to see the problem are generalists working on the front line whose job it is to make the thing work as a whole.
The corruption runs deep. Our age is characterised by a quite extraordinary dominance of the executive over the people who actually do things. The Cambrian explosion of doctor-regulating bodies at the end of the 20th Century speaks of desperation, a fad, a cult, a playground craze. But the even more extraordinary thing is that the people who actually do things largely acquiesce. Even in our proudly democratic culture we display the ‘serf mentality’ which Vaclav Havel bemoaned as a characteristic of the Russian people.
We seem no longer to trust the evidence of our own eyes, of our own judgement. Technical hubris has brought with it nemesis for the personal aspects of life. We have experienced a massive loss of confidence in our human abilities. Everywhere these abilities have been replaced by system. The popular perception of computers is that they have destroyed people’s jobs, but it is much worse than that. They have usurped and humbled our humanity and left us with little reason for being here. And we are being told that this change is inevitable; it is progress; it is the future. Worse than that; we are telling ourselves these things. We are abdicating our birthright, and we are doing it willingly, with a smile.
And the whole thing is based on a misunderstanding, a false belief that the world can be sorted out for good; a gigantic simultaneous equation solved for the millennium. The end of history. The end of science. Aren’t we clever…
The new understanding is that life is not a simultaneous equation, however much logic tells us it ought to be. It has no single solution, however intricate and beautiful we believe that solution could be.
Our lives have opened out into two parallel and utterly disparate paths. We are moving forward in two ways which cannot be formally reconciled. Structure and freedom, the fixed and the fuzzy, the professional and the amateur, the modern and the post modern. Two by two they walk along. The specialist and the generalist, the game and the life, the virtual and the reality, the ‘them’ and the ‘us’. Somehow we need to link these paired hands with the magic of balance and respect. And that can only be done with the vital ingredient mystery which classical science denies. And it has to be done without denying classical science.
It seems a ridiculous idea. As ridiculous as matter being made of waves and particles but never of both at once. But that mystery is something which classical science tells us is true.
So try this ridiculous idea for size: Perhaps, at last, rigid, classical thinking has reached the end of its two and a half thousand year tenure. Perhaps our new confrontation with the profound mystery of reality is going to force nothing less than an historic accommodation with romantic philosophy, from which classical philosophy diverged in ancient Greece.
If new ideas do not seem ridiculous, they seem dangerous. The Inquisitors who forced Galileo to recant his discoveries probably feared chaos would descend, that the dark ages would return, if their orthodoxy was overturned. But the Earth stubbornly continued on its course around the Sun, refusing to remain at the centre of the universe as the inquisitors would have preferred. Chaos did not descend, and instead mankind moved on to a higher understanding.
Today science is our defence against the mysticism, mumbo-jumbo and pseudo-science which are such paradoxical features of our supposedly scientific age. Medicine provides particularly clear examples of this phenomenon. But although it might easily appear that doubting the computability of nature is playing into the hands of this dangerous anti-science and threatening chaos, in fact it is nothing of the kind. Nor did the acceptance of the bizarre uncertainty of quantum mechanics represent a capitulation to irrationality. Truth, stranger indeed than fiction, cannot for ever be denied. What’s more, moving on to a more sophisticated understanding is the legitimate way to spike the guns of those who reject the whole of science because they find the present orthodoxy leaves undeniable parts of their experience unexplained.
Just before I started my study leave. Christopher Everett lent me a book written by a second world war fighter pilot, Richard Hillary, who was shot down during the Battle of Britain. It was written, quite clearly as a kind of therapy, during his recovery from a long succession of plastic surgery operations for terrible burns to his face suffered while escaping from his blazing cockpit. It was called The Last Enemy and enjoyed great popularity in the post-war years. Another classic.
The following passage described an incident when Hillary and a fellow pilot who had been up at Oxford with him were alone in a railway compartment. They were travelling south to fetch two new Spitfires for their squadron, which was based at Montrose in Scotland. The friend, Peter, whom the author paints as an extraordinarily admirable young man, certainly the hero of the book, who was killed a few days later, reluctantly tried to put into words his private reasons for believing in the war:
This passage made my spine tingle. Here was a voice from the dead – from a generation of young men who died to prevent the things happening that are worrying me so much today. But now we walk with open arms, with a welcoming smile, towards the danger that they saw, and only a few of us seem to feel the fear any more.