the decline, of choice

Americans are suckers for our own decline. As this New Yorker piece reminds us, declinism as a rhetorical strategy is nothing new, although according to Adam Gopnik, only Spengler did it right. Whatever the case may be, we have got nothing on the British, who, as the LRB showcases, are now mourning the last time they mourned their decline. The NHS, the great cradle to grave upshot of the previous decline of the UK, is now under assault, the piece tells us, by shadowy corporate forces that threaten to make it more efficient in the guise of making a profit.

I don’t pretend to understand the merits of privatizing or cost cutting in the NHS. Health policy is probably best left unfiddled with by philosophers. However, the normative component of the article attracted my attention.

The disturbing issues raised by the ASR hip fiasco – why was DePuy not obliged to test the device more rigorously by the authorities in Britain? Are other metal on metal hips a risk? – obscure a deeper question. Why are medical implants being marketed like iPhones, as in Smith & Nephew’s video for the Birmingham hip at, where to the accompaniment of a driving guitar track, strong, shadowy dudes with artificial hips ski, play football and climb rockfaces?

All the rhetorical questions in this paragraph are not equal. The first two deal with regulatory issues which we hope for government to address. But the “deeper question” conceals an insidious illogic that really upsets me.

This deeper question gets posed in two ways which the article treats as equivalent and which share little in common. The first is a concern about conflicts of interest corrupting physician-patient interactions.  Thus, “Cobb pitched hard for the ASR hip, as Atkins remembers it, telling him the hip had ‘just come out’, that in a matter of six weeks he’d be playing golf again, even tennis.” Meanwhile, “What Atkins didn’t know was that Cobb had helped design the hip he was promoting.”

Conflicts of interest are an old problem that currently appears acute in this particular context. But the second way the “deeper question” gets asked makes much less sense. After all, what got Atkins to replace his hip wasn’t the self-interested doctor. The clincher was,

a marketing video from DePuy showing a series of real people who were seemingly thriving with ASR hips. ‘There was a golfer putting putts down from 25 yards. At the end there was this guy, apparently the coxswain of a West Country lifeboat, at the wheel of the actual lifeboat in very rough seas.’

…Impressed by the video, he signed up for the operation.

In the midst of several genuine problems, the LRB needs to drive home the point that marketing videos may exaggerate the benefits of their particular product.

This particular iPhone commercial, which, if you look, comes nowhere close to the polish and aesthetic of actual iPhone commercials, led a patient to “Four years that blighted my life and that of my wife. I couldn’t sit; I couldn’t stand. I was on 500 mg of ibuprofen twice a day. Since that operation I really haven’t played any sport at all.”

Wow. That’s a crappy iPhone.

Let’s think what would’ve happened had Atkins purchased an actual iPhone rather than a hip replacement. At the risk of being too cute, we can be fairly certain that the iPhone would access the internet. Since, I have the internet right in front of me, I can use google to search for hip replacements. Since google leads me to Wikipedia, I can, within 5 seconds, see a section on “Risks and complications” of the aforementioned major medical procedure. The Mayo clinic and other trusted resources also appear in my browser window. If the preceding sounds banal, then you probably would not consent to a major medical procedure without googling the relevant literature. One interesting fact about regulatory literature is that all of it is in the public domain, on the internet at your fingertips. So conceivably, aside from watching a real live coxswain in a bad video, you could also access the databases of the FDA and look at the innovative new procedure which was not really approved by that august body before opening up yours.

What I am trying to get at has to do with an attempt to open up a federal case against an old word: choice. In the LRB article, weasel-like non-choices appear out of rodentine crevices like business schools. They hungrily gobble up all the good reassuring government love and leave shit behind them.

I punched the postcode for Dr Mantgani’s surgery into the NHS Choices website, together with ‘hip replacement’. Under the changes brought in by Labour, patients can choose from five hospitals within five miles and 59 within 50 miles. The closest is the Wirral’s NHS hospital, Arrowe Park, three miles away; just across the Mersey is the Royal Liverpool University Hospital; the closest private hospital, the Spire Murrayfield, is only slightly further away. The site suggests you’d have to wait 11 weeks from referral to treatment at Arrowe Park, seven weeks at the Royal Liverpool and only five if you went to Spire. On the other hand, Spire doesn’t have the full range of emergency services should something go wrong; nor is it likely to take difficult cases. If my hip was hurting like hell, I’m not sure I would want to take these choices on myself. Why should I? Like most patients, I’m not a doctor. Dr Mantgani admitted: ‘The patient often says: “You tell me where I should go.”’

Whether or not choice in general looks more like the weasel or the rat, in this case, a real choice does exist. It’s very simple. People choose to believe in the goodwill, love and care of medical practitioners. While some doctors doubtless exude such love and care, others are probably self-interested human beings or even giant assholes.

But the weakness of the British authorities in the face of the ASR hip, and the ease with which DePuy salespeople persuaded British surgeons to use the ASR implant when tried and tested alternatives were available, doesn’t make one confident that the people who run our health system have a clear idea of the difference between ‘choice’ and ‘marketing’

According to the article, choice and marketing are like exits 7a and 7b on a highway. You can easily miss one for the other, but one leads to a real crappy place, and the other is great. This facile distinction, coupled with the revealing asides about doctors snuggling us and telling us it will all be ok and the whole really bad commercial for animatronic hips gives us the setup for the Manichean declinism narrative LRB wishes to sell us. Of course, caveats abound. “There can be few people who haven’t experienced a moment of uncaringness or worse somewhere in the system.” The NHS “can resist good changes,” etc. Still, the NHS represents “a very idealistic model, but by God, it’s vulnerable to people ripping it off.”

Without replaying the last few years’ healthcare debates, we can note the accretion of a narrative in the LRB article which consists in oversimplification and associational logic. Simply put, the example of the hip replacements, however tragic, is a bad example. At no point was a cheaper procedure hidden from patients. Similarly, doctors’ affiliations and regulatory paperwork are all on the internet in plain English, searchable by google. The excuse for non-choices—that we wish for simpler times when money was no object, that we want someone to reassure us or that we saw a commercial, are all just that, excuses. The truth is that choice does exist, even if the choices are unattractive. If you can choose between two self-interested schlubs, you can still choose the more convenient or knowledgeable or nattier of the two. What does not exist are perfect choices. These would be choices of an idealized past over an imperfect present, choices of altruistic saintlike figures over corporate overlords, or the choice to play lots of sport and be a professional coxswain after a major hip replacement.

Declinism opposes real choice because the difference between unpalatable choices and the maturity required to bite the bullet on one end or another can always be contrasted with an imaginary choice free zone. This choice free zone often appears in marketing videos. Sometimes you are screwed, but you can prudently opt for the hip replacement that doesn’t shear little bits of titanium into your blood. You might not play sport anymore, but you can avoid years of pain by keeping three words in mind. Google fucking exists.

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