Unwieldy Power: When Our Medicine Takes on a Life of Its Own
Notes from a Family Meeting, Vol. 3, No. 4
I am now - what joy to hear it! Of the old magician rid; And henceforth shall ev’ry spirit Do whate’er by me is bid; I have watched with rigour All he used to do, And will now with vigour Work my wonders too. Wander, wander Onward lightly, So that rightly Flow the torrent, And with teeming waters yonder In the bath discharge its current! And now come, thou well-worn broom, And thy wretched form bestir; Thou hast ever served as groom, So fulfill my pleasure, sir! On two legs now stand, With a head on top; Water pail in hand, Haste, and do not stop! Wander, wander Onward lightly, So that rightly Flow the torrent, And with teeming waters yonder In the bath discharge its current! See! He’s running to the shore, And has now attain’d the pool, And with lightning speed once more Comes here, with his bucket full! Back he then repairs; See how swells the tide! How each pail he bears Straightway is supplied! Stop, for, lo! All the measure Of thy treasure Now is right! Ah, I see it! Woe, oh woe! I forget the word of might. Ah, the word whose sound can straight Make him what he was before! Ah, he runs with nimble gait! Would thou wert a broom once more! Streams renew’d for ever Quickly bringeth he; River after river Rusheth on poor me! Now no longer Can I bear him; I will snare him, Knavish sprite! Ah, my terror waxes stronger! What a look! What a fearful sight Oh, thou villain child of hell! Shall the house through thee be drown’d? Floods I see that wildly swell, O’er the threshold gaining ground. Wilt thou not obey, Oh, thou broom accurs’d? Be thou still I pray, As thou wert at first! Will enough Never please thee? I will seize thee, Hold thee fast, And thy nimble wood so tough, With my sharp axe split at last. See, once more he hastens back! Now, oh Cobold, thou shalt catch it! I will rush upon his track; Crashing on him falls my hatchet. Bravely done, indeed! See he’s cleft in twain! Now from care I’m freed, And can breathe again. Woe, oh woe! Both the parts, Quick as darts, Stand on end, Servants of my dread foe! Oh, ye gods protection send! And they run! And wetter still Grow the steps and grows the hail. Lord and master hear me call! Ever seems the flood to fill, Ah, he’s coming! See, Great is my dismay! Spirits raised by me Would I lay! “To the side Of the room Hasten, broom, As of old! Spirits I have ne’er untied Save to act as they are told.”
Johann Wolfgang von Goethe, “The Sorcerer’s Apprentice,” translated by Edgar Alfred Bowring
Some folks describe modern healthcare as a conveyor belt. Once someone’s on it, they glide toward a pre-specified destination receiving pre-specified interventions along the way. I guess this means that those conveyed are machines. Their particularity can remain unknown since general knowledge of their replaceable parts is sufficient to move them to the next station. Clinicians are the technicians along the line or are, mechanized themselves, robots offering sub-specialized techniques at their assigned times and places. Sometimes you can hop on and then hop off to get back to your life, but the sicker you get, the more time you spend on the belt. Sometimes you can’t survive off the belt at all. Of course, not everyone’s experience is just like this. Some struggle to even get access to the factory floor, or the belt stops for them when they can’t pay for production anymore, or they fall off when a robotic arm doesn’t know what to do with them. But in a healthcare system that feels impersonal, inscrutable, and inexorable, the conveyor belt metaphor comes in handy.
I’ve sat in many hospital and clinic rooms with patients who have been brought to impossible circumstances by the belt. One thing after another had led to what clinicians sometimes call futility. Everyone involved is disoriented. Clinicians fall back to discussing what are, at that point, frivolous details - what’s the blood glucose? How can we keep the blood pressure from falling further? Sometimes patients and their families join in there as a way of coping with the disaster. Other times they fall on their faith or else just opt out, not wanting to participate anymore. Whereas before everything along the conveyor belt seemed so well-ordered and capable, once you reach this point the factory has gone dark and the machines are menacing, malfunctioning, or misplaced.
Power Without Wisdom
In Goethe’s poem, a sorcerer’s apprentice seizes the opportunity provided by their master’s absence to tinker with some magic. The capability and independence is exhilarating. Real work gets done. Merely imitating their master’s technique allowed them to unleash power. The apprentice soon learns, however, that a little technique isn’t enough to control that same power.
We clinicians are the sorcerer’s apprentice. We control technology that, to the untrained eye, appears magical. We put that power to good work. We make many good things happen. It’s pretty awesome what we can do when we apply elbow grease and compassion to a problem.
But then the power gets away from us.
The same power that was so helpful in clinic later unleashes the catastrophe of chronic critical illness and disorientation about dying in the ICU. This power saves lives and cripples economies. It cures infections and breeds resistant microorganisms. It soothes anxiety and depression and confounds identity by reducing it to neurotransmitters and brain circuitry. It blurs the lines between healing and enhancement. The strength of technical prowess becomes our weakness when we reach its limits. The technology takes on a life of its own. As I wrote elsewhere:
“Who could have predicted the advent of chronic critical illness with the invention of the ventilator? This pseudo-agency of technology is best captured by McKenny: ‘…the very technology that originates in the effort of the modern subject to bring the external world under his power ends with the power of technology to recoil back and destroy or radically refashion the very subject whose power it is.’
To someone with a hammer, everything looks like a nail. The hammer did that to them. The inventor of the hammer likely didn’t intend to turn the world into nails. And so it is with the chemotherapy, the CT scanner, the scalpel, the DSM, and so on. Technology carries ideas, even whole stories, that causes it to grow around and within us. It grows beyond its intended use.”
The power that invigorates our tools also lurches through the pages of Mary Shelley’s Frankenstein. Victor Frankenstein, just like an apprentice without a master, was eager to control the “spirits” that led to the creation of his monster. But under the gaze of the creature’s jaundiced eye, Victor realized that he had overstepped a boundary. Everything he studied hadn’t prepared him for this. The creature was beyond his control and it also knew where things stood: “Remember that I have power; you believe yourself miserable, but I can make you so wretched that the light of day will be hateful to you. You are my creator, but I am your master;--obey!”
Like the sorcerer’s apprentice who wields the master’s technique without the master’s power, we, too, assume that a flourish is sufficient to control the “spirits” of medical technology we unleash upon human bodies. But, also like the apprentice, we “forget the word of might.” That “word of might” isn’t something new we need to discover, but something we need to remember. Hidden under the shadow of our progress, we forget the limits of technique and technology. We forget the humility of our human frame. We forget the purpose of our interventions. When we forget, our technology runs amok like the apprentice’s broom.
Once we’ve gotten in over our head, we scramble to employ new methods, techniques, and tools. They too promise to bring things under control. The apprentice abandons magic and resorts to an axe. Clinicians try other things (hopefully not an axe). Neither approach works out. The result is the same: a multiplication of disaster. In the case of the clinician and their poor patient, these kinds of interventions can exacerbate a glut of troublesome clinical information that doesn’t resolve the underlying dilemma, making it harder to perceive those things that matter most to patients. How does the information produced by a Swan-Ganz catheter help a dying person? Yet many a rounding clinician will ponder what the numbers mean and how to move them in a certain direction. Or how does an additional brain scan help someone with dementia who doesn’t have enough caregiver support? Yet the team will gather round to admire the pictures, watching cortex wither away.
Neil Postman described it this way:
“Technology increases the available supply of information. As the supply is increased, control mechanisms are strained. Additional control mechanisms are needed to cope with new information. When additional control mechanisms are themselves technical, they in turn further increase the supply of information.”
At the end of the day, clinicians, like any other human, only have so much attention. We want to give our attention to things we think matter, things that we feel like we understand or can eventually come to understand. In medicine, we want to use our attention as a means of control. In so doing, we can forget there are other forms of attention that might serve us better, like wonder and love. When overwhelmed, then, we fall back on the technical interventions and technical explanations to regain control, which themselves make us even less likely to remember as we should.
So, when our techniques and our analytical attention fail us, we might try to push them away, like Frankenstein with his monster. We want to stop everything we’ve wrought, to take away the technologies that sustain our distress, even our disgust. I’m likening the technology, not the patient, to Frankenstein’s monster here. When confronted with that failure, here was Frankenstein’s sentiment:
“I passed the night wretchedly. Sometimes my pulse beat so quickly and hardly, that I felt the palpitation of every artery; at others, I nearly sank to the ground through languor and extreme weakness. Mingled with this horror, I felt the bitterness of disappointment: dreams that had been my food and pleasant rest for so long a space, were now become a hell to me; and the change was so rapid, the overthrow so complete!“
What Victor describes isn’t only the horror at his singular act of vivifying the creature, but also the perpetual knowledge that this thing lives and roams around the world. It’s beyond him. Clinicians might empathize with Victor (I know I do), discovering that their best attempts to help someone brought their patient to greater depths of suffering through a process that is still ongoing. Sometimes the syndrome of “one damn thing after another,” as Atul Gawande calls it, is a series of intrinsic pathologies that we try to stop or subvert. Other times, it’s a cobbling together of iatrogenesis - one more doctor’s best attempt to use plastic or chemistry to make things better. How can we undo it? How can we fix it?
A Different Master
Given the power of medical technique, several parties vie for the role of master of the clinical encounter: the government (via regulation), the clinician (via self-regulation), payers (via financial incentives and disincentives), the patient (via consumerism). Each has some say about how clinician and patient work together. Their voices blend together in an often conflicting cacophony of guidance. None are masterful enough to put the “brooms” away and use the “spirits” for a better purpose, though.
Unlike Goethe’s apprentice, no master has left us. Rather, we ourselves have left, like a younger son striking out from home with his share of the inheritance. We’ve run away and left wisdom. Her guidance, after all, chafes against the promises of our ingenuity. How much better to choose our own path! As we find out too late, all paths without wisdom are dark and dangerous. Can we heed the stories that teach us the importance of her companionship? Without her, the creatures we’ve created and let loose in hospitals and clinics will be our masters. The conveyor belt will draw us all into the darkness.
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
Carl Elliott writes of the silly and ineffective attempts to manage ethics with mandatory courses - often video modules but sometimes live classes. These aren’t truly lessons in ethics, but rather recurrent reminders of policy and law. It’s important, of course, to know policy and law that’s relevant to your field. It’s also important to know where the gray areas are and how to think critically. There are very few opportunities to learn about these latter issues.
“Death brokering: constructing culturally appropriate deaths”
I had never considered my job as a hospice and palliative care physician as one in which I “managed death.” Yet Stefan Timmermans makes a compelling argument that what I’ve been engaged in has been a practice of “death brokering,” the practice of making individual deaths culturally appropriate. This means my work serves not just a clinical role, but a cultural, meaning-making role too. It also means such work is going to be hotly contested as culture changes. One challenge, as I see it, is to help folks and those around them use their dying time well. This involves conversations at the bedside, of course, and also bigger conversations away from the bedside in venues like Notes from a Family Meeting.
“Experts troubled by Canada’s euthanasia laws”
Incidents like these, where euthanasia is being expanded and even abused, have been reported for some time from Canada. It hasn’t seemed to alter the broader conversation either within Canada or internationally, namely, the growing popularity of these practices. A gracious interpretation is that this is compassion run amok without wisdom, but I worry it’s just cold utilitarianism. It reminds me that death can’t be a goal of care.
A paper written about an old tension within the field of healthcare ethics consultation that still exists today. This is the tension between the technical expertise offered by an ethics consultant who is familiar with hospital policy, and the more prophetic role (my words, not the author’s) that an ethics consultant might serve. I describe it as “prophetic” not that these people predict the future, but that they resist the busy status quo of the healthcare system to hold space for deep moral and existential reflection. This yields a fundamentally narrative-driven process in which a path forward is collectively discerned, or else at least everyone’s role in a morally charged environment is better clarified. In the latter case, at least we might have a better appreciation for what we owe one another, even if we can’t agree. Given the overlap between ethics consultation and palliative care, much of this also applies to my own clinical work. But there’s certainly a distinct role for ethics consultation; palliative care is no replacement for that.
“When private equity takes over a nursing home”
A dark portrait of further devolution and mutation of the nursing home “industry.” This is one step beyond treating humans like machines, but certainly a step further down that path. If machines become obsolescent, is there a way to at least make money from maintaining them since they can no longer “produce?” In such an environment, how can we not protect older adults, but also halt the degradation of a culture that would treat them this way?
Closing Thoughts
“Do not be daunted by the enormity of the world’s grief. Do justly now. Love mercy now. Walk humbly now. You are not obligated to complete the work, but neither are you free to abandon it.”
Pirkei Avot
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