Heroes Not Zombies

There’s an excellent collection of articles about health in this month’s “Philosophie” magazine in France.

The cover instantly reminded me of the great quote by the American physician, Oliver Wendell Holmes –

Throw out opium, which the Creator himself seems to prescribe, for we often see the scarlet poppy growing in the cornfields, as if it were foreseen that wherever there is hunger to be fed there must also be a pain to be soothed; throw out a few specifics which our art did not discover, and it is hardly needed to apply; throw out wine, which is a food, and the vapors which produce the miracle of anaesthesia, and I firmly believe that if the whole materia medica [medical drugs], as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes

Health is a much more complex and nuanced phenomenon than the simplistic ideas we are offered by the current dominant model of health care – that of Big Pharma and statistical medicine (drugs for every problem, protocols for every health care professional).

One of the central themes explored in this issue is summarised by the lead title of “Health, is it in your head?” There are those who promote the idea that all illness begins in the psyche and expresses itself in the body (Freud?), and others who promote the idea that all illness is physical, material change in the body whilst the psyche remains separate (Descartes?). There is a third option discussed, whose roots are traced to the philosophy of Spinoza – that the psyche and the body just express the same underlying disturbance, but each in their own language.

I like that third idea – it seems totally congruent with the core value of my lifetime of medical practice. I refused to divide a person into two parts – a mind and a body, and I used the philosophy that there is a system or a force within all life forms which produces growth, maintains health and repairs the organism when it is damaged. It’s interesting to see how the more recent discoveries of neurobiology are showing us more and more interconnectedness within a person – with amazing multitudes of connections and pathways between the different organs and tissues. It’s becoming increasingly untenable to hold one of the divided views.

One of the articles mentions an old essay by Kant, written in 1798 “Du pouvoir du mental d’être maître de ses sentimentsmaladifs par sa seule résolution”. In that essay he distinguishes between “la sensation” and “le savoir” of health – in English, perhaps, something like the difference between what health feels like and the knowledge of health. This strikes me as close to the nub of the issue.

We experience health. It’s something we can all assess and comment on. We can say when we feel well and when we feel ill. But we have also developed ways of knowing about organ or cellular functions, so we can discover what our blood pressure is, or what level of haemoglobin exists in our red blood cells (two things we could not know by “sensation”). The point is, both of these perspectives are real. We do not have the kind of nervous system which can make us aware of the moment to moment functions of the organs of our bodies at a conscious level. Indeed, how could any of us live that way? But the connections exist. A certain level of heart cell dysfunction may be experienced as palpitations, pain or breathlessness. However, the heart can malfunction without us being aware of it at all – the investigation known as an “ECG” (a cardiogram) can reveal a “silent infarct” – damage which occurred to the heart from a clot without the person having experienced any pain or breathlessness.

The connections which exist between “sensation” and “consciousness” are complex but clearly non-linear – in other words, a small change in one area can have either a large, or a negligible, effect on another.

Isn’t this why we can encounter a person who feels very ill, but whose investigations are all “normal”, and why we find people who have “abnormal” results in investigations, but who feel completely well?

Where modern medical practice goes wrong, I believe, is by attributing truth to “knowledge” whilst dismissing “experience” as unreliable and so, not useful. This has come about from our obsession with measurement. We can measure physical changes, but we can’t measure pain, breathless, dizziness, nausea, or any of the other “sensations” of illness.

But to attribute symptoms (sensations) to mental disorders when physical test results are all within the normal range is neither rational, nor clever.

I think we need, in every case, a person-specific synthesis of what the tests tell us and what the person is experiencing. A person’s experience can be communicated to us by their telling of their story – which has the additional benefit of allowing us, together, to make sense of what is happening – by which I mean to explore the meaning of the illness.

Keeping focused on the narrative which includes this synthesis also enables us to explore the individual’s values, hopes and fears, allowing us to make more relevant, more holistic, diagnoses and so, hopefully, to offer more appropriate choices for each patient.

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