From time to time newspapers print league tables concerned with which city in the UK offers the best quality of life. And medicine has widened its traditional aims of prolonging our lives and repairing our bodies to include improving our quality of life. The term has become so familiar that it is easy to forget that its frequent use is quite recent. Indeed, in the period 1961-65 there were no entries at all indexed in Medline under the key term 'quality of life,' whereas in the period 1996-2000 there were a staggering 12,749. Presumably these articles were concerned mainly with attempts to define and measure quality of life. But can it be defined for the individual or the community, or must it remain entirely subjective?
To try to answer this, let us go back to the Greek myth of Sisyphus. Sisyphus was King of Corinth and got into trouble with Zeus (over a woman). His punishment was that he had to push a boulder to the top of the dreadful mountain of Tartarus, and when he reached the top the boulder would roll back to the foot creating huge clouds of dust. This process had to go on through all eternity. Some European writers, such as Camus, have taken this as the paradigm of a life with no quality or meaning.
Let us try to develop some lessons from the myth. We shall suppose that Asklepios (the demi-god of medicine) negotiates with Zeus to improve Sisyphus' quality of life. Suppose he gets the place of punishment moved from Tartarus to a decent Munro. Has his quality of life been improved? Yes! Clean air and attractive surroundings are surely improvements for the individual and the community. Suppose further that Sisyphus is allowed visits from friends. Again, this helps a lot – we need company. Suppose Sisyphus is allowed to push up different boulders and make a shelter or a cairn at the top. This would surely add something important to quality of life because the labour now has a point to it, or is given a meaning.
Readers can add their own improvements – perhaps every weekend off – but the point is that we seem to have a reasonably objective way of looking at quality of life, a way which might carry over into the life of a city. Unfortunately however some people will say that I have omitted the one factor which is of supreme importance for a good quality of life, at least in the eyes of successive governments and perhaps the public too. The life of Sisyphus has been improved by the advocacy of Asklepios and the agreement of Zeus, but Sisyphus himself has had no choice. But choice, it might be claimed, is the supreme factor for a good quality of life, so important that it must spread from the supermarket to education, healthcare, and whatever.
Is there a problem with choice as a key to a good quality of life? Well, suppose Asklepios says 'Okay, you can come down from your Munro and tell your friends to go home because instead of these benefits I am going to offer you choice!' In reply Sisyphus says 'Great, I'm going to choose to go right back to the casinos and brothels of Corinth.' Has his exercise of choice improved his quality of life? Some might say 'yes' – indeed, if choice is the supreme good it is currently depicted as being, they must say 'yes' – but I would prefer to argue that whereas choice might be a necessary condition for a good quality of life it is not sufficient – it depends on what you choose. There is some evidence (what J S Mill calls 'the accumulated wisdom of mankind') on what factors in the long run improve quality of life. Whether in the life of the individual or the city I'd back friends and attractive surroundings over brothels and casinos.
I have looked at quality of life in terms of what we might call 'objective properties,' and in terms of choice, but there is yet another way of approaching the idea. Suppose there is an outbreak of swine flu on Mount Olympus and Asklepios has become incredibly busy so that he hasn't time to negotiate the changes in the life of Sisyphus mentioned earlier. In the six minutes of consultation available to help Sisyphus, all Asklepios can do is to put him on a course of pills, with the result that Sisyphus now enjoys what he is doing. He sings as he pushes the boulder up and shrieks with laughter as it rolls back down. Has his quality of life been improved?
I asked some young doctors this question once and they thought his quality of life had improved. The elderly doctor training the younger ones immediately shouted: 'Anyone who thinks that is going out of my practice!' Well, that produced a re-consideration of the issues. The elderly doctor had got the point that I had been telling them a political story. The typical patient in his deprived community was a single mother living in damp housing with no friends or support. His view was that a course of anti-depressants would simply compound her problems. He suggested that the doctors should look for and encourage support groups and community action. He was suggesting that medicine, at least at the GP level, should not be separate from political and social action. Was he right?
I have suggested three ways of looking at quality of life and they each have implications for what it is to be a flourishing human being, and what makes for a good society. The third idea – that the human self is a kind of empty bucket to be filled with pleasurable feelings – was well worked out in Huxley's 'Brave New World.' But the idea is still around in the 'enhancement technologies' of Prozac, Viagra and Botox injections (and more to come).
The second idea – currently dominant in our society – that choice is all-important depicts us as essentially individualistic consumers. The US is further down that road, and its nature and the social isolation it brings, can be seen, for example, in paintings by Edward Hopper. The first view depicts human beings as essentially social, requiring a community, meaningful activity, an aesthetically pleasing environment and absorbing leisure interests for their fulfilment. Are these just my middle-class values?
Return to annals homepage