ISSUE 6 - WINTER 2017
iâ&#x20AC;&#x2122;m here for you
perspectives on mental illness in recent hip-hop
from the editors
family medicine, home visits, holistic care reflection
viewing medicine through a different lens
overfitting and its relation to the effects of music on goals, goal-oriented cognitions, and pleasure
archimedes, the principal
re-create outreach: art studio interview
reading between the iv lines
a discussion on medical paternalism
THE MUSE â&#x20AC;˘ WINTER 2017
FROM THE EDITORS couldn’t compromise on. We wanted The Muse to be a place where personal relationships could be formed, where we would operate under honesty and transparency, where leadership did not mean taking control, but meant taking initiative. There will inevitably be changes in The Muse, and there already has been change. These changes are not something to avoid; they are simply an eventual move forward with the flow of time. There is no question that we’ve had our ups and downs. Coming into The Muse as Editors-in-Chief, we are embarrassed to admit that we did not fully recognize the weight of this position. It was only through the various experiences that we understood the responsibility of being held accountable, the importance of details, and listening with an open mind. There were many moments of doubt and frustration, but having one another for support was extremely comforting and encouraging. Our journey with The Muse has truly been one of learning, discovery, compromise and humility.
Dear Reader, Stepping into this role, we were filled with both excitement and trepidation. With a leap of faith and the question of “what if?” that resounded in our minds, we went from general editors to Editors-in-Chief. And what a journey it has been, both for ourselves and for The Muse. We wondered to ourselves if we truly grasped what the field of medical humanities encompassed, as we begun our official duties as Editors-in-Chief, struggling to define and explain what it meant. Not only to ourselves but to those who had never heard of it. We wondered if we could fill in the gaps that Anna had left behind when she decided to retire from this position. Did we know enough? Were we passionate enough? Were we worthy of this position? Somewhere along the way we must have realized that we weren’t going to be able to keep The Muse as it always was, and that was okay. We didn’t quite know where to begin, but what we did know was what we
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We are not perfect, just as medical professionals are not - or any human being, for that matter. It is so easy to get caught up in the scientific aspect of medicine, forgetting the complexity that exists within the relationships and personal lives of healthcare workers and patients. But there is so much more to the person than their title and we can only hope to be given the opportunity to showcase the beauty and intricacies of one’s story. Lastly, we would like to give a big thank you to our faculty advisor, Dr. Amster, for her endless support, and all of the members of The Muse, for working together to achieve new heights. And to our readers, we certainly did not forget about you. Thank you. Sincerely,
Katherine Kim & Nikki Wong
The End By Owen Dan Luo Art by Grace Huang
Finds us – unprepared – running, As our finale caught up, We paced forward – oblivious Our world of possibility torn asunder, A flurry of white coats – dance around us In this final blizzard Like jagged pines, Staggering in the face of – The mighty Northern gales A white rapid, Jargon-filled suggestions flood our lives – Cold and rushed
Overwhelmed; We struggle – merely afloat, Blindly following commands, Our legs are bound – we are less of a risk – Confined; to a steel cage, That wheels us about Our voices are silenced Our will unheard; Are we mute? Or are they deaf? Our life handled by another, Managed by another, Disregarded by another How have we become Bystanders – In our own health? Intubated, our final breaths Our ultimate wish – often unanswered – To say goodbye: On our terms.
ABOUT THE AUTHOR Owen Dan Luo is in his third year in the BHSc Child Health specialization. THE MUSE • WINTER 2017
stage ii Art by Katherine Tang
they swallow light and expand like this is kingdom like this is theirs to own they clip the long hair you always held back but you did not ever collapse. your hair broke the fall each time landing on the white bed like sacrifice i never learned to accept you with short hair tucked under a knitted hat (you were the first aunt to teach me how to knit). i am sorry i imagined you like samson when your grip is so much stronger than those that invade your temple critters exuberant i wish i could cut all of them away like preschool crafts. but your hair is long again. it reaches your shoulders and i braid your bangs into a crown. oh how i wish that every knot i tie is another minute longer with you k.k.
THE MUSE â&#x20AC;˘ WINTER 2017
Family Medicine, Home Visits, Holistic Care Reflection By Yipeng Ge Art by Michelle Yao
Background Information on H.E.A.L. Blog Founded in 2014 by a medical student at the University of Ottawa, Humanities Education, Artistic Living (H.E.A.L.) is a student-driven initiative, creating space in medical education for reflection, dialogue, and selfcare via the expressive arts and health humanities. H.E.A.L. promotes the humanities as a cornerstone of medical education and practice, empowering medical students to find and give expression to their own voice as a source of strength and resiliency. Our program is a part of the student-led arm of a comprehensive interlinked humanities curriculum at the University of Ottawa, Faculty of Medicine. We are fortunate that our medical school formally recognizes the benefit of humanities training. We feel that it’s very important that there be a component which is student-driven and run, as the expressive arts will serve a crucial contribution to wellness amongst medical trainees. Throughout the course of medical education, students participate in circumstances that strain the bounds of the human experience. The traditional coping mechanism of professional detachment is insufficient to nurture the full complex emotional and spiritual plurality of the medical students who began. To prioritize empathy, insight, trust, and an understanding of the human experience of suffering in the training of healthcare professionals, there is a pressing need for enriched humanities exposure in medical training. Aside from the numerous pedagogic outcome benefits, including reflective, empathetic and analytical skills essential for providing good care, it also promotes wellness and healing.
am so excited about medicine. Having completed a handful of family preceptorship sessions, a few electives, and having had a few exposures to talking to patients oneon- one, I am so excited. What is exciting? It is learning about another human being and immersing yourself in their stories and their concerns – to be present and to be there for them. I was
fortunate to tag along to many patient home visits for my most recent family preceptorship session. These visits certainly struck a different tone for me compared to when my family medicine preceptor and I met, greeted, and worked with patients in the clinic. We entered, or rather, we were warmly welcomed, into people’s homes, their sanctuary, to see and ask about how they were doing. It was truly something
different, humbling, and eye-opening. For me, it brought the humanity piece of medicine completely into context. The environment, the home, that someone lives in, can tell you so very much about them. Something that is a bit strange about patient home visits is that there is not always a clear “objective” for the
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Family Medicine, Home Visits, Holistic Care Reflection patient encounter. This contrasts with the classic patient interactions that are introduced to us and taught within the classroom and even within the clinic. The electronic medical record system forces the visits and patients into compartments. And the main concern of the visit is clear and defined, described on the computer monitor in front of us, before we enter the room and address the patient. But patients, and people, are more complex than this. We as human beings are more whole than this. A holistic and caring approach is what the patient home visit felt like. Even though there was no defined “objective” to address with the patient, a brief interaction with the patient in their home can tell us so much about their current mental and physical status by uncovering things like their daily living habits and overall mood. Much can be explored through insightful conversation and objective observation of the patient and their surroundings. This can simply be a discussion on current topics in the news or observing the fresh food in their fridge or if they happen to leave a towel for you to wash your hands.
“I remember that they live complex lives and at the crux of it all, they are another human being with unique goals, direction, and worries.” My family medicine preceptor said something that will certainly stick with me for a long time. In my head, it went something along the
lines of: “I remember and think of the places, the homes, that my patients come from when they sit in front of me at the clinic, I remember that they live complex lives and at the crux of it all, they are another human being with unique goals, direction, and worries.” It is an incredibly humbling and insightful experience to learn about a patient and their life in the context of their own home. It is also an excellent opportunity that emphasizes the importance of the social determinants of health and the complexity of people’s lives that predisposes them to poorer or better health. As a medical student learning about the details and pathophysiology behind certain medical conditions, it is amazing to learn first-hand about humanity in medicine — something
that cannot be learned in a classroom. And from this experience, I come face to face with my own humanity and life. After all, we are all human beings, and need to remember such. The unique goals, direction, and worries that I have are not so different from what others experience, including our future patients and colleagues.
ABOUT THE AUTHOR: Yipeng Ge is a M.D. candidate at the University of Ottawa Faculty of Medicine. He completed his undergraduate studies at McMaster University in Health Sciences, specializing in Global Health. Yipeng has an interest in the humanities and arts within medicine and primary care. Yipeng co-leads the H.E.A.L. (Humanities Education, Artistic Living) blog at the University of Ottawa.
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Connection By Katherine Kim Art by Adhora Mir
Names and details have been changed for the privacies of the patients and individuals mentioned in this piece.
s a student striving for medical school, one of the unspoken “must-dos” is volunteer at a hospital. While this is not officially the case, I was still determined to get this “requirement” checked off my “list.” When I decided to volunteer at St. Louis Hospital, I didn’t think much of it. As if it were a prerequisite course, I stepped in without much interest, focused on getting the job done, done, done, for whatever lay ahead in the future. My volunteer position was in the Hemodialysis Unit. I was to help wheelchair patients to and from their respective units every Tuesday, from eight to ten in the morning. This felt like the most useless volunteer position. What could I possibly learn from transporting patients here and there? It seemed like the only benefits were volunteer hours and another activity to put on my resume. I soon learned this was not the case. On my first shift, I met my partner Aria, who had been volunteering
at the hospital for a few months and was to train me that day. We waited in the main lobby for the hemodialysis patients to arrive. Our first patient was a grey-haired man in a baggy black t-shirt. Aria immediately greeted him by his name, assisted him onto the wheelchair, and escorted him down the long hospital hallway. The two spoke casually, like old friends, and I listened carefully to their conversation, trying to pick up patterns. But the more I listened, the more I realized how personal and unique their conversation was – one that you could not replicate. When a vending machine came into view, Aria slowed to a stop. The patient grabbed a coke, after which Aria smoothly resumed down the hallway. All of this happened like a routine, something the two understood without words. I wondered how long it had taken to develop this bond and what good it even was, apart from growing close with someone you would
eventually have to say goodbye to. The first patient I escorted was a grandfather with blue eyes and the kind of smile that reminded you of Christmas mornings. Beginnings are always full of small talk, as should be expected, but I almost felt ashamed of having Aria follow behind, listening in on such a boring conversation. How come I couldn’t develop a bond with my patient? How come I felt like a robot, spewing words from a script written by another man? As the weeks passed by, I continued to give away my hours, starting off reluctantly, yet slowly, becoming thankful. After all, they say that you receive just as much as you give, if not more. And every time I transported a patient, the long, empty stretch of the hospital hallway became a safe space for us to share stories. Finally, after see-
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Connection ing the same patients every week, we had developed the bond I was craving – the unexplainable urge in human nature that draws us closer to one another. Despite it being over a month since I last saw them, I still remember them all. To the man who rarely spoke, I valued our quiet journeys. There was peace in our small conversations of thank yous and goodbyes and something so pure in the act of giving and receiving. To the lady with the young heart and unforgettable laugh, bright enough to crush mountains, I valued the minutes we spent waiting for the taxi and our routine of checking each taxi’s number until we found yours. You told me about your love for records as a teenager, but you also told me about how some days you felt so much pain that you could do nothing but lie in bed. You always remembered the me with black hair, as well as the me with blonde hair. You wore red slippers one day, and runners the next. Despite our ever-changing outer appearances, our relationship remained constant. To the man I assumed did not speak English, I am sorry. I had assumed you were a foreigner who did not want to speak, so I engaged in very little conversation, merely only saying hello, and talking to my partner instead. This was my mistake, and once again, I am sorry. I will never forget the moment you spoke up; when in broken English, you shared how you had been in a car accident. In that moment, I felt the weight of the human heart. How despite the presence of a language barrier, we still reach out to share our stories, to have our voic-
es heard, as though there is a certain power and healing to letting sorrows be vocalized. Every step shared in that hospital, I found my minutes were not wasted at all. The diversity of the patients astounded me, and I realized that all of the patients were essentially of the same human body. Our anatomical features were synonymous, yet each and every one of our conditions different. The job of a doctor is to diagnose and treat in the midst of all of these differences, on top of the diversity of patients’ histories and personalities as well. Saying goodbye was the most difficult part. Our see you next weeks turned into final goodbyes, and the closing of a taxi door was like the closing of a chapter. Waving goodbye for the last time reminded me of the inevitability of human life: People come and go, a cycle that we will never get used to. Oftentimes, our days are so busy that we forget there are moments to share. The seconds and minutes constantly pass by, against our own wills. Nevertheless, I have come to learn that there is therapy in human connection. I would like to thank Aria, my partner, for being there with me every step of the way – quite literally, every step – from the main lobby to where we are today. I thank you for opening up to me within those hospital walls, and most importantly, I thank you for reminding me that we are strongest when connected by spirit and belonging.
ABOUT THE AUTHOR - Katherine Kim is a second year student in the BHSc program. She has a background in creative writing and hopes to continue integrating the arts into her science degree throughout her undergrad. She is currently the Co-Editor-in-Chief of The Muse Magazine.
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Overfitting and its Relation to the Effects of Music on Goals, GoalOriented Cognitions, and Pleasure By Alexander Blackburn Art by Adhora Mir
verfitting occurs when overly precise models are fit to a finite dataset, which leads to inaccurate predictions due to the focus on the particulars of that dataset (Hawkins, 2004). Tools to prevent overfitting usually involve restricting complexity by constraining the number of parameters used to model the data (Mackay, 2003). Occam’s razor describes this concept as: the simpler the explanation, the broader its application. This principle has important applications for the formation of goals and goal-oriented cognitions. In this article, I examine the effect that music has on an individual’s goals, goal-oriented cognitions, and pleasure. I present a new theory of this effect, explain its connection to overfitting, state its causes, as well as state its applications to musical therapy.
I start with the hypothesis that our cognitions are what we use to achieve our goals. If an individual’s goals are easily achievable, and don’t require
complex cognitive processes to achieve, then the individual will derive more pleasure. This is because the individual employs less strict criteria for a cognition to be considered as contributing to their goals. Applied to Occam’s razor: the simpler the explanation, the broader its application, and also the more pleasure derived from this broader application. This is due to the application of less strict criteria for a cognition to be considered as contributing to the individual’s goals, and therefore a higher number of cognitions and experiences are likely to be perceived as contributing to his/her goals. Simply put: simple explanations and the broad applications of these explanations increase pleasure and positive effects in people through increased perceived connection of their experiences and cognitions to their goals. The principle that our cognitions are connected to our goals can be seen when considering how sugar consumption affects learning. A 2012 UCLA study on rats found that a diet high in fructose hinders learning and memory by slowing down the brain (Gregoire, 2015). If our goals are easily achievable,
such as consuming sugar, then our cognitions may suffer. Another hypothesis I’ve made is that experiences or cognitions that an individual finds pleasurable are those that contribute to their goals. Although this is a highly intuitive hypothesis, it does have supporting research. Howe et al. (2013) studied rats as they navigated mazes of different sizes and shapes to retrieve rewards. They found gradual increases in dopamine signals that began at the onset of the trial and ended after goal completion, delineating a positive correlation between perception of goal achievement and dopamine release. Therefore, cognitions that contribute to goals enhance pleasure and motivation. With these principles, hypotheses, and studies in mind, I propose that the simple, pro-social ideas and pleasurable experiences frequently expressed in modern popular music (as well as in most music to date) lower the complexity of the goals of the individual. Furthermore, they lower the individual’s criteria for an experience or cognition to be considered as contributing to their goals, and therefore
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Overfitting and its Relation to the Effects of Music on Goals, Goal-Oriented Cognitions, and Pleasure
decrease the possibility of overfitting, and increase simpler explanations for stimuli. This in turn increases the broadness of these explanations’ applications, as well as the pleasure the individual receives from these explanations and from comparatively less complex cognitions, through increased perception of their contribution to their goals. One reason that music is capable of doing this is through emotional contagion. Emotional contagion is the tendency for moods and emotions to spread between people or throughout a group (Johns and Saks, 2014). Also relevant to the tendency of emotional contagion are mirror neurons. Mirror neurons are thought to be essential to empathy because they fire when an individual performs an action or watches someone else perform the same action (Fink et al., 2007). Therefore, as the individual is listening to the simple, pro-social ideas and pleasurable experiences expressed in music, the individual empathizes with the singer. Although the complexity of an individual’s goals are lowered, the pleasure derived from these less complex cognitions are increased. This is done so through an increase in the rewarding of simple explanations for stimuli, resulting in an increased perception of his/her contribution to personal goals. Another function of emotional contagion is that it can change an individual’s attribution of how others must think and feel. Due to sexual selection pressures (Hosken and House, 2011), humans are innately competitive and generally try to do at least as well as the majority in order to reach their social and career goals. Support for this conclusion
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comes from social comparison theory, which states that people learn about their own abilities and attitudes by comparing themselves with other people (Akert et al., 2013). What would be the purpose of these comparisons if they do not provide a reliable mechanism to assess the effectiveness of individuals’ abilities and attitudes in relation to their goals? The sociable and simple ideas as well as pleasurable experiences expressed in music might lower the competition between individuals. A more simple, pro-social, and pleasurable attribution of how others must think and feel would reduce complex goals and lower the individual’s criteria for a pleasurable experience or cognition. Instrumental music can also cause a change in cognition. Instrumental music mimics the human voice and therefore conveys emotion (Alleyne, 2009). Fast music in the major key communicates happiness and slow music in the minor key communicates sadness (Hunter et al., 2010). Through emotional contagion and changed attributions of other people’s thoughts and feelings, happy instrumental music can increase the individual’s perception of happy feelings in those around them. This can increase the perception of others’ support for the individual, thereby decreasing the complexity of obstacles to goals. As explained earlier, reduced complexity lowers the criteria for an experience or cognition to contribute to an individual’s goals and therefore increases pleasure and positive affect. Furthermore, I propose that the detection of emotional tone in music validates one’s own emotions, which can decrease the stress of external expectations on
cognition and behaviour. Since the individual uses less strict criteria for goal-contributing cognitions, perception of previous thoughts and feelings involving desires of emotional fulfillment is prioritized over that of stress involving external expectations.
This theory has important implications for understanding how music therapy works. Music therapy has been used for improving movement, communication, speech in autism spectrum disorder, improving memory in Alzheimer’s disease and dementia; self-esteem, social skills, and attention in mood disorders; and memory, movement, and speech in stroke victims (Stegmoller, 2017). I propose that through these benefits, specifically the functions of increasing the pleasure the individual receives from less complex cognitions due to increased perception of contribution to their own goals, as well as increased perceptions of social support, music can reduce stress related to the individual’s disorder or affliction. Not only that, it can also increase positive effects in the individual, as well as alter previous preconceptions of not being able to meet personal goals, thereby improving their symptoms. This theory may have important implications for how music therapy is used, the broadness of disorders it can be used for, and the rate of its use. In conclusion, I have stated the effect of music on goals, goal-oriented cognitions, and pleasure, as well as its effect on overfitting.
Overfitting and its Relation to the Effects of Music on Goals, Goal-Oriented Cognitions, and Pleasure
I have also discussed why music is capable of having these effects, as well as the possible implications for music therapy. I think it is important to note that music can also have the opposite effect of increasing the complexity of an individual’s goals and the strictness of goal-contributing criteria for experiences or cognition. This can be done through the methods described above (social contagion and other changed attributions) or a desire to increase the complexity of goals, whether conscious or unconscious. Furthermore,
I believe that the theory I have proposed may have implications for the psychological study of movie and T.V. watching, social interaction, sex, proverbs, fear, and mental illness. It would be interesting to explore these topics further to see if any meaningful contribution to the literature could be made. As sung in the song “One More Time” by Daft Punk, “music got me feeling so free”.
ABOUT THE AUTHOR - Alexander is a second year undergraduate student at McMaster.
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I’m Here for You By Nikki Wong Art by Alice Lu
e was born a day early at 5 lbs 2 ounces on July 26th, an otherwise unremarkable day in 1991. The sky outside was clear and the weather pleasant. An ordinary day with another life brought into the world. But with that life, mine would change, and in that life, my whole world laid. His little hands reach out to me and I take them gently but firmly. His eyes tell me he’s scared and I smile and whisper back, “Don’t worry. I’m here for you.” I pull him up by the arms and lead him along, his face scrunched up in concentration and legs stretched out. Step by step he walks.
We walk together hand-in-hand through the school gates as the sun filters down on our faces. The door opens and they welcome us in. At three years old he knows nothing but his mother. He looks at me, lower lip trembling and face full of unease. It’s funny that after only three years of life, these expressions are so adult-like, so complex, hiding a thousand other emotions. “Mom,” his voice shakes as he looks up at me. “I’m scared.” I smile and stroke his silky hair, strands weaving through my fingers. “Don’t worry. I’m here for you.” And he gives me a brave little smile. That little boy of mine. I strap on the helmet and give it a knock. “Does that hurt?” I ask, peering into his light brown eyes. He thinks for a few seconds, then shakes his head. One leg stretch-
es out and hangs over the bike as he positions himself onto the seat. He waits, with his weight resting on his right foot. Looking up at me, he gives a little frown and says, “Mom. I’m scared.” I move to stand behind him and rest my hands on his shoulders. The weight of my palms seems to reassure him. “Don’t worry. I’m here for you.” He turns back as I smile at him. His foot leaves the ground. The crowd breaks into raucous cheers and applause as the girl in the pink dress makes her way down the stage. From behind the curtains, we stand and wait, listening to the teacher announce the next performance. He sighs and squeezes my hand tight. With eyes trained onto the brightly lit stage, he says, “Mom, I’m scared.” I squeeze back and pat his hair, now full of thick curls that almost cover his eyes. He’ll need to cut his hair soon. “Don’t worry. I’m here for you.” He looks at me for a minute as the applause starts up again. A breath goes in. Goes out.
And he lets go of my hand and steps away. Low whispers and conversations mingle with the occasional cough or sneeze as phones ring and the rush of footsteps resound through the white hallways. I stroke his face, hoping to smooth out the wrinkle in his forehead. Somehow, time has stolen all his baby fat. His curly hair, once long and unruly, is now cropped so short it almost looks straight. “Mom…,” he begins. “Don’t be scared,” I say. He shakes his head and puts his hand on mine, “Mom, don’t worry. I’m here for you.” I look up at him from the hospital bed and smile. He smiles back, that brave little boy of mine.
ABOUT THE AUTHOR - Nikki Wong is a second year in the BHSc program. Being an avid reader from a young age, she gradually came to love writing as well. Some of her favourite authors include Brandon Sanderson and Cassandra Clare. Currently, she is one of the Co-Editors-in-Chief of The Muse Magazine. THE MUSE • WINTER 2017
Perspectives on Mental Illness in Recent Hip-Hop By Maaz Muhammad Art by Peri Ren
ip-hop as a genre has gone through multiple paradigm shifts: originating as an outlet for expression among primarily African American adolescents, both its production and lyrical content have changed dramatically since its nascence, yielding a large array of subgenres with unique thematic and musical signatures. Rap has never shied from pushing the limits of social acceptability – itself originating as subversion against racial and social oppression – from its loose profanity to its bravery in portraying the grittiness of the street life.
song is of Vert’s abusive relationship with his suicidal girlfriend, the pain of which drives him to abuse
Xanax for escapism. However, this leads him to struggle with a Xanax addiction: “Please, Xanny, make it
As rap has lent its voice to almost every issue of the past two decades, so too does it now with its startling new focus: mental illness. Perhaps the rapper most responsible for this budding interest in mental illness is Lil Uzi Vert, whose 2017 song “XO Tour Lif3” tackles suicide and abuse. While at the surface the wildly popular song seems like it is making light of such serious issues through its upbeat production and its catchy chorus “Push me to the edge/All my friends are dead”, such a superficial analysis belies the deeper, darker meaning of the song. The narrative of the
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Perspectives on Mental Illness in Recent Hip-Hop go away/I’m committed, not addicted, but it keep control of me”, leading to depressive thoughts for Vert himself. Interestingly, some have argued that his line “All my friends are dead” actually refers to his materialism, suggesting his only “friends” are the “dead” presidents on his money notes. While “XO” is the most standout example of Vert’s innovative subject matter, hints of such dark introspection can be seen throughout his recent album “Luv is Rage 2”. If Vert has opened the floodgates of this thematic development, then XXXTentacion, perhaps more than any other recent rapper, has rode the tide. His album “17” is the most sustained contribution to this fledgling canon, with a track list that includes titles such as “Depression and Obsession” and “Everybody Dies in Their Nightmares”. The troubled rapper’s struggles with mental illness are well documented, owing to his willingness to share them on social media. While many are quick to dismiss him because of these troubles, as well as his graphic abuse of his ex-girlfriend, “17” and his social media have sparked industry-wide discussions on mental illness and its acceptance – and therein lies the objective. Rap as a genre, has historically been promulgated based on bravados and big personalities, from the gangsterism of Tupac to the jet-setting Jay Z. In such a boastful environment, the contribution of Vert, X, and others is to turn the focus of rap inwards, into previously unexplored aspects of the self. While introspection can be hardly said to be
their innovation, introspection on depression, abuse, and addiction (in a disparaging light rather than a bumptious one) was virtually inconceivable.
It can be said that the long thematic trajectory of rap has been a gradual turn inwards: while the 1990s focused on external social issues, the 2000s began to explore the concept of self in the context of the surrounding milieu, and now the 2010s has become about the internal spirit in itself. Whether it is consequential or coincidental that this new development of hip hop comes at a time when increasing awareness of mental health issues is being advocated at all levels, it is arguable that these rap innovations will help the cause. X has managed to deconstruct the traditional image of a rapper as a fast-living libertine into a vulnerable person with internal struggles. In this sense, he has exposed the industry and the world at large to this new conception. The awareness of mental illness that has been generated because of the likes of X is unprecedented. Suddenly, millions of fans have been exposed to such taboo ideas, thereby contributing to their destigmatization – that eternal goal of mental health advocates. By showing people that their idols
and celebrities are also vulnerable, mental illness becomes easier to discuss and talk about. Most notably, it removes the shame from admitting to one’s own mental health issues: if idols like Kanye West can go through mental breakdowns, then it is not so strange that an ordinary person would. While rap’s erstwhile bravado perhaps contributed to masking mental health issues amongst listeners, the newly emotionally introspective rap is conducive to an unmasking of those feelings. Lastly, rap touches demographics that may be difficult to reach with public health initiatives: adolescents and racial minorities.
The influence of rap as a cultural paradigm shifter ought not to be underestimated. The problems faced by inner-city adolescents are now well known and publicized, owing largely to rap. Similarly, this new focus on mental illness will likely lead to heightened awareness of mental health issues throughout rap’s many and varied listeners. It is easy to see a focus on previously unprecedented subject matter developing in rap, whether from Vert or his students. Of course, the most important benefit of this new paradigm is the novel perspective on mental illness it will bring to millions of impressionable listeners, helping them to appreciate the virtues of vulnerability over impenetrability.
ABOUT THE AUTHOR - Maaz Muhammad is a second year BHSc student with a passion for hip hop (especially Kanye West), powerlifting, and baking.
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Archimedes, the Principal By Michal Coret Art by Alice Lu
e sat in his chair, waiting for something. I entered his room and it seemed to relieve him. “Finally,” he breathed slowly. I sat down beside him, wondering what to offer. “Would you like anything? Some water?”
“I… think… no… that’s quite… alright… yes… I have some.” He spoke like a cryptic poet who weighs every word. My question was about a mere styrofoam cup filled with water, but he seemed to weigh it like a philosophical dilemma. He was Archimedes wondering what had been displaced. Then, “There is… a program… at 5:00,” he told me. “What program?” He stayed silent. His hair was grey and cut in a cool, youthful way. He wore glasses like mine. My mind, hopeful for a connection within the silence, decided that he must be a writer. “I worked… as a principal… you know,” he said, as if he read my thoughts. He looked up at the clock, 4:49 pm. “Did you teach before you became a principal?” “Yes… I taught… high school.” “What subject did you teach?”
“That… I don’t remember. There is… a program… at 5:00. I will go… to it.” His sentences came one after the other without connection or explanation. He glanced again at the clock.
Finally, he said, “I will go… alone.”
I sat silently beside him as he ate his dinner. Each bite of lasagna was a slow mission of piling food onto the fork and then guiding it to his mouth. He focused intently on his own hand. I felt intrusive sitting there beside him, watching his private ceremony of piling food and guiding it, piling food and guiding it, slowly and hesitantly.
“Okay, so let’s get you back into bed.”
“I don’t know… what I want… to say. I… can’t explain… it.” His loss for words seeped deeply into his core, under layers of time and confusion. He checked the clock again, 4:58 pm. Perhaps the clock anchored him to reality, bringing him back from the thoughts and questions that clouded him. A piece of lasagna fell onto his napkin, which someone had tucked into his shirt like a bib. Did he know that he was wearing a bib? Did it bother him?
A nurse walked into our silence. “Phil, all done with your dinner?” He nodded at the clock, 5:03 pm.
“Oh, but he said he had some program at 5:00. Is he not going?” I intervened, hoping to speak up for him. Speak up for him? Who am I to do that? I looked down into my lap, trying to regain my insignificance. The nurse smiled and shook her head at me, “No, hun, there’s no program, there never was. He says that every day.” She left the room with his half-eaten dinner. He lied in bed, staring at the clock. “There is… a program… at 5:00.” I followed his gaze. 5:14 pm. “I will go… alone,” and he closed his eyes.
“A high school… principal,” he said to me, while looking at the clock, 5.00 pm. “Is someone coming to get you for your program, or you will go by yourself?” I asked. He took three more slow bites. I felt my own thinking slow down into a thick, viscous fluid, displaced with more difficulty.
ABOUT THE AUTHOR - Michal Coret is in her fourth year in the Bachelor of Health Sciences program at McMaster. She has a passion for narrative medicine, used books, reading and writing poetry, playing music, overthinking, swing dancing, and travelling.
Interview with Cinema Medica
Viewing Medicine through a Different Lens
Viewing Medicine through a Different Lens What is Cinema Medica? Elysse: Cinema Medica started as an initiative of the Health, Arts, & Humanities program at the University of Toronto. Cinema Medica is a film screening and discussion series that aims to engage students, scholars, and practitioners from various disciplines in dialogue about topics related to health care. What started it all? What inspired Cinema Medica? E: Around 20 years ago, Dr Ron Ruskin, Dr Leo Chagoya, and Ms Charlotte Chagoya started a film series called Docs for Docs for staff, residents, and students in the Department of Psychiatry at Mount Sinai Hospital. Films were usually held in the home of a faculty member. That initiative morphed over time into Cinema Medica, which has grown university-wide to attract a multi-disciplinary, inter-professional audience. Michael and I were recruited in 2011 — he was a second-year medical student at the time, and I was completing a Master’s degree in Cinema Studies. We had to rebrand and collaboratively program the series through our respective lenses of health and the arts/humanities. We broadened the scope of programming to encompass popular narrative films, independent short and experimental works, consumer-created media, etc. This allowed us to consider illness narratives within the context of popular media, to interrogate the formal and stylistic characteristics that support these narratives, and to be inclusive of a wider interdisciplinary audience. Are there any differences between the production of regular films compared to medical-themed films?
E: We do not draw a hard line between films with an overt thematic connection to health care and those that address health related themes in a subtle or indirect way. Since health and illness are broad and universal concerns that intersect with a variety of social, political, and cultural perspectives, we find these themes — aging, mental health, community, resilience — across many different media. Our programming reflects an ongoing interest in structures of looking and narrative as they shape health care encounters, stereotypes and stigma, local and global perspectives, and self-representations of lived experience.
gage audiences! U of T’s Health, Arts, and Humanities Program has other initiatives such as visual art electives and reading groups which have strong attendance, although I find the cinema element really draws in trainees. When we have included more controversial or experimental films, attendees often end up having strong opinions about the films (negative and positive). For example, they might criticize a film’s jarring techniques, or reflect on how they were personally affected by a particular scene. I think the multimodal sensory engagement draws people in and leads them to be more invested in the experience which leads to strong reactions.
Michael: I agree with Elysse. In many cases, we have sought out films with unique or unusual production techniques, including experimental films and those with non-linear narratives. At other times, we have screened films that related to themes in medical education but were not patently “medical films.” For example, we screened a dystopian science fiction film, Gattaca, to an audience of health care trainees to provoke a discussion around bioethics.
Have there been any particular Cinema Medica films that stand out the most to you and why?
What do you think is most unique about the film medium and how it represents the human experience, as opposed to other forms of interdisciplinary dialogues? E: Film engages multiple senses, affecting viewers viscerally, emotionally, and intellectually. This medium allows for multiple entry points into a conversation about a wide range of human experiences, including those of trauma and illness, that seem to exceed the limits of language. M: In the process of engaging multiple senses, film also seems to en-
E: Last year, we screened an experimental documentary called Stand By for Tape Back-Up written and directed by Ross Sutherland. The artist takes a degraded VHS tape featuring excerpts from vintage bank commercials, game shows, music videos, and The Fresh Prince of Bel-Air as a prompt to contemplate the nature of memory, grief, his experiences with depression via an equally fragmentary voiceover narration. Sutherland’s film uses the cinematic tool of repetition to model how to perform a close reading of a film and to approximate the process of rumination. The film was interesting because it was so polarizing — some viewers were frustrated by the disjointed quality and the multiple occasionally contradictory readings offered while others found significant parallels with some of their clinical encounters. M: Elysse stole my pick, so I will mention another one. I have a soft spot for our screening of C’est Juste la Fin du Monde, which was guest
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Viewing Medicine through a Different Lens hosted with an Internal Medicine resident, Wilson Kwong. The Canada/France co-production, written by a French-Canadian director, is about a young writer who returns to visit his estranged family to tell them that he is terminally ill. What made the screening special was not just that the film is excellent, but that there was a true variety of audience members (OTs, staff surgeons, authors) and the discussion afterwards was terrific. What has been the most rewarding experience, since starting up Cinema Medica? E: I’ve really enjoyed working with and learning from Michael over an extended period of time. We’ve been able to develop a common language to refine our objectives for the series. This project has taught me the value of interdisciplinary collaboration; we each bring a unique perspective to every film we program, and we encourage each other to see different perspectives. Anything we’ve prepared or written together always feels richer because it’s informed by such disparate but complementary lenses. M: The key to Cinema Medica is that Elysse is a film genius. I am continually in awe of what she can pull from a film (or even a two-minute segment of a film). As a result, I
now have a much greater appreciation for how to “read” a film, which has also helped me better understand how films can be integrated into teaching health care trainees. Also, now I know what are jump cuts. What have you found to be the most challenging part about overlapping medicine with film? E: We’ve had to challenge certain expectations about how film can and should be used within medical education, to carve out a space for a humanities-informed approach that privileges both content and construction and that moves beyond mastery and illustration—of specific disorders, for example— toward things like contemplation, bearing witness, and critical reflection. M: We screen films in the evenings. One challenge is getting people to show up on a weekday at 7pm to watch and discuss a movie. In general, we have been fortunate to have pretty decent turnout. However, part of this has involved being creative about how to entice people to come. One strategy has been partnering with community organizations. A few years ago, we collaborated with Dignitas for a screening of Triage, a documentary about
Dr. James Orbinski, which drew in roughly 150 people. At other times, we have integrated screenings into course credit. For example, we had several screenings which were embedded into the mandatory interprofessional education curriculum at U of T. Of course, when people are showing up for course credit, you also have to work a little harder to engage them as opposed to if they were coming here on their own interest. What do you think the future looks like for Cinema Medica or film and medicine in general? E: With increasing access to user-friendly, affordable equipment, and online distribution platforms, I hope to see a growth in consumer/client-created films. There also seems to be an increasing emphasis on the client and community voice within various health care milieus. We hope to amplify this voice through our programming and to include the broader community at future hospital screenings. M: We have a terrific line-up of films this year. If you’re interested in finding out about upcoming screenings, they are posted on http://health-humanities.com/. You can also sign up for the listserve there to hear about future events.
Elysse Leonard works at the intersections between film, mental health, and community engagement. She holds an Hons. BSc in Psychology and a MA in Cinema Studies from the University of Toronto. She is a Film Educator in Residence at Mount Sinai Health System and Senior Coordinator of Youth & Community Initiatives at the Toronto International Film Festival (TIFF).
Michael Tau is a fourth-year psychiatry resident at the University of Toronto, and is currently also a chief resident at St. Michael’s Hospital. In addition to his work in Cinema Medica, he intermittently writes music criticism for both professional publication and otherwise.
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RE-CREATE OUTREACH ART STUDIO INTERVIEW with Emma Silverthorne
Can you tell us about RE-create Outreach Art Studio? How did it start and what does it mean to be an open arts studio? RE-create is an Outreach Art studio for youth aged 16 to 24 in downtown Hamilton. Youth can “dropin” to the studio three times a week for free art-making, snacks, and coffee. Youth can use materials to make something as simple as a button in fifteen minutes, or as extravagant as a six-foot wood-crafted sculpture. The youth coming to RE-create are often facing social, mental, physical, and financial barriers which can prevent them from making art due to the costs and the space needed.
gy care, restorative practice, family life-planning and mental health resource support. RE-create is one of these supported programs and currently offers studio times: Mondays 12:30-3pm, Tuesdays 7-9pm, and Thursdays 4-6pm. “Open” is a good word to describe RE-create. We are open to whoever comes through the door, for howev-
er long they want to stay, and open to the things they want to express artistically, even if they just want to vent about their day. The studio is kind of like a family. In this sense, RE-create is an open community. The youth and volunteers who walk in really define what the space is going to look like and make it the artistic and familial community that it is.
“We are open to whoever comes through the door, for however long they want to stay...” RE-create opened its doors in September 2003. Betty Brouwer, our artistic director and an art therapist, saw a need for artistic opportunities and places for at-risk youth to express their stories in downtown Hamilton. RE-create moved into its current studio space in November 2011 at 126 James Street North. RE-create’s mother organization is Shalem Mental Health Network. Shalem Mental Health Network has a counselling centre at 875 Main Street east and supports many programs ranging from cler-
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RE-Create Outreach What makes RE-create unique from other community programs/organizations? What I have always found so unique about RE-create is that youth aren’t coming to the studio to just “get” something. Yes, there are free art supplies, cookies, and coffee, but the youth that come in are creating something from themselves - which is an act of giving. Youth gain an artistic voice, friends, empowerment, and a routine by coming to the studio. They find a role at RE-create through showing someone how to use Photoshop, welcoming new folks to the studio, or coming up with an idea for the next Art Crawl. In return, they develop a sense of belonging, a sense of responsibility, and hear the words “you are needed here.” For these youths, when most of their time may be focused on what they are eating and where they are sleeping, it is a relief and a gift to bring whatever it is they want to express into the studio. Here, they can escape into a world of creative fantasy and make something that is just for them. As such, my role as the Studio Coordinator is not to tell people what to do or how much space they can take up, but to be attentive to what is being birthed creatively and what is important to the youth. It is a community that will cheer you on through life’s processes. I think that is why people keep coming back. Why did RE-create decide to work with youth instead of other age groups? Being a teenager is tough. From the ages of 13 to 24, everything is constantly changing, and it can be isolating, lonely, and confusing. In addition to this, precarious housing, not being able to afford basic necessities, or just not having a place for themselves, amplifies the complexity and intensity of adolescence.
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Youth have more vulnerabilities being young, have fewer life experiences, and deserve the support and empowerment to navigate life — especially marginalized youth. Any human needs community, role models, and some sense of security and stability in order to create a good self-perception and to take risks and grow. Youth need this as they are discovering their identity; they are bubbling with new ideas, fresh perspectives, and curiosity, which is a privilege to work with. I believe people have the power to change through their lifetime, but I know that the role models and experiences I had in my youth really shaped how I see myself, what I believe I am capable of, and who I am now. RE-create wants to take part in this formation for youth, witness and support their resilience, and empower youth who are disadvantaged.
“Being a teenager is tough ... everything is constantly changing, and it can be isolating, lonely, and confusing.” What kinds of social change does RE-create facilitate by empowering street-involved youth? RE-create generates social change by empowering street-involved youth to advocate for their needs through their art-making by giving them a voice to communicate with youth services in Hamilton. RE-create has run two grants that were civic-engagement art pieces. The first is called “The Sights and Sounds of Where We Belong”. This piece gave youth the chance to reflect and make art about what plac-
es in the city felt safe for youth. The second is called “Growing up Queer in the Hammer”, which allowed LGBTQ+ youth to make art reflecting on their experiences of growing up LGBTQ+ in Hamilton. These projects gave youth the opportunity to comment on their experiences of being a young person in Hamilton. Both initiatives garnered media coverage and invited social service providers in Hamilton to both attend exhibits and learn how to make their services more youth and LGBTQ+ friendly. These exhibits led to discussions about gender-neutral bathrooms at different youth centers in Hamilton, and the creation and distribution of an educational zine for youth-centers in Hamilton with LGBTQ+ resources. How does the medium of art aid in helping youths with mental health (or any other problems)? Art is a form of self-expression. If you are not able to express your feelings in some way and release the pain, anxiety, or suffering in your life, your mental health will suffer. Art is a way for youth to release, tease-out, understand, and process what they are experiencing. The simple act of being able to depict your feelings visually can be extremely liberating and empowering. It gives people the opportunity to express hardships and share them with a community so they feel less alone. It gives a voice to those who do not often feel heard and to those who feel alone. Being able to express yourself is a crucial way of dealing with life’s challenges. Art is one beautiful way of doing this. Why do you think youth gravitate towards art as a method of healing? I can’t say that all youth gravitate
RE-Create Outreach towards art as a method of healing. I think people in general gravitate to art as a method of healing because it can often encapsulate what we lack to describe in words. Art can be soft and quiet, or it can be loud and disruptive. Either way, it demands your attention as it will evoke something in the viewer. I think this is attractive to youth who don’t feel they are being heard. It could be alluring to youth because it gives them a voice to describe their own path. Their art might say, “I am here and you can’t ignore it.” Or, it might just evoke a strong sensation or feeling that is important for them to express. Art allows us to leave the linear, logical “reality” and dive into something that we don’t have to understand. It lets ourselves exist in the uncertainty and discomfort. As a medical-humanities magazine, The Muse believes in sharing stories through sickness and healing in order to promote empathetic understanding. How do the youth at RE-create share their stories, besides through their artwork? Is there a shared understanding between the artists (the youth) and their community?
edent for them to share anything about themselves, but over time, and if they want to, youth confide in volunteers, in other youths, and in the staff at the studio. This happens organically and has been beautiful to experience/witness. Youth also have opportunities to share their work and stories publicly at local Art Crawls, exhibits, and through partnerships with the Hamilton Public Library, as well as 541 Eatery and Exchange. These projects, among others we have run, aim to critique Hamilton’s services for youth and connect the youths’ stories to the broader community. We also have a specific program called “Opening the Circle” where youth are given the opportunity to share in a peer support group about their lives or topics of interest to them twice a month. The most important things we can foster at the studio are the relationships with each youth. We acknowledge that trust is needed in order for story-telling to happen – we wouldn’t want to ask for a story if we have not earned the right to hear it. RE-create aims to safely build these types of trusting relationships by seeking consent from the people involved, thereby allowing for empathetic understanding.
We have the privilege of really getting to know a lot of the youth who come to the studio. There is no prec-
Emma Silverthorne, email@example.com - Emma is the Studio Coordinator for RE-create Outreach Art studio. Emma has a Bachelor of Arts in Social Psychology from McMaster University and has worked with youth for over 6 years in a variety of settings. Emma started as a volunteer with RE-create the summer of 2015, ran the “Growing up Queer in the Hammer” project from January 2017-June 2017 and previously worked for 2 years as a personal support worker with adults with developmental disabilities. Emma is pursuing a Masters of Arts in Psychotherapy and Spiritual Care at Laurier’s Lutheran Seminary and can often be found hiking the bruce trail, making ink and watercolour drawings, wearing glitter and learning how to foster healing and growth for the people she holds dear in her life. Emma has an interest in enriching the lives of the dying, and reframing our perceptions of death in Western society, and would like to open a palliative care center in the future. THE MUSE • WINTER 2017
A Discussion on Medical Paternalism:
The Respect and Preservation of Patient Autonomy By Judy Chen Art by Cathy Lu
here are altogether five pillars in medical ethics that healthcare workers stand by: autonomy, non-maleficence, beneficence, utility, and justice. For the most part, these pillars provide a simple and morally clear pathway for medical providers in treating patients. However, the relationship between patient and healthcare provider can be easily complicated in situations where individual values diverge. In medical paternalism, defined as the overriding of patientsâ&#x20AC;&#x2122; actions or decision-making for their own good, the pillars of autonomy and beneficence clash. Paternalism is dichotomized into weak and strong, with the difference resting on whether or not the patient remains mostly capable of acting autonomously.1
Most agree that strong paternalism is, in almost all cases, certainly unjustified, though contention remains regarding situations involving weak paternalism. Prior to discussing ethical situations regarding weak paternalism, it is necessary to first place attention on the general paternalism in our society. There are many pieces of legislation of paternalistic nature: laws requiring seat-belts to be worn at all times when vehicles are in transit; laws forbidding persons from swimming at a public beach or pool when lifeguards are not on duty; laws making it illegal for children to work; laws regulating the uses of certain drugs which may have harmful consequences; laws against duelling, etc. These laws exact restrictions on the liberty of individuals in society for the purpose
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A Discussion on Medical Paternalism of their own good, and furthermore, impose themselves regardless of citizens’ capacity for autonomous behaviour. In light of these laws, it seems that our society accepts strong paternalistic interferences on the basis that, one which Gerald Dworkin argues in his essay Paternalism, we recognize the achievement of the good these restrictions can achieve. But is this absolute? John Stuart Mill would object to this overly simplistic notion, arguing that such coercion would deny the person of their status. He states that the capability of choosing should not be given on the basis of what is chosen: “It is the privilege and proper condition of a human being, arrived at the maturity of his faculties, to use and interpret experience in his own way” (Mill). Gerald Dworkin reconciles this conflict by introducing two burdens on the state – the burden of going forward and the burden of persuasion; the state must demonstrate the exact
benefits that the paternalistic legislature will bring and convince the public that it is needed. Bringing these concepts to medical paternalism, one central ethical controversy concerns the physicians’ decision of complying with a patient’s request for information regarding their illness when it is almost certain that it would be harmful to the patient. With an understanding of the general practices of paternalism in our society, let us discuss two perspectives of this issue held by Alan Goldman and Terrence F. Ackerman. In The Refutation of Medical Paternalism, Alan Goldman argues that paternalism is unjustified because patients have an inherent right to autonomy, and that overriding this right by not disclosing requested information does more harm than honouring it. He defines “harm” as “the development
of an individual capable of freely and creatively formulating and acting to realize central life projects is blocked” (Goldman). Goldman criticizes supporters of paternalism because he assumes they place values such as health and prolonged life above all others. This, he asserts, is not necessarily the case, nor should it always be so – for if this was the case, we would spend entire government budgets in health-related areas – and we would not even be able to justify defensive wars; when the autonomy of a nation is threatened, a war where many lives can potentially be lost is a rational stance for the country (Goldman). After all, what is life without a certain quality of autonomy and dignity? Furthermore, he believes that people are willing to go through pain of the same kind if they are confronted with ‘harmful’ information, to complete their central life projects.
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A Discussion on Medical Paternalism Lastly, echoing Mill, he believes that decisions – such as those affecting health – that are crucial in one’s life, are so important that they cannot be relinquished. The value of self-determination overrides all senses of beneficence a healthcare provider can offer and thus, should be honoured. Terrence Ackerman disagrees. In Why Doctors Should Intervene, he suggests that we are mistakenly equating the respect for patient autonomy with non-interference (i.e. simply being an informant and technician to the patient), which it is not, for it does not rationalize the metamorphic effects illnesses inflict. Paternalistic actions that attempt to return full control to the patient regarding their central life projects can be justified because illnesses are barriers between the mind and the body. Thus, they may cause drastic changes in the patient’s daily living habits, and are often also aggravated by cognitive and informational limitations which can be further amplified by negative emotional states. Patients do not have the expertise of the physician to evaluate their own condition appropriately such that they can make subsequent decisions on their life projects (Ackerman). Furthermore, if they are cognitively or psychologically affected by depression, anxiety, or fear, they may be unable to make decisions that secure their desires. The effects of social and cultural expectations may likewise affect the patient negatively. Thus, it should be up to the physician’s best judgements to choose the right course of action to take, whether it be non-interference, or a rather more paternalistic one. If the physician deems that the information would only exacerbate the patient’s illness, then it would be unwise to disclose this information to the patient (Ackerman).
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One should keep in mind that both Goldman and Ackerman are concerned with respecting and preserving the patient’s right for self-determination; they differ only on how one might best go about doing so. How might we be able to reconcile two such differing perspectives?
The value of selfdetermination overrides all senses of beneficence a healthcare provider can offer and thus, should be honoured.
Firstly, Goldman’s faulty logic makes an assumption that can be challenged. For his subsequent arguments2 to be deduced he must believe that a patient’s ordered values will not change in light of the new information, since he only allows paternalism when the patient is “acting irrationally in regards to his/her long-range preferences.” In his arguments, “acting irrationally” is ill-defined, for he does not stipulate clearly how one can possibly differentiate an irrational and extreme shift in values from a rational one.3 Without this distinction, Goldman’s stated circumstances that allow paternalism remains unclear, and so there is room to challenge the subsequent cases he discusses by placing the burden of proof on him. In other words, Goldman must provide sufficient evidence that the patient is indeed acting rationally and will continue to do so even after the disclosure of information. On the other hand, there are also
issues with Ackerman’s assertions. Though it is true that illnesses have transformative effects, oftentimes it is very difficult to distinguish what the patient may be like without the illness. For example, not all illnesses come and go as easily as Ackerman suggests – chronic illnesses such as diabetes, or even congenital diseases such as Klinefelter syndrome may have such a transformative effect to the extent that there is no distinguishing between healthy and ill states, but merely better or worse, at best. In such cases, would paternalistic approaches by physicians still be justified – especially since the physician would remain paternalistic throughout the patient’s life? That does not intuitively seem fair, since those living with chronic illness can learn how to cope with it so well that they live as almost normal-functioning persons in society. Ackerman also makes an implicit assumption that the physician must be the patient’s shield against social and cultural expectations. Such a requirement bestows upon the physician the dangerous power of justified manipulation to people s/he deems as “forcing” expectations upon the patient (e.g. family members). He also assumes that the physician would not allow or does not have their own psychological and sociological influences. For example, a Hispanic physician may better understand a Hispanic family’s need to avoid speaking of death in front of the dying and to keep the dying unaware4, and perhaps endorse it more so than a physician of another culture. Indeed, the Hispanic physician may be using self-judgement without noticing that they are acting in accordance with their own cultural values, which manipulate other patients’ families to keep quiet about the patient’s imminent death. At the very least, cultural and societal influenc-
A Discussion on Medical Paternalism es are so pervasive that they cannot be eliminated if one lives among people, and so this matter is more complicated than allowing the physician to do what they think is best. Thus, by introducing these psychological and sociological considerations, we must work with finer lines, yet Ackerman fails to untie all the intricate knots they manifest in. Ultimately, it seems that the controversy of paternalism stems from the conflict regarding the precise definition of justifiable paternalistic actions. Goldman’s definition remains unclear, and Ackerman’s definition involves too much of the fine print of each case pertaining to physical, psychological, social, and cultural constraints to be of any generalizable use. The current legal stance that has been widely accepted is, as Ackerman states: non-interference by the physician (due to the possibility of an unfair advantage in the event of a disagreement), the fear of the
abuse of power on the patient’s part, and the fear of being accused of abusing power on the physician’s part. I believe this legal stance is a culminating reason for non-interference. However, we must not forget Goldman and Ackerman’s perspectives for a more adequate legal framework. It is true that not all patients value the prolonging of life. It is also true that illnesses are more than simply technical, bodily function issues. What the framework needs is a definition of paternalism that is borne out of these nuances… one which we have yet to reconcile. The one notion that we can delineate from the study of Dworkin, Goldman, and Ackerman is that although an individual’s right to self-determination is sacred and must be respected and preserved, patients may still consent to paternalistic actions if it enhances their ability to rationally consider and carry out future decisions. Furthermore, physicians bear great
responsibility for their patients in the reinstitution and returning of autonomy. There are three key fundamentals one must keep in mind: Goldman and Mill stress the importance of honouring self-determination because of its necessity in becoming individuals who can value autonomy, Dworkin emphasizes the sine quo non5 of proving the beneficial nature that each action can bring, and Ackerman reminds us that illness or disease is more than corporal suffering that may be alleviated by the most recent advancements in biomedical and pharmacological research, but has metamorphic consequences in a patient’s psychological and social states that may prevent the patient from making the decisions necessary to truly get better. Only then can some semblance of a reconciliation manifest itself, and if not at the policy level, then at the individual level.
FOOTNOTES 1 Precisely, weak paternalism is the overriding of patient autonomy when the patient is deemed incapable of acting autonomously – for example, patients who are severely mentally ill (e.g. suicidal) 2 i.e. that patient autonomy cannot be compromised from derivative values such as prolonged life 3 A very clear example illustrating this concern would be to take the case of a lady that has been health-conscious all her life, but upon discovering that she has terminal cancer, decides to spend the rest of her life on a cruise around the world. Clearly, there was a dramatic shift in valuing prolonged life to enjoyment and pleasure of her remaining time. 4 Note that this attitude towards palliative care and death is not limited to the Hispanic culture, but to many other cultures, such as Asian culture as well 5 Without which nothing; essential REFERENCES Ackerman, Terrence. “Why Doctors Should Intervene.” Hastings Center Report 12.4 (1982): 14-17. Print. Dworkin, Gerald. “Paternalism.” The Monist 56.1 (1972): 64-84. Goldman, Alan. The Moral Foundations of Professional Ethics. Totowa: Rowman and Littlefield, 1980. Mill, John Stuart. On Liberty. Ed. Mary Warnock. London: Fontana Liberty Edition, 1962.
About the Author - Judy is a second year Bachelor of Health Sciences student at McMaster University. She has a particular interest in mathematics and philosophy, and in her spare time, she enjoys experimental cooking and reading literature from the 18th and 19th century.
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Reading Between the IV Lines: Book Reviews & Recommendations By Abirami Kirubarajan
Orphan Number Eight Kim van Alkemade
Young Rachel Rabinowitz was Orphan No. 8 in horrific medical experiments conducted at a Jewish orphanage in the early 1900s. Decades later, she has the chance for delayed revenge when her former medical experimenter becomes her elderly patient. Conflicted by her history and personal ethics, Rachel’s relationship with her medical experimenter becomes almost too much for readers to bear. This riveting historical fiction explores the evolution of American bioethics, as well as what it means to gain redemption. I could not stop turning the pages to reach its stunning conclusion. “Sometimes I ask myself if there’s any limit to the harm people can do to each other.”
The Birth House Ami McKay
During World War I, another battle looms closer to home in Eastern Canada. Midwives and physicians fiercely compete for labor and delivery patients, each profession clinging to its own beliefs regarding childbirth and women’s health. This touching historical fiction navigates the lives of several women as they struggle with maternal health following the Halifax Explosion. The ethics of sexual consent, pain relief, and medical experimentation are explored powerfully through this family-driven narrative. In particular, I was drawn to the depictions of historical medical practices – from “vibrating hysteria cures” to elixirs promising “twilight sleep” and painless childbirth. Trigger warnings: Rape, sexual assault “How a mother comes to love her child, her caring at all for this thing that’s made her heavy, lopsided and slow, this thing that made her wish she were dead … that’s the miracle.”
Small Great Things Jodi Picoult
What happens when a parent demands to have a white nurse, and an innocent child dies as a result? A black nurse suddenly finds herself as a racial scapegoat in a devastating media storm and legal trial. This novel takes a thoughtful approach in depicting the role of privilege in healthcare, and what it means to “do no harm.” While I was initially skeptical, the author is very upfront in that she does not speak for Black Americans – instead, the author focuses on the role of allies who are in denial regarding their privilege. I also appreciate the author’s strong research and collaboration with Black advocates (I suggest reading her Author’s Note). For Picoult, claims such as “I don’t see race” are no longer good enough. “When it comes to social justice, the role of the white ally is not to be a savior or a fixer. Instead, the role of the ally is to find other white people and talk to make them see that many of the benefits they’ve enjoyed in life are direct results of the fact that someone else did not have the same benefits.”
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Reading Between the IV Lines
Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America Mary Otto
Have you ever wondered why dentistry is a separate profession from medicine? This new piece of health journalism features definitive research that oral disease worsens both quality and length of life, especially for those most marginalized in our society. In particular, Mary Otto uses her health journalism prowess to immortalize the story of Deamonte Driver, an American child who died in 2007 from not receiving an $80 tooth extraction. Otto examines the role of public health in oral disease, and what is necessary for sustained change in the American health system. This book is undoubtedly a game changer in the field, one that I hope will dominate headlines. “Surprisingly, the mouth is part of the body.”
Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present Harriet Washington
From the Tuskegee experiments to mass illegal autopsies, the history of medical malpractice on Black Americans is absolutely horrendous. Harriet Washington systematically goes through centuries of medical mistreatment, thoughtfully analyzing its longstanding effects on Black Americans today. Her research tackles popular misconceptions and controversies, ranging from the pseudoscience of eugenics to the crimes committed by the founder of modern gynecology. Washington’s research is simply shocking – this history must be understood by anyone who is at all interested in social inequality in medicine. Trigger warnings: Rape, extreme violence, torture “History and today’s deplorable African American health profile tell us clearly that black Americans need both more research and more vigilance.”
Hunger: A Memoir of (My) Body Roxane Gay
The critically acclaimed author of Bad Feminist is back with a powerful memoir about eating disorders and weight bias. Roxane tackles the stigma of eating disorders for obese and overweight patients, deconstructing the notions that physicians often hold regarding the “ideal patient.” I particularly appreciated this nuanced take on eating disorders — mainstream media disproportionately features young, thin, white women in their (often romanticized) portrayals of eating disorders. Roxane’s haunting prose and courageous story are much-needed. Trigger warnings: Rape, violence, self-harm “My father believes hunger is in the mind. I know differently. I know that hunger is in the mind and the body and the heart and the soul.”
ABOUT THE AUTHOR - Abirami Kirubarajan is a 1st year medical student at the University of Toronto. Abirami has previously reviewed books for NetGalley and The Echo Magazine. Her favourite genres include historical non-fiction, memoirs, mysteries, and novels written in verse.
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