Tuesday, June 23, 2015

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will “make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health” in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her golf swing, or a family physician might administer amphetamine injections to people who want to feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed, doctors daily witness death and terminal illness. If we know CPR, do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine, is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism ... composed of parts. It is a structure and not a heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes, “large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine and we would be remiss if we didn’t study this purpose carefully. Without a purpose, medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.

Tuesday, June 2, 2015

Empathy in Medicine

“You’ll h-h-h-have to... excuse m-m-m-me. I’m a little slow because I had a stroooooke,” he told us before we explained to him what his wife’s treatment would be. His voice was nasal and his speech deliberate as he slowly and poorly enunciated each word. He wore sweatpants and a long-sleeved shirt with a blue and white hat pulled down over his eyes. Stubbornly refusing to stay tucked away, gray hairs peeked out the sides of his chapeau and covered his ears. He looked to be in his seventies. His wife lay on the bed in a hospital gown, slippers still on. She wore a winter hat that concealed a bald scalp, one of the many side effects of potent cancer medications. Her eyebrows were gone and her sinewy frame was exaggerated as cachexia set in. She needed extra rounds of chemotherapy for metastatic cancer.

Image via Flickr: Tim Hamilton (CC)
That afternoon, I ran into the husband in the hospital lobby. He had just bought food and was going to bring it back to his wife, but he was heading the wrong way. He asked a fellow student and me (he recognized both of us) how he could get back to his wife’s room and we pointed him in the right direction. We watched him shuffle towards his wife in the cancer ward. This couple was neither wealthy nor well-educated; they were suffering and attempting to navigate the healthcare system as well as the overwhelming size of an academic hospital. They seemed helpless together.

It’s in such moments, as in many others, when empathy wells up in medical practice. I could clearly imagine myself or my family members in their position. Their emotions became all too familiar and upsetting to me. I wanted to do everything in my power to help them and to fix their situation. But this strong sense of identification seemed odd given how brief my interaction with them had been.

In reality, however, such a feeling is not so unusual. Robert Louis Stevenson, the famous nineteenth-century Scottish writer, co-authored a short story called The Ebb-Tide. It is an account of three criminals who steal a ship and the deeply troubling moral situation they subsequently encounter. When one of them falls sick, Stevenson describes the healthy comrades’ feelings:

A profound commiseration filled them, and contended with and conquered their abhorrence. The disgust attendant on so ugly a sickness magnified this dislike; at the same time, and with more than compensating strength, shame for a sentiment so inhuman bound them the more straitly to his service; and even the evil they knew of him swelled their solicitude, for the thought of death is always the least supportable when it draws near to the merely sensual and selfish.
Image via Shutterstock

Given the power of this selfless commiseration shouldn’t we cultivate it in medicine? No doubt it will help us to act altruistically even when we see the worst in patients or colleagues, thus leading to a better bedside manner and better patient care. Jean-Jacques Rousseau, the Genevan philosopher, saw such feelings differently, however. In Emile, or On Education, Rousseau points out that empathy is really an outlet for selfish passions, even if its effects can be positive. Rousseau writes that,

if the enthusiasm of an overflowing heart identifies me with my fellow-creature, if I feel, so to speak, that I will not let him suffer lest I should suffer too, I care for him because I care for myself, and the reason of the precept is found in nature herself, which inspires me with the desire for my own welfare wherever I may be.
Such cynicism about the underlying nature of empathy still has its advocates today. In the September 2014 Boston Review, Yale psychology professor Paul Bloom questions our high regard for empathy. I recommend reading his essay and his exchange with other scholars, including Peter Singer, Sam Harris, and Leslie Jamison. Bloom points out the dangers of unchecked empathy: “Strong inclination toward empathy comes with costs. Individuals scoring high in unmitigated communion report asymmetrical relationships, where they support others but don’t get support themselves. They also are more prone to suffer depression and anxiety.” And this is especially the case, Bloom points out, in the medical field in which a doctor can lose a sense of objectivity and a cool head in an emergency. Bloom distinguishes between cognitive empathy, which is empathy tempered by rational feeling, and emotional empathy, which can be dangerous. Bloom writes of an older relative of his in the hospital:

He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect.

This makes sense. I can imagine how exhausting it must be to feel so strongly about every patient. It would cause burnout and depression. But the psychologists Lynn O’Connor and Jack Berry respond to Bloom in the following way: “We can’t feel compassion without first feeling emotional empathy. Indeed compassion is the extension of emotional empathy by means of cognitive processes. Only if we have the capacity to feel empathy toward loved ones can this sentiment be generalized by the imagination and extended to strangers.” This addition to Bloom’s argument is absolutely vital. Both types of empathy are important.

Such balanced empathy keeps the physician honest. There are many times when, in a rush to complete the work of the day or under the pressure to see every patient, physicians take their frustrations out on patients. Empathy tames our impulsivity and gives us pause. It forces us to consider the actions we are about to take. And we can project empathy using reason and emotion. If an elderly woman is being difficult, instead of reacting with frustration and annoyance we can step back and ask ourselves, “What if is this were my grandmother or my mother? How would I want her physician to behave?” To do this is not easy, but it can make an immense difference in how one interacts with a patient.

Empathy may or may not spring from selfishness, and too much of one aspect of it (like too much of any emotion) can be a bad thing. But physicians do need empathy, both the emotional empathy that we feel towards some and the cognitive empathy that we can extend toward all. In the cogs of an impersonal medical system, it leads to the dignified treatment of a suffering patient.