The celebrated series, Downton Abbey, presents a vision of the twilight era of a system in which one’s social and moral value was framed by an unwavering and internalized awareness and acceptance of one’s societal role. Early in its course, we see how these factors come to influence medicine by determining the perception of patients and access to medical innovation. Using the case of the Drake, the farmer from the second episode, as a lens, we observe the fundamental conflict between Britain’s rigid historic hierarchy, in which moral status accrues from one’s successful performance of one’s role, and the modern hierarchy, in which moral status stems from common humanity that dominated this historical era.
When Drake develops dropsy (pericardial effusion), many characters (Lord Grantham and his family) focus almost entirely on his productive capability weighing his life in strikingly finite and quantifiable terms. This pragmatic sentiment is unsurprising as it pervades many of the Lord’s considerations, including his views on giving people’s lives purpose through employment and even his own marriage. The Lady Grantham, like so many rich American heiresses of her era, was valued initially by her noble but cash-strapped husband as a means of saving his estate, while he in turn held for her the allure of a title. It is the dowager countess who takes this dynamic to extremes using Drake’s treatment as a means for demonstrating her influence over the hospital. Even in death, the purpose of a tenant in her eyes rests in providing valuable service. The Countess’ rival, Mrs. Crawley, in contrast, despite her recent up jump in status and desire to conform to social etiquette, is unable to escape her drive to use her skills in service of the common good for no other reason than that those in need are her fellow men. This conflict regarding how best to allocate moral status raged during this era as a struggle for the soul of modern England waged, perhaps most furiously, by the era’s prime minister, Lloyd George. Himself the son of a teacher and raised in large part by his cobbler uncle, Lloyd George, succeeded in passing the National Insurance Act of 1911. This act made provision for sickness and invalidism, and a system of unemployment insurance, essentially creating a world unimaginable to Lord Grantham in which the tenant became the British citizen and value came not from personal production or skillful service, but unified national identity. With her cry to have pity the Countess was perhaps asking to be spared the burgeoning of this modern era in which Lord’s work, their mothers perform direct patient care, servants assert free speech rights, and moral status accrues to all people equally as for Drake to be left to die peacefully.
This episode also illustrates that where one has the misfortune of falling sick can have striking consequences on the outcome. Drake’s disease occurred far from the rapidly modernizing cities of London or Manchester; then as now, low-income individuals who live in affluent, highly educated cities live longer. Two central pieces of why this is the case, as witnessed through the lens of Drake, are access to innovation; the use of adrenaline was well established in the city and a dangerous novelty in the countryside and infrastructure. A cottage hospital was at best composed “of a kitchen and a back shed, with perhaps two bedrooms, which are often without a fireplace; the windows, small, low and frequently not made to open.” London, in contrast, had hospitals like Saint Guys with hundreds of beds and the best of England’s physicians. Even conceding 19th and early 20th century conditions this represents a striking improvement. All of this forces us to contemplate our society’s determination of whether a person’s moral status derives from their pecuniary or social utility or the inherent worth of a human life; a quandary the British left us along with the title of superpower. America now stands at the same precipice Britain once did with the rich ascendant and those less fortunate forced to accept what care they can get approved. What step we take next will profoundly shape the values and destiny of our nation.
Ben Bolt and Julian Fellows, writers. “Episode Two.” In Downton Abbey. WGBH Boston. October 3, 2010.
 Meyrick Emrys-Roberts. The cottage hospitals, 1859-1990. Motcombe, Dorset: Tern Publications, 1991.