Tuesday, May 19, 2015

Death is Inevitable but Fear and Loneliness Need Not Be: What Medicine Learns from the Humanities

Often the best way to understand health care is through fiction, religion and philosophy.  Ultimately, health care should improve the human condition and not only treat the biological elements of disease and pathology.  One can learn more about the human condition from stories as told in literature, in faith, and in philosophy than from research that is published in medical journals even as the medical journals enlighten the science behind disease diagnosis and treatment. As Andrew Solomon, in his review of Oliver Sachs new memoir, “On The Move”, writes in the New York Times Book Review, “Medicine is dominated by the quants.  We learn about human health from facts and facts are measurable.  A disease is present or not present.”   That is the current state which he calls, “arithmetical naivet√©.” He describes Sachs career in contrast as being devoted to the “unfathomable complexity of human lives” and quotes from Sachs new book (which I must confess I have not yet read however I have read all his other books) “All sorts of generalizations are made possible by dealing with populations but one needs the concrete, the particular, the personal, too.”
   
My thoughts about medicine this week were triggered by an article from, of all sources, the on-line magazine, “Outside.”  The article entitled, “My Dad Tried to Kill Me with an Alligator” is a story of a father doing something that appears irrational and stupid.  In this true story, Harrison Scott Key’s father has him and his brother jump out of their boat to dive down to find a lost fishing rod and reel in a bayou filled with alligators.  That has the effect of helping his sons, especially his somewhat overweight, bookish son overcome fear and understand, in the words of the author that “safety should not be the defining virtue of a life.”  Analogously, while safety should not be the virtue of a life, addressing the biology of disease to avoid death should not be the only virtue of treating people who are ill.  While avoiding death is a virtue it is not the only virtue and for some, may not even be the most important at a particular stage of life. 

Yet in today’s medical world we seem to approach all health risk and all illness as being removed from the elements of life that may make life worth living.  Mass media suggests that science has an answer for everything and that taking a certain pill, or enrolling in the right diet or exercise program will make all your health problems melt away, the implication being that illness and death are optional.  Science, according to the medical reports on the news and the commercials we watch will have your believe that we can live forever and avoid or easily cure all illness.  They don’t acknowledge the reality that the wonder of living inherently involves taking chances and making autonomous choices in a complex world full of uncertainty. 

As physicians and health professionals, we know the reality of disease however we fall into the trap of believing that a person’s biology is the most important element of their life when in reality, it often is rather low on the list, even in the face of devastating illness.  The most important elements of life for most people are related to the values they have, the social environment in which they live and the people they care about.  When we ignore the complexity of the human condition, and when we focus on the medical only, and not the joy of life, then we lose the ability to help our patients truly heal. 

Interestingly enough, the “quants” can even show this with data.  For example when you study why people are readmitted to the hospital, it is related to their lives more often than it is related to their disease.  Living alone is the number one risk factor for being readmitted to the hospital in those over 65 according to a recent study in the Journal of the American Geriatrics Society.  That is not something you can see on a pathology slide but it is part of a person’s story.  Another review compiled research on the marriage health connection.  Married people are healthier than unmarried people and have lower health care costs.  Interestingly enough this is despite the fact that they have more obesity which some point to as the root of all health care cost problems. 

We see this understood quite well in the 23rd psalm, The Lord is My Shepherd, perhaps the most famous of all the psalms.   In Harold Kushner’s book interpreting the 23rd psalm, he speaks of the protagonist as being someone in despair.  Rabbi Kushner writes, “The psalmist cried out to God and this miracle occurred.  The miracle was not that the man’s fortune was reversed, but that he was not alone.”  Thus the data on readmissions and the one chapter of the bible that many in the English speaking world seem to know by heart give the same message – that being alone worsens the pain and despair that illness can initiate and that by having someone at one’s side, healing is more likely  to occur.  As Harold Kushner states it, “God’s promise is not that we will be safe but that we will never be alone…We will hurt but we will heal.”  While having a spouse by one’s side is a bit different than having God by your side, the point of loneliness being associated with poor outcomes when in a time of stress was well known before the scientific quantitative studies were done and was even published!  (This relates to a joke told by Israeli academicians asking whether God could get tenure at an Israeli university.  The answer is “no” because he only had one publication and it was not in English.)   

None of this is to suggest that the medical aspects of care are unimportant, only that the human elements are just as important as the medical.  Thus the humanities, as our window to the human condition are important in the understanding and treatment of people who are ill.  Just as Harrison Scott Key writes of facing up to and overcoming fear and the 23rd Psalm talks of God as helping us not feel alone, we as health professionals have to find ways to help us understand people with all their complexity and make health care into something more than purely scientific ways to avoid the inevitability of death.