Article
Care
Comment
5 min read

The healing touch in an era of personalised medicine

As data powers a revolution in personalised medicine, surgeon David Cranston asks if we are risk of dehumanising medicine?

David Cranston is emeritus Professor of Surgery at Oxford University. As well as publishing academically, he has has also authored books on John Radcliffe, and mentoring.

A doctor looks thoughtful will holding a stethoscope to their ears.
Photo by Nappy on Unsplash.

In 1877 Arthur Conan Doyle was sitting in one of Dr Joseph Bell’s outpatient clinics in Edinburgh as a medical student, when a lady came in with a child, carrying a small coat. Dr Bell asked her how the crossing of the Firth of Forth had been on the ferry that morning. Looking sightly askance she replied;  

 “Fine thank you sir.”  

 He then went on to ask what she had done with her younger child who came with her.  

Looking more astonished she said:   

“I left him with my aunt who lives in Edinburgh.   

Bell goes on to ask if she walked through the Botanic Gardens on the way to his clinic and if she still worked in the Linoleum factory and to both these questions she answered in the affirmative.  

Turning to the students he explained  

“I could tell from her accent that she came from across the Firth of Forth and the only way across is by the ferry. You noticed that she was carrying a coat which was obviously too small for the child she had with her, which suggested she had another younger child and had left him somewhere. The only place when you see the red mud that she has on her boots is in the Botanic Gardens  and the skin rash on her hands is typical of workers in the  Linoleum factory.   

It was this study of the diagnostic methods of Dr Joseph Bell led Conan Doyle to create the character of Sherlock Holmes.  

A hundred years later and I was young doctor. In 1977 there were no CT or MRI scanners. We were taught the importance of taking a detailed history and examination. Including the social history. We would recognise the RAF tie and the silver (silk producing) caterpillar badge on the lapel of a patient jacket.  We would ask him when he joined the caterpillar club and how many times he had had to bail out of his plane when he was shot down during the war – a life saved by a silk parachute. We would notice the North Devon accent in a lady and ask when she moved to Oxford.  

The patient’s history gave 70% of the diagnosis, examination another 20% and investigation the final 10%. Patients came with symptoms and the doctor made a presumptive diagnosis – often correct - which was confirmed by the investigations. Screening for disease in patients with no symptoms was in its infancy and diseases were diagnosed by talking to the patients and eliciting a clear history and doing a meticulous examination. No longer is that the case.     

At the close of my career, as a renal cancer surgeon, most people came in with a diagnosis already made on the basis of a CT scan, and often small kidney cancers were picked up incidentally with no symptoms. The time spent talking to patients was reduced. On one hand it means more patients can be seen but on the other the personal contact and empathy can be lost.  

Patients lying in in bed have sometimes been ignored. The consultant and the team standing around the foot of the patient’s bed discussing their cases amongst themselves. Or, once off the ward, speaking of the thyroid cancer in bed three or the colon cancer in bed two. Yet patients are people too with histories behind them and woe betide the medic, or indeed the government, who forgets that.  

With computer aided diagnosis, electronic patient records and more sophisticated investigation the patient can easily become even more remote. An object rather than a person.  

We speak today of more personalised medicine with every person having tailored treatment of the basis of whole genome sequencing and knowing each individual’s make up. But we need to be sure that this does not lead to less personalised medicine by forgetting the whole person, body mind and spirit.  

Post Covid, more consultations are done online or over the telephone -often with a doctor you do not know and have never met. Technology has tended to increase the distance between the doctor and patient. The mechanisation of scientific medicine is here to stay, but the patient may well feel that the doctor is more interested in her disease than in herself as a person. History taking and examination is less important in terms of diagnosis and remote medicine means that personal contact including examination and touch are removed.  

Touching has always been an important part of healing. Sir Peter Medawar, who won the Nobel prize for medicine sums it up well. He asks:  

‘What did doctors do with those many infections whose progress was rapid and whose outcome was usually lethal?   

He replies:  

'For one thing, they practised a little magic, dancing around the bedside, making smoke, chanting incomprehensibilities and touching the patient everywhere.? This touching was the real professional secret, never acknowledged as the central essential skill.'

Touch has been rated as the oldest and most effective act of healing.   

Touch can reduce pain, anxiety, and depression, and there are occasions when one can communicate far more through touch than in words, for there are times when no words are good enough or holy enough to minister to someone’s pain.   

Yet today touching any patient without clear permission can make people ill at ease and mistrustful and risk justified accusation. It is a tightrope many have to walk very carefully. In an age of whole-person care it is imperative that the right balance be struck. There’s an ancient story that illustrates the power of that human connection in the healing process. 

When a leper approached Jesus in desperation, Jesus did not simply offer a healing word from safe distance. he stretched out his hand and touched him. He felt deeply for lepers cut off from all human contact. He touched the untouchables.   

William Osler a Canadian physician who was one of the founding fathers of the Johns Hopkins Hospital in Baltimore, and ended up as Regius Professor of Medicine in Oxford,  said:  

“It is more important to know about the patient who has the disease than the disease that has the patient”.  

For all the advantages modern medicine has to offer, it is vital to find ways to retain that personal element of medicine. Patients are people too. 

Article
Assisted dying
Comment
Mental Health
6 min read

No, it is not your life to dispose of

What could not be said about the assisted dying debate

Steve is the former vicar of St Matthew's Oxford.

Empty bus seats are lit in dark neon colours.
Vy Tran on Unsplash.

It is 1979.  I am aged 23 and have been in great mental and emotional anguish and pain for years. I am on a pointless journey, on Greyhound busses, from the East coast of America to the West, and am presently sitting in a parked bus just outside a city in Arizona; the powerful engine idles as we wait for departure time, giving a gentle to-and-fro rocking motion to the bus.  I have not eaten for days, am unspeakably tired of my life, and have made a written list of possible ways to end it.   

But not on that list is one possibility I have not previously considered, but which is now before me.  As I look out to my right, up into the Arizona desert hills, I realise that here is an option which perfectly fits with my desire, not so much to do away violently with myself, as simply to drift into a passive oblivion; I realise  that I could simply rise from my seat right now, get off the bus, stumble off into the desert hills, lie down, and wait to die.  I need not shoot or poison myself after all.  I know I can do this, and fairly easily; to die will take time, but no matter.  No-one knows where I am, no-one will know I am missing, no-one will come looking for me, and probably no-one will find me.  It is suddenly an immensely attractive prospect, and I am seconds away from rising up from my seat...  

There is one thing, one thing only, that makes me hesitate; it is what other people would call ‘a religious belief’, but to me it is simply a truth. 

It is this; I am absolutely sure that there is a God.  And suddenly there is something grimly, darkly humorous even, in what I thus believe will follow my death; I will find myself, not in peaceful oblivion, but in the presence of God. I will, as they say, ‘meet my Maker’.  And what then will I say to God?  I will say: “Apologies: I could not go on, there was no other way out for me”.   But what, I reason, if God were then to say: “You are wrong. There was a way forward. Look: you could have stayed on the bus, and had you done so, let me show you how your earthly future would have panned out…”   And I will listen, and I will watch, as the film rolls on, showing me an alternative future.   But of course, by then it would be too late… 

And suddenly, sitting on that bus, in a moment of cold clarity, I realise, with a kind of desolate logic, how I am caught.  In a very real sense, my belief in God my Creator means that I am not in fact ‘free’ to dispose of myself; more, that what I refer to so glibly as ‘myself’ is not in fact MY self.  The bus ticket in my pocket may be ‘my’ ticket, my rucksack ‘my’ rucksack, but my life is not after all my possession, mine to dispose of; it is a loan, a gift, from a Giver, to Whom I am responsible, answerable… 

I remain in my seat.  The bus continues its gentle rocking motion a while longer.  The driver gives his familiar 1970s Greyhound driver’s recitation, the various admonitions and prohibitions I have heard so many times as I have crossed America, I could give the speech myself (ending with the words ‘and no marijuana’, which always raises a smile) – and the bus pulls out onto the freeway.  I look back over my shoulder at the desert hills as they recede, and feel I am leaving more than the desert hills behind; I am still in deep pain, but know I have left a possibility behind me, for good.  Months later I will reflect on this moment and realise with a smile that the name of the city where I had put death behind me by not rising was Phoenix. 

And so my journey has continued – on, in due time, to a return to England, to a measure of healing, to getting ordained as an Anglican priest, to thirty-four years of Church ministry, to marriage to a very remarkable woman, to fatherhood of two children - and, at some future moment, to my own death: all in God’s time. 

How shoddy, shrunken and lonely, is our much vaunted and trumpeted vision of the autonomous individual. 

The word ‘God’ was probably used very little, if at all, in the MPs debate on assisted suicide - and this debate has really been about assisted suicide, not ‘assisted dying’, given that people will be given drugs to self-administer. Even the Christian MPs who spoke, did not mention God, as they knew what could be said, and what could not, in order for them to be heard at all.  The public arguments for, and against, the legalisation of assisted suicide have almost without exception had to be premised on one agreed assumption, apparently the only one now permissible in a post-Christian, liberal humanist, agnostic/atheist society: the assumption that my life is mine.  The arguments used for assisted suicide resolve down to: “It is my life: I should be allowed to decide when to end it”.  Most of the arguments used against resolve down to: “Yes, of course, granted, agreed, it is your life: but there may be unintended consequences for others in allowing you to end it, others may feel obliged to end their lives”, etc.   At no point could anyone say, as I so passionately would claim: “No, it is not your life to dispose of”; there is now, it seems, no public place for the apostle Paul’s blunt statement in his letter to the Church in Corinth: ‘You are not your own.’ 

Yet this is now one of the most fundamental beliefs of ‘my’ life: and I have found it to be totally liberating and beautiful.  I think of those glorious sculptures on the outer walls of Chartres Cathedral, including the representation of the creation of Adam, presented as emerging from the very mind of God.  I think of the glory of man and woman made in God’s image as stewards of creation.  I think of the extraordinary wonder of the Incarnation, of God embodied in Christ.  I think of the sufferings of Christ on the cross; and I think, yes, of course I think, of the sufferings of my fellow men and women and children, and of my own sufferings, and of the call to me to shoulder the burden, both of living, and of dying, in God’s time.   

And, alas, I think I also see something of how shrivelled, how wizened in comparison, how shoddy, shrunken and lonely, is our much vaunted and trumpeted vision of the autonomous individual – “my life, my rights, my body, my choice” - in the dominant contemporary Western mindset, eating away steadily like a corrosive acid any wider conception of community and the social institutions that enshrine it, and any sense of a deeper accountability to God. 

Where will the current assisted suicide decision ultimately lead?  What is the destination?  It is difficult to predict, but the signs from other countries who have gone down this road are not good.   

But what do I know?  Do I have answers to all the questions around assisted suicide?  I confess I do not. But one thing has become clearer to me: I am on a very different journey from the one my nation is travelling now.