Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Not so very long ago facial transplants would have been the stuff of science fiction, but now they are the stuff of reality. At the moment they are performed on people whose faces have been horribly injured, but in L P Hartley’s dystopian novel, Facial Justice, published in 1960, they were performed for political rather than for medical or aesthetic reasons.

Hartley (1895 – 1972) is now mainly remembered for one novel, The Go-Between, a fine evocation of traumatic sexual awakening in the upper reaches of the Edwardian society to which Hartley remained forever attached. In all, he wrote sixteen novels whose quality, says the Dictionary of National Biography, declined as their frequency of publication increased. Hartley, who was invalided out of the army by Sir Frederick Treves in 1916 without ever having seen action, died of the complications of alcoholism: by no means the first or the last author to let himself be mown down by the bottle.

Facial Justice takes place after the Third World War, when the surface of the earth has been more or less completely laid waste. Some of humanity survives, but underground; in England half the population, dissatisfied with its subterranean lot, makes the daring move to go above ground.

There the New Society is created, ruled by an otherwise nameless Dictator. It must be admitted that Hartley’s imagination was not strong enough to make his dystopia come alive, as do, say, Brave New World and Nineteen Eighty-four, for neither the details nor the history of the New Society are consistent or plausible. I suppose that is why the books remains relatively unknown and unread.

Another reason, perhaps, is that it is a satire on the notion of equality that is now so dear to us. In the New Society there is a Ministry of Facial Justice which works towards the equalisation of women’s faces by means of surgery. Divided on grounds of natural beauty into three categories, alpha, beta and gamma, plastic surgeons operate to give alphas and gammas entirely new beta faces according to a pre-ordained pattern, so that there should be no envy because of the possession of unfair natural advantages or disadvantages: for in the New Society envy is seen as the root of human evil, especially violence. Mediocrity in all things is the goal of the society, and a series of slogans – beta is best and alpha is anti-social – are inculcated into the population to drive the message home.

After an accident, the main character in the book, an alpha woman called Jael, undergoes involuntary betafication (the local equivalent of beatification) carried out by the plastic surgeon Dr Wainewright. She revolts against this and indulges in a conspiracy to bring about the downfall of the Dictator, whose identity no one knows. The result is chaos and violence, in which Dr Wainewright is killed: the message or warning of the book, in so far as any story so unconvincing and ill-constructed may be said to have a message or carry a warning, is that once democratic mediocrity is thoroughly installed in a society, there is no going back and the alternatives are worse.

Harley obviously intended the book to be a satire on what he saw as the mediocrity of the England of his time: and whether this has any meaning today for you depends crucially, I suppose, on whether you think that NICE should really be renamed NICM, the National Institute of Clinical Mediocrity.