Faith in Medicine
As objective as we try to be, doctors are not computers - making judgements requires an element of faith. Dr Simon Cowap takes a break in Bali and ends up wondering what faith actually means.
In the words of the old Redgum song, I've been to Bali too. In fact, I'm here at the moment for the first time since 1990. It was lovely then and it still is, albeit groaning under the weight of even more tourists - though as one of their number it would be hypocritical to complain.
But despite the intensification of what was already a pretty intense tourism industry, one thing hasn't changed - the central role their Hindu and Buddhist faiths play in everyday life. Temples and shrines are everywhere and well attended. Offerings are made every day, and with the arrival of the festival of Galungan this week everyone is busy making penjors, elaborately decorated curved bamboo poles that give thanks for the bounty of nature. While we hedonistic tourists may not understand these rituals, it’s plainly evident that practising their religion remains extremely important to the Balinese. Despite the most full-on exposure to western (and other eastern) cultures, they have clearly neither lost their faith nor had it reduced to a curiosity for tourists or anthropologists.
Issues of faith occur regularly in mental health practice. People lose faith in their ability to be happy, that they could ever be loved or valued, in their capacity to deal with the world.
Being surrounded by all this faith got me thinking about its role in my own life. As a dyed-in-the-wool sceptic I am not religious, though I have no time for people like Richard Dawkins whose life mission seems to be rubbishing the beliefs of those who are. Any literal minded school child can point out the logical difficulties that need to be overcome to cleave strongly to any particular god or gods, but it's what comes next that is the hard part. In fact, the older I get the more I wonder if secular western society hasn’t thrown the baby out with the bathwater when it comes to abandoning religion.
If I were to adopt a faith, Hinduism or Buddhism would be likely candidates. But the absence of a big F faith from my life doesn't mean I don't engage in countless acts of faith every day. To me, faith means having a belief or conviction something is true in the absence of strong objective evidence. The belief I have that my values are good is essentially a matter of faith. Logic can tell you if your values are consistent, but it can't tell you if they are right.
On a slightly less grand (pompous) level, it got me thinking about the role of faith in clinical practice. On the one hand, we are of course all focused on evidence-based medicine. We aren't faith healers; obviously we can't advise treatments for which there is no evidence. But as the placebo effect demonstrates, it still helps if patients have faith in their treatment. Trying to maximise this at the same time as sticking within the bounds of EBM is something of an art.
Some clinicians would say it’s a dark art that shouldn't be practised. They advise a 'just the facts ma'am' approach. ‘Treatment X has a 72% chance of success with a 3% chance of serious side effects.’
Clearly we do have to give these statistics, particularly during the shared decision making phase, but once someone has decided on a treatment approach I do try and foster optimism that it will work. The feeling of confronting a problem and taking action, allied with the belief that treatment is possible, has an additive therapeutic effect to the physiological mode of action of whatever specific treatment we prescribe. To the extent that we can maximise this, I think we should.
Of course we can never guarantee treatments will work, and if we oversell them and they fail we run the risk of loss of faith. I try and avoid tying faith in treatment to any particular treatment, outlining at the beginning that there are a number of options, and that while I expect the current one to work it’s no disaster if it doesn't. Faith can be invested not just in this or that treatment, but treatment in general, medicine in general, and to a degree also in the practitioner.
Issues of faith occur regularly in mental health practice. People lose faith in their ability to be happy, that they could ever be loved or valued, in their capacity to deal with the world. While some of this might be explained by cognitive distortions, I think a certain irrational exuberance or the lack of it also plays a role. Correcting those cognitive distortions and how they influence our internal monologue can help us feel less anxious or depressed, but perhaps they only arose in the first place because we lost faith in our ability to cope or be loved. Likewise the ‘what’s the point?’ nihilism that so often accompanies depression is no more or less than a loss of faith. Our myriad daily actions only have purpose if we believe they do. By and large I find metaphysical discussions with nihilistically inclined depressives of little help – it’s as easy to find reasons to doubt the meaningfulness of daily life as it is the existence of God. We need to encourage belief, not sceptical analysis.
So in some ways I find myself in an awkward, if not inconsistent position. An atheist when it comes to religion, I’m an evangelist for the meaningfulness of the quotidian. The Balinese certainly seem to find purpose in daily life, and if they haven’t quite converted me to religious faith they’ve strengthened my belief in the value of holidays!
Dr Simon Cowap MBBS (Hons), FRACGP
Simon is something of an accidental GP who likes to pretend he’s an artist trapped in a professional’s body. He dropped out of his first degree (arts) and went to London to play bass guitar in a band too musically challenged even for punks. Dropping back in to university, he subsequently also failed to complete a science degree and a Masters of philosophy. His remarkable lack of artistic success has been continued by the non-publication of his several novels. Somewhere along the line he did finish a medical degree. He still harbours dreams of literary success but his family have forbidden him to give up the day job.