Wednesday, July 25, 2007

Medicine and optimism

To be or not to be
This NY Times article was sent to a skeptical internet discussion group. It provides interesting insight into some challenging philosphical considerations regarding phsyciatric medicine and is food for thought when thinking about medicine and science in general.

Medicine, Constantly Redefined and Redefining Lives
By ELISSA ELY, M.D.

"About 15 years ago, I had a shy patient who ate nothing but white foods and
who assaulted anyone who entered her air space on the hospital ward. She was
mute but not uncommunicative, and with a little effort it was possible to
learn her language.

Some of her problem was her psychosis. Most of it was her mother, who was her
legal guardian, appointed by a court to monitor her medications. But the
mother was also convinced that psychiatric medications were poison; the
patient would go home on weekend passes and return with all her pills in
bottles and without a shred of sanity.

This continued for months. Her mother brought a notebook listing side effects
to each visit. She said the medication caused seizures, diabetes and heart
disease, though the studies at the time showed none of these side effects
associated with the drug we were giving. We thought she was sadistic, intent
on standing between her daughter and independence. She thought we were evil
experimentalists. The patient herself dreaded controversy and wished,
wistfully, to please everyone.

Finally, we petitioned to remove the mother as guardian. It was controversial,
against nature, to question a family member's competency or guidance. When we
met before a judge, both sides were filled with strong emotion. But we were
also filled with strong data.

I remember looking at the mother across the courtroom while testifying about
the hazardous nature of her beliefs and their effects on the patient's mental
state and future. Her size had changed. When she visited the hospital,
something vibratory and angry about her made her seem to swell, so that
neither her daughter nor I could look her in the eye. From the secure height
of the witness box, though, she seemed to be shrinking - an ineffectual old
woman, laboring under false beliefs, growing smaller as these beliefs were
exposed one by one.

The judge listened without expression and took the case under consideration.
We had no doubt about the power of our presentation. Within a week he had
ruled in our favor. The new guardian did not oppose our antipsychotic drug,
and the patient flourished. It was like time-lapse photography: in what seemed
like only a day, she smiled, spoke, became lucid, joined a day program, began
overnights in a residential house and was discharged.

We were full of public satisfaction, and private righteousness. Some aspects
of psychiatry are clear-cut; they can be counted on. There might be no proof
of the existence of Freud's ego and id. But antipsychotic medications treat
psychosis - this can be proven - and the patient's life was going to be better
for taking them.

It was, too. For a while, she sent happy, mostly intelligible letters from her
residential house. The letters became holiday cards, and eventually, in the
fullness of her world, they stopped. Someone else told me, years later, that
she had developed diabetes and required insulin. The research by that time was
clear: there was no doubt whatsoever of an association between her
antipsychotic and diabetes and other metabolic problems. The studies had been
confirmed again and again.

Kierkegaard wrote that we understand backward but live forward. Politicians
say - using a tense so passive that it slinks out of the room before it can be
noticed - "Mistakes were made."

The facts we had then were incomplete, even if we didn't know it at the time.
We were right but we were wrong, innocent but at fault, acting in good faith
with bad results. The ground beneath professional feet should grow firmer over
time - one ought to feel more certain of what one knows. But the more I know,
the more I am afraid."

This story is interesting on a few levels:

It is reminiscent of other "state vs guardian" under age face offs like the Abraham Cherrix or Katie Wernecke cases where the legal system wrestled with the concept of informed choice and the meaning of responsible parental guidance among other things (such as what constitutes acceptable medical treatment?). Very broad grey areas of meaning an intent, especially in older children makes it very difficult to navigate on generic terms- what precedence should be used? The interests of the child from the courts or the parents point of view? Is it a case by case issue? The age old canard of medical "free choice" can be heard rumbling in the background; but does take a back seat to a bigger issue here. (Incidentally, with the increasing societal awareness of possible animal abuse/human abuse correlations, along with expanding knowledge of veterinary forensic science, the guardians leeway for "proper and acceptable care" of animals may become more limited or at least better defined- certainly could have obligatory implications for vets).

Interestingly, today I was reading the history of the Apollo One tragedy . Although on a different scale, it seems to resonate with Dr Elys' story. It manages to describe through tragedy a larger point of view reflecting a way of thinking, of achieving goals through critical analysis, expanded understanding, and knowledge. So maybe "mistake" may not be the best descriptor of Dr Elys story given a larger context- though the legal realm (i.e.; often an "answer the question- yes/no" scenario) might describe it this way. Scientific evidence can be exceptionally difficult to explain and interpret and inappropriate assumptions can be made even by "experts". On the other hand, if you take a more strict approach (i.e.; take away historical context, balanced intent, past knowledge levels) you could almost call Dr Elys' experience an example of gross neglect and abuse of power.


Though philosophy of science discussions often revolve around fascinating "what is true scientific observation and what does it mean?" teleological knots, the scientific grunt work goes on and some times manages to improve the human condition (i.e.; Norman Borlaug).

In this vein, phsycology is now probing huge unknown mental territories in new ways. Neuroscience and neuropshycology are shedding light on cognition, brain region dynamics, and neurological functional parameters unimagined a few short years ago and promising new treatments and therapeutic modalities may loom close.


Though Dr Elys' angst is understandable- most doctors (or anybody for that matter), are often tormented by "what ifs", "I thought", or "if only"s', she seems to take a rather pessimistic view of what can be known. Dr Ely mentions Kierkegaard and seems to (at least implicitly) concur with his "subjectivity is reality" form of existentialism by expressing doubt regarding the firmament of medicines knowledge base; a "the more you know, the less you know" restrictive perspective. Many would disagree and posit a "the more you know, the more you need to re-know, then the more you need to know" expansive perspective. Perhaps neuroscience will bring more empirical insight into some of these apparently metaphysical matters.


At any rate, if Dr Elys' goal is to remind us that medicine is a sometimes equivocal and uncertain affair- all well and good. But where Dr Ely seems to give way to fear when faced with doubt, change, and the unknown, others might be humbled, excited, and awed.

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