A Journey to Present-Day Medicine

This week’s class discussion regarding the history of drugs touched upon an area that in the context of today’s modern medicine, has become crucial in determining the success and failure of any new drug intervention. We explored the nature of placebos in our previous class meeting and observed how an innocuous treatment such as a sugar pill can influence people’s recovery and impact their perception of health and well-being. Our discussions led to me to explore this subject in greater depth, specifically, with the intent of analyzing the ethical implications of using a placebo in clinical trials. And, the first thing, I did was to look up the etymology of the word, and found that it derives from the Latin word, “placere”, which means to please. So, then it makes sense that patients or research subjects who are given a pill that achieves that end (specifically, allows them to experience some kind of improvement in their existing condition experience) is for that reason called the “placebo effect”.

But prompted by our class discussions with my peers and Dr. Bhattacharya, the question that I was now pressed to consider was this - is the use of placebo acceptable in one setting but not the other? Is it reasonable to utilize placebos in research, but not in medical practice? What permits its use in either case? Is it its idea of efficacy or the potential of a placebo treatment to cause harm to the subjects receiving the treatment - that should receive superiority when determining the ethical implications of its use? A kiss on the cheek from my mother after I fall from the stairs is also a placebo for it makes me feel better by alleviating my pain in some way. Yes, I’m still hurting, but sometimes this might very well help one to heal better or faster. Then, would that also not count as a kind of placebo? The question that now comes to mind is, if there already exists an effective treatment or cure for a given medical condition, should we still prescribe a placebo (in our situation, the mother’s kiss) to a patient and/or research subject simply because it has those physiologically pleasing, not to mention, pain relieving effects? Following that logic, would it mean that it is proper to undertreat somebody by not prescribing them the proven cure that already exists on the market?

In my view it’s indisputable that for finding the right cure for any disease, we will always require powerful research, but I think our concern should be more to do with modifying the design of future studies in a way that reduces the possible health risk to patients, rather than getting rid of the whole notion of placebo-aided studies. Without utilizing placebos in clinical trials, how can the doctors know if a given medication is truly effective and safe? This paper published in the PLOS journal indicates how clinical researchers are advised to compare their interventions with placebos when initially there exists uncertainty about the effectiveness of a treatment. Doing otherwise would mean that the researchers run the risk of approving drugs based on flawed science and that would be something just as unethical as the deception involved in administering placebo in such control studies.

The authors in this paper indicate how stemming from this rigid concern to be ethical, advocating testing of new interventions against proven effective treatments, puts researchers and clinicians at the risk of actually being unethical. Stang et al. point out in this paper, and rightly so, that diverse features of a clinical study’s design, including, but not limited to, sample size, quality of study conduct and patients' compliance can all have significant impacts on the results of successive trials. The idea of new treatments and drugs to be tested against existing effective treatments, instead of placebos should, therefore, prompt us to take the term “proven effective trials” with a grain of salt.

As I was researching this topic of the placebo effect, I also found this interesting reference to one of the episode from the famous TV Series (which we incidentally, also watched briefly in our class meeting, discussing War and Medicine) MASH. In this episode, the doctors run out of morphine and convince the triage patients that their false placebo treatment (who knows if it was water or saline) was a more powerful painkiller. Of course, the doctors make use of the healing powers of caring and compassionate nurses and other staff to convince their patients, and as one would expect, everyone appears pacified. Watching this episode, I wondered, what was it that made the patients pain-free - the nurses and the doctor’s conduct while administering the placebo, or the placebo itself? And, does it matter, so long as the placebo effect serves to prolong the patient’s survival?

But, like we discussed in our previous class meeting, there are cases, in reality, however, where the patient may only be feeling superficially relieved, while on the inside, his/her biological condition may actually be deteriorating. At the end of the day, I believe any subjective reports about enhanced health conditions must be verified with scientific laboratory tests because our primary concern must be to improve the final outcomes, and people’s subjective feelings alone cannot be the basis for advancing medicine. If anything is clear on this subject so far, it is that we need both caution and care when considering the application of placebos and assessing their ethical implications, because, ultimately, the clinician’s and the researcher’s focus must be on safeguarding the best interest of the patients who are on the receiving end of healthcare.

I still can’t help but wonder, that if the power of belief is such a potent factor in determining the recovery of a patient, then if one were to take deception out of the equation (and therefore, to an extent, settle the question of what is acceptable and what is not by allowing for informed consent), don’t we still encounter a similar conundrum? If a patient or a research subject believes that a given treatment is less effective or not real because he/she now knows he’s being given a placebo, I wonder, is that individual less likely to heal as opposed to someone who got a placebo, believing it was a real proven and effective treatment?

Seems like the catch-22 of belief to me!

This week’s readings indicated how a history of war has over the decades raised some important questions about the ethics of procuring bodies - especially for the aims of advancing medical knowledge. Emily Bazelon’s article in the Slate Magazine, “The Nazi Anatomists” discusses how during the 1930’and 1940’s, the use of unclaimed bodies had reached its zenith. The Nazi regime had legalized the anatomy act which permitted the bodies of executed prisoners to serve as ready supply for scientific research and teaching anatomy in Germany’s medical schools. Today, even though the use of unclaimed bodies for anatomical practice is no longer accepted in this part of the world, there are however places on other side of the globe, especially where I come from (India) where majority of the medical institutions rely on this supply of unclaimed bodies for teaching anatomy to the first year students. I work with this nonprofit organization that is venturing into private medical education and this practice of using unclaimed bodies, on my end of the world, seems to have become part of what we consider “normal” because it has been legitimized by the government for decades now. And, I have to admit that this week’s readings and my further research on this subject have led me to uncover some dark facts about human intent.

As I reflected on the different articles assigned for class this week, one key idea stood out prominently. It was the notion that the origin of these dead bodies was not a moral concern for the Nazi anatomists, so long as the unclaimed body was adding to some scientific gain. Now we consider this practice as ethically questionable because of all the atrocities that took place within the political context of the Nazi regime. What makes us immediately consider this to be unethical is the immense human suffering that was furthered under the pretext of medical research. But does the absence of pain, suffering and illness propelled by war within the larger society make this practice any less unethical? Are the circumstances alone leading to the availability of the bodies (such as those from the Nazi concentration camps) reason enough to question the ethical nature of such practice? These are the kind of questions that I was pushed to consider as I sat reflecting on this week’s readings for class and the direction of my future, professionally.

Now the nonprofit I work with is undertaking this medical enterprise, and I recognize how I share with them this concern of educating the members of my larger national student community. Understandably, towards that end, scientific exploration of human bodies is of utmost importance. Having said that, I am at the same time pushed to consider that these human bodies that our medical institution will legally lay claim to, also are integral to our very humanity. And the harsh truth is that I had never stopped to acknowledge that the manner in which we (and I am referring to the majority of medical institutions in the country today) go about procuring this material reflects our greater human values. Yes, obtaining unclaimed bodies for our medical institution (yet to be founded) would be the easy solution for anatomy heads at this institution to be, but I am pushed to recognize its moral dimensions and ask myself, if this is going to be the ethical way forward?  

In the last two decades, there has been a mushrooming of private medical institutions in India and needless to say, there is an unmatched demand for cadavers for teaching anatomy dissections to students. Just because the state act has made the procurement of such unclaimed cadavers legal, I see now how that does not make it any less ethical. Even though the state has laid out the anatomy act, there is nothing mentioned about the procedure through which the institution receives this unclaimed body. In my own state, the law does not require any documentation of the source, the date the body was received by the institutions, identification marks of injuries or photographs. That practically means that if a person were to die on a train tomorrow, with his belongings lost, his/her body would be shifted to the mortuary by the local police. If after three days, the body were to still remain unclaimed, it will, in all likelihood, end up on a dissection table of some medical college. It’s horrendous to even acknowledge this reality but this week’s readings have urged me to look beyond the routine and casual way that this profession is practiced in some parts of the world, including my own. And I can see how given the cultural and religious makeup of my society, it is going to be an enormous challenge for medical institutions to establish relationships of trust with the local community, but as we discussed in our earlier classes, body donations, seem to me, to be the only right way forward in preserving both our profession and humanity.

This week’s reading about the atrocities of the Nazi regime talk about how the anatomist Hallervorden was committed to studying the human brains driven by his scientific curiosity. He seemed to not be bothered with the fact that the euthanasia program was exploited to provide the brains for his future research subjects. Now, taken in isolation, he seems to have had useful ends in mind that did further our cumulative knowledge of a range of medical conditions. But, my takeaway from this week’s readings is that ethics and scientifically worthy intentions will always be linked with one another. And so even in the absence of such human suffering as was witnessed during the Nazi regime, the anatomist and the entire medical profession in that regard, can never be freed from their joint responsibility to respect for the dead. Nor does the manner in which the medical institutions procure and handle these cadavers reduce their moral obligations for the individual who is now dead – war or no war. We cannot allow our well-meaning intentions of learning driven by dissection to trump our larger ethical, social and moral concerns.

Even when the primary concern of anatomists in my part of the world is to educate their admitted medical students and advance therefore, the commercial success of their institutions, that does not take away from the fact that an unbalanced emphasis on such medical education screams of a lack of informed consent and that in itself makes the use of unclaimed cadavers unethical. The more I think about this subject the more I begin to see how there is a vicious circle at play that inhibits the prevention of this practice. Before I explain what I mean, I would like to share this image that I found as I was researching this theme of the use unclaimed bodies in some parts of the world. The Wired magazine published this article titled, “Inside India's Underground Trade in Human Remains” which essentially points out how tucked away in one of the country’s largest cities is this abandoned warehouse that belongs to a leading distributor of human skeletons. Horrendous as this reality is, one is forced to acknowledge that even after a legal process of procuring these bodies for medical institutions, there are people out there who draw monetary gains from selling these cadavers.

Allan M. Brandt and Sloane in the chapter, “of Beds and Benches”, talk about how a history of spatial arrangement can be used as a lens for understanding the evolution of suffering, disease and medical healthcare. Our field trip to the MGH hospital last week allowed us to glimpse into the origins of modern medicine in America. The Ether Dome, housed in MGH’s Bulfinch Building was the place where the first public demonstration of ether as an anesthetic took place. This particular site was crucial in advancing my understanding of the history of medicine not simply because this was the place where such an important medical innovation took place, but more so because this precise discovery, viewed through the lens of the architecture of this historic building, allowed me to understand, more importantly, the evolution of the modern hospital. Brandt and Sloane discuss point out in their chapter how with the promise of advancements in technology, the hospital evolved from being a site that was primarily concerned with bringing order to the chaos associated with suffering and illness to a place that promised redemption from the disease itself. 

But my visit to the ether dome made me reflect on the week’s readings more deeply and made me wonder whether success of ether could ever be possible without the larger web of social interactions between the doctor and the patient. Our trip to the Boston Public Museum further allowed me to see through its granite sculptures and inscriptions, how the universal themes of suffering and the patients need to relieve pain paves the way for any triumph of medical science. Wiebe Bijker, in “Of Bicycles, Bakelites and Bulbs: toward a theory of sociotechnical change” points towards a similar appreciation of technical innovations. He indicates how the development of any medical or technical innovation is a social process, and not merely a scientific one, since any breakthrough in medical science (or any technology, for that matter) is shaped by the social and cultural factors in the immediate world in which it’s birthed and should not be taken to simply mean that the world alone is always changed by such discoveries, as if the development and design of any technology was a one-way traffic. Any innovation, like the discovery of ether which was commemorated with the Ether Memorial, changes the future of that world to the extent that its past is carved by the heterogeneity of political, cultural, social and economic factors that form the very structure of that world. 

This week’s worksheet served as a useful tool as I began contemplating this week’s blog post. Until the discovery of ether, the entire process of surgery would be one that inevitably had agony written all over it. But the use of ether as anesthesia allowed for a complete and safe procedure to take place, when earlier, it would be dreaded only less than death itself. So, when the world discovered that this component causes insensibility of pain, the medical world was awe and pride, so much so that the doctors decided to immortalize this event that ushered science into a new age. 

Before arriving at MGH and entering the Ether dome, the images from the first class worksheet given to us came to mind. We had this image of Ether dome where students were seated up in the theater and observed the doctors perform the operation of the patient. This was the image I brought with myself as I entered the ether dome, excited to relive this medical milestone, along my classmates, who were just as excited to be part of such grand history of medicine. But to my surprise, I saw this painting right in the center of the amphitheater which looked remarkably different from the one we had seen in analyzed in our first lecture. As I looked closer I saw how the spectators in this particular painting by Hinckley had the spectators standing very close to where the action was taking place. In the earlier painting that we examined in class, the students were all seated at a distance. Not so in this painting by Warren and Lucia Prosperi.

I clicked this image from our trip to ether dome and noticed how the colors in the painting give it a more evenly lit appearance, compared to the original painting by Robert Hinckley which has darker tones as can be seen in this image (taken from the History of Anesthesia Exhibit at the Wood Library Museum, at Schaumburg, Illinois) am sorry that the brass plaque at the bottom of the painting isn’t visible due to the lighting in the room and distance from which I clicked this image from my phone. Nevertheless, I think it is definitely worth sharing with the rest of you here.

I needed to look up the original painting in color to analyze the painting we examined in class (which was black and white), in greater detail. In the original painting, named “The First Operation under Ether” we don’t necessarily see blood on the surgeon’s hand, and even the observing students, though observant, seem more divorced from the entire process as they are sitting up in the seats. Prosperis’ painting depicts how blood is more visibly a part of the whole setup and can be noticed on both the surgeon’s hands and the basins alongside. Here we can notice how the paintings capture essentially the same event, but yielding a somewhat different view to the audience while at the same time evoking a markedly different emotional response in them. 

The history of space as structured in Bulfinch’s building’s amphitheater allowed for painters to immortalize this revolutionary surgery since this was the spot where all the drama unfolded. My trip to Ether dome and later the ether memorial, last Monday, allowed me to come to this realization that disease and suffering as much as discoveries of the science have shaped the evolution of modern medicine in America.

In the handout given to us in our last class, was a prompt, “Is it different to dissect a human corpse for art versus dissecting it for medical purposes?”. When I noted down my thoughts on that sheet of paper, unconsciously my present understanding of modern medicine to an extent guided my response. I saw the question with the understanding that art and science were actually two unrelated fields. And I somehow tried to reason that the two were inherently distinct from each other. Yet, as I reflect on this week’s blogpost, I think that it is only because of the growing advancements in medical field and added knowledge from CT and MRI scans and ultrasound scanners of every kind that we have come to think about science and art as two diametrically opposite fields of study. But, even then, it just took me only a brief look at the shared history of art and science to understand how dissection and art have always been two facets of the same coin.

Leonardo da Vinci turned to dissection in order to illustrate art on his sketchpad (in the form of detailed drawings of the human form) just as Andreas Vesalius turned to dissecting human bodies in order to uncover truths about the human anatomy. I think without the corresponding element of art, the science behind dissection would never have led us to the knowledge that forms the very foundation of modern medicine today. Like Nero's dissection of Agrippina, there would have been nameless others who would cut into dead bodies of other executed criminals to discover more about the functioning of their own body. But come to think of it, would that act alone, be sufficient on its own, to produce any kind of long lasting knowledge? This riveting article, from the Telegraph, indicates how the renaissance man, Leonardo da Vinci, had invented a new vocabulary for scientific illustration, long before we had the modern technology of MRI scans that allowed us to further our knowledge of the human anatomy.

Preserving what those dead corpses revealed to us, it seems, was as essential as slicing apart of a body that is dead. Contrary to popular belief, I would assert that the very practice of recording the dissection of cadavers had served to blur the line between art and science. The practice of dissection didn’t set science apart from the arts, but rather, served to bring them ever closer. One can easily notice from the sculptures and drawings of Michelangelo, Vinci and Vesalius that one can’t do art without doing a wee bit of science, just as one can’t do scientific discoveries about the human body, without some knowledge of those anatomical drawings.

But our class discussion about cutting open of the bodies and its producing a certain element of wonder has led me to question nevertheless: Is dissection really producing that sense of wonder at seeing our own mirror? While initially - after our discussion with Dr. Bhattacharya and my peers in the last meeting - my impressions were that any dissection of the human body derives from this inherent curiosity to know about the human body, and thus, even though the intents of the individual doing the dissecting may vary, their driving force remains the same – fascination with the human form. On deeper reflection now, however, I could hardly agree more. I think that cutting open the body, whether for an artist or a scientist requires first and foremost to distance himself or herself from the subject of their study, in this case, a cadaver.

Our last three class meetings and the ensuing discussions on the history of disease, diagnosis, and, hospitals, have pushed me to reflect on a very fundamental interrogation about the nature of disease. In this week’s post, I attempt to elucidate the manner in which the codification of diseases has contributed to our understanding of the modern day diagnosis and treatment methods. Prior to our class discussions, I had never stopped to consider whether this ongoing underlying process of classifying diseases actually hindering (as some involved in the compilation of DSM-III manual argued) or ensuring clinical flexibility.

I took some time to analyze both our assigned readings and class notes and informed by our class discussions, I found myself asking: could the Boston hospitals be ready at the time of 2013 bombings without there being a separate entity for the diseases that demanded treatment? I am of the opinion that without there being an operationally defined disease, our contemporary hospitals with all their efficient medical equipment and trained workforce would have failed to deliver the quality of healthcare that they did in the face of tragic incidents like the Boston Marathon Bombings. One mustn’t forget that whether we came to identify illness and develop our understanding of the human body by looking through the sense of sight (i.e. visibly seeing the body), the sense of hearing (i.e. listening to sounds coming from bodies), or by touching it to examine the manifestations of disease on the physical body, such categorization is what has facilitated our knowledge base in the first place.

Without there being a way to articulate stable disease entities whether it be through imposing a diagnostic criterion to mental illness or through the practice of physical diagnosis to unravel the diseases of the body, there would never have occurred this present proliferation of chemical, imaging techniques and the consecutive discovery of treatment methods. We boast of our latest advancements in medical expertise that facilitate the treatment of diseases but we forget that without the precise understandings of disease as an actuality in itself, an entity in its own right, we would not have had the basis to make those precise medical discoveries.

This particularly reminds me of our class discussion about the fable of these blind men and the elephant. Like the different revelations of the blind men lead to a cumulative understanding of the elephant itself, it is this gradual understanding of the varied vocabulary of disease that permits in the first place, the advancements, and expansion in the modern day hospital care. The hospitals may vary depending on their point of efficiencies, the degree of centralization, and the overall texture of their patient experience yet without the very methods of naming and defining a disease we could not imagine having hospitals that would be so well equipped to deal with even the most severe of fatalities.

Rosenberg’s article from our 3rd class meeting indicates at one point how disease labels give a sick person the visibility he/she needs and consequently the promise of good health. Inspired by his argument, I did some online reading and found this article that talks about the risks of our ever-increasing fascination with labeling diseases and also how our preoccupation with tagging diseases is revealing the hidden financial interests of some medical professionals that may ultimately harm the patient. I chose this specific online source to include in my weekly blog post because it informed my own examination of the benefits and more specifically, the evils of categorizing diseases.