How medicine has exploited rationality at the expense of humanity: an essay by Iona Heath

Iona Heath has just published a very well crafted piece in the BMJ .....

http://www.bmj.com/content/355/bmj.i5705

critiquing preventive EBM's 'ludicrous' claims for efficacy, and calling for more patient awareness of life's intrinsic uncertainties, and calling for more 'humanity' - attention to those parts of medical practice not captured by the biomedical science map. I fully endorse these ideas and as a GP myself for over 25 years have witnessed and accompanied folk on those non EBM-calculable lives.

What is interesting is that she alludes to the value of non-biased EBM, as if this is a possibility. But isn't this to ignore the original bias in Descartes' Cogito, the faith in a benign God, that presumes the primacy of the 'mind' over the Body? This original ideological bias is what fulfils EBMs primacy over medical practice. The fundamentalism of EBM and capitalism's desire for surplus have combined to create the destructive juggernaut we witness today.

Science is not an innocent, and language and words do not just open emotional avenues for compassion. And compassion, whilst essential, is always prey to the ideological.

In addition we need to raise medical professional awareness of capitalism's (ideological) corrosive powers, that function through EBM, and a deeper sceptical and political perspective. If I were to suggest anything extra, it would be that medical students should be introduced to alternative philosophies, and to a primer on media literacy.

More follows, if interested see below, or go to:

https://myownprivatemedicine.com/2016/11/08/compassion-also-can-be-prey-...

Capitalism is a key development in mankind's history - and resistance to its harmful consequences must be thought through.

Science and Capitalism are mutually reciprocally supportive, and language, discourse and it's rhetoric, represses our awareness of this.

EBM, as a scientism, embraces, as the truth, our senses' representations of the world as 'real', and this blinds us to the imaginary status of our gaze on the world. It is a kind of religious faith. As such, it and its faith, is essential for capitalism to function. EBM's faith in the validity of the calculable, is essential to the market and exchange value and hence to making profits. And the market uses EBM as a tool to generate profits. EBM's crisis is that it is both corrupted and corrupting.

Importantly, I believe, we have available to us today a well developed philosophical construct. In this construct (developed by people such as Zizek, and Kordela, and many others, building on the work of such as Freud, Marx, Foucault and Lacan) historically, scientific empiricism and mathematical rationality have emerged co-collaboratively with capitalism, where capitalism is a particular novel modern socially pervasive and inescapable mode of production of the means necessary to our everyday existence and survival, whose essential feature is the creation of surplus value through the exploitation of waged labour.

The co-collaboration has resulted in the gradual development of a new form of collective and individual consciousness that believes in the (illusory) narrative that EBM's aims are benevolently utilitarian, but, especially in the field of preventive medicine, as Iona and Sackett pointed out, the essential nature of 'capitalist scientism' is a 'thoughtless' faith in growth, limitless growth, in Adam Smith's 'invisible hand' and the trickle down effect. In practice, EBMs aims are just as much to maximise growth, which translates into its 'ludicrous' claims for the efficacy of its preventive technologies, and the way, in practice, its coercively implements these.

It is good to raise awareness of life's intrinsic uncertainties and Medicine's limited capacity to affect these - but there is also a political battle to be fought fundamental to tackle the pervasive colonisation of medical practice by the 'capitalist scientific' consciousness and it's faith in the truth of objective scientific knowledge - 'always' biased by Capital's interests to create surplus value, as the dominant mode of medical practice.

It is probably unpopular, and perhaps abstract and difficult to swallow, but we may have something to learn about the mechanisms of medical excess from both Marx's historical materialism (consciousness develops in accordance with our modes of survival), and psychoanalysis (under capitalism, the role of faith in narrative fantasies that sustain illusions of precarious precarity and immortality).

So far the arguments neglect any input from a powerful way of thinking about the way the capitalist world works.

I must admit to something between frustration and vexation, whenever I come across discussions such as this one. In their responses, Edoardo Cervoni (5 November) drew attention to ‘Guidelines, which were initially thought to help us in making choices, are increasingly becoming barriers aiming to keep our spending budgets under control, rather than promoting excellence’, and Leopold Kroll (6 November) has pointed out ‘Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ and ‘all those working in clinical care can note the daily reminders of the best (and most compassionate) parts of humanity, and we should hold onto these moments, and build a truly more compassionate and caring true evidenced/value based health care system’.

As I have previously pointed out, ‘the evidence base’ applies to populations, whereas decision-making is at the level of individual patients (ref 1): furthermore, while guidelines can indeed become tyrannical, Cervoni’s sentence seems to assume that the person who would be reading the guideline, the doctor, is the person who makes the decision – that is an inadequate description of the decision-making during doctor-patient interactions. The same assumption – that the doctor is the decision-maker, as opposed to being the expert about clinical factors – is present in the first of my quotes from Kroll, unless we are explicit that EBM describes only ‘the how of medical treatment’ and is not an appropriate term when ‘consent to being treated’ is involved.

The second of my quotes from Kroll, ends with ‘and build a truly more compassionate and caring true evidenced/value based health care system’. This, is why – from my perspective as a family carer, and for the end-of-life at home situation – I am vexed by articles such as this one.

Highly-intelligent doctors, write about the complexity of issues such as those raised by Iona Heath, but have not yet sorted out many conceptually-simpler issues, which afflict end-of-life: that baffles me. Currently, and despite there being an obvious potential solution which I have described (ref 2), it is largely a matter of luck whether the family carers of some EoL patients who die at home (those patients who happen to die before the GP has recorded the death as 'expected' within 'the system'), find themselves being effectively treated as suspects by the police immediately after a death: 'early deaths' are not the fault of those family carers, and this behaviour is exactly the opposite of ‘a compassionate and evidence-based health care system’. Perhaps, before attempting to define humanity and compassion, doctors and in particular GPs could usefully cast their eyes over contemporary end-of-life guidance and correct its flaws: if they look, they will find decisions described as wishes, opinions described as decisions, and unavoidable uncertainty treated as if it is of itself indicative of wrong doing.

GPs have been making it clear of late, that they are very time-pressed: so the people best-placed to listen to, and understand, decisions expressed by end-of-life patients, will often be their families. But the 999 Services are currently working to guidelines and protocols which tell them to ‘look at the records made by the GP’ instead of asking the family carer who called 999 to explain the situation. The ‘healthcare system’ seems set on ‘distrusting by default’ family carers – where is the ‘compassion’ in that ?

Some years ago, I was discussing EoL behaviour with a senior paramedic, over a lengthy period. It struck him, during the discussions, that he had an elderly and very frail relative, and that if this relative collapsed and arrested at home, any 999 team summoned would almost certainly attempt CPR. The paramedic told me that he and his family would be horrified, by such a CPR attempt. The NHS is still adopting the wrong approach for EoL at home: it is determined to ‘follow a records trail [which has been ‘audited’ by the GP or by a senior nurse]’. The paramedic sent an e-mail to me, about 5 or 6 years ago, and he wrote:

‘We are a long way from doing this (although I would!!) But at least we are beginning to agree .. Resus in my opinion is just a clinical intervention like any other skill and should not be seen as a mandated right by health care professionals .. After all if we were not called it would not have been done!! The simple answer is to ask why were we called and how can we help!’

The paramedic was wrong, unfortunately: if anything, the role of ‘the records’ has been strengthened, and ‘listen to family carers – who have been involved long-term and who understand everything except narrow clinical issues better than you as a newly-involved 999 paramedic can understand the situation – and be guided by what they tell you’ - has not been enshrined within guidance.

I repeat: I am perplexed that highly-intelligent doctors, endlessly discuss some very profound issues such as those raised by Iona Heath’s video and article, but have not yet applied their considerable brain-power to the resolution of many significant problems which face patients and especially family carers, when patients are dying at home – and this is even more baffling, in the context of an NHS objective to allow more patients to die at home if they wish to, and when people have been dying since the NHS was established [so GPs cannot claim to have not had enough ‘thinking time’].

Mike Stone mhsatstokelib@yahoo.co.uk

Ref 1 http://www.bmj.com/content/353/bmj.i2452/rr-3

Ref 2 http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj...

It is difficult (or even impossible) to map the territory of human suffering by the sole means of clinical tools, diagnostic tests and biomedical concepts. Or to say it differently, it doesn’t seem easy, nor reasonable, to answer the questions « How to live a better life? », (or « How to have a good death? ») with the vocabulary of evidence-based medicine and statistical tests.

Health professionals have a major role to play in relieving suffering or helping their patients cope with it. But to do so, they have to forget temporarily their clinical knowledge. They have to turn into ethnographers [1] in order to better understand how illness affects the life of people, and what it may be like to feel what they feel.

By the way, it is not so much about understanding than imagining. Through imagination, we are able to explore the emotional landscape of our patients [2]. These persons are confronted with the transforming power of illness. We meet them while they are enduring a long, costly and exhausting transformation. Our compass, in such an exploration, is not Harrison's Principles. Let's say rather Pedro Paramo [3] and Guimaes Rosa’s Jaguar [4].

References:

[1] Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294.
[2] Halpern, J. (2003). What is clinical empathy? Journal of General Internal Medicine, 18(8), 670–4.
[3] Rulfo, J. (1994). Pedro Paramo. Grove Press.
[4] Guimaraes Rosa, J. (2001). The Jaguar and other stories. Boulevard books

Iona Heath's essay, sensitive, worldly and wise, is everything one could hope for, and more, from an intuitive doctor, with a lifetime in primary care.

Iain McGilchrist explored in fascinating detail, the ways in which our right and left cerebral hemispheres interact and influence our perceptions and attitudes. He wondered, in his last chapter, what the world would look like if the left hemisphere became so far dominant that it managed to suppress the right hemisphere’s world altogether ? (1)

Iona Heath’s essay is a succinct response, intended or not, to McGilchrist’s question.

Her table of the ‘Two sides of the consultation’ is almost a juxtaposition of the respective views of the hemispheres. Modern medicine is moving towards the domain of the left hemisphere, where the broader view gives way to a narrower, more detailed but restricted focus.

We hourly, and gratefully, utilise the enormous advantages that flow from applying scientific and technological advances in our community and hospital roles, but our very familiarity with those pathways reminds us that many of the primary care patients we see deserve to be guided away from, protected from, routine over-active, intrusive medicalisation.

Heath’s concerns reecho the plea of Oliver Sacks, forty years ago, “ ..it is the fundamental business of caring for patients - recognising their individual needs and problems, responding to the uniqueness of each situation - which constitutes the first and last duty of being a doctor... the Juggernaut advance of contemporary medicine .. needs a humanisation of its power -- before it is too late.“ (2)

Heath, previously a columnist for the BMJ and a President of the RCGP, is too charitable to comment on the dehumanising efforts of those two institutions.

She briefly refers to the need for publication of more qualitative research, without mentioning the recent negative response of the BMJ to an unprecedentedly large and almost unanimous postbag of requests from readers, asking for more qualitative papers. (3) Nor is there mention of the platform that the BMJ has provided for the abuse of colleagues who choose the very same patient-directed approach that Heath seems to point us towards. (4)

Clinicians, Heath points out, have a responsibility, “to enable sick people to benefit from biomedical science while protecting them from its harms.”

The prescribing of psychotropic drugs is a contentious issue. A vital source of income for the pharmaceutical companies, the appropriateness of much psychotropic prescribing is a cause for serious concern because evidence of their benefit rests, often, on equivocal trial results, and on our profession’s unwillingness to digest the mounting evidence of damage, and deaths, that result from psychotropics. (5,6)

Recent comments on the RCGP’s approach to sponsorship of its meetings, moved the chair of the Council of the College to point out that they have “a robust sponsorship policy that is fully in line with ABPI guidelines.“ (7)

The ABPI represents UK pharmaceutical companies, whose first responsibility is to maximise shareholder return on capital.

If people with mood disorders, PMT, menopausal symptoms, IBS, Fibromyalgia, etc, seek advice from their GP, and leave with an SSRI prescription, are they made aware of all psychotropic safety issues, and RCGP sponsorship details ? And are they informed of other treatment options ?

Perhaps Iona Heath should resume her BMJ column ?

1 Iain McGilchrist, The Master and his Emissary, Yale 2009.
2 Oliver Sacks, British Clinical Journal, January 1974
3 http://www.bmj.com/content/352/bmj.i563
4 http://www.bmj.com/content/351/bmj.h5624/rr-6
5 Peter C Gotzsche, Deadly Psychiatry and Organised Denial. Peoples Press 2015.
6 David Healy http://davidhealy.org/
7 Maureen Baker http://www.bmj.com/content/355/bmj.i5585/rr-0