Fabian Tassano has produced a forceful critical study of an extremely important, but generally neglected subject.  (It is surely scandalous that up to the time of writing the present review no daily or weekly journal had noticed his book).  Because patients are as such in need and presumably desirous of relief from some disagreeable and perhaps even mortally dangerous condition with which they are afflicted, and because doctors are expected to be able to provide that relief, doctors are necessarily in a position to exercise power over their patients.  And, since there are always temptations to exercise powers improperly, all powers need to be in some way checked in order as far as possible to ensure that they are not misused.

In the last forty years there have been two developments which have vastly increased the powers of doctors, and hence the need to ensure that these powers are properly employed. One is the enormous and continuing increase in medical knowledge, and hence the increasing power of doctors to cure disease and to prevent pain. The other is the nationalisation of the supply of medical services, which makes doctors effectively monopolists unchecked by the disciplines of competition.   This last point is happily brought out by comparing the days of George Elliot's Middlemarch, in which it was possible to correct one doctor's failure to diagnose typhoid by calling in another, with our time when "as an NHS client . . . one needs to get the permission of one's GP before one can get a second opinion" [p.20:  emphasis original].

Moves towards the complete monopoly control by doctors of all pharmaceuticals and all treatments began of course well before the establishment of the National Health Service.  And today this monopoly extends "to practically any medical technology, beyond the level of first aid.  You cannot, for example, have an X-ray taken without the approval of your GP" [p.66].  Clearly there is scope here for some salutary deregulation even before the unwinnable drug war is at last abandoned and the sale of the offending drugs is decriminalised.

Another consequence of the major developments since World War II is that a much larger proportion of all the treatments of serious illnesses is conducted in hospitals, where abuses are more easily concealed than they would be if they occurred in the patient's home.  That there must be a deal of abuse here of which the public is not aware is indicated by the evidence which has recently emerged from Broadmoor - an institution whose compulsorily confined "patients' are peculiarly helpless:  "In view of the secrecy of the medical profession, it is reasonable to suppose that any incidents that come to light are merely the tip of the iceberg." [p.35].

Not only are doctors almost invincibly reluctant to testify against their fellow doctors, but even when doctor offenders are arraigned and condemned by their peers it is usually for sexual rather than medical malpractices, and even then the penalties are often ephemeral:  "For example, it was recently revealed that more than half the doctors barred by the General Medical Council are subsequently reinstated [p.36].

Two features of the monopolistic powers of the medical professions are egregiously obnoxious to libertarians.  One is "that individuals are not in a position to manage their own pain, but depend on practitioners to provide them with the required medication" [p.77].  Dr Tassano quotes a horrifying passage from a research report showing how nurses and doctors are inclined to minimise the severity of patients' pains and, consequently, to refuse to give timely and sufficient doses of anaesthetic drugs [pp.77-8].  The other egregiously obnoxious feature of the medical monopoly is that although "Medical technology . . . makes possible the painless ending of life . . . The drugs which . . . kill quickly and painlessly are not available" except to and from doctors [p.87].  (Since the right to life proclaimed by the American Declaration of Independence entails the right to death, just as any right to free association entails the right to refuse to associate, the Supreme Court - if ever it again
has a majority committed to doing its sworn duty by the Constitution rather than to implementing the liberal agenda - must in accordance with the Ninth Amendment strike down all legislation criminalising either suicide or the assisted suicide of voluntary euthanasia.)

Dr Tassano points out that "The reluctance of doctors to provide individuals with the means of bringing about their own deaths is often justified by reference to the sanctity with which they are expected to regard human life" [p.87].  Against this he protests that "This defence rings somewhat hollow . . . in the face of what happens in practice.  For we find that doctors do make "termination' decisions as a matter of course, and without the consent of their victims . . . As we shall see in the following chapters, there is evidence to suggest that doctors apply involuntary euthanasia to the elderly, to the comatose and to handicapped babies, among others" [p.88].

Dr Tassano sees this as a growing tendency accelerated by the fact "that the state medical systems are rapidly approaching a demand/supply imbalance of such
proportions that severe cutbacks in the extent of services offered will inevitably have to be made" [p.125].  Since no politician wants to admit that the National Health Service can no longer fulfil its original promise to provide all comers with the best theoretically possible treatment, and to have to make and defend decisions about what is and is not now practically possible, the inescapable decisions about what treatments are not to be provided and for whom are being
made by the doctors and in the main, presumably, according to their conceptions of what is in the public interest.

One of the great merits of Dr Tassano's book is that it points out that the determinations of which individuals are and are not  qualified to have what treatments do not have to result from either the collective decisions of politicians or the professional consensus of doctors.  Instead, noting that "it is becoming increasingly difficult to find support from any source   for the idea that human health is not a collective commodity to be manipulated by social agents in the interests of the community" [p.154:  emphasis original), Dr Tassano nevertheless insists that it is possible to demonopolise and privatise the supply of medical services while still ensuring that the basics remain available to all.

"Where private medicine is concerned", he writes, "there should not be any question of discussing "morality' at a public level, medicine should be regarded as a contractual arrangement between an individual and one or more practitioners.  Treatment should extend as far as is consistent with the client's requests and his ability to finance (through perhaps in part tax-funded insurance or otherwise) the services he requires" [p.161].  Doctors should of course remain free to consider as individuals or to discuss in groups what they morally ought or ought not to be willing to do. "What is not acceptable, however, is that such groups should be able to legislate, either directly or by means of a "closed shop', against any particular service that is demanded" [p.161].

Antony Flew