A Thousandth Opinion (by Albert Lim Kok Hoo)

published in Khaleej Times on Nov 11, 2009

I know a man who has seen a thousand doctors. Let us call him Thomas. He is 80 years old but even so, a thousand is a huge number. In a year, he would have seen 12 new doctors on the average. A thousand different doctors means perhaps 20,000 consultations. Sometimes Thomas sees three different doctors in one afternoon.

Some of Thomas’s friends are doctors. Some of his doctors become his friends. His doctors range from the junior to the senior, from those in government hospitals to those in private practice, from generalists to specialists. Men, women, foreigners, graduates from local universities; he has seen them all. Sometimes he sees them just to measure his blood pressure.

Sometimes it is for a more serious matter like an unexplained chest pain. He has spent about $230,000 in his lifetime on doctor visits, blood tests, medications, X-rays, scans and 
minor surgeries.

He has no regrets. Others may splurge on flashy cars or the services of a sommelier, but for Thomas it is doctors, doctors and more doctors. Sadly, Thomas was diagnosed with lung cancer recently and was referred to me. I wonder how many more oncologists he has seen or will be seeing.

Thomas came across as a well adjusted gentleman. He did not exhibit any verbal or physical tic. He spoke well. He gave his medical history clearly and answered most of my questions willingly and appropriately. Having gained his trust, I decided to explore his need to see so many doctors. He was forthright about it. He is afraid to die.

So many of us, with or without cancer, are not willing to admit to our fear of death. We couch our fear like this: “Doctor, I am not afraid to die but I fear the process of dying.” Others of a more poetic bent will say, “Oh, death, where is thy sting?” It is a badge of honor we proudly wear on our sleeves.

Thomas was afraid of death, and he was not afraid to admit it. That’s courage. He was going to do his best to postpone it. Of course, seeing a thousand doctors does not help. It may even be harmful. Conflicting opinions lead to confusion and anxiety. Excessive and unnecessary X-rays and CT scans increase the chance of radiation-
induced cancer.

Apart from his fear of death, Thomas also disclosed a distrust of doctors. He was seeking as many opinions as possible before deciding on treatment. He had his doubts. Now you know why I gave Thomas his moniker.

Is Thomas suffering from hypochondriasis? The condition is characterised by fears that minor bodily symptoms may indicate a serious illness. The hypochondriac constantly examines himself; self-diagnosis becomes a preoccupation. He expresses doubt and disbelief in the doctor’s diagnosis. Thomas has some traits of a hypochondriac but that is too easy a label to stick on him. Thomas had a CT scan of his chest two years ago that disclosed a shadow in his lung. He was treated for pneumonia. The possibility of cancer was excluded when most of the shadow disappeared with a course of antibiotics. The doctors should have gone the extra mile to exclude cancer with a PET/CT scan and a biopsy.

Some may diagnose Thomas with thanatophobia — an undue obsession with death (especially one’s own) to the extent that it becomes psychologically crippling. Again, this would be too convenient a label. Thomas is a successful entrepreneur and is socially adept.

I really don’t know. We tend to medicalise every little symptom and discomfort. From an infant’s excessive crying to teenage angst to a wage earner’s blues. There is a pill for everything: insomnia, erectile dysfunction and the sadness of bereavement. Perhaps Thomas has the time and money to see many doctors and he feels good doing this. It is therapeutic for him, if you can forgive my use of the word. It may be no different from some others I know who spend as much as Thomas does on audiovisual systems or eating unmentionable parts of endangered animals.

I shall help Thomas fight his cancer. I will dissuade him from unnecessary blood tests and scans. I will not judge him. Most of all, I will not medicalize his fear of death. It is about being human. There is no pill for it.


Albert Lim Kok Hooi is an oncologist based in Kuala Lumpur

Who are we? / Quem somos? / Quién somos?

1] Age and country / idade e pais
2] Favorite music / musica favorita
3] Book you are currently reading / leitura atual
4] Did you ever read any of my books? / Voce já leu algum livro meu?

OBRIGADO. THANK YOU. GRACIAS. MERCI

Kierkegaard on the Couch (by Gordon Marino)

(this article was originally published in New York Times on Oct 28, 2009)

All progress paves over some bit of knowledge or washes away some valuable practice. Within a few years, e-mail and Twitter moved the art of letter writing to the trash bin. And in an age when all psychic life is being understood in terms of neurotransmitters, the art of introspection has become passé. Galileos of the inner world, such as Soren Kierkegaard (1813-1855), have been packed off to the museum of antiquated ideas. Yet I think that the great and highly quirky Dane could help us to retrieve a distinction that has been effaced.

These days, confide to someone that you are in despair and he or she will likely suggest that you seek out professional help for your depression. While despair used to be classified as one of the seven deadly sins, it has now been medicalized and folded into the concept of clinical depression. If Kierkegaard were on Facebook or could post a You Tube video, he would certainly complain that we, who have listened to Prozac, have become deaf to the ancient distinction between psychological and spiritual disorders, between depression and despair.

There is abundant chatter today about “being spiritual” but scarcely anyone believes that a person can be of troubled mind and healthy spirit. Nor can we fathom the idea that the happy wanderer, who is all smiles and has accomplished everything on his or her self-fulfillment list, is, in fact, a case of despair. But while Kierkegaard would have agreed that happiness and melancholy are mutually exclusive, he warns, “Happiness is the greatest hiding place for despair.”

Despair is marked by a desire to get rid of the self, an unwillingness to become who you fundamentally are.

Kierkegaard was called “the Fork” as a child because of his uncanny ability to find people’s weaknesses and stick it to them. His lapidary “Sickness Unto Death” is a study of despair, which in the Danish derives from the notion of intensified doubt. Almost as a challenge to keep out the less than earnest reader, Kierkegaard begins “Sickness” with this famous albeit slightly ironic bit of word play:

A human being is a spirit. But what is spirit? Spirit is the self. But what is the self? The self is a relation that relates itself to itself or is the relation relating itself to itself in the relation.

For those who do not immediately pitch the book across the room, the magister continues, “A human being is a synthesis of the infinite and the finite, of the temporal and the eternal, of freedom and necessity.” Despair occurs when there is an imbalance in this synthesis. From there Kierkegaard goes on to present a veritable portrait gallery of the forms that despair can take. Too much of the expansive factor, of infinitude, and you have the dreamer who cannot make anything concrete. Too much of the limiting element, and you have the narrow minded individual who cannot imagine anything more serious in life than bottom lines and spread sheets.

Though it will make the Bill Mahers of the world wince, despair according to Kierkegaard is a lack of awareness of being a self or spirit. A Freud with religious categories up his sleeves, the lyrical philosopher emphasized that the self is a slice of eternity. While depression involves heavy burdensome feelings, despair is not correlated with any particular set of emotions but is instead marked by a desire to get rid of the self, or put another way, by an unwillingness to become who you fundamentally are. This unwillingness often takes the form of flat out wanting to be someone else. Kierkegaard writes:

An individual in despair despairs over something. So it seems for a moment, but only for a moment; in the same moment the true despair or despair in its true form shows itself. In despairing over something, he really despaired over himself, and now he wants to be rid of himself. For example, when the ambitious man whose slogan is “Either Caesar or nothing” does not get to be Caesar, he despairs over it … precisely because he did not get to be Caesar, he cannot bear to be himself.

In America, there is endless talk of the importance of having a dream — that is, a dreamed-up self that you will to become: a millionaire, a surgeon, or maybe the next Dylan or George Clooney. But master of suspicion that Kierkegaard was, he goes on to note that while the man who has failed to become Caesar would have been in seventh heaven if he had realized his dream, that state would have been just as despairing in another way — because in that giddy self-satisfied condition, he would never have come to grasp his true self.

On the issue of depression of which Kierkegaard and his entire family were very well acquainted, Kierkegaard could have been a reductionist. He seems to have recognized that we could be born into the blues. In 1846, he sighed:

I am in the profoundest sense an unhappy individuality, riveted from the beginning to one or another suffering bordering on madness, a suffering which must have its basis in a mis-relation between my mind and body, for (and this is the remarkable thing as well as my infinite encouragement) it has no relation to my spirit, which on the contrary, because of the tension between my mind and body, has gained an uncommon resiliency.

The spirit is one thing, the psyche another: The blues one thing, despair another.

How might Kierkegaard have parsed the distinction for the Doubting Thomas who will only believe what he can glean on an M.R.I.? Perhaps he would describe it this way.

Each of us is subject to the weather of our own moods. Clearly, Kierkegaard thought that the darkling sky of his inner life was very much due to his father’s morbidity. But the issue of spiritual health looms up with regard to the way that we relate to our emotional lives. Again, for Kierkegaard, despair is not a feeling, but an attitude, a posture towards ourselves. The man who did not become Caesar, the applicant refused by medical school, all experience profound disappointment. But the spiritual travails only begin when that chagrin consumes the awareness that we are something more than our emotions and projects. Does the depressive identify himself completely with his melancholy? Has the never ending blizzard of inexplicable sad thoughts caused him to give up on himself, and to see his suffering as a kind of fever without significance?

If so, Kierkegaard would bid him to consider a spiritual consultation on his despair, to go along with his trip to the mental health clinic.