I want to talk about rationality in medicine, and rational choice theory as it applies to the actions of physicians and patients, with special reference to the somatizing patient.
My thesis was on the epidemic disorder, RSI, previously known as writers' cramp. What I want to say holds for any other somatoform disorder, or indeed the treatment of any disorder for which there is no specific rational remedy.
The profession of medicine has always accommodated two divergent and complementary philosophies: rationalist and empiricist. I will argue that empiricism is not rational and is therefore unethical.
These philosophies have their roots in the cults of Aesculapius, Hygieia and Panacea.[1] Hygieia 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.'
Panacea specialised in the knowledge of drugs and symbolised the belief that ailments could be cured with herbs and earth substances. The word Panacea embodied the illusion that there are remedies available for all problems. The cult of panacea justifies the increasing encroachment of medicine onto problems it has, as yet, been unable to influence. It accounts for increasing health spending without improvement in health status. These minor cults of Hygieia and Panacea informed the philosophies of the Rationalists and the Empiricists in Graeco-Roman medicine.[2]
Empiricists rejected the study of anatomy and physiology as having no bearing on the practice of medicine. Their philosophy was rooted in the doctrine of scepticism; that all knowledge was uncertain, that causes could not be investigated, and that the only valid reasoning in medicine was by experience, experiment and analogy.
The delivery of empirical remedies itself is not considered unethical. However it involves non-rational interventions, not telling the truth to the patient, a certain amount of optimistic self-deception by the physician. There is no hope of effecting a cure with an empirical remedy, nor of anything better than a placebo response. One has to ask, if it is not time that empiricism in medicine was subjected to ethical scrutiny?
Rationalists emphasised theoretical principles and believed that it was necessary to study the structure and function of the body in order to know the cause of disease. A rational treatment is one which is designed to bring about remission or cure of the relevant disease. Rational treatments are not always available, so what happens?
According to Freidson, the North American trained physician in 1970 was a crude pragmatist and not a scientist. He looked at the world through a clinical mind, and his aim was not knowledge but action. Unsuccessful action is preferred over no action at all. The tendency to take action for its own sake is based on the spurious assumption that doing something is better than doing nothing. As most illness ger better without medical intervention such a practitioner needed to believe that he did good rather than harm, that what he did made the difference between success and failure and to prefer his own 'clinical knowledge' to book knowledge. He argued that he could not suspend action in an emergency simply because he was uncertain and this provided him with a psychological ground from which to justify his pragmatism. He relied on what he took to be probabilities. I would argue that he lived in a state of mindlessness.
Scheff reported on the medical literature concerning 'iatrogenic,' or physician-induced disease and identified the process by which the physician unnecessarily caused the patient to enter the sick role.[3] Scheff rejected the notion that iatrogenic disease was 'merely functional disease' in the sense of being 'functional' for the patient. He took the position that the cause of 'functional disease' lay in faulty medical procedures and the frequency with which physicians made incorrect diagnoses and treated patients for non-existent diseases.
For a physician to dismiss a patient when he was ill was a type I error, and to retain a patient when he was not ill was a type II error.
It goes without saying, goes the axiom, that judging a sick person to be well was more important to avoid than judging a well person to be sick. The former might affect a doctor's reputation, but will only rarely have a permanent effect.
Scheff questioned the doctors' assumption that type II errors and the useless or placebo treatments based on them were harmless and that it was better to be safe than sorry. In order to believe this, one had to believe firstly, that untreated disease would put the individual at risk and, secondly, that medical diagnosis of non-existent disease was without consequences.[4][5] He suggested that following the 'better safe than sorry' rule placed in the sick role patients who could otherwise have continued in their normal pursuits.[6]
The , type II error has more lasting effects. Scheff argued that the type II error involved the risk of having a person enter the 'sick role' in such cases where no serious consequence would have ensued had the symptoms not been attended. Such changes were not taken seriously by the medical profession, but Scheff believed they profoundly influenced the course of an illness or even a life.
Show me a somatizing patient and I will lead you back to a type II error. Iatrogenic illness is the consequence of the administration of useless remedies without regard of the implications of what this treatment behaviour means to the patient who soon comes to regard himself as intractably ill.
Culver, Clouser and Get adapted rational choice theory to medical practice and argued that a direct but underground connection existed between rationality, and ethics so that only rational medical diagnosis and treatment were ethical behaviour.[7]
Rationality, as defined by Culver and Gert, contained two inter-connected elements: 'the holding of true beliefs' and 'the maximising the satisfaction of one's desires.'
Rational choice theory is based on the notion that rational action is that which maximalises desires. Motives concern some good which is too occur in the future. Reasons are based in the past, and both are dependent on beliefs and on the social arrangements.
It is axiomatic that rational medical action leads to the maximisation of the ultimate desire or 'good' within that system, namely health. 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 wishes, above all, to restore that patient to that status. Good health would be considered the object of desire of the top priority, and ill health, an evil to be avoided at all costs.
However, desires are often in conflict with each other and choices are made, often subliminally, in accordance with personal values. That is to say, being sick holds attractions, especially in matters where the sick role is rewarded by certain institutional and cultural arrangements. Having a sick patient can be lucrative, in these hard days of too many doctors. Motivation to ill health is usually unconscious precisely because it conflicted with conscious goals, values and ideals. Motivation to maintain a person in ill health is unconscionable. Yet is that not what we do when we give 'supportive' psychotherapy, or administer vitamin infusions?
Decisions are made in accordance with beliefs about the body, and false beliefs abound. Some patients believe themselves to be diseased even though there is not evidence in the real world for such a state. They seem to seek out those physicians who will maintain them in the sick role in accord with their own beliefs. Physicians who are willing to enter into this pas de deux of simulation collusion act as magnets for somatizing patients, and extract a high toll, willingly paid, in the form of ambivalently grateful submission to empirical remedies. Such physicians are full of reasons, which we would call rationalisations and they are based on their idiosyncratic beliefs. They stop collecting evidence to challenge their beliefs, when they know enough to justify their practice. The .beliefs that they choose are those which conform with their own desires which might include research grants, large spheres of influence, the adulation of patients, big practices, influence, or simply the good feeling of being a member of a social movement aimed at the improvement of workplace conditions
Clouser and Gert wrote that it was important to distinguish a reason from a motive[8] Reasons are based on the past and can be used to make non-rational behaviour seem to be rational, and in some discourses these are called rationalisations. If we considered only conscious motives, then most motives are reasons. According to this definition, a reason is not a motive is not because it was not a belief about avoiding an evil or gaining a good in the future. Reasons come from the past.
Clouser and Gert made the point that actions based on false beliefs were usually irrational, primarily because such actions did not usually lead to maximisation of desires for the actor.
Treatment actions based on type II errors, diagnoses to the effect that the body was diseased when it was constituted neither rational nor ethical behaviour for a physician as they were unlikely to bring about the good intrinsic in medicine, health. Indeed, the unconscious motivation behind the type II error, is unconscionable, a desire that the patient be seen as sick, and the physician as useful.
Is a type II error justified? Perhaps briefly in a life threatening emergency, until the situation is clarified. After that it will need undoing. However most Type II errors are not made in emergencies. They are the consequences of irrational beliefs, firmly held, believed and disbelieved simultaneously but underpinning action. An irrational belief was one that is, firstly ,held by a person with sufficient knowledge and intelligence to know that it was false; and secondly it is logically or empirically incompatible with a great number of beliefs that the person knew to be true and thirdly its incompatibility was apparent to almost everyone with similar knowledge and intelligence. Thus irrational beliefs were not merely false beliefs but they were beliefs whose falsehoods were obvious to people with the same training, the same intellectual backgrounds and capacities as the person holding them. It is necessary to collect evidence to support beliefs and when a physician refuses to collect information or chooses to disregard that which does not suit his or her personal desires, this behaviour might well be subjected to ethical analysis. The capacity to hold true beliefs about what is wrong with the patient is an index of one's medical competence and that a matter for ethics.
Empiricism can be very lucrative especially when the patient is not motivated towards a cure. I propose to call this transaction ‘simulation/collusion’ and not to return to it today. One of the norms of a society might be how much simulation collusion is to be allowed to occur on the public purse.
MacIntyre as provided a cumbersome definition of altruism in practice, the pursuit of goods internal to the practice, and this is the pursuit of health. Physicians need to be altruistic because, if pursue goods external to the practice of medicine, money, fame and adulation, and they have more than enough willing partners in this pursuit and ill health the consequence of this pursuit. Anything less than altruism is a compromise of ethics.
[1] Dubos R. Biomedical philosophies Man, Medicine and Environment. Harmondsworth: Penguin, 1970 pp 76-88.
[2] Veith I. Hysteria: The history of a disease. Chicago: The University of Chicago Press, 1965.
[3] Scheff TJ. Decision rules, types of error and their consequences in medical diagnosis. In: Tuckett D, Kaufert JM, ed. Basic Readings in Medical Sociology. London: Tavistock Publications, 1978: 245-253. Scheff first published his ideas dealing primarily with psychiatric issues in Being Mentally Ill: a sociological theory. Chicago, Aldine 1966.
[4] He shared Friedson's concern and accepted the capacity of the type II error to harm where a diagnosis was erroneously made of a stigmatising psychiatric condition.
[5] The physician might be operating on this kind of assumption, and if questioned he or she will justify his type two error thus. however, barring angina, there is no life threatening disease which presents as a symptom in an arm.
[6] Lamenting the lack of empirical data for type II errors, he cited Bakwin's 1945 study of physicians' judgments regarding the advisability of tonsillectomy for I,000 schoolchildren. Of these, some 6II had had their tonsils removed. The remaining 389 were then examined by other physicians, and I74 were selected for tonsillectomy. This left 2I5 children whose tonsils were apparently normal. Another group of doctors was put to work examining these 2I5 children, and 99 of them were adjudged in need of tonsillectomy. Still another group of doctors was then employed to examine the remaining children, and nearly one-half were recommended for operation.' Almost half of each group of children was adjudged to be in need of the operation. Even assuming that a small proportion of children needing tonsillectomy were missed in each examination (type I error), the number of type II errors in this study far exceeded the number of type I errors. Bakwin H. Pseudodoxia paediatrica. New England Journal of Medicine 1945;232:691-7.
[7] According to Culver and Gert, all theories of rationality agreed that to label something as 'irrational', was to express an unfavourable attitude to it. Culver CM, Gert B. Rationality in medicine. In: Philosophy in Medicine; Conceptual and Ethical Issues in Medicine and Psychiatry. Oxford: Oxford University Press, 1982: 22-39
[8] A reason is a conscious and rational belief that one's action will result in someone's gaining a good or avoiding an evil. In the context of neither good or evil being clearly visible, a reason is a means of maximising one's desires. A motive explains why an action was performed.