As a medical student, I immortalized myself with my classmates when I informed a lecturing psychiatry professor that I considered Freud’s theories slightly more credible than the nuns’ tales about guardian angels. The lecturer ignored my obnoxious comment and continued his lecture. But, Freudians have been on the defensive for the past decade. This trend culminated when the Library of Congress was forced to cancel a tribute to Freud in the name of political correctness.

Freud has always been viewed with suspicion by cultural conservatives. Freud rejected the concept of sin and explained abhorrent behavior in terms of unresolved conflicts among competing brain factions — id, ego, and superego — that stemmed from childhood experiences. His treatment was to delve into an individual’s childhood and attempt to resolve these conflicts — psychoanalysis.

But it wasn’t pressure from the religious right that canceled the Library of Congress tribute; rather a combination of feminists and neuropsychiatrists. Freud theorized that unflattering female behavior could be attributed to “penis envy,” a verboten concept in the age of political correctness. But what is truly destroying Freud’s credibility is the exploding field of neuropsychiatry. While medicine has made exponential advances over the past century, the fundamental physiological function for many organs has been understood for centuries. The heart pumps blood through the body by contracting. The stomach sucks nutrients out of food and produces waste. The tongue facilitates speech. But the brain is a whitish gray blob. How does it allow us to reason, lose our temper, or fall in love?

It wasn’t until the advent of a 20th-century invention that scientists were able to conceptualize the brain. The brain is a computer, perhaps one that is almost infinitely complex, but a computer nonetheless. Through our senses, the brain takes input from the environment, processes it through a multibillion unit network of wires called neurons, and returns a response.

Once this is understood, it is obvious that an individual’s behavior will vary according to the brain’s wiring. This wiring is determined to some extent by the blueprint given to us by our parents, our DNA. Thus, we are inundated with breakthroughs, practically on a weekly basis, as to how some behavior patterns may have a hereditary basis. Researchers have located genes that may be associated with risky behavior, obesity, and sexual orientation.

But our brains are constantly being reprogrammed by our experiences. We learn that making obnoxious comments to our teachers can result in a lower grade and that picking fights with guys who have tattoos can result in large dental bills.

The genius of Sigmund Freud was that he conceptualized how the brain works without ever hearing of a computer or of DNA. He also understood that trying to resolve our fears and irrational behavior through therapy was better than resorting to violence or substance abuse. Neuropsychiatrists who prefer Prozac, Xanax, and Elavil to psychotherapy miss the point. Yes, these drugs alter the
brain chemistry, but on a primitive level that is poorly understood.

Furthermore, what happens to the brain chemistry with psychotherapy? When a patient alters his behavior in response to a psychiatrist’s analysis, a biochemical change in the brain is occurring too. A patient who decides to be more assertive has, one way or another, altered the biochemical structure of his brain. It doesn’t happen by magic! Physicians can debate the relative efficacy of each approach, but they shouldn’t completely discount the value of psychotherapy.

Like Columbus, Freud has been subject to the vicissitudes of public opinion. It is true that Columbus was an intrepid explorer who began the exploration and colonization of the Americas. It is also true that as governor of Hispaniola, he butchered and brutalized the Arawak Indians who would not consent to being enslaved. Freud’s personal life was less than perfect. He manipulated patients to obtain contributions for his research. He fell asleep and wrote letters during therapy sessions. But in spite of his flaws, Freud made the quantum leap required to treat brain disorders in a rational manner, and in the long run, he will be given the credit that he is due. His guardian angel will see to it.

A friend of mine, whose husband was dying of a brain tumor, complained to me that she was unable to get him placed into an experimental protocol that entailed inserting radiation plaques into his skull. She knew of another individual with a brain tumor who was receiving this “advanced” treatment. My response to her was that her husband was the lucky one because his death would be much more comfortable. Several months later, when both the afflicted patients had passed away, she told me I was right.

A recent study published in JAMA reported that, in spite of numerous legislative efforts, we physicians still continue needlessly to give our patients uncomfortable deaths. The study analyzed the treatment of over 9,000 patients with terminal diseases such as metastatic lung cancer, end-stage emphysema, end-stage heart failure, and coma.

The results were discouraging. Fifty percent of doctors did not even know that their patients did not desire cardiopulmonary resuscitation. Thirty-eight percent of patients spent over 10 days in intensive care units, and 30%reported that they were in moderate or severe pain in their final days of life. The study concluded that “to improve the experience of seriously ill and dying patients
…more proactive and forceful measures may be needed.”

The media attributed the study’s results to the medical profession’s arrogance and persistent attitude of perceiving death as a failure. I wish it were this easy. Most physicians with a terminal illness will not let a doctor near them for anything other than pain control. They know when treatment is futile and when it will, at best, give them several additional months of painful life.

Why don’t they give their patients the same courtesy? Physicians have been shell-shocked by our litigious consumer-driven society into abandoning common sense. It is not unusual for physicians to establish a consensus within a family to allow a loved one to die in peace, only to have some “son from California” arrive and demand that everything be done. Physicians thus choose the path of least resistance, preferring to pursue aggressive care rather than later being accused by some lawyer of “allowing Grandpa to die.”

When I worked as a volunteer physician in Haiti, I had the luxury of being able to do what I thought was right for patient comfort. Patients with pain never suffered. I would mix morphine in a bottle of normal saline and titrate the dosage until my patient was comfortable. I did not have to worry about being served papers if I hastened death by several hours. Furthermore, my judgment was never questioned. If I thought treatment was futile, my patients accepted the verdict. No useless and painful procedures were imposed on living skeletons afflicted with AIDS and drug-resistant tuberculosis.

To expect physicians ever to command such respect in the United States is impossible in our rights-oriented society; however, it is possible to structure our health-care system so that patients no longer suffer needlessly. National protocols should be established so that insurance companies, Medicare, and Medicaid are not forced to pay for useless treatments. Rather, hospice care for the terminally ill should be encouraged. Doctors should be able to prescribe painkillers, including marijuana, with impunity in terminal patients. Limits on awards in medical malpractice cases should be in place.

Alas, these reforms are unlikely. No wonder Dr.Kevorkian is so popular!

The most disturbing book published in recent memory is Hitler’s Willing Executioners: Ordinary Germans and the Holocaust, by Daniel Jonah Goldenhagen. With overwhelming evidence and logic, Goldenhagen debunks the myth that the Holocaust was the creation of an evil man who terrorized the German people into “following orders.” Rather, he postulates it was the logical endpoint of centuries of German anti-Semitism and intolerance.

Goldenhagen reports that Hitler did not need to coerce the Germans into participating in the unspeakable barbarities in what became humanity’s darkest hour. There were plenty of volunteers. His thesis has unleashed a raging debate in academe: do humans engage in such barbarism because of conditioning, or is it part of our nature. The answer, sadly, is both.

Several decades ago, social scientist Dr. Stanley Milgram performed an interesting experiment. He placed an actor in a booth and hooked him up to a wire. Participants in the experiment were asked to teach the actor a task and administer a shock of increasing intensity when the actor has performed the task inadequately. Of course the actor was receiving no shock, but the participants didn’t know this. Milgram found that a large percentage of the participants were capable of giving lethal shocks, even though the actors feigned intense pain during prior shocks. Milgram came to the glum conclusion that one-third of the human population was emotionally capable of working in a concentration camp.

In his classic, King Solomon’s Rings, evolutionary biologist Konrad Lorenz postulates why humanity is unique in the animal kingdom in inflicting senseless pain on its own species. Lorenz noted that a species’ tendency towards violent behavior among its members is inversely proportional to its strength. For example, rabbits are the most violent of creatures. Mercilessly gnawing at a competitor for a mate, rabbits are capable of inflicting tremendous pain but lack the physical
strength to cause death. Gorillas, on the other hand, are relative pacifists. Fights among males for mating rights consist of a single blow. The weaker male immediately concedes. Bears don’t even bother to fight. They map out their territory by clawing up a tree. Smaller bears making lower claw marks conclude that there is no sense in fighting a larger opponent and move somewhere else.

Why is this? Lorenz theorizes that since both bears and gorillas are physically equipped to kill each other, fights rarely escalate to a lethal level. Such behavior is not good for the survival of the species. So why do humans engage in such sadistic and brutal behavior? Lorenz believes human intelligence evolved too quickly, without a concomitant decrease in our violent instincts. Our primordial ancestors quickly realized that while crushing a human skull was virtually impossible with a fist, it could easily be accomplished with a rock. It takes tens of thousands of years for evolution to cause physical and behavioral changes in a species. But in the case of humanity, it took only a few thousand years to perfect the technology of killing. In fact, in the past one hundred years, we have “advanced” from primitive Gatling guns to hideous thermonuclear weapons that can destroy the planet. Yet our primitive and barbaric instincts still lurk in the hypothalamus and limbic system of our brains.

Any neophyte politician soon realizes that appealing to people’s emotions gets you farther than appealing to their logic. As has been shown so many times in history, leaders often assume power by fallaciously blaming a particular group for economic and social difficulties. That is why it is so important that our democracies have independent media outlets that can fearlessly expose politicians who engage in demagoguery and prevent monsters like Hitler from emerging. Diffusing power is the best way to insure that our barbaric impulses don’t get the better of us.