When EPs hit the wall, they must each find a motivation to care, endure and have compassion. EPM invited Drs. Greg Henry and Terry Mulligan – an associate professor at the University of Maryland – to face off on the meaning of life, survival of the fittest, and the role of faith in medicine.
[Because the conversation veers into the realm of quantum theory, we invited Jason Bryslawskyj (JB), physicist at the Brookhaven Particle Collider and a student of German philosophy, to comment in the margin]
EPM: Greg, in your July column titled “Don’t Touch My Telos” you said the following: “Of the four things needed every day in the emergency department, only the first, knowledge and technical skill is evidence-based. Everything else is from the only place which we cannot measure, the soul; which is no higher than the sky is high, no wider than the heart is wide.” Greg, what did you mean by that?
GREG HENRY: We are the only animal species that we know that has ever had the ability to contemplate both past, present and future. We plan on things which may not happen for 50 or 100 years. We plant trees we know we will never see in their maturity. The human being looks outside of themselves. Now, what causes that is a question of great debate. I am a firm believer that there’s a level of interaction – whether you call that the ten-dimensional universe or string theory – there is a force which humans have or have discovered that is beyond the four-dimensions in which we usually function.
EPM: In the article, you specifically called that “the soul”.
GREG HENRY: Well, I could call it a god. I could call it a soul. I can call it a force which we do not understand. You’ve got to remember that most of what we talk about these days didn’t exist a hundred years ago. There was a bill in Congress in the late 1890s to close the patent office because they thought everything useful had been invented. We used to talk about atoms, and now we’re talking about quarks and gluons. I think there is almost no end to our discovering what’s in the universe. And to think that some of that is not transmitted at a psychological or emotional or a spiritual level I think is a huge mistake. We make decisions about how we treat patients – our kindness, our decency – based on something much more than the fact that we’re going to be punished if we make a mistake. My dog avoids certain behaviors not because it is right, but because he doesn’t want to be punished. And I think that that is the difference in humans and the other species of which we have knowledge.
TERRY MULLIGAN: I agree there’s definitely an otherness that humans have that other animals don’t have. Though there’s argument whether some animals have it. I think it comes down to the higher aspects of consciousness or our ability to have abstract thought. There are some experiments that suggest that chimpanzees and dolphins may have some aspects of these characteristics, but we have it to a fine, fine degree. Where I disagree with you is in your suggestion that we have to reach outside what’s explainable by science. Certainly things are not explained yet. But I think the scientific process, although it’s very far from being able to describe this otherness that you refer to, shows that there is a gettable answer and the best way to get to the answer is through the scientific process.
There are a hundred examples of abstract thinking that we access that other animals don’t, which we don’t have a good explanation for yet. But we have more explanation for them now than we did even ten or 20 years ago. It’s been estimated the amount of neuroscience, neuroimaging, neuropsychology has been doubling on a five to ten-year basis. In other words, we’ve learned more in the last ten years than we knew in the previous hundred. So, we’re having a doubling of data and knowledge and understanding in these areas every five, ten, 15 years. And while that might still only give us the first one-percent of real understanding, it’s a huge amount compared to where we came from.
EPM: Greg, you talk a lot about compassion in your column. Is pure science enough to inform the physician’s practice when compassion is called for?
GREG HENRY: I’m an Aristotelean. I believe that there needs to be a final cause. After all, we know great science. The Germans who developed the gas chambers for Auschwitz were very good engineers and scientists. They just had the wrong telos – the final cause – as Aristotle would say, in mind. I think that science is neither moral nor immoral. It is amoral. Which means there needs to be something that guides us. We all know doctors who are perfectly good scientists and yet they don’t know how to communicate with patients. As science moves ahead what we are doing is piling up more and more data, but that does not mean we’re supplying meaning. Now, does meaning come from each individual person? Maybe. But if you look back at the greater thinkers, they believed that there was a polis, that people come together to function in very complex ways for the betterment of each other. And I think that we’re no farther toward deciding what that is today than we were 5,000 years ago.
TERRY MULLIGAN: I disagree with the suggestion that we haven’t made great headway in explaining some of these things, like the search for meaning. Why are we social-seeking animals? Why do we have ethics and altruism? In a lot of experiments in the last 50 years, we’ve been able to describe these with real scientific validity, through evolutionary psychology. For instance, why are we social animals? Evolutionary psychology suggests that given our evolutionary accolades – our hands and tool manipulation and big brains – we could do more together using intellect than we could with hair and teeth and claws and strong muscles.
So we have a real need to socialize, unlike a lot of other animals, because the social tendency gives us tremendous evolutionary advantage. So it’s not a coincidence that people come into the ED searching for a social connection. There’s a scientific explanation for it. We don’t have to resort to the numinous to explain it.
GREG HENRY: Well, I’m not sure that that’s the case. By the way, we’ve been through multiple versions in our quest for meaning. If you’re a Big Bang theory guy, it presupposes a creator. After all, what happened a nanosecond before the Big Bang? Who was there? What did it mean?
The physicists that I deal with say, “Oh, you can’t ask that question.” What do you mean you can’t ask that question? “Because there was no time, there was no space, there was no anything.” I say, “Well, how can you have nothing? We don’t know of anything that comes from nothing.”
Regarding your point about evolving as social animals, why would that make anybody or any group of people not lie, cheat or steal? After all, if you can get away with it, why not do it? I mean, is there some other force here? If these people who believe in the Big Bang theory – and I have a lot of good things to say about Big Bang thoughts and the solar furnace in which we produced the first elements – we still have to get down to the bigger questions. In the ten-dimensional universe, what are these other six dimensions that we’re dealing with and can we call that “God?” Just because we don’t like this name given to a guy with a long white beard and people playing harps doesn’t mean there isn’t a force at play, a force which has presented itself differently to different peoples. I don’t think it’s as simple as: “It’s evolutionarily better that we’re nice to people.” You know what? That doesn’t explain the World Wars.
TERRY MULLIGAN: Sure it does! The idea of in-group/out-group selection explains a lot of this animosity. The theory is that long ago we were designed by evolution on the Savanna, having been homo sapiens for anywhere between a hundred and 200,000 years. We were more or less hunter-gatherers in small bands of 50 to a hundred people, and our advantages over the other animals came from our thinking capacity. So, as the theory goes, if you were born with a thinking tendency of being nice to everyone you meet, that was an advantageous instinct. Because in your small band of 50 to 150 people, most of the people who you met were either related to you, or were people you were likely to run into again and so this was a tit-for-tat, or a group altruism. Small groups pay a lot of attention to gossip and reputation. In these old times, if you encountered somebody who was not in your in-group, they were likely to be a competing band of humans from nearby. It was correct for you to treat them as your enemy because they were likely trying to take your mates or take your food or your space. So, if you expand that over the course of hundreds of thousands of years . . .
GREG HENRY: Wait a minute. So, obviously you don’t know my family. Because they’re likely to take your space, anything you’ve got, shake you down for money. We have both in-laws and outlaws in my family. I think it’s more complex.
TERRY MULLIGAN: There could be a lot of crossover with this in-group/out-group theory. If you expand it, it gets turned into tribalism and then that gets turned into nationalism and that gets expanded into racism and sexism. This is just an example of what evolutionary psychology is looking at: What are the psychological tendencies that we have and can they be explained using evolution, or gene competition? The anthropic principle says: we have that tendency now because it must have been advantageous.
GREG HENRY: That’s a self-fulfilling argument, Terry. It must have been good because that’s why it’s been kept in the gene pool.
TERRY MULLIGAN: It’s not that it must have been good, but it must have given an evolutionary or survival advantage.
GREG HENRY: Well, the competitive advantage question can always be used to say: ‘Well, that’s why it’s there. That’s why we evolved toward it.’ I don’t think that answers all the other questions. Again, the “something coming from nothing” still has to be explained.
TERRY MULLIGAN: There’s a physicist, Lawrence Krauss, who is of a school that is now showing with quantum theory, something can come from nothing.
And without getting too detailed, he says that we don’t have an instinctive understanding of physics at large, large, large scales or the teeny tiny scales, like on atomic or subatomic levels. Krauss writes that at the subatomic level, the concept of cause and effect is not the same as it is on our scale.
GREG HENRY: I don’t disagree that that idea has been put forward. But while we can agree what the speed of light is, and we can agree that Newton was right in his formulas on gravitation, we cannot agree that string theory has a basis other than what man has created in his head. That’s no different than talking about a God being created in one’s head.
TERRY MULLIGAN: The progression of science has taken so much away from what used to be described by religious thinking – like what the sun is, where babies come from and what happens after you die. Religion was our first attempt at philosophy, our first attempt at explaining human interactions, our first attempt at psychology, our first attempt at science. And like most first attempts, it was simple and I think proved wrong. And our thinking has evolved since then. Every time science explains something and then by that explanation suggests new questions, the theologians say, “Oh, that new missing space that your answer just suggested – it turns out that God is in that gap.”
GREG HENRY: It sounds like the scientists use the gap of evolution and the strict theologians use the God of the Gap. But you would agree that there’s an awful lot of stuff we don’t know or understand and things you watch every day of which we have no simple explanation.
TERRY MULLIGAN: I agree that there’s a lot that we don’t understand about medicine and science. There’s a lot that we don’t understand about human psychology and our needs and motivations. But we’re getting better at explaining a lot of these things. We’re applying evolutionary theory to things like psychology and ethics and motivation. And it actually is for the first time providing some really good answers. But there’s no doubt there’s more that we don’t know than we do. But just because we don’t yet understand something on an evidence basis, it doesn’t necessarily mean that it’s wrong. It just means we don’t have good data for it.
GREG HENRY: Speaking of data, we talk all the time about the number needed to treat, the number needed to produce various results. But the truth is each one of us practices at that moment with one patient: the N is one. And to think that we can apply the same kind of treatment modes to everyone, particularly where they all have different inner cores and thought processes and desires would be a mistake. You can always look at the rulebook to decide how a game ought to be played. The day you play it with the team opposite you, knowing their players and what’s happening, that’s what we call the application of a scientific principle to a human problem. Wouldn’t you agree?
TERRY MULLIGAN: I agree. It doesn’t take long into the history and physical of any particular patient to find out that this person is unique in the world. It’s not a lip service to say everybody’s different. It really is true that everybody is different. You know, one person’s COPD could be completely different than somebody else’s COPD. And I think that part of the art of medicine is to realize that there’s an overall framework or structure when we’re dealing with this person, but there is actually nowhere near the evidence available that could be applied to this unique individual.
GREG HENRY: And that’s what we call medical judgment, isn’t it?
TERRY MULLIGAN: We’re using a lot of our higher capacities to access that stuff. We’re doing parallel processing, etc…
EPM: Terry, you touched on motivation and evolutionary psychology. How do you as a physician access that kind of necessary compassion when maybe the in-group/out-group philosophy isn’t there? Let’s say someone truly feels like they are outside of your group and it is going against the grain for you to show the kind of care and compassion that you might need to as a physician.
TERRY MULLIGAN: You know how ER shifts sometimes have an accidental theme? Well, yesterday was my irrationality day. I think I saw 19 or 20 patients yesterday but about six of them were there for no rational reason at all. These are people who were extremely involved in drugs and violence. It just didn’t seem to make sense to me that a person could be in this situation. But as a physician we see this all the time. I had a psychiatrist teacher who taught us during medical school who said: You have to be able to recognize and accept irrational behavior and irrationality because most of the time that’s what’s happening. And he was talking about psychiatric patients but I think that’s really true about human behavior. There is a reason behind it but it’s not a science.
GREG HENRY: Terry, he wasn’t just talking about the patients. He was talking about us. Understand that most things we do are irrational. And if you had to defend everything on a rational basis, maybe hemlocks and razor blades wouldn’t look so bad. I think it’s very tough to treat humans as semi-computers who are so programmed to do it right. That’s what Mr. Spock was all about on Star Trek. He was logical. None of the rest of us are logical.
TERRY MULLIGAN: I agree with that. We have to dig deep so much every day, and there’s only so much psychic and psychology energy that you have and at some point it becomes taxing – we develop a sort of ‘compassion fatigue’. I think part of the frustration comes from expecting things to be different than they are. When I was a youngster in medicine, my expectation was that they were going to take our advice, take the medicine, go to the follow-up and straighten themselves up. But obviously a lot of people don’t. But in my best moments what I draw on is this – this is the human condition. The human condition is irrational. And the irrational is more deserving of compassion than the rational. We do things that are against our best interest. It turns out a lot of this behavior itself can be explained by the competing genetic tendencies that we contain in our own bodies. You know, it’s not the individual that’s being selected for or against. It’s the individual genes inside that individual. And so we have often conflicting drives inside our own biology and hence the irrationality.
GREG HENRY: Darwin felt that smallpox, if we let it alone, would clean out the less viable and the less stable in the population. It would do natural selection of the herd. You realize if you are into a Darwinian mode of how man progresses – toward nothing, by the way – then you must believe that medicine itself is anti-evolutionary.
TERRY MULLIGAN: Well, no. Evolution also produces altruism. It also produces deeper insight. Meaning is something that human minds create and consciousness creates. There is no meaning that exists without a consciousness to create it.
GREG HENRY: Well, it has to interact with something, correct. Are you saying we should no longer teach Kant and Camus and Aristotle, but only focus on neuro science on the way to medical school?
TERRY MULLIGAN: Well, you can teach all of it. I don’t think they teach deep philosophy in any medical schools anymore, except for maybe the opening quotation on somebody’s PowerPoint. But I think philosophy is evolving. It’s been proposed that the two most evidence-supported theories in science are: the theory of evolution and quantum theory. Even though nobody can have a good mental picture of it, quantum theory is so unbelievably supported by evidence. I mean, just look at the Higgs boson that was discovered. It was predicted over 50 years ago to exist if certain quantum physics theories were true.
GREG HENRY: Higgs boson was projected on the mathematical base of: Where’s the mass? But remember, the code name for the Higgs boson was: the God particle.
TERRY MULLIGAN: Look, I believe that there is a mysterious part of our psychology that is being overlooked in medicine. But I don’t think we have to reach into the supernatural in order to explain it. While survival of the fittest is true, evolution has also produced consciousness. And it’s produced our ability to look past survival of the fittest. We’re not going to be able to supersede science or physics. But we can supersede evolution. And we don’t have to do away with altruism and compassion just because things are scientific and you don’t have to resort to the supernatural to describe them.
GREG HENRY: It’s all in how you view it. Montaigne said: ‘Ignorance is the softest pillow on which a man can rest his head.’ And I think that sometimes we accept as science things which are not proven. And there’s just as much B.S. in quantum theory and in string theory as there is in the conventional religious doctrines which have been taught. There are forces there that we yet do not understand. Can they all be reduced to an equation? Well, I don’t think I will live to see it in my lifetime.
TERRY MULLIGAN: I don’t think it’s possible to reduce these things to equations. In emergency medicine we see really complicated etiologies. If you ask: Why is this person here? Well, it turns out that it’s their whole life really that brought them there.
GREG HENRY: What you’re asking is the Aristotelean analysis which looks at the material cause, the formal cause, the efficient cause, the final cause, that finally brought you here. Aristotle wasn’t all wrong.
TERRY MULLIGAN: When I was going through college, I visited Auschwitz and after that I read Victor Frankl’s Man’s Search for Meaning. He was a camp survivor and he said that among the other drives we have – you know, the drive for food and water and shelter and sex and self-preservation – we also have the search for meaning and that we’re driven by meaning. And I think what meaning is is a human tendency to make sense out of the data that we put together. We construct stories out of what happens to us and then we imbue those stories with meaning. You ask, “where does a physician’s compassion come from?” There’s a quote from Victor Frankl that I used to have on my refrigerator that said: “Between stimulus and response there is a space and in that space is our power to choose our response. In our response lies our growth and our freedom.” So when we have our evolutionary tendencies to either decide in-group versus out-group, decide whether or not to show compassion, we can reach to a higher ground, a higher level and recognize in this patient or in our interactions with them that there is so much that we don’t know, there’s so much that we don’t have solutions to. And sometimes we should just retreat back to what we do know and just provide care, provide care for the patient.