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Biblical Reflections on Modern Medicine

Vol. 10, No. 2 (56) 

Contents:



John Sarno, M.D.: Healing Back Pain: The Mind-Body Connection

or

Knowledge Is Mobility

I first heard of John Sarno, M.D., on "20/20." It seems that an employee of Rosie O'Donnell had been almost totally incapacitated by back and leg pain for several years. She even had a special scooter to carry her around, since she could not walk without severe pain. She had been to numerous physicians and tried virtually "everything" without success.

In desperation, she appeared on Rosie's show to see if there were something or someone that she had not tried. As a result of that show, she went to see Dr. Sarno in Clinical Rehabilitation Medicine at the New York University School of Medicine. He examined her, diagnosed "Tension Myositis Syndrome" (TMS), talked to her briefly, and had her watch a few hours of himself describing the relationship of the mind and the body, especially the back. With no further treatment, she again appeared on Rosie's show, dancing a jig and virtually pain free. No drugs, no surgery, no physical therapy, no exercises--just "lectures." (His latest book is Healing Back Pain: The Mind-Body Connection, Warner Books, $13.99, 193 pages).

Dr. Sarno's theory is that extreme emotions trigger tightness in muscles, particularly those of the neck, back, and legs. This tightness (TMS) results in decreased oxygen flow to these muscles, causing pain. The patient becomes more careful, decreasing activity, which further decrease blood flow and increases the pain in a vicious cycle. When patients with such pain go to Dr. Sarno, he makes a thorough examination, including appropriate tests, to confirm that there is not another serious problem. 

Three things are especially fascinating. One is that findings may include a herniated disk, "pinched" nerve, osteoarthritis ("old age" arthritis), scoliosis (curvature of the spine), spondylolisthesis (slippage of one vertebra over another), spinal stenosis, and other disorders of the back commonly blamed for low back and leg pain. He believes that these findings are coincidental and rarely a cause of the pain.

Early in his career, he noted that patients' symptoms did not fit their physical findings. For example, the pain would extend beyond the area of innervation of the pinched nerve, sometimes even affecting the opposite leg -- which should not to be affected at all. Then, he developed his theory about decreased oxygenation of the muscles.

The second fascinating thing is his therapy. It is simply to have the patients view videos in which he discusses his theories. The cure or amelioration of symptoms happens when they accept his theory as an explanation of their problems. His success is phenomenal. In a series of 109 patients with herniated disks, 96 (88 percent) were "free of pain, or nearly free of pain, (with) unrestricted physical activity"; 11 (10 percent) "improved, (had) some pain, some restricted activity"; and 2 (2 percent) unchanged. "The two patients who did not improve were found to have severe, persistent psychological problems and continue in psychotherapy to this day." Other statistics that he gives are just as impressive. 

Astute readers and knowledgeable physicians will recall that we have dealt with large Numbers Needed to Treat (NNT) on these pages. For example, from one study on lipid-lowering drugs, 43 patients had to be treated for one to benefit. Here Dr. Sarno's ratio is almost one to one!

Some Caveats

"Aha!," you think, "Dr. Payne will now show this charlatan for what he is." Not at all! I have only minor criticism of Dr. Sarno's approach. First, he is not a Christian, as far as can be identified from his writings. Because of his unbelief, he theorizes about the "unconscious" and emotions in ways that are not Biblical.

Further, he may go too far in downplaying functional care of the back, such as proper lifting techniques, soft (bad) vs. hard (good) mattresses, and downplaying weak abdominal and back muscles as a cause of back pain. However, he may be totally correct about these admonitions, as he certainly has as much or more evidence on his side, as anyone else has on the other side.

In addition, he more than compensates for this limitation with his advice for people with back pain not to limit their activities, as they are able to function without pain. Many patients, after instructions from their physicians, have lived in fear that the slightest miscue might put them in a wheel chair or severe pain for the rest of their lives. Dr. Sarno frees his patients, even encourages them, to be as active as possible. 

I have some personal experience with back pain. Four years ago, I was diagnosed with a bulging disk and pinched nerve. Fortunately, I received good advice from my orthopedic physician who did not restrict my activity. Also, I noted that he wrote "Lumbar Syndrome" on his billing sheet, not a bulging disk or pinched nerve. 

This diagnosis was curious to me until I read Dr. Sarno's book. My physician had either been influenced by Dr. Sarno or by similar thinking about low back pain. I was in severe pain for eight weeks, but continued to run as far as 5 miles, walk 18 holes of golf, and other exercises. Today, I have few days without some back pain, but it has been no more than an annoyance since then.

Dr. Sarno has extended his TMS theory to areas outside the back, such as tennis elbow (tendonitis), bursitis, temporomandibular joint (TMJ) pain, sprains and strains, plantar fasciitis (pain in the ligaments and tendons of the underside of the foot), etc. I worry that many of these are indeed caused by overuse, wear and tear, or injury, but he surely has sufficient evidence to consider emotional causes as contributors or causes of chronic pain.

Dr. Sarno even extends a similar application of emotional states to heart disease, infections, allergies, cancer, headache, gastrointestinal problems, etc. We have to tread more carefully here, but certainly there is plenty of evidence that emotions play a role in many of these problems.

Anger

The third fascinating thing about Dr. Sarno's approach is his discovery of the role of anger. While he has had his approach to back pain for several decades, more recently he has been pursuing the role of anger in back and other kinds of chronic pain. In fact, the role of anger does not appear in his first book.

"The more I work with TMS the more impressed I am with the role of anger," says Dr. Sarno (p. 43), especially from "family relationships." Sometimes, anger occurs in people who are carrying out their responsibilities but resent the burden in their lives: parents caring for newborn babies or grown children caring for their parents.

Now, the role of anger is Biblical and virtually ignored by the medical profession. I am attuned to the role of emotions in disease and disability. Family physicians are taught to be. I have asked about conflicts in patients' lives, usually one of the Big Three relationships (spouse, child-parent or parent-child, and job) or the Big Three emotions: worry, sadness, and anger. I have asked in particular about causes of sadness, despair, and hurt. I have asked about anxiety, worry, and fear. However, I have never asked a patient what he or she is angry about!

Curious! Surely, anger is the most powerful emotion--one that can kill, if unchecked. Yet, physicians rarely are taught, and therefore rarely, explore situations of anger in their patients. What a severe oversight--one that Dr. Sarno brings into focus. 

And, that focus is surely Biblical. Jesus warns about anger in the Sermon on the Mount (Matthew 5:21-26). But, there is a more basic anger, against God (Romans 8:7). The "peace" of the Christian is primarily the resolution of this anger (Romans 5:1). But, we are also angry with each other (Ephesians 2:11-16) and with the world (James 4:4). 

I hope to pursue the role of anger in appropriate problems with which my patients' present. All of us ought to pursue the role of anger in our own states of health, as well as conflicts in our own daily lives. I suspect that it is more common than we generally acknowledge.

Patient Non-acceptance

"The reality is that only a small proportion of the back pain population would be open to the diagnosis" (of the mind-body connection, p. 88). I have had the same experience with diagnosing spiritual problems related to or causing physical problems. Most patients, including nominal and committed Christians, want a pill or treatment, not a change in their thinking and behavior.

Dr. Sarno is a thinker, and therefore a pioneer. He has been able to think beyond the orthodoxy of modern medicine when his observations and conclusions were incompatible with the evidence in his patients. Rare is the physician who does so. He is not 100 percent correct, but were other physicians as discerning, modern medicine would explode in its ability to help and heal patients. I highly recommend his book with the few small caveats named above (along with a few others).


Religious Science: Distortion and Misrepresentation. Two Letters.

There is a growing movement about "health" that borrows from Christianity, yet fails to credit its truth, and worse, pedals that information as free-standing fact. There are hundreds of studies that have researched a relationship between "religious" practices and health. The large majority of these have involved Protestant or Roman Catholic beliefs and practices. However, these highly specific beliefs in the "scientific" process become a vague spirituality. 

The February issue of the Journal of Family Practice is a recent promoter of this paradigm. (See first letter following in response.) In an editorial entitled, "Inclusive Spirituality," Drs. Thomason and Brody write:

"The neglect of spiritually in medicine is based partly on a mistaken notion that spirituality is synonymous with religion....

"Further research is certainly needed to develop and test the validity of scales that measure spirituality independently of religiosity or religious practice. Such instruments need to assess spiritual needs in patients in language and concepts that are inclusive of the spiritual lives of nonreligious persons, as well as those for whom religious faith is at the core of their spirituality."1 (Ed's emphasis)

Perhaps, such statements show the (un)disciplined rigor and thinking of modern scientific medical research. The statement underlined above is an oxymoron, a non sequitur, and nonsense. One cannot be "spiritual" by any common or traditional definition without that spirituality having some content. Questions and wonderings about death, the afterlife, ultimate meaning of one's life, and conduct in this life are either associated with specific religious content or they are the isolated mental meanderings of an individual who believes that only he (or she) knows ultimate truth.

Certainly, one may pursue additional answers beyond oneself, but this pursuit is really quite limited: to others' opinions on spirituality as individuals or organized groups. Organized groups are religious groups because they have to have a core around which to organize. 

Interestingly, few people claim to be "independent thinkers" (another oxymoron that cannot be dealt with now). In one study cited here, only 5.1 and 7.3 percent of respondents listed no religious denomination.2

In the United States, the overwhelming "spirituality" is Christianity. Yet, "scientists" want to find some vague notions of something to avoid this specificity. As Christians, we know this motivation: they are enemies of God and would deny the reality of His Creation (Romans 1). I have challenged them with the letter below. Likely, they will not even understand what I am saying, but they need to be challenged in their own forum (if they publish the letter or one similar). 

Then, there are professing Christians who are so anxious to be "scientific" and "prove" that Christianity is healthy that they so blur its distinctions that it becomes just another "religion." (See 2nd letter following.) The second letter is one that I wrote concerning a conference on "spirituality" and health that was primarily promoted by professing Christians.

Of this same ilk are Christians who try to persuade others about the truth of Christianity through science. One most recent and persistent example is that "prayer" influences medical outcomes for the better. Well, I have cited one such prayer-promoter whose beliefs are devoid of any Christian content at all (Reflections, September 1997, p. 5).

Also, of this same ilk are modern churches who profess "no creed but Christ." That is, they oppose definitive statements (creeds, catechisms, confessions, and church doctrine) about what they believe. They "believe the Bible." On the one hand, that is the most primary belief for any Christian. The Bible is fully and completely true. But, there is a saying, "One can prove anything from the Bible." While that statement is not exactly true, it conveys that some specificity and understanding about the Bible is necessary; i.e., creeds, catechisms, confessions, and church doctrine.

In a real sense, modern Christians have allowed the vacuous thinking in the editorial cited above. They have so avoided specificity of doctrine and worshiped at the altar of science (particularly "scientific evidence" of evolution) that they indeed appear to have no consistent beliefs.

However, there is an orthodox Christianity, both Protestant and Roman Catholic (even if the two are ultimately incompatible). More specifically, there is an uncompromising core without which Christianity is not the Gospel and Biblical truth. The battle most needs to be fought within churches and in the "public square." A few of us fight it in the realm of medical (pseudo) science.

Letter to the Journal of Family Practice

February 26, 1999

Paul A. Nutting, M.D., M.S.P.H., Editor
The Journal of Family Practice
1650 Pierce St.
Denver, CO 80214

Dear Dr. Nutting:

"Science" has a way of making the sacred into the mundane. Sometimes, it is in danger of distorting the truth. Drs. Thomason and Brody discuss the differences between "religiosity" and "spirituality," as though they are making significant excursions into new territory.1 Drs. Daaleman et al. and Ellis et al. have scientific paradigms for research into family physicians' "attitudes," "beliefs," and "practices.2,3 Most other researchers relative to "religion" have done the same.

However, there is a specificity to "religion" that is entirely ignored in these endeavors and discussions: Christianity. In Daalemans's study, 80.7 percent of family physicians and 88.5 percent of the general population were specifically Christian: Protestant or Catholic (more accurately Roman Catholic).

Thus, the large majority of "religiosity" or "spirituality" of these articles is Christian. Yet, the sterile, scientific jargon in which they are discussed belies specific doctrines and tradition. Yes, there are many Protestant churches. Yes, there are variants of thought among Catholics. However, there is much more unity than diversity within each. There is an orthodoxy by which a true Protestant church can be measured. Roman Catholics have an even greater specificity.

Science is treading on dangerous and deceptive ground here. Regardless of what one's desire may be for inclusion, apples and oranges exist. More than 80 percent of the American population and its family physicians practice Christianity, not some vague spirituality or religious experience. Almost entirely, the researched health benefits of religion have been done on Christian populations. To extrapolate these to any form of "spirituality" is deceptive and a misrepresentation of the belief system that fostered it.

There is no question that religion is central to health and the practice of (family) medicine. However, it is not "religion," primarily, but Christianity mostly. To discuss "inclusive spirituality" in general terms is also to misrepresent and to distort what is much more specific.

While not intended, such general discussions convey the notion that whatever one believes is all right (healthful), as long as one is consistent and sincere. Christianity condemns such notions in its core beliefs. Scientists (and physicians) should be careful not make claims for "spirituality" that is specifically Christian.

The avoidance of what is identifiably Christian by science in general, and medicine in particular, is a curious phenomenon. I once presented a marriage seminar that was broadly religious and highly practical to family physicians and their spouses at a national meeting. Yet, it was rejected for future inclusion solely because of its Christian content (based upon attendees comments).

We can pat ourselves on the back and feel good about researching "religion" and applying it more in our practices, but our patients live in the real world of specific religious content, mostly Christianity. To ignore this reality is dishonest and detrimental to our patients (and ourselves) and dishonoring to the God of Christianity.

Sincerely,

Franklin E. (Ed) Payne, M.D.
Associate Professor
Medical College of Georgia
Augusta, GA 30912

Note to readers: There has been insufficient time to know whether this letter will be published.

References

1. Thomason CL, Brody H. Inclusive spirituality. J Fam Pract 1999; 48:96-97.

2. Daaleman TP, Frey B. Spiritual and religious beliefs and practices. J Fam Pract 1999; 48:98-104.

3. Ellis MR, Vinson DC, and Ewigman, B. Addressing Spiritual Concerns of Patients. J Fam Pract 1999; 48:105-109.

Letter to David Larson et al.

October 16, 1996

David B. Larson, M.D.
National Institute of Healthcare Research
6110 Executive Blvd., #908
Rockville, MD 20852

Dear Dr. Larson:

The compromise of modern Christians has long disturbed me, but for Christians to be on the same program as "African Spiritual Healing Practices," "Islamic Spiritual Healing Practices," "Christian Science Healing Practices," and many other "spiritual healing" practices is an abomination to the Father, Son, and Holy Spirit of the Christian faith.I will allow you one caveat. If you stand on the podium and declare that "(Jesus) is the way, the truth, and the life" and that "no man comes to the Father but by (Him)" as a evangelistic endeavor, then you have a reason to be there. 

You are caught up in the religion of modern science that has to conduct endless studies "proving" the validity of some approach. Philosophically understood, (medical) science cannot determine truth because it starts with assumptions (axioms, first principles, presuppositions, premises, etc.), all of which are a faith position in themselves.

Just how do you justify your work? Are you trying to prove that God is real and that He heals? That the Christian religion is any better than another? Can you accept that healing, especially of the soul, is possible apart from Jesus Christ, e.g., in "African" practices? Is there any true healing apart from Him?

Not only are you prostituting the Christian faith on the altar of modern science, you are prostituting it as only one among other equally valid religions. I am sure that the Angel of Light rejoices in your adultery.

Or, perhaps, my whole letter is in error -- you are not now a Christian and have rejected Christianity altogether. One religion for you is a good as any other.

I must warn you not to dismiss this letter lightly. God often only gives us one warning of our errors. How can I speak for God? I don't have to -- He has already spoken in His Word. May God richly bless or condemn you according to judgment by that Word.

As co-sponsors with you, the Templeton Foundation, the Christian Medical and Dental Society, and The Center for Bioethics and Human Dignity, and others are guilty by association. Thus, I have forwarded letters to them.

Praise Father, Son, and Holy Spirit!

Sincerely,

Ed Payne, M.D.

Ed's Note: I never received any response from anyone.

cc: 
Dr. John M. Templeton, Jr., President, Templeton Foundation

Dr. John Kilner, Director, Center for Bioethics and Human Dignity

Dr. David L. Stevens, Executive Director, Christian Medical and Dental Society

E-mails on the Fate of Frozen Embryos

Dear Dr. Payne,

I write today hopeful that you would advise me on a difficult case. There is a couple in our congregation with four children. The first three of the children were conceived two years ago through in vitro fertilization using the husband's sperm and the wife's eggs. Today, the husband contacted me to let me know that the couple had just been notified that they need to make a decision as to what they are going to do with five other cryopreserved eggs that were also fertilized two years ago. The couple has been given four options:1) use the embryos, 2) donate the embryos to other couples, 3) dispose of the embryos, or 4) continue to store the embryos for a fee

Clearly, number three is a not an option. Number four only postpones the decision. Number one seems a possibility, but the mother has had a torn uterus and has been told that another pregnancy would be life threatening. Option number two appears to me to be the most acceptable option in this very bad situation. Of course, this option has its own problems, as it surely would affect the family in unforeseen ways, and it raises the issue of the responsibility that this couple has to care directly for their embryos. 

This case surely does show the ethically precarious standing of in vitro fertilization, particularly when all fertilized eggs are not given a chance to survive from the start.

I welcome any observations or advice that you may have as I seek to give wise and Godly counsel to this couple. Fortunately, they desire God's will, but I do not see any simple way to guide them through this ethical quagmire.

A Pastor (name given, but withheld here)

Ed's Reply

One truism is, "There is no right way to do a wrong thing." As you acknowledge, the freezing of embryos is problematic -- wrong in my opinion. With the sanctity of life that is Biblical, I can see no justification to place this new life in such jeopardy, including the fact that a significant percentage do not survive the freezing/thawing process. 

This couple received wrong advice for their original decision, as it seems that many (most?) Bible-believing Christians are accepting of the idea of frozen embryos.

But, trying to do right in this situation... Number four continues a wrong ethical state for these embryos.

Assuming that the "torn uterus" might be life-threatening, Number 2 does seem the best option. However, all legal options to this couple -- knowing who the parents are and the recipients knowing who the donors are -- should be closed. I don't know if such closure is possible in the illogical and immoral legal system that we have today. But, this action would essentially be an adoption. The recipients become the parents, legally, morally, and actually. This business of adopted children finding their "birth parents," in this case, "gamete donors," is heinous and morally wrong. Parents are those who face the rigors of child raising.

Followup Letter

Dear Dr. Payne:

While reading your reply over again, a couple of questions occurred to me.

1) If the mother is fit to carry the embryos herself, do you think that there is a need for her to do so with as many of the embryos as possible, in light of the immorality of keeping the embryos in a frozen state? I ask this because it seems that the risk to the mother may be reduced if she carried fewer embryos over a longer period of time.

2) Could you elaborate, or give me further information, on the need to create closure to prevent the donating parents from ever becoming entangled with the adopting parents or children? I agree that this needs to take place, but I would like to be better equipped in the event that I need to argue this with the parents. From your remarks, it is apparent that you have thought this through.

Thank you very much.

Ed's Second Reply

1) That is a difficult question of which I am not sure of the answer. They already have four children. Delaying impregnation somewhere means continuing risk to the frozen embryos. I believe that the woman, if able, should have at least one insertion of one or more embryos, understanding that a multiple birth cannot be "reduced" by the elimination of one of the unborn babies. The others should probably be implanted in other women, as soon as possible, to get them out of their state of "limbo." I am not sure of this thinking, but that's my first inclination.

2) Adoption is a contract. The adopting parents agree to accept ALL responsibilities for the adopted children. The parents of the adopting child are stating that they cannot carry out their responsibilities as parents, so by forfeiting these, they also forfeit future blessings of children. By being raised by parents, children are given responsibilities for their parents (5th Commandment), so they enter into a contract, as well.

Morally (spiritually), a parent is a parent. There are not half parents. That is, today I am the parent of a child but I'll take a holiday tomorrow. That is what is wrong with our current system of "foster" parents: what better way to confuse and destabilize a child by shifting him or her in uncertain circumstances.

The wish to "know" a person's biological semen/egg donors is a fantasy that has no purpose other than the whim of the "child." He has a family that has obligations to him/her and vice versa. 

That is all that comes to mind at the moment. If you have more time, perhaps I could pursue it further.

2nd Followup Letter

How do you think that Y2K and its potential effects, particularly on the healthcare system, should influence this couple's decision about the timing of implanting embryos? It seems that it might be wise to get as many embryos as possible implanted right away that birth might take place before the new year. On the other hand, any kind of complications would have to be faced right away as we enter the new millennium at the hospital which is 45 minutes away. The truism, "There is no right way to do a wrong thing," surely applies here. Nevertheless, it seems that the Y2K threat should be taken into account in some way. Your thoughts?

Ed's 3rd Reply

The Y2K problem is somewhat theoretical, while the precarious state of the embryos is actual. They are imminently in danger. Regardless of Y2K, their status should become in utero as soon as possible.

Acknowledgement

I agree. Thanks for your reply.

3rd Followup Letter

I wanted to update you on the counseling situation that I have here. The couple has learned that their embryos are being stored in three vials holding two, two, and one embryo(s) each. They are going to begin the steps necessary to have two of the embryos implanted. If these are successful, they will immediately donate the rest. If the first implant is not successful, they will try again with the additional embryos. 

The couple understands that these embryos should be in utero. They also believe that they have a responsibility to take care of their own embryos, as much as possible. This responsibility was heightened when they learned that there was no guarantee that their embryos would not be donated to a lesbian couple or some homosexuals who were going to hire a surrogate (Ed's emphasis).

As I spoke with the couple tonight, they acknowledged that they wish that they knew three years ago what they know now (Ed's emphasis). We discussed how the medical community has taken a very amoral approach to this whole procedure, and how this couple really had little awareness of all the ethical issues involved. They also acknowledged their responsibility in the situation, and how their own impatience to have a child influenced the process. 

We concluded by discussing the sovereignty of God, and how His Word must be kept before us as we consider the lengths that we may go to fulfill our desires. We also observed how God's sovereignty is a comfort when we know that we have gotten ourselves into a real predicament.

Ed's Final Comment

This couple's willingness to receive Biblical counsel is enlightening. How many Christians are being misled by pagans and by less discerning Christians, who are quite willing to follow Biblical counsel were it given? God has promised these false shepherds a particular reward (Matthew 18:6, James 3:1).

Another E-mail from a Different Source!

Dear Dr. Payne,

My wife and I are members of _________ Presbyterian Church in __________. I understand that you are an elder at First Presbyterian Church in Augusta. I am a deacon here. We have read a portion of your book. It is always encouraging to hear that there are men and women who are diligently striving to answer life's tough questions based on God's wisdom in His Word.

My wife and I are dealing with some infertility issues right now and are contemplating some questions concerning in vitro fertilization. We have done some fairly extensive research, both medically and Scripturally, and have spoken with our elders and friends at the church about this. Our pastor suggested that we contact you. Would you be willing to take some time to answer some of our questions for us? If so, I'd be happy to compile them into an e-mail and send them to you. If you are unable to do so at this time, we understand that, as well.

A Couple (names given, but withheld here)

(Ed's Comments)

In God's Providence, these e-mails arrived almost simultaneously. One principle of ethics that I find helpful is that any situation that has harmful consequences should be examined closely for violation of ethical principles. For example, the physical and spiritual harm of sexual immorality screams that there is some violation of a basic ethical principle.

In the case of frozen embryos, their precarious state alone is sufficient to question the morality of technology that placed them there. With the loss of life that occurs in the freezing and thawing process, there can be no Biblical argument to allow embryos to be frozen in the first place.

The desire for motherhood is tremendous, and it is moral. However, the ends never justify the means. Both the means and the ends must be righteous. God warns that the drive of a barren woman is dangerous:

"Three things are not satisfied, four never have said, Enough! Sheol, and the barren womb, the earth not filled [with] water, and the fire, [these] never said, Enough!" (Proverbs 30:15-16)

Even Biblical Christians must be careful that powerful emotions and right desires do not justify means or ends that the Bible proscribes.

AIDS: Issues and Answers

Vol. 13, No. 2 (81) March 1999

Physician-to-Patient HIV Transmission

After HIV (human immunodeficiency virus) infection was diagnosed in an orthopedic surgeon in 1994, practicing in a Paris suburb, attempts were made to contact 3004 former patients. A total of 983 patients responded to the search. 

One was infected (0.1 percent). She was a 67-year old woman who had undergone a "difficult 10-hour" hip replacement in 1992. 

"Phylogenetic analysis" revealed that the env (genetic) sequences of HIV from the patient and the surgeon were similar and probably belonged to a unique and as-yet unidentified HIV subtype....

"On in-depth questioning, the surgeon reported frequent cutaneous blood exposures and almost weekly percutaneous injuries. His orthopedic surgical colleagues reported a similar frequency of percutaneous injuries, especially while suturing in a blind cavity or while placing metal wires or pins. Few, if any, of these exposures were reported. This remarkably high frequency of high-risk exposures was common to orthopedic surgeons and was not shared by other surgical colleagues." (Infectious Disease Alert, February 15, 1999, p. 73)

Commentary: This case involves only the second case of health-care-worker-to-patient transmission of HIV. I have reported several times on the case of David Acer, a dentist in Florida, who transmitted HIV to several of his patients. 

I wince at the number of "percutaneous" cuts, nicks, and sticks that occur during orthopedic surgery. However, these are unavoidable, if the surgeon is not to make larger incisions or keep the patient anesthetized longer than is healthy for the patient.

I do not know the statistics, but I suspect that risks of hip surgery are considerably greater than the transmission of HIV: pneumonia, reactions from blood fusions, wound infections, stroke, heart attacks, etc. Taken altogether, the mortality rate is likely to approach 0.1 percent, given the nature of the surgery and that these patients are generally quite elderly and frail, as this lady was.

HIV is one of the least of a patient's worries undergoing hip and most other surgeries

However, there is an interesting ethical query by a physician who commented on this case in the above periodical.

Do Numbers Make Moral?

"One could argue that patients would want to know their potential risk and that the availability of successful therapeutic intervention provides a rationale for early case identification. However, based on the lack of documentation of any similar cases of HIV transmission, despite thousands of surgeries and invasive procedures having been performed since the beginning of the HIV epidemic, the justification for the invasiveness of this investigation does not seem warranted. On the other hand, when is sacrifice of civil liberties justified? How many lives is it worth? And who decides? I ask myself if I would have seen this article in a different light if, for example, 30 patients had been discovered, none of whom knew that they were HIV infected?" (Carol A. Kemper, M.D. commenting on the above report)

Commentary: Dr. Kemper asks a good question, "Do numbers determine moral courses of action?" Or, I would ask, "Do numbers determine moral courses of action for Christians?" Readers should ponder this query before reading on. How would you respond to her?

We often hear the expression, "Well, if only one life is saved, then it (some course of action) ought to be done." Biblically, we strive for clear principles, even absolutes. Surely, then, it is wrong to determine moral choices based upon numbers.

A simple illustration answers the question. Are you, as an American and a citizen of some state, willing to drive your car 5 miles an hour? That's at least an hour to work, if you live 5 miles from your job site. That's 28 hours to Atlanta for me (now a 2.3 hour trip). Gotcha!

Five miles an hour for vehicles would save approximately 30,000 lives each year, for I doubt that many lives would be lost at that speed. In a fallen world, there are risks with which to be reckoned. I am not sure that a particular number suffices for a dividing between what is right and what is wrong. Certainly, one-in-one, even one-in-two, perhaps one-in-ten, but not one-in-a thousand, as Dr. Kemper states. And, not one in 86 (lives lost each year per total population), as that is the cost of driving current speeds in the United States.

This concept is extremely important in the modern world and especially in medicine. I have often mentioned what no one says. There is an underlying assumption in modern medicine that we can prevent all disease and injury, regardless of the cost. The current epidemic to place virtually everyone on "statins," drugs that lower fat levels in the blood in an effort to prevent heart attacks and strokes, is one example.

A worse example is the plan of the American Red Cross to add additional screening to prevent HIV-transmission in blood transmissions when the rate is only about one in one million now! And, various government agencies are "protecting" "lives" and the "environment" with similar numbers.

The reality is that danger and risk exists in our fallen universe. The state, and the church as well, have a role in protecting lives and preventing disease and injury. However, some risks must be taken. Both the numbers and the reasonableness of the preventive effort must be examined. Except in those areas specifically assigned to the church and the state, the overwhelming choices should be left to individuals and families. Only they can determine to what extent they are willing to sacrifice and to take risks, because the cost is personal, real, and out-of-pocket!

Relative vs. Absolute Risk

Hilton P. Terrell, Ph.D., M.D.

The United Kingdom Prospective Diabetes Study (UKPDS) on the benefits of tighter control of adult onset diabetes continues to be misunderstood. The technical nub of the misunderstanding is the focus on the reduction on the relative risk. That is, tighter control of blood sugar in diabetes produces, say, a 30% reduction in a given complication. Stating the outcome that way exaggerates greatly the actual impact. The better way to think about such interventions is in terms of the absolute reduction in risk. 

By wearing certain eye protection, I could perhaps reduce my risk of snow blindness by 6000 percent, compared to my not wearing the goggles. Since I live in an area in which snow is rare and present only briefly (Florence, SC), however, the absolute risk is miniscule with or without protection, something less than 1 in 100,000.

That is the technical nub of understanding. The motivational nub is that physicians do not want to see the truth when it does not please us or our patients. We do not get our egos stroked, we do not make money, and we do not secure protection from lawsuits, when we step out of the herd of our peers and say that the emperor of treatment has no clothes. This refusal to see can take almost bizarre forms. One physician recently opined in print that "doctors should not give patients the chance to turn down the treatment that they need" (Medical Tribune, October 22, 1998, p. 19). Wow! What I need is to sic the KGB on my patients. That'll teach 'em to comply with my directives!

Another misuse of UKPDS information and related, lesser, studies is a rush to systematize the treatment of the disease when the information actually does not encourage tight control. Increasingly, this treatment is being attempted by pharmaceutical companies or managed care companies who do not have any personal knowledge of the patients. The managed care companies seem to think that they are going to save money and improve outcomes, despite a lack of evidence on that point (Family Practice News, December 15, 1998, p. 37).

Ed's Note

I recall a study from more than 20 years ago, confirmed by numerous studies before and after, that only 10 percent of patients lose and sustain weight loss when managed by a team of experts. Now, in the real world of patients, virtually on their own, can we even expect them to achieve the 10 percent level of compliance, not only on weight loss, but other "healthy" schemes, such as, diabetes (of which weight control is one important component of management), cholesterol, cigarette smoking, and exercise?

Further, I want to make the radical suggestion that it is not my responsibility as a physician to motivate patients about these things. Yes, I should tell them if some habit is detrimental to their health, but they usually already know that. Yes, if they have questions about such changes, I should know enough to answer them. 

We live in an age of a glut of information on every subject from A to Z. Information on health is present at every supermarket check-out counter, in bookstores, on television programs, and on the Internet. Anyone with the motivation can know all that he or she needs to know about their health and disease processes. Why should a physician spend his time (personally, I do not) to get patients to do what they obviously do not want to do? I can use that time to treat more patients that do need immediate attention. Besides, no Third Party yet pays significantly for that time, in spite of all the hoopla and hype over the importance of "prevention."




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