Biomedical Philosophies; Ethics and the Solitary Empiricist

Some biomedical philosophies provide tools with which the practice of medicine can be analysed, and, theoretically corrected. To manage increasing demand, we must ensure rational behaviour, encourage doctors to spend their time on activities that revitalise rather than disable and prevent epidemics. I do not decry the marvellous advances in medical treatment. But something more sinister is happening on the streets.

In 1972, the fathers of the first National Health Scheme, Medibank, expected that if better access to health care were made available, the health of the nation would improve and we would need fewer doctors. How wrong they were.

Can doctors, or anyone, articulate and explain to politicians why it is that when Medibank was first introduced, each Australian visited a doctor an average of 2.2 times each year, and now that average lies between 12 and 15 times, and the great majority of consultations still end with a prescription. There is aging and AIDS, but they cannot account for it. 

If we measure health by demand to see doctors, take medicines or use of hospital beds, the fathers were very wrong indeed. Something around having more doctors and more medicines appears to have created a problem.

Some people actually know what the problem is, and have known for 30 years. This knowledge is unpopular, well documented and well repressed.

Two years after Medibank was introduced, in 1974, Ivan Illich published Medical Nemesis about the epidemics of modern medicine, demonstrating how doctors were responsible for the creation of the larger part of the ill health that they treated.[i]

His book, according the British Medical Journal reviewer, sent a volley of grapeshot across the bows of the medical establishment. Well, the navy is still afloat, and the grapeshot has bounced off steel without even scratching it.

Morbidity, the professional word for the amount of sickness around can be measured by disability, days off work, social security statistics, doctor-patient contacts, hospital bed and costs.

I have researched two, much publicised, doctor-induced epidemics, examples of the many system failures, RSI, the epidemic of arm symptoms that came and went in the late 1980s and the current epidemic of mental illness that has escalated since the early 1990s. This refers to the doubling of the numbers seeking mental health care, the trebling of suicide attempts and completed suicide of patients under mental health care.[ii][iii]Since June 2001, an additional 257 mental health beds have opened. By June 2005, an additional 40 beds will have opened.[iv]

What exactly is it that doctors do? In 1959, Baroness Shirley Wootton, a philosopher in the House of Lords, suggested that a distinction needed be made between what is treatable by medical means' and 'what doctors treat', that is between what doctors do when they are behaving in the special fashion peculiar to their profession, and what doctors do when they drop the Aesculapian mantle (or white coat) and behave as ordinary men and women.[v]

No one took a scrap of notice, as taking on the medical profession is a risky business for legislators.

When doctors determine who is, or is not, legitimately ill for the purpose at hand, they are hiding behind a taken-for-granted authority and expertise in this area. But as soon as they have to explain their decisions to ordinary men and women, why one person complaining of symptoms is ill and the other not, they soon come to the boundaries of medical knowledge.

Disease and illness are the central concepts in the philosophy of health.[vi] After four years of scholarly analysis in learned journals of philosophy and medicine, in the late 1980s, the conclusion reached was that they did not exist other than in context, and could be defined only in terms of power. The authority of the doctor alone determined just what disease and illness were to be.

Medical power alone justified the intrusion of medicine into many spheres of life.

Merskey, a psychiatrist, points out that it is commonly believed that one could get away with anything with the help of a doctor's note, and he cites the literary example of William Wycherley's Restoration Comedy, "The Country Wife".

The plot turns on the deception practiced by a man who persuades his doctor to put it about that he has become impotent so that his acquaintances trust him with rather ready access to their wives and daughters.

Other possibilities for using a doctor's authority include Sick notes, compensation payments, how much work it is safe to do, disability support, not having to look for a job, housing, nursing and domestic help, legal excuses for bad behaviour.

The key to all of this is that the doctor must write something, on an appropriate letterhead, preferably, but not necessarily, in the language of medicine, to signal that that the patient is not fully responsible for inability to meet a social obligation and is therefore entitled to an exemption.

In 1986, Merskey, a psychiatrist, suggested

"That what doctors treat can be accepted as disease provided that we recognise that the significance of disease must vary with circumstances."[vii]

Merskey's definition fails and must fail because it is entirely circular, yet it cannot be ignored as it is precisely this view of illness and disease that informs today's debate, passes for "common knowledge" and forms the rationale for the interventions of doctors into all spheres of life, stress, crime, marriage problems and common human unhappiness.

Jeremiah Barondess, a physician, cut actress the debate with a Wittgensteinian, linguistic solution, Disease, he said is a biological event, characterised by anatomical physiological or biochemical changes or by some mixture of these. It may persist, advance or regress through a variety of mechanisms and may or may not be clinically apparent. Illness, on the other hand, is a human event, the product of stressful life events or a reaction to a threat. The stress causing illness may be a disease, but often it is not. Half of all of doctor patient contacts take place without a definable biologic basis.[viii]

So illness and disease are not the same thing. Disease is in the body, and can make you ill, or not.

Illness is the product what you feel and fear and that and it can give you symptoms the body as well.

Treating the somatic manifestations of illness like tiredness and aches and pains, will not make causal stress go away. Somatic, from soma, refers symptoms being experienced in the body but does not mean that the affected part of the body is diseased. This generates costs and makes little difference to the patient's condition, other than to persuade her that she is incurable. The pain is real, and to a non-professional, indistinguishable from pain that is underpinned by disease. Doctors can be learn to tell the difference but it is simply not in their interests to know, for a number of reasons: They need to be sure or they can be embarrassed, and it is harder to deal with social stressors in a 'medical' way if one really has to confront the fact that stress is making the patient sick.  

We do not expect to find local pathology in weak knees in an anxious person, nor the chest wall where stress related pain is often felt. Body parts can be sensitised by a variety of mechanisms, not least, beliefs and fears about their condition. The RSI epidemic provided us with an example of what happens if three government departments, and many trade unions, clinics and teaching hospitals al focus on the arms of workers. 

The relationship between disease and illness is taken for granted but it is complex. Some disease, like malaria, are accompanied by toxic illness, whereas others, such as advanced heart disease and cancer may or may not make you ill, until it is too late.

In 1988, Jurisprudence Professor, Ian Kennedy, reasoned that unquestioned jurisdiction over the determination of what was and was not an illness gave doctors unlimited power.[ix]

He pointed out that the notion of 'possession' (as in demonic,) had not fallen before the onslaught of scientific medicine but has been retained, in that the body of an ill person is now suspected, almost assumed, to be 'possessed' by disease, even in cases where the only evidence for disease is a complaint.

Kennedy saw that the doctor encouraged the process whereby he was seen as the purveyor of panaceas. Even though doctors would be the first to deny having any, it was gratifying to their perception of themselves as helpers, as it guaranteed they would never cease to be wanted. Quite simply, it gave doctors power.

The panaceas come from drug companies, collectively known as PhaRMAs. The term PhaRMA comes from the initials of the Pharmaceutical Research and Manufacturers of America. If they sell a lot of drugs, they make big profits, and they can do that only by influencing doctors to prescribe their drugs.

The profession of medicine has always accommodated two divergent and complementary philosophies:  rationalist and empiricist. I would argue that, when practiced by individuals, empiricism, which is currently dominant, is not rational and is therefore unethical.[x]

These philosophies have their roots in the cults of the god Aesculapius, his daughters, Hygaeia and Panacea and their followers, rationalists and empiricists.   

Hygaeia symbolised the belief that men would remain healthy if they lived wisely and within the laws of reason. Today we have hygiene, and the motto, 'mens sana in corporo sano,' a healthy mind in a healthy body.

Panacea, muse to the empiricists, embodied the illusion that there are remedies available for all problems. She specialised in the knowledge of drugs and symbolised the belief that ailments could be cured with herbs and earth substances. 

Empiricists rejected the study of anatomy and physiology as having no bearing on the practice of medicine. Their modern counterparts care little about diagnosis, only about treatment. Their philosophy was scepticism; that all knowledge was uncertain, that the only valid reasoning in medicine was by experience, experiment and analogy. They ask me, facetiously, ÒHow so you know?Ó And then they do not wait for an answer.

The delivery of empirical remedies itself is not considered unethical. However it involves a certain amount of optimistic self-deception by the physician and not telling the truth to the patient. There is no hope of effecting a cure with an empirical remedy, or anything better than a temporary placebo response.

Treatments that lay no claim to efficacy are called 'placebos', with 'placebo' meaning ÒI shall please.Ó Note the future tense, which make us doctors feel better, do better.

Philosopher Sisela Bok has argued against the use of placebos on ethical grounds. She makes the points that they involve deception and so they cannot be given with the informed consent of the patient.[xi]

She points out that such practices cumulatively generate huge costs and burdens without improving the health of a community.

According to Eliot Freidson, a physician philosopher writing in 1970s, the North American physician is a crude pragmatist and not a scientist. He looks at the world through a medical gaze, and his aim is not knowledge but action.[xii] 

He prefers unsuccessful action to no action at all. The tendency to take action for its own sake is based on the assumption that doing something is better than doing nothing.

As most illnesses get better without medical intervention such a practitioner needs to believe that he does good rather than harm, that what he does made the difference between success and failure. He prefers his own 'clinical experience' to book knowledge.

He argues that he cannot suspend action in an emergency simply because he is uncertain and this provides him with grounds to justify his pragmatism.

But then he then behaves the same pragmatic way when managing conditions that pose no danger to life at all.

In his haste, he might well mistake a symptom of illness for a symptom of disease, and act accordingly by delivering a physical remedy, and thereby creating in the patient a belief that he had a disease.

To give an example where empirical action is justified:  To a general practitioner, late at night, all chest pain suggestive of a heart attack must be acted on as if it were a heart attack, sent to hospital for a cardiogram, possible intensive care and enzyme tests. Nine out of ten will be stress-related 'illness'. 

Of those who are ill, eight will be happy to have no disease, but the occasional patient will find or seek out a doctor who is willing to maintain him in the sick role by advising that he 'nearly had a heart attack' and must in future avoid stress. He stays sick, might not get back to work.

Too often, the physician who prescribes placebos has not made a diagnosis. Incapable of mitigating the social stresses that are manifesting as illness in the patient's body, he is prone to see the patient's predicament through a medical gaze, to suspect disease, and then feel that he has the obligation do something rather than nothing, better be safe than sorry and so on.  

He is deceiving both himself and the anxious patient and getting paid, and he is likely to be unaware of what motivates him to do so. He would have a dozen reasons and my analysis would release indignation. He would argue that nowadays, as panaceas abound, that he uses active drugs, not placebos.

But active drugs used as placebos not only cannot cure: they might have side effects that cause further problems.

Empiricism is the practice of doing something rather than doing nothing. It takes us back to the 17^th Century when the symptom was the disease. That which could not be seen with naked eye was not known.

Scheff, a sociologist, examined the medical literature concerning functional illness, and identified the process by which the physician unnecessarily caused the patient to enter the sick role. Scheff rejected the notion that illness was 'functional,' in the sense of useful, for the patient. He took the position that the cause of 'functional disease' laid in faulty medical procedures and the frequency with which physicians made incorrect diagnoses and treated patients for non-existent diseases.[xiii] 

It goes without saying, by the axiom, that misjudging a sick person to be well is more important to avoid than judging a well person to be sick. The doctor who misses the real heart attack is reviled by his peers, criticised by his patients and may attract a negligence suit.

Nothing is done about the doctor who tells the man with clean coronary arteries that he 'nearly had a heart attack' disables him with an incorrect diagnosis. Some patients would go elsewhere and seek a second opinion, but such a doctor acts as a magnet for patients with psychosomatic illness. Primed for vitamin infusions and placebos, they enter a pas de deux of simulation and collusion to maintain in both parties the illusion of sickness and treatment.

Scheff questioned that telling people that they had a disease when they did not, was harmless, and that placebo treatments were harmless and that it was better to be safe than sorry and use an active drug, 'just in case'.

Following the 'better safe than sorry' rule placed in the sick patient role people who could otherwise have got on with their normal pursuits.

The medical profession did not take this seriously, but Scheff believed that such mistakes profoundly influenced the course of an illness or even a life.

Show me a patient, ill with no disease, says Scheff's theory, and I will take you back to a mistaken diagnosis by a doctor that is at the base of it. 

The notion of rationality has permeated philosophy from its beginning. Rationality equates with goodness. Rational choice theory, Racho, as it is fondly called, is well explained by Jon Elster (1994).[xiv]

In brief: people i.e. patients and doctors, individuals (or groups like PhaRMAs) seek to achieve their desires, by doing something (or nothing) or acting (or not acting,) in accordance with what they believe to be true, against a background of social norms and social values, which tell them what is a good outcome or achievement, and what is permitted or not, and what they can get away with, in order to maximise their desires.

That's simple enough. We go for what we want, as hard as we can, within the law and without upsetting others too much, and we are guided by what we believe will achieve those goals. If it is health we want, we think we, or our doctors know how to achieve it.

In 1982 Culver and Gert adapted rational choice theory and applied it to medical practice. They argued that a direct but underground connection existed between rationality and ethics so that only rational medical diagnosis and treatment constituted ethical behaviour.[xv]

Rationalists, unlike empiricists, maintain that knowledge about the human body is essential, as are true beliefs, good diagnoses and remedies that provide what is expected. Rationality contained two inter-connected elements: 'the holding of true beliefs' and 'the maximising the satisfaction of one's desires.'

A rational treatment is one designed to bring about remission or cure of the relevant disease

Rational choice theory is based on the notion that rational action is that which maximalises desires and the ultimate desire or 'good' within the practice of medicine is health.

Rational choice theory can analyse the actions of patients and doctors and any stakeholder, their beliefs and desires, their reasons and motives doctors to identify where problems exist, where medical care went wrong.

Rational practice is predicated on the assumption that the patient wishes, above all, to be restored to a state of health forthwith and that the physician is capable and has no greater desire than to restore that patient to health. It also assumes adherence to the Hippocratic oath: Primum non nocere.  Above all else, I will do no harm. This is not an absolute, as some treatments have harm among their side effects.

Beliefs are imperfect in a variety of ways and held for a myriad of reasons, people stop collecting evidence when they find one that suits them. Desires are not always achievable and costs are involved, so they are placed in a hierarchy, by individual preference. Treatments carry risks and side effects, not all goals are reliably achievable, Desires are often in conflict with each other and choices are made, usually unconsciously, against a matrix of personal values.

Being sick holds attractions where it is rewarded by institutional and cultural arrangements, compensation, sick role and pensions.

Motives concern some good, which is to occur in the future. Reasons are based in the past, and are dependent on beliefs.

Motivation to maintain self or another in ill health is unconscionable. It is usually unconscious precisely because it conflicts with conscious goals, values and ideals.

Medical decisions are made in accordance with beliefs about the body, and false beliefs abound and are promoted. Disease mongering exaggerates the danger of blood pressure, depression, menopause and work. Awareness campaigns are backed by vested interests; PhaRMAs hold out a remedy to eliminate these newly identified risks.[xvi]

When exposed to disease awareness campaigns, some clinicians do not recognise that the PhaRMA is trying to move the goalposts, to persuade them to diagnose hypertension and ten points lower, diabetes with only occasional high blood sugar, diagnose 'depression' where others would see unhappiness, stop collecting evidence about the patient's condition. Reassured of their skills by the propaganda machine and glossy brochures, they no longer need the views of others who might challenge their beliefs, they ignore negating evidence when it suits them to do so, they beliefs and desires stay in a balance when they know just enough to justify their practice. Their newly acquired knowledge is so tainted that they find it hard not to diagnose a much-promoted condition where there is the slightest suggestion of it.

The beliefs that they choose are those that conform with their own desires, which might include all those goods external to the practice of medicine, money, fame and popularity.

Making the incorrect diagnosis or administering treatment without known efficacy constitutes neither rational nor ethical behaviour for a physician.

Closer and Gert made the point that actions based on false beliefs were usually irrational, primarily because such actions did not, and could not succeed.[xvii]

The tragic fact is that medical education of our doctors, and medical students is in the control of vested interests, colleges, professional groups, professional associations, pharmaceutical companies that control journals and fund conferences. John Merson calls this problem 'epistemic capture.'

Now for some examples:

In the 1980s, a small group of doctors created tens of thousands of cases of RSI because they were told by a group of vested interests, the occupational health lobby, that symptoms in the arms of workers were evidence of traumatic disease.[xviii] They were identified to get referrals (read: popularity, money) if they were prepared to provide certificates to remove afflicted workers from their tasks lest they become even more injured, to the point of total and permanent collapse, stage 5 of RSI.

Had they given the appropriate consideration to the sudden appearance of RSI, its symptoms and its epidemiology and distribution in the workforce, they could not have operated on, splinted or medicated or antidepresssed and disabled hundreds of thousands of workers.

Writers' cramp, a mental and behavioural disorder, had become epidemic every other time in history when doctors were encouraged to pay attention to arm symptoms and were generously rewarded for providing useless remedies.

The example of depression

To practice ethically and rationally, to respect choice and autonomy, prescribers have to make their patients aware of side effects. But drug companies do not tell doctors enough for them to get informed consent. Informed consent and patient autonomy are basic tenets of medical practice.

In recent years, Australia and the United Kingdom have been exposed to campaigns to identify and defeat depression Ð funded by PhaRMAs that desired a large population to use their new products, loosely termed 'antidepressants.' A cultural phenomenon, some like Prozac and Zoloft are household words.

It was known that 'biological depression' the condition, which carried a high lifetime, risk of suicide was a rare condition and the suicide rate of could be halved by existing drugs, tricyclics, known as TCAs. As a last resort, ECT or shock treatment was very effective.

Then came a new group, serotonin boosters, mood brighteners, which did not work on biological depression but had the effects best described as 'activating' s if taking small doses of cocaine and amphetamines, but legal.[xix] Prozac was not the first, but because of a cunning promotional campaign it hit the ground, running. Eli Lilly told the public through a massive publicity machine it caused weight loss.

That turned out to be a lie, as it does the opposite, stacks on weight.

To get doctors to prescribe them, they lied that they were not non-fatal in overdose but this is not true of all of them.

In order to find a market for these substances, PhaRMAs marketed a new 'disease' by promoting a notion that a shortage of serotonin was the cause of depression, and that their serotonin booster could 'correct this imbalance.'[xx]

Another lie: Serotonin has never been found to be abnormal in depression and 90% of it is in the gut, not the brain anyway.

This lie defined 'depression' as a 'disease' and not an illness, which you will recall from the Barondess definition, is a human event by stress.

The clever marketing of 'depression' as the disease of having low serotonin levels, which these drugs correct, created a false belief system, which profoundly influenced the collective actions of doctors.

The indications for these new drugs had been expanded to include anxiety (which makes people miserable, but does not kill them), obsessive compulsive, eating disorders, unhappiness, grief, rage, the consequences of failure and abrasive relationships at work. 

These human ills were converted into a disease state so successfully that 4.7% of the Australian population, or one adult in twenty, currently takes an antidepressant, and they believe they are correcting a deficit condition like diabetes.

As with heart attacks being a side effect of the painkiller, Vioxx, there is an ugly underbelly.

New drugs never have side effects, because we do not know about them. Studies kept coming in, telling doctors that one person in 20 who took these wonder drugs got more not less depressed, one in 70 became suicidal and one in 500 committed suicide. Many others became psychotic or violent.

We were repeatedly reassured that antidepressants did not cause suicide with the mantra,  ÒIt's the disease, not the drug doctor.Ó But this did not wash when the patient was being treated for grief, mourning, anxiety or menopause, conditions with zero suicide risk. And they knew all along, as they did about Vioxx.[xxi]

We now know that between two and eight times as many people were killing themselves on these drugs than would have done if left alone with their miseries or taking sugar pills and having conversations weekly, 200/100.000 v 30/100,000 on sugar pills or untreated.[xxii]

Improbable candidates on antidepressants were committing homicide followed by suicide.

The availability of a remedy for depression has caused a thousand fold increases in its diagnosis. And their lethal side effects have increased by the same multiplier.

In September 2003, the publication of studies from the United States Food and Drug Administration showed that the manufacturers of the new generation of antidepressants had hidden these suicides from both doctors and patients. 

Congressional Hearings and a House of Commons inquiry followed, but Australia still has not posted FDA warnings about suicide.

This seems to have been a political decision that invites ethical analysis.

When PhaRMAs engage with doctors and governments, rational choice theory analysing their actions, what pass for their beliefs alongside outcomes would suggest that they have but one desire: profits.

In the United States, the fourth highest cause of death after heart disease, cancer and strokes are adverse drug reactions, known as ADEs. They are responsible for over 105,000 deaths each year. They fill hospitals their sublethal side effects, which do not get diagnosed because doctors were not told there were any side effects. If one adds improperly prescribed drugs and those taken incorrectly, ADEs become the third highest cause of death.[xxiii]

A score of drugs licensed in the 1990s have been withdrawn for lethality which apparent in clinical trials but not disclosed to prescribers or patients. The recent withdrawal of Vioxx followed hundreds of thousands of heart attacks, 50 to 100 planeloads of lethal heart attacks. Vioxx was defended, as 'safe' until two weeks before its withdrawal, by what might be Merck's, the manufacturers, last breath.[xxiv]

PhaRMAs select their promotional material out of a hierarchy of beliefs, selecting those that suit their desire, profits; they create, amend, massage and tailor the beliefs they promote.

Doctors were told that Vioxx does not cause excess heart attacks, but that Naprosyn, which was the comparator drug in these studies, protected from heart attacks.

We are reassured that a schizophrenia drug, Zyprexa does not cause suicide, but clozapine reduces suicide risk by 75%.[xxv] Yet one in every 208 patients in the Schizophrenia trials committed suicide in the FDA trials, and one on comparator drugs.[xxvi]

PhaRMAs know their drugs cause harm to some users and decide, on commercial grounds, to lie, provide doctors with false beliefs and face litigation while pursuing market share.

They tell lies, misinform their lay educators, who charm us with their dinners, wines, pens, gimmicks and luxury conference funding, and generous honoraria for speakers, termed 'opinion leaders' who are willing to transmit beliefs favourable to them.

They donate to political parties both sides of the aisle. That of course, is another area of ethics, subject to changes in societal norms and values. Government leaders accept PhaRMA hospitality. Health ministers have been known to cut out experts, to order multimillion-dollar purchases of drugs on information provided in company summaries as opposed to demanding to know how they performed in clinical trials.[xxvii]

Lawsuits by individuals are afoot but, more significantly, attorneys general in a score of American States are taking legal action against the drug companies, with budgets the size of small European countries, expecting to recoup hundreds of millions of dollars that the side effects of deceptively advertised medicines have cost the health care providers. New York's Attorney General, Eliot Spitzer, won a settlement of $US430 million against Warner Lambert, a subsidiary of Pfizer, Inc. for illegal and deceptive promotions of one of its blockbuster drugs, Neurontin. Spitzer said. ÒMarketing strategies that deceptively and illegally promote drugs for unapproved purposes in order to increase a pharmaceutical company's bottom line will be aggressively investigated.Ó[xxviii]

It is too frightening not to trust. There is an inclination to assume both good will and competence to doctors.

Gorovitz and McIntyre in their paper "Towards a Theory of Medical Fallibility" warn:

The physician's propensity for damaging error is widely denied, perhaps because it is so widely feared."[xxix] 

Politicians fear doctors and their power. No political party can stand images of sick babies awaiting humidicribs, or men on crutches awaiting surgery, no matter that they know they are being manipulated.

In 1974 Ivan Illich popularised a technical term, iatrogenesis, for what was then a Ònew' epidemic of doctor-made disease, composed of the Greek words for 'physician' (iatros) and for 'origins' (genesis).

It was clinical, when the pain, sickness and death result from the provision of medical care.

It was when social, when the organization of health care generated dependency and ill health, and

It was structural where doctors, and their delusions of efficacy, undermined natural confidence of ordinary in caring for each other.

In his critique of Illich, the Marxist, Vicente Navarro saw iatrogenesis as a by-product of the struggle between the powerful classes and the less powerful.[xxx]

In his explanation, responsibility for iatrogenesis did not lie with the medical profession at all, and but with the powerful corporate classes which had a dominant influence in health care delivery. These were big PhaRMA, big business, governments; insurance companies all of which determined how and what kind of health care was to be delivered.