For a couple of reasons I’ve been thinking again over the last few days about the ethics of medical advice, evidence vs. experience, the moral obligation we have to those we love and those to whom we owe a duty of care. I realised this morning that one of the reasons this exercises me so much and so consistently is because of my own (limited) experience. It might therefore be illuminating I’m some way to record that here.
A couple of years ago now – indeed, maybe longer than that – I finally bit the bullet and submitted to seeing a therapist, having been diagnosed and indeed re-diagnosed with what I think is termed something like ‘mild-to-moderate depression’. (Believe me, it doesn’t feel mild-to-moderate subjectively, but no matter – that’s another question for another time.)
This isn’t intended to be a record, analysis or explanation of the causes and effects of depression or mental illness, whether ‘mine’ or more generally, so I won’t go into history, circumstance or anything else – not evading it, just don’t want to risk topic-drift.
I began seeing a therapist (which I still do, albeit far less frequently and arguably for different reasons) and found a lot of consolation in having a regular and disinterested point of reference and source of help. It became clear though that my mindset at the time was not such that allowed particularly successful work on dealing with the problems themselves, and we therefore spoke about the possibility of consulting with a doctor with a
view to potentially being prescribed medication.
I should stress that I believed at the time (and still do) that in my case and I suspect the majority of others’ the aim of medication was not in itself to solve any problem, but rather to provide respite from a fevered mind and a calmer and steadier foundation on which to begin to build.
I had a consultation therefore with a doctor here in Berlin – a single meeting, but quite a long and in-depth one. She confirmed the depression diagnosis (the therapist later altered or clarified the diagnosis slightly but within the same ‘family’, but that’s immaterial here) and we discussed medication options. I was and remain hesitant to take medication specifically designed to alter brain function (I enjoy drinking, but what can I say? I’m a hypocrite), and so we agreed on the softly-softly approach.
I was prescribed tablets against anxiety and low-level depression, the active ingredient of which was herbal. Given the prevalence of homeopathy in Germany I made a point of confirming with the doctor that this was not what I was being prescribed – I was assured it was not, an assurance which was in itself entirely accurate.
I now understand that the tablets were a form of Bach flower ‘remedy’ – I’m not currently at home, but would otherwise fish out the pack to report more accurately. This I took as directed for several months, to no appreciable effect. (I don’t intend to go into matters of efficacy or multiple causes here – maybe another time.) I returned to the doctor as arranged, discussed how things were going, and was moved onto a more pharmacologically hardcore drug, albeit at a relatively low dose. That (apparently) had rather more of an effect, and with the usual caveats concerning causality, environmental factors and anecdotal ‘evidence’ I was able to start putting things together, take control of my thinking and responsibility for my behaviour and ultimately have ended up doing really rather well. I reiterate that to what (if any) extent this improvement was down to the pills is an entirely moot point for the purposes of this post.
At the time I was prescribed the herbal product, I was not nearly as well-versed in questions of EBM, efficacy, trial data and the like. It’s also perhaps the case
that I was not mentally in a position to take proper responsibility for that. Had I been, I would certainly have looked into the background and evidence-base of what I was being prescribed. As it was, I blindly trusted in the consultation process and medical advice from a professional.
(To be clear, this was/is a well-qualified medical doctor operating a clinic quite within the bounds and structure of the German medical establishment, not a ‘herbalist’, homeopath, energy healer, wizard of other purveyor of snake oil – perhaps ironically it is not them I am questioning here.)
When I did finally look into what it was I was actually taking, I found that the evidence of efficacy for what I was initially prescribed was effectively non-existent. Although it is not strictly homeopathic, it was developed by a homeopath and does not adhere to scientific standards of efficacy above placebo. Of course, don’t take my word for any of this – I very much encourage you to research Bach flower ‘remedy’ (I refuse to remove the inverted commas for reasons which should need no explanation) and apply your own standard of analysis.
Without attempting or intending to absolve myself of the burden of personal responsibility, I do feel that this behaviour amounts to a betrayal of the doctor/patient relationship. Although I acknowledge that the onus is on me to educate myself as to what I put into my body, I’m not sure I was psychologically in a position to take that responsibility, and even if I were, many other patients would not be, and a doctor would not realistically be able to determine that from a single consultation.
Without being excessively melodramatic, the doctor would also have little way of being sure at what level of risk that particular patient is. In my case there was little harm done – a few more months of being minimally functional and feeling like nothing, some wasted time and no doubt bad (or indeed absent) decisions, but nothing which harmed me in the long-term.
But what if I had been a suicide risk, as well as unable to analyse for myself the pros and cons of various treatments?
If someone takes their own life in part because they have not been prescribed a drug with an established efficacy but instead something ineffective but side-effect free, does the doctor bear some responsibility? Morally I would argue certainly she does. Legally I have no idea.
This doctor I happened to get along with very well. She is extremely pleasant and clearly cares very much about her patients – I have no doubt that she acted and acts the very best she knew how for the good of those she serves. I have no reason to believe anything other than that she believed the product she prescribed to be potentially efficacious. Nevertheless, I believe she should have a legal obligation to explain the evidence and arguments for and against a prescription clearly, explicitly and in a manner which each patient understands. If I were not inclined to check this myself, there must be few mental health patients who would be. Further, and away from mental health, I suspect that many (the majority of?) people aren’t accustomed to weighing up the facts on this stuff – it’s just too complex and too specialist. This is what we must trust doctors of medicine to do, and I believe a form of auditing would be justified, resulting in severe penalties for prescribing unproven products to people without explicit explanation.