Article

Care

Comment

21 June 2023

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

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

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Community

Politics

8 November 2024

10 min read

How to respond when politicians talk about “our way of life”

Alasdair MacIntyre’s thinking helps us understand what we share across society.

Joel Pierce

Joel Pierce is the administrator of Christ's College, University of Aberdeen. He has recently published his first book.

Four men in suits, sit next to each other smiling, in the House of Commons.

Reform MPs in the House of Commons.

House of Commons, CC BY 3.0, via Wikimedia.

What is “our way of life”? It’s a phrase which slides easily into the rhetoric of politicians of every stripe. It’s what the Reform Party says is threatened by multiculturalism, but what do they mean by it? What kind of politics is sustained by talk of “our way of life” and is there a better way of thinking about such politics?

This summer, we made an exception to the time limit rule for television in my house, mainly so that I could have the Olympics on from morning to night. It’s a habit I acquired growing up in the United States, where an obsession over the quadrennial medal count is one of the few remaining things which bridges political and regional divides. During the Cold War, the Olympics were a way for Americans to proudly affirm the superiority of our way of life over the rigid training schedules and alien ways of the rival Soviet Union.

Although my memories begin around the fall of the Berlin Wall, old habits die hard, and so the Olympics, to me, was endless coverage of plucky underdog Americans overcoming the odds to defeat the machine-like discipline of a new set of rivals–now Russia and China

I moved to Britain just before the 2010 Vancouver Winter Olympics at which Britain won exactly one medal. At first I was bemused by the BBC’s coverage, which, of necessity, had to focus on British Olympians with little chance of winning. I was invited to cheer on eighth or ninth place finishers who had committed their life to a craft which would never bring the rewards of lasting fame or financial security. For them the reward was the Olympics themselves, the chance to compete amongst peers, to push themselves to their highest level, enjoying their sport and their performance for what it was, not for any external reward. In the terms of philosopher Alasdair MacIntyre, what these Olympians displayed was dedication to the internal goods of their sport–those goods that make a particular activity worth doing for its own sake. The Olympics were not about medals for them, but about showing what could be achieved if, as Olympians must do, they made their sport their way of life, dedicating themselves to its unique forms of excellence.

Sports, for MacIntyre, are but one example of a broader category he labels ‘practices’. Although MacIntyre has a technical definition of what counts as a ‘practice’, the general idea can be conveyed through examples he gives such as farming, researching history, architecture, chess, and chemistry. Practices are human activities which are worth doing for their own sake, which require a degree of skill and excellence, and in which what counts as that skill and excellence is, in part, defined and discerned by the people who participate in the practice. This last criterion points at something important about practices for MacIntyre: they are inherently social.

This is obvious in the case of sport. For an individual athlete to compete in a race they need not just other competitors to race against, but also trainers and coaches to prepare them for it, governing bodies to organise it, and, hopefully, spectators to cheer them on. It is, perhaps, less obvious in the case of individual farmer, but even here, one has to be taught to farm and, if one is wise, continues to learn and adapt through consulting with other farmers. A different way of putting this is that practices are the kinds of things which it’s not absurd to call “a way of life”. For an Olympic curler, curling is a way of life, just as much as farming is for a farmer.

There are many ways of life, many modes of being British, as diverse as the professions, hobbies, and passions which we find to have inherent worth.

However, this seems to offer little help in defining “our way of life” if it is being used in the way our politicians like to talk about it. If there’s one thing that I learned from all those BBC features of British Olympians way back in 2010, it was that aside from geographic proximity, there was not much that their way of life had in common with mine. I may be within driving distance of the rink where Winter Olympian Eve Muirhead learned to curl, but my workdays of wrestling spreadsheets and answering emails have little in common with ones spent lifting weights, studying strategy with coaches, and perfecting the just right spin on a stone as it’s released.

And, of course that’s not just true of Olympic athletes. The investment banker who attends our church shares a way of life with his colleagues in Edinburgh, London, and Tokyo, that is completely opaque to my wife and I, immersed as we are in the worlds of ministry and academia. I glimpse some of the internal goods of the practices of our dentist watching her check my daughters’ teeth and our plumber as he fixes our leaking radiators, but their way of life, the rhythms of their days, and what gives them satisfaction in their work as they move from appointment to appointment, eludes my understanding.

Where does this leave the search for a British way of life? If practices are as important to forming us as MacIntyre thinks, then the quest for any singular British way of life will ultimately be fruitless. There are many ways of life, many modes of being British, as diverse as the professions, hobbies, and passions which we find to have inherent worth. And even this characterisation does not go quite far enough, because all of these practices have a way of bursting the boundaries of Britishness if they really are worthwhile. A century and a half ago, football, rugby, and cricket were quintessentially British sports. Now they belong to the world.

Similarly, valuing these practices well within Britain has a tendency to open us to accepting those from outside our borders who can help develop them. The best footballer in Britain is Norwegian. Many of the doctors who ensured my daughters arrived safely after complicated pregnancies were originally from India and Pakistan.

Still, one might wonder if thinking about community through the lens of practices, as MacIntyre does, is too much of a solvent. Isn’t it a way of imagining us living near each other, but not with each other; siloed in our practices, in each of our communities, not understanding what our neighbours are up to? Not necessarily. For MacIntyre, the familiarity that arise from living near someone, hearing their worries at planning permission hearings, arguing with them at the local school’s parent council meetings, organising a community fundraiser together, or, even, being part of a family with them, can help develop an understanding of the internal goods of practices which we do not take part in. I haven’t lifted a brush to paper to since my secondary school art class, but my mother-in-law’s virtuosity with acrylics has led me to acquire an increasing appreciation for painting. Part of what helps facilitate this recognition is that, as MacIntyre argues, although the internal goods and the skills required to achieve them tend to be different for each practice, the virtues which we develop while pursuing them–patience, honesty, courage, self-control–are universal. Part of what helps us recognise others’ activities as practices, as worth doing for their own sake, are the virtues we see them develop as they do them.

This sort of recognition requires familiarity, the sort I might have with my neighbours in our corner of rural Aberdeenshire, but that I am unlikely to have with fellow citizens in Cornwall, Cardiff, London, or Glasgow. How then are we to respond to national politicians talking about “our way of life”? One answer might be: with extreme scepticism. This is MacIntyre’s approach. He rejects the nation-state, which he calls “a dangerous and unmanageable institution”, as a potential channel of communal unity. Instead, he calls on us to admit that modern nation-states exist as a contradiction, being both “a bureaucratic supplier of goods and services” and yet also something treated as sacred, which we are asked, on occasion, to surrender our lives to preserve. He notes with characteristic acerbity, “it is like being asked to die for the telephone company.”

However, here I’d temper MacIntyre’s rhetoric somewhat. While my attachment to bankers in Canary Wharf is largely a happenstance of history, a contingent fact generated by long forgotten necessities of eighteenth century geopolitics, it has nevertheless resulted in both of us being issued the same passport, governed by the same tax regime, and having the same set of regulatory agencies to complain to when things go wrong. Those may be manifestations of what MacIntyre disparages as “a bureaucratic supplier of goods and services”, but they nevertheless do bind us together. As such we both have an interest in making sure this bureaucracy acts as justly as it can, not because it is the embodiment of all that is British, Britain is much too diverse and interesting to be fully embodied in our political institutions, but because we all have an interest in the institutions in which we are enmeshed, British or otherwise, being run as justly as possible.

Surely politics is all about securing as much money and resources as possible for the people most like oneself. That, it seems, is often the unstated assumption when the talk of “our way of life”

Because we find ourselves tied together by these institutions to a diverse collection of people, we have an interest in learning about those with whom we live. Even those who are far away. And to also celebrate when goods and services delivered by our institutions result in success to which we, in a remote way, have contributed. I may not share a way of life with Adam Peaty, but, thanks to the BBC, I can have a glimpse into what his way of life is and can be happy that through my taxes I have contributed, in a small way, to helping him win another medal. Since that 2010 Winter Olympics Britain has come quite a long way and there is nothing wrong with a little vicarious pride in our athlete’s accomplishments.

But I can also be proud of athletes who didn’t win. Ones like BMX rider Beth Shriever who handled her unexpected last place finish in her final with a kind of grace and maturity, the kind of virtue, which someone more dedicated to her practice than to just winning can demonstrate. It is the facilitating of this kind of moral achievement which is more valuable than any medal.

Similarly, I can rejoice when a new hospital gets built in a neglected area in London, or more council housing is supplied to people in need in Edinburgh, hopeful that these lead to my fellow citizens achieving the kind of flourishing lives they deserve. I can be angry, when I discover that the money I’ve paid towards postage has been used to prosecute innocent victims of a computer glitch, and pleased when the opening of a new rail line eases the otherwise stressful commute of tens of thousands in London. The state may be a bit like a telephone company, but a well-run utility can do a lot to supply people with the goods they need to make their lives. As long as I’m a subscriber, as long as I’m tied to people through national institutions like the state, I have a moral duty to ensure that they’re run as well as possible.

This way of thinking about politics may strike some as idealistic, the kind of view only a naive Christian ethicist could endorse. Surely politics is all about securing as much money and resources as possible for the people most like oneself. That, it seems, is often the unstated assumption when the talk of “our way of life” is deployed and why so much coalition building in our politics turns on finding a convenient other against which to define “our” similarity. Take your pick: immigrants, the EU, woke elites, the Tories, or Westminster (among a certain brand of politician here in Scotland).--. Growing up in the USA, the Soviets, and then the Chinese, and now, depending whether one lives in a Republican or Democratic district, the other political party, have served the same purpose. The problem is that we aren’t that similar, we are and always have been a diverse lot with diverse needs. Every nation is. There is no one British way of life and to allow our politicians to try to sustain the fiction that there is lets them off the hook. Solving deep seated economic and social inequality is hard. Blaming immigrants for not embracing our way of life is easy.

So, perhaps the sort of politics that I am talking about here is idealistic, nevertheless it is the only kind that can sustain a just government in the long term. Without acknowledging the importance of goods we only partly understand which are pursued by people whose ways of life are different from our own, we cannot hope to sustain the minor miracle of coordination and mutual aid that history has gifted us with in our united kingdom.