In Remission

As the haze of the sedatives receded I perceived the face of the gastroenterologist. His expression of uneasy concern brought me to full awareness faster than would have otherwise been the case. He was holding a Polaroid, indicating a trouble spot with a pen. "Bob, remember where that polyp was? Now there's a bleeding ulcer in its place. I took some biopsies, but regardless of what it shows, you're going to have to have surgery."

The implications were immediately known to me. A bleeding ulcer at the site where a severely dysplastic polyp had been removed six months previously was unlikely to be anything but cancer. Within a few days I was at the office of the surgeon.

She was all business, as so many surgeons are. She had reviewed the medical record, including the ambiguous pathology report from the ulcer biopsies, and outlined to me that the best course would be to undergo a right colectomy. "If possible, I'll do it laparoscopically. That way the recovery is easier." I was scheduled for December 27th, 2010.

I was to be the afternoon case. I remember changing into the gown and feeling cold on the hospital bed. My wife and sons came back and sat with me. The anesthesiologist came in and introduced herself, making sure I knew that she had gone through training at the VA where I am Chief of Medicine. The next thing I remember is someone telling me they were aware I was in pain and they would get it under control right away. Then I felt what I thought was a colostomy bag on my right side, and I was discouraged. They transported me to a room and my wife was waiting for me there. "Look," I said to her, "they had to give me a colostomy." A nurse, she examined my abdomen and said, "No, that's an ice bag." Thank God, I thought. The incision had severed the superficial nerves such that I could not feel cold.

I was in the hospital for three nights. "You can go home as soon as you pass gas," declared the nurse. You have set the bar rather low, I thought. I had a beautiful view from my window, as the foothills were dusted with snow. A number of visitors came, and Allison and the boys were there much of the time. I never got a meal as such; I think the most I got was full liquids. Discharge could not come soon enough, and I was home for the New Year.

It took about ten days to learn the findings on the pathology report. My wife kept after me to call the doctors, but I was content not to know for the time being. At least I could pretend to myself that it was just an ulcer caused by compromised blood supply as a result of the thermal cautery of the base of the dysplastic polyp. But then the gastroenterologist called, followed by the surgeon: Adenocarcinoma.

There were unfavorable characteristics. For one, the tumor was rather large, almost 2 centimeters. There were many poorly differentiated cells, the most chaotic and rampaging of cancer cells. There was perineural involvement, implying that this cancer, like so many bad ones, does not respect tissue planes and will grow in any direction it chooses. There were favorable characteristics as well, however. The margins were clear, and all 38 of 38 nodes were negative. It was now time to complete the staging with imaging studies.

I underwent an enhanced CT of the chest, abdomen and pelvis. Waiting for the interpretation by a radiologist was one of the most difficult legs of the journey, but eventually I got the call from the surgeon's office: No sign of metastatic disease. T3N0M0. That means Stage 2. I was referred to an oncologist.

The oncologist reviewed my case as had the surgeon. He described the characteristics of my cancer to me, taking care that I understood it. Then he said, "I recommend chemotherapy, but not strongly." I had unwittingly plunged neck deep into one of the great controversies in oncology: What to do with stage 2 colon cancer.

Colon cancer has four stages. Stage 1 is a localized, small tumor and when it is resected it is very likely that the patient will remain in remission for the rest of his or her life. Stage 3 disease has positive lymph nodes, and stage 4 disease is metastatic (cancer has spread to distant organs). Stage 4 of course has a poor prognosis; while chemotherapy prolongs life, most stage 4 patients will die of the disease within five years. Stage 3 patients benefit from chemotherapy significantly more than do stage 4 patients, but even then most of them have had the cancer return by ten years. By contrast stage 2 patients have a relatively good prognosis. As many as 80-85% of the patients remain disease-free at ten years, but for reasons that remain obscure, these patients do not enhance their odds appreciably by undergoing chemotherapy.

Considering all of the aspects of my case, the oncologist estimated my odds of staying in remission without chemotherapy at 75-80%. "Many people in your position would not undergo chemotherapy, Bob," he observed. "But you have to ask yourself this question, and you have to be comfortable with your answer. If your cancer recurs in the next couple of years, will you regret not having undergone the treatment?"

I was not prepared to answer him at that time. It was a decision I would have to make through a fog of depression and pain, but after a couple of weeks or so, I had determined that I would not take the combination of oxaliplatinum, 5-FU and leucovorin. For although having recurrent disease might cause me to regret not having taken chemotherapy, the thought of having taken the chemotherapy and then having the cancer return was even worse. This treatment, also called FOLFOX, would make me feel sick and weak for almost a year and carries with it a ten percent chance of permanently losing the feeling in my hands and feet (neuropathy). If I have to face a return of cancer, I thought, I would rather do it having felt well for a couple of years as opposed to feeling badly for one year and then hopefully pretty well for one year. For little or no chance of improved survival, it hardly seemed worth it.

So what this cancer has left me with is a 20-25% chance of recurrence. If the disease returns, it will almost certainly be incurable, and my life expectancy would be approximately 22 months. I suppose most of those months would be relatively poor quality.

It was as if I had somehow found my way into one of those parallel universes the theoretical physicists write about. I had awakened in the life of someone else, someone significantly less fortunate. How did this happen? Certainly cancer runs in our family. One of my cousins had a heart attack; he protested to his cardiologist that members of our family don't have heart attacks, they get cancer. Not long after that he was diagnosed with hypernephroma, a cancer of the kidney. Three of my four grandparents died of various cancers, and my mother died of cancer as well.

Also there was lifestyle. I ate too much of the wrong kinds of foods and exercised too little. I was overweight and I piled psychological stress onto myself as if it had no effect on me. I had enormous stress at work and terrible stress at home; there was no place in my life of quiet refuge. I smoked cigarettes for 15 years and then cigars, and it was not unusual for me to consume as many as three or more beers with a spicy, fatty meal. Excess, I suppose, was the way I had chosen to deal with the lack of peace in my life.

I also considered more metaphysical causes. Perhaps people who felt wronged by me, residents or students I had spoken harshly to, or people I had otherwise disappointed somehow, might be able to forge their resentment and harmful thoughts and wishes into some kind of malevolent turn of fate. Or perhaps God, disappointed in how I had turned out, had determined to crush me into small pieces for the purposes of reshaping me into something that bore the mark of his craftmanship better than me.

In the wake of my surgery, I became convinced that the cancer was going to kill me. I developed a terrible insomnia, and in the dark hours of the middle of the night, I saw an endlessly repeating film loop of my suffering and wasting and death. I saw my skin turn yellow, I saw myself struggle for breath, I watched in horror as I acquired a strange and unpleasant smell and I vacillated between discomfort and pain. I helplessly observed the grief and horror on the faces of my wife and sons and then there was the inevitable funeral, dark, dreary and defiantly scornful of hope.

During this period of time I lost my sense of humor. Other stressors had besieged me as well: A lawsuit, behavioral problems of one of my children, major health problems of my in-laws and their effect on my relationship with my wife. The worst psychosocial sequel of this terrible experience was that it created a gulf between my family and me. I had foolishly anticipated that my wife and sons would rally around me and support me in the dramatic lifestyle changes that offered me an improved chance at survival. But in their individual universes this terrible business was happening to them as much as to me, and they were just as needful of support as I was. I had to learn to give them a wide perimeter, not to discuss the cancer and my need to confront death. They resented my demands to keep junk food out of the house and instead eat healthy, organic and vegetarian for this was to deprive them of one form of comfort. Instead of minimizing behaviors that caused me psychological stress, they increased them, as they were locked in struggles of their own. I got a therapist to help me process my dread at the unanticipated and yet certain outcome of life but in the end, the greatest support was from the other damned--other cancer victims.

It turns out that having cancer is like being in a very awful club. People I had known for some time came to me and said, "Well you know, I had cancer" or "I have cancer, and they say it's incurable." They tell you that although your doctors don't say so, there are things besides chemotherapy you can do, like exercising and making dramatic dietary changes (1). They help you to see that hopelessness, depression, insomnia and alienation from family are normal for people with cancer. And you cry together. I felt like I had become a character in the Clive Barker novel Cabal, part of a group of people condemned to live in the shadowy margins of society, in the underground vaults where the sunlight of carefree happiness does not shine. I thank God for those other accursed people though, for without them I fear I would have been flung deep into the cold silence of hopelessness.

How do you prepare to live and to die at the same time? This is the fundamental issue before me at this moment in my life. And there is seemingly only one answer, and it comes to you indirectly, circumventing reason. You ponder it, you consider it, you journal about it, you question it and underneath all of that processing you evolve, mostly unaware of it, into someone you have not been since early childhood. You become someone who lives in the moment, and so many of the choices you have made no longer make sense. Thoughts that accompanied me for much of my terrestrial journey, like "Things are kind of difficult right now, but eventually I'll retire and it will have been worth it because my retirement will be relatively comfortable" now carry little weight with me, for perhaps I will not live to retire. So anything I had planned on doing at retirement, I had better get done right now! Career achievements seem much less important than they used to, and in their place is an appreciation for the quality of each day lived one day at a time.

While the last stop on the journey of my life is certain enough (although the time of it is not), I am not certain about the destination of my psychological evolution. It has widened, to some extent, the chasm between me and my family, for they have not had the most common form of denial torn away from them, so they remain concerned with details that seem somewhat trivial to me. But I have to admit that I like what it has done to me so far. I hate it that it came to this for me to realize something so fundamentally true, but if you are courageous enough not to worry about tomorrow, today becomes a much nicer place to abide. Now I work to have at least a fairly long string of very nice todays, which is worth more than a million troubled tomorrows.

I could never have read an essay like this one and implemented its lessons without having been forced to look cancer in the face. But I fervently hope that out there somewhere someone will read it and realize that the life we live is kind of an illusion and that the underlying reality, while pretty terrifying in a lot of ways, is perhaps the only pathway to real psychological freedom.

(1) The Anticancer Book, by David Servan-Schreiber MD PhD. Physician, scientist and cancer victim, he has written a book based on available science that gives us a sense of empowerment where we otherwise felt powerless. Everyone who has been diagnosed with cancer should read this book.

(c) Copyright 2011 Robert Albanese

Ratio

This essay is Part 2 of "Psyche, Mind" in the series of essays on Anthropiatry that deal with the structure of the mind. In this section we will examine the approach to knowledge that involves reflection almost exclusively: Rationalism.

According to Charles Freeman in his work "The Greek Achievement (1)," Western Civilization began when a Sicilian Greek named Pythagoras proclaimed that a^2+b^2=c^2: The Pythagorean Theorem. Now to say that a simple mathematical equation marks the rise of the most technologically advanced civilization in the history of man is an extraordinary claim. And yet it is quite true. It was the first time a man had ever articulated a universal law arrived at by the use of reason.

As we saw in the previous essay, Empiría, one way of looking at the world is through observation. But with Pythagoras, we see another, quite distinct way of discerning reality. The universe, it seems, can reveal itself to us through introspection and thought; we can cast our minds out into the far reaches of the heavens, and like Noah's dove, they return with the olive branch of knowing. This is as utterly amazing as any natural phenomenon upon which we marvel. Of all the experience that suggest the existence of a creator, to me this one is the most compelling.

As Aristotle is consecrated the Father of Empiricism, his teacher Plato carries the title for the Rational way of knowing. Plato believed that the reality surrounding us was in some ways illusory, that the elements and objects we observe are actually imperfect representations of things that exist somewhere out there, in the Land of Perfection, in the Dimension of Perfect Reason. Geometry, the only area of mathematics where the Greeks far surpassed their teachers (the ancient scholars of India), illustrates how the Rational reality differs from the Empirical reality. You can in Geometry for example appreciate various the various characteristics of geometric shapes, none of which exists in reality in its pure or exact form. "I can prove that triangles exist," Plate must have said, "but you can't show me one." This character of rationalism can be illustrated by an episode from my third year in medical school.

I was on the Internal Medicine inpatient rotation and we had a patient admitted to our service with lobar pneumonia. My attending Dr. Peter Lichstein (2) examined the patient and said, "this patient's examination is perfect. There is pectoriloquy, aegophany, and dullness to percussion (3). This patient is the Platonic Ideal of the physical examination for pneumonia." We can say with some confidence that the empiricist views reality uncompromised by imperfect reason, and the rationalists views truth as uncompromised by imperfect observation.

Geometry and reason are products of each other. In geometry we encounter reason, for example, as we undertake the proofs we did in high school. Mathematics is pure reason, after all; there is no such thing as an experimental or empirical mathematician. In the proofs we did in high school, Geometry illustrates the essential character of the process of rationalism: our representation of reality is the theorem (or theory), and we prove or disprove theories by the use of reason. The corollary for the Empiricist is to prove or disprove a hypothesis with the use of observation and/or experimentation. Do not lose sight of the fact that the root word for Rationalism is ratio, a mathematical term.

Two examples of great rationalists of the modern age are Freud and Einstein. Freud contemplated the characteristics of the mind and produced one of the great works of the 20th century: Psychoanalytic Theory (4). Einstein considered the characteristics of the universe and produced the Theory of Relativity. Of interest, drawing a connection between rationalism and empiricism, Einstein called his process of applying thought to understand processes "gedankenexperimentazion," or thought experiment.

A sophisticated and accomplished use of reason is like that of observation in that it does not come without training and proficient use. And like Empiricism, Rationalism has certain inherent flaws. Rationalists project thought into the chaos of a problem and upon its return, it bears a theory. Since theories are generally arrived at without a great deal of observation, there is always the possibility that the theory is incorrect. As the great French neurologist Charcot observered, "La théorie c'est bon, mais ça n'empêche pas d'éxister (5)." Similarly, Hippocrates said that theories of disease are good as long as they are accompanied by close clinical observation.

This problem can be illustrated by a Founding Father named Benjamin Rush. Rush was a physician who has been called the Father of American Psychiatry; he was the first American to author a textbook on psychiatric diseases. Like most of the great men of his age, he was a rationalist; it was after all the 18th Century, The Enlightenment, The Age of Reason. He was a practitioner of an old form of old Greek medicine concerned with the Four Humors: Sanguine, Melancholic, Choleric, Phlegmatic. Under this theory, patients with fevers underwent bloodletting because blood is hot and wet and since fevers make patients hot and wet, removing excess blood should be therapeutic. Dr. Rush was so faithful to this theory of medicine that he continued bloodletting feverish patients despite the evidence he must have encountered that it was harming them. Rationalists become so devoted to their theories that they risk ignoring observations that refute them.

Because of his allegiance to a harmful medical practice Dr. Rush is held in contempt by many in the modern age. They blame him, for example, for the possibly premature death of George Washington. And yet, to be really fair we should not remember him only that way; he was a passionate patriot, a signer of the Declaration of Independence, and a tireless advocate for the alienated mentally ill. Like most great men, he had his flaws, and who's to say that someday our practices in oncology and other areas of medicine will not be viewed the same way as bloodletting.

Rationalism has one distinct advantage over Empiricism. Reason is the father of Ethics; during my empirical medical training one of the islands of rationalism was our ethics class. The humanistic moral vision (6) that gave profound meaning to practitioners like my father was a direct outgrowth of the rational pillars of scientific medical thought. As our medical profession has surrendered rational ground to empiricism, it has simultaneously lost its lion-hearted character, and since practitioners have difficulty seeing their patients as human beings as opposed to "outcomes," their work is not as meaningful and they suffer burnout.

Another advantage of rationalism is that it is, like observation, a process. Those who are good at reasoning problems through have a distinct advantage in almost every context. Once I met an Ivy League medical student summer intern at the NIH, Paul Krauss, who was doing high level research without ever having done it before. I asked him how he managed to do research with essentially no training. "Knowledge," he said, "is for people who cannot reason."

(1) Penguin Publishing, 2000.

(2) Every medical student has supervising physicians who inspire them and whom they seek to emulate. Dr. Lichstein was such a teacher for me. He was a general internist, but he had had psychosomatic training under George Engel at the University of Rochester. He admitted psychiatric patients to the inpatient unit at East Carolina University's hospital.

(3) These are characteristics of lobar pneumonia that can often be detected on physical examination. As with most diseases and disorders, the physical manifestations are usually not present in an unmistakable way.

(4) Remember that whenever you hear the word theory or theorem, you are in the realm of Rationalism. When you hear hypothesis, you are on Empirical turf. It is important to remember that theories are no less true or scientific than hypotheses or vice-versa; each has is most appropriate use.

(5) "Theories are fine, but they do not affect reality." Charcot was world famous for his work on hysteria and Freud studied under him at the Salpetrière Hospital in Paris. Freud's time under Charcot was seminal with respect to the formation of Psychoanalytic Theory.

(6) Humanistic Moral Vision, despite the presence of the term moral, has nothing to do with morals or morality except in that it takes the position that it is immoral not to approach the patient humanistically, without caring. In the context of a humanistic moral vision, the physician sees him or herself as a champion for mankind, as a combatant against disease, suffering and meaningless death. Without a humanistic moral vision, contemporary medicine struggles to see patients as human beings as opposed to laboratory results or as an aggregation of statistical characteristics.

(c) Copyright 2011 Robert Albanese

In the Moment

When you draw back the veil of the worry for tomorrow, you will be astonished at the beauty of today.

(c) 2011 Robert Albanese

For Your Consideration

Life is like a day off. You wake up in the morning, the sun is shining, the whole day is ahead of you and you are going to do great things! A moment passes, and then it is late afternoon, the sunlight is red and the shadows are long. Where did the day go, you ask, and will there be time to do much with what is left? Another moment passes and it is night, and you are preparing for bed, hoping for another tomorrow.

(c) 2011 Robert Albanese

ANTHROPIATRY PART I: PSYCHE, THE MIND

What begins with this essay is a medical study of the human being. For in medicine we have pulmonologists, cardiologists, endocrinologists but we have no humanologists. Each of these essays will have the Anthropiatry Symbol, above, to signal that what follows is another in this series of concepts. The goal here is to engage health care professionals in the discovery of what it means to be a human being and to generate an emphasis on health and life in medicine to balance the current emphasis on disease and death. We begin with an exploration of what is the mind, starting with thought, and within thought, empiricism.

Anthropiatry: Psyche, or The Mind

As we begin our study of the Human Being, we examine the Mind. The Atlas of the Mind includes thought, memory and emotion. We will start with thinking or Thought, and since we are focused on the Occidental Tradition, we examine the thinking of the West.

The Three Kinds of Thinking of the West include Empiricism, Rationalism and Mysticism. We will begin with Empiricism.

Thinking Part I: Empiria

In the gleaming white hallways of Academic Medicine, the word "Empirical" has the character of the all-holy. The word is nowadays used as a kind of whip by the Academic Brahmans to slash ideas that are unworthy or dangerous, or not "empirical." That which is empirical, however, is the highest form of thought, and if you want to be properly anointed and get a key to the executive washroom, you had better be an Empiricist.

At the University of Virginia during my residency in medicine and psychiatry I observed the process of the widespread conversion to this form thinking at the expense of all others. We had been an outpost of The Enlightenment since, after all, we were intellectual heirs of Thomas Jefferson; but in the end even the Rotunda could not resist the empirical tide (1). The psychoanalysts were no longer revered and suddenly the behaviorists could no longer be bothered remember your name. Medical reasoning began to lose its value and in its place arose that which was "evidence based." It reminded me of the Old Norse Saga "Thidrandi Whom the Goddesses Slew," where the wise Thorhall sees in strange events that a New Faith (Christianity) is coming to Iceland. "I am laughing," he says, "because many a hill is opening, and every living creature, great and small, is packing his bags and making this his moving-day (2))." All of the adherents to the old way are put to the door.

When I was a fourth year resident (3), I had rotated onto the Oncology Service. Our Attending Physician was Charlie Hess, one of our most revered professors. Knowing that I was also training to be a psychiatrist, Dr. Hess felt compelled to make this observation: "No offense, Dr. Albanese, but my problem with Psychiatry is that there are no testable hypotheses." In other words, psychiatry was not sufficiently empirical.

Now Medical Schools have many Academics, but they don't have too many scholars (3). How could they? Their training teaches them to be scornful of the humanities, for they provide so little of substance! And yet to say that one is empirical makes direct reference to the philosophies of the ancient Greek Fathers, who were the first to distill its meaning. To me the evidence is that those who wield the empirical war hammer are not fully aware of its significance, what are its historical origins and even what is its proper use. Now that I have dropped the gauntlet, as it were, we will examine the origins of Empiricism and view this essential approach to knowledge in its appropriate historical context.

Empiricism, and empirical, have as their root a Greek work, empiría, meaning experience. Empirical knowledge, then, is knowledge that is acquired through experience or observation. Although Babylonian and Egyptian astronomers were great observers of natural phenomena, generally the title of Father of Empiricism is accorded to Aristotle, the most famous student of Plato. I suppose he occupies that position because of his stature as a philosopher, so monumental is his work. Also, while he may have perfected the classical empirical point of view, he is also the doorway between empiricism and Western Civilization.

Now as I describe empiricism, I will be guilty of oversimplification, and my philosopher friends will be justifiably scornful. But I am a physician by profession and not a philosopher, and in Medicine the goal is to simplify to the extent possible. We have Occam's Razor in Medicine, for example, a principle which states that the simplest answer to a problem is usually the most correct. When I'm trying to describe a medical problem to a patient or to a patient's family member, complete accuracy generally comes at the expense of the full understanding of the patient.

Aristotle's empiricism may have been a reaction to the Rationalism (we will take this one on later) of his teacher Plato. For Plato, I imagine, was like a Renaissance scholar, withdrawn into a place of study where his thoughts and theories could be analyzed and refined. Aristotle, by contrast, felt that to understand the world one had to experience it, to get out into it and record one's observations. It is no accident that Aristotle's work had a great deal of impact on how we study and understand the natural sciences.

To be an accomplished empiricist, an individual must develop the ability to be observant. This is a very difficult skill to acquire, and even the more difficult to teach. William Osler, the patron saint (so to speak) of Internal Medicine wrote: “The whole art of medicine is in observation…but to educate the eye to see, the ear to hear and the finger to feel takes time….(5)” The process of observation requires sensory attentiveness, in other words the observer must consciously direct his or her senses to phenomena and maintain a heightened level of awareness. This is not just awareness of what one is observing, but also awareness of how one's observations might be influenced by other factors. This is the great difficulty of being an empiricist: Knowing how your observations might be affected by internal and external elements.

Because empiricism involves physical proximity to what is being studied and because its adherents know the world through direct experience, empiricism has the aroma of that most unattainable thing in science: absolute truth. There are two great pitfalls in empiricism, however. The first one is physical, mechanical. We perceive the world through finite senses, each sense having a specific spectrum within which it functions. Vision, for example, is limited to those wavelengths between the infrared and the ultraviolet, and we see poorly in limited light. Similarly there are frequencies of sound waves too high and too low to be perceived by the human ear. No matter how one augments the senses by the use of various technologies, one must always be aware of the fact that observation cannot be absolute.

The second great limitation on observation is that of assumptions. If everyone in the world believes the world is flat, and they send a ship to the west and the ship never comes back, they conclude that the ship has fallen off the edge of the world. In reality the ship has gotten stranded on the North American shore. The problem with assumptions is that observers frequently don't know they have them, so erroneous conclusions derived from observations may have long and prosperous lives. An example of such an assumption comes from the field of Medicine where for many years it was believed that the spleen served no important function. When individuals sustained injury to the spleen, as is occasionally the case with blunt abdominal trauma, surgeons simply removed it. The surgeons observed that when they removed the spleens, the patients recovered better from the trauma, so splenectomy established itself as the standard of care. Later on specialists in infectious diseases observed that patients without spleens were more likely to die of certain kinds of infections (encapsulated gram-negative organisms); now surgeons make a much greater effort to preserve the spleen. The scientific term for these kinds of assumptions is bias.

One interesting aspect of empiricism is that it has two forms, one very old and one rather new. And you can use one form to prove that God exists, and another to prove that God does not exist. What a conundrum! The two forms are linked in the French language, by the verb expérimenter, which means both experience and experiment.

So the older form of empiricism is an empiricism whereby if a person observes or experiences something then it is real, or true. It could be called classical empiricism or radical empiricism, but I call it existential (6) empiricism. Let us say that a person is trying to determine whether or not God exists. This individual goes on a spiritual journey of sorts that includes, fasting, meditation and so on. One day this person has a dramatic experience of insight, inner peace, emotional and cognitive transformation. That person will now tell you that he or she has experienced God directly and that to that person, the existence of God is as certain as is the fact that they themselves are alive. By way of another example, let us say that you are hiking deep into the forests of central Idaho, and suddenly you encounter a Gigantopithecus! It grabs you, shakes, you, empties your pockets and knapsack of food items, gathers them up and lopes away. Now you know that Sasquatch exists! Experience, after all, is reality. To the scientific community, however, and to your friends for that matter, you are mad.

The second, newer (but not new) form of empiricism is what I call objectivist empiricism. In her book, Introduction to Objectivist Epistemology, Ayn Rand challenges the existential order by saying that reality is composed of absolutes, and to the extent that there are differences between people over what those absolutes are, it is because there are differences in the quality of observation. In scientific terms, the objective empiricist states an assumption called a hypothesis. Then this scientist designs experiments that are meant to test this hypothesis. The experiments are conducted, the results are carefully observed and recorded and the hypothesis is either proved or disproved. The trick here is to design experiments that, under the same circumstances, will have the same outcomes no matter where they are done, and no matter who does them (reproducibility). In addition to reproducibility, the scientist has to do his or her best to make certain that the results of the experiments do in fact answer the question that is being asked. For example, let us say that a scientist states the hypothesis that treating depression improves cancer outcomes. So she pulls together a group of 200 depressed cancer patients. One hundred will get treated with a new antidepressant, Acarcinol, and the rest will not have treatment for their depression (7). In the end it turns out that those who get the new antidepressant not only have less depression, they have improved survival with chemotherapy than those who do not. Triumph! The researcher publishes an article in a peer review journal and she is promoted to professor!

Later on other investigators try to reproduce her results. Using different antidepressants to the one she used, they find that treating depression, even when the depression is much improved, does not improve survival in the cancer patients. Later on it is discovered that the particular antidepressant she used in her trial has specific anticancer activity and it was this characteristic, not the antidepressant effect, that led to improved outcomes. So the experiment she designed does not actually answer the question whether or not treating depression improves cancer outcomes. Her experiment actually answered the question (hypothesis) whether treating depressed cancer patients with Acarcinol improves cancer outcomes.

Another pitfall for empiricists is that they have to be as neutral as they can be with respect to proving or disproving their hypotheses. We always have to entertain the possibility that an academic with a career at stake or a pharmaceutical company with a hundred million dollars at stake may have so much interest in a specific outcome that conscious or unconscious factors may enter into the experimentation and thereby influence the outcome. An associate professor may develop an idea on paper and publish it; if he later demonstrates with empirical evidence that his theory was correct he has a great deal to gain, for example full professorship. If his experiments demonstrate that he was wrong, however, it is just more data for the scrapheap and his promotion will have to wait.

Objectivist empiricists tend to be atheists, like Ayn Rand and also like Carl Sagan. In his television series Cosmos, Sagan said "I don't believe in God because I can't see him." More broadly, if you state the hypothesis that God does exist or that he does not exist, you cannot design experiments that answer that question. For the orthodox objectivist empiricist, that is as good as demonstrating the non-existence of God, for anything that exists can be proven to exist.

It was necessary for empiricism to branch into these two (objective and existential) forms because humanity has two meanings: individual human beings, for whom reality is rather subjective, and the whole of humanity, for whom reality is best viewed objectively. It incorporates the fact that the two different visions of reality, existentialism and objectivism, although opposite to one another, are paradoxically both true.


(1) Because of the historical connection to The Enlightenment (the Age of Reason), this conversion process took place at UVa, I believe, well after it took place at most universities.
(2) Eirik the Red and Other Icelandic Sagas, translated by Gwyn Jones, Oxford University Press 1961.
(3) I trained in a combined residency in Internal Medicine and Psychiatry, which lasts for five years. Despite offering one of the most useful skill sets in medicine, these residencies struggle for survival.
(4) I define a scholar as an individual who holds all knowledge as precious and worthy of acquisition. Since those in Medicine often have a dismissive attitude toward the arts and the humanities, it's hard to number them among scholars using this definition.
(5) The Quotable Osler, American College of Physicians (2007).
(6) We will say more about existentialism later in this collection of essays.
(7) To withhold treatment for depression as part of a scientific study would be considered to be unethical nowadays, thank goodness. Not too long ago it would have been considered acceptable.

Copyright 2011 Robert Albanese

Wisdom of the Fathers

Several years ago, when I was in management training (Network Executive Healthcare Leadership Institute), I attended a lecture on "Generational Dynamics." We were warned as managers that the young people today have difficulty dealing with criticism, constructive or otherwise. Current educational and parenting models, it would seem, have so emphasized reinforcing self esteem that when these children become adults they are too easily shattered by negative feedback.

Elder Porphyrios of Kapsokalyvia was dismayed at these modern ideas. Children are not edified by constant praise, he argued. He expressed concern that they would have unrealistic ideas about their importance relative to others, setting the mill of egotism in motion.

Perhaps if we were as impressed by wisdom as we are by fashionable ideas, we would not fall into similar sorts of traps with every generation. I fear we may have erected hard obstacles to our young people on their path to growth and fulfillment.

Copyright 2011 Robert Albanese

The Origin of Financial Armageddon

As our nation speeds toward economic calamity, one may well ask how we got into this predicament. I believe the answer is rather simple.

Although they differ in some respects, what unifies Liberal and Conservative politicians is their belief that mankind is fundamentally Evil and therefore must be controlled by the state. Then they tell us they love mankind! Well if they believe mankind is Evil and they love mankind, then they are themselves Evil, and well aware of it.

Ultimately the blame falls on the voters. If we would rather vote for politicians because of the sweetness of their creative unreality than for someone who would tell us the truth, we get what we deserve. Perhaps the politicians are right about us....