High Functioning Autism (Including “Asperger’s Syndrome”), Memory, and Time

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Do you have some memories that are so vivid that they are like three-dimensional realities re-playing in your mind? I think most people have some memories like that–a death in the family, a romantic breakup, one’s wedding day–but what if your collection of such memories was larger than just a few? What if, even if you lacked a photograpic memories of everything, had entire groups of memories dating back twenty or more years that could re-play so intensely that it feels as if they fill your heart to bursting? For many people with High Functioning Autism Spectrum Disorder (including what in DSM-IV was called “Asperger’s Syndrome), time flows differently from most people who do not have autism. More memories are preserved intact than are found in so-called “neurotypical” people, and when they are remembered they are so real that one feels as if he were participating in reality once more.

I noticed this at my thirtieth high school reunion in 2010. Although people generally remembered one another (and they remembered me and I them), they lacked vivid memories of high school. But for me, although I had forgotten most days, I remembered much more concrete detail and many more events that most of my fellow class members. Most were not memories of earthshaking events that number in the hundreds. Some examples: Walking down the hall looking at the class photos from the 1950s and early 1960s, thinking myself part of a larger tradition at my high school and wondering about the days my aunt and mother went there. Playing chess in the cafeteria at lunch and some of the conversations and insults players hurled at each other. Feeling overwhelmed at the end of a semester and talking to a fellow student about it–he signed my annual that day and wrote, “Keep studying and you’ll make it.” I’ll not bore you with more examples–the point is that no one else had that many vivid memories of high school. One student remembered arguing with me in history class but did not remember another student who argued with her constantly. To me, that was amazing, and it was other people who were different, not I who was.

Does time and memory function differently for the (high functioning) autistic person? Why are my memories (and the memories of other students I know who had Asperger’s traits) so vivid that one re-lives them as if they were the present moment? A student from another local school from chess tournaments with Asperger’s traits talked to me about twenty-five years after a tournament and remembered the specific game we played including the opening and the moves! Such vivid memories are a gift–and a curse. Memories of times I was bad come back to the point that I feel guilty as h..l over things I did when I was a small child. Memories of swinging on a tree swing at Granddaddy and Granny’s are so powerful that I feel like I am there and am heartbroken when I realize that I am not. I have heard other HF autistic people say similar things. Time, to us, seems compressed, with thirty years in the past at times seeming like the present. We certainly do not experience time as God does, an eternal present, but it may the closest someone gets to that on earth. Sometimes memories, even the good ones, hurt so much that I shut them out. Each good event that is in the past seems like a little death that I want resurrected–I wonder if others with HF autism have had the same experience–reply to this post if you have and/or if you think this is an autistic trait. It seems like autism itself–wonderful and terrible, a blessing and a curse, God’s gift and God’s scourge–and something I would not want to live without.

The Fundamental Goal of Medicine

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The fundamental goal of medicine is the patient‘s good. Edmund Pellegrino and David Thomasma both focus on that point in their 1981 book, A Philosophical Basis of Medical Practice, the book that has most influenced my approach to medical ethics. All other goals–having an up-to-date facility, having the best equipment at a clinic or hospital, turning a profit, and efficiency in finances, must be subsumed under that primary goal. The good of the patient may involve curative care, or it may involve palliative care in the case of a dying patient. The human person is a whole, body and soul, so medical practice must focus on the good of the whole person and not just on body parts and diseases. The good of the patient may include physical good, but it may also include psychological and spiritual good. Recognizing the complex dimensions of personhood and treating a patient as a person, not as a thing, will do more for the good of the patient than merely diagnosing and treating a physical disease. Even a “physical disease” contains a psychological component, since the patient’s mood can influence the course of the disease for good or ill. Sometimes a physical disease can be triggered by psychological stress. Extreme emotional stress can activate the HIV virus so that a person gets full-blown AIDS. Other diseases may be activated by stress: cardiovascular disease, cancer, rheumatoid arthritis, lupus, infectious diseases. Part of a medical practitioner’s job is to recognize when a patient is having a great deal of emotional stress and encourage the patient to deal with that stress.

Treating the patient as a person implies that assembly line medicine is not ideal. Despite massive debt that young physicians often try to pay off with a high volume of appointments, at some point a provider is spending too little time with patients and comes across an uncaring. Constantly looking at one’s watch does not help. Talking to a patient in a real conversation does. Of course any doctor, PA, or nurse practitioner must have some limitations on patient appointments in order to receive all those in need. Finding the correct balance is not subject to exact rules and is a matter of prudence. Prudence is the ability to make a good decision in both routine and in more troublesome and complex situations. It is an essential virtue, necessary for both everyday medical, as well as for moral, decision making. A list of absolute rules to follow will not help in ethical dilemmas in which rules conflict and are only prima facie, which higher-level rules may supercede.

The fundamental end of medicine implies the principles of benevolence, nonmaleficence, and justice. Autonomy is trickier, since it is an enlightenment concept that may be conditioned by contemporary Western Culture. Kant himself thought we would autonomously give ourselves the moral law, but the term is used today for “the right of every adult to make choices based on their own value systems.” In practice, there is limited autonomy in medicine; not everyone can practice medicine, and drugs must pass FDA approval before being placed on the market. These limitations are so patients will not be misled by quacks or those pushing an untested, ineffective, and perhaps dangerous, drug. Autonomy in patient decision making recognizes that it is the patient’s body who is being affected by medical treatment, and that the patient’s values are not necessarily the physician’s values. I think of respecting autonomy in terms of respecting the free will of patients to make their own decisions regarding health care.  This helps preserve the dignity of the patient in a setting in which the sick patient, feeling powerless, tends to lose a sense of dignity.

There are a number of controversial issues in medical ethics that focus on the nature of the patient’s good, or even if there is a patient present to whom the health care provider does good or harm. The abortion issue is one of these–if the fetus is a patient, then abortion amounts to murdering a living human person. If the fetus is not a patient because he is not a person, then the opposite conclusion seems stronger. My own view is that personhood begins at conception, so that any doctor or health care worker helping with an abortion is violating the fundamental end of medicine. The same would follow for euthanasia and for physician-assisted suicide. Many people will disagree with these positions, and I welcome rational argument on any position I set forth in this blog.

Most issues regarding the fundamental good of medicine are more mundane that the large scale bioethical issues often discussed in undergraduate medical ethics courses. Usually the practical everyday issues involve the amount of time spent with patients, dealing with difficult patients, keeping information confidential, keeping medical records accurate instead of falsifying “the little stuff,” and so forth. All these issues involve remembering that the patient is a human person with feelings, with a life, with loved ones, just like the health care provider–and that providers can help a person leave better than when he arrived.

Dr. Richard Nilges: A Tireless Advocate of Truth

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Dr. Richard Nilges, neurologist and long-time critic of brain death criteria for human death, died last month after a long, productive life. I never met him in person, but via e-mail and telephone–the first time was in 1996. I was interested in editing a book of essays opposing brain death criteria. Never having edited a book before, I asked both Dr. Paul Byrne, a neonatologist and the dean of opponents of brain death criteria, and Dr. Nilges to help, and both graciously agreed. Dr. Nilges wrote a chapter for the book, which was published in 2000 as Beyond Brain Death: The Case Against Brain-Based Criteria for Human Death (Kluwer [now distributed by Springer-Verlag]). Dr. Nilges’ chapter, “Organ Transplantation, Brain Death, and the Slippery Slope: A Neurosurgeon’s Perspective,” was the most passionate chapter in the book, reflecting a lifetime of difficult battles against the medical establishment. He retired early after serving as an Attending Staff Member in Neurosurgery at Swedish Covenant Hospital, Chicago. His conscience would no longer allow him to declare patients dead using brain=based criteria. For many years after his retirement, Dr. Nilges, writing with Paul Byrne and others (such as Dr. David W. Evans and David Hill in the U.K.), spoke out against brain death criteria when medical and scholarly opponents of brain-based criteria for death were scarce (the late Professor Hans Jonas of the New School for Social Research was an exception). During the 1970s and 1980s, Dr. Nilges’ position was considered to be a fringe position by the medical and medical ethics establishments. But the work of Dr. Nilges and other pioneering opponents of brain death criteria eventually bore fruit. Professor Stuart Youngner began to hack at the medical arguments in favor of brain death criteria, bringing out arguments concerning continuing brain function in patients declared “bran dead” which Byrne and Nilges had noted years before. The real breakthrough came with Dr. Alan Shewmon, a pediatric neurologist at the UCLA School of Medicine, came out in opposition to brain death criteria. Eventually an entire network of physicians, philosophers, sociologists, and other scholars came to oppose brain death criteria; many questioned the morality of the current system of organ transplantation. If brain death is not death, then removing vital organs from the “brain dead” patient involves killing the patient. Not all opponents of brain death criteria oppose organ transplantation–Dr. Truog does not–but even Dr. Truog believes that people contemplating signing a donor card and families considering donation ought to be told that organ transplantation from a beating heart “brain-dead” donor kills the donor.

Now articles opposing brain death criteria have been published in major medical and bioethics journals. Some younger scholars are writing against brain death criteria, such as Professor Scott Henderson in his Death and Donation (Wipf and Stock, 2011). Thus there is a third generation of scholars willing to oppose the medical establisment’s continued support of brain death criteria. This would not have been possible without the pioneering and courageous work of the first generation opponents, including Dr. Richard Nilges. His legacy and influence will live on in the patients he helped over the years and in the scholars he inspired to have the courage to question what they may have previously taken for granted.

Dr. Nilges was a devout Roman Catholic whose faith was central to his life. Requiescat in pace.

Borderline Personality Disorder

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Borderline Personality Disorder Awareness

Borderline Personality Disorder is a disorder I have been blessed not to have, though I’ve known individuals, some close to me, who were borderline. BPD is essentially a problem of emotional control. Borderline people have wild mood swings, though they are not usually bipolar. They can love you and think you are the most wonderful person in the world one moment, then turn on you, demonize you, and hate you. Those shifts can be unpredictable and can happen quickly, leaving family members hurt and wondering how to react. Borderline individuals tend to put people they know into lose-lose situations. If the borderline person is angry with you, whatever you say will be the wrong thing. You will, as one bestselling book on BPD alludes to, be “walking on eggshells.”

Borderline people can be manipulative, just like narcissists, but unlike sociopaths or psychopaths, they do have a conscience and are capable of love. Often, however, their love is twisted, oriented more to feeding their egos (like narcissists receiving “supply”) than truly focusing on the other person. They are good at making themselves look “too good to be true,” seeming to be interesting in everything you are. Some borderline individuals will lie about their accomplishments in order to impress others; other borderline individuals find it difficult to tell the difference between appearance and reality. The latter group can go into a dissociative state and not remember what they did during that state. If you quote the borderline’s statements to you to his family and friends, often they will stare at you as if you are crazy–because the BPD person told you that something happened that, in truth, did not happen.

BPD individuals, like narcissists, psychopaths, and sociopaths, often have a great deal of charm, which they use to their advantage. But the advantage is only temporary as people pick up on the fact that the BPD person “ain’t quite right” as we say in the South. Instability in jobs and instability in relationships may lead to the BPD going through multiple jobs quickly, moving many times, and going through multiple marriages. All relationships are unstable. The borderline person is afraid to lose anyone in his life, yet does not realize that his behavior drives people away. Sadly, the BPD individual is usually miserable inside and lonely, desperately wanting a friend. Most BPD persons do not recognize that their behaviors drive away other people; others may recognize that fact, but believe that their traits are essential for their emotional survival. That points to the greatest problem borderline individuals have in overcoming their disorder: a failure to take responsibility.

So many mental problems are due, in part, to someone believing they are the slave of fate, that given one’s background, one cannot help the way he is. For that reason, he refuses to take responsibility for his actions and blames others for bad things that happen to him. The most difficult obstacle psychologists and psychiatrists have dealing with borderline people is the borderline’s refusal to take responsibility. The borderline often tries to manipulate the therapist. Sadly, many affairs with therapists occur that way. One psychologist told me that of his fellow therapists who fell into affairs, probably over 95% of the lovers were borderline individuals. Since flirtation gains the borderline attention and helps with low self esteem (which only masquerades as high self esteem), many borderlines are extremely flirtatious. Not all will go to the point of a full-fledged affair, but many do.

BPD usually has its origins in childhood. Oftentimes, childhood sexual abuse by a parent or stepparent is the cause–though this is not the only cause. BPD usually manifests in a person’s teens. Some borderline individuals spontaneously recover in their forties; others never recover. Therapy is notoriously ineffective, although newer cognitive methods work better than previous therapies. It is a joke among psychologists that the way to harm an enemy psychologist is to refer a borderline patient to him. If the psychologist can get the borderline person to admit that he is not the slave of forces beyond his control and that he is able to change, the major step toward recovery has occurred.

Are borderline individuals sick or evil? Some borderline behavior seems to be evil: the lying, the manipulation, the willingness to say or do almost anything to get what one wants, the sudden turns toward absolute hatred. I know of one therapist (not my therapist) and one person who works in the criminal justice system who consider borderline people to be evil. In my opinion, most of them do not begin as evil, though, like any human being, they may become evil due to habituation. They are trying to survive something that hurt them so much as a child that they believe that their behaviors are the only way they can survive in the world. They may believe that if they did not behave the way they do that they would fall apart–indeed, their personalities seem to be fragmented. These sad, frightened people need to be guided toward healing–but they must be willing to get help and be serious about it. To anyone who may have this disorder: I pray for them to get help, to engage in positive behaviors that support solid relationships with others, and to find peace in their lives.

For Profit Medicine: An Oxymoron

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As a traditional conservative I oppose for profit medicine. The classical liberal who calls himself a “conservative,” would probably label the previous sentence as an oxymoron. However, conservatives are not all of one stripe. The ethics of medicine must stem from the nature of medicine itself as an inherently moral enterprise. A patient, sick or injured, in need of help, comes to a health care practitioner. The practitioner, whether he be a physician, a D.O., a physician assistant, or a nurse practitioner, has the moral responsibility to use his skills and knowledge for the good of the patient. The profit motive should not enter into the patient-practitioner relationship–if it does, it becomes inherently corrupting.

For-profit hospitals are a monstrosity. When part of the responsibility of the physician is to the shareholders, business decisions often end up trumping medical decisions. This can lead to suboptimal patient care in order to bring more profit to the corporation, especially in a capitation system in which the practice keeps money left over that is not spent on patient care. . Even in “non profit hospitals,” business decisions affect medical care, and business people “run the show.” Hospital administrators are paid enormous salaries (500,000+ per annum in some cases) along with expensive benefits. I know of a case in which a CEO received a huge bonus even though the hospital had been in the red the previous year. Does this sound familiar? Remember the Wall Street bankers.

The American system of medicine, then, is run as a business rather than as a practice. It is no longer a true profession. Physicians are distrusted. Lawsuits are common and sometimes result in big judgments against a physician.

In reading UK newspaper articles about accidents or shootings, I have found (informally) that paramedics and physicians in the UK are more aggressive in starting trauma codes than their American counterparts. This is, of course, anecdotal–it would be interesting if a large-scale study could be done to compare the numbers in both systems. American physicians used to work up to two hours on a patient in a medical code (that did happen with my mother, who lived with no neurological sequelae). Now, three shocks interrupted by CPR, and often that’s it. Twenty minutes, perhaps thirty, and in rare cases, over an hour–but shorter periods are becoming more and more the norm. Doctors will say this is due to the low success rate–still, twenty minutes even in witnessed arrest in which the patient has no DNR is a short time to say, “He’s dead Jim,” given the utter finality of death. Money may play a bigger role in these decisions than medicine. The UK lacks the profit motive in medicine outside the private health facilities there, so the incentive is to keep trying in a code rather than stop in order to save money (I am indebted to my friend Megan for this insight).

Is it possible for a traditional conservative to endorse a non-for profit single payer system of health care for the United States? It has already happened: Paul Craig Roberts, whose conservative credentials are stronger than most self-styled “conservatives,” has endorsed that system. Affordability in the age of massive deficits is the problem, but if the system is run correctly more money might be saved in the long run due to decreasing health care costs–and if tort law is revised so as to protect physicians from frivolous suits, this could help even more. I am not quite ready to endorse such a system, but the more greed I encounter in the present privatized system the more I am tempted to endorse a nationalized system of health care.  It would at least take out the profit motive that is corrupting current medicine and taking it away from its proper ends.

The Boundary Between Mental Illness and Evil

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Was Jared Lee Loughner, who allegedly murdered six people in Tuscon and wounded 13 others, including Congressman Gabrielle Giffords, insane or evil or both? Leonard Pitts and other columnists and bloggers have openly wondered whether “evil” is a more appropriate description of Mr. Loughner than “insane.” Psychiatry and psychology tend to medicalize deviances in human behavior, sometimes to the point that they tone down the role of human responsibility. For example, classifying alcoholism as a disease alleviates the moral responsibility a person may have for engaging in the heavy drinking that made him dependent on alcohol.  Classifying mass murderers as “psychopaths” may be accurate as a descriptive label for their condition (no empathy, no conscience), but such classification does not address the issue of whether psychopaths are evil. There are several bad arguments that someone who medicalizes terrible human actions may use. For example:

1. If person x has a mental illness, and that mental illness contributes to x’s destructive behavior, then x is not morally responsible for x’s actions.

2. Person x has a mental illness.

3. That mental illness contributes to x’s destructive behavior.

4. Therefore, x is not morally responsible for x’s actions.

The weakness of this argument is premise 1. Just because a person is mentally ill, and that mental illness causally contributes to his behavior, does not imply that the person is not morally responsible for his actions. The reason is that the mental illness may be a necessary but not sufficient condition for x’s destructive behavior. X’s evil moral character may still play a causal role as well. Or x’s evil moral character may have causally contributed to his mental illness.

Another bad argument goes as follows:

1. Deviations from normal brain structure are correlated with psychopathy and other personality disorders.

2. If deviations from normal brain structure are correlated with psychopathy and other personality disorders, then the individual with such deviations is not morally responsible for his actions.

3. Psychopathic [mass murderer, swindler–take you pick of crime) individual x has deviations from normal brain structure.

4. Therefore psychopathic individual x is not responsible for actions that are due to his psychopathy.

One problem with this argument is that correlation is not causation. Even if a causal relation could be established, this does not answer the question of which direction the causation goes (the “chicken-egg problem”). Do the deviations from normal brain structure cause psychopathy or does psychopathic behavior cause deviations from normal brain structure? Unless one accepts reductive or eliminative materialism, then one cannot automatically claim that a twisted mind and behavior are caused by an abnormal brain. To make such a claim would be to beg the question on the complex metaphysical issues surrounding the mind-body problem.

I do not know where the exact boundary between evil and mental illness. A rough answer that seems reasonable to me is that if a person’s mind is utterly divorced from reality, then he is not as responsible for his actions as someone who has a firm or even partial grip on reality. Where should that line be drawn? This is the difficulty. It seems to me that psychopaths are evil people. Borderline personality disorder is (and I’m not trying to be “facile”) is a borderline case–but if a person suffering from borderline personality disorder destroys another person’s life, emotional health, and/or reputation due to manipulation and lies, then the person seems as much evil as having a medical disorder. The refusal of many borderlines to get help or take responsibility for their actions are basic elements of an evil character. Munchausen’s Syndrome and Munchausen’s by Proxy fall in the same category–the drive for attention is twisted to the point of doing evil and manipulative actions. I know that many professional psychologists and psychiatrists would disagree. But they do not know everything any more than I as a philosopher know everything. I know there is a level of mental illness that totally removes a person’s moral responsibility for heinous actions.  But since evil is by nature a distortion of the personality, there may be some individuals who are considered to be mentally ill but who are actually evil, or some individuals who suffer from mental illness and have an evil character.  Human beings are a mixture of good and evil, and that battle, as Alexander Solzhenitsyn said, is fought in every human heart.

“Evidence-Based Medicine”: Dangers and Opportunities

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“Evidence-based medicine” (EBM) is a mantra mouthed by many physicians and health care policy makers today. The idea sounds good on the surface: that medical treatment be based on sound studies showing a significant statistical benefit (vs. harms due to side-effects) of a particular drug or treatment. When wasteful and ineffective treatments are rooted out of the system, patients will benefit, and treatments will be more cost-efficient. This is, advocates of EBM affirm, a continuation of the tradition of medicine since the scientific revolution of the seventeenth century: good medicine is based on the best science of the day. What could be the problem with that?

Set the clock back to the 1970s. Medicare and Medicaid, even then, were costing taxpayers dearly. Medical costs were rising rapidly, and policy makers sought some means of controlling such costs. Government officials began to collect data from doctors and from hospitals on the drugs and medical procedures used to treat particular diseases and injuries. This included data on the average number of days spent in the hospital, for example, after surgery for acute appendicitis. In this way Diagnosis Related Groups (DRGs) were born.

DRGs were originally meant to be useful data so Medicare and Medicaid could better know how their money was being spent. But in the early 1980s, Medicare  and Medicaid used DRGs to limit care to what had been customary. These federal programs would only pay for customary care; if a patient had to stay in the hospital an extra day after surgery, tough. Later, private insurance firms established similar policies, policies that ignored the needs of individual patients. Not everyone is “customary” in the care needed. Someone with a fever after appendicitis surgery might need to stay in the hospital an extra day or two, but insurance companies make it difficult for the patient to be compensated.

Now “evidence-based medicine,” if used the wrong way, can function like DRGs. It can be used to place all treatments and patients undergoing those treatment into a single category that ignores individual differences between patients. This can lead to undertreatment, in the case of a patient that needs more drugs or a treatment that “evidence-based medicine” does not support. Or it could lead to overtreatment if a patient has a condition that would normally be considered risky, but that patient is an exception. Take the rule of thumb that more than six PVCs (“skipped heartbeats” that originate in the ventricles, the lower chambers of the heart) a minute are a danger sign. Often I get far more than six a minute–sometimes fifteen a minute, sometimes ten, sometimes with runs of bigemeny (one normal beat, one PVC, and so on), sometimes trigemeny (two normal beats, PVC, two normal beats, PVC, etc.) But after I was given a stress test it was determined that I was one of the exceptions and that these PVCs are not dangerous for me. But suppose a physician followed the general rule and treated me with beta blockers. These carry their own side effects and risks. The point is that even the best evidence-based conclusions may not fit every individual patient. So prudence remains necessary in applying evidence based medicine to particular patients–medicine is based on science, but medicine itself is a practical art. Hopefully, evidence-based medicine will be used wisely to benefit patients and prevent needless or harmful treatments. Applied solely as a cost-cutting measure or applied legalistically without prudence, it can do patients more harm than good.

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