University of Michigan Medical and Nursing School - Aequanimitas Yearbook (Ann Arbor, MI)

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Answer the Questioner-Not Simply the Question Glenn W. Geelhoed A frequently discussed dilemma in medical ethics is the ques- tion How much should the patient be told? . When a patient asks a question regarding his health status and future, what should form the limits ofthe reply? The inconsistencies in policy regard- ing the approach to this problem reside, I believe, in an incorrect focus. It is not the question that should be addressed in reply, but the questioner. In interchange of professional information with colleagues, there is an orientation of simply the facts, Ma'm -answer the question: no more, no less. From this crisp communication an attitude is carried over to the patient that the patient's disembod- ied question is an entity in itself. But questions do not ask them- selves, they arise from the needs of persons. He who focuses on the question and looks no further into the need that gave rise to it has not satisfied that need, and is often deceived as to what in- formation exchange occurs. In the interpersonal communication that constitutes the pa- tient-doctor relationship, questions nearly always are not what they seem. What man, no matter what his medical sophistication, who has fretted for weeks in frightened insomnia wants a light- lipped reply to his heavy-hearted query I wonder if the rectal bleeding l've been having is serious? Few of us pour out our whole soul to anyone on nrst encounter, particularly in a hospi- tal. Some of us know from personal experience that the complaints we bring to professional attention are often the most trivial de- tails overlying our gravest obsessions. But in consulting the phy- sician, it is hoped that the unasked question will be answered or that the healer will draw out unacknowledged fear and comfort the sufferer. A simply affirmative or negative reply is obviously the last bit of information sought when a patient with advanced disease asks with a grim smile, 'fWell doctor, will I live? He is asking the physician for hope, pleading that the sting may be taken away, and looking for compassionate comfort in his failing struggle with an irrational heartless disease. Similarly translated, the desparate young girl who approaches a physician after a dozen subterfuges with the plea 'fl want an abortion is really pleading I need help. Specific demand for medical services is often an intellec- tualization covering fear of helplessness, the underlying plea being to do what is best to help the questioner. The greatest teachers and physicians have always been aware of the distinction between the superficial question asked and the deeper level of the person's need in asking it. The Socratic meth- od was essentially an unmasking of the reasons why questions were asked to illumine the underlying real conflict that prompted the abstract question. Christ saw beyond the questions brought to him so that his followers went away illumined, not merely with a reply. And when sophisticated leaders asked a carefully formu- lated captious question, he ignored the question posed but replied to the deeper conflict, thereby answering both, for: they mar- velled at his answer. l The questions asked of a physician are not always candid ones because of the mixed feelings the patient holds in respect to his encounter with the physician: The attitude of the patient approaching the doctor must always be tinged-for the most part unconciouslyAwith distaste and dread: its deepest desire will tend to be comfort and relief rather than cure, and its faith and expectation will be directed towards some magical exhibition of these boons. Do not let yourselves believe that however smoothly concealed by education, by rea- son, and by confidential frankness these strong elements may be, they are ever in any circumstances altogether absent.-2 And, there is this additional bonus for the physician respon- sive to the needs that give rise to the questions: too many ques- tions cannot be answered, every questioner can. l. Matthew 20:26, for Mark 12:17, or Luke 20:26.J 2. Wilfred Trotter in Harrison et al, Principles of I nternal Medicine, 1962, p. 4. 13

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When LSD is mentioned it is usually associated with such institutions as Hippies, Haight-Ashburjy, love- ins, marijuana, and even Mt2d dress, mini-skirts, and long hair. While these institutions may not ft well in one cubicle, they have this in common-in a-year or two they will have been replaced by other easy solu- tions to the world's problems and other undorms of individuality. David Drachler's essay deals with the reasons behind drug use todaryq it is exerpted from his Victor Vaughan paper. Drugs and Man Throughout history man has deliberately sought means to es- cape reality. ln his efforts to go out of his mind man has em- ployed isolation, deep breathing exercises, hypnotic induction, oscillating body movements, prayer, fasting, sleep deprivation, flickering lights, self-flagellation, sensory deprivation, chants, thirst, heat, plants, and chemicals. The current favorite is the chemical LSD, and the controversy surrounding its use is one of the most interesting issues confronting our society. What makes it so interesting is that its sponsors are the elite of society-the in- tellectuals, artists, and youth. To appreciate the acceptance of LSD today one need examine what motivated man to try to go out ofhis mind during earlier generations. For the primitive subcultures, fear and superstition were moti- vations. There was the fear of gods, enemies, famine, disease, failure, and the fear of extinction. I-Iallucinogens, provided the helpless native with a means of acquiring supernatural powers and hope for his future. They were a source ofstrength and power for their leaders, witch doctors, priests, and prophets. They pro- vided the tribe with a mystical ritual which meant that their anxieties, frustrations, and guilt would be eased. The hallucino- geiis were therefore a means of protection, a basis for unity, and a measure to reduce pain and suffering. Many of the trubes attributed the knowledge of the intoxicants to messages from their gods. lt was only natural that the herbs became a sacred substance. These 'ftheobotanicalsn created a trance-like state, increased suggestibility, gave mystical powers to their visionaries, were a means of identity, and served as a source David Drachler of cult unity. They cleared the mind for meditation and enhanced spiritual development. Peyote cactus was the favorite of New World Indians while opium and marijuana satished the European peasantry. For centuries the psychobotanicals were primarily associated with primitive cultures, the lower classes, and mystical cults. Perhaps the first wave to rock the upper classes was created by Thomas DeQuincey's Confessions of an Opium Eater in 1821. De- Quincey was an eccentric Oxford scholar who insisted that the search for euphoria, self-conhdence, and fulhllment could be completed via the poppy. In fact he implied that it was the edu- cated man who could best appreciate the apocalypse of the world within . . The present involvement of youth with psychedelic drugs is unique to the history of hallucinogens. One sociologist describes the situation as being a breakdown of communication between adults and youth. Another blames a crisis over sexual identity in late adolescence. A purely economic explanation is that food and shelter are readily available to modern youth and occupy so little of his attention compared to youth before World War Il. The specific reasons for taking the drugs are legion, but one thing is certain, the movement is a rebellion against the values of our society. lt is a revolution to establish freedom from restraint, freedom to explore, and freedom to escape. It is mystical as well as intellectual. And it is a romantically optimistic revolution be- cause it holds that within one's consciousness there lies greatness. The following five pages are presented more for the readers' edyication and etnohyment than instruction. Hrs! is an essay by Glenn Geelhoed dealing with an aspect ff the physician-patient relationship. Next is a piece by Dick Lewis on the Caduceusq in connection with the paper, it should be noted that the emblem on the 'yearbook cover is not the Caduceus, but the rod of Aesculapius. The poem by Dr. Robert Green is re- printed from the Sept.-Oct. issue of The University of Michigan Medical Center Bulletin where it was pref- aced by these words: Reflections on the management I2 ff a patient with status asthmaticus presented in a post- graduate course on chronic obstructive pulmonary diseasef' The poem echoes the recurring theme of Dr, Gosling's history course. The final two pages are devoted to the Hippocratic oath: The first version of the oath is a more literal translation rf the Greek than the second which is the version used at commencement exercises here. Sandwiched in between are Ralph Sawyer's comnzents on the specyicity, universality, and interpretation ff the oath.

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One Snake or Two Athenian coins dated from the third century B.C. show on the reverse a short staff with a single serpent coiled about it and on the obverse, the head of Aesklapius CAcsculapius in the Roman traditionb. Therefore there can be no doubt that the authentic Aesculapian emblem is a rough wooden cane of variable length, more or less loosely entwined by a serpent with its head upper- most. l l However, the familiar and popular emblem of medicine is not this Aesculapian staff and serpent, but rather the caduceus. This is ordinarily depicted as a short, slender wand, knobbed at its upper end, bearing two extended wings attached near the top, and symmetrically entwined by two small serpents whose heads, uppermost, stretch toward one another. I4 Richard Lewis The Latin etm'uceus is derived from the Greek kwfykeiml and originally from lcwfyx, a herald, the derivative thus meaning a heralds wand. ln Babylonian and Assyrian literature, Ningizzida for Ningish- zidal, a deity of fertilization and fruitfulness, but also of healing, functions as messenger of the Mother Goddess, Ishtar, to awaken life and vegetation in the springtime. This harbinger and proto- type of the Greek Hermes and the Roman Mercury is depicted with a symbol consisting of a rod, two snakes symmetrically twined around it, and two winged quadrupeds in prohle at the edges. Omit the quadrupeds but leave the wings, and the tpyical caduceus with two snakes appears. Even caducei from Egyptian tradition show two snakes. Thus the caduceus with two snakes far antedates that with one snake and should take precedence. On the other hand, those who wish to relate modern medicine directly to Hippocratic foundations may prefer one snake and no wings. As is true in the mythology of all peoples and is apparent in our own stories of johnny Appleseed and Paul Bunyon, all deities derive multiple functions from numerous traditions and legends. Hermes, it seems, was the messenger of Zeus, the patron of fertility in plants and animals, the god of wind and air, patron of commerce on land and sea, god of roads and travellers, god of robbers, thieves and traitors, and guide of souls to Hades, In his earliest days he was also a god of the home and hearth, and as such had some healing attributes, Often he bears a caduceus symbolic in his several functions. The snake symbolized many ideas-wisdom, prudence, health, long life fimplied in the rejuvenation evident in his ecdysisl and also for anything in or under the ground. So Hermes carried the snakes when he escorted the dead to the lower regions. Interesting in this connection is that the Etruscan god of the underworld, Aite Ca corruption of the Greek Hades? held in his hand a simple rod around which one snake twined itself. What was a Hippocratic caduceus to the Greeks was a Plutonic caduceus to the Etruseans. lt has been almost universally agreed that the authentic and traditional emblem of medicine is the symbol of the Greek patron god of healing, a rough staff and a single serpent. How- ever, a provincial criticism of the caduceus with two snakes is improper. The medical mind thinks of symbols as having a one- to-one relationship with the objects they represent, such as a chemical symbol. However, those who study the nonscientihc aspects of sym- bolism assume automatically that any symbol may have multiple interpretations and that any concept may be expressed in a variety of symbols. Thus, attempts to introduce this nonscientific use of symbolism should expect to encounter the considerable solipism ofthe medical profession.