Caruncho and Fernandez interpreted Chopin's hallucinations as
temporal lobe epilepsy.(1) Recently, Karhausen examined the 140 causes of
death of Mozart that have been proposed in the medical literature.(2)
These studies on both composers nicely illustrate how a mechanistic view
of death and disease still dominates modern medicine.
Identifying the cause of death can be difficult. Many physicians will
share the e...
Caruncho and Fernandez interpreted Chopin's hallucinations as
temporal lobe epilepsy.(1) Recently, Karhausen examined the 140 causes of
death of Mozart that have been proposed in the medical literature.(2)
These studies on both composers nicely illustrate how a mechanistic view
of death and disease still dominates modern medicine.
Identifying the cause of death can be difficult. Many physicians will
share the experience that one is sometimes uncertain about the cause of
death. In these instances, cardiac arrest is often written on the death
certificate, which almost seems true by definition; the heart stopped
beating. Intuitively, physicians realise that the mechanistic view of a
single cause and a single effect is not always appropriate. Death
certificates and national statistics however demand the identification of
a single cause of death.
In a seminal paper, Rothman has argued that death and disease seldom
have single causes.(3) His model of causation identifies multiple
components. Sufficient causes are subdivided into component causes. This
model illuminates important principles as multi-causality, the dependence
on the strength of component causes and interaction between component
causes. In his view the death from a fall is caused by the combination of
e.g. visual problems, a loose rug, osteoporosis and sarcopenia. This has
important consequences, since it is therefore recognised that intervention
with any of these component causes is important to prevent the formation
of a sufficient cause for the fall.
In the next century, people will live longer lives without
disabilities.(4) The challenge in the future will be to manage elderly
patients with multiple chronic diseases. A mechanistic view of single
causes of death and disease is not appropriate for our growing population
of elderly patients. A more widespread appreciation of the multi-causal
nature of death and disease could be an important step to successful
ageing in the next century.
1. Caruncho MV, Fernandez FB. The hallucinations of Frederic Chopin.
Med Humanities 2011 doi:10.1136/jmh.2010.005405
2. Karhausen LR, Mozart's 140 causes of death and 27 mental
disorders. BMJ 2010; 341:c6789. doi:10.1136/bmj.c6789
3. Rothman KJ, Greenland S, Stat, C. Causation and causal inference
in epidemiology. Am J Public Health 2005; 95:s144-s150.
doi:10.2105/AJPH.2004.059204
4. Perenboom RJ, Van Herten LM, Boshuizen HC, Van Den Bos GA. Trends
in disability-free life expectancy. Disabil Rehabil. 2004 Apr 8;26(7):377-
86.
I read this article with great interest, as it relates closely to my
own practice teaching final year students in the Middle East. An important
outcome of our family medicine clerkship in the UAE is the ability to
reflect - upon oneself, one's patients and the healthcare system within
which the students work.
Many students find this type of analysis difficult. Part of this may
be related to...
I read this article with great interest, as it relates closely to my
own practice teaching final year students in the Middle East. An important
outcome of our family medicine clerkship in the UAE is the ability to
reflect - upon oneself, one's patients and the healthcare system within
which the students work.
Many students find this type of analysis difficult. Part of this may
be related to language, as alluded to in this article. They are taught in
a second language, English, which for them is the language of textbooks,
lectures and examinations. However the language of their inner feelings
will be their own tongue, Arabic. Hence expressing their personal thoughts
in another language may be more difficult than we appreciate.
However there is another factor which may obstruct students being
able to reflect and draw lessons from their experiences. Our students in
the UAE are from a society with a strong tribal tradition. Tribal
societies used to involve rivalry and suspicion between different groups.
Individuals had to appear strong; admitting weakness or inability made one
vulnerable to attack.
I feel this mindset has been passed down to the current generation.
If so, this limits how much students can be honest with others about
mistakes, or be open about their feelings of inadequacies. Medical
teachers trying to teach reflective practice in settings like Malaysia and
the Middle East must take such cultural barriers into consideration.
Pekka Louhiala argues that "there is no alternative medicine" because
"it escapes a meaningful definition, and 'alternative medicine' cannot
be clearly differentiated from conventional medicine" [1]. I do not
consider that his arguments are valid.
Louhiala does not mention the proposed definitions for "alternative
medicine". For example, Eisenberg defined alternative medical therapies
as "interventions neither taught...
Pekka Louhiala argues that "there is no alternative medicine" because
"it escapes a meaningful definition, and 'alternative medicine' cannot
be clearly differentiated from conventional medicine" [1]. I do not
consider that his arguments are valid.
Louhiala does not mention the proposed definitions for "alternative
medicine". For example, Eisenberg defined alternative medical therapies
as "interventions neither taught widely in medical schools nor
generally available in US hospitals" [2]. Cochrane collaboration
defined: "Complementary and alternative medicine (CAM) is a broad
domain of healing resources that encompasses all health systems,
modalities, and practices and their accompanying theories and beliefs,
other than those intrinsic to the politically dominant health system of
a particular society or culture in a given historical period. CAM
includes all such practices and ideas self-defined by their users as
preventing or treating illness or promoting health and well-being.
Boundaries within CAM and between the CAM domain and that of the
dominant system are not always sharp or fixed" [3]. I do not consider
that these definitions are exhaustive, but they capture what I think is
the most essential.
These definitions consider that the relevant factor for setting up
the boundary around alternative medicine is by the lack of social
acceptance within mainstream medicine. Thus, alternative medicine
consists of interventions that are outside of the "conventional" or
"medical school" medicine. The definitions above do not consider
whether a treatment is effective or not. Effectiveness is located on a
different dimension and it is not part of a relevant definition for
alternative medicine.
Louhiala formulated numerous arguments that do not teach us anything
about the usefulness of the concept of "alternative medicine". Although
I agree that in many cases "modern medicine is much more varied in its
approaches than the propagandists for alternative medicine usually
imply", this statement does not imply any conclusions about the concept
of "alternative medicine".
I do not agree with Louhiala's statement that "alternative medicine
means that the other option is rejected". For example, many of my own
patients describe that they also use some forms of alternative
therapies, but they do not reject me therefore. Nevertheless, whatever
our opinion on this issue
is, that has no importance to the question whether "alternative
medicine"
is a useful concept.
I disagree also with the statement that "if a genuine alternative
medicine did exist, it should produce results that are similar to those
of ordinary medicine". There is much treatment variation
within mainstream medicine, and thus there is no uniform "treatment
result" to which the results of alternative therapists
might be compared unambiguously. Furthermore, when we accept the rather
large treatment variation within mainstream medicine, why should we not
accept variation between mainstream medicine and alternative medicine.
In any case, this issue does not seem relevant to the question whether
the concept of "alternative medicine" is useful.
I agree with the statement that "alternative medicine cannot be clearly
differentiated from conventional medicine". There are numerous cases
where the border between neighboring concepts is fuzzy. Internal
medicine cannot be clearly differentiated from general practice
medicine (e.g. both treat hypertension). Children cannot be clearly
differentiated from adults (e.g. teenagers are biologically adults but
psychologically children). However, the lack of a clear differentiation
does not imply that "internal medicine" or "child" are useless concepts.
Louhiala states that "bundling all the so called alternative therapies
under one heading is misleading. It is hard to see common features
between, say, healing using prayer and healing using megadoses of
vitamins." If alternative medicine is defined by the lack of social
acceptance as described above, that provides an unambiguous
justification to put prayer and megavitamins under the same heading.
Furthermore, there is great variation in the approaches within the
mainstream medicine from surgery to pharmacology to psychiatry. If
Louhiala's argument is valid, we should not bundle such different
methods under the one heading of "medical school medicine".
Louhiala states that "alternative medicine" is a buzzword, which may be
true in certain contexts. However, in mainstream medicine, there are
numerous buzzwords. Laser surgery, computed tomography, broad-spectrum
antibiotics, and many others are in certain contexts used to "impress
laymen", but that has nothing to do whether those methods are useful,
or whether those terms are linguistically sound.
While Louhiala criticizes the vague definition of "alternative
medicine",
he does not consider the definition options for "homeopathy". When I
was young, I studied biochemistry and got a PhD
degree. At that stage of my life, I defined homeopathy as "diluting a
substance to such an extent that there are no molecules left in a
spoonful". Thereafter I studied medicine.
When I started to work as a GP, I realized that there is a
fundamentally
different second definition for homeopathy: "a person goes to a
homeopath and stays there for some time and then leaves". If we ask
whether homeopathy is beneficial for a patient, we should first define
what we mean by "homeopathy", but this was not done by
Louhiala.
In catholic countries, sometimes people go to see a priest for a
confession. I believe that the confession often decreases the anxiety
of a person, and in that respect it leads to positive health
effects. This health benefit has nothing to do whether we think that
there is evidence for God. Similarly, homeopathy as an encounter can be
beneficial for a patient because visiting a homeopath is much more than
biochemistry.
While working as a GP, I have realized that a large
part of the positive health effects that I am generating on my patients
are caused by listening and speaking. Why should we assume that a
priest or a homeopath is incompetent at such an activity? I have seen
many physicians who are rather poor in their communication with
patients. Compared with them, an average priest or homeopath probably
generates greater improvements in health if the major problems of the
patient are
anxiety and depression.
On average, alternative therapists may have better bedside manners than
physicians [4]. Time spent with each patient by an alternative medicine
practitioner
usually exceeds that spent by the average physician. Alternative
medicine practitioners provide patients with understanding, meaning,
and self-care methods for managing their conditions. These elements
are often lost in the subspecialization, technology and economics of
mainstream medicine.
Furthermore, even though it is paradoxical, in some cases homeopathy is
better pharmacology than some popular treatment options of physicians.
If a patient has a viral respiratory infection and a homeopath treats
the patient with a highly diluted solution, the product will not cause
harm. If the same patient goes to a physician and gets antibiotics, the
benefit is non-existent there too, but the harm is not [5,6]. In such a
case, it is the homeopath who follows more closely the guidance "first,
do no harm."
I have a long lasting interest in the concept of alternative medicine.
My personal interest largely arose from my long term research on
vitamin C and the common cold, mainly by carrying out systematic
reviews from various points of view. In the latest version of our
Cochrane review, we pooled the results of 29 placebo-controlled
comparisons measuring the effect of regular >0.2 g/day of vitamin C
[7]. We found that vitamin C shortened colds in adults by 8% (P=0.0002)
and in children by 13% (P=0.0003). In 5 trials with participants under
heavy acute physical stress (3 of them with marathon runners), vitamin
C reduced
the incidence of colds by 52% (95% CI: 36% to 65%; P=0.0000006), but we
found strong evidence with a narrow confidence interval that vitamin
C does not prevent colds in the general population.
Given that there is such a strong evidence, mostly from trials
published already in the 1970s, that vitamin C differs from the
placebo, why does
vitamin C fall under the heading "alternative medicine"? Textbooks on
medicine, infectious diseases, and nutrition have claimed over decades
that vitamin C is useless for the common cold [8-10], and systematic
bias against vitamins in general has been documented in the major
textbooks of
medicine [11,12]. In a Dutch survey, 47% of GPs considered that
homeopathy is efficacious in the treatment of the common cold, whereas
only 20% of the respondents considered that vitamin C was [13]. In a US
survey, 21% pediatricians considered that homeopathy may be effective,
and 21% considered that high-dose antioxidant vitamins may be so (e.g.
vitamin C for the common cold) [14]. Thus, vitamin C is comparable with
homeopathy, and in some cases the credibility of vitamin C is even
lower.
While I was wondering the puzzling discrepancy between the positive
findings in the placebo-controlled trials on vitamin C and
the classification of vitamin C under the heading alternative medicine,
I
started to think that the most relevant way of defining "alternative
medicine" is by the lack of social acceptance. This notion was
formulated to
explicit definitions by other authors [2,3].
Evidence-based medicine emerged because several physicians realized
that many treatments taught at the medical school were useless and
started to speak about it loud. Thus, when a treatment falls into
the
category of "medical school medicine", that will not prove that the
treatment is effective. My own observations on vitamin C showed that if
a treatment falls into the category of "alternative medicine", that
will
not prove that the treatment is ineffective. Thus, social acceptability
and effectiveness are located on different dimensions, and it is the
former that is relevant if we search for a reasonable definition for
alternative medicine. I consider that in his paper Louhiala ignores the
main characteristic that defines alternative medicine [2,3].
At the end of his paper, Louhiala comments that "demand that
alternative medicine be taught in medical schools and/or financed
through public funding has no foundation whatsoever". I disagree also
with this opinion.
Louhiala does not define what he means by teaching. It is possible 1)
to teach the practical methods; how to carry out alternative therapies
at one's own office or 2) to teach about the most usual types of
alternative therapies in a descriptive way, so that a medical student
better understands our surrounding society.
If we follow the definitions described at the beginning of this
comment, it is logically impossible to teach medical students how to
start using alternative therapies, because including a therapy in the
medical school curriculum removes the status "not taught at medical
schools". The therapy that was "alternative" is not so any more.
On the
other hand, I cannot see any basis to oppose the second kind of
teaching. The purpose of education should be to increase understanding
why patients use alternative medical treatments, learning how to ask
about and discuss alternative treatments in a nonjudgmental manner,
learning which therapies can be harmful, and
understanding the basic tenets of the most common alternative healing
systems [15-17].
Furthermore, Louhiala's final comment is illogical. Given that he
states that "there is no alternative medicine", how could "alternative
medicine" be used as a criterion for not financing some activity - if
there is
no alternative medicine.
The purpose of my commentary is not to increase the social
acceptability of alternative medicine. I point out that the lack of
social
acceptability seems to be a reasonable basis for defining
alternative medicine [2,3], but this was not considered by Louhiala
[1]. I do not
hope that the use of homeopathy increases, instead I hope much the
contrary. Nevertheless, the question about homeopathy is more complex
than whether it is absurd from the biochemical point of view.
A Google search with the term "alternative medicine" finds over 10
million
web pages and one survey reported that 40% of Americans had used
alternative treatments over the preceding year [2]. I think that it is
much more fruitful to contemplate on the nature of alternative medicine
[3,4,15-22], instead of trying to argue that such a field does not
exist
[1].
I believe no mental patient should have family members make decisions
for them, as this can make the patient even more irritable. Ask the
patient what they want to achieve. Just like when someone is dying you
wouldn't disrespect their wishes.
You might also be interested in the character of Doctor Bompard (is
this name a French pun?) in Jules Romains' The Body's Rapture and his
long speech towards the end of the book, pages 428-429. This is not
specifically about medicine, though Bompard is a ship's doctor, but about
the purported march forward of science and philosophy since the Renaisance
and of course refering back to the ancient Greeks. In this case it i...
You might also be interested in the character of Doctor Bompard (is
this name a French pun?) in Jules Romains' The Body's Rapture and his
long speech towards the end of the book, pages 428-429. This is not
specifically about medicine, though Bompard is a ship's doctor, but about
the purported march forward of science and philosophy since the Renaisance
and of course refering back to the ancient Greeks. In this case it is not
claimed so much that this is all fraud and self serving deception on the
part of the practitioners but more that people, perhaps the patients
themselves, choose this course rather than confront or deal with
instances in their lives not easily open to rational explanations. Better
the spurious rationality of the medical/ scientific/ philosophic poseur
than the discomfort of the unknown, the unknowable sometimes or the
frankly uncontrollable. He actually makes quite a sympathetic case for
this attitude, a reaction against existance too much in the grip of
propitiating irrational, unknowable forces but nevertheless criticises its
bad faith.
The article “Medical paternalism in House M.D”. by M R Wicclair in
Medical Humanities 2008;34:93-99 made for interesting reading. However
there is one point which needs further clarification in the context of
English Law.
The author states “Informed consent—the principle that, except in
emergency situations, medical interventions require the voluntary and
informed consent of patients or their surrogates—is a core ethical...
The article “Medical paternalism in House M.D”. by M R Wicclair in
Medical Humanities 2008;34:93-99 made for interesting reading. However
there is one point which needs further clarification in the context of
English Law.
The author states “Informed consent—the principle that, except in
emergency situations, medical interventions require the voluntary and
informed consent of patients or their surrogates—is a core ethical
principle in healthcare”.
The law surrounding the refusal of medical treatment, including life-
saving treatment, seems clear: the competent patient has the right to
refuse treatment, and medical treatment without consent, or in disregard
of a valid advance refusal, amounts to a battery(1). Only if a patient is
incompetent and no valid advance directive is in place, can the patient's
treatment refusal be overridden in the patient's best interests(2).
However in Re T (Adult Refusal of Medical Treatment)(3), Lord Donaldson
stated that there was a misconception that the next of kin could be
consulted regarding consent in an emergency situation because the next of
kin had no legal right either to give or refuse consent on behalf of
another. Hence this differs from the authors comment that surrogates/next
of kin’s can provide informed consent for a patient.
Word Count- 200
References-
1.Airedale NHS Trust v Bland [1993] AC 789 (HL) at 882 per Lord
Browne-Wilkinson; Re T (Adult: Refusal of Treatment) [1993] Fam 95 (CA) at
102 per Lord Donaldson MR; Re MB (Medical Treatment) [1997] 2 FLR 426 (CA)
at 432 per Butler-Sloss LJ; R (on the application of Burke) v General
Medical Council [2005] EWCA Civ 1003 at paras 31 and 57 per Lord Phillips
MR; Re AK (Medical Treatment:Consent) [2001] 1 FLR 129
2.Based on the necessity defence, see Re F (Mental Patient:
Sterilisation) [1990] 2 AC 1 (HL) at 78 per Lord Goff; Bland, above n 1 at
883 per Lord Browne-Wilkinson; Re T, above n 1 at 103 per Lord Donaldson
MR
3.Re T (an Adult: Refusal of Medical Treatment) [1992] 3 W.L.R. 782
at p. 786
Dear Editor:
In the editorial written by Deborah Kirklin, "Lessons in Pity and Caring
from Dickens to Melville" (Medical Humanities 34: 57 2008)I found it
interesting and refreshing to read her perspective on the character
Gregory House from the popular television series "House M.D." I have
noticed many articles referencing paternalism and the popular television
series "House," but Kirklin makes an interesting point th...
Dear Editor:
In the editorial written by Deborah Kirklin, "Lessons in Pity and Caring
from Dickens to Melville" (Medical Humanities 34: 57 2008)I found it
interesting and refreshing to read her perspective on the character
Gregory House from the popular television series "House M.D." I have
noticed many articles referencing paternalism and the popular television
series "House," but Kirklin makes an interesting point that I have not
read which is "House" as "a doctor who is willing to risk it all to
fulfill his duty of care to his patients."
What I find peculiar about this character that also coincides with
Kirklin's observations, and which I have seen nothing written, is the
fact that he is also wounded (physically and emotionally)and we do get
glimpses of his "heart," but that too, is wounded. He has wounds we can
see. There is, of course, a hint of "Prometheus" in this character. His
suffering is alleviated only temporarily by the delivery of narcotics, but
he remains a sufferer. He knows something about suffering and thus, has
something in common with his patients. He is both wounded and cannot heal
himself, but will care for his patients at any cost. I hope to see this
angle addressed at some point.
I do think that many of our physicians in "real life" are wounded,
and through their work, they are wounded over and over again. I am not
sure what we want from them. What does concern me, is that in our medical
education system we have the ability to siphon the compassion right out of
them. There is something terribly wrong there.
This was my first copy of The Journal of Medical Humanities and I am
very pleased with Kirklin's articulate editorial and the overall content
of the journal.
In the article by Volandes titled Envying Cinderella and the future
of medical enhancements (1), Medical Humanities 32: 73-76, 2006, the
author highlights the ethical dilemma of providing medical enhancements
for patients while corroding the moral priority that it has traditionally
held as a profession, namely retaining a position of trust based on
professional judgment and advocating for patient's...
In the article by Volandes titled Envying Cinderella and the future
of medical enhancements (1), Medical Humanities 32: 73-76, 2006, the
author highlights the ethical dilemma of providing medical enhancements
for patients while corroding the moral priority that it has traditionally
held as a profession, namely retaining a position of trust based on
professional judgment and advocating for patient's health interests. Many
view cosmetic enhancements as the correction of some morphologic traits
not accepted by the patients rather than correction of a pathological
disorder, and with these physical enhancement technologies, patients may
improve their psychological self-esteem and/or body image (2). Based on a
recent report, while evidence does not justify the continued general
provision of cosmetic surgery in the absence of pathological disorders, it
is not strong enough to justify withholding such treatment (3). Volandes
also suggests that a pay-for-use cosmetic surgery may supplement and/or
support the health care of those less fortunate. Yet why does one
patient's desire to improve their psychosocial function require
justification? The reallocation of cosmetic health care dollars for
patients without health care may be a useful endeavor; however implication
of such a system would devour any financial gain. We would not deny a
disfigured individual reconstructive plastic surgery to better their
physical and psychological self if supported through a government financed
health insurance program. Why should we envy those who chose elective
cosmetic surgery? Furthermore, with the disadvantages, elective cosmetic
procedures should only be carefully and wisely considered.
Beauty is more than skin deep.
1. Volandes, A. 2006. Envying Cinderella and the future of medical
enhancements. Med Humanit 32: 73-76.
2. von Soest T, Kvalem IL, Skolleborg KC, Roald HE. 2006.
Psychosocial factors predicting the motivation to undergo cosmetic
surgery. Plast Reconstr Surg 117(1):51-62.
3. Cook SA, Rosser R, Salmon P. 2006. Is cosmetic surgery an
effective psychotherapeutic intervention? A systematic review of the
evidence. J Plast Reconstr Aesthet Surg. 59(11):1133-51.
This response to T J Papadimos outlines some of the relevant elements
in Nietzsche’s philosophy in order to develop its conclusions. We find
that Papadimos’s attempt to illuminate the causes of litigation against
doctors in America fails through misunderstanding the analysis of
convention and the idea of the superman in Nietzsche’s thought.
Papadimos’s perspective [1] is rather odd, he points out that
‘Medical...
This response to T J Papadimos outlines some of the relevant elements
in Nietzsche’s philosophy in order to develop its conclusions. We find
that Papadimos’s attempt to illuminate the causes of litigation against
doctors in America fails through misunderstanding the analysis of
convention and the idea of the superman in Nietzsche’s thought.
Papadimos’s perspective [1] is rather odd, he points out that
‘Medical malpractice is of increasing concern ...’ (p 107) ie the
physician’s improper or negligent treatment of the patient is worrying,
but seeks a remedy in reducing patients’ litigiousness rather than
improving medical practices. He suggests that ‘a primal cause of the
litigiousness of the public against doctors results from resentment or
“ressentiment” ’(p 107) but avoids stating the relationship between
medical malpractice and resentment, perhaps because it is too obvious. He
understands such litigiousness to have its 19th century source in the
American courts relaxing ‘the standard for institution of civil tort
suits’ (p 107) but this remark does not indicate or explain the required
just standard between doctors’ practices and patients’ health outcomes.
Instead he seeks to offer Nietzschean ideas to explain and reduce the
public’s apparent litigiousness against doctors.
Papadimos is a sympathetic observer of the health of American
society; he thinks the medical community ‘must encourage health care for
all’ (p 110) but the Nietzschean vehicle he has adopted to reduce
litigiousness does not fire on all cylinders. The analysis he has
developed bears little resemblance to Nietzsche’s thought, and it does
remind us that Nietzsche is a subtle writer who does not expose his
thought to the casual reader.
What one has in essence in health care in this context is one social
group providing benefits for society at large. Generally the medical
professions are highly privileged relative to their recipients and the
legal business is available to protect them and their adversaries, but
Papadimos sees resentment as the problem, and from his adopted German
perspective refers only to the doctor’s adversaries. He offers too, the
ambitious solution ‘to limit their exposure to litigation’ (p 107) by
doing some philosophy on the causes of ‘patient / doctor conflict’ (p
107).
Digression on Nietzsche
Nietzsche talks of noblemen as the ancient originators of the idea of
good, but from this myth after a long social process is developed the
fruit which is the sovereign individual or, for convenience ‘superman’.
There may be a number of such supermen at any one time but there would not
be according to Nietzsche a group of them pursuing similar ideals: pace
Papadimos, the idea that doctors as a group would be supermen is not a
concept one could gain from Nietzsche. In giving an account of this apex
of mankind in Nietzsche’s thought an essential element is the idea of
overcoming one’s indoctrinated self, ie gaining an intellectual
independence from conventions. Social forces for Nietzsche are invaluable
in starting the training of the individual to allow him to overcome the
cultural constraints. But we need more: the picture is of the primitive
senuous being gaining a disciplining culture to impose a form on the
bodily feelings but the culture must then be transcended to allow the
development of the impassioned and independent superman. Darwin’s idea of
the survival of the fittest in a species, or that survival is the purpose
of life, is countered by Nietzsche’s method of developing the controlled
passion of the individual: his ideal is the vigorous individual who has
control of himself and his environment.
He opposed Christianity for elevating weakness in society and
imposing control on the individual from outside him; and secular morality
too is rejected as an abstraction from the individual. He sees the mass
of people as cloistered by conventions; these ‘herd values’ replace
individual initiative by passivity. Even the life of reason is denigrated
by him for it assumes the reality of truth and objective standards of
value. The resulting social failing is, for Nietzsche, that the feelings
of the conventional man are interpreted and constructed by the social
ideas around him; a paradigm of this is the influence of the religious
perspective. Nietzsche’s ideal of the strong individual is not a social
ideal; each superman makes his own individual values out of his biological
passions; the resultant ruthless life would justify itself. On this
perspective, to affirm life is to create your own values, and when this
brings you into conflict with others, you must sweep them aside.
We can see that Nietzsche does not regard society as an end in itself
or as a self justifying condition of man. The importance of society for
him is that it provides a breeding ground for the ultra strong person. In
this context his outstanding individual essentially attains his high
status because of his individual passions. What social forces do for the
potential superman is to discipline his passions: the controlled passion
of the individual is then the vehicle for his superiority. Darwin’s
theory of the survival of the fittest takes its context from the group, ie
in a competitive situation the better adapted individuals do better; they
are better adapted to a particular situation; ie their powers or abilities
are good relative to something outside them. What Nietzsche is resisting
here is the complete adaptation of the individual to the social
environment: the superman is superior because of his inner constitution.
As he becomes more himself in his progress to controlled passion he
elevates himself over the social forces which have disciplined him but not
changed his nature: the superman pulls himself up by his own bootlaces.
Nietzsche remarks that ‘Insanity in individuals is something rare – but in
groups, parties, nations, and epochs it is the rule’ (Nietzsche [3], maxim
156). He sees in the way men are trained to think and act an excessive
reliance on conventional thought expressed in groups. The idea is that
the training of the young to adopt conventional thought patterns, perhaps
the A levels of today, undermines the intellectual independence of the
individual. Nietzsche is suggesting that one has to rise above one’s
training which with one’s natural intelligence creates an independence
from social custom. Common sense will then be superseded by super sense.
In Darwin’s theory we see that survival is a relationship to a
situation; there are no intrinsically beneficial characteristics for
success within the individual, it just happens that in this situation this
group of characteristics produced the effect of survival. The immediate
question is What is important in human life? For Darwin, it is the
success of trial and error; differently constituted organisms do more or
less well in competitive situations. Darwin’s success is a relative
success, the larger context, physical or social, determines the value of
the organism. This strikes Nietzsche as a mistake which overlooks the
essential nature of man: he believes the world should conform to its
superior makers. This is the centre of his transvaluation of all values;
the model for sheep is to be replaced with this paradigm for man.
The elevation of doctors
There is a modern element of evaluation of social class in Papadimos’s
exposition of Nietzsche, ie the ‘herd’ is taken as the socially inferior
part of society. But Nietzsche is offering a more neutral or mechanical
model of society, ie conventional thought permeating society is not an
indication of intellect or value. Papadimos believes that the herd
instinct in our contemporary society stems, perhaps with other things,
from a perception ‘that doctors have presented themselves as: “The noble
... (as distinct from the) common and plebeian” ’ (p 107). So the common
man’s resentment would be fired by their perceived arrogance in doctors.
But Nietzsche uses references to the herd to express limited thought, ie
most of society would have this failing. The idea of mass self-deception
is not foreign to Nietzsche’s philosophy; but the idea refers not only to
any socially inferior ‘herd’ but also to relatively elevated groups within
society. He uses the ideas of noble and common to outline the origin of
such conventional ideas as good and evil, ie for Nietzsche these are
myths; and additionally for his scrutinized societies, and ours, doctors
would be part of the herd. They would be governed by conventional ideas
and as such would not be supermen. Papadimos see the doctor as ‘a
sovereign individual, like only to himself, liberated again from morality
and custom ...’ (p 108), but seems not to see from this quote that the
doctor would be free from morality and custom, ie according to Nietzsche,
uncaring of others. Nietzsche says of doctors and nurses that they are
themselves sick, ie their presuppositions are social conventions, eg as in
science. Thus, doctors like scientists, believe that they can build
knowledge only on a firm foundation of truth without any presuppositions;
whilst Nietzsche believes there can be no science without presuppositions:
there must first be a ‘faith’ to give direction, and ‘the value of truth
must for once be experimentally called into question’ (Nietzsche [2] p
153).
Over long ages, conscience has been traditionally burned into the
minds of men, and the individual superman with huge effort has to overcome
this acceptance of conventions. For the member of the herd, his
conscience is illustrated by his denial of self, it is asceticism. This
has been produced by a history of bloody suffering which Nietzsche thinks
is needed for acceptance by the herd of social duties. The sort of
suffering involved is from practices like stoning, breaking on the wheel,
piercing with stakes, boiling in oil, and flaying alive. Papadimos sees
the Hippocratic oath as ‘burned into the mind of ... doctors’ (p 108) but
the terror which accompanies this memory ‘whenever we become “serious” ’
(Nietzsche [3] p 61) refers to the power of convention forming herd
consciousness. We can see that for the superman, his conscience or
dominating instinct is the fulfilment of self. This is a polar opposite
to the conventional man. Papadimos without evidence links the conscience
of the sovereign individual to that of the doctor. Doctors are relevant
here only to the extent that they are part of the herd; the Hippocratic
slogan ‘do no harm’ is a conventionally rational injunction which the
superman rejects.
The superman rarely promises anything and then only when he knows he
can fulfil it; for Nietzsche the practice of promise keeping weakens
people: it makes them regular and predictable. The superman lives in the
present in the full heat of his passions; he is forgetful of the needs of
the herd. Papadimos believes that ‘if doctors are sovereign ... they have
earned the right to make promises (through their education and station)
... (though) Doctors will reason that they never promised the patient a
cure’ (p 108). He thinks it is the patients’ error to think that not
being cured ‘becomes a broken promise’ (p 108). We have the tortuous
display of an attempt to link the characteristics of the superman with
Papadimos’s wish to explain litigation in modern America.
But this failure of explanation pales into insignificance when one
reads ‘The independence of the doctor as a sovereign individual might be
influenced by oversight organisations’ (p 109). As if the superman could
be successfully accused by an oversight organisation of misconduct; this
is something Nietzsche’s sovereign individual would laugh at. He is not
to be trammelled by the moral standards of the herd which he has already
overcome. An observer of doctors may have a high regard for them but it
is counterproductive to seek to describe them in terms of Nietzsche’s
superman.
Doctors facing lawyers
Papadimos wishes to explain the mechanisms of blame; he considers obesity,
cardiac disease or bad lungs and says ‘All surgeries, procedures, and
treatments can have complications, but these complications or bad outcomes
are someone else’s fault from many a patient’s perspective’ (p 109). His
position is that patients ‘cannot bring themselves to blame their obesity
...’ (p 109) but of course in litigation against doctors the evidence
against the doctor would be what the doctor did or did not do, ie the
patient’s physical and mental condition would be a given, whilst the
medical diagnosis and treatment would be under legal scrutiny: blaming per
se would be irrelevant. But Papadimos feels he has to interpret the
lawyer’s contribution in terms of Nietzsche’s description of the ascetic
priest.
He suggests that ‘doctors have tried to decide what was good and
right for patients ...’ (p 107), but we can see that the superman serves
his own values, not the values of others, whether patients or not.
Quoting Nietzsche, Papadimos sees the ‘pathos of nobility and distance’ (p
107) as creating a mentality in the herd as ‘us’ and the physicians as
‘them’ which is ‘abetted, to some extent, by the legal profession (the
anti-ascetic priests ...)’ (p 107). We may remember that Nietzsche’s idea
of the ascetic is the denier of self as illustrated by the believer
mystified by the priest into denying his feelings, ie interpreting them in
terms of the priest’s concept of sin. Papadimos’s view of the lawyer as
anti-ascetic priest, ie by whom sufferers are urged not to blame
themselves, is unconnected with Nietzsche’s account of the priest’s
interpretations of individual feelings in terms of religion. The priest
teaches sinners to blame themselves for their mental torture whilst
teaching them to be redeemed sinners.
Papadimos suggests that the ascetic priest ‘historically represents
the ascetic ideals of disinterestedness ...’ (p 109) but we see that the
priest is most interested in recruiting and maintaining his flock. His
injunction to ‘blame yourself’ is part of his method to bring people to
God, ie ‘your suffering shows you the way to God’. Asceticism for
Nietzsche is literally a denial of one’s subjective self; it is a contrary
ideal to his perspective and the ascetic priest is the arch exponent of
the practice. Generally in this context of the natural or unconstructed
inner life of the individual, Nietzsche talks of ‘a feeling of
psychological inhibition’ (Nietzsche [2] p 130) whilst remedies for this
‘are sought and tested only in the psychological-moral domain’ (Nietzsche
[2] p 130); this latter is his ‘most general formula for what is usually
called a “religion” ’ (Nietzsche [2] p 130). The model is that a set of
bodily conditions in the individual are interpreted by the priest as
mental conditions having their significance in social or religious
contexts. His view is that in fact physiological conditions from various
origins depress the person and the resultant feelings are interpreted by
the priest in terms of religious ideas like sin. It is the success of
this which wins to the church is mass adherents. The resentment of the
members of the congregation is harnessed by the priest to prevent its
exploding outwards into society, and then redirected back into the
individual to maintain adherence to the view and doctrines of the church.
Papadimos sees the ‘lawyer as anti-ascetic priest’ (p 109), ie the
patient is encouraged by him to express her feelings against doctors in
court. But her feelings have to have an evidential and legal basis, ie
the feelings are relevant to the law only to the extent that their verbal
expressions reflect the law. The patient’s resentment is externally
deflected by the lawyer, ie it is treated in a contrary way to the
priest’s method, and with a contrary purpose. We see that there is no
explanation given in the description of the lawyer as anti-ascetic priest,
for they have nothing in common which could be used as a basis to use the
priest’s methods to illuminate those of the lawyer. Papadimos’s attempt
to use the idea of the ascetic priest does not clarify anything about the
role of the lawyer; and one can see this in one of his conclusions about
problems in the practice of medicine: ‘Government inaction ... may be
failing American society’ (p 110).
The simple point is that there is no relevant connection in
Nietzsche’s thought between his concept of the nobility and doctors.
Papadimos quotes comments about the sovereign individual and then links
these to doctors; but there is no textual evidence for this and the
imaginative exercise Papadimos indulges in produces only oddity. In
Nietzsche’s view doctors would be part of the herd, they would be governed
by conventional values; their power or wealth would not save them from
being slaves. Papadimos’s reflection of Nietzsche’s writings is an
unfortunate misappropriation of the thought of one of the finest exponents
in the world’s intellectual history.
Author’s affiliations
C Parker Leeds (East) Research Ethics Committee, Lay Member
Clinical Sciences Building, Room 5.2, St James’s University Hospital,
Beckett Street, Leeds, LS9 7TF
Competing interests: none
REFERENCES
1. Papadimos TJ. Nietzsche’s morality: a genealogy of medical
malpractice. J Med Ethics; Medical Humanities 2006; 32: 107-110. doi:
10.1136/jmh.2005.000223
2. Nietzsche F. On the genealogy of morals, New York: Random House,
1967.
3. Nietzsche F. Beyond good and evil, New York: Vintage Books, 1966.
As a student, I prided myself on having an independent and often
controversial approach to a whole host of contemporary issues. I confess I
looked down on those junior doctors a few years ahead of me who seemed to
do nothing except work and bland activities such as ‘going to the gym’.
Where was their activism, their passion? Surely I would be different,
campaigning for change on issues that mattered most – the developing...
As a student, I prided myself on having an independent and often
controversial approach to a whole host of contemporary issues. I confess I
looked down on those junior doctors a few years ahead of me who seemed to
do nothing except work and bland activities such as ‘going to the gym’.
Where was their activism, their passion? Surely I would be different,
campaigning for change on issues that mattered most – the developing
world, health inequalities in the UK, unravelling the influence of the
pharmaceutical industry in medicine? Amazing how quickly one becomes a
neat little clone. Perhaps you fight against the system for the first
house job, second house job…then the insidious march along the medical
assembly line begins. Suddenly you find yourself auditing the most
unbearably mundane topics in your spare time, getting every procedure
signed for in logbooks, even recording your every movement on monitoring
cards that tell you to write ‘natural break’ when you go to the bathroom.
As the indoctrination continues, you find yourself doing increasingly
bizarre things to comply with the system. One day let yourself are shooed
off the ward, half-completed blood forms in hand, on the stroke of five
p.m. by an agent of the state - ‘Shame you only had time to examine the
patient’s right leg, doctor, but you know it’s a breach of contract to
stay after five.’ The next day you find yourself, still suturing Mrs.
Jones’ arm, being wheeled along with her into the short stay ward. After
all, she has had the audacity to spend 3 hours, fifty nine minutes and 59
seconds taking up valuable space in the Accident and Emergency department.
Every second counts in the new patient-centred NHS. Or even if it doesn’t
– Big Brother is there to count it nonetheless.
Caruncho and Fernandez interpreted Chopin's hallucinations as temporal lobe epilepsy.(1) Recently, Karhausen examined the 140 causes of death of Mozart that have been proposed in the medical literature.(2) These studies on both composers nicely illustrate how a mechanistic view of death and disease still dominates modern medicine.
Identifying the cause of death can be difficult. Many physicians will share the e...
Dear Editor
I read this article with great interest, as it relates closely to my own practice teaching final year students in the Middle East. An important outcome of our family medicine clerkship in the UAE is the ability to reflect - upon oneself, one's patients and the healthcare system within which the students work.
Many students find this type of analysis difficult. Part of this may be related to...
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I believe no mental patient should have family members make decisions for them, as this can make the patient even more irritable. Ask the patient what they want to achieve. Just like when someone is dying you wouldn't disrespect their wishes.
Conflict of Interest:
None declared
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The article “Medical paternalism in House M.D”. by M R Wicclair in Medical Humanities 2008;34:93-99 made for interesting reading. However there is one point which needs further clarification in the context of English Law. The author states “Informed consent—the principle that, except in emergency situations, medical interventions require the voluntary and informed consent of patients or their surrogates—is a core ethical...
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Dear Editor,
In the article by Volandes titled Envying Cinderella and the future of medical enhancements (1), Medical Humanities 32: 73-76, 2006, the author highlights the ethical dilemma of providing medical enhancements for patients while corroding the moral priority that it has traditionally held as a profession, namely retaining a position of trust based on professional judgment and advocating for patient's...
This response to T J Papadimos outlines some of the relevant elements in Nietzsche’s philosophy in order to develop its conclusions. We find that Papadimos’s attempt to illuminate the causes of litigation against doctors in America fails through misunderstanding the analysis of convention and the idea of the superman in Nietzsche’s thought.
Papadimos’s perspective [1] is rather odd, he points out that ‘Medical...
As a student, I prided myself on having an independent and often controversial approach to a whole host of contemporary issues. I confess I looked down on those junior doctors a few years ahead of me who seemed to do nothing except work and bland activities such as ‘going to the gym’. Where was their activism, their passion? Surely I would be different, campaigning for change on issues that mattered most – the developing...
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