Category Archives: medical ethics

The Problem with Pain

My gaze swung between the man on the exam table and the radiograph displayed on the lightbox. He must have sensed a problem.

“What?” he asked.

What indeed. The film basically showed his shoulder blade broken in two.

“When did this happen?” I inquired. He had already told me once; I just needed to be sure that I’d heard it correctly.

“Yesterday afternoon,” he said, ” right after lunch.”

“And why did you wait until this afternoon to come in?’

“Well, I’m here mostly to get my wife off my back. If it was up to me, I wouldn’t have come in, but she thought it might be serious or something, because I tossed and turned last night.”

“Well,” I told him, “It is not a surgical problem, but it is a bad injury. You got lucky.”

After a moment’s reflection I added, “Didn’t that hurt?”

“Kind of,” he laughed, “But it eased up pretty quick.”

“Do you need any pain medication?” I asked.

“Oh, no,” he demurred, “Tylenol is doing fine for it.”

After a few more pleasantries, the man got up, walked out of my office, got in his car and drove back to work. Watching him wince slightly as he turned out of the parking lot, I couldn’t help but think of the patient before him – a fellow with no history of serious injury, a normal MRI of the lumbar spine, and disabling back pain.

The man with the back pain had wanted pain medication. I’d had to talk him out of it, which was a difficult task in that era. Because it was the era before the opioid crisis, when we were in the midst of a pain crisis, according to the medical authorities. Clinicians were directed to take everyone’s pain level the same way that we took their temperature, and to treat the abnormalities discovered by our measurements.

For those with eyes to see, the notion behind pathologizing pain was misguided, at least. The whole scheme rested on the idea that pain was simply activity in the neuronal substrate. Change the activity pattern, by activating opiate receptors, for example, and you get rid of the pain.

I am not being very charitable in my description, but I am being as charitable as I need to be. There are more nuanced depictions, which leaven the mix with talk of psychological context and so on, but the same suppressed premise lurks beneath them all. It is this: a chain of causal events ‘add up’ to pain, and that is just what pain is. X+Y+Z = Pain. But the necessity of such arithmetic has been in doubt even before Hume laid its troubles out so nicely for us Westerners.

Breaking down a phenomenon gives you its pieces, but does not grant commutativity. Activating opiate receptors does not reshape their owner’s pain experience according to a fixed script. Receptor activity is part of the description of a painful experience, along with psychological context, and personal history. Yet there is no prior necessity – necessity by law, rather than necessity in fact. We did not make the distinction.

Secure in our estimation of the relationship between the neuronal substrate and the pain experience, we went after opiate receptors like we go after splinters. Our efforts did not force anyone’s pain experience into a box, but we gave everyone who we treated a new pain experience. Sometimes it suited them better; sometimes it suited them worse. Many, many times it settled in the center of their psyches and they fell into orbit around it.

Our engagement with the epidemic of untreated pain predictably ended in chaos. Now we need to extricate ourselves, and what do we turn to but the tool already in hand.

Instead of the reduction to type, we have rebuilt our story of pain, revising our reduction on the basis of the same mistake. Receptors pertain to behaviors – in the neuronal substrate, and so in the psychology, and so in the organism – but pain is a byproduct of the behavioral mechanism. It is an epiphenomenon. Chronic experiencers need counselling, to convince them that the pain is ineffectual, and therefore not real, at least not in any serious way.

Unfortunately, I get to participate in this second shot at commutative reduction, too. It will go just as well as the first.

 

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Weaponized

There is an interesting post here about jargon. It explores one of the useful aspects of jargon, and as a consumer – indeed a purveyor – of jargon in the medical field, I completely agree. Technical terms give us simple clarity, and simple clarity is one of the most useful things around.

The post focuses on the utility of jargon within its natural environs – dialog between professionals, where it is quite useful as shorthand. As an example from my world, when I say ‘appendicitis’ to someone in the medical field, a fairly specific array of physiologic and anatomic processes comes to mind, along with their likely manifestations, consequences, implications for diagnostic testing and treatment, associated research studies, etc.

The conversation can move right along. Plus by way of its scope, the use of technical terms can serve as a check point in the dialog. If there is a malapropism, it is apparent.

When a colleague says, “The negative ultrasound ruled out appendicitis..”, the conversation must stop. We must clarify why he thinks that the ultrasound ruled out appendicitis, because it is commonly accepted that ultrasound does not, in and of itself, rule out appendicitis. The term ‘appendicitis’ as jargon, contains the understanding of its diagnostic criteria for those in the know.

The situation is different when a patient says, “I think I have appendicitis.”

Typically, the lay person who makes that statement knows little to nothing about appendicitis. The word refers to little if any of the content it carries when I mention it to a surgeon. However, the same process flows from its use, or rather misuse.

The lay person’s usage brings up the question, “Why do you think that you have appendicitis?”

In other words, technical terms provide some solid surfaces in an otherwise squishy conversational world. If we can’t alight upon them, then at least we may bounce off of them in some direction, rather than landing splat in misunderstanding or mere conflict.

The common complaint that jargon is obfuscation doesn’t hold up when we consider the honest usage of technical terms, even outside of their professional environment. There is, however, a dishonest way of deploying jargon.

The current poster-child for such corrupted terminology is ‘mindfulness’. In its original sense, the word referred to a non-reflective state. The idea was: your mind stays fully engaged with what is happening in its scope of awareness, without reaction or abstraction. It was the kind of thing which dart players, test-takers and athletes sought.

Now, though it still gets used to mean engagement with the present, it may also stand for a state of detached self-awareness, in which one is monitoring and regulating one’s responses to one’s present situation. Clearly, the latter meaning is at odds with the former, if only because the latter refers to an essentially reflective activity.  Dishonest users of the term shift back and forth between the meanings depending on the goals of the user’s discourse. If the occasion is a corporate retreat aimed at promoting harmony in the workplace, the second meaning is used. If the speaker wishes to convince the listener that chronic back pain does not require morphine if one simply ceases to reflect upon said pain, then the first meaning of mindfulness is implied.

Clearly, the sort of shenanigans at work when people bat around ‘mindfulness’ are what give jargon a bad name. Mindfulness started out its career innocently enough, as something which Zen practitioners and coaches discussed. But along the way, it picked something up. As something useful, it came to possess an air of desirability. As something desirable, it acquired the reputation of being something good, and then, of being good in itself.

Once imbued with moral character, the technical meaning of mindfulness, along with all associated contents relating to its use, became subsidiary. Being mindful became less important than being a mindful person, and when a moral role presents itself, it is open for definition. The corporate lecturer can tell us what a mindful person does at work. The pain specialist can tell us how a mindful patient takes medicine. The roles make the meaning henceforth.

The situation seems at least a minor victory for the moral expressivists – those who claim that our moral claims are not claims at all but expressions of sentiments like approval and disapproval. It would be a victory too, if the abusers of technical terms were actually making moral statements. But they are not.

When people utilize a bit of jargon with moral character, they are using it as a means to an end. They are weaponizing it. The listener doesn’t receive a sentimental expression from the speaker; the listener is invited to fill in the sentiment. The audience at the corporate retreat must make the connection: a weekly post on the suggestion board means I am mindful, which means I am good. That line of thinking isn’t really moral reasoning; it is a facilitated rationalization.

Jargon as a technical tool is not the problem. Yet, we are right to be wary of jargon. Its use should put us on the lookout for manipulation. But we should not be afraid to use it either.  We must just take care to use it mindfully, by which I mean being critically aware of one’s attitude toward the current subject, which was once known as being an adult. Oops…

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The Harder Problem

I have a purple shirt, or maybe it is royal blue. I was never in doubt about the color until my wife called it blue one day. Up until that point, I never even contemplated calling the shirt blue, or that there might be a difference between my perception of the shirt’s color and her’s.

Maybe there still is not a difference. Maybe our perceptions are the same and the words we use differ unnecessarily. If I look hard, though, I can see how she would call the shirt blue.

Her and my perceptions are almost certainly not the same, nor are anyone’s. The alternative – that people disagree about colors, and so much more, because our language is massively mistaken – seems too incredible. Shouldn’t we have ferreted out even the most minor issues by now? After all, we do so well at finding agreeable words for so many things, even in the realm of aesthetics.

Plus, there is a good explanation for the source of disagreement between me and my wife on my shirt’s color. If one tracks back how each of us learned to classify blue and purple experiences, there are substantial differences. And, those differences do not only effect our use of words; those differences also condition our purple and blue perceptions .

Yet there is another problem lurking. Even if I could magically take a snapshot of my brain at the moment in which I saw the shirt as purple, and show it to my wife, not as a map or photo, but as exactly the same state of affairs imposed upon her neurons, she could still differentiate it upon reflection. The brain state in question would always be her experience of my experience, rather than simply her experience. My experience of the shirt’s color cannot be captured, as mine, by means of physical reproduction.

One might ask, who cares? The upshot of our limitations is tolerable. Big truths may be a little counterfeit by implication, but we are accustomed to working with flawed notions already, and do fine by it. For example, Newtonian mechanics serves us beautifully, even if it is not ‘really true’.

Yet, we do not tolerate our flawed notions. An optimist would say that we are not satisfied with lesser things, and are constantly trying to improve our understanding. Our behavior suggests otherwise, however. We want big truths in principle, and the certainty, the reality, that comes along with them. In physics, we don’t just want quantum mechanics and relativity, we want a theory of everything. In ethics, we want good and evil, and duties to serve.

So, the hard problem does matter, because it is motivating. And, it moves us to a harder problem. We want things to be true which are not merely false, but which are incapable of being true or false. The idea of a concept not being truth-apt is slippery, so an illustration is in order.

Consider the case of Baby K. Baby K was born over two decades ago without a brain. Not only was she(?) born, she pulled off a feat which few anencephalics manage; she lived more than briefly. Or, she maintained a metabolism more than briefly, because her status as a living thing, much less a living human infant, was in question. She would never see a purple shirt, or a blue shirt, or have any experience at all. And since our personal experience is what we value above anything (what choice do we have, after all?) some people felt that a creature without experience and incapable of it was not truly alive, much less human.

Baby K’s mother disagreed. She felt that K was born of a human, exhibited some behaviors, had a heartbeat, and therefore fit into the human peg-hole, albeit imperfectly. K’s remarkable persistence owes to her mother’s insistence on aggressive medical interventions for K, based on K’s status as a human baby. For K’s mother, the rules of classification were categorical. There are Forms in the world, according to this school of thought, and the Forms suck their creatures in, even the most flawed copies.

When Baby K had trouble breathing, her mother took her to the ER and demanded that Baby K be saved, put on a ventilator, and nursed back to health in the ICU. But was health one of K’s capabilities? She needed saving, but for what, and from what? We could not ask K about any of this, ever, even in principle. As her physiology counted down to its end, what was there to distinguish this tick from the following tock, and so provide a basis for valuing more of the physiological process?

When K came in to the ER, the professionals on duty did not want to treat her. Since she was incapable of experience, she had nothing to value (there wasn’t even anyone there to value anything). Efforts to ‘help’ K were therefore empty. There was nothing to help with and no one to accept the helpful gesture.

Remarkably, some argued that further medical interventions merely prolonged K’s suffering. Perhaps they meant to say that further interventions caused the staff to suffer. More properly, futile actions degraded the integrity of the medical professions. We become what we practice, and if the medical professionals practiced service to the beating heart, then they rightfully feared that they would become servants to the beating heart.

The hospital also expressed concerns about the resources that K consumed. This argument was a utilitarian argument and failed in the usual fashion. If K did not occupy the ICU bed, the bed would not move to an under-served area, nor would the unexpended cost of K’s breathing tubes and procedures be converted into mosquito nets for children in malaria-afflicted territories. Values are not generally translatable, any more than their costs are portable.

But the missing cipher in the professionals’ calculation was K’s value to her mother. Someone did experience K’s physiology after all. To waive K’s value on that account was just as degrading as crass service to the beating heart. If the medical professions seek to serve health, and health is function, then the milieu is everything. It was a mistake to consider K’s value on the basis of K’s intrinsic capacity for experience, just as much as it was a mistake to think that the ventilator was saving K herself from or for anything. However mistaken she was about Forms and their efficacy, K’s mother valued K’s beating heart in a consistent way. Harm would come to the mother from K’s heart stopping. It would be the same sort of harm – loss of experience and the possibility of experience – to which the professionals referred in their assessment of K’s lack of value.

All along, the players in the Baby K saga evaluated her with standards that did not apply – that were not truth-apt. It was never the case that Baby K was human or not, alive or not. Her case nicely demonstrates the nature of the harder problem. Our standards – good, evil, human, matter, energy, mine, yours, blue, purple – are not stand-alone things. They are made of their circumstances (our circumstances). Without a doubt, the standards serve us well, since our circumstances are necessarily shared. If the standards refer to the specifics, and the specifics are near enough alike, it’s just good fudging to defer to the standards. It is easy to forget that the standards defer to their instances. And we are motivated to forget, because we value our experience and we value our standards, and we are prone to equate the two.

 

 

 

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They Solved It! They Solved It!

Geriatricians have solved the hard problem of consciousness! From the July 1st issue of American Family Physician: “Some validated scales, such as Pain Assessment in Advanced Dementia…use objective measures to assess pain intensity and response to intervention.” The objective measures: abnormal breathing pattern, increased vocalizations, observed tension in the face and body, and capacity to be calmed by caregiver voice and touch. In short, agitation is synonymous with pain. And how do we know this? Because the researchers have observed that opiates attenuated agitation in their subjects with advanced dementia. That’s how the scale and its underlying assumptions were validated at once.
Many have questioned the utility of philosophy. Well, here it is. The PAINAD scale is valid, no doubt. This is something that can be determined by definition. If two different people observe the same demented patient, it is quite likely, predictably likely, that the observers will come up with the same score on the scale. But that begs the question. The real problem is not coherence. Coherence does not make truth. The real problem is the truth of the claim that agitation represents pain in a person with advanced dementia. Such information is not available to us, at least not in the defined, quantifiable way which we would prefer.
We can’t know anybody’s pain, really. That’s because it is everybody’s pain that gives us the concept of pain in the first place. The sensation I experience when I grab an electric fence, for instance supervenes on the action of the fence charger, the conductivity of my body and the ground, activation of peripheral nocioceptors, mediation by inter-neurons in my spinal cord, and finally my thalamus and cortex where it is contextualized as my very own experience of shock. My experience of the shock from the fence, indeed all my pain experience, is unique. In the case of a shock from the electric fence, my experience is trivially unique – to the extent that I can predict my friend’s response if I tell him why he shouldn’t touch the fence. But the pain-concept supervenes on all those unique experiences in the same way that my own experience supervenes on the collection of events surrounding my hand’s contact with the wire. A thing called pain doesn’t appear out of the process. If that were so, I should have ready access to it and the PAINAD scale would be unnecessary. I would just slap some electrodes on the patient’s skull and watch for the pain signature in his cortical electrical activity. But I can’t, nor will I in the future, though I might have such a tool. Cortical electrical patterns might be the narrow point in the pain experience, the place where the difference in my experience and the patient’s is most trivial. But I must still correlate the activity with some report from the individual or a set of individuals in a similar condition. Some kind of PAINAD-type analogy will always be the best that I can do.
So what does this application of philosophy to pain treatment tell me? What use is philosophy? First, it tells me that I should not expect to fix everyone’s, or anyone’s, pain by stimulating their opiate receptors. The experience becomes pain-type only when it is put in context. We can easily imagine pain experiences where the opiate receptors play a very different role. Take the poet’s description of the pain of a broken heart. Do we write off his report entirely as a quaint analogy as opposed to our serious ones? If so, how is his report effective in communicating a sense of the experience to us? What do we say when we find out that he used laudanum and found some partial relief? Addressing the mechanisms of pain can only go so far, because mechanisms only go so far in explaining the painfulness of an experience.
The application of philosophy to pain can save me from a different pragmatist’s mistake in treating pain as well. I’ll pick on my surgical colleagues for a moment. On multiple occasions, I’ve had a surgeon tell me, “Nobody ever died from pain.” Inevitably, this little bubble of wisdom surfaces in reference to a patient whose pain management has passed from the surgeon to myself. My knee-jerk response is to point out that nobody ever died from hip arthritis either, but surgeons are still quite happy to replace hip joints. Yet I understand the pragmatic meaning of the statement: people have died from opiate overdoses, so we can’t just capitulate to a person’s demands for ever-increasing doses of opiates to treat their pain. As noted above, the notion that simply stimulating opiate receptors necessarily fixes pain is misguided. But there is a subtext. Death is measurable. Respiratory suppression due to opiates does something, and therefore it is real in way in which pain is not. When you get right down to it, pain can be ignored. But it isn’t that easy. The human condition won’t be ignored anymore than it will be medicated. The hard problem remains hard. It isn’t hard because our subjectivity is some spooky ectoplasm or narcissistic property. It isn’t hard because our experiences will never move a dial or tip a scale. It is hard because things which explain and are explained have a reality to them as much as things which do something, yet we’re stuck working with the functional things, like the observed behaviors in the PAINAD scale. So we have a tightrope to walk. We can only ever come close to helping others with problems like pain, and only then if we act comprehensively. We can never completely succeed. But that doesn’t mean we must fail. We can just never get too sure of ourselves when we do something like suppress a demented patient’s agitation with an opiate – and think we can call it good.

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Can You Keep It Real?

On a cold morning, a little girl named Suzy is waiting for the School Bus at the bottom of a steep hill. It was raining the night before, and water has been flowing next to the curb. The water froze in the early hours of the morning, forming a sheet of black ice. The ice sheet extends all the way down to Suzy, and unfortunately for her, passes under the tires of a Cadillac Coupe DeVille parked in the middle of the hill. As the sun hits the hill, the ice loses its grip on the tires and the car slides silently and rapidly down the hill, striking Suzy and killing her instantly.
Now suppose the same chain of events ensues, except this time, the car breaks loose just as the cars owner, Andy, sits down in the driver’s seat and closes the door. The inside door handle is broken, so he can’t just jump back out again. The power windows are up and the horn doesn’t work, so he has no way to warn Suzy of her impending doom. He desperately turns the wheel, but it’s too slick for the tires to grab. Suzy dies just as in scenario #1.
Again, suppose the circumstances are the same, but this time, the owner of the car is different. Let’s call him Brian. When Brian realizes that he is sliding out of control, he thinks, “You know, I’ve always hated that little bitch anyway,” and he turns the wheel to direct the car toward little Suzy. Again, the tires have no purchase on the ice and the chain of events is unaltered.
Is there a moral distinction in the incident between the unoccupied car and the occupied car? Between the incident with Andy and the incident with Brian? If so, where is the independent and objective moral fact in each case?
To take things a little further, suppose Suzy doesn’t die. After the car launches her through the air, she manages to stick a perfect landing in the grassy median, apparently uninjured. But Suzy’s parents soon notice that something is amiss. When they ask her, “Did you enjoy your dinner dear?” she replies, “The meal was such that it would produce an enjoyable sensation in a person so disposed.”
When they ask her, “Are you comfortable dear?” she answers, “My condition is such that a person capable of it would feel cold.” Suzy appears completely impassive throughout. She eats, sleeps, and goes to school just like she did before the accident. A full medical workup turns up nothing. Gradually, Suzy’s parents stop feeding her anything fancy. She does not complain. They dress her in a burlap shift every day. She’s apparently fine with it. They turn off the heat in her room and only crank the thermostat back up if she begins shivering. They say they still love Suzy; the extras just don’t matter anymore.
Are Suzy’s parents behaving immorally? What is Suzy’s moral status and why?
Let’s go one step further. Suppose Suzy lands in a heap, but survives. She is apparently comatose. Her doctors think that they can help though. They begin an infusion of medication that will awaken her. As the medication flows into her vein, she bolts upright with a look of horror.
“What have you done?” she demands, “Put me back. I’ve been grown for years, I have children of my own and they need me.”
What should Suzy’s parents do? Does Suzy’s inner world have any value? If so, why? If not, why?

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The Chthonic

It had a periodicity to it, but not like anything man-made. Instead, it was like a geyser. As it rose to the surface it swirled chaotically around hidden shelves and side-channels, so its interval was uneven. The uncertainty contributed to our tension, the nephew’s most of all.
“Yeeeeeeeeeee!” she screeched, then closed her mouth and relaxed again.
Between screams, she looked as peaceful as a Buddha. Perhaps, her caretakers speculated, the discomfort of prolonged immobility or some occult infirmity drove the screaming. We had given her increasing doses of pain medication, to no avail. Perhaps she somehow had enough consciousness remaining to experience the dislocation of facing the present without access to the immediate past, not knowing moment to moment how she got in the bed, why she felt like she did, whose arm lay at her side, whose mouth was screaming. We had given her anxiolytics and she just kept screaming. Perhaps she was bedeviled by visions. We gave her our best potions against inner demons and her timing did not falter.
“This is Hell,” said the nephew, “She is in Hell. I want this to stop.”
She had chosen well, or someone had. Sometimes, the decision about who would oversee the death defaulted to hereditary proximity, geographic factors, and availability. This nephew had some connection to her beyond practicality. Of course, he spoke for himself. No one knew what her vocalizations signified. We had taken our best guesses and come up short. What he wanted now was not a treatment. He wanted a cure for it all. To be clear, it was not euthanasia he was requesting. He wanted us to ablate whatever remained of her consciousness. He wanted oblivion, or at least its appearance.
It wasn’t killing, but it was taking something away from someone who appeared to have so little. We were always wary of treating extrinsic things, of giving medications to fix a person’s bad relationships or discomfort with herself. It was different for the dying though.
Everything was becoming extrinsic for her. She couldn’t be crying out for something. That time had passed. At best, her screams expressed something which we could not know, but something which was less specific, less relevant to anything inside, as she came closer to death.
He was right. The screams meant what he said: this is Hell; I want this to stop. I had an obligation to her and no choice in the matter. Of course he spoke for himself.
“I will do as you wish,” I said.

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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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The Word from the Land of Absolute Relativism

“Look at all this shit!”
He waved the stack of envelopes at me.
“Look at this one.”
He held up the letter on top. It was from another hospital and marked, ‘Important: Do Not Discard’.
“These are the ones you have to be careful to discard.”
He threw it in the wastebasket, and followed it with the rest of the unexamined mail. I was far enough into my training not to be shocked by this sort of thing. I’d weathered surgeon’s tirades and soaked up jaded, callous humor in the emergency room. Still, my experience with this psychiatrist had me believing for years afterwards that, in his specialty, like sought like.
“This kind of clutter is the enemy,” he continued, opening the top drawer in his desk.
He scooped out a handful of keys.
“Look at these! I don’t know what this is for,” he said, holding up a sturdy door key. Into the bin it went.
He tossed a few more, then dumped the remainder back in the drawer with an expression of disgust.
“We’ve wasted enough time,” he declared, “better show me the case.”
I handed him the chart, with my history on top. He lingered on the assessment at the bottom of the page. Residents sometimes began to sweat when attending physicians paused too long in their documentation review. I did not in this case, because the assessment was not mine in the first place; the patient brought her diagnosis with her from the last admission. He grunted and moved on to the ancillary notes, containing the comments from psychiatric nurses who had evaluated the patient.
“Jesus Christ! Did you read this?”
Now I began to sweat. I hadn’t read the nurse’s notes. He handed me the chart with a shake of his head. I’d gotten lucky; the question was rhetorical. Curiosity displaced my anxiety and I began to read with interest. Immediately, I realized what he was on about.
At the bottom of the page, several of the nurses (a cabal?) postulated that dark forces were at work in the patient’s life. The assessment dwelt upon the young lady’s practice of witchcraft, not as an expression of alienation in a personality dangerously adrift, but as an activity with sinister efficacy. I looked up at him as I finished reading.
“How can we hope to do anything for the patients when we’re up against this kind of stupidity from the staff? Borderline,” he stated, returning to my assessment, “Do you really believe that?”
I shrugged. She had the black nail-polish sign, which every trainee knew was pathognomonic for borderline personality disorder.
“There are some people that fit the bill, but mostly the term is an epithet applied to people who we don’t like because they are frustrating. It’s the DSM used as a cudgel, and it justifies our bringing these people into the institution when their community becomes too frustrated with their behaviors. They come in for a few days or a few weeks until they’ve cooled off, then they go back out with the same problems, to the same problems. So this kind of inpatient treatment is like firing into the tree line: it’s good for keeping the enemy’s head down, but it’s not good for hitting anything.”
His words were familiar in structure and reference. At home that evening, I poured through my memory and my boxes of books, and I eventually placed them. They recalled an image from Heart of Darkness.

Once, I remember, we came upon a man-of-war anchored off the coast. There wasn’t even a shed there, and she was shelling the bush. It appears the French had one of their wars going on thereabouts. Her ensign dropped limp like a rag; the muzzles of the long six-inch guns stuck out all over the low hull; the greasy, slimy swell swung her up lazily and let her down, swaying her thin masts. In the empty immensity of earth, sky and water, there she was, incomprehensible, firing into a continent. Pop, would go one of the six-inch guns; a small flame would dart and vanish, a little white smoke would disappear, a tiny projectile would give a feeble screech – and nothing happened. Nothing could happen. There was a touch of insanity in the proceeding, a sense of lugubrious drollery in the sight; and it was not dissipated by somebody on board assuring me earnestly there was a camp of natives – he called them enemies! – hidden out of sight somewhere.

The image stuck and grew stronger over the years until I ceased to see my preceptor as chief among madmen and came to see him as Marlow on the boat. He was the lone relativist in a wilderness of absolutists who considered borderline personality more than a label on a charge sheet (it is that at least, for the Diagnostic and Statistical Manual which codified the term is a tool intended to itemize mental illness for billing). For his fellow wardens of the institution, there existed a borderline personality fact about certain people, caused by borderline personality pathologies and amenable, potentially, to borderline personality treatments. He saw them firing into a continent. He did not, of course, live in the land of absolute relativism, where everything is an onion made of layer upon layer of motives and relations with no pertinent core. He believed in borderline personality as a country over yonder. It recognized certain commonalities, but those commonalities arose in the villages. They accrued; they did not come down from on high.
He cared about how seriously the nurses, psychologists and patients took diagnoses, not because relativism was true. He cared because absolutes did not obtain. Worse, absolutes destroyed. On occasion, bullets fired into the tree line did hit something, and that something was an enemy by definition. Over his career, he’d seen victory declared over schizophrenia and the state institutions emptied onto the street. He’d seen the profession take a pass on intractable diagnoses, like personality disorders. He’d heard from his predecessors about neurosurgical solutions considered quite successful in their time. It wasn’t that relativism was true, it was just that truth didn’t work that way. It wasn’t diagnosis-friendly, and the truth about psychology all the less so.

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Chaos Theory

The last several centuries have seen the rise of a perverse vision of morality. Going by various aliases this modern moral concept tells us that moral terms refer to something other than good and evil. Instead, the adherents of this viewpoint would ask us to believe that good and evil are mere descriptions, applicable to fashion choices as much as acts of benevolence or depravity. But the modern viewpoint is a lie. Descriptions have no power. They cannot motivate us to do anything. Of course, one suspects that the agenda driving our modern metamorphosis aims at a world where morality is not motivating. With moral focus dimmed, people can be motivated by those things which bring them pleasure and worldly profit. However, the agenda merely trades upon the normalizing effect of objective morality. We could not live as we do by following the path of moral relativism in real life.
Without objective moral terms, chaos would ensue. We do not have chaos, because moral terms refer to real things. Consider the alternative. If good and bad only operate within local frames of reference, we have a cascade of conflicting claims. Sometimes an act is good, sometimes bad. Sometimes an arrangement between individuals is evil, sometimes it is not. We cannot know which is which on the face of it. The authority of moral adjectives saves us from this fate. We need that authority to explain ourselves, and without it, we haven’t the motive power and clarity demanded by the moral challenges we face.
For example, walking among us is a small class of persons without remorse. They have no aversion to murder, and so require a reason outside themselves to condemn killing other people for any reason at all. Without objective moral terms, we have little to tell the psychopath. We can waffle about relationships and ties that bind, hoping to lash the psychopath to us with weak logic referring to dependencies. But what’s to stop him from replying in our own terms, like a serial-killing Popeye, “I am what I am and that’s right for me.”?
With objective moral terms at our disposal, we may respond with authority. “Murder is evil,” we may say, “and evil must be opposed.” A good moral concept is not just explanatory. A good moral concept tells us that we ought to do something, not just why we should think something is preferable. A good moral concept is solid, not riddled with re-words to the point of hollowness.
The moral troubles of the world require something with heft. Consider an even more difficult problem than individuals prone to violence: organized violence. Sadly, war is a fact of life. Our morality must confront it with an obligation powerful enough to justify such a monstrous activity . We can’t reasonably bomb the citizens of Dresden or Hiroshima and say to them or ourselves, “It is inconsistent with your identity as a human being that your group destroy other humans – the very source of that identity. Therefore you must die.”
We must provide a proper justification. We must say, “You have proven yourselves a proper medium for the perpetuation of evil. That is what we are bombing. Your deaths are regrettable, but that’s the best we can do and we are obligated to do our best when it comes to opposing evil.”
We cannot escape the reality of our moral terms, nor should we try. They are bound to catch us, because they do carry the obligations which we see at work in a just war. Nothing demonstrates our situation in that regard better than the way we deal with animals which kill humans.
If a bear kills a child, we execute the bear. We don’t kill the bear for any qualities relative to its bearishness, i.e. being a carnivore, needing to fatten up for hibernation, having an instinct to protect its young. We don’t care about the bear’s reasons; we care about the act. It has destroyed something invaluable. It has shown itself a creature with evil in its nature, and so must die. We are not angry at the bear. This is not revenge. This is justice.
Objective moral entities will finally allow no re-words at all. No relative merits, relations, revenge or reconsideration apply. Nor does scale. Absolutes do not mind scale. Evil is evil, and must be expurgated. What differentiates big evils from little ones is the ease with which they may be expurgated, not the strength of their demand on us.
The analysis at hand extends even to the smallest evils. Every year, 11,000 invaluable human lives are lost to infection with the bacterium Staphylococcus Aureus. We execute these tiny monsters with antibiotics. For the microbes which succumb, that’s the end of it, they have proven themselves minor evils and our obligation has been concomitant. But some do not succumb. Some of the bacteria are resistant to our antibiotics. In the case of the resistant bacteria, our duties are more complicated.
The bacteria in question, the resistant and the susceptible, live in people’s noses. The carriers of these bacteria are therefore complicit in the mediation of the evil which Staph. Aureus perpetrates. We may start by treating the carriers’ complicity as a minor evil and employ appropriate methods. We inform the carriers of their status and offer them the chance to eradicate the evil in their noses. History tells us that some of them will be unsuccessful. In those cases, a greater evil confronts us. The bacteria are persistent because they are resistant and so are better able to kill. As accomplices, we may treat the sub-group of carriers more leniently, though we are obligated to deal with the associated evil. These people have the choice of exile or suicide. These options neatly close the circle of obligation, but that’s not the important thing. What matters is that we have answered to our obligation. We have successfully solved the moral calculus and maximized human thriving. We can answer the carriers as we can answer the citizens of Dresden or Hiroshima. Your excision is regrettable, but that’s the best we can do, and we are obliged to do our best when it comes to opposing evil.

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There’s a Pill for That

While waiting for labs with me in the ER yesterday, a younger colleague made an offhand comment about quitting medicine. She felt frustrated because, instead of helping people get over their health problems and get on with their business, she spent her time treating public health problems in the clinic and emergency room. Even worse, she had begun to feel complicit in the distortion. I didn’t know whether to offer congratulations, condolences, or both. Most medical professionals never get that far. They continue to feel good about encouraging dialysis for blind, depressed diabetics with one remaining limb and prescribing cholesterol-lowering medication to nonagenarians. Thereby, only the superficial dissatisfactions of their jobs remain.

I don’t think that doctors should feel guilty about the public health problems confronting them in clinics. Nobody planned for our society to fail us. We spent so much of our history working so hard to make life easier and more certain that we just didn’t notice when we started working harder and harder to make life easier than we needed. The illusion of increasing certainty helped us zoom past the point of diminishing returns. Once enough surplus accumulated to ensure against starvation, twice the surplus seemed to offer twice the insurance against shortage, but the excess would only mold and spoil the lot. Our surplus is spoiling in us now, clogging our blood vessels and glycosylating our nerve fibers.

A solution to the problem lies beyond the scope of clinical medicine. The only solution may be time and economic dissolution. The furor over limiting soft-drink sizes in New York City does not bode well for self-conscious alternatives. But medical professionals can feel bad about their complicity in the whole scheme, because our business is to tell people that there’s a pill for all that.

We tell the public that we can “treat” and “manage” diabetes, coronary artery disease and heart failure. The proper terms would be “attenuate” and “temporize”. The proper terms would imply a lack of control however, and a sense of control is what we’re selling as much as medication or surgery. We keep the illusion of control on offer in the name of comfort. We want our patients to feel free from anxiety about their health. They should feel empowered, and they do, which is good since they will still be physically ill under treatment, just a bit less so than when they consulted us.

I guess there really is a pill for surplus-mold, at least on a psychological level, but it will cost those who take it a lot of money, and the motive to seek out the roots of their ailment. Besides, it will keep the doctors feeling good about something they shouldn’t be doing. It may appear to buy some time, but it won’t cure anything.