On Medicine and Morality

2018-01-20

I recently went to see the doctor for a routine checkup. It had been a while since I'd gone in, so they had to update all of my medical information and set me up with a new doctor. I guess the best word to describe my new doctor would be "friendly." Friendliness is a good trait for a doctor to have; after all, they have to deal with real people who expect to be cared for, and friendliness is sort of like caring. Sort of.

During my appointment, the doctor asked a series of questions about my lifestyle. I told him proudly that I'd been lifting weights and gaining muscle, that I had gained an impressive sixty pounds over the course of a year, that I'd competed in a weightlifting meet and had actually done pretty well considering how new I am to the sport. I told him that I felt healthier than I ever had before. He gave me a [friendly] smile and told me politely that I needed to lose weight, and that I was, in fact, overweight.

I was a bit puzzled because it seemed like he wasn't hearing me or acknowledging the accomplishment that accompanied my weight gain. He had never met me before, so I suppose he didn't understand that I had never in my life been as "in shape" as I was sitting there across from him. He must have thought I was one of those people who are in denial about their conditions, I reasoned. I continued to explain myself, this time a bit defensively. I told him:

  1. The BMI estimate, calculated from height and weight, was probably not taking into consideration the muscle mass I'd gained,
  2. I had put much effort into gaining the weight intentionally and according to a fairly long-term plan to facilitate my strength gains and overall health,
  3. The quality of the foods in my diet had improved considerably since I'd begun my training, and
  4. As my training continued to progress I would lose some body fat as a natural consequence of my increasing workload.
The friendly doctor, however, didn't concede my position. He insisted that, because my estimated BMI fell into the "overweight" range (as decreed by the National Institute of Health), it was important that I take steps to shed excess weight, lest I become more unhealthy than I already was. A testament to my poor health was that a few weeks prior to my appointment I had deadlifted more than double my body weight. His entire [friendly] argument hinged on the prescribed notion that my health could be understood accurately in matching estimated numbers to a standardized model constructed by a distant committee.

I remember, as a kid, being awed by doctors and psychologists--people who could "figure us out" by gathering information about our bodies and our minds. In the early 90s, this perception may have in fact been true of some doctors, like my wonderful pediatrician Dr. Olsen. But it feels like we're in a different era now; an era marked by overwhelming strain on doctors and a consequent rush and lack of individual attention to the patient. As a child I expected that in order to understand my physical body, doctors would take the time to understand me, and the result would be a focused and accurate evaluation of my health. As an adult, I realize that medicine has become systematized and homogenized to such an extreme that a doctor, though he sits face-to-face with his patient in a closed room, is incapable of understanding what his patient is saying, because the loud command of a greater medical authority floods the space in the form of universal standards and recommendations. The doctor is the expert, of course, so unless the patient is also a doctor, he must be a clueless fool, incapable of making any sense of his own body or experience of reality.

"I sometimes annoyed the group, I think, by saying that we should also discuss the writings of our nineteenth-century forebears, relating what we were seeing in patients to their observations and thoughts. This was seen by the others as archaism; we were short of time, and we had better things to do than consider such “obsolete” matters. This attitude was reflected, implicitly, in many of the journal articles we read; they made little reference to anything more than five years old. It was as if neurology had no history.

- Oliver Sacks, On The Move

I recently encountered some novel perspectives on medicine while reading a book by famed neurologist, author, and overall interesting character Oliver Sacks. In his autobiographical book On The Move, Sacks describes the frustration he felt as a medical student when his peers rejected the notion that "old" medical texts could have any contemporary value. They favored, understandably, studies which were more methodologically rigorous, more replicable, and generally more current. Sacks, on the other hand, wasn't so ready to turn his back on his scientific ancestors, even if their eras were marked by practices now considered at best archaic and at worst barbaric. Sacks seemed to be drawn to scientific and medical thinkers who were also good writers, and who always kept one eye fixed on humanity; such medical thinkers seemed to never forget that each unique bundle of signs and symptoms must be heard in concert with the life of the individual experiencing them.

One such remnant of medical history for Sacks was his own father, a doctor trusted and respected by his community, a man who saw his patients as individuals with unique circumstances. Sacks gives some insight into his father's approach to medicine, explaining, "There were families he had treated for several generations, and he sometimes startled a young patient by saying, 'Your great-grandfather had a very similar problem in 1919.' He knew the human, the inward side of his patients no less than their bodies and felt he could not treat one without the other. (Indeed, it was often remarked that he knew the insides of his patients’ refrigerators as well as the insides of their bodies.)" The loss of such approaches to medicine mark not only a loss of opportunity today, but a loss of potentially relevant historical context for future generations. Sacks was able to pick up and perpetuate threads of medical practice that had been in place for generations before him, but he was also an oddball and practically an outcast. How many future doctors will be inclined (certainly not encouraged) to see their own medical perspectives as part of an historical conversation, perpetuating and contributing not only to the current state of public health, but to an ancient and ongoing field of practice?

Although doctors today seem mainly to engage their patients systematically and from a distance, I think a renaissance of doctor-patient relationships is still possible. In any field of knowledge, stagnation occurs when people stop asking questions, cease to be curious, and come to see themselves as unmoveable obelisks with the word "expert" carved into their surfaces. It's one thing to have earned authority in a field by persistent dedication to the questions that demarcate its boundaries, but it's another thing entirely to equate such authority with infallibility, to assume that education is over the moment a degree has been bestowed or a residency completed, and to arrogantly refuse to believe that those pesky simpletons and laypeople might actually have valuable insights of their own. Sacks himself kept always a spirit of inquiry--a sense that each person he encountered had something to teach him--and he maintained this spirit until his death in 2015. This approach to medicine allowed him unparalleled insight into his patients' conditions, and he made significant contributions to his field and to the lives of his patients. Of course, like everyone else, Sacks learned this approach from his predecessors. In addition to his own father, Sacks cites A.R. Luria as a clinical role-model. Of Luria, Sacks says, "...he combined powers of observation, theoretical depth, and human warmth in a way which I thought revelatory," that Luria "believed his richly human case histories were no less important than his great neuropsychological treatises," and that one of Luria's aims was "to combine the classical and the romantic, science and storytelling." Luria's perspectives on medicine may be acceptable if we see him as a relic from a time when medicine was mostly superstition, hearsay, and guesswork, but it's hard to imagine taking seriously a modern-day doctor whose professional aims include romanticism and storytelling.

Perhaps we have come to expect and maybe even appreciate a certain cold indifference from our physicians. Science, after all, is concerned with the facts, and the facts care nothing for how you or I might feel about them. When it comes to the facts, I want my doctor to give them to me clearly, honestly, and without hesitation. But facts are not just those pieces of life connected to numbers, and in any profession where one must deal with other humans and their unique considerations, facts are only half of the equation. The other half is the realm of human morality. Facts alone mean nothing--it's the meaning and interpretation of those facts that guides our actions in the world. It's the physician's job to administer diagnostics and tests to get the facts, and then to advise the patient on a reasonable course of action based on those facts and the unique circumstances of the patient. Such advising can only be done well if the doctor makes an effort to understand the patient and his or her situation. As long as we continue to ignore science's admittedly blurry moral component, or to replace individual opportunities for moral action with committee mandates, we condemn ourselves to a necessarily inferior science of medicine--one whose practical application in our lives is characterized not by open-minded dialogue, respect, and what's best for the patient, but by undifferentiated "care", expediency, and authoritative decree.