Beyond Dishabituation: Dealing with Moral Distress in Medicine, Elusive Alignment
(Part 2 of 3)
In my last newsletter, I referenced a NYT editorial written by a neuroscientist and attorney making the case that people accommodate to change—even horrific change—by becoming become habituated to small, objectionable changes incrementally that eventually can sum up to a reprehensible personal and collective behavior. I also contrasted the profound divergence of the motives of corporate healthcare with the almost instinctual, deeply bound psyche of medicine that plays out where basic science and consciousness meet, a frontier like sea and shore. Let me summarize those again here to make clear the basis of my argument and why I recommend not using "healthcare" and "medicine" interchangeably.
The drivers of the modern healthcare industry are
Extract from medicine as much wealth with the least investment of resources possible,
Exploit the cultural values that make medicine an almost limitlessly deep pocket, and
Distribute the gains asymmetrically, favoring the architects of the industry.
Industrial healthcare is fundamentally transactional.
The millennia-old practice of medicine exists to help people live the richest, fullest, most integrated expression of ourselves possible. It is about quality of life, lineage, evolution, and capacity. It employs wisdom, observation, experience, and reason. Whatever we make or discover or refine or perform ultimately transmits at a human level, and frankly, that's what it's all about. Otherwise, it would just be biology or technology. Medicine is relational first. That's why there's the joke, "It's not about the money" when it seems that so much is exactly about money. Medicine recognizes that it's nearly impossible to cultivate integrity without having integrity. This is where the value of trust is expressed. We are answering to a different authority than the holy dollar. While that doesn't entitle us to become financially stupid, it views the making of money as necessary for sustenance, not an end in itself. It's about responsibility and making conscious choices and sacrifices.
While I love the idea of being a dishabituation agent, this basically means being awake and brave enough to say what most people are thinking but are often more focused on what might be lost by expressing it than the cost of not expressing it. Dishabituation is about fully registering such ideas and perceptions and then articulating them. I alluded in the last newsletter to some of the problems I see both with the rationale and the fall-out of the habituation explanation for participation in things that range from morally compromising to criminally wrong. My main argument against this theory is that while habituation helps economize our attention, it doesn't actually make awareness disappear. It shifts it and has other effects. In a state of habituation, we record and store what we are witnessing in different ways. Our main clue that the new "normal" isn't normal, that it's not consonant with our doctor OS, is that we don't feel good. There is typically some unpleasant residue. This is the territory of moral distress, and we doctors are often complicit in it by abandoning our own sensibilities and direct messages from our souls and calling that self-abnegation pragmatism. It's astonishing how we can be our own worst enemies sometimes and really brutal to the small voice inside us that desperately wants to be heard.
What is the fate of thoughts and sensations that are not held in focused awareness? As an undergraduate student in Santa Cruz, California with a dog, I was constantly exposed to poison oak and had an itchy, weepy patch of inflammation at some place or another on my body throughout the year. After some months, it ceased commanding my attention--I seemed to have accommodated to it, at least it seemed like I did until I spent a summer month where there was no poison oak, no urushiol, and my contact dermatitis resolved. Peace, utter peace arrived.
Until then, I did not realize what a toll the constant itching had been taking. Once the low-level aggravation was finally gone, I could rest. The same can happen with white noise or the hum of fluorescent lights: there's a sense of relief when they are finally turned off even if we have not been consciously attending to their aggravation. While the timing and content of memory--or learning-- vary, the main categories are implicit and explicit memory. It appears that fetal memories are stored in the later part of gestation as impressionistic right-brain memories that are retained before linkages have developed to the left brain where time sequencing occurs. These are implicit memories, the kind of memories that appear as the timeless present until and unless they are subsequently integrated into the left brain where they gain a timestamp which helps confer a sense of past and present. Could we also consider the in-utero epigenetic modifications that are a response to maternal stress and appear to influence the stress set point and recovery profile throughout life for the unborn child to represent another form of memory? What about repetitive trauma in childhood that detrimentally affects brain development and other behaviors, forming the basis of PTSD even though there is habituation to the abuse? Perhaps habituation normalizes but does not "make normal." This is why doctors are starting to talk about moral distress: it is that residue.
What about another kind of memory trick, the mental adjustment we make when we assume that because things are a certain way, they must either always have been that way or, conversely, are inevitable and therefore unchangeable? This borders on the complacency of habituation, but I think it's more of a thought problem. As biological scientists, we know that we and all things are constantly changing. Do we simply assume that the current formulation is the best because it's what's risen to dominance? In nature, when things become unbalanced and are unduly influenced or pressured by one environmental feature, there is inevitably a correction. How could we not imagine the same about Medicine and healthcare? Some people might even see healthcare as that kind of correction of Medicine, allowing that the pendulum has merely swung too far. Are these forms of mental resignation? Signs of exhaustion or frustration? Self-doubt? How can we not see that this outlook has exactly the same effect as all passengers rushing toward the listing side of a capsizing boat? Instead of providing equipoise and becoming the counterweight, the ballast, we rush in and accelerate the sinking of the ship.
What are other factors that play into watching things go awry? I think of fear. No one wants to be cut from the herd, and we've all seen it happen or had it happen to us. Two of my interns chastised me for taking responsibility for a decision I made that they were being criticized for. "Are you suicidal?" they asked, adding, "Your only job is to pile on and say, Yeah, what were you thinking? when the axe is falling." Perhaps we fear we're wrong, or we distrust what we are seeing. Another factor in medicine is a pervasive idea that we're supposed to suffer, that suffering is righteous and will help ensure we are forgiven for our inadequacies and treatment failures and that it will help us achieve transcendence. Finally, what about the mean-spirited, venal, shadow aspects of ourselves, the parts that feel wronged or cheated or secretly relish the fall or the mess, as if it confirms what we suspected all along? The inner parts that whisper, "I told you so."
So I don't completely disagree with the idea that habituation can contribute to our tolerance of horrible developments or make it easier for us to participate in them, but it's so incomplete, so sanitized and permissive, so blameless when attributed to automatic neurologic phenomena. If we buy this idea, we lose motivation and the necessity of getting down into the weeds, down into the murk of what we're participating in. By skirting the messiness, we also lose the chance to discover why and how we're complicit and where our embarrassing conflicts are, where we have strayed from our own intention and path. More than that, we give away our power. Again. And that is a damn shame.
Do you like stories? Most doctors do because that is, after all, what making a diagnosis is and how we heal: reworking chaos to find and restore order, harmony, and integration. Stories allow us to approach truths a bit obliquely in ways that let messages bypass our inner censors. Dreams can do the same, and I've posted a dream on the Metamorphosis Medicine website that I had in the course of preparing this little series of newsletters. I have also decided to offer a free hour of intelligent conversation to the first 5 doctors who sign up to talk about whatever you are wrangling with in your work or identity as a physician. I won't counsel you or tell you what to do; I will listen to hear your song and struggle and help the picture to emerge more clearly, the way photographic images used to in the darkroom developer bath. My usual charge is $250. Would you walk past $250 on the sidewalk? It's confidential, patient, curious, and honest. Fair warning that I am not the least bit interested in mastering the corporate playbook or endorsing sacrificing the call of your higher self for the sake of fitting into a troubled system. I am, on the other hand, deeply interested in asserting the authentic self and realizing the potential of heartfelt doctoring and of being clever as a fox. If you'd like to dive deeper into exploring core (dare I say archetypal?) themes in the doctor OS or matters like missed or incomplete initiation, schedule a chat with me here (also without charge) about small group events that will take these on.
In the third part (of 3) in this short series of newsletters about dishabituation, the emperor's new clothes, and moral distress, I will explain why I think it's essential to distinguish Medicine from healthcare, and I'm pretty sure that what I have to say is not what you're thinking.
Until then, keep on searching for your light and listening to what your inner doctor has to say about the things you encounter in your work every day.
