Monday, May 21, 2007

Morbidity and Morality

A patient stumbles through the doorway of the emergency room. Her gaunt appearance and look of fear draw your eyes towards her. She's thin and appears to be barely keeping her balance. She's dressed poorly for the weather. Fearing she might collapse a nurse quickly guides her to a stretcher. Her vitals are HR 170, BP 90/50, RR 38, T 36.7C, O2 100%. She seems confused, and somewhat agitated and cannot give you a history. She doesn't appear to have any injuries on physical exam. As you turn to the desk to order further investigations she asks you for a drink of water.

Medicine can be a detective game. Histories, physical examinations, labs and imaging are the clues we use to put together a story and a diagnosis. Sure many cases are straight-forward but the tricky ones can also be the most gratifying. A good night, and a tough case, can leave you feeling like chief CSI of the Emergency Department, and a bad night can leave you feeling like Barney Fife. There is a certain gratification in putting it all together (like House MD, minus all of the unethical and illegal behaviour).

Much of this detective work hedges on the assumption of an anatomic, or physiologic basis for disease. Modern medical training highlights the biological basis of disease; an abnormal urine dip here, an lousy blood gas there, and the case is beginning to add up. But what about when it doesn't add up? What about the times when the patients symptoms don't match the biology of the situation? What do doctors do where medicine and morals meet?

The idea that disease is caused by faulty personal morality is not new. Madness caused by spirits, or demons has been described since written history began. How such creatures gained access to an individual depends on the society in which the events took place. Perhaps it was a misdeed, perhaps it was karma, perhaps it was simply a sneeze (bless you) that let the demon in, and the madness begin. Often the root of the disease was slightly more complex. Often the real cause was a lapse in personal morality. Not surprisingly many early treatments for diseases involve the release of these 'bad morals' through act or ritual. Trephanation, pictured on the right, was used to release from the head not only medical problems (blood clots), but also moral problems (bad spirits).

We of the medical ilk like to believe such superstitious thinking is a thing of the past. Medicine has scienced itself up over the past few decades and our thinking about disease and causality of disease has changed along the way. In the past medicine included any number of diseases caused by 'weakness of mind', 'weakness of spirit' or other equally morally loaded terms. Madness, anemia (chlorosis), schizophrenia, depression, anxiety; all of these diseases have historically been in part attributed to moral causes.

It's interesting to consider how the above mentioned diseases migrated from the realm of morality into the realm of biology, and what that has meant for them in terms of their medical treatment. For the diseases mentioned above, improved understanding of underlying pathophysiology, and improved pharmacologic interventions has drastically changed the way they are approached and treated in modern medicine.

I've previously argued that moral thinking has a far greater strangle-hold on modern scientific medicine than we think it does. Certain diseases (or conditions) continue to be judged more in terms of morality than biology, and as a result are often not treated at all in the context of modern medicine. Two examples are addiction and obesity. Although both commonly present with a particular set of symptoms, and both are frequently life threatening, they are often untreated because they are the fault of the patient. This is in spite of the fact that for both of these conditions there are interventions (both pharmacological, and non-pharmacological) that have been shown to be effective in rigorous and well conducted trials (the bastion of modern scientific medicine). These days no good addictions medicine presentation is complete without a PET scan showing the biologic basis of addiction. Although well intentioned it is unclear (to me) if these scans exist in order to better direct treatment, or just to justify it. Although the pathophysiology of addiction is on it's way to being as well understood as depression, for many doctors it remains a disease of fault (and therefore a disease untreated). I am not arguing for ignorance of the behaviours associated with these diseases. Far from it, I am arguing for effective intervention into these very behaviours.

One of the difficult questions we must ask ourselves in medicine is 'is fault relevant?'. Does it matter that someone with addiction, at some point, choose to use drugs? Does it matter that a diabetic continues to consume 2L of pop (that's soda for you Americans) a day? Does it matter if a patient with lung cancer smoked for 50 years? Does morality (in the guise of causality and hence fault) have a place in medicine?

The case I started this article with could easily be a case of diabetic ketoacidosis, or it could just as easily be a case of cocaine overdose. The real question is (aside from obvious differences in medical treatment); why does it matter?

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