Since our Fearless Leader wants more stuff on health care, I’m contributing an abbreviated version of my first lecture in a course I occasionally teach, called “Professional Standards for Mental Health Workers.” It has a heavily historical/anthropological slant, since my students, though highly competent and hard-working, generally have a lousy background in history, which I feel puts them at a serious disadvantage.
Let’s start with the premise that all professions are priesthoods, and all originate with healing the sick. Terms like “witch doctor” and “medicine man” point clearly in this direction.” “Medicine”, in Native American religious tradition is a synonym for “religious ritual/power.” Like most pre-industrial medical traditions, it is based on the assumption that “sickness” can arise from or affect the body, the intellect, the emotions, and the spirit, in varying combinations. Among the Navaho, for instance, many illnesses are believed to result from “sleeping with kinfolk,” contamination from proximity to corpses, or witchcraft–that is, the improper behavior of the patient or somebody else.
So the “medicine man” has to know things about the patient that the patient would never want to become public knowledge. The patient will submit to treatment (and pay the doctor) only if the confidentiality of that information can be guaranteed.
Arthur C. Clarke, the science fiction writer, says that any technology we don’t understand is for all practical purposes magic. Healing the sick has always been one of the major attributes of divinities and their priests/shamans—a much more useful form of miracle than making water flow uphill or rods flower or whatever. The ability to heal implies POWER, which is scary to those who lack it. It implies, specifically, four kinds of power:
power to heal
power to withhold healing (“I don’t like you, or your brother killed my brother, so I won’t set your broken leg, nyah nyah nyah”)
power to kill (anybody familiar with herbs knows poisons and abortifacients as well as healing herbs)
power derived from knowledge (about the natural world and about the patient–unavoidable access to confidential info) (imagine a delirious patient raving about a passionate interlude with a person to whom s/he is not married, for starters.)
So most cultures generate some kind of code for their priests and healers, to restrain this power and keep it channeled in paths likely to be useful for the culture as a whole. In this lecture, I assign the students to ask any professional or skilled craft person they meet during the week about the professional ethics of that craft, and get written documentation if possible. I have gotten some fascinating samples: taxi drivers, sexual surrogates, veterinarians, child care workers, chefs—a long way from the Hippocratic Oath, which I generally see as the Ur-Document of its kind. But they all have pretty much the same restrictions in common:
Restrictions on use of knowledge and information
first, do no harm: for instance
in some cultures, no abortifacients
no exposure of patients’ secrets (no blackmail)
No favoritism in use of skills and knowledge, which must be made available to all, regardless of personality, affiliation, or resources
No “overreaching”–using rare and necessary skills to extort undue recompense (pecuniary, or, for instance, sexual favors) (The course, naturally, has a whole lecture devoted exclusively to the issue of sex with patients/clients, which seems to be a problem for every profession with the possible exception of accountants, engineers, and veterinarians. We’ve been blogging about Fountainhead lately, so you know it’s an issue for architects.)
The lecture then goes into a wildly condensed and popularized history of medicine, which I figure the various docs here are perfectly capable of providing us far beyond my poor amateurish power to add or detract. The point of it, however, is not what technology and information has become available at various points in our history, but how we use it. Thus, it’s important to keep in mind that there is a big difference between:
(1) what we can conceive of doing
(2) what we can actually do
(3) what we are actually doing
(4) what most people actually have done.
These days we pretty much presume that we can develop any technology we decide we want to develop. The areas of cosmetic medicine, infertility treatment and organ transplantation seem to be where we have actually decided we want to develop technology. Economics is probably the driving force behind these choices. Doing things people want is almost always more profitable than doing things people need. It took medicine a while to come up with serious work in the former area, but now medical science has clearly taken that ball and run with it. More about this later.
At the same time, mental health issues, which seem to be more and more salient as a source of real social problems, are being offered less and less attention from everybody except the drug companies. This is probably economically driven too. Drug companies can make lots of money in large gobs, while the more labor-intensive methods of treating mental illness dribble out the money in tiny drips to lots of people. . The things psychotherapy can do–usually over long periods with close attention–are miles away from what most psychiatric patients actually get.
All of the chapters of the history of medicine exist in the US today, side by side, like the rings on a tree. There is a ring in which sickness is still believed to result from the patient’s improper behavior (these days, we have given up on policing health in the bedroom, and taken up jackbooted thuggery in the dining room instead, but the results are the same.) There is another ring in which the most drastic intervention is the most highly regarded (especially in the treatment of cancer, where chemotherapy does a lot of the same thing that purges and bleeding used to do–the Ben Tre “destroy the village to save it” theory of medicine.) There is a ring in which the doctor’s job is to keep the patient comfortable until nature takes its course (that’s what hospice care is all about.) There is a ring in which medicine actually works, like a well-run car repair shop. And finally, the local “wise woman” is still around (herbal shops and healers in Chinatown, Hispanic neighborhoods, and New Age enclaves, etc.)
The economics of medicine work differently in each of these rings. Undoubtedly, whatever finally comes out of Congress (if anything) will not be fine-tuned to these distinctions. Probably we should be looking for a minimalist and mostly-preventive approach: make sure everybody, regardless of ability to pay, gets vaccinations, wellness counseling, treatment for infectious diseases, mental health care, and palliative end-of-life care, and let the Almighty Free Market do everything else. Mental health care, BTW, should be required to include some treatment for whatever DSM-V calls the compulsion to scream and shout disruptively at public meetings. Without it, our democracy cannot survive.