Monday, May 31, 2010

Can Medicine be Libertarian?


A differently formatted and illustrated version of this article appears in
Black Flag, Issue 231, Mid 2010, pp.20-23, under the title 
‘The war for control of our health. Overview: Libertarian approaches to medicine.’ 

Those who argue that anarchism would never work sometimes cite the practice of medicine as an example of the type of situation where a libertarian outlook would create insuperable problems and have disastrous consequences. Medicine is one of the areas which are sometimes said to be necessarily authoritarian and hierarchical, beyond the scope of a self-managed society based on workers’ control because of its complexities and the specialised knowledge required. Yet critiques of established or orthodox medicine, in theory and  practice over many centuries, have perhaps more often than not taken a markedly libertarian turn, whether from people who tried to find ways of helping and with luck healing themselves and each other, or from reformers within the profession who were ready to demystify and democratise their subject. Some of these have been consciously radical and even revolutionary in intention, seeing collective efforts at mutual aid as pointing a path towards a different organisation of society.

History

Traditional histories of ‘western’ medicine usually pointed out a path of progress, overall, towards ‘scientific’ remedies, and in Britain the supposedly universal access to a health service provided by a benevolent state. Writers who were often doctors themselves paid homage to the great men, ‘fathers’ of this and that advance or specialism – a history riddled with paternity suits, as someone said. By the later 20th century this view was being challenged from various perspectives, including feminist ones; the work of medical historians, notably Roy Porter, transformed the subject, and the debates continue.

Radical Thinkers

In Britain the later 18th century was a time of widespread satire and scepticism about medical practice and the power of doctors. John Moore, himself a Glasgow physician and surgeon, wrote in Medical Sketches, 1786: ‘The difference between a good physician and a bad one is certainly very great, but the difference between a good physician and no physician at all, in many cases, is very little.’ He advocated the ‘healing power of nature’ as against ‘being teased to swallow drugs... a species of distress to which the rich are more exposed than the poor, provided the latter keep out of hospitals.’ 


The pioneer feminist and political writer Mary Wollstonecraft, 1759-97, had quite a lot to say on the subject of health care in her various works. In her Thoughts on the Education of Daughters, 1786, she particularly recommended the study of elementary medicine for women, who were often expected to nurse any ailing relative. Her first novel, Mary: A Fiction (1788) drew on her own experience in this respect, represented in the title character: “Her anxiety led her to study physic [medicine]...” “Mary, with an authoritative voice, insisted on knowing [the physician’s] real opinion. Reluctantly he gave it...”  Fictional Mary finds a “poor woman... dying of a putrid fever, the consequence of dirt and want...” and takes direct action to help her. “Mary sent the husband for a poor woman, whom she hired to nurse the woman, and take care of the children... Her knowledge of physic had enabled her to prescribe... Cleanliness and wholesome food had a wonderful effect.” Among other things, she comments on the harm done by “the close air of the metropolis”. 

The topics of medicine and health care are also more prominent in Wollstonecraft’s best-known work, A Vindication of the Rights of Woman (1792), than might be expected, from advice on the benefits of exercise to further development of the idea of medicine as a career for women. “Women might certainly study the art of healing, and be physicians as well as nurses. And midwifery, decency seems to allot to them...”   She rejected the notion of female delicacy debarring them from such study: “I have conversed, as man with man, with medical men, on anatomical subjects, and discussed the proportions of the human body with artists – yet such modesty did I meet with, that I was never reminded by word or look of my sex, or of the absurd rules which make modesty a whimsical cloak of weakness. And I am persuaded that in the pursuit of knowledge women would never be insulted by sensible men, and rarely by men of any description, if they did not by mock modesty remind them that they were women.” 

This was not a romantic idealisation of traditional female folk-healing: “Women should be taught the elements of anatomy and medicine... for the bills of mortality are swelled by the blunders of self-willed old women, who give nostrums of their own without knowing any thing of the human frame.”  She also took the opportunity to denounce assorted ‘quacks’ and charlatans as preying on the gullibility and folly of many women, as in the “fashionable deceptions... practised by the whole tribe of magnetisers...” Her prescription was typically straightforward: “If the functions of life have not been materially injured, air, exercise and a few medicines, prescribed by persons who have studied the human body, are the only human means, yet discovered, of discovering that inestimable blessing health, that will bear investigation.” “Nervous complaints, and all the vapourish train of idleness” earned her contempt. In medical as in other contexts, she did not believe in passively putting up with whatever was happening around or being done to her; she held strong views and made them known.

Realising at the same time that even basic common-sense measures were not within everyone’s reach, she showed awareness of the social causes of ill-health: from the repression and confinement imposed on female children and the fads and fancies of their mothers, if upper class, to the grinding poverty and ill-paid labour that was the lot of the lower classes. In a second, unfinished, novel, The Wrongs of Woman (a.k.a. Maria) a significant and original character is the asylum attendant, Jemima, the narration of whose life is an indictment of the contemporary society not least in the lack of medical care for the poor. She describes her experiences after an accident at work:

“Hospitals, it should seem (for they are comfortless abodes for the sick) were expressly endowed for the reception of the friendless; yet I...  wanted the recommendation of the rich and respectable, and was several weeks languishing for admittance; fees were demanded on entering; and, what was still more unreasonable, security for burying me, that expence [sic] not coming into the letter of the charity. A guinea was the stipulated sum – I could as soon have raised a million; and I was afraid to apply to the parish...
“... I was dismissed before my cure was completed, because I could not afford to have my linen washed to appear decently, as the virago of a nurse said, when the gentlemen (the surgeons) came.  I cannot give you an adequate idea of the wretchedness of a hospital; every thing is left to the care of people intent on gain... Every thing appeared to be conducted for the accommodation of the medical men and their pupils, who came to make experiments on the poor, for the benefit of the rich...” In her post at the asylum she has no illusions: “The offer of forty pounds a year, and to quit a workhouse, was not to be despised, though the condition of shutting my eyes and hardening my heart was annexed to it... Four years have I been attendant on many wretches, and the witness of many enormities.”

With regard to the care of babies and small children, however, Mary Wollstonecraft found herself more in tune with advanced medical opinion than with prevailing reliance on traditional practices: “I have often heard women ridiculed... only because they adopted the advice of some medical men, and deviated from the beaten track in their mode of treating their infants... [by adopting] new-fangled notions of ease and cleanliness... What a number of human sacrifices are made to that moloch prejudice!” A book to be titled Letters on the Management of Infants was left uncompleted at her death. 

An outspoken critic of doctors in the early 19th century was Richard Carlile, a radical, free-thinking printer, bookseller and writer who was repeatedly sentenced to imprisonment because of his consistent refusal to pay much attention to the law. He could justly claim that some of his best friends were doctors, notable among them Thomas Wakley, the first editor of the reforming medical journal The Lancet, but he did not like the surgeon of Dorchester Gaol, where he was confined in the 1820s. He wrote to this character in 1825, asserting the right to his medicine of choice (in this case an unfortunate one, crude mercury) and took the opportunity to criticise medical education, but explicitly not all medical men, “the majority of the more intelligent part” of whom he counted among his sincerest friends and supporters. 

The less intelligent part he compared unfavourably with their “wiser medical predecessors, the old women [...] Like those old ladies, with you, it was hit or miss, every case an experiment: if the patient is killed, the fault is the disease; if he recovers, wonderfully clever doctor! There is much less chance of being killed by an old woman for a doctress, as she will not be so rash with her experiments [...]”

State Take-over

Later in the 19th century ordinary working people were beginning, or continuing in a different way to take matters into their own hands and organise collectively in case they should fall ill or meet with an accident, forming friendly societies and medical institutes that enabled them to have access to effective affordable medical care. Colin Ward described how “the tradition of fraternal and autonomous associations' sprang up from below and flourished until displaced by a system of 'authoritarian institutions directed from above”. 

When the form of a British National Health Service was still under discussion, not a foregone conclusion, the debate was opened up by the 1943 Penguin Special, The Future of Medicine, by Dr David Stark Murray. The author was a founder member (1930) of the Socialist Medical Association (SMA) and later its President (1951-70), who continued his agitation for what he saw as a truly socialist health service long after 1948. (The SMA re-named itself in May 1981 as the Socialist Health Association “to reflect a shift in emphasis to the prevention of illness through the promotion of good health. The SHA now engages primarily in public education and lobbying on health issues”.)

Although a socialist rather than libertarian, he insisted that medicine should not be the exclusive business of experts and favoured a free, comprehensive, universal service under democratic control, based on local Health Centres. His outlook included the idea that the discoveries and methods of science could provide models for social reorganisation, that science and medicine are deeply integrated with wider society, and that environmental surroundings and the general standard of living are crucial determinants of individual  and national health. Because of the complexity of modern medicine he also believed in teamwork and in the role of the GP, supported by close contact with specialist services.

A Different Approach

A number of noted libertarian doctors have been highly competent, even eminent in their professional lives while believing their expertise should be demystified and made accessible to rational discussion, and that matters of health should be everyone’s concern, since ‘ordinary’ people are well able to take decisions if provided with the relevant facts: for example, in late 20th century Britain, Alex Comfort (author of The Joy of Sex among many other things), Chris Pallis (a.k.a. Maurice Brinton of Solidarity), John Hewetson (GP and editor of Freedom); in 1930s Spain, CNT/FAI adherents Isaac Puente (author of Libertarian Communism), Felix Martí Ibaňez, and Amparo Poch y Gascon.

Anarchists can also point to some small and larger-scale examples where an alternative was tried out and achieved a degree of practical success.

In London, the Peckham Health Centre opened in 1926, in an experiment or 'pilot project' devised by two doctors to study ‘the living structure of society’ and to try to identify ways of actively generating health. Later it was housed in a specially-designed building with day nursery, play area, and swimming pool. Like a club, it had membership, open to local families on payment of a small weekly subscription. Its organisation was on the principle of autonomy. People made their own decisions about medical treatment, taking or leaving the advice given, and members were encouraged to set up their own activities using the Centre's resources. The doctors explained that the centre was not for treatment but for the promotion of health, to detect by periodic medical examination any incipient or existing disease and to advise, without directing, how to obtain treatment if necessary.

During the Second World War it was forced to close but in 1945 its organisers, members and supporters  campaigned successfully to get the building back. A Petition  pointed out that the PHC was “not a polyclinic dealing with the sick but a Health Centre dealing with the cultivation of health.” Although it re-opened in 1946 and continued for a few years after the inauguration of the NHS, the Centre’s respite was temporary, despite repeated efforts to secure funding and endorsement from the authorities. A Research Programme dated October 1949 tried unsuccessfully to interest the Medical Research Council in its laudable objective: “the unfolding of the fullest human capacities” with “organism and environment in mutual synthesis.” But it did not fit in to the post-war scheme of things, on a number of counts: its focus on health not illness; the required, though small membership fee; and its philosophy of encouraging self-activity. In David Goodway’s words “It was based on autonomous administration and so did not conform to the lines of administration laid down by the Ministry of Health. This last anomaly highlights a wider problem of the general hostility in the years after 1945 from within the structures of the welfare state to any initiative originating outside and hence non-statist and libertarian.”

Revolutionary Spain

In a very different context, a more developed version of anarchist ideas on medical practice and health provision is to be discovered in accounts of the collectives established in Spain in the revolutionary upsurge that was sparked off by the Nationalist coup of July 1936. In areas where anarchists and syndicalists were numerous they experimented with new ways of providing health care among other services while struggling to survive, and to wage war.

Public health in the Republican zone during the civil war laboured under massive disadvantages and disruption; international medical aid notwithstanding, the burden in many areas inevitably fell on the local people with whatever skills and resources they had. There were doctors who supported the attempts to put theories of social revolution into practice within the context of popular resistance to the military insurrection; some in the view of at least one historian were among the best Spanish libertarian militants.

Accounts of the collectives, often unashamedly partisan while being backed by copious evidence from witnesses and observers, praise them for having devoted much attention to medical and health services which they endeavoured to provide free of charge at point of use. Gaston Leval collated many detailed reports, based on first-hand observation of their efforts and achievements in various parts of the country: “The socialisation of medicine was becoming everybody's concern, for the benefit of all. It constituted one of the most remarkable achievements of the Spanish Revolution.” (Collectives, p. 278)

In his view, new  placed under “a kind of governmental aegis” were only the old establishments with a change of name, whereas those, much more numerous, taken over by the Syndicate were, with considerably less means, created anew on holistic, organic principles. Like other workers, doctors were directed to places where the need for them was felt most, and no longer disproportionately served the rich areas. When a locality asked for a doctor from the Syndicate, it would first check up on needs and then select from its list of available members the practitioner whose qualifications were most suitable, and he or she would have to give good reasons if s/he wished to decline the posting. Medicine was presumed to be at the service of the community, not the other way round. In the new clinics, operations were carried out free of charge as was treatment in psychiatric hospitals. As Glasgow anarchist Ethel Macdonald reported after visiting a hospital ‘purely under CNT control’: ‘All the staff are comrades and share alike.’

Although doctors’ responses were naturally not unmixed, reportedly more than half the practitioners cooperated voluntarily with such arrangements. Further steps taken were the general organisation of everything to do with  products and improvements in treatment for suffered at work, with full-time medical services in large factories and workplaces. Non-anarchist patients often commended the quality of care they received from nurses, many of whom were trained by the anarchist women's organisation, Mujeres Libres,  which made health care and health education a priority in its work, aided by women doctors.

As the imperfections of profit-driven and bureaucracy-dominated systems become ever more catastrophically evident, the Peckham Health Centre of mid-20th century London and the anarchist collectives of 1930s Spain, among other examples – some of which no doubt have still to emerge from historical research into the hidden areas of people’s autonomous self-activity – attest not only the validity of libertarians’ past critiques of orthodox medicine but their potential for implementing practical alternatives in the future.

Liz Willis
March 2010

Publications referred to, and some further reading    
This article is partly based on ‘A libertarian alternative?’ in The NHS is 60: Undervalued, Under-funded, Undermined. Radical History Network of North-East London, May 2008.

History, Critiques, pre-NHS
Roy Porter, Blood and Guts: a Short History of Medicine. Penguin (2003), and many other publications -  see extensive bibliography at http://www.ucl.ac.uk/histmed

Mary Wollstonecraft:  A Vindication of the Rights of Woman (first published 1792). Penguin Classics. See also biographies of, and other works by Mary Wollstonecraft. And new online March 2015 -
Mary Wollstonecraft and the Doctors: An Intelligent Woman’s Observation and Experience of 18th Century Medicine (16-page article)

Charles Wortham Brook, Carlile and the Surgeons. Glasgow, Strickland Press (1943)
David Goodway , Anarchism and the Welfare State: the Peckham Health Centre. History and Policy paper 55 http://www.historyandpolicy.org/archive/policy-paper-55.html

D Stark Murray, The Future of Medicine. Penguin (1943)
From Murray,1943,as above


Pioneer Health Centre, Peckham

Innes H Pearse, Lucy H Crocker, The Peckham Experiment: A study of the living structure of society (1943) 

Colin Ward, 'The Path Not Taken', Raven, no. 3, November 1987, pp. 195-200.
3 Files in National Archives relating to Peckham Health Centre: MH 52/159; FD 1/299; AVIA 9/91

Spain

Gaston Leval, Collectives in the Spanish Revolution. London, Freedom Press, 1975; Ch. 4. The Socialisation of Medicine, pp. 264-78. http://libcom.org/book/export/html/1933

Isaac Puente, ‘Libertarian Communism’. Cienfuegos Press Anarchist Review. No. 6. (1982). http://flag.blackened.net/liberty/libcom.html

Rhona M Hodgart, Ethel Macdonald: Glasgow woman anarchist. Kate Sharpley Library pamphlet, 2003.

Martha A.Ackelsberg, Free Women of Spain: Anarchism and the struggle for the emancipation of women. Edinburgh: AK Press; 2005.

Dolores Martìn Moruno, Javier Ordòñez Rodrìguez, ‘The nursing vocation as political participation for women during the Spanish Civil War’. Journal of War & Culture Studies, Vol. 2, no. 3, 2009, pp.305-319.

E.A. Willis. 'Medical responses to civil war and revolution in Spain, 1936-1939: international aid and local self-organisation', Medicine, Conflict & Survival, Vol. 24, no. 3, 2008, pp.159-173.

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