Medicine, Constantly Redefined and Redefining Lives

By ELISSA ELY, M.D.
About 15 years ago, I had a shy patient who ate nothing but white foods and who assaulted anyone who entered her air space on the hospital ward. She was mute but not uncommunicative, and with a little effort it was possible to learn her language.
Some of her problem was her psychosis. Most of it was her mother, who was her legal guardian, appointed by a court to monitor her medications. But the mother was also convinced that psychiatric medications were poison; the patient would go home on weekend passes and return with all her pills in bottles and without a shred of sanity.
This continued for months. Her mother brought a notebook listing side effects to each visit. She said the medication caused seizures, diabetes and heart disease, though the studies at the time showed none of these side effects associated with the drug we were giving. We thought she was sadistic, intent on standing between her daughter and independence. She thought we were evil experimentalists. The patient herself dreaded controversy and wished, wistfully, to please everyone.
Finally, we petitioned to remove the mother as guardian. It was controversial, against nature, to question a family member’s competency or guidance. When we met before a judge, both sides were filled with strong emotion. But we were also filled with strong data.
I remember looking at the mother across the courtroom while testifying about the hazardous nature of her beliefs and their effects on the patient’s mental state and future. Her size had changed. When she visited the hospital, something vibratory and angry about her made her seem to swell, so that neither her daughter nor I could look her in the eye. From the secure height of the witness box, though, she seemed to be shrinking — an ineffectual old woman, laboring under false beliefs, growing smaller as these beliefs were exposed one by one.
The judge listened without expression and took the case under consideration. We had no doubt about the power of our presentation. Within a week he had ruled in our favor. The new guardian did not oppose our antipsychotic drug, and the patient flourished. It was like time-lapse photography: in what seemed like only a day, she smiled, spoke, became lucid, joined a day program, began overnights in a residential house and was discharged.
We were full of public satisfaction, and private righteousness. Some aspects of psychiatry are clear-cut; they can be counted on. There might be no proof of the existence of Freud’s ego and id. But antipsychotic medications treat psychosis — this can be proven — and the patient’s life was going to be better for taking them.
It was, too. For a while, she sent happy, mostly intelligible letters from her residential house. The letters became holiday cards, and eventually, in the fullness of her world, they stopped. Someone else told me, years later, that she had developed diabetes and required insulin. The research by that time was clear: there was no doubt whatsoever of an association between her antipsychotic and diabetes and other metabolic problems. The studies had been confirmed again and again.
Kierkegaard wrote that we understand backward but live forward. Politicians say — using a tense so passive that it slinks out of the room before it can be noticed — “Mistakes were made.”
The facts we had then were incomplete, even if we didn’t know it at the time. We were right but we were wrong, innocent but at fault, acting in good faith with bad results. The ground beneath professional feet should grow firmer over time — one ought to feel more certain of what one knows. But the more I know, the more I am afraid.