Monsters: Part 3

The Monster Whisperer

In Monsters:  Part 2, my medical colleague, a very smart adult physician whose office is across the hall from mine, burst in and asked for a urgent medical consultation, assuming I had expertise beyond his own.  He asked me what he can tell his distraught patient to help her get rid of her child's witches.

I didn’t think her child was afraid of the fact that there are witches. She’s not afraid of their power to do things by magic.  She’s not afraid of their malicious motives or the scary way they look or dress or of their scary henchpeople or flying monkeys.  I thought that gentle questioning of the child, while never doubting her belief in witches, would probably reveal that she’s afraid they will come into her room when she’s asleep, and work their bad intentions there.  (I would use this opportunity to point out that it is the child’s concrete thinking that doesn’t usually consider that a witch with magic powers could cast an evil spell from afar, without warning.  In Snow White, why couldn't the evil queen just wave a wand over in her palace, and do her mischief from there?  Despite her apparent powers, she had to get Snow White to take a physical bite of a tangible apple.)  As in Monsters:  Part 1, with the child so afraid of a toilet monster, this child was keenly aware of when she was most corporeally vulnerable.

How can we help?  If we tell them that their belief system is sheer nonsense, we alienate them and make them feel worse.  If we sympathize with them and agree that witches are a constant threat, they might continue to trust us, yet their fear is reinforced and we have confirmed that there is a dangerous broomstick-riding predator somewhere above us just waiting for the right opportunity to strike.  Keep watching the skies!

Our problem is that the child's fear is magical, but we are limited by our physical reality.  Or are we?

• If her specific fear is of a witch entering her room, she might benefit from a meticulous bedtime ritual of closing and locking her windows at bedtime.  If it’s hot and her window must stay open, how about getting a special witch screen that fits the opening?  The openings in a window screen are very small and no witch could fit through.  Or maybe witches can’t fit through those window safety bars that you are going to install to protect your child. (Maybe you should be doing that anyway.)

• Consider a special witch treatment or repellent that is not toxic once dry but is especially specific and new to the child.  My favorite for witches and related hazards is witch hazel, a pre-19th-century remedy for many things with a distinctive smell.  Because it is not in widespread use these days, it might not be easy to find.  But it sounds like a logical product.  So an exhaustive hunt for it with the child in tow will have that much more of a chance of effective pest extermination.  As you go from pharmacy to pharmacy, don’t look on the shelf!  Since the child can’t read, it is not helpful when you tell her that you looked and there’s no witch hazel there.  How can the child be confident of that?  Make a point of asking a manager—always with the child right there—if they carry witch hazel and if not, where you might be able to get it.   Maybe it can be used to seal the joints around the windows and doors.

These aren’t tricks.  I will repeat that lying to your child is never, ever a good idea.  Are these lies?  Is my approach dishonest?  Yes, in spirit it is dishonest, because you don’t, in fact, believe in witches or in the monster du jour.  But these anxieties and beliefs are a normal developmental phase.  I often discuss concrete thinking and the ways a parent has to anticipate and deal with a concrete thinker.  I have also discussed in previous posts the gradual development of abstract thinking as a mark of adulthood.  The kind of thinking that gives rise to this kind of childhood anxiety is called magical thinking.

With magical thinking, there does need to be some sort of a link between observations or events, but it doesn’t have to be rational from the point of view of an adult.  Let’s say your child takes a bath every day just about the time that daddy gets home from work.  One night, dad has to work late.  At bedtime, your child snuggles with you and asks to take a bath.  This seems odd to you, but slow iterative questions determine that he believes that if he takes a bath, daddy will come home.

So my empathic approach, as always, directs our technique to take its cue from the child.  This brings up...

5.  Dr. Wolffe’s Thinking Rule:
Concrete thinkers need concrete actions.  Magical thinkers need magical actions. 

There is no intervention for supernatural issues except for supernatural interventions.  If you wanted to help someone suffering from demonic possession, would you call a surgeon?  Of course not.  You’d look for an exorcist.  How do we accomplish this for the supernatural conflicts experienced by young children, when we might not be experts in the field—and probably can’t easily find an expert.  Think about it...who is an expert on toilet monsters or witches? Maybe we all have enough knowledge for the job we need to do.

All of us, by the way, are a soup of all kinds of thinking.  My bank just changed the way ATM deposits are done.  I asked a bank officer about this, and she helpfully showed me how to drop the deposit into the night deposit slot.  I told her I’d rather change banks—it was intolerable for me to drop an envelope of checks or cash into a blind slot without any sort of record or receipt.  It wasn’t that I didn’t trust them, it was just my need for concrete security.  (Ronald Reagan said, "Trust but verify.")  Now that the holidays are over, do you feel comfortable telling your kid all you really know about Santa Claus?  And what do you do when you are cornered by somebody at a social gathering who insists on convincing you that every English word of the Bible is the literal word of God, despite your knowledge of it being compiled by a committee in London at the turn of the 17th century?  I have met plenty of scientists who follow a religion.  Does understanding the universe convince us that there is no God or that there must be a God?  Whichever we believe, no amount of moot-court argument will change a person’s faith in their belief system.

I’m not lying when I tell preschoolers that I can see an elephant in their ears.  It makes them laugh.  Even if I say I see a dinosaur or a crocodile, they still, mostly, laugh.  They aren’t worried about it because they know, within their magical belief system, that the only elephants that could be in their ears would have to be very tiny ones and they wouldn’t hurt.  Maybe they just acknowledge the elephant I see the same way they would play along with one of their younger peers, and are being indulgent with me because I’m obviously not as mature as they are.  That, indeed, is rational insight.

Problems with Medical Ethics: The Elephant

Fifteen years ago, I did part of my first pediatric training in the pediatric clinic of St. Raphael’s Hospital in New Haven. It was a nice hospital, well-known at the time for their excellent cardiac care. It was run by the Sisters of Charity of Saint Elizabeth, an amazingly generous order that really practices charity every day by helping those who need it most. Some of the nurses were in the order. The exceptional physician who ran the pediatric clinic was kind and really smart. I still use his home-made guide to pediatric neurological exams. We got along well.

When Reyna came into the clinic, she didn’t look particularly sick, just in pain. She was clutching her abdomen. She saw one of the medical residents, higher in the feeding chain than a lowly medical student like myself. Abdominal pain is one of the most studied of medical symptoms, especially because it’s so common. One by one, the resident and I ruled out some of the things it could be. The girl was 16. We needed a pregnancy test. Oddly, there was some sort of a problem requisitioning one. In fact, the clinic didn’t have one on hand. Her pain got worse, and she was admitted to the hospital. That night, her pain worsened considerably. Blood tests showed no signs of infection. The head of the clinic told us that a pregnancy test wasn’t needed. Within a couple of days, she needed an enormous amount of intravenous morphine. Eventually, if I recall correctly, she was taken by ambulance to Yale-New Haven Hospital for emergency surgery that fixed—and ended—her ectopic pregnancy. Maybe the doctor in charge knew a lot more than me about pediatrics. But I am still affected by my memory of this girls pain. Where was his ethics committee?

Every hospital I’ve ever entered had an office for chaplains. I think this is a good thing. Not meaning to joke about it, my post about lollipops discussed my rationale for using a partly physiological and partly placebo intervention to make a child feel better. I have described my use of hypnosis to help with an anxiety disorder. I think that if a child, if any patient, will feel better after an intervention of some sort, I’d like to use it if it’s safe. For the devout, the counseling of a religious guide can make an important difference in their quality of life. I respect it and recommend it when appropriate.

There is no bigger elephant in the room in which medical ethicists sit around and sip their lattes than religion. The topic is deeply taboo, and I can’t help but wonder if my email address will be unceremoniously ripped from the bioethics listserv database.

At a major national meeting a few years ago, I went to all the sessions given in ethics. In one, a discussion was promised concerning the ethical issues of contraception counseling and prescribing for teenagers. One side brought up the sobering statistics we all know about teen pregnancy and STDs. The other side argued that since condoms only work 95% of the time, that’s a 5% failure rate. Since that’s not acceptable, the only reasonable counseling for physicians to be doing is to tell teens is that abstinence is the only effective form of contraception.

More than a decade ago, I attended Georgetown University’s Intensive Bioethics Course. It was well-organized and I learned a lot. After the first couple of days of lectures, I asked why every lecture on any topic, with no exceptions, included mentioning what The Pope had said on the subject. It was Georgetown, and I was not naive about who ran the place. But I didn’t think it was an insulting question. I really wanted to know why my patients—atheists, Jews, Hindus, and Wiccans—might be affected by this*. Are religious leaders, whether laypeople or divinely chosen, gifted in unraveling of ethical complexities by their career success?

In what way, exactly, does holding a title of religious training qualify a person to sit at the medical ethics table? Are they guided by their training or constrained by it? Do their opinions apply only to their flock? What about the rest of us?

A rigorous principle of contemporary medical ethics involves disclosure. It might be in a grey area that all the objects in your doctor’s office—the post-it notes, the clipboards, the pens, even the magazines—have the name of a drug or drug company on them, but as long as the doctor discloses all the side income, then it’s OK. (They usually don’t disclose unless required to do so. Next time you’re in the doctors office, look around. How many of these ‘gifts’ can you spot?) Do we ever disclose religious affiliation? Should we? Should doctors disclose this? Should the hospital tell you that their ethics committee which has set the policy for pregnancy testing of unmarried teenagers is made up entirely of clergy handpicked by somebody who has a whole different set of values from you? What would happen if they did? Would parents of 16-year-old girls with abdominal pain bring their daughter there for evaluation? Here’s a scary thought: maybe they would prefer to bring them there.

If there is some basic foundation of ethics based on truths we hold to be self-evident, what exactly is added by expertise in dogma?

The case I described above is a real one. It was a horrible experience for me, the resident, and of course the patient. She did fine. It was one of the most unethical events I have ever witnessed.

*I really asked the question. What was I thinking? Like Peter Riegert walking into the Dexter Lake Club in 1978's Animal House, suddenly, the huge auditorium fell completely silent. The lecturer awkwardly dismissed my question without answering it, and I was too humiliated to insist.