Thursday, 24 March 2016

The European Union – In or Out?

The European Union – In or Out?
     There seem to be three issues: gut feeling, distrust, and economics. The out-campaign emphasises gut feeling and distrust, the in-campaign emphasises economics. 
     I think we all start with a gut feeling. Are you European or British? Some in Britain feel European, thrilled to belong to the culture of Grieg, Rembrandt, Bach, Montaigne, Dante, Cervantes, Socrates. Others have more local loyalties; e.g. England, London, Chelsea.
     Perhaps the next strongest decider is distrust of strangers.  Do we trust the civil servants, politicians, and judges of other member countries to make sensible, humane, and fair judgements? Or is common sense a British monopoly?  Looking at labour relations, education, transport, etc. it is clear that we should trust the 6 founder western European democracies, and in fact we have much to learn. They (with Britain) account for 60% of the people of the EU (and 72% of the GDP). We still do not know much about the poorer countries on the eastern and southern fringes of Europe, and some degree of caution is perfectly rational.  (Incidentally, though we are the 2nd largest economy in the EU, we are only the 11th wealthiest nation per caput. We have plenty to be humble about.)
     However, most of the discussion is about the financial benefits of membership. Here, I would like to make one point that I have not yet seen advanced by other commentators. I think a nation even of our size is still too small to stand up to large commercial and financial concerns. Our annual gross domestic product is around 2.9 trillion £; the annual cost of the entire NHS is 0.096T£. But the total assets of Barclays Bank are 1.36 trillion £ (T£), that of HSBC 1.84. How can we ‘control’ these banks when they have a common interest and ‘gang up’?  Is this not why all the capitalist economies are getting ever deeper into debt? For debt is the income stream of the money lender.  Nor is it just the banks. Royal Dutch Shell has total assets of 0.35 T£.  Walmart has a net annual income of 0.33 T£.  I think there is a great danger when a country can be held to ransom by powerful independent interests with objectives that differ from the National Interest. 
     It is clear that welding a united Europe is difficult, and may take time. But some level of unity must be achieved. We just have to try harder, with more skill and flexibility. The European Union has required gigantic effort to get even this far. I am for going forward, rather than going back. 

Middleton Cheney, 
Northamptonshire,  OX17 2NB

Monday, 14 March 2016

"Being with and Saying Goodbye"

The art and the Science of Child Psychiatry

(“Being with and Saying Goodbye: Cultivating Therapeutic Attitude in Professional Practice”, Andrew West, 2016, Karnac Books, London.)

At first glance I was puzzled by the title of this book. Perhaps West was challenged by management to say what exactly he did when closeted with his young patients session after session, over a period often extending to months. And West may have eased his annoyance with a deprecatory verbal shrug along the lines of  “Just being there with them!”.  I was further puzzled by Chapter 1. It seemed the first page of the book was missing. We learn about ‘potential space’, the difference between ‘being’ and ‘being with’, between ‘having’ and ‘doing’, the importance of ‘being oneself’, of ‘silence’. But what is this book about? At whom it is directed? What does the author mean by “being with”? The writing is lucid, easy and precise, and the points are subtle; how can he have overlooked these elementary questions? Gradually it dawns on us that West is illustrating his own method; we (the readers) are ourselves constructing the meaning from the ideas strewn in our way. [“..the new…therapeutic ideas…have to be discovered, rather than pushed into the conversation.” p. 55]

There follow two chapters (“The Intrusion of Reality”, “The Nature of Evidence”) in which a torrent of anger is directed against Health Service Managers, commissioners, politicians, and ‘modern life’ in general. Here West inveighs with passion, but his targets are valid and his points well argued. Does the system overvalue numbers? What does ‘in a timely fashion’ mean? Is it better to be ‘timely’ than ‘effective’? Does ‘evidenced-based medicine’ necessarily exclude psychiatry, and the placebo? (In which case, is it excluding too much?) Attention is drawn to the harm of premature diagnosis, of overprescribing, to the value of inaction, to the dehumanising and demotivating effect of uncaring non-clinical managers.  Are we forgetting the value of ”reason, experience, analogy, instinct, and memory?” [p. 53]. West may seem to be doing little more than lamenting, but I ended these chapters feeling that something precious is in danger of being lost, something valuable to the practice of medicine, even something essential to humanity.

A book, West points out, needs two covers; the front cover to attract, the back cover to close, to say “good bye” [p. 156]. In the central chapters we are taken carefully through the entire therapeutic process from the first eye-contact between clinician and patient on their way from waiting room to consulting room, to the solemn “Good bye” that ends the treatment. But this book makes no attempt to be a text-book of clinical practice and the nitty-gritty detail is entirely eschewed. What is examined is the less-easily-seen, the ‘between-the-lines’ stuff, the hard-to-describe stuff. It is this core that makes the book, with its subtle observations and its carefully nuanced writing, valuable and rare (it not unique).

There is, in general, a lightness in the text, and a sense of humour that makes the book enjoyable reading. There are one or two obscurities, and one or two laboured passages. (West, arguing both for and against diagnosis, cannot decide which is going to have the last word.) But there are many lovely points. (The bus driver who turns to his passenger and says “You should never presume a thing”; to illustrate the point that the clinician should not ‘presume’ his duty is to remove the 'presenting symptom’; it may be there because the patient ‘needs’ it. And is it true that the NHS manual of diagnostic codes does not have a code for ‘normal’? Fabulous!)   West clearly enjoys making his readers think. We must distinguish (it seems) between evidence and “evidence”…. “It is a confident uncertainty that needs to be projected at this stage.” And thinking (we are told) does not occur only in heads, but also “in the space between heads”.

This is a creative, inspiring, even an uplifting, book. With luck, the complacent reader will come away from it more aware of his shortcomings and frailties, but at the same time with a vision of perceptiveness and humanity . 

Middleton Cheney,

Tuesday, 8 March 2016

PER DiEM (1)

PER DiEM: Can one Save Europe by appealing to Democracy?

Dear Yanis Varoufakis,

Your remedy against the disintegration of Europe is to “democratize Europe”, and make it more transparent.

The trouble is (and you know this as well as anyone) that a democracy is a rickety boat with a host of opinionated pilots, dozens of helmsmen, and a barely effective rudder. Here, in Britain, we should have as good a chance of it working as anywhere, but it does not work here; the pilots give up and the helmsmen squabble among themselves for a hand on the tiller. We are dazzled and exhausted by the barrage of conflicting views presented by the media. We (in Britain) find that most of our votes are not actually represented in the House of Commons, and so are pointless.

Our forthcoming referendum is of course different; for every vote will count.  But it is even more difficult for the average voter to assess the arguments. There is enormous ignorance in the country about the workings of the European Union, and the mechanisms of power.

It is widely held that democracy, while a poor thing, is the best form of government available. We all pay lip-service to DEMOCRACY. But do we truly believe in it? The counterpart of ‘oi demoi’ is ‘oi aristoi’ ; the opposite of democracy is aristocracy. There is a widespread view among the average working person that these difficult matters are best left to the clever few. And that view is, alas, both sensible and largely correct.  

The ‘demos’, though sound on morality, is relatively ignorant of the details of government. This ignorance is inescapable, for there are very few people that can acquire more than a fraction of the information, and hold it long enough to form and assess arguments. Even these few must blindly trust their sources. It is not for wisdom that we turn to the ‘demos’.  Morality, on the other hand, belongs to the ‘demos’; it can scarcely be said to exist except in the  demos’ . Individuals may be high-minded or base, altruistic or selfish; it is only when you average out all the variation that you can conclude what is “right action”. 

Unfortunately, ignorance often trumps morality; the ‘demos’ can be played upon by anyone with adequate rhetorical skills. Hitler marched a nation to war, while our own finance ministers can trick us into cutting taxes, and benefits. (“The worker voting for a tax-cut is like a mouse voting for a mouse-trap, thinking of the cheese.”)  We can hardly rely on the moral compass of the voting public, except in the long term. It might take a decade. It might take a generation.

So, does one have to join the ranks of those trying to manipulate the public?  You travel, and speak. You blog and post videos. You hope that you inspire some. But your message must be essentially simple, clearly honest and patently disinterested.  I wish you well and would like to help.

Wednesday, 2 March 2016

Windy Weather

     Today is a day of scudding clouds; of brilliant sunshine and pelting rain. The most constant feature seems to be the intermittant wind that 'whistles' round the exposed end of my house. But this is not the ordinary sound of 'whistling' wind, which sounds about as musical as the din you hear when standing on a motorway bridge. My house whistles more like an orchestra. Previous owners seem to have fitted struts that operate like mouthorgan reeds, and television cables that throb like harp-strings. But the triumph, which lifts this house above its peers, are the holes drilled through the brickwork to feed cables from security cameras, vent cisterns and the like. These, when the wind hits precisely the right angle, emit a sound that stops conversation, and brings a startled look to the faces of visitors; sometimes a wail, sometimes a hoot, sometimes high-pitched and sometimes low depending on the bore.
    Even I, who have lived here for nigh-on a year, am amazed when one of these tubes catches a good blast of wind. 

Middleton Cheney