This is my May EMN column.  It’s also at the EMN website:

Hopelessness in the ER

How many times have you had the ‘smoking’ talk with your patients?  How many times have you had the ‘drinking’ talk?  The ‘methamphetamine’ talk?  The ‘STD’ talk?  How many times have you tried to explain, until blue in the face, that a particular activity was unhealthy and counter-productive to your patient’s well-being?  It’s staggering, actually.  You might be able to bill for ‘smoking cessation counseling,’ but it rarely makes an impact.  A few shifts later, you’ll often see them again.

Modern humans, informed and savvy, with 24-hour access to the Internet, television and print media, continue to do the very things that are the worst for them.  And we, as physicians, especially emergency physicians, make a profession of attempting to rescue them from the results of their habits.

But what’s going on here?  Why do they continue to do it?  Why do they shoot up?  Why does that young man with asthma keep smoking?  Why does that young girl keep returning to her abusive boyfriend?

Why do they have multiple sexual partners, knowing as they do the risks of HIV?  Why do they ride motorcycles without helmets?  Why do they divorce, when science has clearly documented the negative effects of divorce, on both the adults and children of divorce?

Why do our patients cut, brand and pierce?  Why do they attempt suicide, and often succeed?  Does science offer any clues?  Does science tell us anything about meaning or purpose?

This is an unprecedented time in history, in which so much of what medicine seeks to heal is the direct result of the bad choices of the patients who come to us in the throes of consequences.

And yet, our media pundits and intellectuals, heck, even our scientists, love reminding us that we are ready to usher in a new era based on research and technology, that will liberate us from what author John Brockman, in What is your dangerous idea?, called ‘the anesthesiology of wisdom.’  Using biology and genetics, electronics and computers, chemistry and every other discipline, we’ll answer the fundamental questions of life and avoid the difficulties.  Nirvana without all that pesky meditating.

But I wonder, is science the answer to the question?  It’s one thing to suggest the power of science to explain physical phenomena.  It’s one thing to use science to answer questions unrelated to the mysteries of human suffering, the depth of the human heart.  But in medicine, we don’t have that luxury.  Humans are our business.  How does science explain human self-destruction?

Though I’m no expert in evolutionary theory, self-destruction seems to run rather counter to the drive to reproduce and survive.  One might make the argument, from a species standpoint, that self-destruction is our individual instinct to clear the way for other members of the species.  But that sort of ‘group-focused altruism’ doesn’t really fit a theory based largely on individual success.  Furthermore, animals might be separated from the herd or preyed upon when weak or sick; or the weak might wander off.  But they don’t typically find bad habits that make them unfit.  It seems science may leave us scratching our medical heads on this one, despite our dedication to evidence-based medicine.

Maybe the terms are wrong.  Maybe self-destruction isn’t the right term.  Perhaps self-loathing is the thing that leads individuals to abuse their bodies.  Could that be the problem?  Is it the fault of society?  Is it the failure of government?  Is it the failure of medicine?  Is it the fault of drug dealers or distillers, tobacco farmers or movie makers?  What’s going on?

How about we simply avoid the question altogether?  Who are we to judge, after all?  We might easily say ‘whatever.’  We might say ‘it’s not our business to judge them, just to treat them.’  Or we might just call up that magical word ‘tolerance’ to suggest that we accept their differences.  But tolerance, in some very real ways, is another way to suggest ‘indifference,’ or ‘lack of understanding.’

Sometimes our attempts to understand turn suddenly into our own loathing of others.  ‘Fine, let them die.  I’m sick of dealing with it.  I wish they would just kill themselves and get it over with!’

We might cynically justify our anger from the perspective of environmental or economic issues. Less people?  Fine, less Carbon emissions.  Less patients?   Fine, easier to fund health-care.  But that doesn’t work either.  We still treat all of our self-destructive patients, and they seldom actually kill themselves, or even die (right away).  Their behaviors may take years to cause their demise.  And even a utilitarian resignation doesn’t help answer the question of ‘why.’  Likewise, resignation doesn’t make us better physicians, but worse.  We’re supposed to treat the patient and seek the answers to the diseases.  It’s just that this disease of self-immolation, so prevalent, is troublesome to answer.  It make us look into the deep, dark hole of human misery.

So, I’ll take a shot.  No academic, no researcher, I’ll just use my years of watching humans, and asking hard questions myself, to offer an answer.  The chief problem I see is that people have no hope.  What happens when we have no hope?  What happens when people believe there is nothing higher in life to live for, to reach for?  What happens when humans become nihilistic, and see no greater meaning in their lives?

What happens is the emergency department, where they come with broken hearts and maligned bodies, seeking physical answers to non-physical questions.  The modern emergency department is a catalog of the failures of man to cope with humanity’s deeper questions.

They don’t come back over and over because we fail.  They come back because they have nothing else to do, and because they idea of their own worth is so distant that any and all self-loathing, self-destruction, self-abuse is simply…something to do, with no ultimate meaning, either good or bad.  But they still value themselves just enough to seek our assistance when the symptoms get bad enough.

That’s not a politically correct assessment.  But it’s true.  Humans are told, in schools and colleges, in movies and music, in books and magazines that the old forms of meaning they relied on are no longer valid.  That earth is the end, that morality is quaint but pointless, that ethics are relative and heroes are failures.  They are told that faith is irrational.  And they do the math.  There is no hope.

When there is no hope, why wouldn’t we abuse our bodies for brief pleasure?  When there is no hope, drugs are as good as being drug free, infidelity is the same as fidelity, drunk the same as sober, risk the same as safety, death the same as health.

So the next time you ask yourself ‘why is he back again?’ ask yourself if he has any hope.  And if you do that, without saying ‘whatever,’ without wishing him dead, without anger, you’ll take one step closer to being a physician who sees into the heart of humanity.

And maybe, knowing the disease, you can help suggest a cure.

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