Biblical Reflections on Modern Medicine
Vol. 5, No. 3 (27)
Contents:
Can Evangelical Medical Ethics Be Foolish?
Or
"If You Love Me, Keep My Commandments"
I have pondered the theme and specifics of this article for the last 2-3 weeks.
I have vacillated between naming people and events to limiting myself to a generic
presentation of principles. I will end up somewhere in the middle.
Is there a minimum number of pillars by which to judge what is or is not
an evangelical, medical ethic? "Where is the wise man? Where is the
scribe? Where is the debater of this age? Has not God made foolish the wisdom
of the world?" (I Corinthians 1:20, NASB)
What, then, is our goal as Bible-believers? Are we to seek common ground with
unbelievers? Are we to argue on philosophical bases without reference to Scripture?
Are we to seek to influence a godless society without requiring them to be born-again?
Are we to argue on the basis of Western tradition?
The answer to all these questions is a qualified, "Yes!" We are called
to be salt and light in the world. However, one is struck by the contrast in
the Bible between the "world" and God's thoughts. For example, we
are not to be "conformed to the world" (Romans 12:2). We are not to
be "friends of the world" (James 4:4). We cannot love the world and
love God (I John 2:15).
Other contrasts in the Bible between man's thinking and God's thoughts are
"light" and "darkness," "sight" and "blindness,"
and "wise" and "foolish." Surely, if evangelical ethics
does not sharply contrast with secular ethics, then something is amiss! I want
to suggest some distinctions.
A Minimalist Approach to Evangelical,
Medical Ethics
First, there must be no compromise on the Bible as the final arbiter of truth
and ethics (right and wrong). More specifically, the Bible must be believed
as being "infallible and inerrant" (IAI). More than any other descriptions
of what the Bible is, this theological language separates Bible-believers from
Bible-compromisers. If you are not aware of these terms, you are not aware of
the ideological battle for truth in the 20th century.
Generally, IAI means that the Bible is conveyed to modern times under the
guidance of the Holy Spirit so that modern translations (by men who believe
in IAI) are the very Word of God. The Bible, then, is IAI when properly understood
in everything to which it speaks.
Admittedly, many who believe in IAI differ over interpretation. However, there
is a great gulf between those who argue within the beliefs of IAI and
those who argue outside the beliefs of IAI. IAI is the two-edged sword
that divides those who defend Biblical truth and those who don't. Those who
believe in IAI may properly be called evangelicals. Those who don't believe
in IAI are falsely using the label evangelical.
Two great conferences have been held in Chicago by the International Council
on Biblical Inerrancy. The first in October 1978 defined the Biblical and historical
position on the inerrancy of Scripture. The second in November 1982 focused
on Biblical interpretation (hermeneutics). These two conferences defined the
modern debate over the Bible as truth and its proper interpretation.
Second, there must be no compromise on abortion. Individual human life begins
at conception (not implantation). That life must be protected and not medically
aborted for any reason except possibly to save the life of the mother. Exceptions
because of genetic defects, congenital malformations, or rape and incest are
compromises that ought to exclude an evangelical, medical ethic.
Third, there must be no compromise on euthanasia. Euthanasia is any medical
act that intends the death of the patient. It is to be distinguished from
withdrawal or not initiating medical treatment because implementation
will have limited value in chronically or terminally ill patients. Sometimes,
this limitation of medical treatment has been called "passive euthanasia."
Passive euthanasia, however, confuses the unbridgeable chasm between euthanasia
and limitation of medical treatment.
A Trumpet Call to Dr. Nigel de S. Cameron,
CMDS, and Others
As this newsletter is being prepared for publication and distribution, a conference
will be held at Trinity Evangelical Divinity School (May 19-21), sponsored by
the school and the Christian Medical and Dental Society (CMDS). It has an impressive
list of speakers, many of whom are solidly evangelical. However, some are not.
I will not name them here, but point to this conference as an example where
its description as "evangelical" cannot be trusted.
Some speakers would not subscribe to infallibility. Some are not strictly
against abortion, as I have described above. Some might not even be against
euthanasia.
Well, Ed, What Difference Does a Failure
to Adhere to These Positions Make?
First, Bible-believing Christians are being misled. By this conference being
called "evangelical," speakers are being included who are not evangelical.
They are wolves in sheep's clothing.
Second, such an approach is dishonest theologically and philosophically. While
all appear to be in agreement on fundamentals, all are not. Consistency, congruency,
and correspondence within a system is at best compromise and at worst an eclectic
patchwork.
Third, such an approach dishonors Christ. Jesus said, "If you love me,
keep my commandments." While none of us understands or keeps them perfectly,
at least the three pillars that I have named are supports for a a truly evangelical
approach.
The Problem Is Not Just Medical Ethics
I am only attacking one arena (medical ethics) where the Church of Jesus Christ
is in serious trouble for her failure to be more discerning. Major evangelical
publishers have published less-than-evangelical books and periodicals. Churches
and Christians have virtually invited the Trojan Horse of psychology and psychiatry
into the pulpit and pastoral counseling. Hebrews 5:12-6:8 calls Christians to
get beyond the fundamentals, but most Christians today cannot even name
the fundamentals, much less teach them or get beyond them. And, perhaps it is
no wonder, with the deception that is perpetrated by their leaders.
However, I weary of those masquerading and prospering as evangelical Christians
who demean the Word of God. I weary of those leaders who know better but don't
call their brethren to account. Many leaders want respectability and the appearance
of being "scholarly" from secular writers and institutions, rather
than confronting them on their godless approach. They have chosen the praise
of the world rather than faithfulness to God's Word.
True American Christianity is going to have to exercise far greaterdiscernment
than it currently does in order to meet the challenges of modern times. A major
arena of this challenge is medical ethics. The Church and our country are floundering
from messages of false prophets. Perhaps, we need an old-fashioned Scottish
revival: a large number of subtractions rather than additions (among leading
teaching and writing evangelicals).
Bob's Banter*
A New Stress for Stress Tests
A 71-year-old man was recently referred to our echocardiography laboratory
for a stress test with dobutamine (a drug that stimulates the heart). Initially,
he appeared to be a calm, soft-spoken man (a reflective thinker? - Ed). His
resting heart rate was 81 beats per minute. During the first dose of dobutamine,
his base-line heart rate was 92 beats per minute.
He then engaged one of the physicians in a discussion about Hillary Clinton
(sic) and the Clinton administration's proposed health-care reform. It was clear
from the conversation that the patient was strongly opposed to it. While he
was talking about health-care reform, his heart rate increased from 91 to 117
beats per minute. When he stopped, his heart rate rapidly decreased to 94 beats
per minute. With an incremental increase in the dose of dobutamine, the patient's
base-line heart rate was 100 beats per minute.
When the discussion of health-care reform resumed, his heart rate increased
to 124, and when the discussion stopped, his heart rate rapidly decreased to
105. With the next incremental dose of dobutamine, the patient's base-line heart
rate was 117. It increased to 147 during the discussion of the proposed reform.
When the discussion ended, his heart rate decreased to 124. The study was terminated
at this point, since the target heart rate had been achieved.
In this patient, the additional stress induced by conversation about Hillary
Clinton (sic) and the administration's proposal for health-care reform caused
an average increase in the heart rate of 26 (+/- 3) beats per minute as each
dose of dobutamine was administered. The discussion resulted in attainment of
the target heart rate at a lower dose of dobutamine than might otherwise have
been possible.
When a stress test with dobutamine is conducted, the addition of emotional
stress induced by a discussion of health-care reform may lower the risk of untoward
effects of high-dose dobutamine. With judicious application of the discussion,
we were able to complete the stress test in a cost-efficient manner.
Further studies are needed to confirm these promising but preliminary findings.
Reprinted from The New England Journal of Medicine, March 24, 1994,
pp. 869-870 (with minor changes for publication here).
Ed's Note
As with any new procedure, major side effects may occur. In some patients
who are even more strongly opposed to the Clinton's plan the "target heart
rate" may be achieved without any medication. Such discussion might
even precipitate a heart attack with even stronger anti-emotions! I recommend
caution with this new approach to stress testing.
* I have named this column after a funny and punning subscriber, Robert W.
Robinson ("Bob"). However, some selections for this column are my
own (as this month). I leave his name attached so that he may achieve all the
credit for good selections. The editor always receives the criticisms for bad
copy anyway!
Hitting the Phantom Curve
by Donald G. Smith
My son developed an interest in sports at an early age. As I recall, he was
throwing a ball in the playpen while ignoring his stuffed animals. A born competitor,
he grew up seeing me as a batting practice pitcher and punt return man as much
as a father, and our blood bond was forged in the fires of competition.
A most important plank in our relationship evolved from the phantom curve,
a rather clever bit of chicanery that I sold to him as the "unhittable
pitch." I had used it in my playing days with the Dakota All-Stars, but
only sparingly because I was acutely aware that this weapon could ruin the game
of baseball. I jealously guarded my awesome secret and refused to teach the
pitch to anyone else. As a player I had used it only in crucial situations and
threw it no more than three or four times a game. As the story went, no batter
ever came close to hitting the phantom curve.
As I said, my son was a competitor, and he was determined to hit the unhittable
pitch, but of course he never did. When he hit the ball, he would look hopefully
at me and ask if that was the phantom curve. The answer was always negative,
but when he swung and missed, we had a different story. That, was the phantom
curve.
He was about eight when he finally saw through the whole charade, realizing
that he couldn't win because I was calling the shots. I alone decided what was,
and what was not, this remarkable pitch. The whole thing was rigged, and he
was the victim of a bit of deceit from a man with questionable pitching skills
and an active imagination.
I recalled the phantom curve recently when I heard yet another speaker castigating
the federal government for its "inadequate efforts" in dealing with
AIDS and the homeless problem. The simple truth is that efforts to date have
been far too ambitious because neither matter is the government's business,
but that is another issue. The point to be addressed here is in the area of
problem-solving. The speaker, and all people of like mind, see the federal government
as a problem-solving institution, a place in which bureaus and departments are
established to deal with social problems. Then, presumably, the problems go
away and humanity takes a giant step forward.
It is another case of the phantom-curve deception because the whole thing
is rigged from the outset and no batter will ever make contact. People who are
awarded desirable government jobs, with all attendant perks, don't work their
jobs out of existence. This is a universal law of human nature and shouldn't
be all that difficult to comprehend. These people don't solve; they regulate.
Solution is terminal, and regulation is forever.
This is not intended as a put-down of government workers, because they are
human and they react. Not being entirely pure of heart, I would do the same
thing if given a plush office with commensurate salary, medical coverage, a
fat pension plan, a government car, and all kinds of business to conduct in
Paris and the Bahamas. The problem is not the people, but the system--a system
that makes problem-solving the kiss of death and problem-perpetuation a one-way
ticket to the good life.
This is something that ourself-appointed humanitarians don't understand. Government
doesn't cure diseases, and it doesn't make the indigent disappear. It doesn't
make the deserts bloom, the blind see, or the lame walk. This is not why we
have government.
It is interesting to note that since Lyndon Johnson offered to cure all our
social ills with the Great Society, we have spent more than a trillion dollars
trying to turn the federal government into the Magic Kingdom, and it hasn't
even come close to working. We have added five cabinet-level departments, all
devoted to some kind of social betterment, and this has resulted in nothing
more than jobs for people who regulate this massive wheel-spinning operation.
All of this leads us back to the phantom curve, the unhittable pitch. Whenever
I hear of a new Federal agency created to solve a social problem, I think of
a seven-year-old boy, digging in at the plate and mustering all his skills and
determination to do something that couldn't be done, simply because the man
who controlled the game wouldn't let it be done. There is, however, one major
difference. The little boy figured it out and went on to more constructive things.
People who should know better are still up there swinging a bat.
Reprinted with permission of the original publisher. The article appeared
in The Freeman, July, 1991, Foundation for Economic Education, Irvington-on-
Hudson, NY 10533 and a recent pamphlet published by the Association of American
Physicians and Surgeons.
Medical Ethics: the Lessons of World War II*
by Stephen Lefrak, M.D.
Why should a hospital devote space and time to a display documenting events
which took place more than 50 years ago? Why should health-care workers, patients,
employees, or hospital visitors be interested in the crimes of National socialism?
Although there are many ways to answer these questions affirmatively, I should
like to emphasize the role medicine and physicians played at all levels in the
Nazi regime, and particularly the view that "National Socialism is applied
biology," as enunciated by Rudolf Hess, Hitler's Deputy Chancellor.
The doctors' trial at Nuremberg, in December 1946, at which 20 German physicians
stood accused of heinous crimes and of whom 13 were found guilty, produced a
convenient record to hide behind for the remainder of the profession. The vast
majority of 95,000 German physicians were seemingly exonerated by the guilt
of these 13 (plus some 250 others tried later). The world's medical profession
could take solace in believing that "real" doctors were not involved
in this evil.
However, the role physicians played in Germany between 1918 and 1945 in determining
the form of society achieved there has just begun to be revealed. What is seen
is nothing to make any physician proud. Instead of seeing a profession which
resisted subversion of its ethical precepts, we find physicians in the foreground
of racism and eugenics, as the initiators and designers of the apparatus of
mass destruction and unethical experimentation. This, unfortunately, is not
a history of a few madmen on the fringe, but rather a revelation of the depths
to which the leading medical establishment of the time sank.
Medicine provided both the theoretical basis and the means by which National
Socialism instituted their eugenic policies. Involuntary sterilization of over
450,000 German citizens was only the initial step in what was to become a vast
eugenic enterprise. Obviously, (the means) to carry out a sterilization program
of this magnitude required the support of the medical profession and other health-care
workers. Physicians betrayed their patients by reporting those with "hereditary"
diseases to the authorities, physicians and academics sat on the genetics courts,
physicians and nurses carried out the procedures, and physicians examined the
pathological specimens.
Soon, the mission to protect the germ plasm of the Volk and to preserve scarce
financial resources moved from sterilization and castration to killing. It began
with handicapped newborns, spread to adult German citizens, and eventually became
mass annihilation. Throughout this entire process, physicians were the killers
or directly abetted them. They reported their patients, falsified death records,
designed the methods of death, regulated the flow of gas in the chambers first
used to "euthanize" mentally ill German citizens, selected those to
die in the concentration camps, and participated in direct killing. National
Socialism could in fact claim that all the killing was medical; medically indicated
and supervised and carried out by doctors. "Lives deemed unworthy of
life" were destroyed, beginning with the handicapped and progressing
to those judged genetically unfit by the physician eugenicists in German universities
and research institutes.
Medicine has avoided confronting this issue by professing that this was the
work of a handful of mad, immoral scientists. We must recognize that it was
not a handful, but rather a plurality of a highly skilled and technically advanced
medical profession who joined the Nazi party (approximately 50% of German physicians
joined, twice the ratio of lawyers) and betrayed their patients and their oaths.
We stand on the doorstep of the 21st century, armed with a new genetics, confronted
by arguments for cost control, encountering increasing participation of the
state in the physician-patient relationship, and challenged by new debates over
euthanasia and physician-assisted suicide. We must learn the lesson of German
medicine during the 20th century!;
(Summary of a presentation at given at several locations. Reprinted with permission
of the author.)
Dr. Lefrak is Professor of Medicine and Assistant Dean of the Program on Humanities
in Medicine, Washington University School of Medicine, and Director of the Medical
Intensive Care Unit and Chairman of the Ethics Committee, Jewish Hospital of
St. Louis, Missouri.
More on Vaccines
There is some debate among Christians, and indeed I am not settled in my own
mind about the need for vaccinations in children and adults. However, a pertinent
thought came to mind as I discussed this issue with a caller recently.
While some childhood diseases for which vaccines are currently recommended
are relatively mild in children, these same diseases in adults are far more
severe. Examples are hepatitis A and B, chicken pox (varicella), measles, and
mumps. Although German measles (rubella) is usually a mild disease in adults,
the threat is to the unborn children of pregnant women who do not have antibodies
to this virus. With more children and adults being vaccinated against these
diseases, those who are not vaccinated are less likely to have the natural disease
and subsequent immunity as children and be exposed as adults when the disease
would be far worse.
All things considered, I favor most currently recommended vaccines (unless
one is trying to hide his child from any form of state registration). The risks
both to natural disease and to bureaucrats seem to outweigh the minimal risks
of vaccination.
Brief News and Commentary
A Politically Correct Definition of
Modesty
"Modesty: A 19th century idea that women's legs are joined
together from the knees up, that breasts are not fit for public view unless
they are on TV documentaries of native tribes, and that all children must be
protected from seeing the human body." (Sheri S. Tepper. "This Is
You." Rocky Mountain Planned Parenthood, Denver, Colorado, 1977.)
Commentary: This example is just another piece of evidence that liberals are
revisionists and distortionists to the core of their being.
Cost of Clinton's Health-Care Plan
for Godfather's Pizza
One executive of the Godfather's Pizza chain has calculated the impact of
the Clintons' proposed health-care plan on his company. The present cost of
Godfather's health insurance is $540,000, with the employer paying 80 percent
of the cost.
Under the Clinton proposal, the same coverage would cost Godfather's $2.2 million,
an almost four-fold increase. (Rush Limbaugh Program)
Commentary: While some claim that politicians must lie (I don't) to get into
office and stay there, the lies of the Clintons on health care (and other issues)
stagger the imagination of any moral person.
Ethical Inconsistency by Medical "Officials"
In January 1994, the American College of Obstetricians and Gynecologists recommended
that "medical services (abortions) be provided by persons who are not physicians."
"'I think the ideal would be that physicians would be performing them,'
ACOG President-elect William C. Andrews, M.D., said. 'But as a pragmatic thing,
if there are not enough physicians who are trained to willing to do the procedure,
other options have to be considered. I think it's an access to care issue."
(The Religion and Society Report, April 1994, p. 6)
Commentary: For decades, great wars have been fought at the state and national
level by physicians to prevent optometrists, chiropractors, and other non-physicians
from prescribing drugs and doing surgical procedures. It seems that physicians
are only willing to release "turf" is when their own have insufficient
numbers to handle the numbers of patients with a particular problem.
Obstetricians have had to allow nurse-midwives because fewer physicians were
performing deliveries. Now, there are not enough physicians to kill unborn babies,
so they are willing to go outside their own.
Two points are important. First, pro-life forces are being successful in getting
more and more physicians out of the abortion business. Second, however, the
few physicians who do perform abortions are deadly (pun intended) intent upon
abortion being available, even if it means yielding their own territory.
Readers should recognize this intent as more than the provision of a contrived
need. It is an intent that has been a 180 degree reversal of physicians as healers.
Physicians have become mass murderers and they will do whatever it takes to
preserve that reversal. With Big Brother taking over more of medicine, being
treated by a physician is becoming an increasingly lethal hazard.
"Throw de Bums (Medical Leaders) Out!"*
President Clinton is claiming the support of all 300,000 physicians who belong
to organizations that have endorsed his Health Security Act, including the American
Academy of Family Physicians (AAFP). Yet 71% of family physicians are opposed
to the Plan, while 12% (+/- 3%) favor it, and 15% are undecided, according to
a recent informal survey by the Association of American Physicians and Surgeons
(AAPS).
AAPS sent surveys to 5000 randomly selected family physicians nation-wide;
about 400 responded.
Given a list of adjectives to describe the plan, 9.5% checked "cost-saving,"
4.7% "quality-enhancing," 29% "access-expanding," 11% "generous,"
82% "bureaucratic," 63% "socialist," 54% "destructive,"
and 34% "unconstitutional." Fourteen respondents suggested an additional
description that was positive or neutral in tone, and sixty contributed a negative
description, e.g. "tyrannical," "deceitful," "unethical,"
and "self-aggrandizing for bureaucrats."
In response to the question, "If the Clinton Plan is enacted, what will
you do?" only 43% checked the answer "sign up with the Plan, submit
to the system, and try to make the best of it." Almost as many (38%) said
they would "work to have the Plan repealed," and 21% said they would
"retire or change my occupation." About 13% said they would "refuse
to participate and attempt to practice privately." (More than one response
was permitted.)
A large majority of respondents were opposed to specific provisions found
in the Clinton Plan and various alternate proposals. An employer mandate is
opposed by 65%. About 65% would object to diverting funds from sickness care
to school-based clinics and other social projects. More than 75% oppose a lottery
for selecting enrollees for over subscribed plans; 71% oppose requiring electronic
data submission for all clinical encounters; and 61% oppose forcing everyone
to pay for a standard benefits package.
The majority of respondents (55%) favor Medical Savings Accounts. Only 13%
are opposed to this concept; 30% are undecided. Here is a sampling of comments.
"I feel betrayed by the AAFP."
"This issue is politically inspired to eliminate the middle class. If
they really wanted to make health care available, all that would be necessary
is to allow tax deductions for giving free care to those in need."
"AAFP never polled its grass-roots members. I am undecided about continuing
my membership as a founding member." [About 8% said they had been polled
by AAFP.]
"This plan would be the end of true democracy."
* Reprinted from the AAPS News, April 1994, p. 2
Ed's Note
"Throw de bums out" (if I remember correctly) was the fans' demands
of the former Brooklyn Dodgers when they were disgusted with their team's play.
With the wimpy, politically correct, and out-of-sync leaders of the AAFP, AMA,
and other organizations, the "rank and file" ought to "throw
de bums out." Or, they (you) should not renew their (your) organization's
professional dues.
Calling All Survivalists! Reflect on Rwanda
I know that some readers either participate in survivalist activities (from
food storage to military training) or know something of the movement. While
I find some activities extreme, the modern growth of and encroachment by the
state does warrant plans for a severe disruption of society as we know it.
Some activists paint survivalism as something that borders on, if not inclusive
of, something romantic. For example, there is the image of the rugged pioneer
in the woods, living off the land, and perhaps marauding against statist forces.
However, the current (or recently past) situation in Rwanda is more realistic
and cautions against such romanticism. Totalitarian government is better
than anarchy. Now, I believe in a free society as strongly as anyone, but
let's not romanticize anarchy. Tens of thousands of Rwandans have murdered and
maimed each other virtually at will. Any police or military actions are more
a part of the anarchy than any control of the situation.
Further, being on the run from a totalitarian government is no picnic either,
especially in light of today's surveillance technology. But, at least a totalitarian
state will maintain some form of order, while underground presses and resistances
are at work.
Yes, let's prepare for the worst, but no, let's not paint a romantic picture.
I don't relish my sons dying in front of my eyes or my wife and daughters being
raped or worse. It's not pretty. My family and I will be prepared as best we
are able, but we don't look forward to it. One assault or one ambush, and everyone
and everything is suddenly gone. May God have mercy on us and our nation.
I know that this subject is not specifically medical, but the picture of Rwanda
has had a sobering effect on me. I hope that readers may profit from my reflection.
Erratum
Under "Bob's Banter" in the March 1994 issue of Reflections,
a University of Texas Professor, Margaret Maxey, was cited for her statement
that the earth's population should be reduced to 2 billion people.
Professor Maxey was speaking against "eco-terrorists" and
"eco-fascists," not for them. She was citing the opposition's statement
calling for a reduction in the earth's population and then dismantling their
argument.
We regret this error and wish to set the record straight on Professor Maxey
who is on "our" side of this debate.
AIDS: Issues and Answers
Vol. 8, No. 3 (52) May 1994
There Is No AIDS Epidemic!
In the first 7 years of the AIDS "epidemic" (1981-1987), 93.2%*
of all reported AIDS cases were either homosexual/bisexual, IV-drug abusers,
or both. Another 3.8% were "heterosexual," that is, in men and women
who had sex with a person known to have AIDS or at high risk for AIDS. Thus,
these categories of "risk behavior" accounted for 97.0% of all reported
cases of AIDS during this time.
In calendar year 1993, 87.0%* of reported cases were homosexual/bisexual,
IV-drug abusers, or both. Another 9.0% were "heterosexual." Thus,
96.0% of all reported AIDS cases during this period were in these two categories.
You may be thinking, "So what, Ed? You have reported these numbers before
as statistics for the AIDS epidemic." Yes, but I was reflecting on these
numbers since the last newsletter. The most serious problem is not AIDS but
immoral and illegal behaviors. I have reported earlier that the life expectancy
of homosexuals who develop AIDS is 39 years and 42 years in those who don't.
I don't know what the life expectancy of IV-drug abusers is, but it can't be
very high with the violence and severe infections associated with that lifestyle.
Further, the life expectancy of those in the "heterosexual" category
is certainly not that of the average American, because virtually every sub-cateory
is also a high-risk for violence and infectious disease.
The point is that the primary problems of homosexuality, IV-drug abuse,
and heterosexual immorality would not go away if we had an instant cure for
AIDS! The people in these groups would die "before their time"
of other dangers associated with their lifestyle without the presence of
AIDS.
You see, the focus of a "cure" is all wrong. The real needed cure
is a change in lifestyle, not the cure of AIDS. Eradication or prevention of
the spread of HIV will change only slightly the general risk of these groups.
You may see nothing new here from what I have said before, but for me this explanation
is a new slant that minimizes the threat of AIDS. Thus, I have chosen the headline,
"There Is No AIDS Epidemic." Now, technically speaking, there is
an AIDS epidemic. In epidemiology, the appearance of any disease or deaths over
a "normal" baseline is by definition an "epidemic."
However, to call AIDS an "epidemic" is to miss the more serious
epidemic that has only a Biblical solution. Indeed, our culture has "sown
the wind" and is "reaping the whirlwind." The "wages of
sin is death," both physically and spiritually.
* These numbers include a percentage from the "Undetermined" category
since most of these are "Incompletely reported." When fully investigated,
they generally fall proportionally into the other risk categories.
New AIDS Cases: Up or Down?
Generally, the news media have been reporting that AIDS cases for 1993 have
markedly increased over 1993. However, if you have been reading this page for
the past year, you will know that most of those numbers come from the expanded
definition of AIDS that was applied effective January 1, 1993.
Discarding the 1993 definition, AIDS cases are down 2% over 1992. There
were a total of 103,500 newly reported cases of AIDS in 1993, with 54% of these
under the new definition. In all honesty, some that were under this new definition
would also have met the previous criteria, with the overall effect of a slight
increase in AIDS cases.
We will see how the news media will treat 1994, when there will be a marked
reduction in AIDS cases over 1993 because the new definition will have already
been applied to the existing pool of HIV-infected people who were not previously
reported as AIDS. (Morbidity and Mortality Weekly Report, March 11,
1994, pp. 160-161, 167-170)
HIV Cases: Up or Down?
"The most widely accepted estimate of HIV infections has been compiled
by the Centers for Disease Control (CDC). It projects that about 1 million
Americans are infected.... Dr. Geraldine McQuillan, who presented new data
at a medical meeting, said that the(se) CDC figures may have overestimated
the extent of the epidemic in the past but they may not be far off now because
the new survey has a margin of error. The true number, based on (her) new
survey, could range anywhere from 300,000 to 1.02 million, she said."
Her more precise estimate was 550,000. Her survey "covered only people
who live at home, not prisoners, the homeless, or hospitalized patients."
(Chicago Tribune, December 14, 1993, Section 1, p. 12)
Commentary: In the mid- to late-1980s, the "official" estimate of
HIV infections was 1.5 million. About 1990, this was reduced to 1 million. Now,
this estimate is even lower.
The facts about the HIV/AIDS epidemic is that the numbers have never reached
even conservative predictions by the CDC. Yet, neither they nor the news media
ever "back off" these earlier estimates. Worse, regulations, laws,
funding, and criminal and civil prosecutions have proceeded on the basis of
worst-case figures. Such distortion of priority is one of the major travesties
that our "officials" have foisted on us because of HIV/AIDS.
Getting the Story Straight: A Lament over
the Medical History
by Hilton Terrell, M.D.*
Yesterday a patient launched into a familiar critique of another physician
who "did not listen to her." Her story was credible. The particular
physician being excoriated varies from version to version, with some area names
cropping up more frequently than others, but with all being named eventually.
While I don't hear myself named, I'm sure I've been named in other offices.
Why is it that physicians sometimes don't pay attention to patients, or at least
give the impression that we haven't listened? A complete answer, could it be
had, would fill volumes, and much of it would be various physician failures.
There are two sides to the doctor-patient equation, however, and one that
gets less attention in print is patient failure. One of the reasons that doctors
don't listen well to some patients is that the patients are so ill-prepared
to talk. (I write here not of the senile, demented, retarded, juvenile or intoxicated.)
In the prodigious transfer of responsibility that has occurred in medical care
in the past 50 years or so, a large measure of responsibility for the medical
interview has passed from the patient to the physician. We are presciently supposed
to know to ask everything relevant, to pick up on non-verbal cues, and to use
efficiently the medical records available to us. Any lapse in the giving and
receiving of information is, ipso facto, our lapse, references to "poor
historian" in our notes notwithstanding. The simple fact is that many patients
are inexcusably poor historians, taking little responsibility for their end
of the communication. Many outpatients cannot even state why they have come
into the medical encounter. They sit like a lump of marble before Michelangelo,
who can carve from it whatever he wishes. Even if a one-sentence chief complaint
can be uttered, the patient has often not considered what else the doctor might
need to know. Questions that involve timing -- when did it first began, how
long does each attack last, how frequently do they occur -- are hardest to dig
out, though critically important. A severe headache that began late night for
the first time ever establishes different priorities than a severe headache
occurring about once every two months over the past decade.
I struggle with timing questions largely because patients do not listen to
me! A typical exchange might be as follows, after the patient has been
given opportunity to state his complaint and a lull occurs when he has finished
his recitation: Dr. "When did you first notice the lump?" Pt. "It's
not painful, really, sort of, you know, I mean, maybe like a little
bit sore, but it's not a pain or anything, you know. I didn't notice
it because it hurt or anything, you know." Dr. "Thank you, ummm, I
believe I've got that much. Now, I need to know when you first noticed it."
Pt. "Oh. Well, ummm. Ummm. I don't know. Dr. "It would help me a lot
to know when you first noticed it. Try to think." Pt. "Well, ummm.
Ummm. I thought you could x-ray it or something. Well, anyhow, ahhh, ..... [triumphantly]
it was right after we got back from the beach." The doctor waits for the
obvious conclusion to this beginning, which is the information as to when the
patient went to the beach, that trip not having been on his personal calendar.
Since it is not forthcoming, he has to ask. "When did you go to
the beach?" Pt. "You mean this last time? We go to the beach a lot.
My brother has a house down there. He was the one who told me I ought to have
it checked, that it might be a cancer or something, and that sort of got to
me. I was like, you know, ummph [gestures with his hands]." Dr. "I
mean when you went to the beach and noticed the lump." Pt. "Oh. We
had to leave the dog with the vet since my sister wasn't here and had to drive
out of our way for that. ..... ..... ..... ..... I think it was about two summers
ago, maybe three."
And thus it goes, dragging the ore from the mine, then refining it for the
precious metal. Patients don't bring their medicines, preferring to think that
a doctor can identify a medicine prescribed on a visit out of state by the fact
that it is pink, or maybe sort of reddish, and the size of a button. Patients
don't know what organs were removed or rearranged beneath their surgical scars.
I once thought that surgeons didn't explain well. Perhaps not, but for some
people there is a decided lack of interest in retaining this kind of information.
Patients don't listen to doctor's questions. They don't rehearse what they want
to transmit. They don't prioritize their agendas, beginning with a skin hickey
question and ten minutes later mentioning that their fingers turned blue yesterday
and they almost passed out. Patients return to old agenda like salmon to their
home stream. A physician who has told them that nothing further can be done
for a matter is a physician whom patients will not believe. It's un-American.
One must do something, even it has proven to be worse than useless.
Patients are not even expected to tell the truth. Physicians have been sued
over acting on information given to them by patients who were lying, because
the physician did not discern the lie!
In the great lamentation that shrills and moans over the failures of American
medicine, physicians need to consider judiciously apprising our patients that,
if they really want to retain their God-given authority over their physical
health, they need to get a firm grip on their God-given respon sibility to participate
with their helper. A rule being gradually disseminated in my practice is that
patients must bring all medicines with them, no matter whether over-the-counter
or prescription, no matter who prescribed them or for what, to each visit. Being
comatose on arrival is excuse for not having the medicines, but not much else.
Repeated failure culminates in the visit being terminated if something critical
is not likely. Someday, some way, as another means of returning patient authority
to the patient I hope to tender the medical record into custody of the patient
and retain only a brief computerized extract. The patient could then write his
own symptoms and signs and the physician could refine from material already
partly dragged from the mine.
Physicians who tacitly accept all of the responsibility for efficiently obtaining
an accurate medical history do patients no favor. We should not routinely do
for another what that person can and should do for himself.
* Dr. Terrell is Assistant Professor of Family Medicine at McCleod Medical
Center, Florence, SC, and the editor of the Journal of Biblical Ethics in
Medicine.
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