The Doctor And The Silenced Patient

In Confessions of a Medicine Man: An Essay in Popular Philosophy (MIT Press, Cambridge, MA, 2000, pp. 109-110) Alfred I. Tauber writes:

Health care providers have to listen, respond, and generally account for the subjective experience of a patient’s complaint. So much of our discontent can be traced to the too little time the physician spends with a client, and how poorly a true dialogue develops. Focusing upon the clinical narrative, the patient’s rendition of the disease experience offers crucial insight to the physician, both as scientist and empathetic, that is, ethical, healer. Beyond obtaining information that may be important in tending to the patient’s particular physical needs, a patient’s own description of the illness presents the physician with the problem of suffering, and the profound disruption, uncertainty, and pain that disease imposes. To ignore this aspect of illness is to deny the patient’s fundamental humanity and relegate them to the status of object.

In an older post titled Taylorism and the Doctor’s Office I had complained about the slavish devotion to efficiency and throughput maximization visible in the work of the physician; an important component of the dissatisfaction I felt then, one not fully articulated, was that my physicians, my healers, were simply not listening to me:

The patient, meanwhile, many of his questions unanswered, his possible inputs to the diagnostic process ignored, returns home, disquieted by the experience, disillusioned by the wonders of face-to-face contact with a fellow human being, and supposedly a healer at that.

This is a real frustration with serious consequences. As a patient, I have a great deal to tell my doctor about my personal experience of the illness: this is how it feels on the ‘inside’; this is how it affects the way I move, the way I relate to my body; these are the kinds of things I want to do and cannot do; this is how I now see myself in relation to the world and my body. I see these as important inputs into the healing process; I see them as descriptions of my dis-ease, a tabulation of the ways in which I am no longer whole and long to put back together again. My illness is not just a set of physical markers; it is an impairment of my being in this world, and I am best placed to report on a very particular aspect of that fractured relationship.

Because I consider myself a good observer, and a good reporter, I come to each doctor’s visit with a sense of anticipation: I will place these reports and descriptions at the service of my doctor, and he will combine them with his expert physiological, medical, and scientific knowledge to produce the optimum healing package. Together, doctor and patient, interacting with each other, will move to a new co-anchored state of being: the doctor becomes a better doctor by healing, by having his skills honed on this new ‘challenge’; I will return to good health.

But my doctor has no time for such niceties; he cannot be bothered to listen to his partner; he cannot wait to hear the ‘other side’ of the story; he is only concerned with test parameters, visible observations, and quick slotting into categories (and the submission of an insurance claim for payment.) To listen to a patient will interfere with the most efficient ‘best practice,’ the one recommended by the management consultant group in charge of his clinic or hospital.

The patient’s experience of the illness falls by the wayside; it is the least important part of the modern ‘healing’ process. And with that assessment, the patient becomes just as marginal, ready to be objectified.

Martin Shkreli Will Have The Last Laugh

‘We’ hate Martin Shkreli. What’s not to hate? He is rich; he gets rich off the misfortunes of others; he buys pop culture icons, treating them like trophies for decorating his den; he postures on video streams as he talks back to those we think can’t be out-talked; he talks smack on his Twitter feed and slathers smarm all over his grinning mug when he goes to Capitol Hill, pompously invoking the Fifth Amendment. Shkreli looks like those familiar assholes at bars, clubs, sports stadiums the world over. You know them well: an extravagant hybrid of the frat boy, the corporate weasel, the jock. He snorts coke off glass tables; he hires hookers; he rides in limos and drinks champagne. Yes, we know the type.

Shkreli isn’t an individual. He is an instance of a type. And he’s acting true to type. It’s all too easy in our social media bubbles to imagine that Shkreli is universally despised or reviled; but he isn’t. Folks like Shkreli aren’t despised that much. They have the wealth, the power,  and the fancy attorney plus accountant crew that every successful person requires. Far more importantly, they  have approval and support. They don’t just have the approval of those who benefit from their monies and who pick up the few scraps tossed their way if they wait attentively and fawningly around the felt-lined tables that Shkreli and his mates dine at. Shkreli works in a world in which the strategies of business lie beyond moral evaluation, where a system exists in order to be worked over, and compromised with. Shkreli’s Twitter account shows much admiration being sent his way; he is after all, an outsider–the son of Albanian immigrants!–who rose to the top, by making the system work for him. The zone he operates in is a morality-free one; it knows little of the table of values that dictates Shkreli assuage our moral sensibilities.

Shkreli wins every time not because he has the money and can buy his way out of any jam he might find himself in; he wins because he faces very little social disapproval of his actions; because he undergoes no systemic pressure to change his actions; because those who would castigate him–like Congress–do little to reign in the culture he represents. Shkreli’s smirk is not just one of bemused condescension,  it is also one of puzzlement; he was told greed is good; that unlimited acquisition was the only foundational principle required to begin acting; that praise would flow his way when he acted so. He has done so, and he is puzzled that a tiny bunch of party poopers want to rain on his parade now.

Shkreli keeps on smirking because he knows no matter how much flak he catches on a few Facebook pages, Twitter timelines, and clickbait websites, he’ll have a lot of friends and admirers left over. And isn’t that all that matters, that more like us than don’t? That he who dies with the most toys, wins?

Jonathan Baron’s ‘Against Bioethics’

I’ve been reading and discussing Jonathan Baron‘s Against Bioethics (MIT Press, 2006) this semester – with the Faculty Discussion Group at the Wolfe Institute for the Humanities at Brooklyn College. Roughly, Baron’s thesis is that utility-based decision-theoretic analysis would improve the quality and outcomes of decision making in the medical sphere, which is currently bogged down in a morass of poorly understood and specified deontological principles, biases and heuristics.

My disagreements with Baron are extensive, even as ironically, I agree with him that some kind of utilitarian decision analysis might often be useful in some domains of medical decision making. I often find myself experiencing what Baron would very likely dismiss as the ‘yuck factor’ – a cluster of heuristics and biases that make it so that I find certain courses of actions offensive or problematic, even when there appear to be apparently very good consequentialist or utilitarian arguments for them. I agree that the ‘yuck factor’ is often not a useful guide to action and can lead to problematic beliefs – such as homophobia for instance. Still, I wouldn’t know how else to characterize my opposition to organ sales (a topic on which I have written before, here, on this blog, where I worried about whether these would encourage the poorest to sell their organs at very low prices), or to using subjects in poor countries for drug trials.

Here, the objections are familiar: both practices are forms of exploitation; they capitalize on the weak–economic and otherwise–situation of those exploited under the guise of providing them a better life. The responses to these are familiar too; ultimately, what we get is the following:

From a utilitarian perspective, the behavior of the researchers…is still better than not doing the study at all or doing it in a rich country, but perhaps not as good as possible. [Or in the case of organ sales, we get better outcomes with organ markets than we do in a situation with no organ markets.]

If this argument–that the ostensible exploiters are making a bad situation better, not worse, by their ‘exploitative’ behavior–sounds familiar, it should. Because it is the same one used to excuse the use of sweatshops in places such as Bangladesh, which every once in a while kill hundreds of their workers. It should also be familiar because the dichotomy presented in it is an old one: either the exploitative action is taken, or the status quo of poverty–pernicious in all its forms–persists. Perhaps the disruption of the status quo is deadly, but that price comes out in the wash for we have better outcomes in the final reckoning, provided the correct option is chosen.

While the acceptance of the terms of the dichotomy is interesting what is perhaps even more so is the uncritical acceptance of, in the case of pharmaceutical industry, a very particular corporate axiom: if observing the boundaries noted by a particular ethical injunction is likely to effect profit margins adversely (note: not doing away with them entirely) then so much the worse for the ethical injunction.  The deployment of these arguments in the case of drug testing shows how well-entrenched this principle has become.

Taylorism and the Doctor’s Office

From this vantage, distant point in my life, childhood meetings with doctors, whether at home–they still made house calls–or whether in the doctor’s clinic, appear as encounters with quasi-avuncular figures, benevolent, mostly-solicitous contacts with a wise, ostensibly caring person. I experienced my share of childhood illnesses, suffered from minor ailments, and almost always looked forward to meeting the doctors who treated me. Consultations took place in their office; preliminary wait in a reception, and then entry into the sanctum sanctorum; I sat on a stool next to the doctor’s desk; the doctor was nearby, walked around to his desk to examine me, and sometimes for more extended examination, moved me to an adjoining recliner. While the waits in the office were sometimes onerous, once told the doctor would see you, you got just that – a ‘meeting’ with the doctor. The doctor’s consultation space seemed made for healing.

The times, they’re a changin’.

To visit a doctor now is to experience a cold, unrelenting blast of Taylorist air, a journey through a land dotted with toll-collectors, each aspiring to rapid and efficient quota completion. You make an appointment and wait in the reception like you always did.  Then you are brusquely asked for your insurance forms, and made to fill out–just like at every other doctor’s office that you’ve been to before–a pile of horribly photocopied forms that ask for details on your medical history, whether you’ve understood your privacy rights, and a host of other legally required disclaimers. Then you wait again. When called in, you don’t meet the doctor. Rather, you are ushered into a small consultancy room, cold and bare, while an assistant screens you by conducting a preliminary examination. (You might have to wait a bit before the assistant shows up.) This preliminary examination over, you are left alone again, sometimes clad in a paper gown.

Then, the doctor–whose voice and form can be dimly discerned as he rushes about in the corridors outside–shows up; clearly in a whirl and a tizzy combined, he is brusque, efficient, and keeping an eye on the clock and his production schedule, his throughput. He reads the pre-examination form quickly, asks a few rapid questions–more often than not, not listening too closely to the stream of information a patient can provide on his body, his ailment–dispenses a quick, snap judgment, and leaves. A battery of tests is ordered; pharmaceutical prescriptions written; and you are told that the ‘assistant’ and the ‘receptionist’ will tie up loose ends. You change, head out the door, are reminded by the receptionist that the co-payment is due, and then, it’s all over. You emerge, blinking, into the sunlight, feeling not so much healed, but as if you had been trussed up, placed on an assembly belt, and had several pounds of flesh withdrawn – by the insurance company, by the doctor’s clinic.

The doctors maximize movement through their clinics; the tests ensure expensive bills can be sent in for insurance claims; the prolific prescriptions pad pharmaceutical profit accounts. The patient, meanwhile, many of his questions unanswered, his possible inputs to the diagnostic process ignored, returns home, disquieted by the experience, disillusioned by the wonders of face-to-face contact with a fellow human being, and supposedly a healer at that.