The Problem of Freedom

The rough, shadowed texture of a log fallen across a meandering stream, the scattered sparkles of the water as it murmurs briefly to a rock it passes, the deep, barely moving green of the leafy tunnel that shrouds the gently dancing blue beneath -these are what I know of freedom: permission to imagine, permission to believe… Nothing else –nothing, at least, that matters more… As Voltaire said, Man is free at the moment he wishes to be…

I’m not sure what I’m supposed to envisage when the topic arises as it does sometimes in the office. I’m not sure what I’m supposed to say, or how I’m expected to react. Freedom is a charged word. A troubled word. It so often refers to an imaginary, or a that-which-is-not. It is contextually defined, and so often spiritually embossed. Like Goodness, or Happiness, it is something to which we are expected to aspire, and because we can never assure ourselves that we possess it, the search, like that for the end of the rainbow, is never done.

It is also a partitioned concept, like being freed from a cage that is locked in a closet that is locked in a room that is locked in a house… To escape from one thing is always to be imprisoned in another –the escape from the innermost Russian doll only to be trapped within the next in line. Freedom, I had always thought, is simply where and when you are; it is a frame of mind, not a frame of circumstance. But I’m not so certain anymore…

This problem of freedom surfaced one day in the office, although I didn’t recognize it at first. The more curious of my obstetrical patients often wax philosophical at unexpected moments. I didn’t think Thira was one of those, I have to admit, but pregnancy –especially the first- has a way of changing a person. Opening them up like the petals of a flower in the morning sunshine. And Thira was a flower. A thin, short woman, she was a Greek with smiling eyes, and spoke with an accent that enchanted me each time we met. I think I sometimes asked her questions just to hear her talk.

But occasionally, she felt it was her turn to ask, and one day, midway through her third trimester, when talk of contractions and labour occupied most of our time together, she suddenly turned serious and her iconic smile disappeared for a worried moment. “Doctor,” she said after I had listened to the baby’s heart beat, “What does the baby’s movement mean?”

I was busy entering in my measurements and the heart rate in the chart, so I didn’t even look up. “What do you mean, Thira?”

“Well, she used to be so predictable. She’d kick after I ate dinner and then start rolling around about ten o’clock when I was in bed. Like she sort of knew what I was doing and was signalling me to say hello. Showing off…”

I looked up for a moment from the chart and smiled. “But you said, ‘used to’…”

The worried look resurfaced. “Well, last night she didn’t stop. She just kept rolling and kicking all night. At first I thought maybe it was the way I was lying in bed, but she kept it up no matter what I did. The kicking even got worse when I got up.” She took a deep breath and looked at the floor. “Okay if I ask you a silly question?” I nodded reassuringly. “Well… I keep thinking she feels trapped in there. I mean, it’s a pretty small space and she’s growing… Wouldn’t it be like being trapped in a small elevator when the electricity and the lights go off?”

I’d never actually considered whether a fetus would –or could- feel imprisoned before. My first thought was to wonder whether the baby, rather than feeling trapped, was actually feeling stressed for some reason –an accident with its umbilical cord, for example, or maybe a change in the placental circulation. I molded my facial expression into neutral so as not to alarm her. “Well, I would think that the uterine cavity space and the darkness is all she’s ever known, Thira. She must be used to it by now, don’t you think?”

She shrugged and painted an anxious smile on her lips. “I suppose… But what if she’s panicking because she’s just discovered she’s trapped? That after all this time, she realizes she’s not actually free?”

I said that before we assumed something like that, it would probably make sense to be sure the baby wasn’t telling us it was in trouble. I reassured her as best I could and sent her right over to the hospital for a non-stress test (NST) to assess the baby’s heart rate in response to its environment; its own movements for example would be the equivalent of someone doing exercise and should raise the heart rate briefly. If there was no change in the rate, or worse, a fall in the rate, it would be unusual and unexpected at the very least. It might signify fetal distress.

The NST was fortunately completely reassuring, as was a bedside ultrasound we did to visualize the umbilical cord and the amount of fluid around the baby. Thira still seemed concerned, though. “I still think she was telling me something, doctor.”

I sat down on the bed beside her. “Well, we can’t find anything wrong, so what do you think she is trying to tell you, Thira? What does she want?”

A weary smile appeared from nowhere. “Freedom, doctor. She wants her freedom.”

I was struck by Thira’s use of the word ‘freedom’ all the time. She didn’t appear at all surprised that there didn’t seem to be any problem we could find with the baby: no umbilical cord around its neck, no decreased amniotic fluid around it, no worrisome changes in the NST. And when I once again reassured her about the findings, she responded with another shrug.

“How can any of your tests measure the need for freedom, doctor? I’m sure most prisoners have normal heart rates, normal responses to exercise…” She stopped talking and looked in my eyes for a moment. “It’s only when you look in their eyes you can tell something is missing. Freedom can’t be tested, I don’t think…”

I had to process that for a moment. “But…  But you’re only 34…” I had to look at the chart I was holding. “34 weeks and 4 days pregnant. Your due date isn’t until 40 weeks… Surely your baby is far too young to appreciate such an abstract thing as Freedom.” I was proud of that response; I thought I had her.

Her face wrinkled in curiosity at my explanation. “I can calm my baby down by talking to her. She seems to respond if there’s music in the room… That’s pretty abstract, don’t you think?”

I blinked. I couldn’t think of another response. But I wondered if this was really cause and effect, or maternal attribution.

“When do babies start to think anyway?” she asked and scrutinized my face. Then she paused for a moment. “Only as soon as they’re born –freed?” she continued after she could see I wasn’t able to answer. “And what about the increasing number of studies showing the abstract conceptual abilities of even young babies?” I must have had a blank look. “Have you read that book: The Philosophical Baby, by Alison Gopnik…?” I hadn’t, actually. “There are others, too,” she said, reading my expression.

“But…” I shook my head slowly in -what? Desperation? Frustration? Or maybe in fascination at something about which only a mother could be convinced.

“If babies only a few months old can demonstrate a sense of injustice or fairness in the studies researchers do with them; if they can be seen reacting to things that seem to them to be unusual or unacceptable, then why would it be so hard to believe they could also have a simple concept of Freedom?”

I have to admit that I didn’t have an answer for Thira, although she certainly opened up a few questions that still trouble me -a Pandora’s box. Is the desire for Freedom innate –like curiosity, the desire to learn, or the impetus to find and create Beauty? Is it so abstract that it doesn’t even exist outside the mind as I said at the start? And is it so integral to our existence, that we need to manufacture it when we don’t think it’s there? There is a problem with Freedom I think: knowing what it is… and where. But maybe Robert Frost got it right: ‘You have freedom when you’re easy in your harness.’  Maybe it’s as simple as that.

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Why do we Know something?

Knowledge is interesting. But what is it, exactly? What does it mean to say you know something? Plato defined it as being justified true belief, but is it? Take Bertrand Russel’s famous thought experiment: the ‘stopped clock case’, for example. Alice looks at a clock and says it is two o’clock. Well, because the clock does indeed confirm that it is two o’clock, it seems justified; and because it is, in reality, two o’clock, it also seems a true belief. She could therefore be said to know that it is two o’clock… But, unknown to Alice, the clock had actually stopped working exactly 12 hours previously, so did she know that it was two o’clock? Or was it a fortuitous guess and not knowledge?

All this is a little out of my comfort zone to say the least, so I’m not even going to attempt straying into such philosophical realms as the ‘Gettier Problem’ (whether something that happens to be true but is believed, as with Alice, for incorrect or flawed reasons should be counted as knowledge). It is truly thought-provoking, though, isn’t it?

But Knowledge is not just a list of facts that happen to be true –whatever truth is- nor a compilation of disparate evidentiary items. It is not only an encyclopedia, it is a diary as well: the story of why it exists. There is often a purpose to it –or at least in its acquisition there may have been a reason, even if you stumbled upon it by accident.

In other words, there is another way of approaching the concept of knowledge other than how we know something to be true –the Scientific Method, for example- and that is why we know it. And I don’t mean to stir the lid of Pandora’s box with the ‘why question’, nor to intimate some sort of heterodox Creationist linkage, but merely to introduce something that I learned from a patient a few years back -a professor of philosophy at one of the local universities.

Nancy was a thin, forty-seven year old woman who had been sent to me for a recent episode of irregular menstrual bleeding. She was otherwise healthy and somewhat embarrassed at having to see me for something her mother and aunt had managed to work through without having to seek medical advice. Her family doctor had ordered an ultrasound of the pelvis and it had not revealed anything suspicious. In fact it had stated that no abnormalities had been seen to explain the bleeding.

I suggested it would be a good idea to sample the uterine cells with an office endometrial biopsy as a final reassurance that nothing had been missed. But I could see that she was uncomfortable with the idea.

“What are you hoping an endometrial biopsy will find, doctor?” she said suspiciously.

“Actually, I’m hoping to find nothing,” I said in my best, confident voice. “The ultrasound didn’t see anything to worry about…”

An eyebrow slowly crawled up one side of her forehead. “I realize that; my GP showed me the result.” The other eyebrow shot up to join its sister. “So… Why would you want to do a biopsy?”

I get asked this a lot. “Well, the ultrasound is not a microscope. It can’t tell anything about the type of cells that are in there.” She still looked unconvinced, I have to say, so I pulled out another of my usual analogies. “I suppose it’s something like trying to make a diagnosis from a shadow. You can guess a person’s height and perhaps her weight from her shadow, but even if you could tell she had long hair, you would have no idea of its colour. Nor would you know anything about her heart.”

Nancy was quiet for a moment, obviously thinking it through. I could tell from her face that she thought it was a rather clumsy explanation -not well conceived, and not terribly illustrative of her problem. “So,” she finally said, looking up at the ceiling for help, “The ultrasound is normal, the blood tests my GP did suggest I’m in the menopausal transition now, the abnormal bleeding only occurred in one menstrual cycle a few months ago, and I’ve been doing well since then…” She dropped her eyes onto my face and left them hovering there for a moment as she shook her head. “Tell me again why you think a biopsy would be a good idea.”

I have to admit that when she put it like that I had second thoughts, but nevertheless I pushed on, regardless. Was I just trying to save face, or was there truly a principle at stake? “Well… clearly there are different ways of approaching your bleeding… But if we do the biopsy, and it is normal, then at the very least we will have a baseline that reassures us that if it happens again in the near future, we can probably assume the cells are still normal…”

Nancy was good; she could read the hesitation in my voice. She smiled gracefully, but it was a polite smile. “Wouldn’t it make equally good sense to wait and see if it starts to happen more frequently and then do the biopsy?”

She had me. “Yes, I suppose that is an equally acceptable option.”

She sat back in her chair, crossed her legs, folded her arms across her chest and stared at me –not unkindly, not aggressively, but curiously, like a mother might watch a mischievous child. “I won’t ask you how you came to that conclusion, or how you know that a biopsy might be justified. Those are all fairly standard medical teachings, as I understand…” Her face wrinkled in concern. “But I’d be curious as to why you know that.”

I returned her stare. Why I knew that? Why does anybody know something? Because they read it, or were taught it, or figured it out… Why indeed?

“We all have options in our learning,” she continued. “There are many opinions to which we are exposed, rival paradigms, competing theories. And they all promise success; they all answer the questions differently. Like a hundred people crossing a single bridge, it’s not the same bridge for any of them. It’s a hundred bridges…”

Her face softened, like a teacher that realizes she has confused her pupil. “From all that reality has to offer, we have to decide what to privilege. There are just too many routes to the truth to take them all. We have to choose…

“But why do we choose one view, one approach instead of another? That’s what I’m asking.” She sighed, as if even the question, let alone the answer to it, was hopeless. “Why do you know one thing and not something else?”

Her question still troubles me. I had no answer for her then; nor do I now. I still wallow in the permutations and combinations of perpectives I confront daily and wonder how I manage to choose my direction without getting lost. Maybe it’s a confirmation bias: I have come to believe in the correctness of a particular viewpoint over the years and so only consider the evidence that confirms it. The diagnosis that points that way. And if the results don’t justify the approach? Well, there’s always rationalization to light the path I’ve chosen.

But do I really know why I know what I do, believe what I believe, think what I think? No, not so far… and yet the fact that I’m even aware of the discrepancy, and see the signs to other roads, is a good start isn’t it? As Marcel Proust wrote: The real voyage of discovery consists not in seeking new lands but seeing with new eyes.

Please and Thank you

Please and thank you –isn’t that what we were all taught? Perhaps it was my prairie upbringing, but it seemed the norm when I was growing up. There was no asking why –no need to, in fact- we all just did it. Indeed its absence was noticed and noticeable –like maybe wearing a suit without a shirt. Nothing dangerous, nothing threatening, but just not done, all the same. Maybe in another culture or in a different era, it might have been passed off as an eccentricity, or perhaps mental illness –but not in my youth. And not now either, I had assumed. Polite is polite. Period.

But mores and folkways are fickle creatures, it seems -pragmatic at best, capricious at worst. At times, they seem rooted in tradition and ancestral wisdom, but increasingly, they smack expediency, fashion –borrowed from somewhere else like a hat for an occasion. And as with trends on social media, they are ephemeral –tales told by an idiot full of sound and fury, signifying nothing…

Or am I being too critical? Too unwilling to accept change? Too… old?

*

Judith was an angry person –or maybe I just met her on an awkward day. But she held her body stiffly, as if any movement might reveal a secret. She had an accent I couldn’t place, but her demeanour didn’t really invite my inquiring about it -another secret she needed to conceal, I suppose. The referral note said only that she had pain but had refused to let her doctor examine her. Judith wouldn’t let me examine her either; she was certain it was caused by an ovarian cyst and she just wanted to talk about it.

I could see her peeking at my computer screen with suspicious eyes. The way I’ve had to configure my temporary desk to accommodate both the ability to access the monitor as well as well as the patient’s face, lends a certain intimacy to the little makeshift office. No longer can I afford to write a note to myself that the patient I’ve been asked to see seems unduly anxious or irritable; I dare not suggest that she is being evasive in her answers to my questions; I cannot even intimate that she doesn’t appear to trust me. All is open to scrutiny during a renovation.

And that’s fine. She can have access to her chart; I have nothing to hide. But as well as her answers to my questions, what I write are merely impressions, conjectures: colours. The subsequent consultation letter to her referring doctor is a collation of these -a considered appraisal of what I have observed and heard. The initial chart is a first draft of things that will later become an opinion. An assessment.

But Judith was persistent. Like someone reading my book over my shoulder on a bus, I have to admit I did feel some boundary issues. I toyed with the idea of turning the screen so she could read it more easily, but my long-held prairie rules of decorum prevented me. Instead, I contented myself with an obviously self-conscious stare at her face. She paid no attention to my discomfort except to wrinkle her face at what I had just written.

I was filling out the reasons for ordering a pelvic ultrasound –outlining what questions I hoped could be answered, and what, specifically, I hoped they would address: The patient has complained of right lower quadrant pain for several months. She may have a right ovarian cyst. Please assess ovaries and characterize cyst if present. Thanks. It seemed a perfectly straightforward request, but I could see Judith shaking her head.

“You’ve got to be more forceful in your request, doctor,” she said, her face tight with concern. “I told you I have a cyst so why don’t you just say so?”

Her response took me by surprise. “I was just outlining my suspicions for them to confirm or refute on the ultrasound…”

Her eyebrows stayed lashed to her hairline. She was shaking her head again, but whether in disapproval or disbelief I couldn’t tell. “And why do they have to know about the pain? That seems to be a breach of patient confidentiality, don’t you think?”

I sighed quietly. “It’s not a breach of confidentiality, Judith, it’s a medical document outlining the questions I want answered, and so it has to have pertinent details about the condition. If it is an ovarian cyst, not all cysts cause pain and not all pain is caused by cysts. I need to know the details of what they see.”

You’d think that would have appeased her but I could tell she was still troubled by what she saw. “And why do Canadians insist on using ‘please and thank you’ all the time? It’s just a request for an ultrasound…”

I sat back in my squeaky chair and smiled. “What would you write, Judith?”

She thought about it for a moment, obviously caught off guard. “Well… How about: I’d like you to describe the cyst on her right ovary.”

“ ‘I’d like you to..?’ Isn’t that just a longer way of saying ‘please’?”

Her eyes narrowed and I could almost hear the gears grinding in her head. “Then… why not just: Assess the pelvis?

I squeaked my chair again. “Seems to me that’s just a command to do something without explaining why. The more information they have, the more they are able to tailor their study.”

A little smile fought for the stage on her face. She was getting into this. “Okay, so: Cyst suspected in pelvis. Confirmation and characterization required.”

I nodded, then turned back to the screen to amend it. “I can accept that, Judith,” I said, as I typed her words onto the requisition. “But I can’t say I agree with it.” I looked up at her. “It seems  too impersonal and uncaring, somehow.”

Her face softened with bewilderment and I could feel her eyes searching my face for an answer. “What do you mean?” she asked after sifting through my words for clues.

I shrugged, not at all sure I could explain. “I guess it’s sort of like the Golden Rule: If a person is standing in a doorway talking to a friend and I want to get past, I could say ‘Get out of my way!’ or I could smile and say something like ‘Would you mind if I squeezed through?’ Experience tells me I’m likely to get more cooperation with the second way. Maybe even a smile…” My chair squeaked again. “I like smiles, even if I’m not there to see them.”

Suddenly her whole body relaxed and a laugh lit the room like the sun coming out from behind a cloud. She reached out in the tiny room and touched my arm. “When I said I didn’t want to see a male gynaecologist, my family doctor said you were different…” She sat back in her chair looking the most relaxed I’d seen her. “Put the ‘Please and Thank you’ back in the form if you want. I think I’d like to see the smile on the technician’s face when she reads it, too.”

The prairie in me sighed. I suppose she meant well- meant it as a compliment… Thought she had gained a unique perspective on a world she had never trusted and maybe never thanked. And yet I don’t think she really understood. What I considered thoughtful, she saw as weak. Not polite. And it bothered me. Am I really so different in being accommodating and respectful when I request a service from someone? Is the concept now so unusual that it draws attention to itself? Attention to me? Thank you, but I cannot let myself believe that. Please let me be right…

Trust

Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.

Medicine and Ideology

Some things are more definitive than others –less ambiguous, more predictable. Reliable, in other words. They lend themselves to yes-no answers, right-wrong judgements, good-bad characteristics. And some people prefer to see the world in black and white like this. Uncertainty is uncomfortable for them; they crave cognitive closure in the opinion of Arie Kruglanski, a professor of psychology at the University of Maryland.

It would seem that there are times in a life –usually inter regna, times of transition- when this eschewal of indeterminacy is more powerful: adolescence, retirement, divorce, and so on. And at those times, when everything seems unstable and unfamiliar, shelter from the maelstrom under any unmoving roof seems prudent. Rules and unequivocal, unchanging answers are tempting accessories. That something is either right or wrong can be comforting in times of stress.

One problem with this bichromatic need however, is that things are rarely static. They are continually modified by circumstance and context; the questions that need to be asked, and especially their answers, expand and mutate. They evolve over time, in other words. So, for example, that someone is, or is not pregnant, may be unambiguous and beyond dispute. But whether that pregnancy continues or miscarries, is healthy or complicated is not. Things change, are unpredictable, and answers –facts?- obtained at one stage may not obtain later. Life is flux -an ever moving current.

And, of course, context is almost as relevant as substance. Nothing is separate from its surroundings. A pregnant woman, say, is a member of a group –however tenuous- or at the very least, a member of a society. A culture. There are obligations and expectations unique to her milieu that may not be immediately apparent –especially to someone not a member of that group. And these conditions do not often lend themselves to a one-time appraisal, a permanent and unbending judgement, or a right/wrong approach. A rigid doctrine -established on whatever principles- does not always work. In fact it imprisons; it imposes an unchanging view on a constantly unfolding reality. It is dogma.

So it was with some concern that I read an article in the Sept.16/14 Canadian Medical Association Journal –in the news section- entitled ‘US politics and ideology enter exam rooms’. In it was outlined some of the requirements in certain states that seem to impose political or moral ideologies on both patients seeking assistance, and medical staff trying to provide it –an arena that one would expect to be free of bias and coercion.

There are some American states, apparently, that require a woman seeking a pregnancy termination to be shown –not just offered-  a view of the ultrasound of her fetus. In my opinion, this is just cruel –a punishment thinly disguised as help. Disclosure. An admonition clothed in the scarily garish colours of useful information. That there may have been extenuating circumstances –whether personal or social- that led to her decision to terminate would seem to be irrelevant. The choice the woman has to make is a painful one –it is seldom capricious, rarely if ever carelessly taken. That someone should be available to help her with her decision and counsel her before and after if she wishes is a given. But it should not be an impediment.

As the article observes, ‘In such cases, it’s not just the doctor and the patient in the room. In effect, it’s the state government, too.’  This is the not-so-thin edge of a wedge that seeks to modify behaviour –even behaviour condoned in law- by mandating seemingly reasonable adjuncts to the process. ‘What could be wrong with offering to show the woman her fetus on an ultrasound?’ one can almost hear them pontificate mellifluously with fists all the while clenched tightly behind their backs. But the operative word here is ‘offer’. The term suggests choice.  Not coercion. Bullying. Threat.

I recognize that I’ve chosen a contentious issue –pregnancy termination- to illustrate a much more fundamental point: the relational autonomy that should be a cornerstone in our dealings with others. And yet it forms –must form- an essential foundation if we are to reach out to those who, constrained by their own beliefs or cultures –their own experiences- are reluctant to seek our help. It seems to me that it is only humane to enable them -actively encourage them- to access whatever aid we are able to provide. It is not merely magnanimity on our part. Not generosity. Not accommodation. It is empathy; a recognition that despite our differences, we are all struggling. All seeking some path through the chaos of one transition or another. And the cognitive closure need not be punitive. Nor dogmatic.

In fact, it can be instructive. Insightful. As Shakespeare observed, It is not in the stars to hold our destiny, but in ourselves. And we must help others to see this. We must enable them, and so enable ourselves.

A Medical Dilemma

Here’s an outrageous assertion: there are some things that we just cannot control. Worse, sometimes they are undefineable – or at least so vague as to defy placing them on some scale or other. Ranking them in terms of importance either to us, or to others. Naming them for future reference. And if we cannot even assign a name, categorization is slippery, too.

All of us experience these uncontrollables. Sometimes we are suddenly enveloped –a fog that obscures direction so completely that we are lost, abandoned in a terrifying limbo- but as often, we wade in from familiar territory until, over our depth, we panic.

Doctors, among others, seem to gather these fractious elements like apples in a basket we scarcely notice we are carrying. Its not that we are incompetent –although circumstances often determine competency, don’t they? It is that situations pile up like obstacles -and detours, of necessity, require changes in direction. Unintended changes. Routes that, until they are explored and charted, make regaining the original destination difficult, if not time consuming.

A recent example from my practice: suppose, for a moment, you are a gynaecologist who has been referred a young woman with a benign tumour, a uterine fibroid, say. Even though fibroids –benign overgrowths of uterine muscle tissue- are fairly common in middle age, fibroids of significant size are unusual in young women. You are reassured by many factors in your investigations thus far, however: the ultrasound appearance, the blood tests measuring tumour markers, and her general good health. She has no pain; she has no symptoms, and the fibroid is small -only 1 cm in diameter. And, as important, a clinical examination does not hint of cancer, or demonstrate a lack of mobility of the lump in her pelvis that might indicate malignant attachments. She has simply been plucked from the realm everyday existence by a test done for something else but which found a tiny mass on her uterus.

She is barely out of her teens and as yet unattached, but dreams of a relationship and children –the proverbial girl next door. Her life has been turned upside down in an instant, and intimations of mortality that should not be collecting outside her door for years are suddenly apparent -a tree branch scratching her window in the night.

You discuss the features of fibroids, show her what she has on a diagram, then answer her questions and attempt to calm her down. Finally, after considering all the factors in her case, you speak to her of what you would recommend: observation and reassessment with another ultrasound in 6 months. Perhaps sooner if she develops any symptoms –pressure, or pain with sex, for example.

But she is worried, and all of your explanations have only served to reify the alien lump, hitherto hidden and unnoticed. It is real for her now, and it shouldn’t be there. The fact that her mother required a hysterectomy for them in her forties after years of heavy periods and pelvic pressure, has always weighed heavily on her.

You put down your pen, and listen as she tells you how she has researched the various therapeutic options online. You have already discussed them, of course, but have counselled against their use because of the small size of the lump. She smiles at you, because she agrees she is not a candidate. No, she wants the lump surgically removed –a myomectomy- before it gets too big. Before it causes symptoms. Before it interferes with becoming pregnant.

It is always difficult to disagree with a thoughtful person who presents her arguments in a cogent and reasonable fashion, but one always has to help the patient weigh the risks and the benefits more objectively. More contextually. Especially when you feel that surgery is not indicated. There are risks to surgery –major risks. Risks that are obviously assimilable under certain circumstances, but in your expert judgment, not hers. Fibroids grow slowly, so there is certainly time to consider less invasive options. Some sort of a compromise is in order.

You attempt to do this, to help her stand back and consider her request within the landscape of her actual needs. You try to help her to separate her concerns about the fibroids her mother had to have treated when she was much older, and her own situation.

But she is adamant. It can be done laparoscopically –belly-button surgery- so she will not even need much time off school, she points out.

When you still are hesitant, she breaks down in tears and heads for the door, sobbing. You relent and say you are willing to refer her for a second opinion, secretly hoping the other surgeon will be able to convince her to wait. But she is not listening any more; you have failed her.

But have you? At what point can failure be assigned? Does a reluctance to acquiesce to demands which are predicated on fear and misunderstanding constitute failure? Or is failure actually the opposite: going against your considered judgment to please the patient?

Years ago, I saw a very similar person –the daughter of a doctor in another part of the country she immediately informed me. She was adamant about wanting surgery –felt she was entitled to it, in fact. And encapsulated in the trappings of my recent specialist status, I was equally certain of my opposition to it. She was quite verbally abusive to me when I wouldn’t change my mind and also walked out of the office, but not in tears… She had a smirk on her face.

She was a heavy woman, a smoker, and although in her twenties, not in the best of health. We weren’t doing many difficult laparoscopies in those days, so any surgery would have required a large incision –her abdomen was obese and pendulous- and several days in hospital to recover. In her case the fibroid was only 2 cm in diameter –still small. Still observable over time.

I was puzzled by the expression on her face until I learned from my secretary that she was actually scheduled for a myomectomy with another surgeon in another town –but not for a month or two. She had been hoping I could schedule it sooner in my hospital.

I felt guilty, although I couldn’t really understand why. She was a poor operative risk despite her age, and the surgery was unnecessary anyway. I wondered whether I had made the correct decision, or whether I had been unduly influenced by her being rude to me when I’d tried to present the reasons for my opinion. Had pride clouded my judgement? Had she been right all along?

So, did I fail her? Or did the other surgeon? Were we both manipulated?

There is a condition called pulmonary embolism that occurs when a clot formed in a vein breaks free of its source and travels to the lungs to obstruct the blood supply. Some factors increase the risk of forming clots –major surgery, obesity, smoking, immobility… An embolus can kill if not treated immediately. Nowadays, we recognize these risks more readily and will prophylactically employ anticoagulation –blood thinners- to decrease the likelihood of clot formation. We ambulate patients more quickly and educate them about the risks.

In those days, I think we were more concerned with the risks of anticoagulation –bleeding internally, for example- than we are today. And so, especially in the non-teaching hospitals in small towns, prophylactic anticoagulation was not a routine standard of care. In fact, it was usually only considered in patients with more extreme and identifiable risks –cancers, for example. The regimens and even the choices of medication were limited then; surgeons were rightly as afraid of the treatment as of what it prevented. Risks had to be balanced. Managed.

I mention pulmonary embolus, because that patient died from one. I only found out weeks later when the surgeon phoned me after he discovered my consultation letter that the referring GP had forwarded to him. He was devastated, as were we all.

It’s easy to be revisionist in retrospect –especially years hence when protocols have changed, not to mention knowledge and available medications. We see the world through modern lenses and judge in the light of current knowledge. Things change. It was –and is- a tragedy that it happened. And it’s a burden which that family –and that surgeon- will carry forever. But in fairness, how critical can we be? Should we be? The assimilability of risks varies over time and things we might consider preventable nowadays, were understandably viewed differently then. Not only do things change, things happen.

Hopefully we learn from them.