On alternative medicine

The most “open-minded” thing I’ve done this year is to try this so-called natural medicine thing from a consumer point of view. Whenever I tell this story people almost gasp in disbelief: Yes, me, an Australian-trained doctor trying this thing we have been taught since medical school is mostly witchcraft. And yes, I admit, that is (or at least was) my own view on this. The common medical literature tells us “natural medicine” is not scientifically-evaluated, poorly understood because for the most part it’s not in line with the common biopsychosocial model of medicine, and that it’s potentially very dangerous.

Sometimes patients ask me what my views on natural medicine are, and essentially they mean to ask my medical opinion on whether certain natural medicine treatments will help their condition or not. My response is almost always the same: “If you believe it’ll work, it probably will. If you don’t, it won’t”. I don’t know if that’s true, but I’m pretty close to certain that it is true when we are talking about homeopathy. My response is also an acknowledgement to the God-blessed and irrefutable placebo effect. And that is about the extent of my knowledge on non-Western (or alternative) Medicine.

My experience with alternative medicine until a few weeks ago did not leave me with the best of impressions, and they were mostly experiences I had had through my patients. However, before starting to share some of these experiences, I would like to say that I don’t intend to vilify or defame something which I have just admitted to understanding so little, in telling these few stories.

The most recent gimmick I fear for my patients sake are the “full-body scans” that promote themselves as being ‘scientifically-proven’ for the diagnosis of a multitude of vague complaints. They spit out beautiful 3D images and buzz words like “inflammation” or “congestion” and the name of a body organ. Patients pay hundreds of their dollars for the beautiful colour printout they get after having their temperature, blood pressure, pulse, and maybe even respiratory rate measured. But the point is they get what they want because some manufacturer has figured out how to give the patient what he wants (to be taken seriously, to feel cared for, education about his condition, etc.) in exchange for what he wants (money). Oh and how it breaks my heart to have my patient come back to tell me he has stopped taking all his heart medication because the printout said nothing about anything being wrong with his heart only about his spleen being ‘congested’. Or sometimes they’ll come back with a list of obscure tests the naturopath or someone has asked he have checked though you think they are not clinically indicated. So you explain to the patient that those tests may be performed privately, with the cost to the patient, and suddenly they think you are the devil because you are the one who told them about the cost even though it’s not a price you’re setting or something you even think they need… There are many frustrating stories out there from clinicians whose patients have sought the services of an alternative medicine practitioner and some have happy endings and some drastically worse, but what I really wanted to share this week was about my personal experience.

Now, a few weeks ago I allowed my mother to talk me into trialling some “alternative medicine” through a Chinese medicine practitioner one of her friends had recommended. This is the common referral method in this field; word of mouth. So I went along to see this gentleman about a vague diagnosis of “depression” which mum had noted I had increasingly being struggling with (since a recent change in my life circumstances, so probably not even real clinical depression but a temporary low mood). But, hey, I thought I had little to lose so I went. The nice Chinese man with only basic English began by taking a routine medical history and a brief clinical examination (checking some aspect of my pulse and looking at my tongue). He asked about medication I was taking, and after looking at my tongue told me I had a problem with indigestion and ‘loose stools’. He also said I don’t like change and that is why I had “depression”, it was so easy, he said, to see that in me (I call that being human, but whatever).  And he said he could help me if I followed him. Then he took me to another room for acupuncture.

As I lay down on the bed, knowing how “well-educated” people consider me to be, I felt I truly had no idea what was going on and what was going to happen or the mechanism by which it was meant to help my very vague collection of symptoms (including the ‘loose stools’ or ‘indigestion’ which I had not noticed or even bothered me before, and the reactive low mood in response to some changes in my life). I remembered what I told my patients, and I decided to trust the guy about to stick needles in me. I wondered if he could sense my ambivalence and distrust, but truth is it doesn’t take any kind of professional to recognise that in another human being. I wondered just why I was going along with this: To “cure” myself of ailments I probably didn’t even have? To please my mother? To see what all this ”quackery” was about? I think it was a combination of all the above, but despite my reasons, I knew there was nothing imaginary about the needles about to pierce my skin.

He came back in the little cubicle with (to my relief) sterilely-packed acupuncture needles and ethanol wipes. He inserted 11 needles in me, on both sides of my body: 2 near the fibular head, one posterior to the medial malleolus, one on the palmar aspect of my wrist, one just behind each mastoid process, and a final one on the very top of my head into my scalp. What I’ve always being told about acupuncture is that they use tiny tiny needles; what I didn’t realise until the day of my first session was that these tiny needles still hurt! After I had the needles inserted, I was left in the cubicle for 30 minutes and a soft harp music was played over the speakers.

I didn’t know what I was supposed to think about for those 30 minutes, so I started thinking all sorts of things. I couldn’t move because every time I moved, sharp stabbing pains would shoot through the spots where the needles were in me. First I thought I was meant to focus on the music and just relax, however I was in the middle of an Asian-dense shopping centre and people were talking and shouting and that kept distracting me. Then I thought I might focus at the point tenderness the needles were causing me, but that got old pretty quick too. So I started to try to decipher how the whole acupuncture thing works. The guy who put the needles in me hadn’t explained it to me, but actually I remembered that one session in medical school where we briefly discussed about alternative medicine. It was something about Chi channels, which don’t correlate to lymphatic or nervous or vascular channels and have possibly no anatomically corresponding structures to account for them. Then something about the balance of the Ying and Yang, which are some metaphysical constructs related to health and life in general… Oh Gosh, I was half making it up and I was still no closer to understanding what I was at that moment meant to be going through.

Finally the 30 minutes were over and the Chinese medicine practitioner told me to get up and follow him. He asked how I felt. Um, I felt like I had just had being laying down for 30 minutes listening to relaxing music while having needles pierced in my skin. What was I meant to feel? Spiritual enlightment? Physical invigoration? Relaxed? I felt relieved, honestly, because my neck was sore and I needed to change my posture. So that’s what I felt, relief; but I didn’t think that that was what the nice Chinese man wanted to hear so I said I felt “better”. I remembered how I sometimes treat patients for things they don’t fully understand (though I try to explain) like hypertension. I tell them the medication won’t make them “feel” any different, let alone any better, it’s not meant to. They may not feel sick, but untreated high blood pressure increases you risk of things no-one wants to have like heart attacks and strokes. So they take the medicines I give them though they don’t notice any change, except maybe some side-effects, and they trust the 2 minute explanation I have given them as to why it’s good for them. I felt a bit like that with my Chinese medicine practitioner, though he asks me how I feel. I like this guy, he’s a nice man, he is trying to achieve something with me here, so though I don’t know what the right answer is, I don’t want to call either him or myself a failure... Better, I must feel better.

He charges me more than I would charge a patient for a consultation of equal duration and he picks out some pill boxes from his shop, all in Asian writing I can’t understand. He says take 40 of these tablets twice a day. What?! No, no, it’s fine, he says. He tells me he can “guarantee” they aren’t going to cause any side-effects; that they are free of these evil “chemicals” the medicines I prescribe have. Of course, they are “all-natural”. I ask what they are. They are “natural remedies” with “natural” ingredients to treat my loose stools and indigestion. Oh yeah, those things that weren’t even causing me any discomfort. He books me in for a further 4 acupuncture sessions which will make me feel even “better”. My heart sinks because my mother has heard this whole exchange and she’s ecstatic!

I went along to the other 4 sessions, my mother kindly driving me in and even offering to pay my fees. My mood is still a bit low and my self-esteem a bit shattered from the personal difficulties I had faced a few weeks earlier, so I don’t have the courage to say no. I even take the 80+ tablets twice a day for a few days until I get constipated… At my second acupuncture session he asks whether I have stopped taking my other “non-natural” medicines yet. I didn’t know I had to, but no, I haven’t. I understand the potential side-effects from stopping my medication abruptly. A cold chill goes through me thinking that this is exactly what my patients face, and no wonder they do stop their medications and suffer the consequences. It seems so cruel to me. He asks if I feel better. Well, time is helping heal my emotional wounds that had being inflicted some weeks ago, and I’m pretty sure that would have happened despite the “natural remedies” and acupuncture; but yes, nice man, I am better. Is the “indigestion” better? Am I free of the ‘loose stools’ yet? Yes, nice man, I am free of those things I didn’t even know were problems... Eventually, I’ve spent so much money, I have got so much “better” (judging by what I am telling the nice man), and my self-esteem and normal affect have returned that I just can’t continue this whole thing.

And am I better because of the intricate placebo I have just trialled? Or am I better because I never was ill? I don’t know, but I have at the least realised the effect of faith has on healing. When my patients seek alternative medicine methods, they are usually at their most vulnerable and desperate to be well again. I would be better to see them more frequently, to engage them, to ask (maybe demand?) improvement from them. Maybe if I keep asking them if they are better, maybe if I keep seeing them once or twice a week, maybe if I make them believe the challenge is not just his but his and mine, maybe if I keep asking him to take his medication time and time again, maybe if I pay him personal human to human attention, he will get better. And I think that is the lesson in this for me: that is the kind of practitioner we need to become a bit closer to being, rather than leaving all these tasks to the alternative medicine practitioner, who may or may not also give the best medical advice.

On money and healthcare: Rights & Priorities - Part 3/3

As a doctor you often see people in a very vulnerable state of health walk into your room. Your job is to provide some sort of health care to that person. It is a paid job just like anyone else’s job for which they trained and invested time, effort, and money. Why any of us decided to become doctors and not hairdressers, teachers, politicians, carpenters, etc., is different for everyone and that is not the point. The point is we are workers same as anyone else doing any job. You do the job for a certain amount of hours, you get paid for doing that job, and then the money is yours to do as you wish. That’s the essence of working in a capitalist, democratic country like Australia and the U.S.A. regardless of what your job actually entails, right?

The doctor is a bit like a hairdresser or an accountant or a lawyer or a politician in that he doesn’t physically sell you a product, but rather a service. A patient walks in, you carry out an assessment, work out what he needs, and advice or give that treatment required. Patients don’t leave the room with a new bag filled with products they’ve purchased, but the same thing happens once you leave your hairdresser or accountant – and yet you are aware you need to pay for the service provided to you. And yet you could say that the service provided to you is at least a little more essential than a haircut or advice about things other than your health. One of these things could potentially be the difference between life and death. I have never heard of anyone who risked death by having long or unkempt hair…

So here is the dilemma I wanted to get to: health, or the access to health care is an essential human right; it is a right every human being regardless of who they are or what they possess deserves for the simple act of having being born human. In countries where there is widespread poverty and having no money really means having no money (i.e. none to spare on food or clothing or housing, and not just meaning poor as in having no money for a tv, a car, a haircut, a holiday, or entertainment, etc.), having a right to free access to health care is one of the great achievements of humanity.

So why am I singling out ‘poor’ countries as separate to developed countries like Australia? Because in developed countries like Australia, we believe that if we can’t afford a holiday or a car or costly entertainment that we are poor. And we don’t want to miss out on these things! To a person in a wealthy country like this, we believe that these things are our rights too - and God forbid that we miss out on these things to pay for what we now consider non-essentials, such as our health care. And that is the cause of the dilemma in wealthy countries: we have for the most part changed our priorities as to what is considered essential and non-essential. Yet we all have a sense of what our human rights are. I will tell you that in Australia we see time and time again people who hesitate and complain about having to pay an out-of-pocket fee to have their health tended to, but will without hesitation hand over large amounts of money for haircuts, for manicures, for holidays, for fancy cars, for video games, movies, etc. And yet, only one of these things could potentially be the difference between life and death…

I don’t know what the right answer is. And I don’t know what the best system of health care is. Surely everyone deserves the right to access health care regardless of what they have or who they are or what they do with their lives. Yet, surely, we have also come to some concerning conclusions when tending to our health is considered less of a priority than funding our non-essential commodities. Personally, I have only ever considered the doctor’s role as equivalent to the mechanic’s, to fix the machine so the machine can go where it chooses and do what it chooses. Doing our job doesn’t make us special people, we just do a special task. But it is a job same as being a mechanic is a job - and in this society, a job implies compensation. Doctors eat too and pharmaceutical companies are not charities, so the reality of it is that health care has become a business. It’s not ideal, but it is the reality.

On money and healthcare: Work & Subsidies - Part 2/3

In Australia, up to 80% of general practitioners accept the rebate provided by Medicare as the total cost of their medical consultation service. Essentially that is to say that they provide to Australian citizens with a Medicare card a “free” consultation service with no out-of-pocket cost to the patient (excluding medications sold through a private pharmacist). That’s a great thing for patients! They can’t use the ‘I don’t have enough money to go see a doctor’ excuse too often since most GPs will see them for "free". Of course, the doctor has to get paid, too – because medicine is a job, not a charity – and Medicare will pay him for doing his job. However, remember, how Medicare is a rebate and not meant as full payment of the doctor’s service?...

There is a big group of people in non-government health care systems (e.g. private allied health professionals, private medical specialists, and around 20% of general practice doctors) who don’t accept the Medicare rebate as full payment for the service they provide. Are they the “better” health professionals, worthy of more money than Medicare provides for? Are they greedy ‘fat cats’ like some politicians will call them? No. They are the same as other health care professionals providing similar services. Often they are the same people who will see some patients at a fully-subsidised cost or charge an additional fee on top of the rebate. They’re not bad people; they are just people in paid employment. They’re people working in a private system practising within their legal right to set their own fees for their service, often actually very realistic fees to cover the true costs of doing their job. Unfortunately, because both types of practitioners operate within the same country, the one who charges what he or she has deemed his service is worth is seen as some sort of evil, money-hungry, exploitative person. Conversely, the one who provides “free” (to the patient) services is often considered less than – and this is what most general practitioners in the eyes of the public are seen as.

On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.

On special occassions

The last time I celebrated a birthday I was 10 years old. People have since asked me if I miss it, is my life boring, do I not receive or give gifts, how can I live a year without having one day of that year designated as special for me? And I’ll tell you honestly, I have not for one day missed it. I could tell you that I don’t enjoy ‘worldly’ so-called “special occasions” because of my religious beliefs, but that’s not the truth. I have in the last week, the week since turning thirty, further cemented my reasons for disliking these kinds of things.

A few years ago, in the week after the Christmas holidays, I found myself in a very interesting scenario while waiting in line at a bank. The bank had been closed a few days over the holidays so I figure that’s why it was particularly popular when it reopened. Tinsel, Christmas trees, coloured lights, and all sorts of Christmas paraphernalia were still around everywhere. Of course, in the week prior to this event the shops had been full of people buying things for others, songs about gifts and Santa (or Jesus), and huge banners reading things about “peace”, “love”, “goodwill”, “sharing”, the goodness of the human (or Christmas) spirit, etc., etc. The atmosphere had been set to inspire the best of humanity, albeit an atmosphere set up by commercial enterprises under the guise of being just a good concept, a religious tradition, a familial tradition, or a combination of any of those things… but I’m digressing.

So, as I waited in line at the bank, an argument broke out between two of the people waiting in line in front of me. I don’t even recall what the argument was about, but it was between a woman who looked to be in her 40s and a man of around 70. It was clear they were strangers to each others and pretty soon they were shouting, calling each other derogative and obscene names, and threatening violence towards each other. The rest of us in the bank stood stunned watching this scene. It continued until the old man said to the woman “Well, merry christmas to you, too”. His words pierced me very deeply because (to me, at lease) it highlighted the irony and hypocrisy of these special occasions.

You know what we do on special occasions? We give gifts. Gifts of our time, effort, material things, courtesy, respect, congratulation, thoughtful gesture, unselfish sacrifice. It’s wonderful to give these things – and to receive them! But… but, that’s exactly what breaks my heart about it. Is that all I’m worth? One day out of every 365? And it’s often not out of the ‘goodness of anyone’s heart’, but rather only because some external party has decided that a particular day constitutes a special occasion. Don’t get me wrong, though, I appreciate the good wishes as much as anyone else, I just can’t deny that some of it feels like tokenism. And you know what I wish most for in the world for my birthday, for Christmas, for Easter, for labour day, for Monday through to Sunday, January through to December? The essential things we all desire of each other every day: love, attention, respect, a smile, a minute of your time, and to know that I’m actually worthy of these things more than one day a year from those that mean a lot to me.

Thanks for your time, guys.

On telling

I remember as a medical student being told by a psychiatrist who was teaching us about clinical communication skills to always ask yourself “is this for the patient or for me?” A little bit of self-disclosure in clinical scenarios is helpful; it helps establish rapport, trust, and confidence that the person we have entrusted with our psychological care knows exactly what it’s like to be human. That’s the purpose of self-disclosure in medicine, that’s how we can justify telling patients our sins, our glories, and just our everyday occurrences. Besides that, all we are being paid to do is provide a clinical service of diagnosis and treatment. Needless to say, it’s not appropriate to start telling our patients intimate details about our personal lives and thus introduce potentially biasing information that will impact on the patient themselves or their views on us as their clinician or the clinical advise/treatment we provide. But this rule about what we tell and don’t tell got me to thinking to how it applies to life in general, not just as it applies to health professionals.

Two key features of a successful and happy relationship are honesty and trust. You want to be able to trust that your spouse/partner/friend/business associate/etc. is an honest person that does not lie or betray you, right? But at the same time you need to be able to trust that they won’t, otherwise the relationship will be ruined by the constant questioning of their (or your) honesty. Consider, for example, an ideal romantic partnership where the two people involved love and care for each other and have romantic interactions exclusively with each other (including sex, but also other forms of physical or psychological intimacy). That would be a good relationship, right? But what if a similar scenario arose where the two people involved in a romantic partnership love and care for each other and have romantic interactions exclusively with each other BUT the partners were repeatedly asking of the other: “have you slept with anyone else today?”, “have you told any lies to me today?”, “do you love me still today?”, etc. etc. Now, the other partner could repeatedly be honest and say “No”, but isn’t it likely that this good and honest relationship will be destroyed by the lack of trust?

Now consider a scenario where you have the trust but not so much the honesty. You could, for example, have two people who love and care for each other but their romantic interactions are not exclusive to each other. They may every once in a while have sex with other people. They don’t, however, ask of each questions of fidelity, it is only assumed – they assume the other person is honest or sexually monogamous or that they have romantic feelings only for them. You could say that these are either happy human beings or you could say that this is not a good relationship, even if the two parties seem outwardly happy with themselves and each other. You may say that even if everyone it is happy then that happiness is invalid because it is predicated on dishonesty – or better said: lack of honesty.

This ‘happy couple’ to me poses a very interesting human dynamic, because as happy as the members of this couple are and as happy as the whole scenario is, it often fails. And it doesn’t fail because of dishonesty or mistrust. No, it fails, because of misplaced and selfish honesty. Again, let me repeat the scenario. There are two people who love and care for each other and are not unhappy in their relationship, but one (or both) of them engages in an act of intimacy (however you wish to define it) with another person (or persons). They’re not unhappy with each other, their relationship works and is otherwise normal. The relationship can function this way for months, years, decades, or until death parts them. What’s wrong with that? What’s wrong with having a happy life and a happy relationship, right? Well, probably nothing, except that it rarely happens. And I’ll tell you why.

After one of the members of a partnership has committed an indiscretion to whatever gravity, something happens but not to the partner who may be blissfully unaware or to the relationship which still has as much potential as it did before, but something happens to the offending partner. You know what it is? Guilt. Guilt creeps in, escalates by the minute, and this thing we call a conscience tell us that we should tell our partner what we did. It goes over and over in your mind, you convince yourself you are a bad person, you are convinced what you did was wrong, but overwhelming the feeling is guilt. Tony Robbins once said that guilt is really a trigger to correct your behavior, it means you have a standard which you haven’t met and as a result of this failure you feel guilt. That’s the point of it, to correct behavior back to what your standard is.

The truth is most of us do sign up to relationships to be an exclusive intimate partnership between only two people; that’s our standard. That’s what we expect to receive and that is what we expect to give in the partnership. So when we fail, when we don’t reach our own standard, we feel guilty. But what a lot of people do is mistake the trigger to change our behavior for one of simply anxiety or an unpleasant sensation. Therefore instead of thinking that what we need to do is change the behavior, we become convinced all we need to is just to relieve the guilt. So maybe we’ve stopped doing what we once did that caused us to feel guilty initially but we continue to experience the guilt because we can’t forgive ourselves. And we’ll keep feeling guilty until the day we decide to do two things: 1) meet our own standards, and 2) forgive ourselves. The second part is actually a lot more difficult than the first one is, so we often – mistakenly – substitute it. You know what we do when we can’t forgive ourselves? We ask others to forgive us.

When you can’t forgive yourself for cheating in a relationship, even if it was a once-off, we often make the mistake of asking our partners to forgive us. And we ask not because we care about them or because we love them and think they deserve to know the truth. No, I don’t believe that at all (although that is what we tell ourselves and our partner)! We tell of our indiscretions purely as a selfish way to ease our anxiety and guilt. This is what I mean by selfish honesty. There is nothing honorable about wiping your filthy hands on someone else just because you want to have clean hands again. That is selfish, self-indulgent, and spiteful. Don’t get me wrong, though, there are cases when we must confess to our indiscretions, such as, if we have placed another person’s health at risk or there are legal ramifications to our acts, etc. And here is where we need to ask ourselves: “is this for the other person or for me?” What exactly do you expect to gain?

If we tell our stories purely to ease your guilt, then don’t expect a reward for your honesty. I think that is so banal. Yet that is often what a lot of people do, confess their “sins” to their partner, tell them that they are confessing because they didn’t want to lie to them anymore (even though they had caused the other person no harm at all), and then expect to be forgiven because that is exactly what they need to ease their guilt. That is an even greater violation to the relationship. We shouldn’t use our partners to wipe our conscience. If the anxiety of holding a secret is really tearing us apart, if the guilt of what we’ve done is eating us away, there are more responsible ways to deal with it. As I said, what you really need to do is change your behavior. And if you must tell, tell a friend or pastor or psychotherapist, etc. The only reason we should tell our partners - hurt our partners, their self-esteem, their self-worth, their trust, their sense of identity, their faith in you – is to benefit them, not selfishly ease our conscience. And then we must expect not forgiveness but consequence. 

On being old enough to know better

Dave Chappelle, comedian, does a very funny yet thought-provoking skit on age and responsibility. The question arose about musician R. Kelly’s 2002 arrest for urinating on a girl who at the time of the alleged incident was 14 years old. The girl in question at one point is said to have consented to being peed on, but still everyone criticized Mr. Kelly because in either case the “girl” was underage and shouldn’t have been sexually involved with an adult. Poor girl, right? Didn’t realise the consequences of her consent, etc. etc.

Then another incident Dave Chappelle discusses is about Lionel Tate, who when he was 12 years old was play-wrestling with a 6 year old girl using moves similar to what he had seen TV wrestlers do. The 6 year old girl died from injuries sustained from this “game”. The boy was arrested and sentenced to life in prison without the possibility of parole. Apparently he should have known by the time he was 12 years old that his actions have consequences, etc. etc.

Finally he talks about Elizabeth Smart, a girl who when she was 14 years old was abducted from her home and taken captive by a couple who lived not very far from her own family home. According to the way Dave Chappelle tells it, she wasn’t physically restrained or locked up, but was advised by her captors not to flee. She obeyed. She remained at this site from June to August 2002 before being relocated elsewhere for a further six or seven months. But for at least two months she was situated very close to her own home, possibly within walking distance, often unsupervised at this place, not locked up or restrained – and yet she remained docile to her captors without allegedly even attempting to flee. Of course, it was unfortunate and not her fault at all that she was abducted, but shouldn’t she have known by the age of 14 years that her actions have consequences, that she could and should act, etc. etc.? Poor girl, right? Didn’t know what to do.... But wait, Lionel Tate knew exactly what to do and how to do it apparently by age 12!

The reason that these stories have come to my mind recently is because of the “poor boy” who was arrested in Indonesia and is being tried for drug-related charges. He is an Australian citizen and he is 14 years old. Those two facts are the main reasons we are enticed to have sympathy for this “boy”. He is alleged to have bought drugs while on holidays in Indonesia. Apparently he didn’t realise the gravity or consequences of his actions either because of his young age or because of his alleged addiction to the drug he sought, etc. etc.

So how old is old enough? How old is 14, really? Old enough to know better, or too young to know what you’re doing? If it’s not old enough, then let the “poor boy” in Indonesia out of prison to live his life and learn what is good and what is right and what isn’t. And let 14 year old girls decide if they want to have sex with adult men or whether they want to get peed on or not without prosecuting the adult involved. But if 14 is really too young to know better, then Lionel Tate deserves a big apology for the malice attributed to him when he was 12 and killed his 6 year old playmate. Luckily for him, this did in fact happen and he was eventually released from prison and went on to learn what is good and what is bad... (Almost a “and he lived happily ever after” story, except for the fact that when he was released from prison he went and committed other crimes  that bought him a fresh 30 years incarceration that he can no longer blame on his young age.)

The ability to make “adult” human decisions relies on the prefrontal cortex of the brain. This part of the human body does not reach its full developmental peak until you hit your early 20s. To me this has some interesting implications not only related to criminal law (as demonstrated in the examples above), but also to medical ethics, and to psychosocial development. In medicine we accept that children (by Australian law, under the age of 18 years) may competently consent to some things like taking a contraceptive tablet, having a blood test, allowing a physical examination by a health professional, etc. By the same token, the same person at the same age may be considered not competent enough to consent to, for example, reproductive sterilization or an organ transplantation / donation. It’s a matter of being competent enough, recognising that a person’s cognitive development is a dynamic thing evolving across multiple tracks until, hopefully, they all eventually reach a maximum and you reach your “adult” competence stage.

The other interesting thing about this gradual stepwise development in our ‘human nature’ relates back to the previous discussion on criminality. Maybe instead of focusing on “is 14 years old enough to be considered responsible for a crime?”, we should consider “is this person who is still in the dynamic stage of their cognitive development able  to be taught or rehabilitated to make choices that will decrease their chances of becoming further involved in criminal activity in the future?” Remember Lionel Tate? He was 12 in 1999 when he killed the six-year-old girl. In 2001 he was sentenced to life in prison without the possibility of parole. He was later released on appeal in 2004. In total he was in criminal detention from the ages of 12 until he was 17. What did Lionel Tate learn from the ages of 12 to 17? Who knows. But this would have been an amazingly opportune time to teach him exactly what the consequences to a person’s actions are, what taking responsibility means, how to get ahead in life without victimizing others for your own advancement. Would he have been a different person if this had happened? Who knows. But really, what have we got to lose?

On euthanasia

Jack Kevorkian served 8 years in prison for second-degree murder, that is murder that is not “premeditated”, or what you may also describe as murder that is not ill-intentioned. Essentially, he was a doctor that assisted many ill patients to die; what we commonly call euthanasia. He argued that he was imprisoned for being merciful, and that his merciful acts were to procure or hasten the death of other human beings. They were merciful because he aimed through his actions to liberate the person from suffering due to illness – when this person had indicated that they wanted or needed his assistance to do just this. The law said that regardless of the intent, procuring or hastening someone’s the death equates to murder and this is illegal even if the other party consents and requests it.

Now, a lot of the issues surrounding euthanasia and death legislation are about semantics, and to a lesser degree also intent. I remember first learning about euthanasia in a bioethics class, and I will describe it briefly now as I was taught it. There were four categories of “euthanasia” described:

1) voluntary active euthanasia (where the patient voluntarily requested help in dying and another person actively helped him achieve this) – E.g. a person asking someone else to inject a fatal substance into them.

2) voluntary inactive euthanasia (where the patient voluntarily requests help in dying and another person acts by withdrawing or ceasing an action that is helping the patient stay alive),  - E.g. a person asking someone else to pull out all tubes providing life-saving support like oxygen or fluids, etc.

3) non-voluntary active euthanasia (where the patient does not actually request or oppose help in dying and he is acted upon so as to hasten his death), - E.g. a non-communicative or possibly brain-dead patient who has made no prior indication of his wishes in this situation being given a fatal substance to hasten their death.

and  4) non-voluntary inactive euthanasia (where the patient does not request or oppose help in dying but another person acts by withdrawing or ceasing an action that is helping the patient stay alive). - E.g. a non-communicative or possibly brain-dead patient who has made no prior indication of his wishes in this situation having all life-supporting measures like oxygen or fluids withdrawn.

“Non-voluntary” is used as opposed to “involuntary” because involuntary implies that it is against the person’s wishes whereas non-voluntary simply that it is not opposed nor is it specifically desired. For example, involuntary active euthanasia could be thought of as common first-degree murder where a person does not want to die but he is purposely killed. Involuntary inactive euthanasia could be akin to a person actively asking for my help to avoid death (which I can presumably prevent by some action) but I withhold from providing this life-saving thing. This is a crime similar to murder in many countries too.

In most countries in the world what the law forbids are active forms of euthanasia, and in fact inactive forms of euthanasia are quite readily accepted – and legal. Every day in intensive care units patients are non-voluntarily actively euthanized, when their treatment is deemed futile by someone other than the patient themselves. And our right to “voluntary inactive euthanasia” is hailed one of the great achievements in medical ethics when doctors were disrobed of the expectation of paternalism to have that same power handed back to the alert, competent patient, in the form of autonomy. Any patient in the world can refuse any treatment in the world even if that treatment is considered life-saving. You can even write down your wishes when you’re still able to communicate them for future reference, for those times when you are non-communicative or no longer medically-competent. But I am digressing here, I could go on for hours on medical ethics, but what I really wanted to discuss is active forms of euthanasia.

Take religion and law away from the argument for a moment and try to discuss why euthanasia is “wrong”. Well, they tell us, it’s inherently bad because it has the potential for abuse and you run the risk of evil people wanting to just kill whoever for whatever trivial reason. Reasons such as, maybe, “he’s no good to society anyway”, “I don’t like him”, “he is of this race or culture”, “he’s poor”, or “he has no family”, or “he will cost more than I am willing to spend to keep alive”, etc. etc. There are many things in medicine with potential for abuse. We often hospitalize and treat the mentally ill; we force-feed those with eating disorders; we prescribe medications with known side-effects; we terminate the lives of foetuses for whom we can’t prove either way whether they are “persons” with an independent right to life or not, etc. I even heard it once said that one of the biggest mistakes in medicine was the idea to try to keep premature babies alive at all costs. Many of these babies will have chronic health problems, and the expenditure on neonatal intensive care units is massive. Some would say we have abused the technology in life-sustaining measures by trying to apply it to each and every patient, even these tiny babies which we are potentially setting up for terrible lives. My point isn’t to argue if these tiny babies are worth it or not worth it; my point is that we do entrust health professionals with many life and death situations all the time. And we do this because we have assumed they won’t abuse their powers just to see a new technology or treatment work without thinking of the consequences.

So then, why else is euthanasia “wrong”? They say because we could make a mistake – and the consequences of that mistake is not reversible. Again, doctors face this potential every day! I think that if you were to filter it down, the real controversies with euthanasia are 1) religion, 2) law, and 3) an expectation (or perhaps misconception?) that the overriding aim of medicine is to prolong an individual’s lifespan (as opposed to other aims like preserving their dignity, ensuring quality of life, and having a social responsibility to the rest of our fellow humans). Unfortunately, like many things in life, when you use one rule to apply to everyone in every situation, you will often get it wrong. Many people do not like to think that their doctor could have the knowledge or ability to perform euthanasia, because they assume doctors are special and, like I mentioned, should only want to prolong a person’s life. However, I believe that keeping euthanasia from the scope of medicine isn’t keeping us from any evil we aren’t already at risk of committing. I also don’t support allowing the scope of euthanasia to evolve without the input of medical professionals. If you’re going to do something, do it right. This is called harm minimization, and is not a new concept to medicine at all.

But why do I personally believe that euthanasia isn’t bad (if it were able to delivered effectively and without inflicting further harm or pain)? Because I believe that every person is free and free to choose to live their life how they choose. I also think it is cruel to deny someone something, especially their freedom of choice, simply because they need someone else’s assistance to achieve their goal. Imagine being denied access to the top floor of a building because you are a paraplegic in a wheelchair and the building isn’t equipped with elevators or ramps. Now, imagine that the reason you want to get to the top floor is because on the ground level where you are there is a fire that keeps intensifying. Don’t you wish someone could help you? But no-one can because then they will be arrested and they would rather not go to prison, even if they’re your friend or relative and they love you. So you’re left to fend for yourself. No-one bans you from going to the top floor, it’s simply a shame you can’t get yourself up there – and that is your only option! Oh well, better just wait for the fire to intensify, your skin to burn, and to watch yourself helplessly, and probably painfully, die. You knew all along that upon going to the top floor you’d only fall asleep and die up there, but hey, wouldn’t it have been nicer? Apparently not. Apparently it is nicer to allow our much-esteemed friends and family members to die in pain and helplessness.

And yet, having said all this, I have to clarify one thing for fear of being called out on my inconsistencies. Fortunately or unfortunately, I am Christian first and foremost, so no, I personally would not help a patient in this way. But I have tremendous respect for people like Jack Kevorkian who were/are courageous enough to serve their patients at all stages of life. Death is simply another stage of life.

On courageous conversations

Last week I attended an education session on Aboriginal and Torres Strait Islander cultural awareness. The intent was to help health professionals engage better with this subset of the Australian population, and as such “close the gap” between the health of non-indigenous and indigenous peoples (who fair terribly worse in morbidity and mortality). The session was run by a man who identified himself as an aboriginal man and he explained various aspects of what is culture from a psychosocial and semantic perspective. It was interesting and he spoke of a thing called “courageous conversations” – you know, all those touchy subjects on elements of our society which if we comment on we’ll be called racist or bigoted or misogynist or otherwise prejudiced. Racism and the history of Australia (or the U.S.A or South Africa or so many other nations) is one of those touchy subjects. So we all listened to the discussion he presented and he played Professor Michael McDaniel’sreconciliation speech and made passing reference to Kevin Rudd’s “Sorry”speech. The things spoken by these two men are along the same vein, but stated quite differently.

On the 13th of February, 2008, Kevin Rudd, the then Prime Minister of Australia gave a speech to acknowledge the past evils that had been afflicted systematically on the indigenous peoples of this nation. The other purpose of the speech was to apologize to aboriginal peoples of past, present, and future who had been (or will be) disadvantaged or hurt as a consequence of the shameful government policies that existed to purposely suppress aboriginal peoples. The speech was symbolic and groundbreaking, intent on paving the way to improving things in future and learning from past mistakes. This very loud gesture was meant to benefit not only the Australian indigenous people who for decades had had their history and rights suppressed, but also of benefit non-indigenous peoples by empowering them with knowledge and freeing them from the guilt of knowing that their ancestors had done something wrong but they now had the chance to right their wrongs. It was by all accounts a very admirable gesture by the leader of a nation.

Professor Michael McDaniel, an aboriginal man who is also Dean of Indigenous education at the University of Western Sydney, also gave a speech related to the reconciliation process that was occurring in Australia. He told one story of a non-indigenous solicitor who met some elders of an indigenous community and tried to tell them that he was aware of the unfairness and mistreatment indigenous peoples had suffered and he had a plan to propose some “reconciliation”, in this case something akin to acknowledging the land rights of the indigenous first occupants of that land. The aboriginal elders when he had finished his courteous and respectful talk, retold him the history of the Aboriginal people. They told him how his ancestors had raped, stolen, killed, desecrated, abused, and hurt their people in previous generations and how the current generation of their people is still suffering because of his people. The young solicitor was taken aback, surprised, and feeling blamed! What do you say to that? You say sorry. And when you say sorry the better man forgives, right? Right. That’s what we do in our culture, but not everyone’s culture is apparently the same in this respect.

Now, I have varying notions of what a sense of responsibility is, but for a while you have to consider yourself in the young solicitor’s shoes also. Prof. McDaniel explains that to the elders they were simply telling their story in their way, that they needed to do this, to vent, if you will. And at that second when the elders meet this young successful non-indigenous man, “For that moment you are Captain Cook. You are Arthur Phillip. You are the Mission Manager. You are the representative of everyone who did those things”. But you may wonder, why should he be designated the “representative of everyone who did these things”? The logic goes that it is because it is as an acknowledgement that the system and society we currently live in was built to ensure the success, exactly as he has, of a non-indigenous person like him and not of an indigenous person like the elders. So is he at fault because he is successful? Prof. McDaniel doesn’t state it quite like this, but he states that the systems that exist are at fault, they’re the “bad” ones. And yet in the middle of all this is a young man trying to do the right thing given what he has. Prof. McDaniel states he just has to “cop it, because it’s part of the healing process”. I know, I was outraged at his logic too. But you know what? Apparently it's hard for us to understand, he says, because (and I am paraphrasing here) ‘as a young non-Indigenous person, we’ve never had a sense of belonging to a society. We’ve never had “a collective sense of responsibility”’.

Honestly, I liked Kevin Rudd’s speech better. I liked it better for two reasons. As a Christian I always remember that scripture in Ezekiel 18:20 that says, “The one who sins is the one who will die. The child will not share the guilt of the parent, nor will the parent share the guilt of the child. The righteousness of the righteous will be credited to them, and the wickedness of the wicked will be charged against them”. Acknowledging our ancestors sins is one thing, we can even apologize for them and regret it on their behalf, but as for being “punished” or held accountable for it, I believe is a bit rich. My second reason can be summarised in this quote by Antoine de Saint-Exupery: “To be a man is to be responsible. It is to feel shame at the sight of what seems to be unmerited misery. It is to take pride in a victory won by one's comrades. It is to feel, when setting one's stone, that one is contributing to the building of the world”. Guilt is a useless thing unless it motivates forward action. It is honourable to take responsibility for righting wrongs even if they weren’t committed by us. It is not honourable to use punishment unless your aim is for retraining. If your camel is already walking to where you want it to go, it is only cruel to continue to beat it.

On being in love (...and being too good)

In 'By the River Piedra I sat Down and Wept' Paulo Coelho tells the story of a boy and a girl who grow up together, get to form a very close bond, but then grow up to have separate lives. The girl goes off to the city and studies at the university. Meantime, she learns of life by working whatever jobs young college students do, and she meets a lot of people who teach her about travel, love, sex, philosophy, etc. She becomes what you could call a very ‘worldly’ woman; a modern educated woman with no theological or philosophical constraint to limit any of her experiences. The boy grows up very differently. He enters a seminary and becomes a spiritual guru of sorts. He is respected and generally considered a very holy man. The boy and girl meet up again as man and woman and what was once an almost fraternal relationship becomes a romantic one. The girl feels inadequate because the boy’s profession requires that he travel, that he dedicate his “free” time to meditation, study, and consideration of deeper greater things, not the mundane things like being a partner in a romantic relationship. He doesn’t tell her this, but she knows it. She wouldn’t ask him either to give up his “gift”, his vocation and talent just to be her husband, boyfriend, lover, or whatever when he could be inspiration, intervention, guidance, and illumination to so many other human beings who need him too. And not to mention the fact that you may consider her a worldly, maybe even ungodly woman, and you may consider him a man truly of God.

One of the most horrible things a man has ever said to me was “you remind me of Jesus”. Now, I’m a Christian and I try to live my life as best I can so you may ask why would that be offensive to me and not a compliment? Because no-one has ever desired Jesus; no-one has ever desired to marry him, to make love to him, to kiss him softly and romantically on the cheek. Of course not. So many of us admire him, worship him, and love him with a firm spiritual belief. But you don’t fall in love with Jesus. No-one ever fell in love with me! And so this man telling me this was such an eye-opener for me; a cold glass of water across my face. Sure we all want to be good at something, but more than anything don’t we all just want to be loved? I think we do. I do.

The other very hurtful thing said to me, and it has been said to me on far too many occasions, was that I’m “too good”. Again, you could say ‘but that’s not an insult!’ No, it isn’t, but try having it said to you time and time again that “you’re too good for me”. Too good; not just good or good enough, but “too good”. Too good for this person to be with you, to love you, to take the risks we all do in love; “too good” for them to even try. There are a lot of people out there with self-esteem issues, and yet this isn’t distinctly the reason why people were telling me that I was “too good” for them. No. It had simply become the new catchphrase like ‘it’s not you, it’s me’, which was a very sensitive way to simply end a relationship you didn’t want but that exonerated you from being the “bad guy” who broke the other person’s heart. So you tell a sweet, sensitive lie like “it’s not you, it’s me” or “you’re too good for me” or “you deserve so much better than me”. Suddenly you’re the hero who is making a sacrifice for this much “better” person. Gee, they should be grateful you’ve broken their heart!  And they would be, if only we didn’t all know that these very nice reasons are just words. I must admit, I personally have used the ‘you deserve better than me’ or ‘you’re too good’ spiels too when I didn’t want to feel bad about ending a relationship I wasn’t dedicated to.

You know what happened to me one day, though? I actually did meet someone I felt was too good for me. And you know what I did? Two things: 1) I became selfish, and 2) I fell in love. Anything is worth it when you’re in love. Mark Twain tells of how when he met his future wife he was a drunkard, poor and indebted gambler. The woman he fell in love with came from a wealthy and educated family. She was too good for him, clearly! But you know what he wrote? “I wouldn't have a girl I was worthy of. She wouldn't do. She wouldn't be respectable enough." He was quite aware of his circumstance and he knew he was being selfish in trying to convince the girl’s father that, yes, he’d most likely ruin his daughter’s reputation, but that he would love her and be with her until the end of their days. Some things are just worth it. Love is worth just about everything, even selfishness. And yet in telling this story I came to understand why it had hurt me so much when people had told me I was “too good” for them. I realised that when I thought that one person was actually too good for me, because I loved them, I wanted to become a better person for them.  So I came to realise that when people had told me I was “too good”, it had hurt me because I knew they were also saying that I wasn’t worth the effort.

Is it selfish to keep on after those one we feel are “too good” for us? Maybe. But it is extremely weak also to give up because you lack something, even if in the end it is purely self-esteem. When you’re truly in love, there is no room for comparisons or measure of a person’s “goodness” or anything else. When you’re truly in love, you want a particular person regardless of who they are, how spiritual or wealthy or educated or healthy or intellectual or adventurous - or anything - they are, or how deficient of these things you personally feel. There are some things that are truly worth the effort in this life. Love, to me, is worth just about everything.

On hierarchy

One of the things that really bothered me when I was working in the public hospital system is the pronounced (and revered) hierarchy of the medical industry. In short, it is what people call “top heavy”. If you’ve ever read ‘The House of God’ by Samuel Shem, even if you know nothing about it from personal experience, you’ll realise that this is a universal system of our industry. There’s an almighty, infallible boss at the top of the pyramid who ‘makes the big bucks’ and has his name attached to the patients “in his care” – even though he may not even be aware of these patient’s existence. Then there’s the half-bosses, charged with making all the hard decisions and often physically doing some of the too-hard things. He makes reasonable money, and you see him once or twice a day, but he also rarely sleeps. Then there’s the minions, working for scraps of money, working for almost every minute of every workday, being dealt all sorts of unpredictable tasks, and who is for the majority of the time a secretary with a medical degree.

If a scenario came up where the minion has just walked across a desert fighting off bullets and helping out injured civilians; he is met at the difficult battles by the half-boss who takes an armoured vehicle from one hard battle to the next (but driving by the lesser battles); and they are met at base camp in an air-conditioned shelter by their godly boss who has been driven in by chauffeured limousine from his 5-star hotel only seconds ago – who do you think will be offered a chair and a cold glass of water? Not the dehydrated, wounded minion with blisters on his feet. No. The boss will take the chair and the glass of water and not even thank anyone for it – he is the boss, apparently he deserves it more than the others.  And that’s life. That is not just the medical industry or the military, it is probably most industries! And that is why I had to get out of the public hospital system.

There’s also another story I don’t often tell about my experiences in the hospital system, and it is related to the above concept, but also about a certain type of discrimination. See, another thing about working in a hierarchy is that you have to respect and worship the hierarchy. You have to! Otherwise how are you ever going to make it to the top if you don’t play by the hierarchy’s rules, worshipping the people above you for their pity, grace, and reward? This is where I went wrong. My mistake was choosing to be honest, and choosing to be true to my own convictions. My mistake was also to be born flawed – but I’ll get to that later.

I was working in a team that was just like any other hierarchy I just described. I was a minion, of course. One day, through no fault of my own, I got sick and couldn’t come in to work. Oh my mistake! I received a reprimand from a (half) boss for staying home sick – how dare I?! But my mistake went even further than that. My mistake was that I refused to kiss ass, or to apologize for being human, to give an excuse or apology for being unwell that day. And I told the boss quite clearly that I would not apologize for being sick. So began my downfall. The next day when I arrived at work I was “kindly invited” to a surprise evaluation of my performance, a discussion led by my boss before a panel of hospital “Gods”. Oh, what a terrible worker I was! Late in the mornings, slow, lazy, absent on so MANY occasions, time-waster, friendly with too many other staff members, too well-like by administration and ward staff, etc. etc. I guess you can’t really say “she’s an insolent b*tch who won’t kiss my ass like she should” so you have to phrase it differently, even if slanderously.

I was then politely asked my opinion to his allegations. Needless to say, I was speechless. One day I am away sick at home, and the next - without warning – I am asked in a panel if I dare to contradict the guy who grades my assessment and who can end my career right then and there if he chooses to. Yep, seven years of university training, a $70,000 student debt, and a lifetime of passionate pursuit of this career on the balance. I kept quite. Even if I could speak, I’d had no time to prepare my defence (aka, stating the truth correctly). In my silence, the man hearing the case, summarised my case based on what was said about me. Clearly I was ALWAYS late to work. Clearly I had TOO MANY days off sick. Clearly I LACKED ENTHUSIASM for my job and my team. Clearly I was SLOW. Clearly I was LAZY. Clearly it meant I was WASTING TIME becoming friends with the people I worked with every day. Clearly I was guilty, because the boss who is higher up in the hierarchy than me said so. I then made only one comment; I said “it sounds like you’ve already made up your mind”. Yes, yes, the panel had. Never mind the fact that I had been working on this team for over 3-4 months with no complaint made about me, that no complaint had ever been made of my performance ever, and that these statements were great generalisations of that one time I was away sick. Was it a coincidence that all these allegations came to light from the man I had apparently disobeyed by being human and being sick, and that they came to light the day after I had refused to kiss his ass? Apparently so.

But before the panel “discussion” was over, one final point was raised. Was it not true that I suffered what is commonly called depression? After all, this can lead to increased work absenteeism, to tardiness, to lack of enthusiasm, to general slowing down… Oh, this is when I lost it! Talk about discrimination – and coming from the same profession that should be advocating against this type of prejudice. It didn’t matter that the things that I was accused of in an act of spite, of revenge, to put me in my place, to hurt me, were false; what mattered was that I had a condition which obviously must apparently make the allegations true. And I lost it because you can’t wash these things off. Did I not suffer depression? Yes. ‘Well, then that must mean that you are slow and lazy and unenthusiastic and take a lot of days off work…’ The only thing getting in the way of that theory was that these allegations weren’t true in the first place. And I was completely symptom-free at the time this all happened. But I couldn’t say no; that would be a lie. It was to me like being asked “isn’t is true that your skin is brown?” or “isn’t it true that you’re Latin?” or “isn’t it true that your native language is Spanish?” But I won’t be ashamed of my skin or my culture or my language, I wouldn’t deny them. It seemed to me at that point that in this world it is politically incorrect to be racist, but not so to discriminate against those with a history of mental illness.

I must admit I have had times where I wish my defect was in my skin or in a spot I could just have surgically repaired and then be on my way. It’s not that easy. If you have a mole on your face that everyone stares at when they look at you, it makes you uneasy. But at least you can have that removed and be more appeasing to those that are superficial and judgemental. What so many people wouldn’t give for a solution that easy.

On being sad

I’ve been reading Fyodor Dostoevsky’s ‘The Brother Karamazov’, and having read a few others of his works I came to question the moods often associated with depression. You see, in his books I’ve always found a character that is just simply a miserable man, a man that is also spiteful despite the fact he is also often the protagonist.

“I am a spiteful man”, one story begins. Here we meet a man that is sad, miserable, unhappy. He wants for nothing because he has already accepted he is a miserable man. He has a job, he knows people, he does ‘things’. He’s not an outcast or necessarily a strange man. In fact there are probably a lot of people who feel just like him. He was sad, yes. But why? I always wondered why, but I now am starting to realise ‘how could he not be?’ I think the answer to this question lies not in looking at what he had (a job, friends, etc.), but what he didn’t have. Where was his purpose? Where was his passion? Where was his love? Where was his self-pride and self-efficacy? And who if not himself could he blame for lacking these things? You have to hate the man who deprives you of these things – and so comes the self-loathing.

In one of my most recent episodes of “depressive” thoughts I was asked why did I not seek adequate treatment once and for all. And pondering this question, I had to remember the spiteful man of Dostoevsky’s stories. Why was his misery untreatable? Because it was a matter of the human condition, not of an illness, per se. (Note, I am not making a general statement about the existence of the illness we call depression, but rather about a personal reflection based on my own experience.) And so what is a man like Dostoevsky’s protagonist to seek treatment for? “Depression”? Or the fact that so many aspects of his life are not yet in place? I remember a quote from ‘The Manual of The Warrior of Light’ by Paulo Coelho: “By now, millions of people will have given up. They don't get angry, they don't weep, they don't do anything; they merely wait for time to pass. They have lost the ability to react. You, however, are sad. That proves that your soul is still alive”. Sometimes I think a bigger sin than being sad is to not be sad at lacking that which enriches life: love, company, passion, freedom, activity, purpose, peace…

Why am I sad? Because I have a mental illness, or because my life is not yet like it should be? Don’t get me wrong, I have many things in my Iife I am very grateful for and I have had many achievements… But instead of telling you what I am lacking, let me tell you of what I am now achieving, how I am “curing” my state. I have found the love of my life and I am planning a family with children. I work a job that I don’t hate. My passion is writing, even this humble blog. And I have finally stopped being afraid of being judged for being myself. I am learning resilience, building my self-efficacy, and I take the responsibility for my own emotions. What I still lack IS worthy of my dissatisfaction. But what I have is worthy of so much joy.

-I used to think I was cyclothymic. Turns out I may just be human.

On skin

I was sitting in with a dermatologist one day learning about skin conditions of the type that are severe enough to make it into hospital. Before I went in to sit with him (as an observer) I had to wait out in the waiting room with his patients. I noticed a red man there with lots of fine scale on his blue work shirt and around his chair. There was also an older lady who I could not discern anything of note from where I was sitting. Then I went in to the dermatologist’s room to sit in the corner as any good medical student.

The man I had seen in the waiting room came in. He was quite animated and greeted both me and the specialist with a handshake and a big smile on his face. He was having another flare up of his psoriasis because he had been working out on a roof (he was a painter, I believe) and didn’t wear his usual long-sleeve shirt that in the Brisbane summer is only best described as torture. He was bright red (beyond what I had learnt the word erythema meant) and was shedding layers of skin everywhere, even as he talked and sat. He had come in his work clothes and he offered to remove it so that I, the medical student, could see and learn just how bad psoriasis can get. He was not a bit embarrassed, and he thought he owed to show me at least the worst spots of the disease, which extended literally from his feet to his face. After his treatment was sorted out and different work strategies were discussed to prevent such frequent exacerbations, he left with a smile even bigger than the one he came in with. The dermatologist explained to me afterwards that he was an extreme example, that he was the worst even he had seen, and that the man was remarkable to continue on with his employment and in such great spirits. I must admit, until that day, I had never even seen any psoriasis at all except in books – and that was not ‘typical’.

The second patient we saw was the other lady I had seen out in the waiting room. She came in, sat down, pulled her skirt up above her knees, and started crying. There were two small psoriatic plaques on her knees, about 4cm long by 1cm wide. The plaques were raised and had some scaly skin on top. There was no redness. This was devastating to her because this was the second or so time this had happened to her in the last four years. One knee, two small spots, and not inflamed. She apologized for having to show us such “disgusting” things that were on her knees; she was clearly embarrassed. The dermatologist treated her as if he had not just seen actually bad psoriasis and tried to dissipate her concerns and offer medical therapy for her skin. I was stunned to see how incredibly emotional she was and how humiliated she seemed to be!

One day I was out walking with a friend and she was telling me how she had always struggled to feel comfortable in her skin because she had a skin condition since she was very young. I had of course noted her skin appearance, but it had never occurred to me that she felt self-conscious about it. She told me how she imagined people thought of her because of her skin. They might think she is unhygienic and her skin is disgusting, that she is ugly and possibly ‘retarded’ or suffering some greater disorder. She said she imagined people would speak of her and comment on how ugly and disgusting she looked, and they would laugh and make fun of her. Just then a group of adolescents with skateboards went past us and were laughing amongst themselves. She said episodes like that made her think it was her they were laughing at. I felt at that moment not pity for her for having a skin condition, but rather offended as a human being not of what she thought people said of her, but what she thought of us, us people other than her.

I had one question to ask her: what did she think when she saw a person with a skin condition like hers? Did she think they were ugly and disgusting? Would she laugh and mock them? She responded no, of course not! I asked her then if she was special, was there something about her that meant she was a good person and the rest of humanity were judgemental, spiteful human beings? She said no, she wasn’t special. Of course she would never think she was special, her problem was one of low self-esteem not a heightened arrogant one! Well, I said, if she is not special and she would never think that way of anyone, what made her think anyone else would think that of her? Here she was accusing strangers, others, of being spiteful, judgmental, arrogant people with vicious mocking thoughts in their minds. Freud called it projecting, the act of ascribing to other attitudes and feelings you personally have. I believe no medical condition, handicap, special ability, money, or other advantage or disadvantage entitles you to cast judgement on other human beings!

There’s an early movie by Pedro Almodóvar called ‘Dark Habits’ in which a group of nuns take on the names such as Sister Manure, Sister Rat, Sister Damned, and Sister Snake. The aim is to humiliate themselves and remind people how even the “good” ones of us are despicable; they believe that “man will not be saved until he realizes he is the most despicable being ever created”. By the end of the film all the nuns have become either prostitutes, drug addicts, drug dealers, and other such “sinners” befitting of their adopted names. At the end, a higher-order cleric visits them to shut their order down and reminds them that sometimes “humility” can be the worst kind of arrogance when you wear it for a badge. Nothing that attracts pity entitles you to act carelessly or exonerates you from being responsible for what you say or do.

On the rules

One day I told someone that I was struggling because there was something that I really wanted to do but that I didn’t do simply because it goes against my religious beliefs. And it wasn’t a fleeting desire, either; no, it was actually a very deeply-seated desire that penetrated and marked me to the core of my being. But, yes, I had a system that I lived my life by and it is religion. People often quote this feature of religion as being one of the “bad” things about it. It’s so restrictive. It rules people’s lives and is a great evil. But everyone lives their lives with at least some rules. Some are there to protect the ego, others to protect our survival, others to keep us out of jail, others to protect our conscience, etc. But every rule serves to protect something – and we all, even the most free-spirited ones of us, obey some sort of rule or rule system. My rule system is basically Christianity.

The friend I told how I was struggling with this feeling I had but had to hide because of my religious system gave me some advice: change or leave my religion. Of course! Why didn’t I think of that?! In fact I had thought of that, but before I tell you about that, let me tell you about something else I really really wanted to do one day.

I was at a restaurant once and this woman pushed me as she walked past. I was furious! I wanted to pull this lady back and pull her hair, punch her in the face, and kick her in the guts. I felt an energy surge through me, it was so strong. My expression changed to one of absolute spite for this woman, so much so that the people around me noticed my anger. They told me to let it go and move on. Someone moved in between me and the woman so I wouldn’t make a sudden lunge towards her. I thought to myself, “Move on?! Let it go? But I feel this feeling so intensely, so deeply, so in my core.” I let it go, though. Do you know why? Because there are rules in society, and even if I don't agree with them, they still apply to me as a member of society. Of course one can always break the rules and accept the consequences of doing so.

This incident is not the only time I've really wanted to hurt someone, nor am I the only human being who has ever had this desire. We have all wanted to hurt someone for even minor spites like being cut off by another car while you’re driving, being spoken to in a rude and impolite way, seeing someone purposely abuse an animal or someone who is weaker than them, etc. All these things can irritate a person and the human instinct may kick in to react with violence to serve our own ‘justice’. Now, should you? It's something you want so why should you have to resist? Because it's against the law? Because it's against social norms? Because it would be morally “bad”? Because it’s against your religion? But none of these norms and rules were devised by yourself, so why should you comply? Do you see what I’m getting at?

I rejected my friend’s suggestion that I change religions because I don't think everything in life should be solved this way. I think this attitude of always having things your way, if not changing your environment (the physical environment/religion/political party/professional membership, etc.) comes from our society's new rules of the self as deity. Our religions, the object of our worship, have become ourselves. We worship by seeking to maximize our personal pleasure and meeting all our desires – often at the expense of... ‘whatever it takes’. And what is wrong with that religion? Nothing. But our religions are not the only rules we face in our lives. Sure you can punch that guy who pushed in front of you in line at the cinema, or you can steal that item you really want from the shop, etc. but you’ll still have to face the consequences of doing so. That’s just how life is, with every rule comes a consequence.

I’ll tell you now how I overcame my struggle. No, I didn’t change religions just so I could obey my desires. I still believe in everything I ever did about Christianity. I didn’t suddenly lose the burning desires I once had. No. The only thing I changed was I accepted the consequences. There are some things that are worth the consequences.

Only God can judge me.

J

On what we don't know

Let me propose a very sinister scenario for your consideration. I propose it only because I don’t know exactly what to conclude from it but it raises a lot of very interesting ideas.

The scenario: There’s a 25 year old man; a man who you know to be a nice guy, who is studious, who is playful and just generally a fun guy. He is a foreigner and speaks with a somewhat funny Indoasian accent. He goes to university and he likes to tell jokes. He is respectfully religious but not over-the-top with rituals. He even volunteers in a community youth group. One day this guy is joking around, playing with a boy who is 11 years old. In the spirit of the moment he makes a penis joke and makes a move towards the child’s genitals. The child pulls away, pushes him, and the day proceeds. One day this man is accused (by a third party) of indecent sexual dealings with a minor because of this particular incident.

Now, all of which I described above actually happened, the actions are exactly as I described. You can picture the man, you can picture the child, you can picture that they were having a laugh and engaging in the physical play which all children enjoy. Even the man in question clearly admits the incident occurred as described. However, the only things we don’t know are the thoughts and intentions of the 25 year old man. The matter went to court and the man was ordered to have no further unsupervised dealings with children, especially not in institutional settings like in his university studies. He was sentenced to 12 months probation and nothing else. Now, most people’s responses to this story are either 1) ‘the pedophile got away with it!’, or 2) ‘I know that guy and he’s totally a nice guy. It is such a shame that he has had his name tarnished with such a terrible accusation’.

Further from this, let’s consider one possibility. In the case it was alledged that the man meant no ill-harm because when the child pushed him away and said ‘no’, he obeyed. It follows from this that the man was acknowledging that this contact was against the child’s wishes. They added this to his character references from people who knew the man prior to this incident to conclude that he was a good man who was innocently playing with a child, joking, and incidentally happened to have made a move towards the child’s sex organs while in the course of a non-sexually intended activity. Makes sense, right? Good guy made bad move.

But imagine for a second that he wasn’t a good guy; propose he is a big bad pedophile. What would a pedophile do in the same situation? He would play a non-sexually-seeming game with the child to “groom” him, to teach him increasingly more sexually-explicit acts that the child will not associate with “bad” (or sexual) things. In the way of this grooming he will “accidently” touch the child’s genitals or allow the child to accidently touch his. The child thinks ‘we’re playing!’, meanwhile the pedophile just scored sexual contact. As I mentioned, the “play” will become increasingly more explicitly sexual, but the grooming for the pedophile involves a bit of trial and error. Sometimes he overestimates his steps; sometimes the child is more docile than first imagined. If the child were to become uncomfortable in a situation, he knows he has to slow down – because a comfortable child is much easier to take advantage of! Can you see where I’m going with this? If the child in the scenario had not pushed the man away, what would have happened? The man would could either have just been playful with the child and possibly never meant to even touch him (like a ‘normal’ person); or he could have sexually fondled the child to his own sexual gratification (like a pedophile). So therein lies my problem with judging the man either guilty or not-guilty of a sexual crime against a child: the fact that he withdrew his attempt does not prove his actions either way.

The second question this case raises for me is which is better? When this case went to court there were four possible outcomes that could have come from a verdict of either guilty or not guilty: 1) an innocent man walks free, 2) an innocent man is punished, 3) a pedophile receives deserved punishment, and 4) a pedophile goes free. All of these outcomes have an equal probability of happening. I would hate to have been a judge in this case and have to make that very hard decision. Ideally the evidence of the case helps you make the right decision (options 1 or 3 above), but as we saw in this case, judging intention is something that maybe only God can do. So now the judge has to make an even harder decision, which is the least unjust finding: set a guilty man free or convict an innocent one? Of course, the case we are considering here is not just any case, but an accusation of pedophilia. And in fact, that is what the judge based his decision on in setting the man free. He reasoned that if the man is innocent because he didn’t actually “do anything” to the child then he hasn’t been unfairly deprived of his freedom. Yet if he is guilty then his punishment will be that his name will be always be known and associated with ‘that guy that tried to touch that kid’.

Of course, to the general population this may not seem be enough (punishment to a presumed offender). After all, don’t the courts and governments also have a duty to protect the public from exposure to harm (e.g. pedophiles and other villains)? Yes, it’s in the constitution of most countries’ governments. But before I consider this last point, you have to excuse me as I recede back a step.

The man in the scenario we discussed in the beginning in fact pleaded guilty to the actions of that day as they happened (and conceded the possibility that they could be deemed to be pedophilic in nature – thought he never said that it what he intended). So the judge never even had to make the judgement of labelling the man “guilty” or “not guilty”, he just had to decide on the punishment for the man’s actions. So in a way you could say that a guilty man walked free based on the judge’s reasoning as was discussed earlier. And maybe that is what we need to focus our attentions on: setting adequate penalties for crimes against children. I know the frustration of victims and of police officers who strive to find the bad guys only to have them go to court and receive a sentence that seems to be but a mere formality and without any intention to actually punish offenders, to rehabilitate them, or even to protect the public.

(P.S. I hope the guy whose story I based my scenario on can forgive me for using his example to illustrate my point. Only God can judge you.)