Is Prevention Always Better than the Cure?
Author: David Zigmond
The potential perfidy of our expanding pre-emptive regulation
To effectively forestall trouble we often need prescience, strength and boldness. Yet greater wisdom and probity sometimes comes, instead, from nuance, discrimination and restraint. A current example from healthcare and an elderly yet prophetic science fiction classic show us how and why.
A preoccupation with the future not only prevents us from seeing the present as it is but often prompts us to rearrange the past.
Eric Hoffer (1954) The Passionate State of Mind
I am sitting with an erstwhile colleague, Dr V – a veteran GP – at the end of a now routinely deadening yet frustrating day for him. Actually it is not the end, or should not be, because he has now a growing backlog of emails. But V tells me he cannot find the will to engage with this life-leeching, illimitably cross-fertilising and tentacled mass: he later tells me of a dream of fatally submitting to a giant octopus.
So V will use the excuse of my visit to stop before the end, with a mixture of relief, nagging anxiety and tugging guilt.
I want to be helpful, so I say: "In this job it’s often inevitable – sometimes advisable – to stop before we’re finished."
"Hm!" V snorts, recognising my good intent, but not any help. "In my case I just hope I know when to stop before I’m finished…" He slows and lowers his voice, a small sampling of a life’s draining reservoir.
In the many years I have known V I had come to expect a glint of warm, playfully defiant good humour in his eyes, even in weariness and misfortune. Now it is hard to find: his gaze may be receiving but it is hardly signalling. I say nothing of this, but V seems to pick up on my thought: ‘I won’t be able to last as long as you did. I’m not sure I’ll stay even until I can pick up my full pension.’ His bleakness carries both despair and anticipatory relief.
I had known V twenty-five years ago, when he first started practice, when his eyes glinted, glowed and communicated. He went on to accrue a solid local reputation, for many years, as a reliable, thoughtful, competent and caring doctor – assiduous, quiet and unegotistical. A privately principled man who avoided public attention, contention and debate. His quiet persona was quickly overlooked by many; his deeper qualities of character slowly engendered loving respect in those he tended and worked amongst.
So what had happened to V in these latter years, to turn this well motivated, gratified, more than good-enough doctor into one who talks like a prisoner or fugitive: miserable, anxious, fatalistic, furtive and caustic?
I have my own ideas and my own similar, parallel, experiences. I have heard many accounts from others, too. Yet it is important that I hear V’s account of his own tribulations.
While we have been talking, the computer screen has been glowing behind V, a silent waiting emissary-yet-master, I am thinking. V again seems attuned to my unspoken thoughts: he turns with a jerky, irascible decisiveness to switch it off. Exhaling a soft musical sigh, he tugs his chair closer to mine, then leans forward and looks up at me. I fleetingly imagine myself as a prison visitor.
"There’s so much to say" I say. This is both innocuously inviting, yet loaded.
V nods his head with a deliberating slowness of agreement. "Yes, so much…" V pauses on the slipway, holding my gaze, before launching himself.
"Look. I’m sort of alright: I’m still here. I’ve got through my appraisals and inspections with enormous time, resentful effort and much stress for me and my staff. And what for? To continue doing a job that is less and less satisfying to me, my staff and my patients. And all to make it look good and ‘correct’ for the authorities. And then they think: if they can get this much compliance from us, then they can get more. So it gets ever denser and more extensive: more regulated requirements, goals and targets, algorithms-to-follow, boxes-to-tick, hoops-to-jump-through. I feel I’ve been put on a treadmill which is turning faster and faster…
"OK. I’m somehow managing, but I know I don’t have enough left or available to offer the kind of personal care and attention I used to … Yes, I can get the authorities to say it’s alright, but I know it’s not: it’s not the kind of care I’d want…" V looks sad and weary as he bites on his lower lip.
"But some old local practices are managing neither, so you’re doing much better than them. They’re really in trouble", I offer, as some kind of encouraging, consoling contrast.
V clicks his tongue and sighs again, as if viewing images of wartime-wrecked, spoliated properties. "Yes, three of them have been taken into Special Measures … I think they’ll close: they just can’t keep up with all the regulations and requirements. So I hear about sickness, staff leaving … burning out, I suppose. And then they really will fail. And then the authorities will be able to say: 'We told you the world is perilous. See what we have saved you from!' But do those eliminations – of the 'inadequate' or imperfect – leave us with a better service? No! We become even more decimated and dispirited…"
"What do you think of those practices?" I ask.
"Well, in earlier, saner days they were alright… mostly pretty good. Much like you and I when we were trusted and enabled to define and decide the best ways of working cooperatively with one another and our patients, and mostly left to get on with it…"
"What has happened, then?" I try to make this question untendentious.
V again seems to pull at a thread of my own thoughts: "It’s what I was just saying", he says impatiently, as if my attention had lapsed. "It’s just too much control, too much management, too many regulations and inspections, too many meetings, too many documents-you-must-read and forms-you-must-fill-in... And then what space and time and energy is left for what you and I think is really important? Understanding people, contexts, complex stories: what room is there now for real thought, or imagination, or experience or healing contact or skilled judgement…?
"OK, our old system was sometimes patchy, but it certainly had room for those valuable things that can now hardly survive." V pauses a while. Normally he errs on the side of reticence: he seems surprised by his robust expression. "Why this now? What has happened to our profession?" he asks finally, as if to an unseen oracle.
I venture a fraternal response. "Your first question I can only answer by a long rumination. For the second, I have handy something snappier for you."
"OK, I’ll have one of those", V decides quickly.
"V, you sound like you’re buying an ice cream. So here it is: General Practice used to be the art of the possible, but we have turned it into a tyranny of the unworkable." I smile at V, miming handing a cornet across the counter.
"I like it. Can I have a chocolate flake as well?" V’s returned smile and laugh now radiate some of his old mirth.
Serendipity. Shortly after my failing-heart dialogue with V I come across a short science fiction story, Minority Report.1 In 1956 Philip K Dick published this remarkably prescient dystopian fiction. He takes us into a future State that controls society through a carefully guarded, ingeniously constructed system of forensic science and prescience: it is not only watching, but also predicting, the conduct of all its citizens. Through this vast and refined governmental apparatus incipient criminality and violence can be foretold and so pre-empted: they know what we will do, even if we do not.
In this world, the ‘Precrime Unit’ develops powerful primacy in society’s wider policing and justice activities: indeed these become often redundant as Precrime’s prediction is vaunted to be so accurate that only swift elimination is necessary: other evidence or considerations can be eschewed. The vast number of precriminals are then safely stored in a state of suspended animation. Murder rates drop to almost zero.
Precrime’s intelligence derives ultimately from a rare human source. Neuroscientists have found that some people, otherwise regarded as ill, have harvestable and remarkable powers of prediction and prevision. It is these individuals that the Precrime Unit uses to feed its computers which then amplify, collate and systematise the preternatural premonitions.2 So it is that computers keep society ‘safe’. The prescients are called ‘Precogs’ and are kept immobile in harnessed captivity in the concealed centre of Precrime, their cerebrally implanted sensors streaming continual electromagnetic clues to construct the essential pre-emptive formulations.
Precrime’s almost incontestable power flows from its supposed infallibility. But this depends on the concealment of an important truth: Precogs’ power of prediction is hypothesised to reside in a group-mind, yet some individual Precogs are markedly discrepant – providing dissenting prophesies than are at variance with the majority – outliers responsible for ‘Minority Reports’. To protect Precrime’s assumed infallibility and omniscience Minority Reports must be either suppressed or leashed firmly to political ends. They are never for public consideration: the system’s inconsistency – and thus fallibility – becomes a dangerous secret.
Apart from this tale – in the real world – we know that powerful knowledge, sequestered and secreted by an elite, rarely leads to beneficent, cooperative enterprises. What emerges instead? It is here that Dick’s parable of the insidious malignity of forensic science turns shockingly corrupt: a political enemy of the chief of Precrime infiltrates the system in order to eliminate his opponent. He will do this by the construction, and then possession, of the ‘infallible’ foreknowledge of a crime he has not yet committed…
I needed several days to digest the meaning and significance of Minority Report for me: how it could help me understand my profession’s collapsing morale, trust and fraternalism.
Of course Dick’s sixty-year-old forensically thrilled Sci-fi story has some details and flourishes that find no easy contemporary equivalence. But there are others of disturbing similarity. For example, Precrime’s mission to make society safer seemed incontestable, but its success in implementing this led also to many innocents, wrongly accused, being held in a state of suspended animation. Precrime then became deliberately corrupted for political ends. The safety net becomes a garrotte.
I have heard many tales of contemporary equivalence.
I tell V of my fortuitous discovery of Minority Report and my views of its sharp relevance for us, now, in healthcare.
Our experiences are kindred: we have both seen how authorities, to eliminate risk, have refined IT systems to command, track and monitor more and more behaviours and events – micromanagement. In the last few years, authorities’ investment – both financial and human – has increased in controlling environments and individuals to prevent the putatively undesirable or dangerous. Regulations and inspections have pullulated to ensure compliance. Soon we develop systems where compliance (or obedience) confer innocence, but non-compliance (or defiance) means guilt.
"So it’s like the concept of Original Sin: we’re guilty unless and until we seek absolution from the authorities. And we can only get that by our pledges of submission and obedience … and then, as their requirements increase – however unworkable or irrelevant we might consider them – so too does our potential guilt and need for absolution … an inflationary system of policing and judiciary. Who on earth benefits from all this?" asks V, glumly.
"No one!" I retort with impulsive finality, only to retract a little ‘well short-term, I suppose, there are winners and losers. The governing authorities – the definers of problems, of right and wrong – are able to decree: 'these are the problems and this is what you must do. If you are obedient you are virtuous; if you demur or defy you are sinner.' Clearly we then become the losers: blamed or eliminated.
"And our ever-tighter procedures of appraisal and inspection are like the Precrime Unit: they, increasingly, are concerned not with what we actually do in reality, but with what they say we might do if we become non-compliant with their ever-expanding preventative regulation. So the authorities – the custodians of the good – see it as their responsibility, their duty, to protect society by acting pre-emptively: our larger society’s safety and wellbeing depends on the pre-cognisance and elimination of outliers…"
V snips sharply at my long thread: "So our management controls us more, trusts us less… and more and more of us are threatened with elimination, or at least suspended animation. More management and then a grievous lack of practitioners who cannot cope with what’s left – that’s what’s happening!," V seems relieved by the clarity of this fatal equation.
"Yes, it is that bad. And it gets worse, V." I grasp his succinct formulation and want to connect it to my longer thread. V is receptive.
"Well, in Minority Report, the inconsistent, inconvenient evidence is 'lost' so that eliminations can be executed more quickly and unopposed…"
V links this to his recent, local experience: "So a lot of practices get caught and incriminated in order for Precrime authorities – the CQC or whatever – to say 'We’re doing our job! We’re catching bad people'."
"It gets worse still. As in Dick’s story the flaws in this assumed omniscient power must corrupt it…"
"Look, it’s bound to happen: the system’s power and vaunted infallibility becomes usurped, by other – often political – agendas.
"OK. Small practices, well liked and for a long time. You’ve seen how they’ve been picked on, been ambushed by hostile 'evidence' then closed down… or offered honourable terms for organisational suicide. That’s NHS Precrime for you. You could be next. And what’s more…"
"No, Stop!" V’s shoulders now sag. I am saying too much. Not just about the weight of his present, but a crushing future I am unwrapping. Saturation stress. He turns to the computer, scrolling to retrieve something saved. He points to a screened image.
"Here. Look at this. It’s the 2002 publicity poster for the Stephen Spielberg film of Minority Report. Look at the bottom line caption."
I gaze at an image of a 2054 darkened cityscape which is centred by the handsome profile of the hero-figure, who must pit his wits against a Precrime Unit that has turned malfeasant. Across the lower screen is emblazoned the film’s title, Minority Report. Below this V is pointing to a subtitled line. It says simply, EVERYBODY RUNS.3
He gives me an intense, fraternal look. "Quite," he says.
As for the Future, your task is not to foresee, but to enable it.
Saint-Exupéry (1948) The Wisdom of the Sands
Many articles exploring similar themes are available via David Zigmond’s blog here. David would be pleased to receive your feedback.
- Minority Report was originally published as a short story by Philip K Dick in 1956. Stephen Spielberg made a film of this in 2002. Dick’s original story is bold and almost uncannily accurate in its predictions. This is all the more remarkable when we consider the 1950s’ technology that Dick inhabited. Spielberg’s film version certainly offers a visually compelling futurama. Likewise his precise depiction of the necessarily elaborate likely technology is a development of Dick’s story. Many, though, are critical of the film’s complex, tangled secondary plots alleging that these subtract and distract from the sparer brilliance of Dick’s prophetic parable.
- Spielberg’s film depiction of this is possibly his best contribution to Dick’s much earlier original story.
- Dr V is real and, at the time of writing, alive and not yet put into suspended animation. For his protection he is here disguised.
The publisher is the Centre for Welfare Reform.
Is Prevention Always Better than the Cure? © David Zigmond 2018.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.