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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.
Prognosis
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.
Experimentation/Research
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.
Natural
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
Epistemological
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
Experiential
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.
Candour
'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.)
Hierarchical
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.
Professional
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.
Biological
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.'
Trajectorial
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.
Aetiological
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.
Asher says:
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
Statistical
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.
Diagnostic
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 grâce is its insistence that every death be recorded with its cause, that is, a specific diagnosis.
Investigational
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.
Therapeutic
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 idée fixe, 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.