Saturday, June 21, 2008

Acedia and Pastiche in Modern Life and Medicine—Can Medicine Escape the Stranglehold of Modernism?

“We live in a Mickey Mouse world in which images flicker with the speed of animation, and confusion is treated as a good. The result is a crisis of values undermined, certainties discarded and fears excited. Trapped in ‘future shock’ by the fear of unprecedented, uncontrollable change, refugees scurry into muddle. Pluralism gets stuck in pastiche.” ~ Felipe Fernandez-Armesto, in Truth – and a Guide for the Perplexed, Bantam Press, 1997, p2.
“Anything must be true before it can significantly claim other merits. Without Truth, all else is worthless.” ~ Gellner E, in Postmodernism, Reason and Religion.

“You see, I went on with this research just the way it led me... You cannot imagine what this means to an investigator, what an intellectual passion grows upon him. You cannot imagine the strange colorless delight of these intellectual desires... To this day I have never troubled about the ethics of the matter. The study of Nature makes a man at last as remorseless as Nature.” ~ Dr. Moreau explaining his research to Edward Prendick, in HG Wells’, The Island of Dr. Moreau, 1896

For many of us, modern life is one individual experience that is singularly all-consuming and intensely personal. There can be no denying our mounting self-importance and our enthrallment with ourselves.

However, for many of us this overriding individualism is veering perilously close to total disregard for others and our so-called humanistic, spiritual or moral values.

Universally, man is losing his spirituality and his awe of the Immanent. Our all-consuming immersion into the here and now has overwhelmed and superseded our previous engagement with our spiritual souls and exhausted our humanistic wonder.

Increasingly we appear to drift through life with a callous listlessness and spiritual apathy—this acedia—which can demean our humanness. (Although having recently read John Gray’s book “Straw Dogs”, one wonders if there is indeed any real or consistent postmodern humanist ethic at all…)

Our self-absorption and self-centredness have now taken centre stage of most of our lives. Other people appear to play only marginal or peripheral roles far remote from our conscience and immediate consciousness.

We are thus poised on the cusp of tremendous changes and profound paradigm shifts which threaten to undermine our humanity.

Our truths are becoming more and more relative. And our science—rigorous as it has been this last hundred years—is becoming more uncertain.

Indeed our scientific revolutionary era may perhaps be entering its own hubris of deconstruction and diminishing power as a social construct and determinant of truth and reality.

It would appear that Heisenberg’s uncertainty principle is rearing its fuzzy head by impinging into many of the tenets of science such that we can no longer be sure if what we know as plausible today would or could withstand the ratification or self-correction or ‘reality’ adjustments of tomorrow’s ideas and ‘truths’.

Consider the case of post-menopausal hormone replacement therapy (HRT) which has now been found to be more harmful than what was thought to be just a few years ago—with greater risks for heart disease, stroke, breast, endometrial and ovarian cancers, etc!

Yet despite such harrowing uncertainties with the continued use of artificial hormones, a better appraisal of how we can better manage the ill-effects of the climacteric has emerged.

Stunned, gynecologists and epidemiologists have now learnt to tease apart nebulous minutiae to determine what remains beneficial and worth offering to the long-suffering woman folk of the modern world.

We can no longer be too dogmatic or sure of our ponderous wisdom to prescribe at will without being challenged anymore… This is emblematic of our current position in today’s medical practice.

So, can many or any of our medical practices withstand the onslaught of increasingly negative or uncertain evidence to the contrary, in the near future, considering that perhaps only 30% of our medical ‘truths’ is evidence-based and proven?

Are we facing our own denouement for the folly of our hitherto paternalistic arrogance, such that we must now redouble backwards into ambiguity and shaky foundations?

Yet with the onslaught of new technology and techniques, many of us doctors are rushing headlong into embracing many of these newfangled treatment regimes, technical wizardries, devices and drugs, with a vigour that defies our much vaunted dispassionate logic and rational wisdom.

It is true that with every passing day, we are being bombarded with ever-newer understanding of our human body, the mind-boggling and paradigm-shifting intricacies of its workings.

And we are devising ever-newer techniques, medications or probes to correct or modify some of these failures or perceived errors of ailment and ill health.

We have even taken to redefining what constitutes health and well-being, with a mindset driven to prolong life to near immortality as possible.

Modern lifestyle expectations and limitations are re-designated as disorders, which can be modulated—without fully comprehending what we are trying to achieve in the long run.

Most importantly, we appear to be creating and offering more and more meddlesome modifications to shape and re-shape our rapidly changing concepts of what constitutes normalcy or disorders, as well as re-conceptualizing functional vs. dysfunctional states.

Thus, the recent eruption and growth of anti-ageing medicine, use and misuse of growth and sex hormones, other poorly tested supplements and supposed youth-enhancing elixirs and concoctions, is symbolic of this allurement of creative ‘medical’ pastiche—artifacts of a modish modernist culture.

When medications do less than they should or could, cosmetic techniques are seized upon: lasers, creams, Botox, direct vitamin C injections, etc. Cosmetology and aesthetics have become big money-churning enterprises, which pander to the narcissism of ageing (and age-fearing) people worldwide by tantalizing their Dorian Gray aspirations for those elusive fountains of youth. Has modern ‘medicine’ descended into these depths of pandering to pedestrian despair and gratuitous opportunism?

Yet, many medical professionals are now turning to this niche of gray and tenuous medicine, where the demand is fastest growing in a wealthier middle-class society.

Many such doctors are happy that for once, few of their clients are demanding too much but are willing to expect less, but are happy to part with more. What better deal with Mammon can there be?

With the human genome now essentially mapped, we are also exploring genetic, proteomic and pharmacogenomic probes and technology to correct indeed to improve or replace some of our inherited genetic lapses or translational errors.

We are now struggling to find the place of human stem cell research and cloning in our search for the ultimate rejection-free tissue or organ replacement (minus their genetic defects) to treat hitherto incurable diseases.

We have still a fair way to go, but the frontiers of ethically-nebulous genetic research continue to be extended relentlessly with the promise of immortality in the biotech horizon…

Only the unknown possibly beckons: with the possible hellish island scenario of Dr Moreau’s misshapen and deformed cloned creatures! (HG Wells, The Island of Dr Moreau, 1896)

While some of these innovations have yielded promising benefits, many of these have been met with surprising mishaps and unexpected complications and miscalculations. We have simply not fully understood many of the cross talks which plague the straightforward models that we have developed—many are too simplistic and therefore incomplete…

Elsewhere, medical technological wonders have totally revolutionized many a disease landscape. Consider the field of revascularization for coronary artery disease.

When Andreas Gruentzig first proposed that using a balloon catheter to dilate the atherosclerotic plaque could improve coronary circulation in 1977, it was a paradigm shift of the very first order. Conceptually and intuitively brilliant, this technique has outgrown itself into millions of procedures carried out throughout the world—from first to third.

Currently angioplasties outnumber surgical revascularizations (CABG) by two is to one. In just a short span of less than 3 decades, interventional cardiologists have displaced and reduced the demigod status of the cardiac surgeons to highly-trained and skilled technicians scrambling and trying to minimise, micronise, and even roboticise their incisions and procedures.
But alas (sic), we still need the surgeons—they have been left with the horrendous end of the CAD stick of severe diffuse disease, poor LV function, diabetics and especially when gung-ho cardiologists screw up, etc.

Of course they are still needed for the ultimate therapy of heart transplant or ventricular assist devices… Cardiologists have even taken over pacemakers, resynchronization therapies and defibrillator implants.

Not shockingly, cardiologists have been promoted to become technology-laden pushers of new cutting-edge devices, newfangled techniques and drugs.

They have morphed into articulate exponents of a new biblical paradigm of technology-driven and costly pinhole surgery, for which their evidence bases are slim and patchy at best.

They have also hewed their hitherto hidden talents to become brilliant miniaturized technicians adept at manipulating and traversing impossibly tortuous and narrowed or occluded vessels…

Many specialists have become so one-dimensional that the expansive breadth of heart disorders has become collapsed into a humungous accretion of one stretched out system of coronary artery disease, period!

What has become so alluring and mesmerizing to erstwhile proponents of the art of action-oriented physicians is the immediate gratification of producing great looking blood vessels, with the aid of balloons, stents etc.

However, nature has its way of coming around again to haunt us with their fight-back, their unpredicted relapse, the less-than-certain prognostic outcome—the restenosis bugbear!

Using the live-demonstration model to teach to a wider audience of doctors, ‘Live’ Transcatheter (Endovascular) Courses have now exploded throughout the world—with thousands of cardiologists crisscrossing the globe to teach and learn from one another, as well as to demonstrate and show-off skills and new devices which are happily supplied by the growing number of vendors and marketers.

Younger doctors and trainees can thus be exposed to how such skillful techniques can be learnt and practiced as well as to share with the experience, and hopefully to avoid the pitfalls and mistakes of the teachers, the proctors and the skilled.

It is true that many a suffering patient has benefited from these new and wonderful techniques, and immediate symptom relief has made many enthralled with the option. In acute coronary syndromes and myocardial infarction, these techniques have been clearly life-saving and prolonging.

However, the longer term benefits for less severe and more chronic forms of CAD have remained elusive or inconclusive vis-à-vis medical treatment per se. Still, this has not deterred doctors from offering more and more of these awe-inspiring technology and therapies…

What is severely lacking however, is the time-honoured tradition of trying to fully analyze what it all means to the unwitting patient out there at the other receiving end. Are we really helping our patients out there, or are we pandering to our misperceived arrogance and self-importance?

Does trying to perform every little thing to correct anatomical lesions, really benefit our patients? Have we improved their quality of life or even their longevity or are we sometimes causing more iatrogenic problems (more harm), which we then try finding other more innovative ways to combat?

Are we causing more harm than good in the long term, or have we lost sight of our Hippocratic dictum of promoting health and treating only ill health, but not creating new ones?

On the other hand, are we guilty of the modern in-thing, to create fresh and faddish disorders or fashionable medicalisation, so that we remain relevant as health care providers, as needed experts and healers?

Have we prostituted our profession to cater unthinkingly to the changing whims and fancies of our ever demanding consumers or the perverted mindsets of our procurers—our medical pharmaceutical industrial innovators? Who’s driving who?

Perhaps it is time to take some steps back and ponder. Is it simply the modern age that’s shaping our mindset, or have we allowed ourselves to lose touch with the real world out there by becoming too attached to the changing fashions of the world?

Have we become so enamoured with becoming engaged players in a ‘reality show” of our own making, so that we stay relevant, involved?

Have our increasingly synthetic world lobotomized our usually better instincts for human values and medical professionalism?

Can we or do we want to lessen or escape the stranglehold of Modernity on the practice of Medicine?

(MMA News Editorial, July 2005)

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