Sunday, September 20, 2009

Shamans, Placebos and Multicultural Ethics

Over coffee I read in this morning's New York Times about how Mercy Medical Center, an acute care hospital in Merced, California, allows Shamans to participate in the treatment of Hmong patients from Laos.

The Merced area has a large Hmong population (from Northern Laos), beautifully described in Anne Fadiman's superb book "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and The Collision of Two Cultures." What's especially interesting is that Mercy Medical Center is part of Catholic Healthcare West, a faith-based system "committed to furthering the healing ministry of Jesus," as well as "to providing high-quality, affordable healthcare to the communities we serve."

It's easier for our scientifically-minded U.S. culture to recognize the importance of religion and magic in dealing with "foreign" cultures than with our own. In my own experience as a psychiatrist, and in my relatively limited interaction with other doctors as a patient, I've been aware of how much of what we do is anthropologically similar to what Shamans do.

When patients ask "so I have a chemical imbalance, right?" and I agree, our exchange has much in common with what is happening when a Hmong patient asks "so a spirit is causing my pain, right?" and the Shaman agrees. Whether or not a chemical imbalance or a spirit is responsible for the clinical state, applying a cognitive model the patient trusts in concert with a trusted healer can have a powerful impact.

In 1986 I made my first and thus-far only trip to China. On a train I conversed with a man who spoke English. I asked how he used "western" medicine compared to traditional Chinese medicine. His answer made excellent sense. "If I have a headache or pain in my back I go to a traditional Chinese healer. If I have pneumonia I go to a 'western' medicine doctor and get an antibiotic."

On returning to the U.S. I was referred a man who had recently arrived from Southeast Asia but who was ethnically Chinese. He had classical symptoms of major depression - depressed mood, suicidal thoughts, weight loss and sleep disturbance - for which antidepressant medication was (and is) the standard treatment in the U.S. He was dubious about trying the medication, so I wrote out my thoughts and encouraged him to discuss the treatment with his herbalist. The herbalist approved of my suggestion and in some weeks the depression was gone, presumably (but not necessarily) due to the medication.

A year later my patient returned and described what sounded like symptoms of erectile dysfunction. I began to ask the kinds of questions I would typically ask in that circumstance. My patient looked horrified at the direction the conversation was going, at which point I encouraged him to see his herbalist for the problem. A few years later I met him at the clinic carrying a baby. Presumably the herbs did the job!

Mercy Medical Center and Catholic Healthcare West are practicing admirable small 'c' Catholicism (in my dictionary "broad and comprehensive in interests, sympathies; liberal"). U.S. medicine needs to extend the same cultural sensitivity and anthropological sophistication to our own practices. We tend to use the term "placebo effect" disparagingly - "the Shaman's ritual is just a placebo effect." Each group takes its own beliefs as literally true and, ideally, acts like Mercy Medical Center with regard to the different beliefs held by others.

If we were more attuned to how much "evidence based" medical practice depends on the power of faith, magic, and the lowly placebo effect, we would be less inclined to flog patients with excessive technical interventions and readier to minister to them in a truly healing manner. When religious fundamentalists persist in using prayer as the only treatment for children with curable cancers we take them to court. But when medical fundamentalists persist in using one technical intervention after another rather than acknowledging that cure is not in the cards our insurance pays their fees.

Years ago a dear friend had come to the end of the available treatments for multiple myeloma and the disease was progressing. When she visited with her oncologist - a leader in technical medicine - he said "the best thing I can do for you now is to give you a hug," which he gave. I've used that as an example of ideal care with medical students.

Our health system can learn a useful lesson from my friend's oncologist and from Mercy Medical Center and Catholic Healthcare West!

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