Tuesday, July 22, 2008

Medical Defence


And here is an interesting article in a recent student BMJ about conscientious objection among doctors - specifically whether doctors are within their rights to refuse to carry out procedures they find unethical. The author is Charles Williams, a medical student, and he writes passionately and articulately and reasonably - but I feel utterly, utterly wrongly - about a subject he has obviously considered at some length. His whole passage gave me a feeling of deep unease, and I'll try to explain what I felt, and why, and why I am less convinced of the rightness of his position after reading his argument than I was before.

(As an aside, as I understand the current Australian legal position, no-one is compelled to carry out an abortion or to provide contraception. In that it's like any other medical procedure. However, duty of care still exists - if you don't provide contraception, you have to make sure that you patient can get access to it somewhere close and cheap and convenient. Otherwise you're not doing your job, and you're liable, which is as it should be).

Anyway. In summary, as I understand him, Mr Williams writes that an inalienable right to conscientious objection exists, and that, as part of that inalienable right, doctors can refuse to participate in terminations. Rather than being penalised or pilloried, they should be praised. He closes by arguing we need more, rather than fewer doctors with the conviction to defend what they believe is right.

This does not convince me, on a number of levels. Lately I have become suspicious when I hear the term "conscientious objection". It strikes me that it is often used as a cheap debating trick - a sneaky appeal to a dubious higher authority. The term "conscientious" evokes a conscience, and by doing so suggests that some final arbiter has been consulted, that the speaker has visited some higher moral plain and returned with something somehow superior to our petty concerns and prejudices. Once something is named as a matter of conscience, it becomes somehow impolite to question or challenge it. There is just a respectful nod and the conversation moves on.

This is a fairly bizarre argument, once you look at it. From what I can work out, it asks the listener to believe that within each of us (or within the speaker, at any rate) there resides an inerrant moral-o-meter, something that enables the speaker to accurately and precisely determine at a glance the moral rightliness or wronglitude of an action, phrase or belief, something whose pronouncements should be taken on faith. I see no evidence of such an organ.

What I do see is a human tendency to rebadge and relabel things to our own advantage, to lie to ourselves and to others in order to maintain our accustomed levels of comfort. It is more comforting - and this isn't the nicest explanation - to attribute thoughts and words and deeds to our conscience rather than to our prejudices, or our laziness, or lack of imagination, or our desire not to think too hard.

Now, that may sound harsh. It is. But if it were true, it would explain how so many of these acts of conscience people talk about somehow end up replicating the same old patterns, making things worse for the marginalized, kicking not only those who are down, but those whom we knocked down in the first place. It would explain how people who draw their inspiration from the Bible and the Judeo-Christian code of ethics, for example, can be at ease with the whole rich man and eye of the needle thing, be udderly unconcerned when a calf is seethed in the milk of its mother, but will be struck with righteous rage when it comes to homosexuals or women. All of a sudden, when it comes inconveniencing others rather than ourselves, the weak rather than the powerful, God is not mocked.

These are ugly ideas. But otherwise we have to say it's an unfortunate co-incidence that Mr William's ideas, if acted upon, would kill vast numbers of women. It's sheer bad luck that Mr Williams' actions would result in sepsis, in fistulae, in suicide and infanticide. It's a terribly unfortunate but totally unforeseeable thing that the prayer-book is followed by the coat-hanger, and the coat-hanger by the coffin*.

Maybe it's not some mythical conscience, Mr Williams. Maybe it's something else, something women have heard from doctors before, something internalised and unconscious but pretty much there all the time.

In simpler terms, maybe it's not God. Maybe it's you.

Anyway. The history of conscientious objection, of people who followed their own moral code rather than that of society or "normal" medical practice, is no cleaner or dirtier than that of any other field of endeavour. One of us is no wiser nor more stupid than all of us.

Sincere, intelligent, diligent men and women have examined their conscience and then sterilized miscegenating women, or electrocuted homosexuals to cure them, or experimented on Jews. In the end, maybe you will get lucky, maybe you won't. If you are a conscientious objector, maybe you will end up lauded as a good person, as a saver of lives, an advancer of knowledge. Maybe you will end up as a footnote, a grainy photograph, a name in an article about Buchenwald or Sakhalin or Tuskeegee.

Either way, you will have done what you believe to be right. But His eye is on the sparrow, mate.

Anyway, I have said too much and left too much of what I wanted to say unsaid. there is a sense in which I don't have a right of reply here, in which the right of reply belongs to those who have seen the cost of the conscientious objectors piety, who have to bury the bodies they created to appease their conscience. That response has been given by Dr Shashi Sigdel, whose response gives less of the air of deliberation of Mr Williams, but more one of desperation and hope, and has the added benefit of being written by the bedside rather than by someone yet to practice.

But I am preaching to the already saved.

In the end, there are only two choices. The alternative to doing what a doctor should do, to doing your job, to healing the sick, to easing suffering, is to selectively doing your job, healing only the sick whom you choose to heal, easing suffering for those who meet your specific criteria. That may be the path Mr Williams has set out upon, and I wish him well with it, but I cannot agree that medicine needs more like him at all.

Thanks for listening,

*If only there had been a robust collection of data about the possible consequences of denying access to abortion, a body of evidence similar to the one that Mr Williams regretfully concedes does not exist about the terrible consequences of allowing abortion. Rather than relying on people's consciences as a guide, we could base this data on, say, scientific evidence, derived from clinical trials and the like. We could call it, I don't know, evidence based medicine.

Stop me when I get too crazy.

Sunday, July 20, 2008


And a very brief note here today, because today is the last day of our house-moving. We (Sarah, myself, the various beasts) are in the old house, the vast majority of our stuff is in the new. The house echoes like a cathedral - a rather grubby cathedral with post-it notes stuck to the walls and scattered science fiction paperbacks in the corners, but a cathedral nonetheless.

Ninety odd percent of our stuff is in boxes. This means breakfast is going to be rye toast with peanut paste. That's not that bad, except that was last night's dinner and yesterday's lunch too, and breakfast was a stale sausage roll from a dilapidated service station, something from which you could have extracted ancient DNA, and before that was rye toast and peanut paste. If I don't get up and get on with it, lunch willl be rye toast with peanut paste, or some stale crackers I was going to give to the chooks, or a packet of cranberry jelly.

There is also the spice rack, but man does not live by garam marsala alone. Once we move I am going to sit down and eat something healthy and fresh. I want a salad with seven or eight essential food groups, including three we haven't discovered yet.

Anyway, the new place. We could only afford second hand - it was built in 1904 - and it has these vast high ceilings and little narrow doors. It actually does evoke something of the cathedral. It is close to friends, and it is cheap, taking into account Sarah's diminished interest in and capacity to work.

Anyway, I must load boxes into the horse-float. Shall reply/post/etc soon. Next post, I promise, will have substance.

Thanks for listening,

Friday, July 11, 2008

In the throws of love

And this post has nothing to do with that title, it's just that I love the phrase. Love throws you. And it gives me pleasant images of rolling around on tangled bedsheets with Sarah, very close. She is interstate at the moment, and I am showing signs and symptoms of withdrawal.

Anyway. Herewith a brief conversation with a client I saw the other day. He is a licensed painter-decorator, the kind of person another client once described as “not the sharpest bowling ball in the shed”. I had seen him previously and discussed cognitive and behavioural approaches to opiate dependence and relapse prevention. He seemed very pleased to see me.

And for those who don't know, ice is the local term for crystalline methamphetamine.

Mr Chu: “This’ll be the last time you see me, Doc. I’m doing all that stuff you said. I've changed the crew I hang out with, I've taken the numbers out the phone, I’m going somewhere where there’s no fucking heroin at all.”

Me: "I don’t know you actually have to –“

Mr Chu: “It's sorted. I’m heading south. Way south.”

Me: “Okay.... Tasmania?”

Him: “Better. Antarctica.”

Me: Stunned silence. Long stunned silence.

Him: “They gotta paint, they gotta decorate. They gotta want some people down there.”

Me: “Mate, I don’t know about – “

Him: "Made up my mind. Anyway, I was talking to a mate, he reckons there’s no fucking heroin at all. No smack, no speed, not even mull. He say's it's paradise.”

Me: “Paradise? Didn’t know that… there’s a lot of ice, though.” I grinned.

Mr Chu: "Really?

Me: “Tonnes of it. Saw it on the telly. Ice everywhere in Antarctica. Situation's out of control.”

Him: “You reckon?... That's horrible shit, that is. Fucks you up real bad. You sure?"

Me, slowly: “I'm positive. Ice. Lots of ice in Antarctica. Lying all over the place. Ice.”

Him: "How come?

Me, even more slowly: “I mean ice. Ice ice. Tonnes and tonnes of it. All over the place.”

Mr Chu, visibly devastated: "Oh, that’s bad. That's no good at all. You sure?”

Me: “Mate, swear to God. Antarctica is covered in ice. Has been for years.”

Him: "Well, that’s fucked that up. What do I do now?”

Me, after one of the longest pauses held by someone who has not actually taken Holy Orders: "Well, there's a weekly narcotics anonymous meeting in South Mordor…”

One of those conversations where I start to worry if it’s me that’s mad, not him. And for me, that's not good.

Anyway, I will post more later - probably not for the next few days, as we are moving house, and I, being too mean to pay for removalists, am moving us, our furniture, our two horses, twenty chickens, two goats and several score cats to our new house by myself. In the meantime I refer you to FW's blog, to which I would link if this bloody cookies thing or whatever was working. She is being all insightful and thought-provoky there. Damn fine stuff.

Thanks for listening,

Monday, July 07, 2008

Welcome back, Tiger - now piss off.


The following contains sexual references.

And here is a link to one of the better medical essays I have read this year - something called "The Itch" by Atul Gawande. He's a damn fine writer, and this is an intrinsically fascinating subject. If you remain silent after reading the sentence that concludes the tenth paragraph, you're dead.

And by the way - it's about itching. A fair proportion of people get itchy reading about itchiness. I just had to stop typing this - and again - to scratch an itch: I get itchy writing about itching. Itching may be one of the few conditions that can be transmitted over the internet, that you can actually contract from someone electronically. Your ISP is a fomite.

What else has been going on? I broke up a marriage the other day.

Now, this will obviously come as no surprise to those of you who know me personally. Chubby, balding, middle-aged man with history of mental illness and interest in superhero comics - doesn't it just scream "marriage-wrecker"? You can tell by the way I use my walk, that kind of thing. But this actually happened. And the following is transcribed as accurately as I can remember it while preserving patient confidentiality - I have not altered it a whit, not a jot.

Maybe a tittle, a little tittle, but that's all*.

Anyhow, back to the marriage stuff. My last patient yesterday was one of my most likeable - a smiling, pink-faced, soft-featured Italian man who had adapted cheerfully to every impediment life had thrown at him. I smiled when I saw his name on the patient list and went out into the waiting room.

"Mr Barbapapa?"

He leapt up and rolled towards me, and extended a pink hand like a pseudopod. We sat down.

"So, how's things?"

"Brilliant. Abso-freaking-lutely brilliant.**"

"That's good..."

"Never better"

"Good to hear it. Now - "

"Yep, moved out, getting a divorce."

"What??" I yelped.

"Yep, all organised."

I was surprised because all through Mr Barbapapa's notes were references to his domestic situation, and in particular the stress that methadone had placed on his sex life. Methadone supresses testosterone secretion, which causes osteoporosis, loss of muscle mass, occasionally depression - as well as depressed libido and erectile disfunction. Mr Barbapapa had not lost his libido, he desperately missed what methadone had taken from him, but he had been unable to have an erection for three years***. To a man in his late twenties, this was a very significant thing.

I had done what I could. We had tried dropping the dose, but it was a difficult thing. Methadone withdrawal knocks you about, and he had a responsible job, a lot of physical labour. We had done the appropriate blood tests, and I had arranged the endocrinologist referral so we could prescribe him supplementary testosterone. And the last visit I had given him a few samples of sildenafil, which is Viagra.

"Try this" I said. And I'd told him that what was going on was a medication thing, tried to do what I could for his confidence, and sent him away.

And here he was. "Yep, it was that viagra stuff you gave me, really sorted stuff out."

I stared. "How?""

"Well, it was a long time coming. I told you - we'd been pretty much just living in the same house for the last three years. So I came home with the tablets and I showed her."

"What'd she say?"

"She laughed." For a moment his face fell. "Said it was a waste of time. She said 'It's not the tablets, you freakin'clown, it's you - you're an arsehole. I've been rooting the guy from the Seafood Shop'."

I stared. "Jesus."

"Yeah, that place on Main South Road, down near the Cashies."


"Yeah. Did you see what those thieving bastards charge for hake? There's no way -" He seemed to refocus. "Anyway - really got things out in the open, it did. Cleared the air. I don't think we'd really been communicating before that."

"And now you are."I managed.

"You can say that again. Anyway, moved out. And she doesn't want custody, so I've got Adam, which is pretty much the only thing that matters. He's four this week. And I got a new job - like close on double the pay, week on week off, flying out to the mines. And I met this woman - she's a librarian, bloody gorgeous, smart, really nice blonde piece. And we've been going at it hammer and tongs."

He reached into his wallet to show me a photo - I declined.

"Anyway, I want to start coming down off the 'done. Reckon it's time. It's the best thing that's ever happened to me. And it's all down to you and that blood y viagra. Wonder drug, it is."

"Right" I said.

We finished the interview, and he stood up to go. Before he did he reached out and shook my hand. "Gotta thank you again, doc."

"No worries" I said.

"Yep, this Viagra - really helped me out."

Anyhow, off to heal the sick.
Thanks for listening,

*At the moment I am talking to people like this, too - frequent digressions, lots of rapid-fire witticisms which only I find amusing, leaping from idea to idea. And I am finding it difficult to sleep, and I have a fair amount of energy, and, most damningly, I feel Fremantle has a chance this week against Geelong in the football. I am compliant with medications and seeing Dr Tesla soon.

** The technical name for this is tmesis, from the Greek temno, meaning "I cut". Actually, it's more accurately an expletive infixation. Now we can all sleep at night.

*** In his defence, not many people can have an erection for three years.

Tuesday, July 01, 2008


A quiet day here, so reading a few psychiatric papers, and something I read stirred memories of training at Mulberry House. And it's a remarkable day here weather-wise: rain is scraping at the windows, a cold wind from the South is blundering around the door, and outside you can see flung birds tumble across the sky.

Absolutely glorious.

Sarah is in the next room, looking at rustic cottages and remarkable chickens on the internet, and having a soft boiled egg, so all is good at the moment.

I was invited to a talk the other day by the Pfizer rep. Most drug reps are female, and young, and blonde, and impeccably presented, and seem very glad to see me, and they talk to me... well, like a woman who will get paid relatively well if she can make me feel important and smart and valuable in fifteen minutes, and relatively poorly if she can't. I find the whole dynamic rather depressing - sometimes I feel we are living in the Leaden Age of Psychiatry.

The Pfizer rep, I'm glad to say, is very different from those kind of people - she's a brunette. Still, she does give out free samples of something I trial my patients on, so we meet.

Anyway - something she said reminded me of something that happened to one of my friends a while back, something he refers to as the Great Last Minute Pizza Hut Suicide Prevention Dash.

This colleague of mine was working in a large hospital in Sydney, out near the shore. It was a sizeable hospital, a wide patient range, a number of consultants, and she was on call about one night in four. This particular night, at eleven o'clock, the phone rang.

"Doctor Rebecca? It's Emily LeStrange."

My colleague felt her heart sink. Emily LeStrange was a woman with a long history of borderline personality disorder. BPD is, at its worst, a truly crippling disorder, something that slashes away at your ability to hold a job, have friends, maintain a relationship, feel anything. One of the problems people with BPD face is that their condition (and I don't know about this "talking about a condition as if it is separate from the patient" thing here) - their condition can be very difficult for the inexperienced (and even the experienced) treating doctor to handle, let alone treat successfully.

Symptoms and signs of the illness, ways in which a person engages with and protects themselves against the world, elements of the disease - these can be interpreted by those around them as attempts to gain attention, as acts of sabotage or of malice. The patient acts, the doctor reacts, the entire therapeutic relationship spirals down the plughole.

Back to our story.

"How can I help you?" said my colleague.

"I just want you to know that before he discharged me, Dr Nardil put me on a MAOI*," said the voice.

MAOIs (mono-amine oxidase inhibitors) are still probably the strongest anti-depressants out there, but they are rarely prescribed nowadays, because of the large number of drug and food interactions. People on MAOIs have to avoid certain foods (cheese, preserved meats, etc.) and drinks (particularly Chianti), because of the risk of a dangerous reaction called a hypertensive crisis.

Every medical student has this drummed into them. If someone on a MAOI eats bean curd, or herring, or (for some reason) banana peel, they may die. Their blood pressure goes through the roof, "possibly followed by their head" as one of my lecturers said.

"Uh huh," said my friend.

"You haven't asked me where I am," came the voice.

Long pause. After a while Ms LeStrange continued.

"I'm in the line at Mordor Pizza Hut, and I've just ordered a Double Cheese and Prosciutto Explosion!" (actual words)... and I'm going to wash it down with a bottle of Chianti!"

And she shook the bottle near the phone. It made a sloshing, gurgling noise. So did my friend.

"Sorry, incoming call," said my friend, and put her on hold. He rang the Pizza Hut.

"There's a woman waiting in line in your shop," he said to the manager.

"Uh huh," said said manager, sounding all of fourteen.

"You can't give her her pizza - it'll kill her."

"Whatever you say, mate," said the pizza guy.

"I'm serious. I'm a doctor. Her head'll explode!!!"

"Mmm, mmm," said the man-boy. "Do you mind if I put you on speaker-phone?"

In the background my friend could hear the sound of a cash register opening and closing. He imagined a line inching inexorably forward. In desperation he shrieked, "Don't say I didn't warn you!" and hung up - and called the police. A few minutes later they burst in through the doors. There was an altercation and apparently Ms LeStrange was wrestled to the ground, and then into the back of the waiting ambulance, shrieking and trying to stuff a hot slice of pizza into her mouth.

Anyway, the medication Ms LeStrange had been given was what is called an "irreversible" MAOI, which means the side effects (including the whole "pizza/exploding-head" reaction) takes two weeks to wear off. My friend went to the tribunal and was given permission for an extended detention order, and Ms LeStrange went to the locked ward and was given no pizza, no beans and no banana peel.

The whole episode was a disaster, to be honest, and questions were asked, predominantly of Dr Nardil. I don't know what came out of it. But it does spring to mind every now and then when I see a pizza commercial.

Anyway, cats to feed and so forth.

Thanks for listening,

*Rhymes with Yowie, a large, mythical Australian anthopoid.