NATIONAL HEALTH

Life-blood

PATRICK COSGRAVE

Richard Titmuss is the most important Socialist in Britain, and the only Englishman who could be regarded as a serious philo- sopher of the Left. His new book*, in form a study of blood donation systems, avowedly restates the theme of his life's work. This is that man has good—altruistic---impulses which have been, and are being, checked and strangled by the historical (capitalistic) in- stitutions of Western society and the values of its market-places, but which can be fos- tered by correct Socialist institutions.

To the historian, acquainted with the complexities of man's sin through the ages, this may seem a flimsy enough argument. The Gift Relationship is, however, designed to show that the facts are on Titmuss's side. There is, today, a tremendous and increasing demand for blood for transfusion. In Britain, the required amounts are provided (with trivial exceptions) wholly by completely vol- untary donations and, as Titmuss establishes, there has been 'progressive and sustained' donor response to increasing demand.

In other countries, notably Japan and the United States, there is a commercial or quasi- commercial market in blood and_donors are paid in cash, medical care, or other kind. In these countries there is a critical shortage of blood, because the system repulses the volun- tary donor. Moreover, in blood transfusion there is a great danger, if the donor is unsuit- able, of infection, particularly of serum hepatitis, a severe and often fatal malady. Hepatitis may be caused by the infection of as little as one millionth of a millilitre of transfused blood and, not only is,there as_ yet no proven way of screening blood, there is no way of screening the donor either. So, the patient's health is dependent on the donor's truthfulness about his own state of health at a transfusion centre. In a commer- cial system, the danger of infection is in- creased (in America it is rampant) because the donor needs the money and will lie.

This case—the superiority of voluntarism to capitalism—Titmuss proves beyond doubt. He concludes, however, that such altruism is possible only in a society as socialistically advanced as ours and (this in the course of an alarmingly superficial survey of the work of such tendentious anthropologists as Levi- Strauss, and with no mention of the rest of the history of Western ethics) claims that socialism in Britain has actually qualitatively improved the nature of man's altruism over that to be discerned in primitive societies— as witness the voluntary blood donation system and its efficiency.

That system, Titmuss argues, is inconceiv- able apart from the National Health Service, though the National Blood Transfusion Ser- vice is administratively separate. This is a

• prejudiced contention, for all his facts prove is that the absence of a market in blood encourages efficient voluntarism. And he might have been a little taken aback had his investigations included the Republic of Ire- land, a country not noted for socialistic achievement.

It is striking that Titmuss refers only once

*The Gift Relationship Richard M. Titmuss Allen and Unwin 70s in his book to the NHS as an organisation for medical care, and that in a very blithe

fashion. For the rest (and this is a balance reflected in other of his works) he finds it above all 'not socially divisive': from this

fact medical and ethical benefits are assumed to flow. Like all socialistic institutions, the NHS is presumed to have a uniquely moral, discriminating, ethical personality.

That this is not the case can be shown by the working of the 1967 Abortion Act, which was remarkable chiefly for its 'social' clause, legalising abortion where there was risk `to the physical or mental health of the pregnant woman or any existing children of her family'. This is a provision which many prac- titioners find difficult to distinguish from abortion on demand, which the Royal Col- lege of Obstetricians and Gynaecologists found to be unethical, and which 47 per cent of gynaecologists would like to see repealed. Leaving aside the great question of whether the deliberate medical destruction of human life is in any circumstances permissible, cer- tain consequences of the act within the NHS are now discernible.

Using criteria generally agreed when the Act was a Bill, we know that the criminal abortion rate has remained steady as, roughly, has the birth rate. Thus every extra abortion since the act—there are now per- haps twice as many as before it came into force—has been a demand created by the un- limited theoretical supply of the 'social' clause and the virtually unlimited practical supply of the mis. Now, the same doctors must abort as treat pregnant women. But the nature of an abortion operation is such that you must take the patient into hospital as soon as possible after the eighth week of pregnancy. This means relegating in your waiting list the pregnant woman who wants to have her baby and who needs pre-natal hospitalisation.

Such legislation might well have had simi- lar consequences in a private practice system, for it is bound to weaken medical ethics. That

it has had such rapid and virulent effects in the NHS—despite that organisation's unique, if imperfect, humanity—is due to the in- herently demand-creating nature of that ser- vice. If all medical treatment is to be free on a universal basis, demand will escalate above financial and administrative capacity to meet it, unless some different system -of financial provision than the present one, which Titmuss regards as essential, is pro- vided; while, at the same time, theoretically unlimited demand will create its own laws.

These facts of ethics and finance deny to the NHS, for all its irreplacability, the par- ticular, superior ethical quality Titmuss claims for it, for a medically ethical system must surely, above all, be able to distinguish between medical priorities. The ethical prob- lem does not concern Titmuss; any likely solution to the financial he would find abhorrent.

Still, Titmuss is, in a different, ideological way, discontented with every single aspect of the Welfare State, notably its income struc- ture. One of his most important tracts, Income Distribution and Social Change was concerned—curiously, indeed, for a man now so preoccupied with altruism—with the economic problem of achieving a socialistic equality of income. Even higher education, he saw, in one of his most important pro- nouncements, as principally the means of improving the earning power of the common man. Equality, for him, has first and fore- most an economic meaning.

That remark about education dismisses the whole history of the achievement and ambitions of Western education as The Gift Relationship dismisses the history of Western ethics, for Titmuss has no sense of, no interest in, no sympathy for, history. This is even more clearly borne out in the other purpose he sees for education, that of being 'a major equalizing . . . force' and of training minds to believe in and administer the socialistic society: thus, as a university teacher, he has used education for many years.

This determined exclusion of unsympa- thetic experience is not a little terrifying and, in a man of Titmuss's influence, has serious implications. Yet, there is a donor typology for Britain in The Gift Relationship which shows that the profile of donors reflects the economic and social constitution of our society, rich and poor, Conservative and Labour. This should at least have shown Titmuss how widespread is the impulse to altruism and how far flung its roots. They lie, I believe, in the ethical evolution of Western Christian society and are as inde- pendent of capitalist economics as they are of the crude economics of Marx and, for all its parade, of the thought of Titmuss. The im- pulse to reform that brought Labour to power in 1945, charged, among other things, to create the NHS, is likewise rooted in the history of our diversities. Because of this, and because of the admixture of sin and virtue in man's nature; because we value, not good merely, but property, and pleasure, and patriotism as well, we will always be equally resistant both to capitalist free- booters and Socialist system-builders. We have still, however, vestigially, a sense of the end of life, lacking which a Titrriuss must strive for abstract, institutional, 'bio- logical' (his word) perfection on earth. Because humanity is alike resistant to his dreams and schemes, not over-preoccupied with equality, he is driven to demand greater extremities of abstract, bureaucratic systems and a brain-washed, 'educated' populace. This is the virus of socialism, by which its original rage against need and injustice is infected and destroyed. The tragedy of Tit- muss is that he cannot see good, however methodical his research, outside his own system. So exclusive a life-view in the end breeds intolerance, in the disciples, if not in the master. And all about us today we see the beginnings of the intolerance of the Left.