Writing into the Silence

Ten years ago an extremely distant relative by marriage, an aged veteran of WWII, commanded me to send a copy of my first book to his wartime senior officer, who became his enduring friend. The book in question (‘My Father’s Compass’, Hybrid, 2007) tells of my relationship with my father, a righteous and loving man who has been my lifelong inspiration. The relative said, ‘Paul will enjoy that book.’

So I obeyed. Paul read my book and enjoyed becoming acquainted with my father, a man like Paul, of unwavering principle.

A correspondence followed. Seven emails a day informed me of Paul’s take on the news. He disapproved of Obama, and of his successor as President; much of Islam (as portrayed in the popular press) offended him as did illegal immigrants. He disapproved of gun control measures (‘if you take weapons away from the good people, we’ll be defenceless against the bad people’). He had a close relationship with God and the Republican cause. He loved humanity broadly. He loved his family with a proud particularity, and he nurtured tenderly the numerous stray cats and partially tame birds who adopted him.

My email feed from Phoenix Arizona included Paul’s never-dull reports on the weather – its extremity and its beauty – on mushroom toxicology, on rattlesnake behaviour and on the conduct of those human snakes who conducted relentless scamming campaigns aimed to impoverish him. He loathed millionaire TV evangelists. He warned Israel’s enemies that ‘Jews will not go quietly to the showers again’. He warned the dictator of North Korea of the obliteration of his country if he started military adventures against the USA. Paul loved his country and he suffered the fiercest extremes of spiritual agony when faced with the horrifying (to him) electoral choice between Clinton and her opponent. While many found that choice troubling, it distressed Paul, so seriously did he take his duties as a citizen.

In due course I met Paul in the flesh, enjoying his company in the house of his daughter Ann. Ann drove us to the sequoia redwoods nearby her California home, where she took a photo of those ancient trees towering over her ancient father, who in turn towered over me.

On a later trip I visited Paul in his Phoenix home where we sat on the porch enjoying the desert sun and where Paul smoked his constitutional cigar. I promised myself I’d visit again in February 2019 when Paul would turn one hundred.

A couple of weekends ago the emails from Phoenix came abruptly to a halt. Then the following appeared on my screen:

Good day all!

 

This is John Jarrett, Paul’s youngest son.

 

On Sunday, November 7th while Paul was getting ready to attend church, he suffered a pretty severe TIA, transient ischemic attack, which has put him under the weather. He has been having some difficulties in his daily routine so we have all been with him 24/7 until he recuperates.

 

Thanks for your thoughts and prayers and I know he’ll be back on the computer as soon as he can. He loves emails, so keep them coming!

 

John

 

 

I wrote to John, with my hopes and prayers for his Dad’s health.

John wrote back:

He had showered and was preparing to drive to Church this past Sunday morning when he became impacted by dizziness and faintness… He’s also “put up” with a heart condition that brought bouts of angina at times and he has been having these TIA’s for several years ongoing…  He has a stricture where his aorta connects to the main part of his heart and was told he was not a candidate for a stint procedure… So, he soldiered on some more…

He had one “spell” (as my sister call’s it) about 3 weeks ago when she was visiting that took 3 or 4 days to show improvement after being 99% speechless for several hours.  About 1 year ago, he was unable to speak while doing business at the banking teller window…  He was getting Christmas gift envelopes for his children and grandchildren.  He tried to type emails Sunday evening but was unable to make is fingers hit the proper keys… The speech problem impacts his typing too it seems… He hears with difficulty (as has been his hearing deficiency for years now) but understands all that he is able to capture in terms of sounds.

He might recover from this most recent bout but each time, full or even partial recovery is becoming increasingly difficult. We are all praying that he improve to the extent he can enjoy his patio, cigars and cats again!  He is extremely weak in his legs/torso and has been impacted by some by minor paralysis in his right hand and arm too…

Fifteen days have passed since Paul’s son wrote. Fifteen days of email silence. In the silence I picture Paul suddenly, taken suddenly mute at the bank teller’s window, as he tries to buy gift envelopes for his children and grandchildren.

Conversations

After I started posting some thoughts arising from the current euthanasia debates, four women whom I hold in esteem wrote in strong response. Two wrote openly on the blog, two privately. I will refer to them respectively as B, M, G, H.

B wrote: Hi Howard,

I’ve just read your maybe not rousing speech but impassioned piece on euthanasia.

If I should be dying and I should be in unbearable pain, and if through that pain I was not able to continue to relate to my loved ones other than to be overwhelmed by my pain, you would be one of the doctors I would reach out to to put an end to my pain and possibly my life.

Will you refuse me?

I first met B in 1971 when she brought about my birth as a doctor. I have not treated her since. Instead we have become colleagues and friends. B’s note shifted my thoughts from the abstract to the concrete. Here was a cry coming from deep in an ancient moment in my formation. The person who wrote is concrete. Reeling somewhat, groping for self-knowledge, I responded speculatively:

Dear B,

I cannot know…

I suspect love would defeat principle or conviction or predisposition to life.

In other words I do not know myself in abstractions but in my instinct and my sentiments.

My ancient affection for you, my strong drive to help – which surfaced in your case in c. 1971 are as likely to govern me as any personal ‘rule’ or law.

I am sure if someone came and demanded I act in any given way my instinct would be to resist.

I anticipated readers would respond with passion and with pain to my piece.

I was right…

You asked would I help you.

I know I would try.

I cannot predict what shape my help might take.

This is a heavy matter. No light answers. And for me, no right answers.

But love will govern.

B again:

From feeling like I was falling into a chasm your response came as a hand that reached out to stop me hurtling to my death. Strange metaphor given I was talking about asking you to help me to die. I am much relieved that love will play a big part in your decision making process, over and above noble and fine principles.

But the debate hypothetically may be akin to Solomon’s choice.

Let’s talk.

My friend G is another colleague, a person raised in a strong religious framework from which she emerged to find and form her own way. I suspect her hard struggle for freedom has left her with a strong respect for my right to find and form a path of my own. G asked:

Would you be comfortable referring one of your patients who met the criteria to hasten their end to another GP who you knew would agree to assist in that wish?

And if that patient asked you to be present during the event would you?

How much do you think religion affects your current view? Or are you unable to separate your religious self from your professional self?

All F’s questions arrived as text message on my phone. Like death a phone message catches one on the hop. An answer will be less considered, perhaps truer for its spontaneity. I wrote a text back:

Hello F,

I’m pretty sure my religious self is absent from this.

It’s as if something deeper and defining is at play.

I imagine that ‘something’ is what brought me into Medicine.

And that drive collides here with itself…

But on the other hand, it was religion that framed my earliest thoughts.

It is on reviewing the texts that I regret not telling F at the outset: I can’t imagine doing anything I will find comfortable. The best I can hope for is to be comforting.

But if a patient wants me there at the end, yes, of course I’ll come. I’ll want to hold her hand as she passes over to ‘that quiet land.’

F resumed by email:

I find people’s responses to this topic rather fascinating (and at times irritating). So many reactions are full of judgement and criticism when it’s a topic that requires the opposite – compassion, objectivity and an acknowledgement of all of the grey. It would appear that a single (subjective) experience of dying makes some people self-appointed experts on the topic. I am of the thought that there is no ‘truth’ in any one person’s experience. And I wonder if those who react so emotionally to the idea of not having the ‘right’ to hasten their own demise have been more traumatised/suffered by the dying of another than the person who was actually dying?

What do I know? I do know that I would prefer not to die of bowel cancer. My experience working on GI wards is that that would be a shithouse (excuse the pun) way to go. I know that until I am dying of a known cause I won’t know if I want the option to hasten my demise or not. I know that having witnessed many people dying of a known cause (some in pain, some in discomfort, some in fear) that I’m still not convinced that assisted death is the answer. But I’m not convinced that palliative care is the answer either – theoretically it should be but I doubt it will ever be financially. I know that those who have reached the palliative stage of their illness should never be admitted to an acute care ward in a hospital – I’ve witnessed far too many cases of what I can only term the neglect of those in their final days/weeks in acute care wards. And the reluctance of acute care nursing and medical staff to adequately manage final stage symptoms. I want to believe in palliative care but I’ve been waiting too long for results.

I know that if you were my GP and I had a terminal diagnosis, I would feel like I had the best GP in the world. I would know that when you asked a question you would be genuinely interested in the answer. And I would believe that you would have a moment of quiet grief when I left this world. And that would be a comfort. As a nurse I never felt any sorrow for an anticipated death of a patient – the overwhelming emotion I felt was relief. Relief that there would be no more pain, no more nausea, no more confusion, no more discomfort from lying day after day in bed waiting to be turned brusquely. But I have a feeling that you experience a moment of sorrow for each death – correct me if I’m wrong.

If I were your patient and I asked you to help me die and you indicated that you couldn’t then I believe I would want your help to find a doctor who would be willing. I would appreciate that you would feel obligated to offer alternatives but if my mind was made up and it was legal then I would want you to support my decision. You might not support assisted dying on moral and ethical grounds but having come reached a fully informed decision I would want your compassion to make that referral to a colleague who you trusted and respected. And the promise that if I changed my mind you would do everything in your power to make my end days as comfortable as possible.

Your friend, F

These words come straight from the bedside. They come from one who has stood with me at the bedside. I cannot gainsay a word of them. Yes I do sorrow for every death. Yes I sorrow for every pregnancy loss. I grieve inwardly for a miscarriage. There is something universal here and something personal. The universal is the instinct that drives all of us to struggle for life. The personal is hard for me to define or even to describe. It comes into focus most sharply for me at the birth of a child. Those moments find their mirror image in a death. The one elates me, the other deflates.

H is a writer friend, a novelist and a family historian whose earlier profession was neurology. She writes humane novels filled with unsentimental empathy. H was another friend whom I disappointed. She wrote:

I’m sorry you feel you could not give this final relief. I am a convert to assisted dying (this is not euthanasia – which implies someone else’s decision that you should die). My feeling has always been that adults who are dying should have some choice about their death, and seeing three dear relatives all the way to death, I am now utterly convinced that such choice should be available. I understand that in states in America where such choice is available, of those who take up the option only a small proportion use the drugs supplied. But, those who receive the drugs and do not use them, are much calmer and happier, for knowing that they have control and can die should they feel they have had enough.

H here echoes an experience described to me elsewhere by B, arising from her work with men diagnosed in the 1980’s with HIV-AIDS. At that time the diagnosis was a death sentence. Some of the doomed acquired the means of ending their lives painlessly, with the intention of using it at a time of their later choosing. Of those men only one availed himself of the drugs. The others lived out their natural term. Knowing they were able to die enabled them to live on.

I close here with one message of straightforward approbation. It comes from M:

Very thoughtful. And probably helpful to those who didn’t like your last post. I have put the link up on my FB page.

M often comments favourably on my blog. When she doesn’t approve she’ll keep her disapproval away from the public eye. M is of course (as she signs herself) my loving sister.

It’s Not How Long You’ve Got, It’s What You Do With It

I’ve got six to twelve, the older man said.

The younger man said quietly, they give me three to six.

But you never know, said the elder, my count is down. A little. I might get longer. Doctors can be wrong…If the count keeps falling, I might last longer than the twelve; I might be able to take the family to Greece next year. I’d love to go…

The younger man said I want to get to my brother’s wedding in February.

Silently we did the sums. February will be after three months.

The elder man’s oval face creased. He said to the younger: maybe you can get into a trial. I’m on a trial drug. My count is down, a bit. Are you on a trial?

No. I’m not eligible. I don’t have the mutation.

The elder urged the other to do things, to try things, not to accept predictions as solid fact: They can be wrong you know.

The young man smiled his crooked smile, stretching the wasted side into momentary symmetry. I know, he said. At first they gave me twelve months. That was five years ago.

The elder man’s eyebrows shot up. Wow, he said, that’s beating the odds. His earnest face relaxed, happier now. Are you on chemo?

I have been. On and off. It’s stopped working.

I keep hearing about people who have their brain tumours removed. Couldn’t they try that?

They did. Twice.

Twice? The elder man winced. He was trying everything, fighting the younger man’s disease.

Whenever he spoke the younger man’s voice was quiet. A physiotherapist, he was trained in disability. Now it had come to him, kept coming, unfolding in his body. His brain analysed each stumble, he processed the growing weakness down the left side, every step was improvised, his studied speech experimental, not bitter.

I stumble too, said the elder man. Last week, I was only one kilometre into the marathon when I stumbled. The ambulance men would have taken me away but Howard here wouldn’t let them. It’s just the foot, it flops.

The younger man said you can get an orthotic to keep the foot straight. They work. They’re not comfortable but you won’t stumble.

The ‘stumble’ was a crash. Down he went, his heavy body accruing momentum that his muscles could not brake. Six of the last eight months in hospital had seen powerful tissues soften and shrink, proud muscles, muscles that had carried this man 39 times the full 42.185 kilometres and across the Line. One of the Legendary Seven, last Sunday he lined up for his fortieth. He walked, he trotted, he shivered wildly, then he fell. Bent forward at my feet the man groaned loudly. He crouched, his head folded under his belly and he groaned again. Blood oozed, first from his knees, soon from the heels of his palms.  Two tall young men materialised, one on either side of the fallen man. They asked questions, good paramedical questions. The athlete groaned. I said, He’ll be alright.

The ambos said, He doesn’t look too flash.

I said, I’m his doctor.

What’s his diagnosis?

Everything, I said. He’ll be right.

At the prospect of unwelcome rescue the runner hauled himself up the helping arms of his son and his doctor. His sister-in-law mopped blood. The tissue was soon soaked. He said to his son, I’m shivering. Can I have your jumper?

He started walking again. People in the crowd recognised him. He was one of the Seven. Good on you, they cried. Legend! Keep going!

The man kept going. So did his teeth, chattering violently now, drumming time with his gait. The doctor in me wondered about fever, the return of infection that had seen him in hospital again and again.

A little short of the Fitzroy Street landmark his wife intercepted him. She took his arm and guided him gently to the kerb.

***

The younger man and the elder had not met before, although each had heard me speak of the other, a person like him, another with a problem that doctors could not cure.

The younger man regarded the elder. This rotund man, this athlete, this grandfather who’d three times risen from his sickbed to run so far. He sat at a remove from his stricken body, his face alight in wonder.

I nudged the younger: tell him what you’ve been doing since your diagnosis. The younger man spoke a little in the voice I have come to know, the voice he always uses when speaking of his living while dying. The voice speaks softly, a grin riding above the speaking mouth, ironic knowing in the background. The elder sat and listened. He heard of the classes the younger man runs for children with disabilities: They’re the kids no-one can do anything for. I mean no-one can fix them. There’s no cure for their cerebral palsy or their intellectual deficit or their severe ADHD.

The younger man did not mention to the elder how he teaches children they can be anything, do anything. His own life is the textbook, held open to the kids.

How do they come to you? Do you advertise?

Not as such. More word of mouth.  And there’s the website*.

A smile dashed across the younger man’s face: We start off each time with a group hug. It’s more a gang tackle – they race across towards me and throw themselves onto me and we hold each other. It will be fun tonight. The younger man glanced at his failing left leg:  Until now my balance and strength have been fine. Tonight I’ll go down and I’ll stay down. He laughed. It was a merry laugh, no irony, just the laugh of a man looking forward to sharing with his small friends the joke that is his health. The joke that is all health that is broken or twisted or failing.

We ate, all of us suddenly hungry. The younger man’s left hand rested in his bowl of hot dhal. I looked down, wondering when he’d remove it. The hand stayed put. The brain that should have perceived and sent the message to the hand neglected its work. The brain has been invaded and the invasion continues.

I asked them both, Don’t you feel angry? (I felt angry.)

The older man said, Why would I feel angry? Look, I’ve lived, I’ve got my wife, my children, a grandchild. I have a lot, I’ve lived. I feel sorry for my mother. She rings me every day, every single day. She worries.

A moment passed while we thought our thoughts. I felt for the younger man sitting at the side of the elder and hearing of the joys of a life lived, of a man full with his generations.

The younger man said, I’m not angry about this. He pointed to his head. I just get angry when doctors won’t listen. I nodded. Some of my starchier colleagues are uncomfortable with a patient  who is more than his disease, one who charts his path, who travels his world so widely and deeply as my friend.

A week earlier I asked the younger man was he frightened of dying. He said no. Later, a characteristically quirky text appeared on my screen: On the way down in the lift I worked out why I wasn’t scared. Dying isn’t scary – if you get it wrong then you stay alive.

*www.camerongill.com.au

Magnified and Sanctified

It’s been ten years, Den, and only now do I feel I can say goodbye to you.

You were sixty three, I was sixty one. You died on Friday night. Your son brought the news to us at our shabbat table.

We buried you on the Sunday. We laid you to rest at an odd corner of the Jewish burial ground, beneath a young gum tree. I looked at the tree at that time and I remembered Dad’s fear of falling gums. I thought, here you are again, going against Dad’s prudent judgement. And I smiled.

You lie now, beyond the judgement of humans. Many were the people who judged you, fewer were those who tried to walk a mile in your shoes. They were big shoes.  Like everything about you, very big. Magnified, sanctified… People who did understand loved you extravagantly, in proportion to your extravagant life.

And now I can let you go. From the time of our final conversation I dreamed of you. The dreams were dreams of helplessness. You could not help yourself, I needed to help, I tried to help, but in those dreams, I could not. You called me that last time. The phone woke me from a dreamless sleep. Your speech rustled and crackled, the sweetness of your voice ruined by seven days with the breathing tube. You had rallied, they’d removed the tube; now, with your breathing failing, they needed to replace it. Your voice crackled: ‘Doff, they want to put the tube back. What should I say?’

I heard your breathing, a rasping, gasping sound. ‘Do as they say Den.’

‘Is it my best chance?’

‘Den, it’s your only chance.’

They returned you to your coma and they replaced the tube. Three days later you breathed your last.

At the cemetery we said, magnified and sanctified be the holy name.

One evening during the week of shiva my son led the prayers in honour of his uncle. He loved you Den. We loved you.

For ten years I dreamed of you, restless dreams, frantic. I was unable to help. Then I started writing about you and the dreams stopped. Now I sleep without the dreams. Sleep in peace beneath your gum tree, Den.

My Private Knee

After three months of physiotherapy and rest and exercises and anti-inflammatory tablets had failed to fix my injured knee, an MRI explained why: the outer cartilage was torn and the inner was tatty. I saw a surgeon last Wednesday and on Friday he repaired what was reparable and removed what was not.
 
 
The next day I sat on my couch in small pain, enjoying a liberal dose of self-pity. I had time and excuse to sit and live slowly. I read the ‘paper. A fellow citizen wrote to the editor in praise of Medicare, our universal health scheme. Her small daughter fell acutely ill and she hurried to the public hospital, where the waiting area was crowded and the public address announced the arrival of a series of ambulances. The delays would be long. However the sick child was assessed in Triage as urgent, was seen and treated expeditiously and expertly. By morning she was well enough to go home and her mother took up the pen in praise and thanksgiving. ‘How lucky we are’, she wrote, ‘to have such an excellent public health system.’
 
 
A second letter to the editor told the opposite tale. The writer suffered a limb injury and attended a public hospital. His injury was disabling and unremittingly painful. It was rapidly recognised as in need of early surgery. That was two years ago. His case is classified in the category of Most Urgent (elective). Every three months since he has returned to the hospital for routine appointments, where the diagnosis and the urgency are confirmed. His letter ends with a lament: ‘How can we kid ourselves we have a health scheme where Most Urgent can languish for years?’
 

****
 
 
The writer and I both suffered injuries. Both of us received expert advice that surgery was necessary. Mine was performed within days, while my fellow languishes for years. My injury was minor but it did not feel trivial. For three months it hurt too much to run. I turned to the bike and the knee felt worse. Soon I could not walk without pain. I watched the muscles of my thighs wither and I lamented. Those legs had been my pride. I contemplated a life without exercise and I knew I would not know myself.
 
 
How is it my leg improves by the day while a fellow citizen suffers a worse problem and waits interminably? I cannot doubt the sufferer subsists on medication which is neither curative nor safe. By now he is surely addicted to his opiates. Why the disparity? The answer is my private health insurance, which, by dint of thrift and belief, I afford. Not everyone is so fortunate.
 
 
Even an unbleeding-hearted economic rationalist would see the disparity as just that, an inequality. I believe there is a solution which is not a new idea, but a forgotten one. I recall a politician by name of Don Chipp who became Minister for Health in the Liberal Government in the days before Medicare was sanctified, beatified and became untouchable. Facing the disparity, Chipp proposed government would underwrite the private health insurance of the poor. All citizens would be insured, all would enjoy choice of surgeon and hospital, the private health sector would expand and prosper through efficiencies that Public Health can never match, investors would rejoice and the Liberals would be congratulated in the polls. Meanwhile Most Urgent Surgery (elective) would be performed within a humane frame of time.
 
 
That scheme, which bore some resemblance to Obama Care, never came to pass. Labor rejected the necessary Means Test as ideologically repugnant. Chipp moved out of his party and created a third force in politics, which soon became a chronic and disabling pain to Liberal governments. Decades later my fellow citizen, uninsured privately, suffers privately, where he could be cured.
 
 

More Unnatural Medicine 

Following my recent blog post titled ‘Unnatural Medicine’ one correspondent bothered to respond thoughtfully and at considerable length. As you will see from the passage below (excerpted from his comments) he writes insightfully and with strong feeling. I quite understand that intensity; health is both a personal and a universal concern. Further, at the head of its hierarchy and ruling our fate, standing over us, exciting our awe and our resentment, are the doctors.

 …On the other hand we see leaders in western medical practice dismiss Chinese medicine, for example, as quackery and voodoo medicine. Despite clinical trials clearly demonstrating the effectiveness of acupuncture, for example, many Scientists declare that there are no such thing as “meridians” in the human body as their existence has not been clinically demonstrated. The hypothesis is dismissed despite evidence gained from the applied testing that they do. Further, many assert that all forms of Chinese medicine, sometimes including acupuncture, should not be considered “real” medicine. (This includes senior doctors advising government and insurers.) Yet this practice has 4,000 years of accumulated clinical practice, is taught in major teaching hospitals in China and practiced daily by doctors in conjunction with “modern” western practice. Numerous clinical trials of diagnostics, treatments and herbal concoctions have been conducted, which are generally dismissed in the west, often merely because they are not available in English. When they are available, the results are howled down because there is no critical mass of such research available. Yet the Chinese pharmacopeia is yielding impressive results in western labs in the treatment of everything from common infections to malaria and cancer. Why is there such resistance to the science of Chinese medicine?
With the social and economic power of the western pharmaceutical industry we continue to see western medicine practised with an emphasis on the provision of drugs as first recourse in treatment. So pervasive is this that you have written about patients who want the prescription of a drug, any drug, rather than wanting to hear a more complex story of how to achieve health and of some doctors who support this approach. We have a culture of “science” where alternatives can often be dismissed and
where pharmaceuticals are pushed to the frontline of treating almost any and every condition. Incidentally, my father peddled Debendox – among many other drugs- to doctors in the 1960s and ’70s for the treatment of morning sickness and later associated with birth defects. It was given to me as a treatment for travel sickness. Hard science and its practice makes mistakes.
Please forgive my self indulgence in presenting my rant, Howard. I know your musings are often light-hearted and exploratory of deeper things. But I guess my point is this: there is an ideological
spectrum in medical practice, which can be said to range from “natural” to “unnatural”. There is medical practice that works with the “natural” processes of the human, which includes an understanding of diet, exercise, psychology, history, social conditions, the environment, etc all having their effects, good and bad, on human lives. In common parlance “natural” usually refers to seeing patients as people first, human beings subject to and part of nature in never-ending cycle of birth, life, death, repeat (depending on your belief). My experience of your practice puts you in this camp. Do as little harm as possible, be cautious, be curious, respect the person, do not jump to conclusions or easy answers, respect the life process. Sometimes trauma means offering treatment (or not) that may cause damage or harm. A difficult choice.
There is also practice that does not respect the human, does not give value to patient’s experience, knowledge of their body, etc. There is a dominant (moot?) practice of prescribing western pharmaceuticals first and asking questions later in the next 15-minute consultation a week later. This well-documented practice is disease focussed
and knows little of health, except as the “absence” of disease. This “unnatural” practice is characterised by a focus on the disease or condition, of which the “patient” is merely the subject. Treat the disease, not the person.
This spectrum lies at the heart of current debate and power struggles within medicine and in policy regarding human health. It has enormous implications also for all policy that focuses on the human species as somehow separate from “nature”, implicitly subject to different rules, with or without the possibility of divine intervention to protect us from
ourselves.
 
I find myself highly stimulated by my correspondent’s comments. I’m bursting with an accumulation of thoughts and feelings of my own, musings and speculations. I suppose these have gathered and grown within me over a lifetime in medicine. (It has quite literally been a lifetime: born into a household that accommodated my family and my father’s medical practice, I grew up in medicine. I was weaned on milligrams and speculums.)
 
My own feelings about western medicine and doctors are as mixed as anyone else’s. I am old enough to need the services of my doctors quite frequently, while still young enough to be doling out medical services to others. Macbeth cries, ‘Throw physic (medicine) to the dogs. I’ll none of it!’ And in a few cryptic words the Talmud declares: ‘”tuv harofim le’ge’hinnom” – the best of doctors can go to hell.’
Does medicine have an ideology? If an ideology is a system of beliefs or ideals or principles, I believe medicine does have an ideology. In the practice of that ideology I see the best of medicine, and in its abuse, the worst. That worst is the exercise of power for its own sake, a petty parochialism, a readiness to denigrate what it does not understand; and, in budget season, a hypocritical piety.(“No, no, no, Mister Treasurer , you must not cut, peg or regulate our fees – or our patients will suffer.’) The best is seen in your doctor’s service of ‘scientia cum caritas’, knowledge with loving care.
For me it is the ‘scientia’ which is the hard bit. Your good doctor is a scholar: the word means ‘teacher’, ‘master’, ‘wise one.’ That scientific doctor applies himself to the evidence. He suppresses his own human hankerings, his romantic leanings, his wishful thoughts. That doctor brings to his work a rigour, an austerity, a devotion to the pursuit of demonstrable truth. When I am sick I truly need that science; and your good doctor brings that to my bedside.
Let me give you an example. While working in the Emergency Department of Alice Springs Hospital last week I watched while five doctors worked to save a man who had been found at a remote roadside, unconscious and convulsing violently. The man was tall, strongly built, apparently athletically fit. His mountain bike was found lying near him. Unable to tell us how or what or when, his powerful body defied his absent mind as it jumped and threw itself around. I stood, quietly appalled, watching a man fifteen years my junior, disconnected from mind, at the threshold of the void.
The doctors watched him for signs. Acutely attentive to which limb moved, which did not; how his pupils reacted to a pencil beam of light; whether and how strongly he responded to voice (initially he’d stir; later he did not), and to a painful stimulus. Here was a biological organism in a near agonal state. The doctors looked up to study the lines and waves and numerals on the screen. How strong is his heartbeat, how effective his circulation? How much oxygen are his lungs delivering to the circulation and – critically – how high is the blood pressure? The readings were elevated above the norm. I misgave and pointed out the elevation to the Team Leader. ‘That’s good,’ he said. He explained that the damaged brain was much more vulnerable to low blood pressure than high. The outcome, he explained, was worse when pressures were low. ‘The outcome’: two words pregnant with knowledge, with meticulously gathered and tested and scrutinised evidence. Tough minds had obeyed tough rules in the gathering of that evidence; now smart scholars would deploy this in our immediate emergency. I witnessed dry science at the service of hot blood. 
It was imperative to control the seizures and to treat pain. Surely he had pain – he’d had a fall, presumably at speed, his skin was torn from his body, gravel and mud grimed his raw wounds – and he was vomiting forcefully on arrival. He must not be allowed to vomit lest he aspirate and block his lungs.
Next the man’s respirations must be controlled. He’d be paralysed and placed on a respirator. He’d become utterly defenceless. The very doctors who would overcame his defences must become his protectors.
To all these ends, all of them critical, all of the utmost urgency, strong drugs would be used – opiates, benzodiazepines, muscle relaxant drugs, anaesthetic agents, anti-emetics. Doses must be calculated minutely, effects monitored, dosages re-calibrated. The precise numbers of milligrams and micrograms would determine whether this man would live, would walk, would think, would speak, read, laugh or love. ‘Will this man ever get back on his bike?’ All lay in the hands of these scientific doctors.
 But how to calculate dosages? Unable to weigh a stuporose man threshing his own body, the doctors had to guesstimate. Too much opiate would lower blood pressure and endanger the damaged brain. Too much anti-convulsant would do the same. And both classes of chemicals might suppress breathing. The anaesthetic drugs must be adequate to paralyse him (to allow intubation and the use of the respirator), but again these agents can defeat their own purpose.
So the doctors injected morphine, eagle eyes upon oxygen saturation and respiratory rate and blood pressure. They injected metoclopramide to prevent vomiting that morphine so readily triggers. They deployed three different anticonvulsants, in doses nicely titrated, before they were able to control the fitting. Now came the intricate business of intubation, the act of introducing a breathing tube deep into the throat in defiance of every natural reflex and physiological objection; this procedure, a pas de deux of surpassing intensity, saw all present hold their breath in unconscious imitation of the patient, now paralysed, whose breath was held from him by chemical restraint. Now the tube was guided truly, now oxygen supply was resumed, hypoxia reversed. All breathed out.
Our patient would never know how medical science saved him. How doctors had used just enough of every hero molecule, how they had threaded that narrow path between his own injuries and the potential harm of their remedies. How every drug might poison him. And of the race of his life, the literal counting of seconds where every second counted, the quietly hectic passage of time when he arrived as quivering meat and was so soon stable. Safe!
Equally deep was the pool of knowledge that detected the cause of all – no, not head injury, not brain contusion, not spinal cord injury – a heart attack had thrown this athlete, engaged in a mountain bike race in unseasonal heat, into coma and convulsion at the threshhold of death.
So, yes, western medicine has its ideology. Last week I saw that ideology save a human person. Clearly I am in awe of that sort of intellectual discipline which is so far above and beyond my suburban skills.
By way of contrast we who practise by instinct, by intuition, must tread the shallows of organic disease, even as we grope in the deeps of human suffering. You cannot afford to indulge our speculative modes of medicine when your damaged organs call out for science.
In the earliest years of my practice I felt frustrated when patients informed me of the advice they’d received from alternative practitioners. Those healers would declare to my patient her spine was out and they’d put it back; they’d looked in her eyes and found her pancreas was sick and they’d cured her with herbs. Not with drugs, no, never with drugs. Those healers prescribed detox diets for the liver, cheerfully unaware that the liver detoxifies all. They told my patient they knew what was wrong, where I knew I did not, where no doctor could – in any scientific sense – know.
I came in time to respect the achievements of these practitioners. My patients felt better for seeing them, encouraged, confident in their recovery. I wondered how this could be and it came to me that the naturopath gave the patient the gift of an unrushed, attentive hearing. The amplitude of time, the emphasis upon natural healing, the resounding vote of confidence in the forces of the natural body helped the patient materially. I realised how intuitive, how insightful, how respectful was this practitioner. I recognised in the naturopath the healer I wished to be. But there was one difference, ineradicable: I never heard a patient quote the alternative practitioner confess ignorance or impotence. Free of the shackles of constraining science, the practitioner never said three words that I need to use every day. Those three words are: I don’t know.
I am pretty confident I have by now offended some readers. This is always a risk with the trenchant expression of strong opinion, of ideology, if you like. And it is not only western doctors who hold an ideological position. I consider it natural to humans, perhaps universal, to cherish convictions about health and its care. These convictions too encompass values, traditions, emotional needs. Mine are distinctively my own. Every distinct human will differ. Expressing my full thoughts on these subjects might offend seven billion humans.
Nevertheless I propose to write a series of short pieces which might include:
Why some doctors resist and resent alternative medicine;
‘Thou shalt not kiss thy patient’ and other absurdities.
Why I recommended acupuncture for a patient whom doctors could not help.
Why doctors prescribe medicines: Big Pharma, big mamma, bad sicknesses;
My Debendox daughter.
In writing on these matters I expect to relieve myself of strong feeling, long pent. And after all that I will scarcely have responded to my correspondent’s weighty concerns.
 
One final vignette before I let you go. In 1972 I joined a rural practice where I worked happily for almost thirty years. Around that time I met a squat jolly man and his slim jolly wife. The couple had three small daughters and I became their family doctor. They were a devout family, members of a small local congregation of a church which is possibly the most widely respected by the secular majority in this country. They wore their piety tactfully – neither crucifix nor yarmulke nor hijab declared publicly their private faith.
From time to time Mother brought the little girls, slim, elfin presences with smiles that sweetened my day. They’d sit on my knee while I discussed their condition their mum. In time they grew up and left their small home town. One of the three, whom I’ll call Sarah, returned and introduced me to her fiancé, a member of Sarah’s church. The two had decided on a career as ministers to the youth in the service of their church. Soon they would marry and take positions in a distant city interstate.
 
When I saw Sarah next seven years had passed. Her father had died of complications of orthopoedic surgery. Her face shone with grief and pride as she introduced her batch of three small children to me. Slim like Sarah, all with biblical names, they played at our feet as we spoke of their grandfather, that squat jolly man, and of his passing. Sarah and her husband petitioned the church for a posting in Melbourne to be nearer the family.
They settled in an outer suburb on the far side of town and I saw nothing of them for about three years, when Sarah turned up in my waiting room. Delighted and surprised I listened as Sarah told me of the strange and slow development of her second child, a boy. ‘Jeremiah might have autism.’ We talked. I told Sarah I was no expert in that condition. She seemed to know that already. She wasn’t after diagnosis, but counsel and for that it was to her old family doctor she turned.
Years passed. Once again I was delighted one day to discover Sarah in my waiting room. She was the final patient of my morning. By chance I had no more patients to see for the next hour and a half.
‘Hello, Sarah. What brings you here?’
‘Howard, this morning in the shower I found a lump in my left breast.’
‘Does it hurt?’
‘No.’
‘Do you have chills, a fever?’
‘No, it’s not mastitis. I weaned Benjamin a year ago.’
I examined Sarah’s left breast. Her slim body habitus made the lump easy to find. It was a hard lump, a little larger than an almond. I felt the opposite breast: normal. I probed her axillae. There, in the left armpit I felt a second lump, also hard. I tried to hide the dread I felt.
Sally looked up at me, searching my face: ‘Can you feel the lump?’
‘Yes. It’s a worry. Please get dressed and we’ll talk.’
We talked for an hour. We talked of the probable cancer, of its possible spread, of treatments, of specialists – who, where, when? Sarah asked, ‘Do think I’ll be cured, Howard?’ I did not think she would. I said the signs were worrying and I feared the worst. Sarah looked down and rummaged in her handbag for her hanky. She sat quietly, tears rolling down her cheeks. She dabbed her eyes and cried some more. The hanky was a sodden ball in her hand. She blew her nose and said, ‘I’m not frightened for myself. The children… they’re so young.’ Fresh tears followed.
At length it was time to finish. I stood up. On blind instinct, driven I suppose by hard feeling, I said, ‘Sarah, stand up.’
She did so. I stepped forward, took her in my arms and hugged her. She hugged me back, hard. I dropped my arms but she hugged on. And on. At length she released me. She took a deep breath, found a small smile and said, ‘That’s what I crossed Melbourne for, Howard.’
I never saw Sarah again. Her surgeons wrote to me from time to time. Eight years after her doctor took her in his arms and breached medical ethics, Sarah died. 

Health is not a Human Right

I am about to make some shocking suggestions: 

Health is not a human right.

The Morrison-Turnbull budget cuts to Medicare Rebates are not completely bad.
Running in the dark this morning, I noticed the illuminated sign outside the local hospital. It read:

PRIVATE HOSPITAL.

 

I felt unhappy reading that. A hospital is a place where human beings help other human beings with their health. The meaning of a hospital cannot be realised with that label. ‘Private’ tells the reader that some humans will be admitted and others turned away. Privacy as a personal property might well have been eclipsed by the internet, but ‘private’ survives with this message, unkind to some, saying ‘keep out.’

 

If health were a right we’d need to outlaw Down’s Syndrome, premature death and disability. We would legislate and make ourselves ridiculous. The error of language here betrays an error of thinking. We cannot assert a right to health, but we can create a right to equal access.

 

I am a private doctor. I am a public doctor. The public is composed of private persons. I treat one person at a time, privately. That is, personally, confidentially; two humans together, doing what every human does in a lifetime: ordinary transactions of care.

 

Doctors generally share a number of characteristics. We are serious, careful, committed and proud. We are defensive of our liberties, self-righteous and voracious of cures. We are expensive; I mean someone, somewhere, always pays for cures. In its new budget the government has pegged Medicare rebates. This skewers doctors and patients: either the doctor loses or the patient loses. There is nothing new in this.

 

When Hayden-Whitlam introduced Medicare I bulk-billed everybody. I thought it was a wonderful thing that a person, be she rich or poor, might consult a doctor equally. I thought so then and I think so still. To assure doctors they would not lose, the Hayden-Whitlam Government set up a referee who increased the rebate in pace with the rising costs of practice. This was costly. So the government told the referee to stop indexing rebates. And I stopped bulk billing. Often patients found themselves facing a choice – see the costly doctor or feed the family. When this occurred all doctors I know abated their fees so the patient might afford both cure and food.

 

What a government does in tightening benefits is to create the need for a new force to operate in care. The force is not one of rights but of grace. The doctor and the patient gaze upon each other as we did through all history, unmediated by refunds and rebates, freer now of the obscuring presence of the insurer. Two humans in a situation of human need.

 

The words ‘Private Hospital’ jolt me. They remind me that health is not merely a matter of economics or of civil rights, but of civil opportunity.