endogenous

An intensive care doctor shrugs as a young woman writhes in bed, fighting her breathing tube in a panic as sedation is weaned for extubation. “Well, that’s what she gets for overdosing.”

During a break in training, an instructor brags about her studied lack of compassion for the addicts she is assigned on the floor, “They do it to themselves,” she spits, “They made the choice to put that stuff in their bodies.”

“She’s non-compliant, and addicted to pain medication. What does she expect us to do for her?” sighs a nurse, reading over a re-admission chart while waiting for the patient to come up from emergency.

A triage tech mutters over her shoulder while struggling to get a blood pressure, “She wouldn’t be having a panic attack if she hadn’t smoked meth in the bathroom.”

Conversations this week echo an entrenched sentiment I have heard repeated in ambulances, emergency rooms, inpatient units, training centers and classrooms. Attributing personal fault to survivors of suicide attempts, addiction, unintentional overdose, or the sequela of mental health conditions of any stripe, the idea that people end up needing healthcare because of deliberate choices at all, gives an easy excuse to detach, disengage, and keep our own shoes on our feet.

I am no stranger to the dark humor that keeps those working on the front lines of emergency and critical care from cracking in the face of the onslaught of trauma and tragedy we witness every day. The humor is not only understandable, but necessary for the clinical detachment, emotional release, and camaraderie it can foster between those who share the strange drudgery of life-or-death medicine. I also appreciate the flares of anger, and where they land. It is easier to displace the flood of emotion at losing a child’s pulse for the last time in a trauma bay towards the rank homeless man with a curb-and-gravity induced head injury, trying to elope from the next room. We cope as we can, and none of us, least of all me, can throw the first stone for callous and judgmental flares in the face of the wash of humanity that we encounter shift after shift.

But some pronouncements of judgement, of declaring a human worthy or worthless of care, are different, somehow. I have spent a good deal of thought this week trying to piece together where and why some cross that line.

Many of the people I grew up around still believe, deep down, that illness is something you bring upon yourself. Do you have hypertension? It’s because you don’t exercise. Do you have diabetes? It’s because you eat junk. Do you have cancer? It’s because you didn’t wear sunscreen, or wore some kind of toxic sunscreen, or didn’t eat enough fiber. Sure breast cancer unfairly strikes down young mothers, but probably they were using deodorant with aluminum, or didn’t drink organic milk. Blame is easy to come by. My mother, for instance, still speaks often of how diabetics only have their poor lifestyle choices to blame, even though her thirty year old, healthy, physically active son-in-law with a BMI lower than hers has an unmedicated A1C hovering around eight and blood sugars in the 200s. These sentiments may not be openly admitted, but they are pervasive. This was reflected recently in an Ohio politician’s attempt to prevent ambulances from responding to chronic overdose victims; a three-strikes response policy. But these value judgements are the natural outgrowth of a society built on a bootstraps mentality, one that tolerates, even if it doesn’t openly embrace, a health-and-wealth gospel. Morality makes you healthy, not genetics, and certainly not chance. (Although when pressed, they may admit that moral, hard working ancestors passed on your healthy genetics, bringing this whole discussion uncomfortably into eugenics territory. But that is for another time.)

And this is where we get into trouble. If someone can still be blamed for diseases that can arise almost entirely from genetic predisposition or accident, how do we even start to talk about the biochemical realities of mental illness and chemical addiction that are less easy to quantify and graph and illustrate on network TV. If your hypertension is your own fault, how is your depression really ultimately due to anything but personal weakness. How is spending your paycheck on a cocaine bender after three months sober anything but your own deliberate choice? Not the fact that your synapses have physically been rewired such that your deepest primal instincts compel you go after the high as matter of survival. That your prefrontal cortex is literally starved of nutrients in those moments, effectively knocking out rational decision making capacity. Yet no one blames the patient with a tumor strangling his spinal column for a sudden inability to walk. These things still remain uncorrelated in our minds; even the minds of the people who should and do know better.

Neuroscience is slowly unlocking the physiological realities driving thought, mood and behavior, but there is a long way to go before even medical professionals with the research at their fingertips begin to accept the messy consequences of epigenetics as a physical reality and not a moral choice. The thing is that the level of detachment which goes beyond clinical necessity and begins to assign personal blame also makes allowances for a poorer quality of care. The health outcome statistics tell a damning story there, and the blame lies with us all.