Monthly Archives: March 2014

Dr. Van Helsing Does Not Practice Primary Prevention

As recommendations for treatment of hyperlipidemia become broader and more generic, drifting toward the poly-pill conclusion, I can’t help but think of Dr. Van Helsing’s predicament in Dracula. In the story, though he has information which suggests the possibility of primary prevention, he practices secondary prevention. It is only after the symptoms appear – Lucy’s mysterious anemia and the rash of similar cases following her death – that the doctor suggests putting garlic around the windows. He has to wait. He’s in a story, so he knows the horrible truth all along, but he can’t reveal it without his patients sending him packing. Every doctor understands Van Helsing’s predicament. Few can see his patients’ logic however. It is one thing to indulge a crazy old man’s belief in vampires. It is quite another to indulge a crazy old man’s belief that a vampire has moved into the old mansion down the street and has begun to prey upon the household.
When doctors tell patients to treat public health problems, like cardiovascular disease prevention, on an individual basis, the patients take it as if they were being asked to put garlic around their windows because there have been vampire sightings in their neighborhood. They are slightly incredulous. And, the patients are right.
If we medical professionals are to treat asymptomatic individuals based on a 10 year risk calculated from epidemiologic data, for a disease which they have may or may not have started to develop, we must be honest with them. We have to admit that medication is the best that we can do, ask for their help, as a group, and then make it easy for them to help. Doctors don’t like to treat populations, though. Individualized care and patient centered care are the current watch words. But the greatest successes of medical science have been the opposite sort of effort. Nobody thinks that we should stop immunizing people for pertussis and move to an individualized prevention program with regular swabs for the pertussis bacteria and antibiotics for every runny nose. The approach is ostensibly patient centered, and it really is in a way, just like Dracula’s interest in Lucy and Mina is patient centered. Looking down from the established high ground, it’s easy to recognize the shift to an individualized strategy for preventing whooping cough as impractical and myopic. Medical professionals are clever enough to avoid bad moves from the general to the specific. However, decisions to move from a dysfunctional individualized program to a population based program can trip up anyone, even though the determining factors are the same.
The problem is Van Helsing’s problem. At the level of the vampire hunter’s interest, garlic around the windows is garlic around the windows. He’s like Dracula that way, for whom young ladies full of blood are young ladies full of blood. Dracula and Van Helsing are at risk of availability bias, cognitively and practically, as are all the physicians with lipid profiles, risk calculators and statistical correlations at their fingertips. There is a insidious, vampiric class of maneuver from population-based conclusions to individualized care. But the patients’ motivations lie outside of the action’s focus, and that focus is therefore myopic. It does matter to patients whether the doctor is asking them to deck the sills in order to cut down on the incidence of vampire attacks or because they should fear the vampire staring at them through the window. The latter request involves adopting an astringent manner of thought and behavior, the stuff of anxiety disorders. The former is an appeal to solidarity and public safety. We shouldn’t be surprised when the same people we’ve been instructing to fear the vampire outside their window come in demanding that we do something about the pale figure lurking behind their cough, in their prostate, or under their nipple. Having ceded the high ground, we’ve no credible response.

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What Dies on the Sharp End

As children, many of us were cautioned not to judge another person until we had walked a mile in their shoes. This simple aphorism is meant, and taken, in two ways. For those with a literal bent, it means that we should withhold judgment until we have the all the relevant information. For those with a more philosophical inclination, the saying means that we shouldn’t judge, or more precisely, we should understand that our judgments about others are always bound to be a little off. The latter interpretation is more accurate, because we cannot walk in another’s shoes. Beside them or in their tracks we can experience their walk, but not in their shoes or their skin. To do so would demand abandoning our own identity. In light of the latter interpretation, the implication of Mom’s trite admonition becomes apparent. We aren’t limited by our subjectivity – the statement is nonsense – our subjectivity makes us. Like so many things which children must learn to get straight, it marks a snag in our understanding which trips the most carefully considered philosophies.
Let’s see how philosophical problems regarding mind fare under the heat of our kindergarten lesson. With no subjective experience of subjectivity, philosophical zombies – hypothetical creatures which exhibit behavior without experience – take a shot to the brain, not because we cannot conceive of behavior which does not entail qualitative experience, but because we cannot conceive of qualitative experience divorced from activity (after all shouldn’t something which is a property of experience rather than a product of it show some sign of life for itself?). Rigid designators – necessary identities – hold for representative entities in logic, but not for the objects from which the logical entities derive (would that it were otherwise; think of the savings on auto repairs and trade-ins alone, not to mention the safety benefits of “the red car turning left in front of me” being true in fact as well as in theory). Determinism becomes an analytical curiosity. There is no quantity of happiness, suffering, or human thriving calculable. There is nothing that it’s like to be a bat – or a human.
Philosophies stumble because most of them have not been field-tested. This state of affairs is understandable; field testing is a grim business. The best contrivances fail in unexpected ways, leaving us deflated and puzzled. Trying to break a precious invention in the course of it’s intended use admits to some basic pessimism, but it is vital. Yet how do we test an idea of how the mind works in the world? What we need is something other than the sort of post-game analysis which always concludes that the contest turned out as it did because one team managed to “execute” and one didn’t, that one managed to fit the criteria of our post-hoc definitions and one did not. We need to know what happens, what falls away, what persists and the shape of the relationship between the whole lot.
Fortunately, we don’t have to go to the trouble of designing a test for philosophies of mind. The sort of test in question happens naturally on the sharp end of a rope. Every rope in use has a sharp end, attached to the lead climber, and a loose end, secured by the belayer. As soon as the leader finishes his knot, things begin to fall away. The belayer is a person who pays attention or not, who arrests a fall or not. He may be a Saint, or he may have walked out of prison that morning; it doesn’t matter. Likewise, the leader is a person who falls or not, who puts the belayer at risk or not. The relationship is quite specific and pertains to the subjects and the salient features, the valuable points, of the situation, as do all the relations and values which fall away. But the test extends beyond the mind-to-mind relationship. In the leader’s experience our ideas about the nature of mind itself get tested, because the leader is the one who grasps the holds. Looking at a hold creates a shaped perception of it. The hold has size, conformation, anticipatory feel, relevance to body position, distance and even strategic utility. But that hold is not the hold which the finger touches, and the leader knows the hold in hand by a different means.
Here is where another important set of ideas breaks down. Contact with the hold demolishes the mental theater. The hand and mind know the hold by assimilation. They know the edge as a hold by becoming the hand and mind which grasp it. The meaning of the feature’s heat, slipperiness, sharpness and adequacy are immediately apparent, because all those remake the first person in the moment of contact. The hand and mind know the feature as a hold because that is how they are capable of knowing it and the situation could not be otherwise in the revised individual. The subject doesn’t transcend the moment by discovering some permanent and essential nature realized in the experience, but by diving in, taking in and being taken into the meaning of the hold.
So what dies on the sharp end is transcendence, permanence, and commitment in the abstract. But these are no losses at all, because we can see that, all along, those defunct ideas were merely mistaken shaped perceptions of engagement, persistence, and understanding of change. With the death of its bearers, on more thing must fall and break in our field-test: meaning as a graven image – of God’s will, nature, humanity or whatever other imagined necessity. Meaning is revealed as, like us, the property of the present moment. The edge on the face of the stone is many things, we think, possibly, but with fingers on it, it is a hold – and that fact accounts for all valuation, all confusion over minds and bats, and the limits of footwear exchanges. This is not mysticism; it is much, much smaller. It is just what we know.

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