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Some Surgeons May Be Psychopaths—But That’s No Bad Thing

Discussion in 'General Surgery' started by Hadeel Abdelkariem, Apr 14, 2019.

  1. Hadeel Abdelkariem

    Hadeel Abdelkariem Golden Member

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    Stephanie and Goobers were born seven months apart. Goobers was a healthy female but Stephanie suffered from hypoplastic left-heart syndrome—in other words, the left-hand side of her heart was underdeveloped. Two weeks after Stephanie’s birth, at the Loma Linda Medical Centre in California in October 1984, Goobers was killed on her behalf. Goobers’s walnut-sized heart was excised and sewn into Stephanie’s chest. The twist is that although Stephanie was a human baby, Goobers was a baboon.

    For three weeks, Stephanie’s simian heartbeat kept her alive. The Times even reported that the five-pound baby was “sucking strongly, crying lustily and as cute as a button.” Then, as a result of the drugs and progressive graft necrosis, Stephanie’s kidneys and heart failed.

    After the child’s death there was a public outcry: the surgeon in charge of the procedure was accused of “playing God.” In fact, Leonard L Bailey had been experimenting with cross-species organ transplants for the previous seven years—but his other surgeries had involved sheep and goats rather than human beings and so had aroused little debate. This new experiment was always going to be controversial. Goobers was a young baboon who had been raised in the hospital’s research colony and Stephanie was the daughter of a poor mother who, it was later claimed, did not give informed consent to the operation.

    Critics of the attempted xenotransplantation (“xenos” means “stranger”) accused Bailey of having exploited Stephanie, who had been sacrificed “on the altar of scientific progress.” Animal rights campaigners accused Bailey of “ghoulish tinkering,” which lead to the killing of “a perfectly healthy baboon in order to prolong a child’s suffering.” But Bailey was unrepentant: he boasted that he was a surgeon governed by “medical altruism” as much as by scientific ambition.

    I thought about the lives and deaths of Stephanie and Goobers while reading two new books about the craft and science of surgery. The first is Thomas Morris’s The Matter of the Heart. Morris is in awe of heart surgeons—as indeed we all should be. The heart is an extraordinary organ: at the end of an average person’s life, the fist-sized muscle has beaten three billion times, and pumped 88 Olympic swimming pools of blood. Morris wants his readers to get to know the exceptional men (and occasionally women) who have had the daring to open up their patients’ chests in order to repair malformations and injuries.

    The second book is Henry Marsh’s Admissions: A Life in Brain Surgery. Marsh is probably Britain’s best-known neurosurgeon, and while he marvels over the mystery of the brain as a physical entity, he is less reverential than Morris towards surgeons themselves. The most remarkable aspect of Marsh’s memoir is his willingness to share—occasionally gleefully—stories of failure. Brain surgeons sometimes make careless mistakes: Marsh pleads guilty to making a few himself.

    These books focus on the two most emotionally freighted organs in the body—the heart and the brain. Part of our sense of wonderment about them is due to the practical difficulties of operating on them: hearts are well protected by ribcages and brains consist of slippery, jelly-like substances inside a hard skull. Long-standing cultural traditions have also marked out these organs as special. In the Middle Ages the heart was thought to be the centre of love and intelligence (the intellect migrated to the brain at a later stage). In the early modern period, Ambroise Paré (the father of modern surgery) maintained that the heart was “the chief mansion of the Soul, the organ of the vitall [sic] faculty, the beginning of life.” Even today, overwhelming emotional events are said to make our hearts swell, ache and break.

    The brain is equally emblematic of what it means to be human. It weighs three pounds and is 75 per cent water, and yet it gives rise to thoughts and feelings—indeed, consciousness itself. If anything is truly “me,” it is my brain. As Marsh eloquently muses, “everything I think and feel, consciously or unconsciously, is the electro-chemical activity of my billions of brain cells, joined together with a near-infinite number of synapses.” When our brains die, we are also extinguished. Each of us is nothing but a “transient electro-chemical dance, made of myriad bits of information, and information, as the physicists tell us, is physical.” This doesn’t make death any easier to contemplate. But it does highlight the mystery of the relationship between the brain as a physical organ and as the seat of individuality.

    “One early surgeon advised that he must have a strong, stable and intrepid hand, and a mind resolute and merciless”

    Beside their admiration at the way surgeons manipulate the heart and brain, the authors share something else: an interest in the dynamic whorlings of human personality. They both understand that surgeons are complex characters. Indeed, their choice of profession marks them as unusual. The days when surgeons were lauded as demi-gods, touring the world to lecture to adoring crowds (as did Alfred Blalock, the surgeon responsible for curing “Blue Babies” in the 1940s) are well and truly over. Nevertheless, some of that “god-dust” still clings to them; and not necessarily in a good way. Marsh has observed that surgeons can be selfish and callous, often making “remorseless use of others.”

    This kind of speculation is not new. Prior to the invention of anaesthetics in the 1840s, a detached sensibility, indomitable nerve and tough stomach were regarded as essential traits for a surgeon. As Paré advised in 1649, he “must have a strong, stable, and intrepid hand, and a mind resolute and merciless,” capable of doing “all things as if were nothing affected with their cries.”

    This was one reason why the prominent 19th-century physician Silas Weir Mitchell failed in his ambition to become a surgeon. In his unpublished autobiography, he noted that anaesthetics had not yet been invented when he started training. He had never been able to forget the “terribleness” of a female patient “held by strong men.” Her “screams, the flying blood jets—and the struggle were things to remember,” he wrote. He confessed that he “had neither the nerve nor the hand which was needed in those days for those operations.”

    More recently, the “nerve” required by surgeons has been called psychopathic. In 2012, psychologist Kevin Dutton published The Wisdom of Psychopaths: What Saints, Spies, and Serial Killers Can Teach Us About Success, in which he argued that surgery was one of the professions with a high proportion of psychopaths. A more rigorous attempt to address the relationship between surgery and psychopathy was conducted in September 2015, when the Bulletin of the Royal College of Surgeons of England published an article by J Pegrum (a trauma registrar) and O Pearce (a trauma and orthopaedic consultant).

    Using the short form of the psychopathic personality inventory, they assessed the personality traits of 172 doctors. They concluded that doctors did, indeed, have higher scores, with “stress immunity” being particularly notable among surgeons. The intriguing thing about Pegrum and Pearce’s article, however, was its subtitle: “Are Surgeons Psychopaths? And, If So, Is That Such a Bad Thing?” Emotional detachment from the fraught contexts in which they have to make life-and-death decisions can result in better choices being made. Being immune to stress might actually benefit patients by facilitating empathy. Too much emotion can lead physicians and other care-givers to turn away from their patients, in fear or disgust. A calm, analytical logic enables surgeons to reach out their hands to help. It is an interesting argument.

    The genres in which they are writing, however, sometimes undermines their readers’ sympathetic engagement. For example, their books wallow in grotesque, macabre and bloody tales. Morris describes the famous neurologist Charles-Edouard Brown-Séquard sitting next to the headless corpse of a criminal who had been guillotined in June 1851. Once rigor mortis set in, Brown-Séquard removed blood from his own arm, whisked it, filtered it through a cloth, and then injected it into the amputated arm of the corpse. When the corpse’s arm lost its rigidity, he rejoiced. The whisking of his blood had removed fibrin, which promoted blood clotting.

    Morris’s readers are treated to scenes in which surgeons thrust their hands into chest cavities awash with torrents of blood. On occasions, blood spurts out with such force that it hits the ceiling. Similarly, Marsh’s patients sometimes vomit so much blood that everyone in the room has to wear aprons and boots. Marsh invites readers into surgical training rooms in which student-doctors operate on recently severed human heads. He observes cold-bloodedly that the original owner of one head had bad teeth. He recounts an occasion when a colleague drives to the hospital with 15 frozen heads in the boot of his car.

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    Healing hands: surgeons face incredibly difficult ethical decisions. Photo: Adrian Sherrant/Alamy Stock Photo


    Human bodies are not the only ones caught up in this blood sport. Animal experimentation has played a key role in surgical advancements. Long before any procedure was carried out on humans, they were practised on animals like Goobers. Indeed, the first surgeon to deliberately operate on a heart was GS Brock from Danzig. His chosen animal was a rabbit, whose heart he proudly brandished at the 1882 meeting of the German Surgical Society. As Morris informs us, “far more experimental animals died during the 20th century than did patients.”

    Whether the experimental surgical techniques are practised on humans or animals—on Stephanie or Goobers, in other words—surgeons are forced to make incredibly difficult ethical decisions. Their decisions determine whether their patients live happily ever after or die on the operating table. Worse: their actions can mean a person experiences a protracted, harrowing death or joins the 7,000 people in the UK currently in a persistent vegetative state. Surgeons are often forced to decide to what extent they have a duty to relieve suffering, or obstinately prolong life. Is it a form of clinical cowardice to hasten the death of a person in unremitting pain?

    In many ways, these ethical dilemmas have been made more difficult by changes in the medical milieu in which surgeons operate. Today, even “god surgeons” work in shifts and are just one member of highly specialised teams of anaesthetists, cardiologists, and imaging specialists. Levels of bureaucracy are formidable, and hospitals often prioritise minutiae and paperwork over patient-physician interactions. The NHS is chronically underfunded.

    “As a result of anaesthetics, the surgeon need not hurry; he need not sympathise; he can calmly dissect, as on a dead body”

    All of these factors affect medical empathy. There have been much more fundamental shifts, however. In The Matter of the Heart, Morris quotes from an important essay by the famous 18th-century surgeon William Hunter, entitled “The History of an Aneurysm of the Aorta, With Some Remarks on Aneurysms in General,” published in 1757. For Morris, the importance of this essay lies in its graphic description of the man’s death. When Hunter’s patient turned over in bed to cough, “blood gushed out with such violence as to dash against the curtains and wall; and he died, not only without speaking but without a sigh or groan.”

    Although this is a very evocative sentence, I think that Morris misses the main difference between 18th-century surgical writings and their modern counterparts. Hunter’s purpose in writing the essay was to introduce physicians to improved surgical techniques to treat aneurysms of the aorta artery. To do this, Hunter believed that he was required to pay attention to the whole patient. Hunter treats his patient—a 39-year-old maker of corsets called Isaac Bradwell—as a person. Bradwell was a “man of a well-made active body.”

    Both the patient and the surgeon collaborated in speculating about how the aneurysm started: was it during a wrestling match or that time when Bradwell hurried too quickly to vote at an election? Did his aneurysm begin because he took a wager that he would be able to walk around a park, or because he had “restrained his breast” too often as he struggled to inset whalebones into corsets? Readers of this surgical case are told that Bradwell’s tumour was so large that it could not “be covered by the expanding hand and fingers” and his pain was “as if swords were struck through him.” Bradwell “had all the terror of death expressed in his countenance.” Bradwell might have died “without speaking… without a sigh or groan,” but he was fully involved in the clinical encounter.

    By contrast, in later surgical texts the emotional lives of patients were of little relevance. The introduction of diagnostic classification systems and changing medical technologies rendered patients’ descriptions of their suffering more peripheral to the healing process. Hospital medicine (as opposed to the domestic bedside, where Hunter often sat) focused not on individual peculiarities but generalisations based on large numbers of people, stripped of individual names and faces. The growth of laboratory medicine also enabled physicians to bypass patient-narratives in their search for an “objective diagnosis” based on knowledge taken from microbiology, chemistry and neurology. The invention and employment of anaesthetics reduced the emotional investment of surgeons to the suffering they were inflicting on their patients. Rather than writhing in pain and being held down by “strong men,” their patients were now unconscious bodies capable of being manipulated in relative silence. As surgeon David Cheever put it bluntly in 1897: as a result of anaesthetics, the surgeon “need not hurry; he need not sympathise; he need not worry; he can calmly dissect, as on a dead body.”

    Neither of these two books reflects on such wider shifts in the history of empathy. While Morris’s book is where readers should go for riveting historical accounts of surgical brilliance as well as hubris, Marsh’s memoir better evokes the human fragility of the surgeon. In an interview he gave in 2015, Marsh cited the lyrics of a BB King song: “Better not look down, if you want to keep on flying.” When witnessing the intense suffering of other sentient beings, it takes courage to balance detachment with the discomfort of compassion.

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