Category: AMBI

This morning we’re starting out with Bob Baker and the Hippocratic Oath. Again, on the oath, but from a different perspective this time, which should be interesting to hear. My education has largely conformed to what Bob Veatch taught the prior week, which I suppose makes sense when you consider who my teachers were. Stepping outside that lineage for a differing point of view is very CHID, and should be educational, at the very least, if not also entertaining.

Baker is talking about why we should still pay attention to the Hippocratic Oath, and why the history of medical ethics is important; which I’m not sure I understood Bob Veatch to say was not important, last week, but he gave us a lot of information, so I might have missed it. Or simply discounted it; as a history person (albeit a weird one), the idea of discounting the history of anything seems asinine and rather ludicrous; history provides both the narrative for our lives, as well as creates a Nietzschean genealogy that we construct ourselves from. (It’s times like these I wish my entire library was unpacked and sorted properly — wasn’t it Deleuze who gave us the more current reading of Nietzschean genealogy, illustrating the never-ending, never-beginning stories our lives are pieced from?)

Anyhow, Juanna’s book is coming up today, of course — this is the book Shapiro recommended I read, and I never got around to. It’s interesting that they’re going back to Eidelstein’s Oath, as I actually rejected using in my thesis, instead opting for Francis Adams’ version of the Oath. They are almost identical, but there are a couple of key differences, the sorts of differences that come up when you’re doing lit crit and interpreting individual words, as well as the words paired up and their meaning. This comes up with Larry having us read through the Oath, as well — something that quite tickles me, since Jon Moreno and I got into it last year, over how many people had read the Oath and how many versions. It was sort of sad that in a conference room full of people, he, Shapiro and I were the only ones who’d read it, let alone read several copies of it. For that reason alone, I’m glad that we’re covering it — even if it seems that we’re covering it in depth. I will prove Moreno wrong! (Even if it’s slowly and over a succession of years.)

So, Baker is saying that Bob Veatch wanted to discard the Hippocratic Oath and start over with something else, and that part of his tactic of doing so is to link Hippocrates to Aesclepeus, a religious cult pre-dating the Hippocratics. The supposed argument is that religion and religious cults should be written off, therefore so should the Hippocratic Oath. This doesn’t work for me, primarily because the first time I ever encountered the link between the Aesclepians and Hippocratics was in a comparative religions class, and something that stayed rather constant during all my time in the field. Quite obviously, the most evident link would be the caduceus, a twined snake around a staff. Snakes were the sacred symbol of Aesclepeus, able to heal and harm, depending on how they were used. Not only snakes, but twined snakes — the same twining snakes we see in our modern medical sigil.

Because I think genealogy is so important, that the narratives and history we encounter matters, I don’t think writing off the connection between these two groups as wishful thinking on the part of someone who’d like to go “bah, religion” (which I’m not terribly convinced of, either) is necessarily valid. It seems to me that it’s instructive to look at the origins of the Hippocratic Oath in conjunction and connection with Aesclepeus, and how the cult did what Karen Armstrong argues all successful religious offspring have done: co-opt some important pieces of the religion, but change it to your own needs. We can of course see the caduceus as co-opting, a way of taking legitimacy with them, while expanding broadly upon the Aesclepeans. For example, there was a general prohibition against touching patients, especially women, at that time. Yet now we know that touch in and of itself is incredibly therapeutic, and something that the Hippocratics did.

Philosophically and historically, I also have issue with the concept that Hippocratic medicine is successful because it endured. I don’t think endurance works well as an argument; it seems more like a conclusion constructed out of desire to support the Oath, rather than historically mandated. For, how long does something have to “endure” to be successful and working? Slavery existed until 100-odd years ago; it endured for longer than the Oath. Does this mean slavery worked? Galenic medicine was the norm for hundreds upon hundreds of years; it’s only been the last few centuries that we move away from it, and really took the advent of modern medicine (specifically concepts of cleanliness and antibiotics) to create a big change in how we practice medicine. Does this mean Galenic medicine was successful and should be kept around because it endured so long? I don’t think so — change, progress happens.

In this case, I think that’s exactly what happened — change happened. It’s not that medicine found itself screwed up and wrong in the 1970s, so much as medicine changed. Suddenly medicine, in a very, very short period of time (especially when you put it on the timeline of humans) changed rapidly and dramatically. We went, in a few short years, from being able to do nothing to being able to prescribe antibiotics to God Squading people and their lives. Medicine desperately needed help negotiating the new terrain of technology, because technology rapidly got ahead of medicine — and the Hippocratic Oath. It’s not a screw-up of medicine; it’s the confluence of medicine, technology and a culture that suddenly valued freedom and independence above all else. Things that medicine was not equipped to deal with; and like any doctor when faced with something s/he is not trained in, medicine did the only thing it could: it referred to outside help.

I do agree that it’s necessary to familiarize yourself with history, know your genealogy, and what is influencing the narrative you construct. I just don’t think that necessarily means holding on to the Oath; I think Bob Veatch still has it right, and while we should keep the baby, the bathwater has got to go.

~*~

Larry McCullough is, in no uncertain terms, a Texas gentleman. That is, he’s charming, funny, and has very sharp teeth. I found myself taking copious notes about the Texas act that I’ve to present on later this week, but otherwise simply listening to him talk and crack jokes. It was a nice downtime, and a chance to simply have the words wash over and rest upon me. I did find his conversion about Gregory particularly interesting when he loops both Bacon and Hume into it. Gregory uses Bacon because that’s the closest there is to an underlying concept of medicine (which doesn’t exist at the time — George Ingel being a bit away yet). Gregory defends the dignity of medicine because it was under attack, being ridiculed. And he did this using Hume’s idea of engaged concern and sympathy; this notion of experiential pain might very well be one of the earliest examples of an actual, engaged action of affect. Unfortunately, I don’t have a net connection at the moment; I’d love to do a quick Google and confirm my memory of Hume, through the Scots, having light exposure to Spinoza. This could be an interesting direction to trace the Anglicized notions of affect through, a sort of sideways and decidedly not postmodern history. Which, you know, if I can step away from Deleuze for a while, I’m all for it. Well, for that matter, do we even need to go through Hume for the Scottish influence? Gregory himself was in Edinburgh during the Scottish Enlightenment, which is about when Spinoza was brought over. Interesting — although I suppose this space is not the appropriate one for chasing my preoccupation with Spinozan affect.

Anyhow, McCullough is simply talking about early evidence-based medicine, and the virtues of giving attention to the patient as well as providing care and candor. Doing this, and conforming your practice to standards of evidence — of being a professional, in a way Glenn would probably approve the use of (since he did ask us to think about what a professional is) — is good medicine.

~*~

It’s towards the end of the day, now, for Liva’s lecture, which is a shame. I’m hurting, pretty badly, and having to ration out my medications. I can’t see anyone here until September, so I’ve to very carefully control my pain medication. Unfortunately, this means pain towards the end of the day, which significantly impacts my interest in anything at all. Add to that empiricism never being my forte, and it’s hard to concentrate. I prefer “pure” research, if you will — read and dream research. So far, this is reminding me of the last conference I presented at, on my thesis, where the psych students all asked me, after my presentation, what my research was. Where were my numbers? What was my p value? Where were my controls?

Sorry, can’t control Spinoza…

I’m finding it hard to keep up with the constant shifts, too, between whether or not we should or should not be considering law. I feel like, if we’re just looking at ethics, we get the law thrown at us (terrifically confusing for me, too, since I’m from states with radically different laws), and if we consider the law, we’re told to think in pure ethical terms. I feel like there’s got to be some signal, some switchsign, that I’m missing.

I’m tired and ready for today to be over.

It’s been a long week. I was supposed to go out this weekend with some people I’ve recently met, but opted instead to spend most of the day at Borders, using the wireless connection and trying to find my roots. Trying to laugh.

I know it’s cliché, but wow — people are different back here. I’ve always thought that the idea of the abrasive, confrontational New Yorker was, well, fiction. Something that might have been a relic from an earlier time, taken by writers and comedians and ran with. I would be wrong in that assumption. I fit the West Coast — laid back, relaxed, not terribly concerned with protocol. Although I think I’ve surfed maybe three times in my life, I feel like the out of place surfer moved somewhere strange and landlocked, sticking out like a sore thumb, wanting to go back where everything is familiar. Where I know the rules of the game, how it’s played, how to play it.

But I’m stuck here, in this confrontational and blunt world, and going to instead suck it up and work on my CV, and try to focus on the bright points of the prior week. I just wish they weren’t so much like lightning bugs, fleeting and impossible to hold for long.

Sue’s lecture today comes at a timely period, when we begin to discuss the idea of testing pharmaceuticals on captured populations, quite literally: prison populations. Of course, AJOB itself, in its most recent issue, has an article discussing equipoise in research, and the idea of testing on indigenous populations being ethical because it would do them good to get at least the established, beneficial drug. I’ll spare you my thoughts on that AJOB article’s argument at the moment, and instead focus back on what Sue talked about, which was drug trials, and specifically (of course) Nazi experimentation.

Of course everyone knows that the results of the Nazi experimentation was the trial of 25 Nazi personnel, and the establishment of the Nuremburg Code — a code that, somewhat ironically, was first adopted in the United States by the US military (I believe the Navy first, although they were so quickly in succession of one another it really doesn’t matter, unless you’re a military brat looking for bragging rights).

The interesting question behind Nuremburg is the idea of the trial itself. What standards do you use to try someone for something that you recognize is a crime, yet there are no laws or regulations explicating the crime? How do you go about a fair trial without imposing one culture’s standards on another, yet not going the way of moral relativity, either?

Of course, on top of that, with the Nazi’s you have the question of what to do with the entire German medical population, as well as the data culled from the experiments the Nazi’s conducted. Some people adamantly want the data locked away and never seen, while others think that some good should come from the horror — both opinions held by actual survivors of the experimenters.

On the side of how to you judge, I don’t fall into Kant’s ideals of a universal morality, so I think you’ve to be careful about imposing others cultural standards on a culture that is not their own. So, I suppose I think that Rawls offers us the easiest out, in his veil of ignorance. I’m sure it’s an inaccurate perception, but I do feel like that gives us at least a slightly more neutral answer.

What to do with the doctors? Well, post-WW2, we regulated and watched Japan’s military — seems that regulating and watching Germany’s medical professions is the equal answer. Simply run oversight until you’re convinced they can do it on their own, when a generation not participating in the war has been raised. Is that too simplistic? It feels as thought it must be.

So far as what to do with the Nazi data… I have always fallen in the camp that something useful should be done with the data. That it should be clearly acknowledged where the data came from, the horror of the methodology (if you opt to be so generous as to call it methodology), but the value that can be extracted for fellow man. Don’t let the pain and suffering go to waste! I realize, though, that this is a controversial view, and as I’ve gotten older, and perhaps more enmeshed in the bioethical field, see the other point of view as well.

~*~*~*~

I took a break during Sue’s lecture today to use the restroom. Instead of returning to the classroom, I sat on a window ledge and leaned back into the sun. The temperature was finally near perfect — cool, but the warmth of the rays of sunlight bathing me, taking the knife-edge off the chill.

I watched a large, white cloud, fluffy and cottony, breeze slowly across the impossibly blue sky, the green of the tree leaves outside the window standing in stark, rich contrast against the yellow-y orange brick of the building across from me.

Tension melted under the light, and there was just this moment of rich synergy and rightness with the world. A week later, and when I have the chance to quietly reflect on, not necessarily the class, but the opportunity being given to me, I remain in complete awe.

Today Bob finished his lecturing, wrapping up the four distinctions in avoiding killing, and running through the different states of competence in patients. It was technical in rattling off lists fashion — he was obviously in a hurry to finish his data — and there wasn’t a lot of deliberative information. Of course, I suppose in part I feel this way because I’ve had Bob’s texts assigned in the part, and none of this information is particularly new — I’ve debated and argued over it, and honestly don’t remember a lot of the debate. Nor did I find there much today; Bob ignored a lot of questions in order to move forward, and those that were asked were along the line of challenging his authority to even explain the distinctions and his knowledge of philosophy, the sort of questions that just make me groan and wish I was in another room.

What I did find interesting was that the Josef Kamp case was not resolved by the bioethicists, or the family, or even the doctors. In the end, the family likely saw that their wish was honoured, and Josef was kept alive until Allah took him home. No convincing to change beliefs or treatment, just a lot of agonizing debate in the background, which ultimately came to naught as Josef’s ravaged body gave out and refused resuscitation.

I would have liked to know how Bob felt about this, how the doctors felt about it, and how the parents felt about it. All the people involved, what was their emotional reaction to this end? As this week is ending, I find myself shifting away from the law and more towards the emotion, which is probably a good shift. (Or at least, one where I can play, since I have no aspirations to practice law.) And this makes sense, it is in line with my thesis research. How are we connected? How do we feel about each others actions, how do our actions impact, affect others?

How did Josef Kamp’s death affect everyone surrounding him?

While Bob didn’t answer this question, he did tell us a beautiful story, one that grounded me back in my feelings and emotions. While I did shift from worrying about law (and especially worrying about my utter lack of NY State law, and the frustration I felt at things shifting from ethics to law to being told I was clueless) to thinking about emotions, it took a distancing first, where I felt very cold and remote from the subjects we were talking about. Passion, fire, drive, it was all behind a wall, allowing me to think but not experience. Bob yanked this wall down with a simple story. A beautiful story.

I cannot do justice to this story. I can’t tell it on paper (digitally) in a way that will move you the way Bob’s voice will move you. I cannot make this text crackle with tears and restraint. It’s a simple enough story, of death in an ICU. The sadness comes in the hopelessness, in the knowledge of the pain of the death, for the patient and the family. A girl, dying in the ICU, blinding fluorescent light in her eyes that the nurse wouldn’t allow turned off, despite her begging pleas, parents unable to spend more than 5 minutes at a time with her due to The Rules, no chairs in the room, no privacy, nurses not bothering to cover the dying girl’s body because she kept throwing the blanket off, and it irritated them. The futility Bob felt, inability to help her, do more than stand there and touch her and wish he could do more as he accompanied her life to its end. Her painful, long and lonely death in that hospital. And Bob’s decision, as he witnessed this, to do his best to make sure no one else ever had to die that way again.

Beautiful, moving, touching.

I’ve thought, since the story, about this. About the fact that we all have stories that have moved us to wanting to make this difference, practicing bioethics, to get involved in the debates and decisions between doctors, patients and families. And I’m curious what those stories are — I’d love to be able to simply go around and ask people to tell me their story, to record it, to see if there are similarities, and note the differences. Are we all motivated by the same thing? What variety is there in our emotional, moving story or stories? Is there a single clear point, as there was for Bob, or is it a composite of experience?

It’s the ultimate philosophy question honed to a specific field, isn’t it? Why, why are we here?

Today we deviated for a while on the idea of consequentialism and non-consequentialism; I wonder why some philosophy hasn’t been required for the LIM students, at least, or having a glossary of terms available in the Giant Book of Doom? Might have saved us a lot of debate on whether or not these terms are actually in existence, real, true, etc and so forth (to list three of the basic arguments offered). Lisa Newton has a great, three or four page explanation of the terms, in a basic ethics book, that would work really well as a simple explanation and catching up document for people. That’d be today’s suggestion for improvement.

Anyhow, this comes up because Bob wants to look at actions we can use, aside from the guidelines of the Hippocratic Oath, to practice medicine. What is there aside from beneficence/non-maleficence? I’m looking forward to this, because I find the Hippocratic Oath limiting. I think not enough people take enough consideration in the restrictions about deadly drugs, abortions, and surgery — these things are there, and I’ve read several explanations as to why, but few people seem to acknowledge it. My favourite pet theory is that the Hippocratic Oath was the oath for one variety of doc, and there was likely oaths available for people who provided abortions, performed surgery and were apothecaries. But, I am also very indoctrinated into the idea of there being four principles to the ethics of medicine, and I feel like the Hippocratic is missing the principle of autonomy (in fact, it’s heavily paternalistic) and justice. Of course, if you have a theory of medicine that doesn’t recognize autonomy, you have no concept of informed consent.

Another issue I do have with the Hippocratic Oath is that gender stereotyping is built in to our early medicine, and because of that, it is also built into the Oath. How useful is something written in heavily gendered language? Yes, we can understand the culture and the time and say “this was the norm” — but the norm was to treat women as a second class, and that’s in the language itself; should we continue to respect that language? (The AMA certainly doesn’t. While you might argue that it’s a Hippocratic-derived oath, it’s nothing like the Oath itself, and in fact seems to drift away from Bob’s quadrant of individual consequentialist on his diagram and towards a more middling social non-consequentialist oath.)

Bob left us with the first of four distinctions to avoiding killing, and in our conversation after I jumped the gun to the third distinction, which is the doctrine of double effect, an idea I still find extremely interesting — I wish we had been able to spend more time on it, especially time reflecting on the ethics of double effect.

“There is, I assure you, a medical art for the soul. It is philosophy.” —Cicero

Aaah, Cicero, Epicurus, and laughter — it must be time for Glenn to lecture again. The amount of off-the-cuff quotes I have in my notebook are amusing, but I’ll spare you those and just add them to my signature file.

Today Glenn passed out Martha Nussbaum, bringing me back, once again, to my undergraduate education. Of course, I’ve never read this particular Nussbaum, but I’ve read enough and I’m not terribly fond of her. It was hard to not visibly groan and roll my eyes at the idea of a two hour lecture on Nussbaum; hearing that it was going to be a dramatic misreading was, at least, a cheery note.

The misreading itself is very interesting, and based on the Cicero quote above: medicine is just a philosophy, and that ultimately, medicine is philosophy. You must treat the holistic body, and in order to truly heal the body, you must treat the soul. Chrysippus, whose name I’m undoubtedly misspelling, says that “philosophy is supranumerary to medicine in therapeutic treatment.” The person who seeks to assuage suffering, then, must understand philosophy — an argument I suspect that Eric Cassell would strongly agree with. Suffering, after all, is distinct and separate from pain. Pain is a physical response, something that echoes through-out the body, in the nociceptive system. Suffering, on the other hand, is a non-corporeal concept, something that depends on several non-tangible and non-physical criteria. You must have enough consciousness to be aware of time, of past and present, as well as future, because you must be able to apply an experience of pain to the future, anticipating further pain. This anticipation is suffering.

Treating suffering, then, is not the same as treating pain. I think we most clearly see this in the treatment of chronic pain diseases, or painful terminal illnesses. It’s been shown, time and again, that simply the knowledge that adequate pain relief is available is enough to reduce the suffering of those in pain — without having to take any medications. So you can treat pain all you want, but still have a sick, suffering patient. The patient needs to be assured that their fears of future pain have been addressed, and are not valid. To do that takes more than just psychology, I think it does take the techne of philosophy.

I do have to wonder if the most difficult thing in this world really is being trustworthy. A quote from Buffy the Vampire Slayer says that the hardest thing in this life is simply to live, which rings a lot truer and broader than ‘simple’ trust.

* This must, of course, be said as Val Kilmer’s Doc Holliday (Tombstone) would say it, for maximum humour.