Wednesday, December 10, 2014

Toward a Philosophy of Being at the Bedside of the Living and the Dying

And now for something completely different...perhaps...

I have been giving consideration lately to the conceptual framework of therapeutics, a philosophy of therapeutics, which I don't think necessarily equates to what passes for philosophy of medicine. The philosophy of medicine seems to me more of a game, a nodding of philosophy and medicine to one another, an exchange of a knowing smile. I am loathe to jump into the naturalism/normativism, objectivism/constructivism (these pairs are, for the most part, synonymous) debates right now,  though I acknowledge the value in these 'discussions,' so long as they don't get too dogmatic.

So, my ophthalmologist (yes, doctors do see other doctors, though we deep down don't trust doctors) told me recently that my eyes are normal and healthy, as he was writing down my diagnosis of 'cataracts.' I laughed at this, and his response was telling and refreshing: cataracts are like your gray hairs: are they not normal and is your hair not healthy? Your vision is fine and your hair looks good. This is living a life. Or words to that effect...

Apparently, my diagnosis described something other than disease. I imagine if I couldn't drive at night because of oppressive glare and visual compromise, I'd have been invited to the operating room to remove those cataracts. Treatment depends on 'what's going on,' and diagnosis is a statement of 'what is.'

If anyone has high blood pressure she pretty much carries diagnoses of Stage A heart failure and and Stage I chronic kidney disease (please, no one panic; I don't--and I have high blood pressure, too). Often, treatment is an interpretive gesture, and its nature depends on the meaning of 'what is.' Meaning often gets its punch from context, and not all diagnoses mean the same thing. A diagnosis of cancer, for example, identifies a potentially lethal process that requires treatment. Many of us don't want to be told we're normal and healthy with a diagnosis of cancer, nor would we expect non-urgency to inform treatment; unless, of course, context doesn't punch so hard. I don't know who would want their prostate or breast cancer treated with harsh, often intolerable therapies if such a person were 96 years old, with dementia and frail. 

Sometimes value systems enter the fray. The presence of a diagnosis, even an objectively ominous diagnosis, does not necessarily demand an aggressively toxic course of therapeutic action. The meaning of the diagnosis must align with the meaning of treatment in a rational approach to therapeutics, and therapeutic action is as much determined by diagnosis as it is by the values that determine quality of life.

Deconstructing normativism does not lead to naturalism, nor is the converse the case. Deconstruction leads to freedom and assertions of meaning, and lives on the bar between what I am calling objectivism and constructionism, here;  and between what we call disease and health. Such deconstruction leads to discovery of what events are taking place in diagnosis, what is going on when doctors treat, and what is going on when patients present for 'treatments' for 'what is', even when 'what is' is neither a diagnosis nor a disease.

Although such treatments could be part of 'esthetic medicine'--medical/surgical procedures that treat the perception that one is getting older, wrinklier, and less attractive, I am thinking more of the treatment of symptoms regardless of the underlying diagnosis. Bracketing off whether or not medicine should be in the business of beautification, I consider what is happening, for example, at the end of life, when aggressive, disease-focused therapy is irrelevant, in which risk outweighs any benefit. Such symptom-driven, non-curative, palliative treatments enhance quality of life by reducing suffering caused by troubling and disabling symptoms such as pain, or shortness of breath; they might also lessen anxiety caused by such symptoms and impending death. Such treatments rarely manipulate the causes (primary causes) of suffering though of course they can ameliorate final causes.

Sometimes diagnoses are not descriptive of malfunction of statistically determined normal processes. Sometimes they just state 'what is,' what the symptom is: pain, confusion, shortness of breath, and the existential suffering of the impending loss of life. What is natural or normative, what meets criteria for objectivism or constructionism, becomes secondary if not obscene at the bedside of the dying. Opening the therapeutic relationship to the event, to healing, matters more than formalization of concepts. The event can lead to more living among both the living and the dying.

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