Venus is the black dot in the upper right quadrant of the sun. The plan was to finish the I Can’t Breathe series with Magic is from Venus but then the word Nurture popped onto my radar. There is a Venus Rising to come.
The word autonomy starts appearing in medicine and in bioethics sometime in the 1950s, give or take a few years, linked to the emergence of Informed Consent. The idea of informed consent took shape in law suits around the treatment of breast cancer and the use of electroconvulsive therapy (ECT) – See Shock Therapy and The Swinging Pendulum. Autonomy originally meant that we had a right, or something like a right, not be interfered with in ways we didn’t agree with.
This was not absolute. Medicine at this time was largely about acute medical care – the treatments that were delivered when people were having heart attacks, strokes, had pneumonias, bowel obstructions or were psychotic. Few people were in much of a position to say ‘wait a minute I want to know all about the options before you do anything’. We took a lot on trust. Autonomy was something more like – we will continue to take most things on trust but we want you to recognise that there is a line you can’t cross without some kind of consent. ‘It may be after the event but get this wrong and we will sue you’.
Sometime in the 1990s, give or take a few years, linked to a rise in medical consumerism, autonomy changed meaning. It was no longer about there is a line you must not cross. It was more about ‘this is what we want even if you don’t think it’s a good idea, hand it over or we will sue you’. The boot was on the other foot.
Doctors were shocked when the first informed consent judgements came down. ‘They can’t be serious was a common response. How on earth can anyone figure that someone off the street can have a view worth taking into account compared with me who has 20 years of medical experience. Informing them – sure I’ll inform them but then they have to consent’.
Doctors more recently have been shocked when the Ontario Supreme Court has handed down verdicts that they have to agree to patients requests for terminations of pregnancy, and gender reassignment or make an effective referral – that is send the patient to someone who will agree. Otherwise, they should give up medicine or if they stay in medicine it should be in pathology or radiology where they will have no patient contact.
As with informed consent where the judgements were handed down for breast cancer treatment and ECT, the Ontario Court’s judgments will apply to Medical Assistance in Dying (MAiD) but also likely to patients coming wanting treatment for ADHD, young people who want antidepressants, and pretty well anyone who figures there is something out there that will enhance their wellbeing.
A change like this looks tectonic – deeper plates on which we are all sitting are shifting and when they butt up against each other they lead to volcanoes or earthquakes (law suits).
Patients to Citizens
Up till 1950, dependence on doctors was largely accepted. The image that appeals to all doctors was Fildes’ painting of the Good Doctor. The image conjured up wisdom, and someone on whom patients and families could depend. A parental presence – someone to step in when parents had reached their limit.
Then came an influx of new treatments – antibiotics after the War, cortisone and the steroid hormones came on stream in 1947, leading to oral contraceptives in 1957. Nitrogen Mustard drugs appeared for cancer (1947), antipsychotics (1952), tranquilizers (1955), anticonvulsants (1955), diuretics (1955), antihypertensives (1957), antidepressants (1957) oral hypoglycemics (1957), and lipid lowering drugs (1960) followed. Death from infection became rare. Mental hospitals began to empty. Unwanted pregnancies were about to plummet even as love became free.
The stigma of disease began to lift. We became citizens of the medical realm rather than subjects – patients. We became far more health literate.
There was an equally profound change in pharmaceutical companies who under new management began to change their mission from helping medicine treat the problems we sought help with to transforming medicine into a distribution channel through which we would get what we thought we wanted – relatively unaware that these wants had been planted in us by pharmaceutical companies.
Citizens to Consumers
We began changing from citizens to something very different – consumers.
The politics began changing as well. For a century, it had made sense for left leaning progressive parties to seek a seat at the capitalist table – the table where everything was being produced from automobiles to televisions to pharmaceuticals.
As the capacity of industries to produce ever more stuff grew, transforming us into an affluent society, it made even more sense for progressives to have a seat at the table. It made sense for industry that is to have progressives at the table as they represented the citizens who would have to become consumers to consume all that was now being produced.
We know the consequences of this in terms of climate change and plastics filling the oceans, the air we breathe, and the breast milk babies now drink.
What has been less obvious is the amount of chemicals we now put in our bodies every day. We have moved from having less than 1 medicine per person on average in the 1960s and then for only short periods of time to most of us having 3 or more every day of the year by the age of 50 and 5 or more every day of the year by the age of 65.
The progressive politicians – Tony Blair and Bill Clinton – got roped into persuading us all to take statins, osteoporosis drugs for minimal bone thinning, blood sugar lowering drugs for what was called Type II Diabetes, along with anti-hypertensives, SSRIs and other drugs – many of which can be almost impossible to stop.
The progressives stood by while industry filled our medical journals with plastic (ghost-written) articles about their drugs while at the same time sequestering clinical trial data. So complicit have the progressives been in this – so at the table while it was happening – it almost impossible for them now to back away from it and deny responsibility.
The result of this was to internalize political problems within each of us – a privatization of public problems. If we were unhealthy it was not down to the fact that 90% of cancers are environmentally caused or that Type II diabetes is down to obesity, bad diets and sedentary lifestyles. The answers to these problems became take a pill. Health has swallowed up religion and politics – or politics has hidden behind health.
This is most obvious in what is called ‘mental health’. To have problems with your mental health now means having a negative emotion. Catatonia, puerperal psychosis, schizophrenia and melancholia, old-style mental illnesses, are no more a matter of having a negative emotion or of being traumatised than dementia paralytica (GPI- tertiary syphilis) was. But just as with these illnesses, if you have a mental health problem now, the number one answer is an antidepressant.
There is a lot of news about sea levels rising and other environmental changes but almost nothing about Life Expectancy stalling or falling as it has been in the US for 10 years before Covid.
A report last week pointed to declining Birth Rates in the US. The commentary was about Covid – some women at least are saying they are holding off getting pregnant because of pandemic uncertainties. This may be true but the decline antedates Covid.
The fall in birth rates in some groups stems back 3 decades and coincides with the introduction of the SSRIs. Besides birth control, antidepressants are now the commonest drugs used by women of child-bearing years. These drugs inhibit sex, increase miscarriages and voluntary terminations. Taken prepubertally or with exposure in utero, they appear capable of producing asexuality. Taken by men, they reduce sperm counts of which we also hear a lot of these days.
While we possibly don’t want more people on earth just at the moment, aggravating climate change, the factors producing this decline in white people (its primarily white people living shorter lives and being less likely to reproduce) are the same factors that are leading to climate change
It’s the belief in technical solutions allied to technical means of evaluations that lose sight of the bigger picture (controlled trials in the case of drugs) and an industrialization process that leads to pretty well the entire medical literature on these drugs being ghost-written and all of the clinical trial data being sequestered, allowing companies to portray their drugs as sacraments – something that can only benefit and cannot harm.
This logic was very clear back in 1995 when The Antidepressant Era was being written. Near the end of the book there is the following:
As with other aspects of the modern marketplace, therapeutics at present seems to be leading to an atomization of distress. Just as the ideal market arrangements would have everyone living in a single’s apartment, each complete with washing machine, dishwasher, fridge-freezer, so also treatment development disconnects individuals from their social milieu.
Followed by this:
For example, in 1982 Jachuk and colleagues looked at the perceptions of doctors, patients and relatives of the effects of antihypertensives. They found the doctors reported 100% efficacy – blood pressure was reduced. The patients were mixed in their views, some reporting benefits and others reporting problems with the medication. Three quarters of the relatives, however, reported that treatment was having an adverse effect – the patient was now complaining of side-effects and the process of diagnosis and treatment had made them hypochondriacal. Whose view is most ecologically valid? If treatment of a disease which wasn’t affecting a family up till then has more effects on a family than the disease itself, who should be making the risk-benefit assessments and what should be put in the equation?
This brings out the social features that were being stripped away. One of the greatest ironies of all was a major study a few years later using the same drugs Jachuk was studying that showed that while the blood pressure figures were going the right way, no lives were being saved.
It’s the same with the antidepressants. There is a net loss in lives from suicide and other causes. It’s one thing to put up with adverse effects if you stand a chance of having your life saved – its quite another if you don’t.
Health needs a Greta Thunberg. It needs someone young or Green, or both, who has not been part of the system and can point out the growing lunacy.
It also needs to reject the bait and switch that was autonomy. We have less autonomy now than we once had. None of us make ourselves in splendid isolation. We make and get made in relationships in which we depend on and nurture each other. It takes nurturing to make a citizen.
The problem we are up against is operationalism. This is not a feminist issue as such. It can even co-opt feminism by appearing to promote autonomy (even for women). A recent book Uberland by Alex Rosenblatt (a woman) brings this out beautifully.
When it first appeared operationalism billed itself as a branch of philosophy but it isn’t. It’s pretty well the antithesis of philosophy. It replaces reflection and judgement with operations and reflexes. See Algorithms are from Mars.
Relationships have a basis in something else – that almost dares not speak its name – affection. Care or affection plays a key role in steering us away from reflexes and toward reflection and the kinds of judgement calls that make people.
Autonomy is from Mars, Nurture from Venus. See The Girl who was not Heard.
Illustration: The Doctor’s Nightmare (from Fildes), © 2012 Billiam James