When Doctors Are Wrong

As medical students and resident physicians gain experience they also gain
knowledge and confidence. Consequently, young trainees eventually reach a
level of comfort in speaking with families and patients about prognosis and
disease course. This is part of the purpose of training, as these
conversations happen so often that they are an integral part of practicing
medicine. But it isn’t certain that with experience and confidence also comes
accuracy.

***

Soon after finishing sign-out on a night shift I received a page. The
nurses told me that a patient’s daughter had arrived and wanted to speak
with me about her father. The patient was an elderly but relatively healthy
gentleman who had been admitted with abdominal pain. Multiple imaging
studies had shown little to account for his discomfort. But the pain was so
intense that he could not eat anything. Even going to the bathroom was
difficult — he held in his stool to avoid the agonizing act of defecating.
As a result, he became constipated, which then exacerbated the pain. Thus,
the medical team administered anti-inflammatory treatments, stool softeners, and IV
fluids as they searched for the etiology of this troublesome symptom.

The patient’s daughter asked me about the latest imaging studies and labs
as she sat holding her father’s hand. Buried to his chin under the covers,
the patient participated in the discussion, asking when he would be able to
eat and go to the bathroom easily again. I explained that all the tests had
been negative so far and we were unsure of what was going on. I then left the
room, and the daughter caught up to me in the hallway. She seemed worried,
speaking hurriedly and pleadingly: “How long do you think my father has
left to live? How much time do I have left with him? Should I start making
funeral arrangements?”

The questions took me aback. I had seen plenty of patients in the
intensive care unit
who were on the verge of death and they looked so different from her father
— a profound pallor, somnolence, lethargy, disinterest in conversation
and food. But this patient wanted to eat again, he wanted to see his
family, he wanted to watch basketball on TV, and he was interactive and
conversational. His cheeks certainly did not exhibit the deathly pale hue
of those crossing over to the other side. I assured the daughter of this:
“I don’t think you have to worry about that. The most important thing right
now is that we figure out what is going on. I can’t tell you how long he’s
going to live but I would be shocked if he had only days or weeks left.”

This interaction repeated itself for the next three nights, always with the
same diagnostic uncertainty. On further imaging there was evidence of some
abnormal fluid in the abdominal cavity. Interventional radiologists
extracted the fluid to test it for any cancerous or infectious cells, but it
would take perhaps a week or more for definitive results to come back. In
the meantime, the patient’s pain improved and he moved his bowels without
issue. Even though we didn’t yet have a diagnosis he seemed to be doing
incrementally better each day.

On the fourth night I again saw the daughter and she asked: “You don’t
think I should be planning the funeral for my father, do you? He’s not
going to pass in the next few days?” I understood why she was asking the
question — any child ought to be concerned for the well-being of a parent.
But I was also surprised because her father was on the mend. I told her
that if he continued to improve he would leave the hospital, and his primary
care doctor would follow up the lab results and see him in clinic.

At around 2 a.m. that same night, a voice over the hospital loudspeaker
echoed throughout the halls as I jumped out of my chair: “Code blue, 7th floor, code blue, 7th floor.” There was a
patient in cardiac arrest. I ran out of the workroom and met up with
another resident. Which patient was dying? On my way to the code I ran
through the patients on the coverage list that evening; I did not expect
anyone to pass away. As the other resident and I ran down the hall I saw
the code cart containing all the medical resuscitation equipment necessary
to treat cardiac arrest outside of the room I had visited every night for
the past four nights. My heart leapt out of my chest; I pleaded with some
higher power that it not be that patient. But it was.

The resident, nurses, and I immediately began CPR. The anesthesiologists
burst into the room and stuck a tube down the patient’s throat and into his
trachea to protect his airway as the respiratory therapist attached the
tube to a ventilator to help the patient breathe on his own. After multiple
rounds of CPR, his pulse returned. We wheeled the patient — attached to
tubes, and poles filled with intravenous fluids — to the ICU for closer
monitoring. He didn’t respond to our questions or poking and prodding, but
he was alive.

Alas, as soon as we got to the ICU, his heart once again
stopped beating and his IV line ceased working — his veins (which can
happen as we age) were friable and brittle, and the small vein carrying the
volume and force of the IV infusions burst. Without an IV we could not give
medications. We turned, then, to an

intraosseous (IO) line
. This entails drilling a hole into the bone and infusing medications
through that hole. It is a proven method of administering medications when
physicians and nurses cannot obtain IV access. I opened the IO kit and
attached the drill to the IO needle, placing it on the shinbone and drilling. It
slid into the bone, I detached the drill, and hooked up the
IV tubing to the IO line jutting out of the patient’s bone. At this point,
the code had been going on for nearly 15 minutes and the patient’s family
had arrived. They watched as we furiously attempted to revive their loved
one. At some point a family member shouted “Stop, please, enough!” Time of
death: 2:45 a.m.

I sheepishly held my head down, avoiding eye contact with the family as
they sobbed. The medical team and nurses quietly left the room, leaving the
patient in peace. As I passed by the daughter, I could only say “I’m so
sorry” — little else would have sufficed. Not only did we not save him, but
night in and night out I had given the daughter a false impression that he
wouldn’t die. Perhaps, I wondered, I had been disingenuous in some way.
Either way, I was wrong.

 ***

Alas, physicians are wrong relatively often, and there is ample
evidence for this. In a systematic review in the

British Medical Journal in 2012
, researchers found that each year up to 40,500 adult patients in American ICUs die with a misdiagnosis. The Journal of the American Medical Association published an analysis in 2009, concluding, among other things, that “while the exact prevalence of
diagnostic error remains unknown, data from autopsy series spanning several
decades conservatively and consistently reveal error rates of 10% to 15%.”
The American Journal of Medicine published a

separate analytic review article in 2008
, concluding that diagnostic error occurs up to 15% of the time in most areas
of medicine. The authors further theorized that overconfidence often
accounts for at least some of the errors. These reports have reached a wide
audience in the laymen’s press as well. In 2015, the Washington Post published an article indicating that diagnostic errors affect 12 million adults each year. The
impacts of errors, as we see in the story above, don’t just involve the patient
but the patient’s families, too.

Though these statistics are shocking, it is almost impossible, from the
patient perspective, to look at them and subsequently be skeptical of everything a doctor says. After all, we are not only practically but also emotionally dependent on them: We want reassurance from our
physicians and we want definitive answers. As a patient, it is frustrating
to hear “It may or may not be cancer and we can’t be sure” or “I don’t know
how much longer she has left.” Indeed, when the path ahead of us is no
longer clear, we turn to physicians for answers because of their
experience. We want them to be the kinds of people none of us can
be — always right, always knowledgeable, always calm and composed. But they
are fallible, despite the impossibly difficult and long road they’ve
traversed.

And what can we as physicians take away from this? Doctors want to be
the kinds of people their patients expect them to be. But the statistics
of medical errors are the reminders of how impossible that is; how many years of studying and
experience are necessary even in order to be competent; how difficult,
despite the many exams we take and pass, it is to apply knowledge
appropriately. Not only are we fallible, but the science we rely on is not
always helpful either. Indeed, the best studies are useful merely for inferring what will
probably happen — they do not tell us definitively what will happen to the
patient in front of us. Moreover,

scientific evidence does not exist
for every treatment in every situation or every diagnosis in every
situation. Once again in medicine,

our ideal does not match with the real
, and our preconceived notions are sometimes shattered in moments of frustration
and uncertainty. Perfection is unattainable, but we must
constantly seek it out, always aware of how out-of-reach it lies.

When patients and their families now ask me questions about prognosis or
treatment I always preface what I say with: “Nothing is 100% in medicine.”
Though I will be wrong again in my career and will, hopefully, learn from
my mistakes, I never want to give a false impression. We often tend to ignore uncertainty or wish it away, but we must always remind
ourselves, whether as patients or doctors, that no doctor and no science is perfect.

The Burden of Medicine on Mt. Kilimanjaro

The imposing mountain of Kilimanjaro in the East African country of
Tanzania stands alone amidst the surrounding flatlands and swallows up the
horizon with its snow-capped peaks. At once alluring and intimidating, its
enormous size provides the kind of thrill and sense of wonder that a child must
feel when it becomes conscious of the seemingly infinite universe.
This impression, I imagine, drove explorers a hundred and fifty years ago to
try to climb

the mountain’s approximately 19,000-foot

peak. In 1861, for example, Baron Karl Klaus von der Decken, a German
explorer,

attempted to summit Kilimanjaro

with English geologist Richard Thornton. Poor weather prevented the
completion of their trek. A year later, von der Decken tried again, but once more the weather stymied his ascent.
Others made further unsuccessful efforts in the
decades that followed, but in 1889 a German geologist, Hans Meyer, and an Austrian gym teacher and mountaineer, Ludwig Purtscheller, became the first to reach Kilimanjaro’s highest peak.

Since then, thousands have traveled to Tanzania to brave the altitude
and
sub-zero temperatures and to climb the mountain. A
friend and I, during our last year of
medical
school, were two of those people. We wanted to do something truly unusual, a trip that
would take us as far as possible away from the hospital to a world
we might
never get a chance to see again. It is not unusual for fourth-year
medical
students to take a trip like this — a last hurrah of sorts before
graduation. And, of course, one hopes that after separating oneself
from medicine one would return to the hospital world refreshed,
motivated, and ready to begin the grueling process of residency.

My friend and our guide, about two days before reaching the summit of Mt. Kilimanjaro.
Photo: Aaron Rothstein

One of the most notable aspects of climbing Kilimanjaro is of course
its high
altitude. Because the partial pressure of oxygen in the air
decreases as
one ascends, tissues within the body require higher volumes of blood
to get
the same amount of oxygen. For comparison, at Mount Everest Base
Camp on the Nepalese side (at 5,360 meters or 17,600 feet elevation),
the partial pressure of oxygen is half of what it is at sea level;
Kilimanjaro stands at around 5,900 meters or 19,300 feet. At these
heights the body must adjust to compensate for the drastic
decrease in oxygen availability. During the earliest stages of exposure to
high altitude, the respiratory rate increases to take in more oxygen, the
heart rate goes up to deliver more oxygen to the tissues, and the blood
concentrates oxygen-carrying hemoglobin by getting rid of excess fluid
(this is called

altitude diuresis
 and it is why one urinates more at higher altitudes). Then, if one
spends several months at high altitudes, the body further adjusts by
increasing the number of red blood cells
through the release of erythropoietin,
a hormone that acts on the bone marrow to increase red blood cell
production.

The way exposure to high altitude manifests itself on a step-to-step basis
is remarkable. As my friend and I ascended, it became more and more
difficult to hike. Shortness of breath plagued us at slight inclines or
fast-paced walks. Eventually, at the top, the slow slog felt
like a sprint, our bodies desperately crying out for air. But it wasn’t
just this odd sensation that was new to us. Climbing at these
altitudes comes with certain risks, some of which can be deadly and which we got to experience up close.

***

The night we began our hike we awoke close to midnight, unzipped
the tent, and stepped out into the bitter cold night air. The
stars playfully glistened in the clear sky reaching out in all
directions. We drank hot tea, ate some porridge, and
headed on our way. Despite the brightness of the moon, we needed
headlamps
to see the details on the path before us, especially as ice covered
every
inch of ground. In
the distance we saw other trekkers only by the small lights of their
headlamps, tens of them slowly ascending, enveloped by darkness.

But there was one light that seemed to be getting closer rather than
farther. And it seemed to be trembling, its owner unsteady. It was an
unsettling sight, but we couldn’t keep looking as we were in the midst of trying not to fall, while also sipping water from our backpacks almost continuously so that it wouldn’t
freeze. When we finally managed to look up
again, the light was much closer and we made out two people in the pitch
black: one was a Tanzanian guide and the other was a Caucasian hiker leaning
on the guide for support. As they passed us the hiker slipped, barely able
to stand on his own feet. We turned around and asked what had happened: “He
fell and hit his head and a team is on the way to come help him down,” the
guide answered. It seemed unusual that a head injury would make a patient
this unsteady. But there were no medical supplies, no places
for a med-evac to land, and no oxygen tanks. The only option for the
hiker was to get down to base camp as quickly as possible. So the patient’s guide continued
on, supporting the man as they descended the mountain.

What had actually happened was something far more serious. The hiker had

High Altitude Cerebral Edema (HACE)
. People who live at low altitudes and suddenly ascend are at risk for
this particularly affliction and it can occur at altitudes anywhere
over 8,200 feet. Symptoms initially include altered mental status,
unsteadiness or dizziness, nausea, vomiting, headache, and drowsiness,
progressing over hours to days. With decreased availability of oxygen, there is
an increase in the body’s stress response leading to vessel dilation and
increased blood flow to the brain. Pressure increases within the
vasculature of the brain as autoregulation of pressure is impaired. Fluid
leaks out from the cerebral vessels, creating higher and higher pressures
within the fixed compartment of the skull. With no place left to go, the
brain herniates downward through the foramen magnum
(the hole in the base of the skull through which the spinal cord connects with the brain). This will cause death.

The best treatment for HACE is to descend as quickly as possible to lower
altitude. Supplementary oxygen can help, as can steroids (to
decrease swelling), but these are merely temporary fixes to a deadly
problem. And that night, the climber, with no oxygen, no steroids, and no
chance of descending in time, died from HACE shortly after we passed him. On
our descent we found out the news and even saw his body. A blanket
covered the outline of a human form, still, silent, with no chest rise or
fall.

The moment, in some respect, tainted our trip. Was there more we could have
done? It appeared to be a hopeless situation and, in the thick of that
night, gasping for air in the freezing cold as we let the man and his guide move on, we wondered if there was more. Nevertheless, short of helping him down, which would not have happened in
time to prevent his demise, there was no equipment, no medication, no
treatment we could have offered.

Mt. Kilimanjaro, about one day before reaching the summit. Our path took us around to the other side of the mountain before our final ascent.
Photo: Aaron Rothstein

In the 2015 New York Times article
Is There a Doctor in the Marriage?
, the writer Anya Groner discusses her husband’s grueling hours as a doctor.
After he assists with a medical emergency during a plane ride,
she realizes that he is, in some sense, always on call. Work is ever present. Whether there is turmoil in one’s thoughts
about a patient or whether one is being asked advice by
friends or family, the profession demands constant alertness and
preparedness. Even on the slopes of Kilimanjaro, which only a century and a half ago hardly anyone dared to climb, medicine followed us. If we have any sort of
conscience, there is no escaping the practice of medicine. This is why we must
love what we do, but it is also why we must be prepared to live with it wherever we go.

Becoming Cynical, Part 4

I have written quite a bit about why physicians become cynical (see herehere, and here). What follows are some more thoughts on this topic
that relate to my previous post on Parkinson’s Disease (PD).

Recently, a sixty-three-year-old patient came to the neurology clinic for a left-handed tremor that had become worse. He and his wife gave a classic history of the
onset of PD. His tremor occurred only at rest. He felt his left arm was weaker than his right arm — this was evident in some sessions with his personal trainer. He noticed his handwriting had become slightly smaller. And his wife said she couldn’t hear him well anymore.
She initially thought it was due to her own hearing loss, but her friends also found that his voice had become harder to hear. The attending physician and I asked other questions
regarding sleep (sometimes PD patients act out their dreams), drooling, and cognitive status. After a physical exam, a cognitive test, and some more
questioning, the attending physician concluded that the patient had PD.

At this point in my short career I had seen multiple patients with PD, some in its early stages, some advanced, and some in-between.
I was at least superficially familiar with the course of the disease. So when we broke the news to the patient and his wife, it felt slightly banal:
another PD patient, another diagnosis, and another prescription for PD drugs.

Shutterstock

But this patient’s reaction took me by surprise. Most people are upset, ask for some information about the disease, take
their prescriptions and leave. But in this case, the patient’s questions were far more detailed than I was used to (the attending, given the extent of
his experience and knowledge knew exactly what to say). The conversation eventually led to a discussion about the advanced stage of the disease. We explained
that medications and deep brain stimulation would become less and less effective. Ultimately, he would get dyskinesias and end up in a wheelchair.

We all know we’re going to die — that is one of the few things in medicine that one can say is 100 percent certain. But there is something eerie about hearing
exactly how you’re guaranteed to deteriorate. The attending was telling the patient in a very diplomatic way that his life would look just so in about twenty
years. It was said gently, but the patient understood the meaning well. His wife began to cry and he teared up, too. His movements, his hobbies, and control
would slowly peter out and vanish.

After I told this story to someone with experience in the medical field, the person responded with, “I don’t know what they’re so upset about — it’s just
Parkinson’s Disease.” This probably seems callous and insensitive. Just PD? Think of the horrible symptoms, the side effects of the medications, the
creeping debilitation. Imagine, eventually, being locked-in, frozen and unable to move, relying on a pill that becomes less and less effective for allowing such simple functions as turning
around or walking. It is indeed a terrible disease.

But for a physician who has seen far worse — such as ALSCreutzfelt-Jakob diseasetrauma, Sudden Infant Death Syndrome (SIDS), all of which involve rapid debilitation and death — PD can seem preferable, with its long course and all the available treatments, however limited they may be.

This tendency to compare the severity of varying illnesses is perhaps one of the greatest traps in practicing medicine. Physicians see so much that
diseases that are serious to most patients seem mild relative to the more horrifying ones. I have found myself falling into this pit more than once. I remember
doing CPR on a patient who had burst a pulmonary artery (a major artery in her lungs) as a complication of her lung cancer. As I did chest compressions, blood poured out of her mouth and onto my pants, soaking my shoes and scrubs. While this was going on, I got
a call from a nurse about a patient with a history of drug abuse who wanted more pain medication. He may very well have been in serious pain. But compare
his needs to this woman’s death. Clearly, one was much more affecting, disconcerting, and significant than the other, and it was a while before I
could address the drug patient’s pain appropriately. It can be all too easy to dismiss as a “mild” disease or complaint the sorts of conditions against which our exposure has hardened us.

Thus, with experience, our expectations change; it takes more to move us. We shrug off the majority of hospital cases as “not that bad” or “benign.” I think
all this is inevitable in a career in medicine. One must pinch oneself every day, at the very least, to recognize it.

A Tour of the Intensive Care Unit (ICU)

I have a rendezvous with Death
At some disputed barricade,
When Spring comes back with rustling shade
And apple-blossoms fill the air—
I have a rendezvous with Death
When Spring brings back blue days and fair.

It may be he shall take my hand
And lead me into his dark land
And close my eyes and quench my breath—
It may be I shall pass him still.
I have a rendezvous with Death
On some scarred slope of battered hill,
When Spring comes round again this year
And the first meadow-flowers appear.

God knows ’twere better to be deep
Pillowed in silk and scented down,
Where Love throbs out in blissful sleep,
Pulse nigh to pulse, and breath to breath,
Where hushed awakenings are dear …
But I’ve a rendezvous with Death
At midnight in some flaming town,
When Spring trips north again this year,
And I to my pledged word am true,
I shall not fail that rendezvous.

—Alan Seeger, I Have a Rendezvous with Death

The Intensive Care Unit is an uncomfortable place. It is where the sickest patients in
the hospital reside. Because many of the patients require emergency medical interventions or close monitoring, the layout resembles that of the emergency department (ED). Patient rooms encircle a nurse’s station where computers sit on a long table. As in the ED, each room is filled with machines
projecting vital signs, EKG tracings, IV fluid rates, and other information towards the physicians and nurses. And the nurses in “the unit” (as it’s
commonly referred to) are always active, checking in on patients throughout the day and night.

There are many different types of intensive care units: some for patients with heart issues (cardiac ICU), others for patients with neurological issues
(neuro ICU), pulmonary or general medical issues (medical ICU), surgical issues (surgical ICU) and cancers (oncology ICU). What we see in each unit,
however, is equally disturbing. And what follows are the some of the things one might see (and which I have seen) in different ICUs over the course of a
day.

Image via Shutterstock

In the neuro critical care unit, one patient lies unconscious with a massive and deadly brain bleed. In another bed across the room, a patient with a rapidly expanding
brain tumor cries out in searing pain from a headache. In the cardiac intensive care unit, a patient, hours after receiving a ventricular assist device (VAD), a device which helps the heart’s ventricles pump out
blood after being weakened by disease, receives chest compressions from a nurse as he goes into cardiac arrest. Another unconscious patient in the far
corner of the room is on ECMO, or extracorporeal membrane oxygenation, after
having massive heart and lung failure. ECMO takes blood out of the venous system, oxygenates it in a machine and then pumps it back into the arterial
system, thus bypassing the heart and the lungs. In the normal circulatory system, blood goes from the veins into the right side of the heart and
subsequently to the lungs where it is oxygenated, flows to the left side of the heart and is pumped into circulation to nourish the body’s tissues. ECMO
temporarily maintains circulation until the patient’s heart and lungs can function on their own.

In the oncology unit, a middle-aged cachetic patient lies face-up in the bed, staring at the ceiling while fungal and bacterial infections cause his blood
pressure to drop and heart rate to increase. Despite the medications used to prevent these infections in cancer patients with very low white blood cell
counts, sometimes the microbes sneak by. And because chemotherapy used to treat cancer destroys white blood cells, the cancer patient has nothing left with
which to fight off the infection. Even the most minor bacterial invasion can be fatal for these patients, as it eventually was for him. Meanwhile, in the next room, another
patient had just passed away and her family crowded around her bed sobbing and mourning their loss while holding the expired patient’s
hand, hoping for the return of warmth.

Unusual sounds percolate from room to room in these dank areas of the hospital. Most noticeably, IV poles beep
constantly as they run out of their fluids or medications. Cardiac monitors sound alarms as patient heart rates dip too low, rise above a normal level, or register abnormal
rhythms. Some patients moan and scream, losing all sense of time and of themselves. Or, perhaps they curse and threaten nurses while withdrawing from
alcohol. Others vomit and pass gas. Some patients demand the impossible: “get me out of here!” or “leave me alone!” Sometimes patients need to be strapped
down to the bed because they pull out their IVs as they wail and moan and thrash about. During the day, minimal light shines into the unit and it is
tainted by the sickness and suffering which pollute the air and tint the windows. Foul smells, which I wrote about here, are most potent in the ICU. Many ICU patients,
though washed by nurses, have not bathed in weeks. The stench of sweat, stool, and blood permeates the unit when nurses change patients’ diapers,
suck accumulating mucous out of patients’ mouths, and clean up blood-stained sheets.

And if you think it’s bad for providers, imagine what patients experience. The ICU must feel like a kind of hell on earth. Sleep is rare when your
neighbors expectorate, choke, vomit, and shout, and nurses and physicians constantly wake you up, draw blood from your veins, and examine you to ensure your
mind still functions correctly. Some patients can’t eat or drink because they need surgery (it is safer to put patients under anesthesia for surgery when
they have not eaten because food will not come up from the stomach and choke the patient or travel into the lungs while they are unconscious) and so they go to bed hungry and
thirsty. A patient may even go to sleep not knowing whether he or she will wake in the morning. You may be one of those who
has a rendezvous with death tomorrow; you may be one of those who survives; you may hang on by a thread for weeks. Who would ever want to end up in an
ICU?

And yet, it is in the ICU that patients receive the most fastidious care. Nurses watch over only one or two patients and thus can keep a close eye on them.
Physicians trained in the art of emergency procedures, like intubation, are always around
and watchful. Nobody will be more attentive to your medical needs than an ICU team, which monitors every sign of life you emit: breaths, heartbeats,
skin color, blood pressure, electrolyte levels, blood counts, infectious disease cultures from your urine to your spinal fluid. The advantage of being in
the ICU is that you receive the care that you need even if it is in a frightening environment. I hope I never have to be there, but if I am severely ill at
some point in my life, the ICU is the place I would choose to be.

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in
trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes
on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also
confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I
mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever
discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to
it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is
why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will
“make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted
something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was
having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the
elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health”
in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my
question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an
answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a
technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there
will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the
purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her
golf swing, or a family physician might administer amphetamine injections to people who want to
feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed,
doctors daily witness death and terminal illness. If we know CPR,
do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the
prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy
are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines
breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely
solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine,
is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the
Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism … composed of parts. It is a structure and not a
heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that
make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is
not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and
buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts
and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This
demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children
who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis
to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human
being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not
involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic
surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought
to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for
patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes,
“large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine
and we would be remiss if we didn’t study this purpose carefully. Without a purpose,
medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.

designer deaths

Death is such a bummer, but you know, that’s just a design problem:

Bennett’s fixation on death began with the death of his father. He was close to his dad; in a recent talk, he likened his childhood to the plot of Billy Elliot, a story “about a little nelly gay boy who twirled in the northeast of England” and the exceedingly masculine father who dared to love him. Bennett, in fact, traces his identity as a designer to the day in 1974 when his father, Jim, a former military pilot, brought home The Golden Hands Encyclopedia of Crafts. Jim Bennett then spent the next two years sitting with his son, making macramé and knitting God’s eyes, so that sensitive little kid could explore his talent and find his confidence. In 2001, Bennett’s father wound up in a hospital bed, stricken with bone cancer. Bennett was 5,000 miles away at home in San Francisco. He told his father he’d be on the next flight, but Jim ordered him not to come. Eventually, Bennett understood why. His father had painstakingly maintained his dignity his entire life. Now “he was trying to somehow control that experience,” Bennett says. “He was designing the last granule of what he had left: his death.”

In 2013, Bennett started sharing his ideas with the other partners at Ideo, selling them on death as an overlooked area of the culture where the firm could make an impact. He had a very unspecific, simple goal: “I don’t want death to be such a downer,” he told me. And he was undaunted by all the dourness humanity has built up around the experience over the last 200,000 years. “It’s just another design challenge,” he said. His ambition bordered on hubris, but generally felt too child-like, too obliviously joyful, to be unlikable. One time I heard him complain that death wasn’t “alive and sunny.”

T. S. Eliot, 1944:

I have suggested that the cultural health of Europe, including the cultural health of its component parts, is incompatible with extreme forms of both nationalism and internationalism. But the cause of that disease, which destroys the very soil in which culture has its roots, is not so much extreme ideas, and the fanaticism which they stimulate, as the relentless pressure of modern industrialism, setting the problems which the extreme ideas attempt to solve. Not least of the effects of industrialism is that we become mechanized in mind, and consequently attempt to provide solutions in terms of engineering, for problems which are essentially problems of life.

Ah, don’t be such a downer, Possum! Everybody, come on, sing along!

Death and Twitter

Yesterday Gabriel Garcia Marquez died, and suddenly my Twitter feed was full of tributes to him. Person after person recalled how deeply they had been moved by his novels and stories. And yet, I don’t believe that in the seven years I’ve been on Twitter I had ever before seen a single tweet about GGM.

This has happened often on Twitter: I think of Whitney Houston, Paul Walker, Philip Seymour Hoffman. People poured our their expressions of affection, gratitude, and grief — all for those whom they had never mentioned on Twitter until then. Why?

Well, death always does this to us, doesn’t it? When you hear that an old friend has died, even if you haven’t seen her in years and years, your memory draws up all the good times you had together: they appear before you enriched and intensified by the knowledge that they can no longer be added to. The story of your relationship takes vivid shape in light of its ending, as often happens also with stories we read.

But I think on Twitter that natural and probably universal experience gets amplified in the great cavern of social media. You tweet about Whitney Houston’s death in part because other people are tweeting about Whitney Houston’s death and you don’t want to seem cold or indifferent, and as the avalanche builds, it comes to seem that Whitney Houston was of great importance to a great many people — even though most of them hadn’t thought about her in fifteen years and wouldn’t have noticed if they never heard a song of hers again. Such are the effects of what Paul Ford and Matt Buchanan have called “peer-to-peer grieving”.

I’m reminded here of a brilliant piece by the playwright Bertolt Brecht called “Two Essays on Unprofessional Acting,” in which he comments:

One easily forgets that human education proceeds along highly theatrical lines. In a quite theatrical manner the child is taught how to behave; logical arguments only come later. When such-and-such occurs, it is told (or sees), one must laugh. It joins in when there is laughter, without knowing why; if asked why it is laughing it is wholly confused. In the same way it joins in shedding tears, not only weeping because the grown-ups do so but also feeling genuine sorrow. This can be seen at funerals, whose meaning escapes children entirely. These are theatrical events which form the character. The human being copies gestures, miming, tones of voice. And weeping arises from sorrow, but sorrow also arises from weeping.

To this we might add, “And tweeting arises from sorrow, but sorrow also arises from tweeting.”

And there’s one more element worth noting: When someone like Philip Seymour Hoffman dies, at the height of his powers and of his fame, the grief that people express is distinctly different from that they express for a faded star like Whitney Houston. Since they have no recent encounters with her music, they cast their minds back to their own youth — which is of course lost. As Gerard Manley Hopkins said to the young girl weeping over a forest losing its leaves in autumn, “It is Margaret you mourn for”.

All this said, I wonder if it might not be useful for all of us to spend some time thinking about those artists and musicians and writers and actors and thinkers whose death would — we know now, while they’re still here, without any crowdsourced lamentation — would really and truly be a loss to our lives. And then maybe tweet a line or two of gratitude for them before death forces our hand.

The problem with defending death

Todd May has a short essay on death at the New York Times‘s Happy Days blog. The argument is age-old (so to speak), but he reiterates it in a concise, compelling, and beautiful way:

Immortality lasts a long time. It is not for nothing that in his story “The Immortal” Jorge Luis Borges pictures the immortal characters as unconcerned with their lives or their surroundings. Once you’ve followed your passion — playing the saxophone, loving men or women, traveling, writing poetry — for, say, 10,000 years, it will likely begin to lose its grip. There may be more to say or to do than anyone can ever accomplish. But each of us develops particular interests, engages in particular pursuits. When we have been at them long enough, we are likely to find ourselves just filling time. In the case of immortality, an inexhaustible period of time.
And when there is always time for everything, there is no urgency for anything. It may well be that life is not long enough. But it is equally true that a life without limits would lose the beauty of its moments. It would become boring, but more deeply it would become shapeless. Just one damn thing after another.
This is the paradox death imposes upon us: it grants us the possibility of a meaningful life even as it takes it away. It gives us the promise of each moment, even as it threatens to steal that moment, or at least reminds us that some time our moments will be gone. It allows each moment to insist upon itself, because there are only a limited number of them. And none of us knows how many.
Well put. But wouldn’t Todd May’s argument about the importance of omnipresent death in shaping our lives become somewhat twisted and strained if it actually were possible to halt aging (as life extension advocates believe will someday be possible)? It is one thing to argue for the wisdom of accepting death when it is an inevitability. But it would be very different to make a positive case for death when it is no longer inevitable.
In his blog post, May notes that “it is precisely because we cannot control when we will die, and know only that we will, that we can look upon our lives with the seriousness they merit.” But, although we can already decide to die if we so choose, might it not be much harder to look upon our lives with the same seriousness if we had to control when we died? Whatever the choice, our lives would take on a farcical quality, either from the emptiness of living without limits or the tragic absurdity of choosing to die rather than face that prospect.
(Hat tip: Brian Boyd)
[Image: “Q” from Star Trek: The Next Generation, portrayed by John de Lancie]