Article
Care
Comment
5 min read

The healing touch in an era of personalised medicine

As data powers a revolution in personalised medicine, surgeon David Cranston asks if we are risk of dehumanising medicine?

David Cranston is emeritus Professor of Surgery at Oxford University. As well as publishing academically, he has has also authored books on John Radcliffe, and mentoring.

A doctor looks thoughtful will holding a stethoscope to their ears.
Photo by Nappy on Unsplash.

In 1877 Arthur Conan Doyle was sitting in one of Dr Joseph Bell’s outpatient clinics in Edinburgh as a medical student, when a lady came in with a child, carrying a small coat. Dr Bell asked her how the crossing of the Firth of Forth had been on the ferry that morning. Looking sightly askance she replied;  

 “Fine thank you sir.”  

 He then went on to ask what she had done with her younger child who came with her.  

Looking more astonished she said:   

“I left him with my aunt who lives in Edinburgh.   

Bell goes on to ask if she walked through the Botanic Gardens on the way to his clinic and if she still worked in the Linoleum factory and to both these questions she answered in the affirmative.  

Turning to the students he explained  

“I could tell from her accent that she came from across the Firth of Forth and the only way across is by the ferry. You noticed that she was carrying a coat which was obviously too small for the child she had with her, which suggested she had another younger child and had left him somewhere. The only place when you see the red mud that she has on her boots is in the Botanic Gardens  and the skin rash on her hands is typical of workers in the  Linoleum factory.   

It was this study of the diagnostic methods of Dr Joseph Bell led Conan Doyle to create the character of Sherlock Holmes.  

A hundred years later and I was young doctor. In 1977 there were no CT or MRI scanners. We were taught the importance of taking a detailed history and examination. Including the social history. We would recognise the RAF tie and the silver (silk producing) caterpillar badge on the lapel of a patient jacket.  We would ask him when he joined the caterpillar club and how many times he had had to bail out of his plane when he was shot down during the war – a life saved by a silk parachute. We would notice the North Devon accent in a lady and ask when she moved to Oxford.  

The patient’s history gave 70% of the diagnosis, examination another 20% and investigation the final 10%. Patients came with symptoms and the doctor made a presumptive diagnosis – often correct - which was confirmed by the investigations. Screening for disease in patients with no symptoms was in its infancy and diseases were diagnosed by talking to the patients and eliciting a clear history and doing a meticulous examination. No longer is that the case.     

At the close of my career, as a renal cancer surgeon, most people came in with a diagnosis already made on the basis of a CT scan, and often small kidney cancers were picked up incidentally with no symptoms. The time spent talking to patients was reduced. On one hand it means more patients can be seen but on the other the personal contact and empathy can be lost.  

Patients lying in in bed have sometimes been ignored. The consultant and the team standing around the foot of the patient’s bed discussing their cases amongst themselves. Or, once off the ward, speaking of the thyroid cancer in bed three or the colon cancer in bed two. Yet patients are people too with histories behind them and woe betide the medic, or indeed the government, who forgets that.  

With computer aided diagnosis, electronic patient records and more sophisticated investigation the patient can easily become even more remote. An object rather than a person.  

We speak today of more personalised medicine with every person having tailored treatment of the basis of whole genome sequencing and knowing each individual’s make up. But we need to be sure that this does not lead to less personalised medicine by forgetting the whole person, body mind and spirit.  

Post Covid, more consultations are done online or over the telephone -often with a doctor you do not know and have never met. Technology has tended to increase the distance between the doctor and patient. The mechanisation of scientific medicine is here to stay, but the patient may well feel that the doctor is more interested in her disease than in herself as a person. History taking and examination is less important in terms of diagnosis and remote medicine means that personal contact including examination and touch are removed.  

Touching has always been an important part of healing. Sir Peter Medawar, who won the Nobel prize for medicine sums it up well. He asks:  

‘What did doctors do with those many infections whose progress was rapid and whose outcome was usually lethal?   

He replies:  

'For one thing, they practised a little magic, dancing around the bedside, making smoke, chanting incomprehensibilities and touching the patient everywhere.? This touching was the real professional secret, never acknowledged as the central essential skill.'

Touch has been rated as the oldest and most effective act of healing.   

Touch can reduce pain, anxiety, and depression, and there are occasions when one can communicate far more through touch than in words, for there are times when no words are good enough or holy enough to minister to someone’s pain.   

Yet today touching any patient without clear permission can make people ill at ease and mistrustful and risk justified accusation. It is a tightrope many have to walk very carefully. In an age of whole-person care it is imperative that the right balance be struck. There’s an ancient story that illustrates the power of that human connection in the healing process. 

When a leper approached Jesus in desperation, Jesus did not simply offer a healing word from safe distance. he stretched out his hand and touched him. He felt deeply for lepers cut off from all human contact. He touched the untouchables.   

William Osler a Canadian physician who was one of the founding fathers of the Johns Hopkins Hospital in Baltimore, and ended up as Regius Professor of Medicine in Oxford,  said:  

“It is more important to know about the patient who has the disease than the disease that has the patient”.  

For all the advantages modern medicine has to offer, it is vital to find ways to retain that personal element of medicine. Patients are people too. 

Article
Assisted dying
Comment
Freedom of Belief
Politics
5 min read

Holding an opposing view is not 'imposing' belief on the assisted dying debate

Opposing interventions from believers on dishonesty grounds is a sinister development in public debate

Nick is an author and Senior Fellow at Theos,a think tank.

A graphic shows a gallery of people with religious symbols on their clothing.

“There are some who oppose this crucial reform,” Esther Rantzen wrote recently of MPs who dared to opposed Kim Leadbeater’s Terminally Ill Adults (End of Life private member’s bill. “Many of them have undeclared personal religious beliefs…  [do] they have the right to impose them on patients like me, who do not share them?” 

This is a peculiarly common argument for those who support the right to Assisted Dying, which is surprising as it would be hard to come up with a less coherent case against religion in public life. The idea that elected MPs engaged in parliamentary debate are “imposing” their will on other people is odd. The idea that MPs have undeclared personal religious beliefs is strange too. I think it’s fair to say that most people know that Shabana Mahmood is a Muslim or Tim Farron is a Christian, and for those that don’t know that but do have access to Google, it takes less than five seconds to find out the religious beliefs of an MP. 

Perhaps most tellingly, however, why is it that we should be alert to – read wary of – MPs religious beliefs? Do the non-religious not have beliefs of which we should be cognizant? If my MP is motivated by a philosophy of relentless, Peter Singer-like utilitarianism or vague, incoherent secular humanism I’d like to know. 

In truth, Rantzen’s intervention in this debate, like that of a number of others – Lord Falconer, Simon Jenkins, Humanists UK, etc. – is part of a recent and rather dispiriting attempt to de facto exclude religious contribution to public debates by accusing them of being dishonest. 

To be clear, secular voices have long tried to exclude religious ones, but the tactics change. Back in the New Atheist heyday of the early twenty first century, all you needed to do was splutter something about sky fairies or Bronze Age beliefs or mind viruses to close down any sort of religious intervention. If, as Richard Dawkins famously put it, faith was one of the world’s great evils, comparable to the smallpox virus only harder to eradicate, no sensible parliament could possibly want to heed what faith had to say. 

Even back then, however, there were subtler arguments against faith, which usually came in the form of semi-digested Rawslian political liberalism, and demanded the religious participation in public debate had to obey the strictures of “public reasoning”, using logic and language that “all reasonable people” will understand. 

There are quite a few holes in this particular away of thinking (who are “reasonable people” anyway?) but as a rule of thumb, it’s not a bad one to follow. It is quite right and proper, if only as a matter of pragmatism, to speak in terms that your opponents will get, just as it is right and proper, as a matter of courtesy, to be open about what ultimately motivates you. 

And so that is what religious figures – MPs, leaders, institutions – do. Having read through pretty much all their contributions to the assisted dying debate, in parliament and beyond, I can testify that not many people, on either side of the debate, quote scripture or invoke papal teaching as a way of persuading, let alone commanding, others. (As it happens, parliamentarians haven’t really done that since the 1650s, but that’s another story).  

Rather, they argue in terms of policy and principles. They talk about the risk of legislative slippage, of changing attitudes to the vulnerable, of the need for better palliative care, of existing pressures on the NHS, etc. This is quite right and proper. As James Cleverly remarked in the Common debate in November, “We are speaking about the specifics of this Bill: this is not a general debate or a theoretical discussion, but about the specifics of the Bill”. And so that is what they did. 

Does anyone seriously think it is a good idea to compel a believing Jew to stand up in parliament and declare her faith before she were allowed to speak? 

In effect, religious public figures, whether or not their beliefs are “declared”, do what they have (rightly) been asked to do by those who have appointed themselves as gatekeepers for our public debate. And so this has forced the usual suspects to pivot in their argument. No longer able to dismiss religious contributions for what they say (“don’t quote the Bible at me!”) they are now compelled to dismiss them for what they don’t say. Hence, the trope that has become popular among such campaigners – “you are not being honest about your real motivations”. 

A new report from the think tank Theos, entitled, How much have your religious views influenced your decision?”: religion and the assisted dying debate, unpacks the various objections that have been levelled at the religious contribution to the debate, and then systematically dismantles them.

Some of these objections are old school in the extreme.  

Religious belief is too intellectually inadequate or disfiguring for debates of this nature. 

Religion is insufficiently willing to adapt and compromise for politics.  

Faith is ill-fitted or even inadmissible in a secular polity or culture.  

But the report majors on the newer objection, so clearly displayed by Esther Rantzen, what we might call “dishonesty” objection, that religious contributors are fundamentally dishonest about their motivations and objectives. 

In truth, this is no stronger than the more tried and tested objections, and it displays a serious, possibly intentional, misunderstanding of what a religious argument actually is. To quote the political philosopher Jeremy Waldron, such secular campaigners “present it as a crude prescription from God, backed up with threat of hellfire, derived from general or particular revelation, and they contrast it with the elegant simplicity of a philosophical argument by Rawls (say) or Dworkin [and] with this image in mind, they think it obvious that religious argument should be excluded from public life.” 

Contemporary arguments against religion in public life are slightly more sophisticated than Waldron’s caricature here, but not much. The idea that religio should be “declared” as a competing interest, so as to stop religious participants in debate from being “dishonest” is every bit as sinister, against both the letter and the spirit of plural, liberal democracy. Does anyone seriously think it is a good idea to compel a believing Jew to stand up in parliament and declare her faith before she were allowed to speak?  

As the assisted dying debate returns to parliament for the final push, there will be much animated debate. That is quite right and proper. A democracy needs vigorous and honest argument. But part of that honesty involves opening the doors of debate to everyone, and not subtly trying to exclude those with whom you disagree on the spurious grounds that they are being dishonest.

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