Nothing is harder than doing nothing, especially when it’s the best alternative among a pack of difficult choices. Medicine’s prime commandment – Primum non nocere – often requires that the physician refrain from treatment when the remedy is worse than the malady. While the maxim is endlessly preached, it is rarely observed. The urge to intervene is more powerful than a hundred suns.
An example of this human demand for something even when all know it to be ineffective is present in A Short Guide to Electioneering often attributed to Cicero’s younger brother Quintus Tullius Cicero. “People would rather you lie to them than refuse them your help.”
Another literary example of the necessity of useless medical intervention is brilliantly depicted in War and Peace Book III, Part One, Chapter 16. Tolstoy’s encapsulates the therapeutic compulsion in five paragraphs. Natasha is suffering from what we would today call depression. These paragraphs should be required reading for all medical students. In fact, everyone should read them.
What would Sonya and the Count and Countess have done, how could they have gone on watching the weak and languishing Natasha, had there been nothing for them to do, had there not been those pills to administer by the clock, the warm drinks, the chicken patties, and all the rest of the regimen prescribed by the doctors, the carrying out of which kept them occupied and provided consolation? The more meticulous and complex the orders, the more comfort they afforded the members of the family. How would the Count have borne his beloved daughter’s illness had he not known it was costing thousands of rubles, and that he would not grudge thousands more to benefit her; or had he not known that if she did not recover he would not grudge the additional thousands take her abroad for consultation; or had he not been able to explain in detail to people how Métivier and Feller were baffled by the symptoms, but Friez had understood them and Mudrov has been still more successful in making a diagnosis? What would the Countess have done had she not been able to scold the invalid now and then for not following to the letter all the doctors instructions?
“You will never get well like this,” she would say, finding refuge from her grief in vexation, “if you won’t obey the doctor and take your medicine when you should! You can’t trifle with this, you know, or it may turn into pneumonia,” she would go on, deriving great comfort from the utterance of this word, which was incomprehensible to others as well as to herself.
What would Sonya have done without the gratified consciousness that she had not had her clothes off for the first three nights, in order to be ready to carry out all the doctors injunctions promptly, and that she still kept awake at night so as not to miss the proper time for giving Natasha the not very harmful pills in the little guilt box?
Even Natasha herself, though she declared that no medicine can do her any good and that it was all nonsense, was pleased to see so many sacrifices being made for her, and to know that she had to take the medicine at specified hours. And it was even pleasant to be able to show, by disregarding the orders, that she did not believe in medical treatment and did not value her life.
The doctor came every day, took her pulse, looked at her tongue, and disregarding her dejected face, joked with her. But afterward, when he had gone into the next room, to which the Countess hastily followed him, he assumed a grave air, and thoughtfully shaking his head, observed that though the patient was in critical condition, he had hopes of the efficacy of this last medicine, that they must wait and see, that the malady was more mental than… And the Countess, trying to conceal the gesture from herself as well as from him, would slip a gold coin into his hand and return to the sick room with a lighter heart.
These two quotations nicely define the world of 2020, the most inaptly numbered year since the dawn of numeracy. If years had names, this one would be the year of the blind. The year we’re enjoined to follow the science that leads to lockdowns, masks, quack nostrums, social distancing, runs on toilet paper, sports without audiences, empty theaters, dueling experts, mass panic, governmental meltdown, fiscal suicide, outsized unemployment, school closures, medical personnel in hazmat suits, the death of retail and restaurants, and on and on. All done in the uniform of well being disguising the garb of authoritarianism.
Ask yourself, alone and in the cloak of darkness, if we’d be better off had we done nothing instead of literally scaring ourselves out of our wits. Of course, it’s possible that there might have been a path between zero and mass suicide, but we’ve reached a point akin to the worker of the song who owed his soul to the company store; in the current crisis the company store has been replaced by the government and a coterie of absolutist experts.
To understand that nothing is often the best solution, you must be capable of independent thought and good judgement. If you mandate hospital personnel to wear the modern equivalent of chainmail and suits of armor, the number of coronavirus patients they will be able to care for will be limited. Hospitals will be overwhelmed even when half their beds are empty. So when they announce they are at or above capacity the translation of this plea is that they are above a self imposed limitation, one that would not exist is they had adopted a different approach to the appearance of a novel virus. The usual isolation procedures employed by hospitals would have sufficed to handle this new situation had not outsized fear overwhelmed the world. Just as politics trumps economics, fear overwhelms reason.
The world could not function without 95% of requests and duties being handled by a null response. The larger the bureaucracy the more likely the result to a directive is to say yes and then to do nothing. Nobody notices and the machine plods on. Rarely the request or order is repeated and a reluctant action occurs, but such events are rare. A positive reply followed by inaction usually satisfies everyone but the most obsessive.
The hardest lesson for a physician to learn is to sort the real, significant, and important information from the noise that surrounds it. Osler advised nascent doctors to stay quiet and listen to their patients as they were trying to tell them the diagnosis. What he didn’t add was that these same patients were also trying to camouflage the diagnosis with a host of supernumerary complaints. Hence the “Take two aspirins and call me in the morning.” Another way of saying I don’t know what’s wrong, but it will likely go away on its own. Tincture of time is still a top ten prescription.
Even if my observations are off the mark, restraint (especially during a crisis) is always better than panic in hands that wield power. As humans are the only species that know the certainty of our demise, why should we panic at the appearance of something that is uncertain and mild when compared to our inevitable fate. Morituri te salutant. Who? I don’t know.