Witches in White Coats: Native American and Western Medical Ethics
An early version of this essay appeared in News From Indian Country XII:5, Mid-March 1998
I use the word witchcraft as a synonym for what in Mexico is called brujeria, sorcery, meaning the abuse of spiritual power: attempting to disempower, coerce, harm, or control others or to influence events using means that are unethical or socially disapproved. (Readers should note, however, that in European culture, the term witchcraft may have a positive connotation, referring to ancient forms of pagan spirituality such as wicca. Practitioners of wicca, like Native Americans, recognize that Power is not inherently moral, but may be used ethically by an ethical practitioner.) Even without malicious intent, a Native community may label a person a witch if he or she repeatedly harms others. The key here is "repeatedly." All healers have failures, but one who continues to practice interventions that harm is probably under the spell of an evil power including perhaps his or her own ego.
At first glance, the power exercised by white-coated physicians has little relation to the subtle forces used by Native American healers. Yet, upon deeper inspection and reflection, we realize that both types of practitioners ultimately help the patient to heal him or herself. The surgeon's knife and the traditional healer's feather are mere tools towards this same end. The power of the healer and the doctor are also equally subject to misuse. In fact, there may be more witchcraft practiced among white physicians than among Indian doctors.
Dangerous Procedures and Dismal Prognoses
Recipients of western medical intervention often suffer more from the treatment than the disease. Iatrogenic disease-- diseases caused by incorrect, excessive, or unnecessary medical interventions--are epidemic in Western medicine. These include psychological or physical side-effects from medication such as depression, digestive problems, liver disease, or kidney failure; "complications" after surgery or invasive diagnostic procedures, including the prevalence of blood clots, heart attacks, and strokes after orthopedic surgery; rejection of transplanted organs or artificial body parts; weakened immunity after antibiotics, chemotherapy, and steroids; and the mutation of microbes into drug resistant strains because of excessive or incorrect medication. In the United States each year there are more than 100,000 deaths from hospital-originated infections. According to the Journal of the American Medical Association, drug reactions account for up to 140,000 deaths annually, more than 10,000 from anesthesia administration alone. The JAMA article states that adverse drug reactions cost an estimated $136 billion per year, "higher than the total cost of cardiovascular care or diabetes care in the United States." (Classen, David C., M.D., M.S., Stanley L. Pestotnik, M.S., R.Ph., et al. "Adverse Drug Events in Hospitalized Patients: Excess Length of Stay, Extra Costs, and Attributable Mortality," Journal of the American Medical Association 277:4, January 22, 1997, p. 301). Negligence is also rampant-- in New York State hospitals, approximately 30,000 cases of negligent or dangerous care per year. We might be apt to excuse these figures as an unavoidable by-product of increasing patient-to-doctor ratios and the impersonal nature of technomedicine: doctors often seem more interested in test results than in the patient. I and my Native colleagues tend to view these statistics as proof of the prevalence of "bad medicine" in both senses of the phrase.
Sometimes diseases can be traced to grim prognoses that act like hexes. Unkind words instill in the patient a sense of uncertainty, dread, and vulnerability to further suggestive influence, including the influence of his or her own thoughts. A doctor who tells his patient, "The condition is terminal" or "You may die of a heart attack any minute" may create a self-fulfilling prophecy. In The Lost Art of Healing, cardiologist Bernard Lown recounts the story of a patient who was recovering from a heart attack. He suddenly took a turn for the worse. His pulse was racing, and he had signs of cardiac congestion. Dr. Lown traced the likely source of his reversal to the morbid fear the patient experienced when he overheard residents and physicians indicate on various occasions that he had "coronary thrombosis, myocardial infarction, and an acute ischemic episode." When he asked the nurse about his condition, she said, "You'd better not ask." He knew that he had had a heart attack, but what about these other conditions? How could he possibly survive? You can imagine his relief to learn that all of these disease labels were various terms for the same condition! Imagine if he had been told, instead, "You have a beautiful heart, and it is mending."
Expectant trust can be a force for helping or harming. If the patient believes in the power and authority of the doctor, then words of hope and support can encourage healing. Conversely, if the doctor's words, tone of voice, or use of images (including disease labels) communicate discouragement, despair, or condescension, the patient may feel compelled to oblige the doctor's expectation. Patients whose privacy and sense of integrity are invaded by highly personal questions and the probing of body parts are especially vulnerable and susceptible to such effects. It seems odd to me that it is nevertheless considered ethical for the physician to avoid ordinary physical touch. An orthopedic surgeon will saw through the patient's femur, but dare not administer a healing hug.
The saying, "The operation was a success, but the patient died," is a sad commentary on modern medical practice. How many doctors are willing to admit, "This disease may or may not kill you. The same can be said of my treatment." Unfortunately, futile, unnecessary, or dangerous interventions are sometimes more a result of fear of malpractice than prudent care. "Better safe than sueable" betrays the escalating lack of trust between patients and their providers, fueled by the astronomical costs of health care and health and malpractice insurance, a litigious society, and human greed.
Unnecessary and heroic procedures are also a direct result of the West's compartmentalized view of the body-- it becomes more important to save a disconnected body part than to preserve quality of life and soul. As Lawrence J. Schneiderman, M.D. and Nancy S. Jecker, Ph.D. remind us in their insightful work, Wrong Medicine: Doctors, Patients, and Futile Treatment, "Keeping a heart beating or lungs breathing does not accomplish medicine's goals when a person will never again regain consciousness, or never leave the intensive care unit, or never be free from intense and unremitting pain.." (p. 129) The subject of medical care, they tell us, should be "the suffering person, not the biological organism or failing body part."
By contrast, Native American medicine is generally helpful and empowering to the patient. The patient receives a treatment designed to improve quality of life and enhance relationships with the community and the Creator. The patient is encouraged to maintain the healing benefits and prevent future recurrence by taking greater responsibility for his or her own physical, psychological, and spiritual health. The Indian doctor does not fix the patient, but rather facilitates help and guidance from the realm of Spirit. Therapeutic interventions, including herbal medicine, very rarely have harmful side-effects. People die routinely from western medicine; I doubt if many die from indigenous medicine. Native treatments are non-invasive and respectful of the privacy and dignity of the individual. The goal is healing, making whole, rather than curing. Curing is, of course, the most desirable outcome, but Native healers realize that this is ultimately in the hands of the Great Spirit.
Hospitals Are For Sick People Native healers create a sacred, supportive, and healing atmosphere to affect the patient at both conscious and unconscious levels. Their office or operating room is the tipi, hogan, wikiup, kiva, longhouse, or other sanctified place, filled with a community of praying people and ceremonial helpers. No one would think of breaking the reverent silence with any words or actions that do not contribute to or augment the healing energies.
Compare this with the surgeon who knocks out the patient to both humanely anesthetize the pain and ensure the patient's unawareness and inability to protest the loud music, lewd jokes, and disrespectful behavior that sometimes accompany surgery. Physicians place patients in institutions filled with sick people who confirm the patients' fears and insecurity. Positive expectations are quickly dashed in the grim, almost morbid setting of the hospital. Contrast this with the Indian doctor who surrounds the patient with an empowering milieu of healthy, concerned people and symbols of well-being. Sick people have a greater need than healthy people to be surrounded by healthy people and healing environments. Native healers realize that a healing place encourages hopefulness and a positive state of mind, factors that are essential for healing.
First Do No Harm
Doctors are taught the admirable rule, primum non nocere "first do no harm". This saying dates from a time before the advent of technomedicine. It refers to far more than denying a patient the appropriate technological intervention. Harm can be inflicted by attitude, tone of voice, and body language. Perhaps western doctors can learn something from one of the rules of Indian medicine, "First, do good." Focus on health rather than pathology, on a patient's strengths rather than his or her weaknesses. Inspire the confidence to overcome challenges.
Ironically, the rule of "do no harm" is not a requirement of medical school education. The long, grueling hours of work and study and the rigid hierarchy of the hospital disempower the sincere student. It is no surprise that doctors feel most comfortable with patients who are "compliant." The doctor's fragile or shattered ego is compensated by a false projection of power and confidence, backed up by a society for whom the doctor is a priest in service of the god Science. A patient who wishes to take responsibility for his or her own health pushes the doctor dangerously close to his own shadow.
Technical jargon and dismissive or condescending replies to questions further disempower the patient because it creates an impression that only the physician understands or is capable of healing the patient. Yet, isn't it obvious that no matter what help the patient receives from external sources, it is ultimately the patient who must heal him or herself? Sadly, some physicians attempt to disempower the patient in order to hide from personal feelings of inadequacy. Human beings reinforce delusions of superiority by making others look inferior.
Rather than using difficult medical terminology, a far better model for physician-patient communication would be medical humor. Humor is a powerful way of coping with, managing, and surviving personal suffering, and doctors should model it for their patients. Why not make Therapeutic Humor a required course in medical school? Doctors would not graduate residency without demonstrating clinical humor competency. If a patient has lost her hair after chemotherapy, why not suggest that she is having "a no hair day"? Perhaps an obese man visiting your office with his spouse would feel less embarrassed about his problem if you asked the couple to reveal their "combined average weight." Instead of putting herself above the patient, the physician could put herself at a lower level. "You may lose some brain cells in the operation, but being over age 50, I have already lost most of mine!"
Humor, including self-deprecating humor, is common in Native American healing. Humor is empowering for the patient. It creates empathy between the patient and healer. The healer never laughs at the patient, but should be willing to laugh with him.
The Price of Healing Western medicine is a profit making business. Patients' options are limited by their ability to pay or by their insurance companies' willingness to cover expenses that they deem necessary. Quality medical care of both the living and dying is often a matter of what the patient can afford. Let me share with you two anecdotes that highlight the dismal and immoral nature of a medical system driven by economics.
A surgeon was about to perform an emergency bypass operation on a twenty year old patient that had been brought in by ambulance. As he looked over the patient's medical records, he exclaimed, "Wait a second. She has no insurance! Who is going to pay me?" The assistant surgeon looked at his colleague with disgust and said, "Put it on my master card."
A few years ago I was wading in a pool on a hot summer afternoon. A distinguished looking man in his sixties struck up a conversation. When he asked me what I did for a living, I replied with what I thought was a politically correct statement, "I teach alternative medicine, specializing in indigenous healing systems." This was evidently tantamount to making a declaration of war. The man informed me that he was a medical school professor who also sat on advisory panels for various medical societies and government organizations. He said, "If you people have your way, in ten years we will be treating cancer by sticking a lettuce leaf on the patient's big toe." After several other equally misinformed statements, I proceeded to calmly cite experimental and peer- reviewed journal evidence for alternative medicine's efficacy. I also reminded him of his own profession's reliance on placebo and untested procedures.
After my half-hour long sermon, the man, whom I had previously mistaken for a gentleman, rejoined, "I must admit that I cannot refute this kind of evidence. It makes sense. I see that you are well-educated and well-informed, and I believe you. However, I also believe that people like you should be shot." "That's not a very Christian thing to say," I said in amazement, not sure if he was being maliciously contrary, dangerously threatening, or just ornery-- the latter being a characteristic I sometimes admire. He continued, "I mean it, you should be shot. You are threatening the wonderful salaries we doctors make." This statement was made with utmost seriousness. I felt like countering with some inane statement about the importance of the patient, but realized that it is useless to argue with someone who has different or perhaps no values. Instead, I said with a profundity equal to his own, "It seems that we have very different points of view." I waded over to a different section of the pool. When I saw him in the changing room, he stated again, as though calmly citing a fact of life to his medical students, "You really should be shot!" Not wishing to tempt fate, I made no reply.
According to Native tradition, healing is a grace from God that may or may not occur in spite of all our best efforts. It is given as a gift; patients also pay the healer with gifts. The healer never charges a set fee for his/her help. A high fee would tax the limited resources of a patient during the time when he is most in need of help. Money and healing gifts should flow to the patient, not from him.
Native witches, by contrast, work for a high or inflexible fee. They are tempted to enter their craft because of a desire to demonstrate power over others by wantonly harming, or because of envy, greed, and a desire for wealth. The prohibition against fee setting is so strong among some Native people, that a person attempting to heal may be accused of witchcraft if he tries to take economic advantage of the patient. Witches, like some unscrupulous doctors, prefer to victimize the most wealthy. According to Clyde Kluckhohn's classic Navaho Witchcraft, after a witch inflicts disease, the witch's partner offers a costly cure; the two split the fee.
One of the strategies used by witches to exert power and control over others is by fostering dependency. Although "bad medicine" may sometimes be practiced without the victim's knowledge or belief, it is much more effective if the victim is made fearful of the witch's curse or presumed power, and thus vulnerable to suggestion.
The goal of an ethical healer should be to make his or her own work obsolete. This does not seem to be the goal of western medicine; it encourages relationships in which patients become emotionally and financially dependent on the information and technology of expert doctors. Since many of the interventions are themselves causes of disease that require technological cures, the patient soon feels trapped in a system from which there seems to be no escape. Ultimately, the patient becomes dependent on institutions that profit from biotechnology: government, industry, banks, and educational institutions.
Among Native American populations, there are further ethical issues. Western physicians undermine Indian cultural values and self-esteem if they portray themselves as representing the only official or legitimate healing system. I have spoken to Indian Health Service physicians who, in spite of long tenures among Indian Nations, were completely unaware of Indian methods of healing or counseling and never attempted to consult with the traditional health-care providers. (Sometimes the doctors are disillusioned by the degree of social and psychological problems that they witness-- contrasting sharply with previously held, unrealistic stereotypes. Yet it is as unfair to judge Indian healing by the patients in an IHS clinic as it would be for an Indian doctor to judge white people based solely on experiences working in an inner city drug rehab center.) How many needless suicides, abuses, or diseases could have been prevented by consulting with a wise clan-mother or traditional healer? Although I recognize and commend the fine collaboration that is occurring between allopathic and Native medicine (e.g. the work of the Four Worlds Development Project and the Swinomish Tribal Mental Health Project), it is still far too infrequent.