© 2011 A.D. Gaines, A.S. Kurlenkova
2011 – № 2 (2)
A.D. Gaines is interviewed by A.S. Kurlenkova
Dr. Atwood D. Gaines is Professor of Anthropology, Bioethics, Nursing and Psychiatry, and Program Faculty in Ethnic Studies and Women and Gender Studies at CWRU and its Schools of Medicine and Nursing. His MA, C.Phil. and PhD, all in Cultural Anthropology, were earned at UC Berkeley. His MPH was taken from UC Berkeley’s School of Public Health. He holds a Certificate in Ethics from Case’s Law School.
Dr. Gaines is a medical anthropologist with public health training with research interests in health and social identity (ethnicity, “race”, social class, gender, age), ethnopsychiatry, bioethics (cultural bioethics), gerontology (dementia) and the cultural studies of science. His books include, ‘Ethnopsychiatry’ (1992) and two volumes edited with Robert Hahn called ‘Physicians of Western Medicine’ (1982, 1985) that initiated cultural studies of Biomedicine. He has published nearly 70 articles in journals and books in the fields of medical anthropology, ethnopsychiatry, dementia (especially Alzheimer Disease), aging, bioethics, anthropology of religion, social identity, cultural studies of science, American Studies and European anthropology1.
Key words: anthropology of biomedicine, cultural bioethics, cultural/social studies of science, ethnopsychiatry, Alzheimer’s disease (dementia), consensus statement, euthanasia, clinical trials, clinical equipoise, therapeutic misconception, distributive justice, US biomedicine
Abstract: Within the interview professor Gaines describes his academic journey throughout the studies of medical anthropology and bioethics, its main milestones and speculates over the subject and object of these disciplines. He gets more into detail, analyzing the state of art and the perspectives of biomedicine and bioethics in the USA, focusing in particular on double blind clinical trials, distributive justice and psychiatry.
A.K.: Dr. Gaines, tell us please about your background both in medical anthropology and bioethics.
A.G.: Well, I started my anthropology degree, my PhD, not as a medical anthropologist, because it didn’t actually exist at that time. I was in UC Berkeley and I was focusing on psychological anthropology and psychiatric anthropology, religion and ethnicity in Western Europe – these were my areas of concentration. So I finished school, was advanced to candidacy, and went off and did my fieldwork in Strasbourg, France on religions and ethnic identity.
And when I came back in 1975 or so a new Medical Anthropology track had been developed at UC Berkeley, and I thought that seemed interesting. Then I thought it might be a good idea in terms of obtaining a job to make myself more marketable by getting some public health training. And I got into the public health school at UC Berkeley (this happened before I finished my PhD) and started coursework there. The public health school allowed to take a lot of electives, so what I did I took electives in medical anthropology (the new program in medical anthropology). Then I finished my PhD and the same year I finished my public health degree. It makes me somewhat unusual, may be unique, I’m not sure, to be a senior medical anthropologist who was actually trained in medical anthropology, because most are not (they finished school before there was medical anthropology).
So I was a dyed-in-the-wool medical anthropologist and was able to secure a post-doctoral fellowship in psychiatry at the University of Hawaii from the National Institute of Mental Health. It was run by Tomas Moretsky who was a medical anthropologist, but he did not start that way, because he was far too old. He was actually German by birth and he had started the healing bath in Germany as a form of hydrotherapy. So that became his medical topic and then he started studying German physicians and how they were different. So I was in psychiatry with him for a year and he had an NIMH grant. In the Department of Psychiatry of Burns School of Medicine at the University of Hawaii I learnt psychiatry and studied it at the same time.
So psychiatry became a topic of my anthropological research. Learning it I was learning what the psychiatric residents were learning: they were taking classes on various drugs and symptoms of the symptoms, and how you treat patients. But then I was also standing outside of it and studying it as a cultural phenomenon. So from that research I came back to Berkeley as a post-doctoral fellow and did some writing, and then I was hired by Duke University in anthropology, but also I was hired in psychiatry. There I got to put into practice something I had actually done during the public health study, and that’s again the study of psychiatry. When I was in public health I did a study of psych residents that was published in the journal I now edit, and that is “Culture, Medicine and Psychiatry”.
It was in 1979 and that was the beginning of what is now called the anthropology of biomedicine. I ran into Robert Hahn, MD, who was an internist, and together we edited a journal and a book called “Physicians of Western medicine”. And that’s the beginning of the anthropology of biomedicine – cultural studies of biomedicine.
A.K.: So when medical anthropology was started as a field at UC Berkeley…
A.G.: …it was the first formal program in medical anthropology, it was George Foster who started it.
A.K.: So the question is – didn’t it include the anthropology of biomedicine?
A.G.: Oh, no, it didn’t exist. While studying public health I took electives that were the new medical anthropology courses. And in one of the seminars directed by George Foster, I had the idea to study some people that I knew – psychiatrists. So I said that I was studying them and at the end of the semester I presented my paper, and Dr. Foster didn’t think it was actually anthropology. Because, you know, we have real medicine in the United States, and other people have folk medicine. So how can you study biomedicine culturally?
So I continued to write the paper and decided that I would submit it to Arthur Kleinman in “Culture, Medicine and Psychiatry”. And as I was finishing it, Arthur Kleinman actually came to the University of Hawaii where I was in psychiatry to give some talks. I told him I was preparing it for his journal, and he said, well, let me read it. So I gave it to him, and he was just thrilled, he said this is wonderful, so it was subsequently published. And that was the beginning of the anthropology of biomedicine. About 1999 or so I said there was a shift in the study of biomedicine. Now so many people study biomedicine, they have no idea who I am, or Robert Hahn for that matter, because it became the thing that people did and they think they thought of it or something.
But I realized what was going to happen and I was doing it – I kept abreast of psychiatrists and noticed there was an increasing interest in dementia, in Alzheimer’s. So I started studying not really Alzheimer’s, but studying people who worked with or studied Alzheimer’s. And those turned out to be not only psychiatrists, some were neurologists, some were pharmacologists, and so forth. So I studied them and it became a different kind of study, because they are international groups and they go to meetings.
So I started going to those meetings with the help of Peter Whitehouse who was a neurologist here at Case, and who was one of the leading researchers in Alzheimer’s. Still all of the drugs that are currently used for Alzheimer’s are based on his research, and he would tell you – none of them work … (laughter). And he has been treating patients for 20 years as well.
So he founded an organization and he called me for advice about how to get… You know, at these meetings you have Japanese scholars and physicians, Swedish physicians and Argentinean physicians, and American, German, French, Russian, English – and how is he going to organize all these meetings and keep them all focused, with all these people apparently? So he asked me to be a consultant, and I found myself sitting with several groups of them as they subdivided into small groups.
One of the groups was actually on bioethics, so I became a part of the group that talked about bioethics. Another group was on psychiatric aspects of dementia, what they called behavioral, psychological effects – I worked on that committee.
So I went from being a consultant to being rather a member of the organization. And from the outset I told them I was studying them. They knew I was studying them, so for years I would go to these meetings. When people were introducing themselves I would say “I’m Atwood Gaines, I’m anthropologist”, and several people would say “and he is studying us”… (laughter) Peter Whitehouse and I published several articles on that work. That shift was a shift from studying psychiatric theory and practice to a study of the sciences that psychiatry applied – neurology, pharmacology, and so forth. So I thought in 1999, that’s a really different thing. I didn’t call it cultural studies of science, because it is an anthropological enterprise. So it’s different than the social studies of science, or science and technology studies which are sociological mainly, sometimes history of medicine – because we are focusing on cultural issues, and we are conceiving of the scientific enterprise as a cultural issue.
So one paper we published, for example, was “The meaning of consensus in international meetings”. Every major international meeting has consensus statements – that is one of the things they work on. They say, “We are going to come up with a consensus statement on bla-bla-bla…” So they work on this consensus. The research I did on several of these meetings showed that people actually don’t agree. But they would only object once or twice, and in the interest of international cooperation they stop talking. They don’t want to push an argument, and they think the object is to have a consensus statement. The consensus statement does not actually mean they agree, they just appear that way. But the consensus statements are then used by other groups of scientists as a proof of something.
Like, “We have a consensus statement on…”, the last one I remember doing was, “We need to develop a consensus statement on MCI (mild cognitive impairment) as an early stage of Alzheimer’s”. Only a few people agreed there was such a thing. But they said, “Well, the so and so meeting had a consensus statement that this is an important thing to study, so we need to address this issue”. And finally everyone agrees that we need to study this. Then the subsequent meeting would say that Stockholm meetings have consensus statements on this, so the agreement is building that there is mild cognitive impairment (MCI). I didn’t go to other meetings, but I knew that consensus was just like the one that I was involved in. So not necessarily very many people are agreeing, usually the chairman gets to agree and he gets everyone along with it. Those consensus statements are really important, people say this is the landmark that shows interest and the clinical utility of this concept and so forth. And it doesn’t really. So what you see is science making up reality. They really are making it up.
I was also interested in bioethics of a number of things: treating people with drugs that do not work, and charging them for it (chuckle). Things like that. But also work that can slow the progression of symptoms – one would say that’s a very good idea – but if you have a degenerative mental condition, do you want it to take longer for people to die? Because long before they die they are not with us any more.
A.K.: Are you talking about Alzheimer’s?
A.G.: Alzheimer’s, yes. And the group I was in was a working group for the study of dementia guidelines, but they meant Alzheimer’s, they were not talking about other types of dementia (there are a lot of other kinds). Slowing the progression of dementia was seen as a good idea, but if you think about it – and Peter Whitehouse was one who mentioned to me that is not necessarily a good idea – is that it means longer time for people to be sick and requiring total care which means billions of dollars more. You are keeping them alive, but one of his issues was the quality of life. They are alive, but they don’t know you are there. They don’t know anything is anywhere, they are just blank. They sit in rooms, and they don’t move, they don’t talk, they don’t do anything. But they require complete care: feeding, bathing, washing, and so on and so forth.
So slowing the process of the disease is not a good idea, it seems like a good idea, but you can easily bankrupt in economy doing that (laughter). On the other hand, it sounds terrible, “Oh, they are going to die!” There are countries (Belgium, Netherlands) that have euthanasia. Before people become incapable of recognizing others or thinking at all, they can ask to be euthanized. And in Belgium and Holland they can be, with a very strict procedure to do it requiring several doctors who are not related and don’t work together. And they both have to agree the condition is fatal and irreversible, and the quality of life will be terrible, and the person is now cognizant. So, you can’t do it late, you can’t say, “Well, this person is gone, let’s euthanize them”, you can’t do that, they have to be clear. And most people, of course, think, “Well, if I’m clear now, may be I’ll be still, you know, in a year or two, and then I can go out and never come back”. It does not occur very often.
People think if you start doing that then you have a slippery slope (bioethics term) that you start killing all kinds of people. That actually tells you more about the American mind than anything else. Because there is no slippery slope in Belgium and Holland: the times that is used each year is fairly few, like fifteen times a year (you think there are hundreds or thousands! No, fifteen). But it does tell you something about the American mind – hey, if you can do it, then let’s do it a lot (laughter)!
My interest in bioethics also began probably 12-13 years ago accidently, and that was the bioethicists as that department developed would periodically come and ask me to do something. Or would I help them teach a segment of a class that had to do with religion and faith, because I was an anthropologist of religion, and how that might affect their values and so forth. Sometimes caring for older people – what is the value of caring for older people in different cultures. So for several years I was doing that, primarily with Stephen Post who was in Bioethics department. He became very famous for the ethics of the elder care, primarily for older people with dementia: how we treat them, what environment we should build for them, and so on and so forth. He would always ask me to come and give a class, so I probably did ten of fifteen classes with him.
And then Eric Juengst, he asked if I would co-teach a new graduate program in bioethics. I actually served on admission committee, and for five or six years I actually co-taught with Eric Juengst a segment on concepts of disease, and concepts of normality, and abnormality, and stigma, and so forth. Somewhere between that program whether I can have a joint appointment, and I said, ‘Well, ok’, and decided that I could see bioethics not only as something that anthropologists could help with (and often bioethics was helping biomedicine).
I said no, we need to study bioethics, just like we study biomedicine, not necessarily do what they want us to do, but to study why they think that, why they want people to do this. Sometimes bioethicists are helping biomedicine in getting informed consent. The question would be why we want their consent. Do we really want to do this to those people? Rather than how I should get informed consent. And I would probably not do that – that kind of bioethics. What I wanted to study, well, let’s study the nature of that research enterprise, and why these ethical issues come up, and so on and so forth.
So I got into bioethics, and did a presentation – that was a bit of what I would later call ‘cultural bioethics’. And then I started actually teaching a class “Anthropology and Bioethics”, and still teach it periodically (because I’ve got a great many courses that I teach, so I can’t teach them every year or every other year). So I taught it three or four times so far, and developed more the idea of cultural bioethics. So I see it now as the study of the bioethical enterprise and its uses by the medical establishment. But also another component of it as I see it now is asking sociological, or rather anthropological questions, ‘Why is this patient sick now? And why are they here in the hospital, what brings them here?’ And these kinds of social science questions can’t usually be asked by bioethicists, because they are not social scientists.
After I developed that a couple of years after (and that about 7-8 years ago) I read an article by a famous sociologist Renée Fox who became a bioethicist later in her career (although she considered questions that are considered ethical 30-40 years ago). She retired and she was interviewed in a journal. She said that bioethics is really a problematic enterprise in many ways, and it should be studied. And then she said, ‘Really all bioethicists should be trained in social science before they are trained in bioethics’. So I sort of use Renée Fox as my charger for one part of cultural bioethics. So that one part is – why is this person in Cleveland Clinic? Or why are they in UH? Or why are they in Hillside hospital? So how do they get to the hospital? Why are they in the hospital? And why are they sick? Not – what they have, but why they have it. Is it from their environment, are they in the hospital because they don’t have insurance, or they do have insurance2? If they have insurance, how do they get it (as an employee and so forth)? What’s the risk to their relatives? If they are sick here are their relatives at risk?
So, it’s really a social analysis of the patient. Medicine doesn’t ask those questions, and ethics don’t ask those questions either. They usually ask, ‘What is the nature of the problem?’, and ‘How is the best to treat them?’ An ethicist would say, ‘Well, you can do this, but you shouldn’t do that’, but they don’t say why this person is here, and why they are sick in the first place.
So the study of biomedicine led me to see more and more problems with biomedical treatment. And it’s not to say that biomedical treatment is not good at life saving, but Chinese medicine, and Ayurvedic medicine, and Unani medicine, and Kampo medicine – they are also life saving sometimes. It’s not that they are no good, those medicines still work, that’s why they are still around after two, three, five thousands years. Because they do work. So because it works sometimes does not mean it’s true. Biomedicine assumes: people get cured and that’s why it’s true. We can say that with Ayurvedic medicine people get cured all the time!
And also as I have explored, German medicine is rather different from French biomedicine, French biomedicine is different than American and German, and Italian biomedicine is different than Mexican biomedicine. So there is no one biomedicine, there is a whole bunch of different biomedicines depending on the culture in which you find it. Sometimes it’s an import, for example the psychiatry of Greece was all imported by England. So it is English psychiatry layered onto Greek culture, they don’t have their own. People became crazy, they kicked them out of the family, no one cared about what happened to them. They didn’t have any place to go, or an institution.
A.K.: So, may I ask you another question then?
A.K.: In your opinion, what are the socio-cultural values that drive the development of American biomedicine and bioethics in comparison with European biomedicines and bioethics (in plural)?
A.G.: Well, it’s hard to speak about everyone, but American biomedicine began rather as a battle against disease, and doctors were soldiers in a battle against disease. In early period, before and after 1800, Benjamin Rush had a very formative influence on US medicine. He actually believed that if you killed the patient with treating them it was actually better than letting the disease kill them. It’s all right if the therapy killed the patient, does not matter, because you are in this battle against disease. But by defining medicine like this, this discourse became a way to keep women out of medicine, because women can’t be soldiers. They started to let women be physicians, then stopped.
So this theme (fight against disease) became a manly enterprise, it produced a very aggressive tendency in biomedical practice. It there is a disease, you want to smash it. You get drugs that are more powerful than you need to, you try to do things more quickly than you need to. You can have slower therapy that last over a long time that are less harmful to a patient, but we would tend to use therapies that are more powerful and that have more side effects.
We are so often focused in this aggressive treatment of disease that we often do harm to people. Some of the new psychiatric medications: they can improve thinking a bit and emotional instability, but some of the new ones are also fatal, they will kill you as a side effect. If it were my medicine, well, I would say I will never use that drug. Some have immediate side effects and some have slower side effects. Like Zyprexa™ (a psychotropic medication) damages pancreas, so it will turn you into type-2 diabetic. And then it’ll turn you into Type 1 diabetic. So, I’m a diabetic and I asked my dietologist what the outcome is of a person who is schizophrenic and becomes a type 1 diabetic. And he says, ‘Oh, the outcome?’ he says ‘Oh, it’s catastrophic. A schizophrenic can’t take care of themselves, because diabetes is a very complicated illness, it requires a lot of monitoring, and they can’t do it. So they will die’. That’s new super-wonderful anti-psychotic, that’s crazy, why would you use that? Well, you can monitor, and if it starts happening stop it. But generally they say that mental results are so much better, so they keep them on it.
I’ve been reading a couple of articles where they are arguing that they should go back to some of the old psychotropic medications. They have side effects too, but they are not fatal (laughter). Some people get Parkinsonian tremors [from old medications], some people do, but a lot of people don’t, and those don’t really have significant side effects. And they are cheap. Several of the new ones can have fatal side effects, and they are extremely expensive.
In some countries – and this is an ethical issue – for instance, in Japan, the drug administration does not allow you to even test drugs that have very dangerous side effects. The gold standard form of research is the double-blind study, so you have a control group and the group that is getting the medication. People who get the medication or don’t get the medication don’t know what they are getting. And the physicians, nurses and coordinators don’t know who is getting what (although they often can tell from the side effects who is getting the drug… yeah, they do).
With the diabetes we have a diabetes center control test, a huge test known about 14 years ago or so that finally confirmed this is high blood sugar that causes the diabetic complications (they thought so, but they didn’t actually know). In that study they had one group where blood sugar was being controlled, and one group that was not being controlled. So for two years they watched this group go blind, kidneys fail, heart attacks and die. You can’t do that in Japan. You can’t have a group of people and give it something you think is good, and not give it to another one.
A.K.: I thought in the US it is the same – they have to put an end to a trial like this…3
A.G.: Oh, they did. The side effects were so dramatic that after about two years they stopped it, and started controlling everyone’s blood sugar – but it went for a year and a half. For other drugs – e.g., does it improve survival after heart attack? – oh, they do it all the time. And they watch people die. It’s our standard way of doing research. I think it is a major ethical flaw in the US research. Some people say, ‘Well, how else will you know?’ I say you have expectations and stats from 50 years or something for various problems. If you try a new drug on people and don’t see these problems, you know it’s doing good! (chuckle) You don’t have to allow people to die.
This is the danger too: people get into drug studies in the hopes that a new drug that’s being tested will help them. Well, half of the people are not getting the new drug. So they are in the study for no reason at all. This does not sound ethical to me. For practical reasons this research is heralded as the best type of research, but it is in no way, shape or form ethical. Then, what happens is biomedicine shifts from individual ethics when you are worrying about the best care for the patient. And they say, ‘Well, but from this study we will learn so much that will help other people down the road’. So it means you let these people die for the sake of other people they don’t know (laughter). I’m not sure that’s ethical either. They switch from individual ethics to communitarian ethics (which in itself is suspicious). They are supposed to ‘do no harm’. Well, in studies like that you are doing harm to people. You might say, ‘But they are getting this medication, they wouldn’t get it other way’. Yeah, but they might be doing other things to get better, and they are in that study thinking everything is fine. As some people say there are problems with biomedical theory and practice, and taking role as a medical anthropologist in bioethics to help bioethics help biomedicine is not necessarily ethical (laughter)! So we should be critical. I mean anthropology is a science, it is a multi-faceted science, but it is a science. It is not a service profession, we are not social workers.
A.K.: Could you give other examples of cultural differences in bioethics, and how bioethical issues are conceptualized and addressed here and, for example, in France (or other European countries)?
A.G.: Oh, there are lots of differences. One of them is in France they’ve addressed the major bioethical issue in health care – and that is making sure that everyone has it (laughter). I mean in the US all bioethicists, at least part-time, should be clamoring to make sure that everyone has access to health care. But they don’t. So working with French bioethicists I saw that they can scarcely even talk about it, they can not conceive of us not providing health care for everyone. And when you say, well, people get sick and don’t have insurance to pay for them, they ask, ‘What happens to them?’ ‘They die’. They say, ‘How can you possibly do that?’ You say, ‘Well, I don’t allow it to happen, but the society does’.
I have a good friend who is a famous medical anthropologist, Margaret Lock. When she finished Berkeley (about 5 years before I did), she took a job at McGill (she is English by birth). And she said she would go to McGill, she wouldn’t stay in the US, because they don’t have a health care system, and that is just unacceptable. So, that’s one big difference – all other industrialized countries have addressed the major bioethical problem, and that is the issue of ‘health care for whom’ (the distributive justice issue).
As well in France they have addressed it such that… One would think that if you are poor you get different care in the national system than if you are rich. Not true, there is no difference. There is a long-term difference, because people from different social classes actually care for themselves differently. So the medical interventions, the surgeries, and so forth – those outcomes are identical. But two years later, if someone has a kidney transplant, the well-to-do people will be doing better than poor people, because poor people will tend not to take care of themselves as well. In some cases that’s why they got the problem in the first place. At least the life-long care of the self which is up to an individual – that’s not equal. But the medical care and the medical interventions are equal.
One of the major barriers in the US is money, because our medicine is a for-profit enterprise. It is not in France. This year, in particular, when I taught my bioethics class [in France], we asked the physicians, ‘Do you think about the money when are deciding to do a transplant?’ And they said no. We asked, ‘Well, doesn’t the hospital get mad at you for doing…?’ And they said no. There is no consideration of money: what is the best therapy – that’s what you do. You don’t count how many you did, or, you know, is this person worth it? And this is the ethics of medical practice – it’s very freeing for them not to have to think about money at all. So in a US hospital when you say, ‘We want to do this therapy’, they say, ‘Uuuu… hospital is not going to like, it’s going to cost a lot of money’. You know, doing PET scans, and CT-scans, and so forth – it’s going to be a lot of money, so we will do just one test (laughter). And the insurance company is not going to reimburse for two of those tests, and bla-bla-bla… In the United States they play the money game all the time, but they don’t in France.
And that’s a long answer for ‘What is the driving force of medicine in the US?’ In the US it used to be that battle against disease, it is now really a money-making enterprise. There are still people who want to help people, that’s why they become doctors. But the constraints on those people are fairly substantial.
Then, if you take the profit out of medicine, it becomes much less expensive. Because you are not paying doctors a million or two million dollars a year. People who were in transplant services can easily make a million, or two million dollars a year. So you have to bill a lot of patients a lot of money to pay for those people and all their fifteen assistants, and so forth. In France they are not paid any more than a pediatrician. There are salaries, and they don’t go up very high. A dean of a medical school that I know he told us what the salary was – 150,000 euro a year (which is may be $220,000). But he is senior, and he is the dean of the medical school. You can get higher paid than that. And when he turns 65, he has to retire (laughter).
Transplantation is another issue – we value our specialists differently, that’s unethical too. People who treat children are paid less money than people who treat adults. People who treat older patients are paid less – because the real and true patients are adults… Adult males – OB/GYN get less. We call it dimensions of stratification in US biomedicine. One of them is patients that you treat. The other is – what is the extent of somatic intervention. Do you cut the body; do you do something with it? If you don’t, then your income is lower.
Today’s psychiatrists get all these medications, that is considered a somatic intervention. So they are paid more than psychiatrists who did talk therapy. As well, if you a psychiatrist giving drugs, you don’t really do long-term case histories, you don’t talk to patients very much. So you may see them once for an hour, but after that it is for ten minutes. Or you might see five patients in an hour, and you get the same paid as when you do talk therapy with one patient for an hour. So you can make five times as much money.
For the first time because of all these drugs psychiatrists can now make much more money than they used to. It’s a different psychiatry than when I started, and to be honest – far less interesting. As another senior psychiatrist told me, they used to know their patients pretty well. And that’s what attracted me to study psychiatry – because you would here all these amazing human stories. Psychiatrists were actually often very philosophical, very existential. Because they sat and listened to terrific problems and difficulties. And now they just say, you know, ‘I’ve got a depressed patient, I’ve got them on such and such drug’. They wouldn’t be able to tell you the life situation of a person. Some would, but usually no. They think that the problem that a person has is biochemical imbalance, and this drug can somehow rectify it…
I mean I see shortcomings of biological psychiatry, because I have students who are on various medications. Because I do psychiatric stuff, they come see me. They don’t go see their psychiatrists, because they don’t want to be put on another pill, they want to talk to someone. So I send them to the psychoanalytic institute to find usually an MD who is a psychoanalyst (who can prescribe drugs). And I’ve talked to psychoanalysts, they are getting more patients. Modern biochemical psychiatry was outlined to me by a guy who was a president of the American Psychiatric Association long time ago (30 years ago or so). He said that in the future psychiatry would be exclusively biological, and we would have drugs for all of the problems, and we would have tests for the disorders, and social workers would take care of all those other social issues. And he saw that as a wonderful bright shining future of psychiatry. And he was head of the APA at that time.
A.K.: Professor Gaines, thank you for sharing this with me. It was a really enriching interview.
- Information is retrieved from http://www.case.edu/artsci/anth/gaines.html.
- A big segment of US bioethics is devoted to issues of justice in health care. American health care system is market-driven in contrast to Russian ‘socialized’ system of medicine inherited from the Soviet period. Despite the fact that health insurance is a most popular form of covering medical bills, as of 2009 around 18% of the US population do not have any health insurance at all (data from the website of Centers for Disease Control and Prevention).
- The practice described by Dr. Gaines would violate the ethical principle of ‘clinical equipoise’ for controlled clinical trials. According to Benjamin Freedman, ‘There is widespread agreement that ethics requires that each clinical trial begin with a null hypothesis. In the simplest model, testing a new treatment B on a defined patient population P for which the current accepted treatment is A, it is necessary that the clinical investigator be in a state of genuine uncertainty regarding the comparative merits of treatments A and B for population P. If a physician knows that these treatments are not equivalent, ethics requires that the superior treatment be recommended’ (Freedman, 1987, p. 141). On the other hand, while these ethical considerations guide ethically-minded researchers, there is still a lot of clinical research conducted in violation of this principle.
Freedman, B. (1987), “Equipoise and the ethics of clinical research”, New England Journal of Medicine 317, Vol. 3, pp. 141-145.