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A suspended doctor in England is running a company that sells people sick notes to excuse them on medical grounds from their work. “When you’re ill,” said an advertisement for the company, “our prices will make you feel better.”

A reporter for the Daily Telegraph newspaper managed to obtain a certificate from the company to excuse him from work for five months, because he claimed (falsely) to be suffering from the long-term effects of COVID. He obtained the note without providing any medical evidence whatsoever.

The only thing that surprised me about this was that anyone thought that it was necessary in Britain to buy or pay for such a certificate. I thought of the famous lines of Humbert Wolfe, the otherwise all-but-forgotten England man of letters:

You cannot hope
to bribe or twist,
thank God! the
British journalist.
But, seeing what
the man will do
unbribed, there’s
no occasion to.

The same might almost be said of British doctors, many of whom, I suspect, issue such certificates incontinently, for one of two reasons: fear of their patients, and sentimentality.

“Even outright faking can now be construed as an illness or disorder, provided only that it goes on for long enough or is deceptive enough.”

Not surprisingly, doctors do not like unpleasant scenes in their consulting rooms, and refusal of requests for time off sick can easily lead to such scenes, and occasionally to threatened or actual violence.

Naturally, no doctor likes to think of himself as a coward, the kind of person who caves in to such threats. The best way to avoid so humiliating a thought is never to risk having to think it, that is to say by granting the patients’ wishes in this matter immediately.

But in order to do this without feeling self-contempt, it is necessary to rationalize, that is to say to find supposed reasons for why everyone who wants a certificate should be given one. The English philosopher F.H. Bradley once said that metaphysics is the finding of bad reasons for what we believe on instinct, adding however that it was a human propensity to do so. In like fashion, we could say that doctors find bad reasons for giving sick certificates when they suspect that not to do so might lead to a confrontation with a patient.

Thus they convince themselves that if a person tells them that they are unfit for work, for whatever reason, it would be wrong to question it. No one would make a claim to be unable to work unless he were in some way discontented, unhappy, depressed, anxious, stressed, in a word suffering, and it is the object of doctors to reduce human suffering.

The doctor is aided in this train of thought by the looseness of psychiatric diagnosis, so that practically all forms of distress can be fitted into the procrustean bed of diagnosis. Even outright faking can now be construed as an illness or disorder, provided only that it goes on for long enough or is deceptive enough.

Does this mean that the patients seeking sick notes are all faking it? The matter is more complex than this would suggest. There is, of course, conscious, outright fraud, but this is comparatively rare. Just as doctors don’t like to think of themselves as cowards in the face of their patients, so patients don’t like to think of themselves as frauds.

Distress can be conjured out of almost anything and is not necessarily proportional to whatever causes it. Dwelling on the ill treatment one has suffered—and who has not suffered ill treatment at some time in his life?—can magnify something minor into something major, to the point at which it seems almost to have ruined one’s life. And it is certainly capable of rendering a person unfit for work in his own estimation—though in fact continuing at work would be a remedy for, rather than an exacerbation of, the problem.

However, where economic loss is not too severe when stopping work on medical grounds is possible, medical grounds will be both sought and found. In the days of the Soviet Union, the workers had a saying: “We pretend to work, and they pretend to pay us.” In our kinder and more enlightened societies, we pretend to be ill, and they pretend to treat us—except that the word “pretend” does not quite capture the subtlety of the transactions between doctor and patients.

There is an analogy with tort law. A large proportion of the suffering, sometimes practically all of it, caused by actionable negligence is caused not by the original injury but by the subsequent legal process, often lasting years. Plaintiffs have their injury constantly before their minds; they become obsessed by the wrong done them and by its supposed consequences. They have every motive for exaggerating the consequences, and since they, like the abovementioned patients, are not out-and-out liars, they come actually to suffer what it is in their interest to suffer. I have known a few admirable persons who escaped this abominable vicious circle by refusing to exaggerate, and by not playing the game of poker to extract as much as possible from the wrongdoer. But they are few by comparison with those who go to the bitter end for all that they can get—which, of course, is rarely enough, in their own estimation.

Moreover, since the plaintiff is small and the respondent is big, or at any rate bigger than the plaintiff (otherwise he wouldn’t be worth suing), there is a bias in favor of the plaintiff, who on account of his smaller size is the underdog. Which of us is not sympathetic to an underdog and does not side with him against the vast forces, organizations, and institutions by which he is (like the rest of us) confronted? We are apt to believe that the small man does not lie or cover up inconvenient facts as those who direct and profit from vast organizations do.

For this reason, I have known judges, highly intelligent and incorruptible as they were, fail to draw the most obvious inferences from the conduct of plaintiffs, who claim that some wrong done to them has rendered them incapable of leaving the house when the record incontrovertibly proves that they have gone on holiday to Brazil or South Africa.

Sentimentality has very serious consequences. It can corrupt whole populations.

Theodore Dalrymple’s latest book is On the Ivory Stages (Mirabeau Press).