SIR DOUGLAS BLACK
Douglas Black is one of Britain’s most respected medical figures. Born in Scotland in 1913-2002 he rose to become professor of medicine at Manchester University, a post he held for nearly twenty years. In the early 1970s he was chief scientist at the Department of Health and Social Security, and from 1977-80 he chaired the Research Working Group on Inequalities in Health, which resulted in the publication of the controversial Black Report. He has published extensively in medical journals and was president of the Royal College of Physicians from 1977-83.
I interviewed him in 1997. Here is what he told me then.
You were a son of the manse and grew up in Scotland. How far did these two factors influence and shape the man you became?
Being brought up in Scotland gave me the accent you can hear, and being a son of the manse gave me the twin advantages of poverty and culture. My father’s salary peaked at £300 a year, but we had plenty of books. There was no television, thank heaven, and we didn’t even have a radio, so I was able to read and think.
Did you ever think of following your father into the church?
Not really. This was not from any aversion to the church at all, but just that my father was rather keen for me to become a doctor and I had a fairly strong scientific streak. Being Scots, I had C. P. Snow’s two cultures embedded in me – my subjects in the higher school certificate were English, Latin, physics and chemistry.
I assume your family were Church of Scotland … did the Presbyterian ethic stay with you throughout your life, would you say?
Very much so. I’m firmly adherent to the so-called Protestant work ethic, but I’m very ecumenical in my outlook. I mean, anyone who’s seen patients and mixed in the world could hardly be a narrow-minded adherent of one particular sect, but I still think that religion means something. Like anyone else in this day and age I’m puzzled by the conflicts between cosmology as revealed by science and ‘truth’ as revealed in the Judaeo-Christian scriptures – or the Koran, if it comes to that.
When you qualified as a doctor, the National Health Service was not yet in place. What are your chief memories of medical practice at the time?
I qualified in 1936 and so I had twelve years before the NHS came in. Four of these years were spent in the Royal Army Medical Corps as a biochemist – not that I knew much about biochemistry, but that’s where I was put, and I went where I was told. What I remember about general practice was – to put it dramatically – you could have young people coming in with lobar pneumonia, and one in five would die. Nowadays you would expect one hundred per cent of them to walk out of hospital, but before antibiotic medicine it was a different story. Some people talk about complete conquest of infection, but that of course is nonsense. At the moment we are bedevilled by at least two infections – BSE, to give the topical one, and the terrible AIDS business. Bacteria and viruses often just jump ahead. The other striking difference between then and now was access. In the old days only rich people could buy good treatment, not always as good as they thought they were buying, but they could still buy it. Poor people could go to the voluntary hospitals as they then were, and again get pretty reasonable treatment, but the poor middle class was greatly disadvantaged because they could not afford specialist fees, and stubborn pride – certainly in Scotland – kept them from soliciting charity.
Were you a young idealist then? Did you want very much to make your mark and improve conditions?
Very much so, both medically and socially. I wanted to practise good medicine, and also to investigate the leading edge of medicine. My own research field was body fluid, because someone told me when I was a medical student that the body was sixty per cent fluid, so I thought, well, that’s for me. I’m an opportunist and a pragmatist.
Since you started out the medical world must have changed beyond all recognition. Have all the changes been improvements, would you say?
The improvements far outbalance the non-improvements. The National Health Service was a tremendous success for the first twenty-five years and shrewd people celebrated its twenty-fifth birthday not knowing what was going to happen thereafter. The incursion of market values has made very big changes. Whilst market values are tremendously important in other areas, for example in publishing, I think in medicine it’s a shade different. I’m not being idealistic or starry-eyed here, but I would say that health is so important to people that there shouldn’t be an additional financial barrier placed on top of the disability of illness.
Would you say there is a need nowadays to remind ourselves of the founding principles and values of the National Health Service? Do you think we have perhaps moved too far away from the original concept?
Yes. The NHS has been reorganized four or five times since 1973 and no service can stand up to that. It’s so disruptive. What has happened is that a somewhat artificial system of contracts has been introduced to govern all transactions which used to be quite informal. And doctors have been made to think very much more about finance. While it’s good that doctors should know what they’re costing the public, it’s bad if they have to think of money first.
Doctors traditionally maintain a professional detachment from political and social issues. In your own case, did you feel a responsibility, a duty perhaps, to go beyond the mere medical issues involved, or is it more the case that you think medicine cannot be isolated from other social issues?
My favourite answer to almost any question is both. I’ve got a built-in social interest, not a strongly political one, but one which just makes me feel for the poor. That’s part of being Scots, I think. My spontaneous interest was strongly reinforced when I worked in the Department of Health for a short period as chief scientist, and I was asked to get a working party together to study the relationship between social class and health. I found that social class is really not a particularly good indicator of poverty because there are those in social class 1 who are struggling quite hard, and conversely in social class 5 you can get people who are unskilled but who have the Midas touch. That made me take a much more structured interest in these problems.
You are perhaps best known for the Black Report into inequalities in health-care which had considerable political impact in 1980. You established beyond doubt the links between social deprivation and ill health. Were you surprised by your own findings, or had you always expected as much?
What we discovered was not particularly surprising, since we have records going back to the last century showing that poor people have shorter expectation of life and experience more ill health than people who are substantially better off. That’s of course something that anyone could see just by looking, but it was in the middle of last century that it was put on a quantitative basis by a man called Chadwick. Our particular contribution was to produce such a mass of statistics that it’s now an unassailable fact that poverty and ill health are linked. That doesn’t actually mean that poverty inevitably causes ill health, though it can do, just as ill health can lead to poverty. But we were able to argue quite strongly that there was evidence of poverty causing ill health, and the simplest evidence for that was that often the children of working-class people, manual labourers in particular, experience illness that accompanies them throughout their lives. It’s unlikely to be due to their being weaklings, forcing themselves to be poor; it’s more likely the other way round, though it’s contentious.
Is it true that Mrs Thatcher tried to suppress your report and would not accept your recommendations on the grounds that they were too expensive to implement?
The formal evidence we have is that Patrick Jenkin, then Secretary of State for Health, wrote a foreword to the report in which he admitted just that. It’s then conjecture whether Mrs Thatcher herself had anything to do with it, bearing in mind that it is unlikely that any secretary of state in her government would come out with such a potentially contentious statement without first having secured her complete backing. There may even have been dirty tricks, because our report came out in a dull cover in a pretty tatty condition. My friend Peter Townsend later brought out a shorter version in Penguin which had tremendous sales throughout the world. Some years later the Health Education Council brought out a further report called ‘The Health Divide’, and quite remarkable events attended its appearance. A press conference which had been arranged was cancelled by the Director General. There were strong denials that ministers had in any way tried to influence the abandonment of the press conference, but it seemed to me that the very strength of the denials implied they were untrue.
No one really disputes the association between poor health and poverty, but what exactly constitutes poverty in your view? Is there a minimum standard above which the term poverty no longer applies?
In this country there is of course no poverty approaching the extremes of third world poverty, which is accompanied by extreme morbidity and mortality. In Britain you get some people who are pretty destitute and others who are pretty affluent, so there is a graduation. A definition of poverty is rather elusive, partly because there’s a tendency to think that if someone has a television set, he is not experiencing extreme poverty. The official definition is actually when someone has resources of less than half the average wage.
But poverty is such a relative term. I mean, there must be a difference between what we now call poverty and what you yourself observed growing up in Scotland in the 1920s…
That’s right. As a working doctor in Scotland I saw people at the outpatient clinic in bare feet and woollen long johns which they wore because their houses were so cold. But to some extent these conditions are coming back, as you can see from the number of people sleeping in doorways.
Would you also allow that there are some people who sleep rough through choice? They’re healthy enough, but they perhaps don’t want to work, or are not disciplined enough to work.
I think that’s true. It’s difficult to know to what extent they are prey to circumstances and to what extent they lack motivation.
Did you distinguish between poverty and deprivation in your report? Which is more closely associated with poor health?
In a way deprivation is easier to define than poverty, because it’s not purely economic, it’s also cultural – lack of education and lifestyle factors which are linked with poverty, but are not of course a necessary part of it. For instance, it’s paradoxical that people in social class 5 on the whole smoke more than people in social classes 1 and 2, but it may be their only consolation, their way of escape.
Doesn’t the question of what can or should be done about inequalities in health remain an ideological one which can only be decided by politicians?
It has ideological components, that’s for sure. I mean, the degree to which people want to do something about inequality depends on their political set of mind. But it’s a blurred picture. For example, it’s not the case that all socialists have nightmares about poverty and all conservatives never give it a thought; it’s much more complex than that. May people in the Conservative Party are deeply unhappy about the relationship between poverty and health and the extent to which poverty has been recreated.
You have been critical of both Labour and Tory administrations of the health service. Although Labour were sympathetic to the principles of the NHS they were guilty of what you call ‘doctrine socialism’ with regard to private practice. Under the Tories you suggested in 1988 that the National Health Service was threatened by ‘monetarist and managerial dogma’. Where are we as regards political approaches to the NHS today?
A lot of this is about power and who makes decisions. To me there have been two shifts of power which are a direct result of reforms. One shift has been from the professionals – doctors, nurses, biochemists – to the managers. Of course the health service needs management just like any other comparable enterprise, and I’m totally in favour of strengthening management wherever that can be well done. The second very considerable shift of power has been from a service centred on hospitals to a service centred on family doctors and other people. There are strong elements of good in that because, after all, more people see their family doctor than are ever going to need to go into hospital. But where it’s not so much of a good thing is that general practitioners, instead of producing clinical arguments in favour of their patients being admitted to hospital, now have a financial stick with which to belabour the hospitals, and I’ve seen some very bad consequences of this. Sometimes hospitals literally run out of money with only a month or so to go, and conversely there is sometimes a budgetary surplus which leads to all sorts of unnecessary expenditure for its own sake. The annual budget has big problems.
How do you view the National Health Service today?
It’s not as good as it was ten years ago. I don’t think it’s as bad as the reforms might have made it, because we’ve still got the people who are reasonably dedicated to the original objectives of the health service. My major worry is that if the market forces continue and increase, then recruitment to the health service will bring in a different kind of person.
In an article in the British Medical Journal three years ago you wrote that the recurrence of monetarism over the last dozen years has revived evils that should have been relegated to history. What are the evils you were thinking of?
I can be just as rhetorical as any politician when I’m writing a rather popular article, but the sort of evils I had in mind were unequal access to health care and an increase in the disadvantages of poverty and unemployment, two of the huge changes in the past twenty years.
In the same article for the BMJ you quoted John Ruskin who said: ‘Above all a nation cannot last as a money –making mob; it cannot with impunity go despising literature, despising science, despising art, despising nature, despising compassion, and concentrating its soul on Pence.’ This is quite strong stuff. Do you really believe our priorities are quite wrong, that we have lost our souls to money-making?
That’s a rhetorical statement in a rhetorical article followed by a rhetorical question. No, we haven’t lost our soul, though I think we’ve damaged it.
There appears to be a class factor in the use of tobacco and the quality of diet, and the amount of exercise taken. Isn’t the answer – in part at least – better education leading to prevention? Or is that a pie-in-the-sky approach?
It’s a very important approach, but it’s certainly not one that ranks tremendously high in efficiency. To give a very concrete example, the Royal College of Physicians has produced four reports on smoking in general, and a further one on smoking among young people. But there are more young women smoking than ever, and also more young children. So education is not the only answer.
Where do you stand on the question of medical treatment for those who refuse to help themselves – by continuing to smoke, for example?
We should treat them as well as we possibly can to the limit of our resources. I’m against any kind of moral sanction on so-called self-induced illness. One sometimes feels the temptation, but it’s one to be resisted. No we’re not there as judges, and we’re not there as padres; we’re there as doctors, and our job is to do the best we can for an individual. Of course by doing the best for the individual, we may be acting unfairly to the rest of society. But when I was in clinical practice, the basic principle was just take the case in front of you and not to worry too much about the hinterland…very reprehensible.
Do you think we are moving in the general direction of making medical treatment conditional upon responsible behaviour in the patient?
I doubt it. I think that some of my fellow puritans would want to do that, but I’m not so convinced of the veracity of my own attitudes that I would want to impose them on anyone else, either by implication or exhortation.
You regard yourself as a puritan, rather than a liberal?
I’m not against liberalism as such, but I think it has to be balanced by responsibility. There has to be a balance between liberty and libertarianism, between rights and duties. Nowadays rights have been elevated to such a huge extent, and duties have become rather neglected. For example, when you enter marriage you are not only entering a career of great enjoyment and promise, you’re also undertaking some obligations. I think the emphasis has to some extent fallen away from the obligations.
As a doctor – setting aside any moral principles you might have – are you in favour of the current relaxed attitudes towards sex…I’m talking about safe sex, of course.
I’m afraid I’m a dyed-in-the-wool puritan. I can’t justify Puritanism, but I just can’t help thinking that on balance extra-marital sex does more harm than good. Sex is a good thing, I agree with that all right, but I also think it has to be controlled to some extent.
Are there any moral absolutes in the practice of medicine?
If you think about it, there are none at all – even if you consider something like ‘Thou shalt not kill’. If I had someone with a disseminated cancer and he got a lobal pneumonia, I’d be only too happy to let him die from the pneumonia. Philosophers say that that’s no different at all from taking a syringe of potassium and pushing it into a vein and killing in that way…I can only say that it feels very different. I myself have never actually given a lethal injection, but I have some sympathy with people who do it in cases of intractable pain that they can’t otherwise relieve, even though I think it’s a very slippery slope that doctors shouldn’t go down.
When I interviewed Baroness Warnock she said that she did not believe in the sanctity of life at all costs, and that compassion was the single moral absolute. Would you agree?
No, I wouldn’t agree. I’m not a believer in absolute moral dogmas at all. When I have to formalize it, I’m a situation ethicist; in other words, I believe that the facts of a given situation are so preponderant over moral principles that one shouldn’t have absolute moral principles. In the case of the man with pneumonia who’s riddled with cancer and in unbearable pain, I’d let him go. I think that’s compassion, but I don’t make that an absolute, otherwise I wouldn’t be inclined to condemn lethal injection.
Would you agree that developments in medical science are now so rapid that they happen before our moral thinking is ready for them?
Yes, and it’s almost inevitable, because as soon as some apparently worthwhile medical discovery is made, everyone wants to apply it that week. Science runs and ethics comes plodding along behind it, and that’s probably not how it should be in an ideal world.
Since it is undoubtedly true that things which people scarcely entertained as possibilities are now actualities, and assuming this trend continues, isn’t it going to challenge the whole moral fabric of our society?
Yes, of course it is, but I think that the challenge should be directed at the scientists and doctors themselves.
What sort of ethical restraints, if any, should be placed on doctors?
Most important is the judgement of their peers in a moral climate. It’s very difficult for outside people to know what doctors are doing, let alone come to a judgement of whether it’s right or wrong. Obviously the extreme case is easy; it’s the marginal case that’s always the difficult one.
On the question earlier this year of whether or not a woman should be able to use her dead husband’s sperm, you wrote to The Times supporting her case. You said amongst other things that the woman was a victim of ‘corporate tyranny’ and that ‘people banded together are capable of follies and excesses beyond what the same people acting as individuals would perpetrate on other individuals’. This was a reference to the Human Fertilization and Embryological Authority. First of all, what in your view is the alternative to such an authority, which is there to safeguard standards and to see that the rules are implemented?
It so happened that I was on the original committee which was the Voluntary Licensing Association. My experience of the work of the VLA made me very watchful for the future of the statutory licensing authority. It seemed to me they were applying general principles too rigidly to particular situations. That’s really the germ of my idea that there might be such a thing as corporate tyranny.
Well, how can this corporate tyranny be avoided? What would you replace it with?
I’m not generally an advocate of centralization, but I think I would feel happier with a central committee on ethics which would have a general surveying function, and which as specific cases arose could call in the appropriate experts to acquaint them in depth with the medical aspects. That would be a better long-term solution than a whole lot of ad hoc committees, each of which might become too narrowly focused on its own neck of the woods.
As regards the woman in question and the issues arising from her case, do you think that women have a right to have children, come what may, provided medical science can provide them with the means?
It’s not a universal right – I wouldn’t go as far as that – but unless there are strong contradictory circumstances, I think the woman is the best judge as to whether she should have a child or not.
You obviously believed in the case of Diane Blood that the authority in their decision had caused her undue stress and hardship. But haven’t we also a duty to consider the implications for a child born in these circumstances? Can we be absolutely sure that it is morally right for the child to be brought into the world in this way – not only fatherless, but using the sperm of its dead father?
It is difficult to exclude remote possibilities, but if we come to the evidence in this particular case she said that the husband wanted a child, and it’s not an unreasonable thing for a husband to want. What is the disadvantage to a wanted child of having lost one parent? Pretty small I would say.
But I’m talking about the psychological effect of being born from the sperm of a dead father…
Well, it might worry many people, but it certainly wouldn’t worry me. Maybe I should explain why I wrote the letter. There was perhaps a reasonable case to prohibit the use in this country, but when the authority then became so determined in their opposition as to preventing her going abroad, I regarded that as a step too far in pursuing an attitude about which I feel they shouldn’t have been one hundred per cent certain. But I have learned something since that worries me, and that is that the sperm was taken by rectal stimulation. That strikes me as being distasteful. It doesn’t mean that it’s necessarily immoral or wrong, but it is distasteful.
But aren’t you also morally offended, if only by the very unnaturalness of it?
No. I’m a kind doctor, and it seems to me that the advantages to Mrs Blood of having a baby outweigh a hypothetical psychological disadvantage based on imagination – this business of the dead father. I mean, it is an aesthetic worry, not a moral worry. I’ve always tried to distinguish between things that are aesthetically wrong, morally wrong and illegal, because they are each different. They can be the same in so far as a lot of illegal things are also immoral and distasteful. But there are things which are distasteful which are perfectly legal.
Coming from someone with your views, there is surely a contradiction there…
Yes, I’m a contradictory chap.
Well does the time factor play any part here? Would you feel happy if the same woman wanted to use her head husband’s sperm after, say, ten years? Would there be a stage where it would be viewed as a morbid obsession with the past unlikely to benefit the resultant child?
That question could only be properly answered by meeting Mrs Blood and having a talk with her and coming to some kind of a view about her psychology.
There is much talk at present of genetic engineering and cloning. With such possibilities, do you ever get a sense that Huxley’s Brave New World is closer than we think?
It depends how close you think it is. Huxley’s Brave New World involved the universal use of drugs to make people feel better, and something like that is not too far beyond the horizon. But I don’t think there ever will be human clones because prohibition by government will prove to be sufficient.
People in general react very passionately to such issues, whereas doctors are renowned for their dispassionate approach to medical ethics. Is it mainly a question of knowledge and ignorance here, that is to say that the vast majority of lay people are deeply ignorant of the facts?
No, I think it goes far beyond ignorance. It’s the doctor’s real dilemma in a way. You have to maintain your professional detachment, otherwise you get so emotionally involved that you can’t really provide the kind of help the patient needs. The patient introduces all the emotion that is required, and if any were lacking, the relatives would introduce still more. So I think one has to keep one’s professional cool. That doesn’t mean that one mustn’t. You’re no sort of doctor if you fail to do that, and appreciate what an illness is doing to a person – that’s a necessary component of medicine, but you mustn’t get so carried away by total sympathy for patient and relatives that you don’t give them the best medical advice possible. Old-fashioned paternalism is out, even though I’m something of an old-fashioned paternalist myself. It is very difficult to be detached. Many patients have caused me great sorrow and I’ve taken actions that I have had cause to regret, but it wouldn’t really have helped the situation very much if I had, you know, gone mad.
You were president of the Royal College of Physicians from 1977-83. What were your responsibilities there, and did holding that office enable you to achieve certain goals?
I have a hedonistic approach: if you’re enjoying a job, it’s at least possible you may be doing well, whereas if you don’t enjoy what you’re doing it’s almost certain you’re doing it badly. I tremendously enjoyed my six years at the college. My main responsibility was to supervise professional standards in the interests of patients, a very worthwhile objective.
Where do you stand on the question of attitude of mind being able to influence health and illness? And are you a believer in alternative medicine?
There’s inevitably an interaction between body, mind and soul, and psychosomatic conditions are certainly rife. There’s no doubt that attitude of mind plays a big part. To answer the second part of your question, one really has to approve of anything that’s going to help patients, and undoubtedly many patients are greatly benefited by alternative medicine in all its various forms. I have a twofold difficulty with it: first, that the burden of scientific proof is often difficult to obtain, and secondly, nature itself is a very good doctor, so a lot of the good things which happen may not necessarily be due to the alternative medicine but rather the healing power of nature. There are some areas where getting an actual operation done is terribly important, acute appendix being the most straightforward example, so I would say that people should obtain an informal medical opinion before they go off to alternative medicine if they feel really ill. Apart from that, it’s not for me to condemn it.
Do you think that in our more secular society we are increasingly less able to come to terms with the fact of our own death? In the old days people felt themselves to be in God’s hands…
I’m certainly against prolonging life that’s past its purpose, as it were. I’ve had to think about this a lot in the last year or two because I’ve been chairing college committees on brain-stem death and also on the persistent vegetative state. I certainly think that there are some states of life that are worse than death. The decline of religion may have made people stick more to this terrestrial life, but like so much else, it’s a mixed non-blessing.
How do you feel about your own mortality?
Not much in the way of fear, though when I wake up in the morning I recognize that as a blessing. I once gave a lecture in which the opening paragraph recalled Joseph Addison’s essay about a crowd of people crossing a bridge which ends in a series of broken arches and is also perforated by trapdoors through which some of them fall into the flood below. Some of them clamber precariously from one arch to another, but in the end they all fall. That’s very much the sort of picture you get of life as a doctor. There’s a tendency in my profession to think that illness is something that happens to other people, but when you get to my age you have to recognize it’s going to happen to you.
If you look back over your own lifetime, do you think society is more chaotic now, in the sense that the old certainties have been eroded, and material improvements in our standard of living, for example, have perhaps led to a corresponding decline in other areas?
Yes, I do. I once wrote a paper called ‘Dead Sea Fruit’, and I think perhaps we’ve experienced some of that. So many of the things that blossom brightly with promise have turned to ashes. In the 1960s we were promised universal happiness, but it hasn’t quite worked out that way.