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Oct 31, 2002

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Nearing the End of Medical Dark Ages

What we do not know, and what we cannot do in medicine, still far outweights what we do know and can do.

By Tom Koch


Whatever the discipline and irrespective of perspective, the question
facing us all is clear: What facts - individual datum that are accepted as true - do we credit? The problem runs across the sciences - social and biological - and throughout society at large as well.

As a medical ethicist involved with persons with chronic illness I see the problem on a daily basis. An exercise trainer involved in alternative medicine tells me she has significantly helped a person with multiple sclerosis. The wonderful, natural power of the body, coupled with the non-prescription goop she sells, has wrought miracles in a client. That's the fact, the datum. It will be a benefit to all.

But do we credit the individual case? How many cases do we need before a point is made and a fact (great goop) accepted as true? How do we make sure evidence serves to firm up the point not of a miraculous, eccentric improvement but of efficacy in a treatment for a specific condition?

“What type of MS did she have?” I asked. Relapsing and remitting MS comes and goes, those who have it present periods of recovery that last for weeks, months, or years. Other forms of the disease are inexorable and progressive. Well, my friend says, it was the former . . . but why nit-pick? The person is better and, she says, that's what's important.

The interesting question is why we are so eager to use the uniquely individual as if it argued for the whole. In medicine, at least, the answer seems clear. We are in a period of rapid technical advance whose rising expectation promises more than can be delivered, at least at present. Despite all we've learned in genetics, cellular biology, etc., we are only nearing the end of the dark ages of medicine. What we do not know, and what we cannot do, still far outweighs what we do know and can do. There are no miracle cures for a host of chronic conditions (ALS, MS, MD, Alzheimer's, etc.). Traumatic brain and spinal chord injuries are still permanent. Everyone remains at risk to the common cold.

So if, for all its advancing wonders, science remains hobbled and imperfect, well, why not seek elsewhere? We expect tomorrow's science today. Failing that we seek salvation (as we always have) in the promise of the individual tale, the single case, and the unsubstantiated, miraculous fact.

Healthcare

Last spring the B.C. government announced a radical reconstruction of the provincial healthcare system because, it said, the existing system was financially insupportable. Ever since it has insisted upon the necessity of change as a given, a fact.

Is it “too expensive” compared to the relative cost of public health in other jurisdictions? And if so, do we compare B.C. with Washington state (or Louisiana), Ontario, or perhaps the state of Friesland in Holland? What are the long term costs - in health and in social health - of the contraction of service government changes present?

Even if we accept the necessity of service contractions based on economic limits, what do we make of the result? This summer the government proudly announced a maximum two-hour delivery time to hospital for persons living anywhere in B.C. This is, they said, a significant advance. It is the first time a service delivery promise had been made in B.C. (and perhaps in Canada). It is a fact, a datum we can take pride in.

The idea of catchment areas is not new, however. Nor should these be seen as an object of pride. For those requiring rapid treatment - persons suffering a stroke, a heart attack, or serious traumatic injury - two hours is forever. It is too long. As importantly, the catchment area only gets persons to the hospital. Closures of emergency room facilities and acute care beds means they must wait hours more for treatment once they arrive at a hospital.

So what to make of the fact of a service area so vast as to be meaningless in terms of exigent care? Is it a B.C. first? Probably. Is it good news? Probably not. Is it reasonable compared to service delivery in other jurisdictions? The answer is yes if the other jurisdiction is Mexico, probably not if the comparable area is a developed nation.

Missing Women

Outside medicine the same thing occurs. We have, for example, constructed a tale that blames the disappearance of many Downtown Eastside women on police indifference and inaction. The fact is women have disappeared and the DNA of some has been identified at a suspected killing site whose owner is under charge.

The current cry is that the police were deficient, and perhaps uncaring in their investigation. But police did work the case for more than a decade before an arrest was made. They sifted thousands of interviews and clues, albeit fruitlessly. These are all facts. What do they mean?

The legal system is set up and police are trained to investigate allegations in ways that are legally verifiable and judicially acceptable. Absent a body it is near impossible to say if a crime occurred. Everyone, Point Grey matrons and downtown sex workers alike, are officially missing until a body is found. It's a truism of policing that without a corpse it is almost impossible to prove a murder occurred.

No bodies were found in the Downtown Eastside. Some of those earlier listed as missing turned up alive in other parts of the country. The fact that the case was not solved does not mean police were inactive, or negligent. It means they were unsuccessful, at least until a subject was arrested.

And, honestly, no constabulary is prepared for a serial killer. They are rare events in the course of human affairs. Police are not trained to recognize, let alone investigate their occurrence. Worse, as SFU graduate Kim Rossmo's work has shown, serial killers are tracked by locating first the final location of the body (the dump site), and secondly, the site where killer and victim met. In this case the first was unknown and the latter unclear.

Still, we find it convenient to state as meaningful fact that the police should have solved these disappearances earlier. We want to think they can protect us - just as we want to think medicine can save us - and when they can't, well, we seek to condemn. Facts make blame easy, permitting us all to ignore the real complexities that pervade our limited knowledge set, that make their interpretation, and the responsibilities it presents, unclear.

Facts are not firm and hard bricks by which we build our public knowledge. Data are not the anchors on which opinion easily rests. They are the real subjects of our disputes, the objects of our debate. Forget that and we find the easy path to questionable knowledge, false certainties, and the easy assignment of blame to others. It's sloppy, but it takes the pressure off our own moral uncertainties, at least for a time.

Tom Koch is adjunct professor of gerontology and a forum associate at the David Lam centre for international communication. His web page can be found at kochworks.













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