|Science, Hegemony and Violence (UNU, 1988, 301 p.)|
|5. Violence in modern medicine|
MANU L. KOTHARI
LOPA A. MEHTA
I. A paradox?
The popular image of a doctor is of an angel in a white coat. Few are able or willing to perceive the reality behind the image and the violence which today is inseparable from modern medical science. This violence is not limited to human beings; it extends to the environment, to animals, to the fiscal fortunes of a person or a society.
Violence as a Term
The root of the words 'violence' and 'violate' is the Latin vim, which is related to the Sanskrit vyas (he goes). The term implies interference that smacks of righteousness, thoughtlessness or willed ignorance. But violence is also transgression of what Einstein called self-evident truth. The perception of such truth does not seem to be a function of 'development', as the tragic experience of the last 200 years shows. Learnedness, industrialization and modern media - indeed, the more we have of these 'achievements', the less we perceive the self-evident truth that 'progress' and violence go hand in hand. With 'progress', more and more leaves are suffocated with grime, deforestation spreads, more fish die and more whales get harpooned, and the balance, the regenerative capacity of nature, is irreparably damaged.
Psychodynamics of Medical Violence
Medical violence is a curious product of the physician's arrogance, trappings of technique, and the laity's love of the fanciful coupled with an undying hope that, given enough money, there is no physical or mental problem that some Cooley or Barnard cannot solve. The ethos has been piquantly summed up by Burnet:
One might justly summarize American medicine (and all those who reverently follow the American lead) as being based on the maxim that what can cure a disease condition (assumed, simulated or natural) in a mouse or a dog can with the right expenditure of money, effort and intelligence, be applied to human medicine.1
The quote exposes the man-centred temper of modern medical science. It strives to achieve something for man, against man's disease and man's death. The outcome is that the USA, the UK and India increase their spending to the point of bankruptcy and get less and less of health. The Rockefeller Foundation summarized the current predicament in a book titled Doing Better and Feeling Worse - Health in USA.2 In the midst of the ever-widening gulf between medicine's promise and performance, most people - including doctors and patients - have lost sight of a self-evident fact, namely that the way to iatrogenic (doctor-made) hell is paved with professedly good therapeutic intentions. The only way out of this mess is, as Ivan Illich suggests, for the laity, the patient, to wake up to the realities effectively kept away from them by the medical profession.
L. Dossey, himself a physician, has bemoaned 'the philosophic backwardness in contemporary medicine', even though any allusion to the word 'philosophy' in the context of modern medicine is a red rag to the medical bull.3 Medical men dismiss philosophy as incompatible with scientific medicine. Thus, thirteen years ago, a book on cancer, scientifically documented and annotated, was condemned as mere philosophy.4 During these thirteen years, the only comment the book has elicited from the cancerology establishment, both local and global, is that the book is 'philosophical'. The data in the book have not been questioned; the reasoning has not been found faulty. For establishment cancerologists, the book is philosophy and therefore not worth serious consideration. 'Philosophy', evidently, is not used in the lexicographical sense; it is a pejorative term tagged on to anything the establishment disapproves of - even dissent within the community itself.
Cancerology's obsessive resistance to philosophy has made the discipline, in the words of biologist J. B. Watson, 'scientifically bankrupt, therapeutically ineffective and wasteful'.5 A panel appointed by the national Cancer Advisory Board, USA, has found that highly reputed scientists could deviate from accepted standards of integrity when tempted to bolster their theorems and prejudices with huge sums of the public's money, and an American scientist has advised other scientists: 'Stay out of cancer research because it's full of money and just about out of science.'6
The heartlessness of modern medicine can be directly traced to its calculated myopia. 'I am absolutely convinced', says Victor Frankl, 'that the gas chambers of Auschwitz, Treblinka, and Maidanek were ultimately prepared not in some Ministry or other in Berlin, but rather in the lecture halls of nihilistic scientists.'7 Hence the mythology reflected in movies like Coma; hence, the recurrent reality in India where surgeons merrily transplant kidneys from the desperately poor into paying patients. It is not uncommon in such transplants for the donor to get Rs 30,000 while the agent makes Rs 50,000 When we questioned the anaesthetist of a kidney transplant team about this, his reply was scientific: 'We are happy if the donor has been clinically and psychiatrically investigated, and rendered ready by the agent.' A recent review of kidney transplants in the The New England Journal of Medicine concluded that the ease with which a kidney transplant was done lacked any scientific basis, and medicine did not have answers to the problems the transplant created for its new host.8 We must thank providence that Christian Barnard failed in his much publicized brain transplant and that a heart transplant is not yet available commercially.
Solzhenitsyn has shown in Cancer Ward that the best way of dehumanizing a doctor is to look up to him as scientific. In the west, the popular and the professional media persist in portraying all diseases in paranoic terms - 'This disease is killer number one', 'that disease is killer number n' - while claiming in the same breath tremendous advances made by medical science in its battle against all medical problems. The result is that the doctor sees neither the disease nor the patient. All he sees is some enemy that must be destroyed at all costs. And since no killer disease - cancer, heart attack, hypertension, diabetes - has yet yielded to their ministrations, all that happens is that the frustrated physician wrecks his vengeance on disease and death, with the patient as the battlefield.
Some surveys of the medical scene in the 1980s give a fair idea of what modern medicine is, and will be, all about. To quote D. Horrobin,
Lay organizations, whether charities or governments, do not fund medical research for the sake of culture. They believe that practical benefits will follow. It is gradually dawning on the donors that for the past 20 years practical benefits have not followed. During that time there have been no substantial improvements in morbidity or mortality from major diseases that can be attributed to public funding of medical research.9
A. Relman, editor of The New England Journal of Medicine, comments: 'We have learned how to keep alive very old, sick, and feeble - even brain-dead - people as well as infants born terribly deformed.'10 And a journalist has recently echoed Relman. 'I do know', he says, 'that the miracles of modern medicine can prolong life far beyond the point at which it has meaning.'11
Science in this respect has let down modern medicine. Apparently their continuing partnership is a marriage that has soured. Yet the purveyors of modern medicine have a vested interest in the partnership, for it endows them with an invincible halo of propriety and philanthropy. It has allowed the modern medical student, teacher, practitioner, and researcher to completely ignore the fact that most human diseases and death are not only beyond science but also beyond technique - extant, evolving or envisaged.
The mindless craze for gadgets and chemicals leads medical men to create a modern medical police state where symptoms are suppressed and signs are erased. When a child has upper respiratory infection, the body enters into a dialogue with the microbes under an optimal thermal state. But this is deemed as 'fever' by the doctor. Drugs are given to bring down the fever, and antibiotics are administered to knock the microbes out. A peace talk is thus aborted, the child acquires lifelong immuno-deficiency and his natural growing-up is thwarted. Commenting on this common scenario, the English microbiologist J. A. Raeburn has prophesied, 'In years to come, the story of antibiotics may rank as Nature's most malicious trick.'12
A healthy adult is sent for a 'regular medical check-up', considered a business venture in medical circles, and walks out a depressed, harried patient. The reason may be that the doctor has detected a sign as yet nowhere defined but called high blood pressure. What had not bothered the patient ever must now be annihilated to ease the scientific conscience of the doctor. There is no field of medicine in which this police-state approach does not pose a physical, mental, and fiscal hazard for the patient.
The patchwork nature of such doctoring, and the hazards it poses, can be guessed from a recent medical tragedy. In an editorial in The Lancet of 29 January 1983, the story of the benoxaprofen (Opren) was reviewed in the wake of allegations in the media that approximately 60 avoidable deaths had occurred in Britain as a result of an 'unscrupulous pharmaceutical firm, feeble watchdogs and gullible doctors'. The firm had promoted benoxaprofen with the willing collaboration of the media that later turned critical of the drug.13 The verdict was updated by The Lancet in 1984 under the heading 'The Seven Pillars of Foolishness', describing how the practice of medicine had caused the death of patients worldwide, thanks to seven suppressive 'cousins' called anti-arthritic drugs, promoted through collusion between doctors, media, government bodies, bribery and corruption.14 Such tragedies will continue to occur till mankind wakes up to the realization that modern medicine has not and cannot live up to its claims.
If scientism accounts for the violence done to man by medical men, anthropocentrism promotes the violence done to animals. The medical student is brought up on a regime of the dissected frog in the physiology lab; of the experimented-upon dog, killed and dumped into a bucket in the pharmacology department; of the caged monkey, manipulated and tortured in the psychiatry lab. At medical science conferences, papers written with the blood of tens of thousands of experimental animals are deliberated upon. The FDA does not object to poison being administered to unwilling animals if, as a drug, it can be 'cleared' as safe for human consumption. Neither William Blake's maxim that 'everything that lives is holy, life delights in life', nor the Vedic message isavasyam idam sarvam (God permeates everything) is ever made known to modern medical persons. The outcome is that in trying to do good to man by doing harm to animals, the doctor loses the art of hearing the cries of suffering animals. And once he gets used to ignoring a dis-eased animal, as Solzhenitsyn seems to recognize in his Cancer Ward, he learns not to listen to a dis-eased human being.
Victims of Medical Violence
The word victim may be derived from the Indo-Aryan ancestor of the Sanskrit word vinaki (he separates/singles out/sets apart). It implies an individual who will be differently and damagingly treated by the person who sets him apart. Modern medical practice has an unwritten law which does precisely that: when dealing with the same disease, treatment is reserved for the patient, restraint for the doctor when he happens to be a patient.
Erik Erikson lays down the golden rule for medical men: 'Do, or not do, to another what you would wish to be, or not wish to be done by.'15 Erikson elaborates upon this by giving the Talmudic version of the golden rule: 'What is hateful to yourself, do not to your fellowmen. That is the whole of the Torah (the essence, the law, the truth), and the rest is but commentary.'
Medical practice is just the opposite. We recall a case in which we assisted, early in our medical training. In those days, the operation of the portacaval shunt had become fashionable in medical practice; it offered rich cinema stars a way out of their alcoholic lives, cirrhosis, portal hypertension and the danger of bleeding to death from their oesophageal veins. The surgical chief wanted experience in this kind of surgery and he asked the resident medical officers to keep a case ready. Eighteen-year-old Janardan, the only child of a widow, was admitted with seemingly matching symptoms. On doing the preliminary splenoportogram, the senior doctor discovered that the proposed operative site was but a jungle of veins. On the pre-operative day, the resident medical officer said to his chief, 'Sir, I am afraid we shall nick the vena cave and the patient might bleed to death.' The chief's answer was, 'Doctor, as far as it is not my vena cave, I am not worried.' Janardan was operated upon; he died on the table. The surgeon, the resident doctors and the students obviously knew everything save the golden rule.
Walter Alvarez, the eminent gastro-enterologist, muses over the golden rule in his autobiography, Incurable Physician. Referring to the 'curative' and radical surgery of duodenal (peptic) ulcer done routinely on patients, Alvarez observes:
One highly significant fact that shows how the physicians and surgeons in Rochester really felt about the operations for duodenal ulcer was that in all my 25 years at the Mayo Clinic I can remember only one of the many members of the staff with an ulcer who was operated on, and he was driven to it late in life by a complication.16
At our medical school, too, we have seen the most adventurous peptic ulcer surgery perpetrated only on patients; in the last thirty years not one member of the senior/junior staff has taken benefit of this assuredly curative surgery.
In another case we came across, a newborn child developed gangrene of the whole lower limb following a misdirected glucose injection. The mother was told that amputation was necessary to save the child's life. But the mother went away; she returned after a year with the child's limb intact and largely functional. Then the pediatricians decided to do an angiogram (to find out how the limb had managed to survive) so that they could present a paper in a scientific conference. We asked the worthy gentlemen about the proposed angiogram, 'If angiogram on an absolutely healthy artery can lead to an arterial shut down and gangrene, don't you think the chances of losing the limbs are infinitely greater in a situation where circulation is already compromised?' The answer was, 'We need the angiogram so that we can present the circulatory dynamics to the scientific audience.'
A study undertaken to determine to what extent doctors, faced with the prospect of having cancer, practiced what they preached, revealed some startling facts: Doctors, the 'disappointed' investigators generalized, (a) do not seek an early diagnosis, (b) permit 'unjustifiable delay' before 'curative treatment' is started, and (c) choose as their initial consultant a physician whose culpability for delay is as great as that of a general practitioner.17 As the British Medical Journal recently editorialized, doctors investigate and treat themselves or their relatives inadequately by conventional medical standards.18 The British Medical Journal asked the Director of Surgery at St Mary's Hospital, London, what he would do if he had cancer of the rectum. His answer was:
I am absolutely certain - and this I am sure will bring the wrath of most colorectal surgeons on my head, but no matter- - I would not have an abdominoperineal resection with a colostomy. However managed, however much we delude ourselves, a permanent, potentially incontinent abdominal anus is an affront difficult to bear, so that I marvel that we and our patients have put up with it so long. It says much for the social indifference of the one and the social fortitude of the other.19
Teachers in medical colleges are known to ask their colleagues to promise that, should they have a heart attack, they should not be put in the intensive care unit, known in the US as the pressure cooker. The way the psychiatric and the nursing staff view (and treat) themselves is startlingly different from the way they handle the patients. It would be interesting to find out how many psychiatrists have undergone electro-convulsive therapy, and how many had had the horrifying and now-discarded prefrontal leucotomy that won for its inventor a Nobel prize.
This divide, this doublespeak and doublethink by medical men, lies at the root of the moral issues of modern medicine. If the divide had not been there, most pills, potions, and procedures would have been abandoned a long time ago. According to a global estimate made by medical researchers, nine out of every ten prescriptions of procedures are unwarranted.
The twenty-first century computerized technology in the American medical scene also frequently leads to financial disaster for the patient. Every fifth case of personal bankruptcy in the US is due to mega-size medical bills. In big cities in India, too, when the cancer/heart/kidney failure patient, after hectic treatment, dies, it is the family that has to be 'buried'. In the case of a number of illnesses - heart attack, stroke, cancer, kidney failure - which, by modern medical consensus, are terminal and which even after treatment can only minimally restore the patient's productivity, the doctors' bills are back-breaking. We are obviously still under the spell of the myth that the millions of the Shah of Iran or of film star Nargis Dutt could buy for them a cure for leukemia or biliary duct cancer. The Shah, precisely because of the astronomic fees he could pay, was given the wrong treatment by a wrong set of specialists. After his premature death, his American, French, and Egyptian doctors engaged in a mud-slinging match as to who really killed the Shah. Nargis Dutt's 'cure' became known only for the millions spent and the number of propitiatory runs her cinema star husband, Sunil Dutt, made round the Sloane-Kettering Institute. Nature has an innate sense of equality, a sense of democracy. In all the major illnesses that modern medicine is researching upon and treating, neither the scope of the treatment nor the quantum of money spent makes any difference to the outcome. This is so, because all these problems are, and will be, trans-technique, well beyond the might of modern medicine.
It is common experience that, on a given case, the proposed diagnostic/therapeutic thrust ranges from extreme conservatism to surgical ultra-radicalism. After attributing such diversities to the physician's idiosyncrasies, two investigators say:
Perhaps all these factors are involved in clinical controversies, but we propose that one explanation has not been sufficiently recognized: that it simply makes no difference which choice is made. We suggest that some dramatic controversies represent 'toss-ups' - clinical situations in which the consequences of divergent choices are, on the average, virtually identical. The identicality of the consequences, no matter what the investigations and what the therapy, is a function of the basic fact that the problem being tackled is beyond the limits of technology.20
The 'toss-up critique' takes away from modern medicine any justification for its current craze of creating - more as an industry than as science - five-star hospitals with their lethal bills in India. Bombay, Madras, Calcutta and Delhi are already caught in the whirlwind, and even such small places as Rajkot and Indore are joining the bandwagon. These palatial hospitals thrive on the creed of fee-for-service which happens to be the motto of the world's most powerful (American) Medical Association. Translated, it means no service without fees, and, often, unwarranted services for generating fees. This twofold victimization - of the poor by denying them the right to treatment, of the rich by exploiting them - stems from the fact that doctors, and medical students themselves, do not know what it is to spend on investigations and treatment. The students get treated as VIPs in the hospitals where they grow up; the practicing doctor gets treated free, partly because of professional courtesy and partly with the idea of promoting one's practice through the doctor so obliged. The net result is that the medical man does not have to go through the experience of financial difficulties that alone can teach him to be considerate towards the patient's purse.
Yet another reason for the malady is the paroxysmal urge to organize and attend conferences/congresses/workshops/and the like, as an endorsement of medical claims to progress and the singular medical inability to own up to past mistakes and the absence of any genuine breakthroughs. VIPs inaugurate such conferences, the media give glowing coverage to them and the common man and his doctor continue to be convinced that medicine is marching ahead. Out of this institutional combination of conferences and the media is born what a physician has called 'the international safaris' - the people's readiness to squander all that they have in the hope that, given enough money, the medical Mecca of the west can cure anything.
The animal world comprises the largest victim-population. Medical researchers experiment upon animals with the idea that human beings and animals share what Romer calls a common vertebrate plan. The medical researcher is always ready to transfer the clinical gains from animal study to his practice and patients, but loses sight of the fact that, because of their very likeness to human beings, animals deserve a better deal.
Animals are blinded, dropped in boiling water, burnt on hot plates, frozen in dry ice. They are allowed to bleed by exposing the carotid artery or by incision through the jugular vein. Electrodes are implanted in the brain to stimulate pain centres; they are subjected to huge doses of radiation and then forced to run on a treadmill to see how long they can survive. They are deafened, mutilated, exposed to infection, and driven mad. Babies are removed from their mothers to study the effects of deprivation. Free-ranging creatures are confined for years in small cages or, worse, in harnessed chairs. They are starved or forced to inhale carcinogenics or toxic material, till they die. Auschwitz, Dachau and the Gulag survive for the animals.21
We know from our everyday life that animals have feelings and that they experience sensations. They are born, they live and they die; they express fear, love, terror and pain. Ecologically, humans have evolutionary roots in the same world as other creatures. If we are dedicated to human service, part of our duty is to share our human rights with other creatures. We have no right to exploit, kill and torture them for our own selfish purposes. Yet the book, Search for New Drugs, complains, chapter after chapter, that animals suitable for experiment are not available, and then goes on to describe the trials and experiments involving the torture and death of hordes of animals.22
Admiration for non-human life is something the medical student learns to keep away from his consciousness. Initially, he is too busy making a career; later he is too busy treating humans. This lopsidedness may be as old as medical practice. The Sushruta Samhita advocates the peacock and the snake as a diet for improving the intellect and the swan as curative for nervous diseases.23 No wonder, medical studies and practice create technocrats who are, in the words of Sir John Apley, overeducated philistines. One cannot expect them to have read an observation in Walt Disney's Wonders of Nature: 'People who have looked into its [the walrus's] watery eyes after it has been harpooned see an expression of amazement and disappointment that there is such cruelty in the world.' A vegetarian Indian doctor prefers not to think that the liver extract he has injected into an equally pious patient for a tidy sum comes from some slaughtered animal. He does not even know that the drug has passed through the patient's body (thrown away by the patient's liver that never needed it in the first place) into the sewers to fatten roaches and rats.
But the greatest victim of medicine is nature herself. The word 'physician' is derived from the Greek physike which means the science of nature. A physician should, therefore, be a naturalist. But anthropocentrism, the lure of money, and the awe of modernity has killed the naturalist. Two hundred years after his death, Voltaire stands vindicated; 'Doctors are men who prescribe medicine of which they know little, to cure disease of which they know less, in human beings of which they know nothing.' The little the doctors know of drugs turns them into purveyors of violence: iatrogeny, or doctor-caused-diseases, becomes a new category by itself.
The Rhine and the Ganga are choked by effluents discharged from the antibiotic plants. Drugs that are patently poisonous (such as methotrexate, which owes its origin to the vesicant action of the gas nitrogen mustard used in World War I) are used by cancerologists, transplantologists and rheumatologists, upsetting thereby microbial ecology so vitally that microbes that were benign turn inimical to humans. Nobel-Laureate Burnett has prophesied that history will show up the pharmaceutical houses of the mid-twentieth century as examples both of the productivity of science applied to industry and of the evils inherent in the technological momentum of a competitive industrial society. This reminds one of Raeburn's pronouncement on antibiotics, to which we have referred earlier.
From the 'little' they know of diseases, doctors imagine, see and show a shadowy enemy. All major diseases remain, to use oncologist Brooke's phrase, discreetly silent for a greater part of their existence in the human body. G. Pickering, a world authority on high blood pressure, has analysed the inherent benignity of disease:
The myocardial infarction, the cerebral infarction, or the gangrene of leg which terminates a patient's life may be seen as the final episode of a series which remains silent over a long period of the patient's life before it obtrudes into his experience and finally terminates it.24
Yet, the proponents of cardiology and cancerology continue to speak of early detection and treatment, a ploy that brings them credit should the patient survive, and no discredit should the patient die (obviously for not having sought the doctor's help early enough). The roster of cancerologists who died of an undiagnosed or late-diagnosed cancer and of cardiologists who died of 'hears' disease ought to be made public knowledge. If there were a naturalist in a doctor, the doctor would view a disease as but a part of human physiological development that reminds the doctor and his patient alike of the perennial proximity of death.
Alexis Carrel, Nobel-Laureate and the father of modern cardiovascular surgery, wrote a small classic, Man, The Unknown. It suggests that medical men, even as of today, know little of the homo sapiens. Medical students and teachers often see a patient as a nuisance attached to an interesting disease. Appropriately enough, at teaching institutes, patients are identified either by the diagnostic tag they bear or by their bed number, never by their name. In Anatomy of an Illness, Norman Cousins describes his experience as a patient and concludes that modern hospital is the last place for any sick patient to be in.25
II. Modes of professional violence in medicine
We have earlier referred to Duke's The Seven Pillars of Foolishness. After detailing the ingenious ways in which drugs are pushed by multinationals for profit, Dukes concludes:
There is an unhappy turn of phrase currently going around in medical meetings which refers to patients as 'the people out there...' Perhaps that is merely symptomatic of the wrong-headedness which besets the world of drug experts. The patients are indeed out there, and the drugs are in here with us, being coddled in warmth. It may be the destiny of the clinical pharmacologists to bring drug policies and policy-makers back where they belong, at the bedside and in the consulting room, with the patient every patient - at the heart of things, whilst the chemists, the stockbrokers, the image makers and the detailmen wait, cap in the hand, at the door for judgement to be pronounced.26
Richard Asher, one of the outstanding medical thinkers of our time, has described 'the seven sins of medicine' as obscurity, cruelty, bad manners, over-specialization, love of the rare, stupidity and sloth.27 In their defence, doctors may argue that what Asher and Dukes have described are human foibles common to all professions, from priesthood to plumbing. Perhaps the Schweitzerean streak does guide most medical practitioners to serve their patients, but we want to draw the reader's attention to the unwitting violence that a medical practitioner inflicts on the patient through aetiology (causology), diagonsis, investigations, treatment, prognosis, research, and image-building.
A leading hospital in Bombay has on its outer walls a prominent inscription: The sick person is my God. According to the Christian scriptures, God can be served by the path of Mary - the path of contemplation, or/and by the path of Martha - the path of action. In a setting where the doctor is the saviour and the patient a victim of a disease, the path of Martha dominates. The patient buys the action, the doctor sells it - fair professional exchange that ignores the equally important but more difficult path of Mary. The latter is the path of restraint, 'inaction', a greater faith in The Wisdom of the Body,28 a healthy scepticism of the physician's powers, and an awareness of the dangers that every new 'miracle' drug or gadget is pregnant with. Alexander Solzhenitsyn says at one place in his Cancer Ward:
Was it possible? Could the question arise of a doctor's right to treat? Once you began to think like that, to doubt every method scientifically accepted today simply because it might be discredited in the future, then goodness knows where you'd end up. After all there were cases on record of death from aspirin. A man might take the first aspirin of his life and die of it! By that reasoning it became impossible to treat anyone. By that reasoning all the daily advantages of medicine would have to be sacrificed.
It was universal law: everyone who acts breeds both good and evil. With some it's more good, with others more evil.
The medical man, a Solzhenitsyn, is in the unenviable position of 'do and be damned; do not and be damned'. But if nine times out of ten the physician is either ineffective or his action is unwarranted vis-is the self-correcting marvel called the human body, then the path of inaction/contemplation could well be preferable. We amplify below this proposition through a discussion of the hazards of active, aggressive medical practice.
Bertrand Russell said as early as 1918 that causation as a concept had disappeared in all advanced sciences. Its survival, indeed, its prosperity in medicine, implies that medicine is either not a science, and/or is not advanced. The fact is that all the major maladies - heart attack, cancer, hypertension, diabetes, arthritis - have no identifiable cause. A search for the cause justifies highly funded research. Its assertion, in practice, makes the clinician look learned. Its eventual unravelling holds out for everybody the hope of a cure - 'the pot of gold at the end of the rainbow of medical research',29 as M. Burnet describes it. Even in a manifestly casual event, such as an infection, from Pasteur's time to ours, we do not know whether it is the seed (microbes) that is causally important, or the soil (the human body).
Anxiety-making, Alex Comfort says, is the curious preoccupation of the medical profession: 'Warn against the signs of cancer and cancerophobia becomes a disease more terrible than the actual malignancy.'30 And the doctor indulges in his penchant for aetiologizing - coitus causes cancer, coffee causes heart attacks, bread causes peptic ulcers, and so forth.
So, life for the common man, especially for one fed on the popular journals, is filled with one cancerogen after another and one nosogen (disease-begetter) after another. For him it becomes a series of dilemmas: whether to breathe (oxygen causes cancer), eat, drink or smoke (if you do, you get lung cancer, if you don't you get bowel/brain/uterine cancer), marry and breed (breeding gets you cancer of the cervix; if you don't, then cancer of the breast or the uterus). Each and every such act is fraught with the danger of some serious disease.
Such rabid cancerogenism has not produced health; it has produced only global cancerophobia. Should people eat, drink, breathe, or make love? The answer is not easy in many societies. For instance, when it comes to cancer, the American society and the many societies which follow it as a matter of faith cease to be sensible: they alternate between states of panic, fear, irrationality, and paranoia. For this, Ingelfinger blames doctors, cancer societies and, of course, the media which specialize in converting trivia into sensational news.31
Fortunately, there is the astounding resilence of human common sense against the anxiety-makers. As the popular limerick goes,
My doctor has made a prognosis
That intercourse fosters thrombosis
But I'd rather expire
Than abstain, and develop neurosis.
Dr Travis said, 'There are some words that always shock the layman. I wish we could call cancer by a symbol like H2O. People wouldn't be nearly so disturbed. It's the same with the word angina.' - Graham Greene
To doctors, diagnosis is merely a word; to patients, it can be a sentence. The very word cancer, psychoanalyst Karl Menninger points out, kills some patients who would not have succumbed so quickly to the malignancy from which they presumably suffer. A patient once committed suicide on being told that she had breast cancer. Not all diagnoses of cancer are correct. Nor do proven cancers kill. But it is the word and the diagnosis of the doctor that spells death for the patient. What is true of cancer holds true for heart disease, high blood pressure, diabetes, and so on. Doctors are wont to diagnose a disease even in individuals fully at peace with themselves, for diagnosed illness is the first, unquestionable link that binds a person to a doctor. Fischer, an eminent American physician, asks of doctors, 'Do you ever ponder the advisability of not making a diagnosis and thereby avoiding a death sentence?' A surgeon from Bombay was hurriedly pushed into a diagnosis of cancer of the rectum and as quickly relieved of his rectum, anus and natural passage, only to learn on a revaluation of the slides that his rectum had been noncancerous. For over thirty years he has been moving around with a colostomy bag.
Whatever cancerology may self-confidently claim, even the most powerful microscopes do not provide infallible signs of cancer. Cancer gets diagnosed when it is absent, and vice versa, depending 'on the barometric pressure and perhaps the bowel tone of the pathologist himself'. In a book published nearly thirty years ago, an English doctor describes the horror of being stamped as an ulcer patient when he did not have a thing to complain about, and being vehemently denied the same diagnosis when his stomach and duodenum were being literally ripped apart with pain.32 The fact is that as many as 33 per cent of ulcers do not show up on X-ray investigations. To the cardiologists' itch for diagnosing heart disease on the basis of the electrocardiogram, Harrison, a senior American physician, has given the name ECG-itis, a disease that commonly afflicts heart specialists.
A psychotic, it is said, is one who builds castles in the air; the neurotic lives in it; the psychiatrist, on the strength of his diagnosing ability, is the one who collects the rent. In the wilderness of modern psychiatry, we had better listen to Peter De Vries, Arthur Koestler, and Isaac Singer; each one of them conveys tellingly modern psychiatry's befuddled diagnostic jargon. Says De Vries:
In the beginning was the word. Once terms like identity doubts and midlife crisis become current, the reported cases of them increase by leaps and bounds affecting people unaware there is anything wrong with them until they have a load of coinages. (Such upswings in the number of cases diagnosed as 'cancer' or 'heart' are common and are pretty commonly christened as pragmatic diagnoses. The pragmatism resides in the remunerative nature of the diagnoses. No wonder there is a distinct clinical entity called chronic remunerative appendicitis!) Once my poor dear mother confided to me in a hollow whisper, 'I have an identity crisis.' I said, 'What do you mean?' She said, 'I no longer understand your father.'33
Can psychiatrists be trusted? Addressing the World Psychiatric Association in London in 1969, Koestler posed this question, and then proceeded to answer it himself:
This predicament is, of course, most drastically reflected in the field of diagnosis and classification. As I seem to be the only outsider at this Congress of Psychiatrists, we must assume that I have been invited to represent that infernal nuisance in the psychiatrist's life, the patient. As a rule, of course, there are too many patients to one psychiatrist, whereas here the situation is reversed. But at the same time it reflects a different aspect of reality, for the single patient is potentially liable to be diagnosed and categorized in a great many different ways, depending to some extent on the psychiatric school, the ethnic background, and apparently even the age-group to which the diagnostician belongs. Thus, should I have the misfortune to be admitted to a mental hospital in England with a somewhat complex symptom-picture, I would have a ten-times higher chance of being classified as a manic-depressive than if I were admitted to hospital in the United States; and taking my specific age-group into account, the ratio of United Kingdom to United States of patients diagnosed as manic-depressives becomes 21 to 1. On the other hand, if I were to go off my head in America, I would stand a ten-times higher chance of being classified as a case of cerebral arteriosclerosis than in England; and a 33 per cent higher chance of being classified as a schizo. In the States I might also be found to show a 'psycho-depressive reaction', a category non-existent in England and Wales.
I am quoting these figures from Morton Kramer's remarkable paper on 'A Cross-National Study of Diagnosis'.34
A diagnostic word is used easily but defined with the greatest difficulty. High blood pressure and diabetes are examples of diseases in search of an agreeable definition. Isaac Singer recognizes this explicitly:
The nosology of insanity, the etiology, the symptomatology, pathology, diagnosis, prognosis, the care - how nicely the textbooks classified everything! How accurately they defined the idiot, the cretin, the imbecile, the epileptic, the hysteric, hypochondriac and neurasthenic. Instead of admitting that little was known about what went in the human brain, either healthy or sick, the professors stacked up Latin words.35
The term diagnosis connotes 'distinguishing through knowledge'. It seems doctors do distinguish, but without knowledge. That is why the same patient/slide/X-ray/ECG is diagnosed as 'x' by one, as 'y' by another, and as neither by a third. When doctors do not know about a patient's disease, a popular saying goes, they get away by giving it a name.
Most of the tools a doctor used 25 years ago fitted into a small black bag. Today the typical American physician owns or has access to $250,000 worth of diagnostic equipment. Whenever one tries to link the development of new technology with any improvement in healing, the empirical response is the same: there is none.
- William Knaus
Given the ever-expanding arsenal of computerized electronic gadgets - CT scan, auto-analyser, PET scan, NMR scan, ultrasonography - the modern medical man looks like a supersleuth, a Sherlock Holmes backed by a Watson carrying with him the latest off the IBM assembly-line. But there the analogy ends. In none of the Conan Doyle stories do the sleuths end up hurting their clients. In the medical field, they do. The seemingly powerful medical men and machines can often be impotent to do any good, but they always remain potent to do harm.
'Invasive investigation' is a medically respected term; it clearly indicates what such a mode of investigation is - actively invading the patient's body by needles and knives, catheters and scopes. A woman of 40 is fully at peace with her hypertension. The latest in the field is to 'work up' such a case by aortography. The needle put into the aorta ruptures it, and the patient dies of a sudden, uncontrollable internal haemorrhage. A man of 75 pleads to be left alone, but a scopy is done for locating his suspected oesophageal lesion. The scope penetrates the oesophagus, touching the heart and causes cardiac arrest. The arrest is revived but a little too late. The patient, now turned vegetative, dies at the end of ten days' struggle. A tumour of the retina is suspected. The only way to ascertain its presence and nature is by the removal of the eye. But one in four such eyes turns out, after it has been gouged, to be noncancerous - a horrendous price to pay for investigative aggressiveness. Many an invasive technique is used because of the 'Everest complex' - it is done because it is there. The victim of the invasion is the patient whose quarrel with the alleged disease is more in the physician's mind than in the patient's body. Pickering cites his personal experience with a woman with mild elevation of arterial pressure, 'too mild in my opinion either for investigation or treatment, whose kidneys were destroyed by aortography. No well-intentioned invasion of any tiny, peaceful nation by a superpower for the purpose of saving it from an enemy has ever done the country or its people any good.'36 Well-intentioned or not, invasive investigation always extracts a price from the patient.
Electronics are supposed to give us instruments with divya-chakshu or magic eyes that tell us all about the patient, without the doctor even touching the patient. This is called non-invasive imaging. The NMR, soon to replace the CT scan, is promising to tell us all. But there is a snag. While the some of the patient escapes invasion, the mind is not spared. A xerograph of the breast raises the suspicion of a tumour, an ECG has the same learned question marks over its hieroglyphics. The cancer/coronary disease may eventually prove to be absent, but it rapidly spreads in the patient's mind. The voluminous iatrogeny that the medical check-ups and screening programmes produce was foreseen by Marcel Proust at the beginning of this century:
For one disorder that doctors cure with drugs (as I am told that they do occasionally succeed in doing) they produce a dozen other in healthy subjects by inoculating them with that pathogenic agent a thousand times more virulent than all the microbes in the world, the idea that one is ill.
'The art of therapeutics', Bodley Scott said, 'is based upon the touchingly naive assumption that there is an answer to every question it poses.' How uncomfortably true that is, and how few people have the courage to say it.
We always say 'What is the treatment of this disease?' rather than 'Is there any treatment for this disease?' Deriving from this we obtain an uncomfortable concept which I believe to be true, but which I find too depressing to accept. This is it. It is better to believe in therapeutic nonsense than openly to admit therapeutic bankruptcy. - Richard Asher
Modern medical practice is like a game of conditioned reflexes that makes a doctor treat every complaint of the patient. The patient's readiness to pay the bill reduces the willing medicalman into giving therapy, rational or irrational. Consider the heart or coronary bypass. A monograph on the subject by T. A. Preston traces the history of such surgery from 1899 to the 1980s, to conclude that surgery, however sophisticated, makes no difference to the patient's chances of survival. In a chapter titled 'Economic factors in coronary artery surgery' the author points out that the routineness of this surgery is rooted in economics:
Having had a general view of the economics of coronary artery surgery, what should we conclude about the influence of economics on the incidence of the operation? First of all, the mere fact that this is big business has no bearing on its justification. Certainly the equipment suppliers and the hospital personnel involved in supporting the operation have no direct influence on the numbers of operations performed. But, indirectly, as pointed out by Ross, the existence of machinery and personnel tends to encourage their use. Certainly if the operation were an unqualified success in relieving the symptom and prolonging life, it would be a justified economic luxury despite the excess profits of some. But the real question is whether the economics of the medical situation influences the medical decision-making process with regard to the performance of the operation. The overabundance of surgeons, the dependence of most adult cardiac surgeons on coronary artery surgery for most of their business, the organization of medical health care delivery and fee payment, and the absence of economic restraint on the consumer are all too powerful forces that make it highly likely that coronary artery surgery is performed more often in the United States than it would be under a different economic system. Although it is impossible to determine the percentage of cases that would not be operated in the absence of economic incentives, the conclusion is inescapable that financial remuneration enters the medical decision-making process.37
The problem has moved from medical science to the morals of the market. Every year India loses some millions of rupees worth of foreign exchange when Indians go abroad for buying this surgery. Even surgeons in India are doing it for astronomical fees. Wilfred Trotter, the eminent English surgeon, called such situations 'the mysterious viability of the false'.
The fiscal, physical and mental violence that medical men inflict on the patient stems mostly from routine medical practice. A fever is suppressed but immuno-deficiency is also induced.
Children and adults are given sugary syrups that silently nibble away at the teeth. Analgesics and antipyretics fire the alimentary tract, kill appetite, induce sometimes fatal, gastric haemorrhages, produce skin rashes, inflame the kidneys, or suppress the bone marrow. Antibiotics displace all friendly microbes, only to replace them with alien, resistant ones. Tranquillizers disturb sleep rhythms. The BMJ and The Lancet have editorialized on the violent behaviour resulting from tranquillizer use. 'III health is big business, doctors and many others make their living by it, and pharmaceutical firms their fortunes.' This summing up by an eminent Canadian psychiatrist in his feed Your Doctor Be So Useless? is a sad commentary on the direct and indirect violence that results from modern medicine.
Medical colleges, books and journals tell us how much is or can be wrong with the human body, without having any time or inclination to learn how well the body manages to do without medical supervision. The doctors, however, have it both ways: If the patient dies, it is the fault of the disease; if the patient survives, it is thanks to medical magic. Probably this is as old as medical practice. Hippocrates advises a doctor to so cultivate the art of prognosis that he would be able to win credibility and esteem, on the one hand, and find the patient guilty, on the other.
In this guessing game, the doctor has everything to gain, the patient everything to lose. As we have already said, a prognosis can kill a patient long before he dies. Moreover, one can say unequivocally that there has not been, nor will there be any clinical or technological method that can enable doctors to make perfect prognoses. All doctors prognose at the individual level on the basis of statistics. 'In individual prognosis statistics function only as a weather vane. From them, the practitioner recognizes the wind direction. He knows nothing of wind velocity, or of weather conditions such as temperature, humidity, or visibility.'38 A young boy of 19 was examined by a top cancerologist for a sarcoma just above the knee. An urgent amputation at the hip was advised as a life-saving measure. The mother asked the cancer surgeon what he would do if it was his son. She was told, 'Don't ask me such hypothetical questions, for my son does not have such cancer right now.' The distraught mother then sought the opinion of a pathologist who said that, since in any case the life-expectancy was not more than six months, it was better that the boy went to the grave with both his limbs, without the benefit of any treatment. It is 16 years since that prognosis, and the boy is alive and well. Circa 1955, Solzhenitsyn's stomach trouble was diagnosed as cancer - 'I give you 3 months, no more than that', the surgeon told him. In a society where personal profit is not the major motive in medical life, Solzhenitsyn has already survived for more than 30 years. As regards medical prognosis, the Taoistic creed of 'those who speak do not know and those who know do not speak' ought to be the guilding principle.
The converse of the prophecy of doom is the prediction that 'all will be well' if the patient takes recourse to the technological utopia of modern medicine. A young girl was diagnosed to have cancer in the middle of the thigh bone. The cancerologist declared that as the cancer was restricted only to the middle of the bone, she should be sent to the USA for excision and replacement of the excised part by a bone graft. The trip, the surgery, and the expense of Rs 400,000 could not save the girl. She died of cancer in less than four months. In the fields of heart/kidney/liver disease, it is the good prognosis based on high technology that reduces many a family to penury. If those who prognose doom are doctors who see death when there may be life, the prognosticators of cure deny the possibility of death when in fact it stares them in the face. As in physics, so in medicine; one can be certain only of uncertainty.
All this is unhappy stuff for someone to be writing who has thoroughly enjoyed a professional career in laboratory research on infectious diseases and immunology. None of my juniors seem to be worried as I am, that the contribution of laboratory science to medicine has virtually come to an end. The big-medical sciences all continue to provide fascinating employment for those active in research and sometimes enthralling reading for those like me who are no longer at the bench but can still appreciate a fine piece of work. But the detail of an RNA phage's chemical structure, the place of cyclostomes in evolution of immunity or the production of antibody in test-tubes are typical of today's topics in biological research. Almost none of modern basic research in medical science has any direct or indirect bearing on the prevention of disease or on the improvement of medical care. - Macfarlane Burnet
This obituary of laboratory research has been written by an eminent immunologist who also happens to be a Nobel Laureate. Yet, like 'priesthood' or 'patriotism', the terms 'experimentation' and 'research' in medical science continue to be unquestionably sacred. Ask the lay or the learned, and the reply would still reflect the optimism of an earlier age.
To some extent this is understandable. The modernity of medical science derives its sustenance from the picture of white-coated scientists poring over test-tubes and peering into microscopes to wage an unflagging battle to defeat the enemy-disease. The medical student, teacher, practitioner or researcher, all move in a world imbued with the 'scientific temper', dreaming of or actually doing experiments or research. On cancer alone, the global output exceeds 700,000 publications per year. Even though no cure is in sight, according to Davis, the American Cancer Society's science editor, cancer research is more rewarding than research on heart disease, stroke, influenza, pneumonia, diseases of early infancy, diabetes, cirrhosis of the liver, arteriosclerosis, emphysema, nephritis and nephrosis.39
A popular quip in medical colleges is: 'Maybe the dean cannot read, but he can count.' So, the motto of the college, like that of doctors the world over, is: publish or perish. 'Virtually any article submitted, whatever its merit or lack thereof, eventually finds publication as it filters down the cascade of journalistic acceptability.' This observation by L. H. Smith, Jr., in his 'Foreword' to Cline's Cancer Chemotheraphy, seems to offer an explanation of what Smith calls the 'population explosion of books (and articles) greater than that of men'.40
Some years ago, The Lancet published an imagined conversation between Socrates and Democritus in which the former asks why these days one does not find professors in a medical college who really know about their patients and can take care of them. Democritus replies that most of them are busy in the laboratories writing 'dialogues' and thus have little time to be with or to learn about human beings.
The beast of burden in the gargantuan medical research enterprise is the common man, the patient. If a drug, instrument or operation is evolving, it is through a trial on the patient. If it has already evolved, the pharmaceutical firms want 272,000 patient years of experience (gained in five years) and the surgeons start on building up a series. If Dr Sensible only operates when he must, and Dr Glamour operates on anybody who comes his way, Dr Glamour shortly gets known in the market as the one with 'a large series'. There are few drugs or operations that are not in fact experimental. Medical students learn of peptic ulcer surgery as being 'curative' when medical therapy fails. And yet, to quote Ian Aird, 'Every operation the surgeon performs for ulcer is an experiment, even though it is a logically necessary and probably desirable experiment.'41 This generalization needs to be compared with the advice of the British surgeon J. Fry: 'Leave an ulcer alone, and it invariably burns itself out in a few years' time.'42 The millions of surgeries for peptic ulcer performed by doctors on their patients (but rarely, if ever, for their own ulcers) represent a gigantic experimental research that, as yet, seems, pace Aird, neither logical nor necessary.
The 'academic' spirit and the thirst for 'knowledge' have often led to the use of 'human guinea pigs' for research. The recent media concern with Dr Josef Mengele, the Angel of Death, is not irrelevant to our times.43 For his case has provided a design for 'healing' that is no longer unknown to us. That the multinationals and the big national companies do their drug trials on third-world peoples is common knowledge. Some years ago, when US researchers chose to make a controlled trial on the effectiveness of penicillin on syphilis, the control group denied penicillin was the back inmates of a prison. Another researcher wanting to study the role of the thymus removed them from the young patients operated upon for altogether different reasons. The 'clinical trials' on poor people and on prisoners, on payment, in both rich and poor countries only testify to the fact that while to medical researchers all patients may be human, some are certainly less human than others.
Professional Image Building
Image building is chronic to the medical profession. Occasions for it are provided at gatherings called conferences, seminars, symposia, workshops, brain trusts, congresses. The subjects of discussion range from dyspepsia to death. When they meet, everyone is free to talk; no one needs to listen. The torrent of words thus discharged finds its way into sleekly bound volumes with attractive and grandiose titles ('recent advances', 'modern trends', 'current concepts', 'latest developments', and so on). Such volumes project the image of a medical system perpetually on the move forward, and convince the laity of the importance of all that the learned doctors say and do. Ultimately the doctors, too, come to believe their own inflated claims.
Though as incurable as cancer, image building differs from cancer in being extremely contagious. It affects both generalists and specialists. The most severely affected is the doctor's vision, particularly the ability to read the writing on the wall. While the pharmaceutical firms and the gadget-makers foot the bill, the medical men confer, discuss, debate and publish to create a sense of well-being and to promise a technocratic utopia.
Koestler has christened the conferees 'call girls'.44 It is an appellation which seems more and more justified. Each recent advance claimed at a conference consists in devaluing an earlier claim. Here is an example from Important Advances in Oncology 1985:
As recently as 25 years ago, the management of early carcinoma of the breast in the United States was routine: Virtually all patients underwent radical mastectomy. Since then, new concepts and approaches have been introduced, and there is now considerable uncertainty and controversy about the optimal treatment of this disease.45
Even more telling is the summary of the situation by Hedley Atkins: 'Our recent studies of breast cancer have made such progress that we now realize that none of us knows how to treat it.'46 Boyd, the eminent Canadian pathologist, pronounces a similar judgement on diabetes: 'The more we know about diabetes, the less we seem to understand it.'47 This judgement can be extended to all other disciplines of medicine.
As if in response to such judgements, doctors today make greater efforts at image building; so do purveyors of medical goodies. The public gets more and more confused and, in the absence of a sharp critical consciousness, continues to believe medical claims. The global image-building movement has successfully spawned the medical-industrial complex, the 'mediplex'.48
A medical-industrial complex of profit-making companies is already firmly established. Profit-making conglomerates own chains of hospitals, nursing homes, kidney dialysis centres, diagnostic laboratories, pharmacies, medical office buildings, ambulatory surgical centres, and shopping mall emergency centres. In the 1970s these chains grew faster than the computer industry. They will inexorably restructure - and could conceivably take over - medical care in the United States.49
In Bombay, cardiologists are putting up a multi-million dollar cardiac complex financed by a major national bank, largely to house intensive-care units and to do bypasses, although these now stand condemned in saner medical circles.
The violence of the medical-industrial complex is manifold: (1) medical care is now for those who can spend huge sums or are prepared to run into insolvency; and medical bills are now made with the same detachment as bills in a five-star hotel; (2) the wall of gadgetry that separates the clinician from his patient is growing more impenetrable; (3) the patient is effectively shielded from his/her kith and kin, and the milieu in which a patient is kept is becoming truly sterile; (4) medicine has turned from the art of caring into a technique of management; human health is a business, an industry, and the mediplex now has, like the military-industrial complex, its unofficial dogs of war; (5) there are bewildering contradictions of the kind represented by the typical medical journal carrying both half-page editorials on the ill-effects of antibiotics and full-page coloured advertisements of antibiotics. (Likewise, while cola drugs are said to produce peptic ulcer, the symposium on peptic ulcer at the annual meeting of the Association of Surgeons of India was funded by a leading cola-drink manufacturer.)
III. Alternatives for a way out
We set out below some principles that provide common-sense approaches to medical care: (1) do no harm; (2) ease the dis-eased; (3) free the patient from dependence on the disease, drugs and doctors; (4) avoid violence in thought, words, or action. The compendium is for the perplexed amidst a kaleidoscope of deceptions. It is derived from certain basic principles.
A physician (physike, after all, means 'nature') should be a naturalist engaged in the study and service of man. He should learn to make the most of vis medicatrix naturae (the healing power of nature) by appreciating, trusting and promoting what physiologist W. B. Cannon has called 'the wisdom of the body'. T. McKeown underscores this by summarizing the basic functions of a doctor as limited to assisting the natural functions of birth, life, and death.50
We shall never know the cause and the course of any illness in a patient, especially if it belongs to the great common mass of intrinsic diseases. Lewis Thomas has rightly called human ignorance the greatest discovery of the twentieth century. J. Bigelow's statement that 'most men form an exaggerated opinion of the powers of medicine' has as much relevance today as it had when it was formulated a century earlier.51
While the doctor only studies a disease, the patient experiences it. Therefore it is the patient who has firsthand knowledge of the disease. This truth, when driven home to a patient, has the potential of coverting a dependent, desperate person into a self-respecting, responsible, self-caring person. 'Many a diabetic patient', Fischer says, 'survives by stealthily eating the bread his physician has denied.' This applies to most forms of therapy.
One-third of all patients who die in the Beth Israel Hospital, Boston, undergo cardiopulmonary resuscitation. And of those who recover from resuscitation one-third say that they had not wanted to be resuscitated and would not want to be in the future. Now that cardiopulmonary resuscitation has become so common, should not patients be asked about their views before the event? The Boston study showed that doctors were frequently mistaken when they relied on impressions rather than direct questions.52
Be it cancer, coronary or kidney failure, the doctor should furnish the data, the patient should make the decision.
'Nature has planted in our minds', Cicero declared around the beginning of the Christian era, 'an insatiable longing to see the truth.' The longing grows stronger in a patient who has smelled the truth that the physician has denied. 'In my experience... it does not usually work out in the long run to be seduced into telling the untruth.'53 This statement by a cancer therapist is matched by one made by a cancer patient: 'The time to be honest about cancer is now.'54 The plea is supported by the American physician-philosopher Richard Cabot: 'I have never known a man or woman made worse by telling them the truth.' Truth, however, is the first casualty in a profession that still clings to the medieval maxim: In the presence of the patient, Latin is the language.
Candour in medical practice builds the bridge of friendship and co-operation between the physician and the patient, a partnership of shared knowledge and ignorance, strength and weaknesses, assets and liabilities. No false promises, no false expectations; no dubious plans, no ruinous expenses; no subterfuges, no longer the air of fear and mystery that otherwise marks every encounter. (For a touching description, see Martha Weinberg's Heart Sounds.)
The one teacher that a medical student and a practitioner can always learn from is the patient. A doctor does not treat a patient; he interacts with the patient to help the patient. 'The most important person in the operating theatre is the patient.' This is how the eminent surgeon Russel Howard puts it in an effort to demystify his profession.
The honour accorded to doctors by lay persons stems from their fear of disease and death. It makes them glorify the physician and thus reverse the moral hierarchy that should guide the medico-legal system. It should be noted, however, that the hierarchical reality has somewhat altered since the rise of malpractice suits in the West. The new, uneasy and estranged relationship between patient and doctor is traceable to many a violation of the code of conduct, which the modern doctor will have to relearn.
From a clinical point of view, sickness, illness, disease and patient have not been satisfactorily defined. It is impossible to be 'sick' because of cancer; only temporary maladies qualify as sickness. That disease really means dis-ease has been forgotten, and it is customary now to talk of disease of the oesophagus or of the dis-eased aorta. A person with arteriosclerosis from head to foot or with 'hypertensive cardiovascular disease' may be more at ease than a person with no diseased organs or tissues. An Englishman, carrying on him a large sebaceous cyst that fetches him two guineas for every appearance at professional examinations in surgery, does not have any disease, but only a sebaceous cyst. Our inability to distinguish between asymptomatic structural or functional alterations - a breast lump, raised blood pressure, high blood-sugar level - and true disease makes us rush into 'treating' every such 'patient'. What Asher says is pertinent here:
I am only anxious to demonstrate how an observation can be interpreted in entirely different ways, according to whether you assume the condition is an illness or not, and to show how easy it is to make such an assumption without knowing it. You cannot say what things are abnormal till you have agreed on what is normal. You cannot describe disease without describing ease first.55
The saddest part of medical science is its inability to define the 'normal'. Psychiatrists find every human being abnormal in one way or another.
If disease becomes our key term, a patient becomes a person who is ill-at-ease or, more appropriately, dis-eased. A physician then turns into a person whose professional role consists in easing the dis-eased. Some corollaries follow:
1. When there is no dis-ease, there is no patient and there is no need for a doctor.
2. Whosoever eases the dis-ease is the doctor. This generalization admits of a holistic approach that sanctions any medical system (-pathy) to the extent it works for the patient.
3. Hoerr's Law asserts: 'It is difficult to make an asymptomatic patient feel better.'56 Stated differently, it is easy to make the asymptomatic patient (a person at ease, and therefore not dis-eased, therefore not a patient) feel worse. So, in many a routine medical check-up, a person walks in and a patient walks out.
4. The idea that the chief role of a medical system is to take care of the dis-eased gives the system only a palliative role. This is as it should be. Oliver Wendell Holmes has described his teacher, Dr Jackson, as one who never talked of curing his patients, 'except in its true etymological sense of taking care of him'.57 Holmes goes to the extent of generalizing that 'the doctor who talks of curing his patients belongs to that class of practitioners known in our common speech as "quacks". '58
Modern medicine is in need of humility; it must give back to 'cure' its etymological meaning. It must recognize that with a concerned physician around, no disease, no death, is incurable. A drug to ease, a procedure to palliate, a word of cheer, the graceful stoicism to hold the dying patient's hand - all this and more falls within the curative competence of a compassionate clinician.
Health is far more universal than disease. With the microbial biomass outweighing the total animal biomass twenty times over, with the world full of carcinogens, with pesticides constituting a part of mother's milk, with every machine and electrical gadget causing noise pollution, it is not at all surprising that we fall ill. But it seems a wonder of wonders that most of us carry on merrily into old age. The diseases that fill up the medical lexicon are legion but they should not detract from renowned pathologist W. Boyd's reassuring remark: 'When all the natural frailties of our bodies are considered, it seems strange that a harp with so many strings should stay in tune so long.'58
An appeal for donations by the renowned Imperial Cancer Research Fund, England, tells the truth effectively: 'It is good to remember that most people live out their lives untouched by any form of cancer.'
Adolph Portmann observes that animal life is configured time.60 When time shapes itself, a human comes into being. As a function of time he or she cuts teeth, the voice cracks, menstruates, grows to be a diabetic, cancerates, pushes up the blood pressure beyond the medically-assumed normal, needs bifocals after the age of 40, gets his coronary arteries blocked, and so on. Most of this is a part of growing, a function of time, and blissfully, discreetly, very, very silent, right unto death. Thus, any pathology, accidentally discovered, is best left alone.
Fabricating theories about the cause of a disease is a favourite medical exercise that justifies the oddest and cruellest of researches, makes the medical man look learned, and reduces the patient to a beast of burden, carrying a heavy load of guilt and repentance. Aetiology is a variant of the karmic theory wherein a current tragedy is linked to an alleged sin in the distant past; it makes the illness more insufferable.
Any form of aetiology has a ring of j'accuse aimed at the patient; it tends to divest the physician of compassion for the distressed patient. Aetiology promotes the illusion that every conceivable thing or action can be a cause of illnesses such as cancer or coronary attacks.
From alleged slips in eating, drinking or love-making doctors have now moved on to the patient's psyche as causing or aggravating an illness.61 We may soon hear a doctor telling a patient that it was not smoking or sex that caused his or her cancer, but the patient's mind was devoid of the right kind of positive thinking. 'So I wouldn't be surprised', Oleg, the hero of Cancer Ward, observes, 'if in a hundred years' time they discover that our organism excretes some kind of cesium salt when our conscience is clear, but not when it is burdened, and that it depends on this salt whether the cell grows into a tumour or whether the tumour resolves.' The popular formulation in the United States, 'what we eat eats away as cancer', has inspired the otherwise severely scientific Science to put on its cover green and red diamonds with the heading: 'The Green Diamond - Eat, The Red Diamond - Die'.62 The aetiologic scienticism that declares that if you eat the red-diamond food items, you get cancer and die is totally unaware of another American finding: in Seeds of Destruction, the first chapter says of the 'role' of cancer in a patient's death, 'Cancers are generally not in themselves fatal; that is, with rare exceptions, they do not produce toxins, or otherwise kill the host directly.'63
From such experiences follow some guidelines for doctors:
1. Aetiology is retrospective speculation that is best avoided. 2. Do not theorize about causation.
3. Remember that the human frame - yours or the patient's - is heir to diseases merely as a function of time.
4. Even if you are convinced about the fault of the patient, do not be explicit about it if it is too late for him or for you to correct it.
5. The acronym DOMP (diseases of medical progress) and the expanding ailments labelled iatrogeny compel us to recognize that, often, the doctor is the aetiology of many diseases. 6. Aetiology-hunting keeps on changing like fashions.
One might just as well argue that the use of wrist watches was becoming increasingly common compared to the Victorian times, and that therefore the increasing incidence of peptic ulcers was attributable to the wearing of wrist watches. Among the guesses, presumptions and conjectures is the assumption that the speed of civilization always involves stress and strain. Crossing the Pacific in a Comet is less strain than crossing it in a coracle, and cave-men were probably as much troubled by shortages of suitable flints as modern man is troubled by his income tax.
The danger of psychosomatic explanations for unexplained diseases is that it is so easy to find them and they provide a comforting illusion that something has been explained, when it has not.
It is important to realize that ideas are much easier to believe if they are comforting, and that many clinical notions are accepted because they are comforting rather than because there is any evidence to support them.64
For medicine, the twentieth century is an era of statistics - satisfying to collect, perfect for publishing papers, impossible to integrate. Statistics are an outstanding failure in modern medicine.
The confusion created by statistical data spawned the concept of statistical significance. It was assumed that if significance was established, a theory was validated. Modern medicine has now become more conscious of the insignificance of statistical significance.65 A 1918 confession by two medical men, on cancer, is equally applicable to other diseases today:
A generation of workers have laboured with great industry, intelligence, and patience, and a mass of information has been collected, but when it is sifted carefully, we find ourselves very much where our forefathers were, so far as any clear ideas of the cause and nature of cancer are concerned. But what is most disappointing, we are precisely where they were so far as the treatment of the disease is concerned. All that they knew was that the proper thing to do for cancer of the breast was to remove it. All that we know is to remove it.66
Knebel, bored with the figures that studies on smoking perpetually produce, concluded: Smoking produces statistics.
Most medical men are unaware that statistics can be easily fudged. A cardio-radiologist may overread the degree of coronary artery blockage, his bypass-friend may underread the post-operative psychoses and other complications; and they may nevertheless produce statistically the most alluring results. As D. H. Spodick observed on the coronary bypass: 'Even after contrary results begin to appear, those who develop a new medical or surgical therapy rarely issue negative reports.'67 Medical men are not exempt from the belief that what the majority does must be right.
Some morals for medical men follow from this:
1. Take statistics with a pound of salt - be it a learned paper from a doctor or a colourful handout from a multinational pharmaceutical firm.
2. In a one-to-one encounter with the patient, that is, in bedside or clinical medicine, trust what you see in the patient, what the patient feels, and what your horse sense says. Often, therapy acclaimed today is therapy condemned tomorrow.
3. In a teaching or a research institute, (a) avoid the 'common man' as one more statistical figure; (b) resist the temptation to build up a series; (c) refrain from making up your mind about the worthwhileness of a drug, surgery or equipment in advance lest your clarity should suffer; and (d) drive home to your students and colleagues the inherent limitations of statistics.
4. What medical statistics reveal may be interesting, but what they conceal is vital. Remember the non-swimmer statistician who got drowned trying to wade through a river with an average depth of three feet.
The doctors found, when she was dead,
Her last disorder mortal.
- Oliver Goldsmith
1. A diagnosis is not an obligatory function of the clinician. When diagnosis is not clear - a situation all too common in the clinic - the best thing is to own up one's ignorance, and treat the patient for the symptoms.
2. A diagnostic label is no virtue. Asher cites two interesting examples:
'I seem to have an inflamed tongue, doctor. Will you look at it?'
'Ah, yes, You've got glossitis.'
'What is this strange condition with red things which expand from the centre in widening circle?'
'That', says the dermatologist, 'is erythema annulare centrifugum.'
The classical diagnostic label that physicians use when confronted by a confounding fever is PIO, pyrexia of unknown origin. A more sincere acronym would be FIKNA, fever I know nothing about.
3. While diagnosing, avoid eponymous terms - Kimmelstiel-Wilson lesion, Guillian-Barre syndrome - especially on the paper carried by the patient or his relations. In place of Kimmelstiel-Wilson syndrome, it is simpler to write diabetic nephropathy/nephrosis; still simpler to write kidney-damage because of diabetes, or, simply diabetic kidney. The authors had a case when a father came rushing, carrying a case paper issued by a consulting surgeon carrying the frightening diagnosis of acute omphalitis, which, translated, only meant a little gravel in the umbilicus of a playful girl, the gravel giving rise to some excoriation of skin and needing only cleaning in place of the antiseptics and antibiotics prescribed.
4. Etymologically, 'diagnosis' means a state of knowledge.
In reality it is a state of circumscribed ignorance, a state of doubtfulness. The diagnosis of hypertension is an act of faith the world over; it is based on the fallacy and unreliability of an average which does not exist in real life.
5. The diagnostic zeal of a clinician should be commensurate with the patient's unease and need. Often, an interesting case means a patient well-at-ease (and therefore, not really a patient) and a clinician uneasy about some finding he cannot reconcile with.
At the end of the range is a patient, say, riddled with secondary cancers, the primary source being unknown, and unlocatable. It is pointless to subject such a patient to biopsy/scopy to establish the diagnosis. For, even if located, it in no way helps the clinician or the patient.
6. WHO have popularized three errors globally: it introduced in 1953 a definition of 'health' that makes everybody feel diseased and hence in need of diagnosis and treatment. Peter Sedgwick68 has listed the side effects of the WHO health-concept as: (a) a progressive annexation of non-illness into illness; (b) the spread of the idea that the future belongs to illness, and (c) that we are going to get more diseases, as our expectations of health become more expansive and sophisticated. Every hospital admission, by WHO requirements, carries a diagnostic label. The result is a global epidemic of diagnosis.
Another kind of error is to classify real and imagined diseases and to codify them by numerals, making it imperative for all hospitals to give numbers to their patients accordingly. The person in the patient is forgotten - as Norman Cousins vividly experienced - and a diagnostic tag, a classification or a code number becomes the driving force for the hospital staff.69
WHO's coup de gr is its insistence that every death be recorded with its cause, that is, a specific diagnosis.
Often medical men ask their investigations to do too much for them; and the inflated expectations create problems. Any investigation into any disease process reveals just one aspect of it, which does not necessarily enable the physician to alter the course of the disease for the better. If investigation or a set of investigations revealed the cause, the whole cause, and nothing but the cause, and if, but only if, the cause can be eliminated without eliminating the patient, the exercise would be justifiable. Very few illnesses fulfil these conditions. Examples are a foreign body in the eye, an abscess, an obstructed delivery, a fracture with bony displacement.
Worldwide investigations into medical investigations allow some generalizations:
1. Laboratory error may be the source of unexpected, unexplained abnormal results, for no laboratory is perfect. A proportion of patients who had unexplained results can turn out to be 'normal' when the tests are repeated.70
2. A majority of unexpected, unexplained abnormal results could be explained if more appropriate normal values were used in the interpretation of the results. (The term 'reference values' is preferable to 'normal' values.) The 'normal values' commonly quoted in the literature have been obtained from male medical students. It is now realized that virtually all serum biochemical factors alter with age and there are differences in concentration between the two sexes.71
3. If each person was subjected to twenty different tests, 66 per cent of healthy people would show one or more abnormal results.
4. Point 3 begets 'false positive results' which in turn spawns what Rang calls 'the Ulysses' syndrome'.72 The characteristic features are mental and physical disorders which follow a false positive result. The syndrome has been named after Ulysses because patients afflicted with it, though healthy at the outset, make a long journey through a large number of awe-inspiring investigations and go through a number of adventures before returning to their point of departure.
The Ulysses' syndrome should be distinguished from an iatrogenic disorder. The syndrome is a side-effect of investigation, not of therapy. The first aetiologic factor in the Ulysses' syndrome, Rang says, is 'the mischievous investigation'. He points out that every unnecessary investigation exposes the patient to the risk of the Ulysses' syndrome. Such unnecessary investigations are produced by (i) mass screening; (ii) insurance coverage of the cost of investigation; (iii) resident doctors in hospitals carrying out investigational overkills to avoid criticism by other staff members; and (iv) lab-request forms on which are listed such long menus of investigations that the doctor who asks only for one or two tests feels that he is rather old-fashioned or has an uninteresting practice. The Ulysses' syndrome is now threatening to become endemic; it is now an euphemism for what we call DIID (diagnostically induced iatrogenic disease/disorder).
5. Laboratory is therefore best avoided.
6. Any investigation, therefore, be it a blood count or a CT scan, should be ordered only if the data already obtained demand the count or the scan, never as a routine.
7. Much of the cost spiral in the health industry is a byproduct of 'routine' investigations medical men can well do without.
8. A dispassionate, epistemological evaluation of the technological gains of the modern medical system reveals them to be in the areas of imagery, accessibility, analysis, association and amplification.
The more the science and the art of the physician interact, the greater is the variety of means by which medical imagery can be obtained. Yet, to take but one example, X-rays, xero-radiography and computerized-tomographic (CT) scan, ultrasonography and nuclear-magnetic-resonance (NMR) imaging, all leave a cancer where it was - diagnosed a little too late. The cannulation of the pancreatic duct or artery for the diagnosis and treatment of pancreatic cancer, or the ability to enter the skull to treat brain cancer leaves the cancer's autonomy untouched. Increasingly refined biochemical techniques allow many substances to be measured with pico-precision (pico = 1/1012), and analytically tell us a lot about heart attack, diabetes mellitus and rheumatoid arthritis, without predictably and/or favourably altering the course of the disease. Epidemiology connects the husband's cigar to the wife's cancer, coffee to cardiovascular disease, and refined sugar to peptic ulcer - an associative exercise that makes more anxiety than sense. The electron microscope amplifies the size of a T-lymphocyte any number of times, only to amplify our ignorance of the cell to the same magnitude.
The term therapist is made of two words. The popularization of the words 'radical' and 'super-radical' and the like for treatment, without medical science having been able to confirm their gains, are pointers to the fact that the therapeutic enthusiast has satisfied himself at the cost of the patient. Radicalism in cancer therapy is dead.
Science in 1980 said; 'The desire to believe in progress in cancer treatments is so profound that people (lay and learned) don't want to hear the disbelievers.'73 Cancerology, rife with all forms of therapy, still does not really know what to do about a cancer case. 'The entire field of orthodox oncology will disappear', an American medical heretic recently declared, 'as chemotherapy, surgery, and radiation for cancer are revealed as fundamentally irrational and scientifically unsupportable.'74
The medical idfixe, that when everybody gives some therapy it must be right, is scientifically wrong, be it in cancerology, cardiology, diabetology or arthrology. What has not seeped into the medical and lay consciousness is that, for intrinsic diseases, there is no therapy and, for extrinsic diseases, the body often recovers on its own. With this preamble, a few points are in order:
1. Every treatment is unique: no treatment is also a form of treatment, and what is treatment is often a euphemism for palliation.
2. If you treat, make the most of the gains possible through readjustments of the patient's life-style. Many a patient of hyperacidity/peptic ulcer can cure the illness by a relaxed meal, chewed deliberately.
3. If you must use drugs, avoid combinations so that should a mishap occur you know what it is due to.
4. If you must operate, inflict minimal trauma.
5. Emphasize that therapy helps the body that basically heals itself.
6. Realize that a patient needs, above everything, joie de vivre which greatly depends on good mood, good food, good air and sunshine.
7. Remember that the chief function of the therapist is to liberate the patient from his dis-ease and from dependence on the doctor.
8. Teach a patient that many a disease can be comfortably and creatively lived with.
9. A part of the therapy is to teach the patient that disease is no enemy, that more often than not it is one's own flesh and blood, an 'ill-fated thing, but one's own'.
10. The ultimate in therapy is not only not to compromise with death, but rather, to facilitate a good, dignified death. If you teach your patient to live with a dis-ease, you may as well teach him to die with that disease.
Towards Minimal Violence in Medicine
The encounter between the patient and the physician is between the patient's body, mind and soul and the expertise of the physician. While the scope for doing good to the patient is substantial, the chances of hurting the patient are equally substantial.
The attempt should be to maximize the patient's ease, and to minimize violating his well-being. This can help the clinician and the patient minimize violence in medical practice. A litany by Sir Robert Hutchison sums up succinctly the art and the science of therapeutics:
From inability to let well alone, from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.