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To treat or not to treat?

Raj Persaud
Raj Persaud is Gresham Professor for Public Understanding of Psychiatry, Consultant Psychiatrist at the Maudsley Hospital, London, and Senior Lecturer at the Institute of Psychiatry, London University

It is easy to forget that homosexuality got removed from official diagnostic manuals not that long ago - as recently as the 1970s - once doctors had "decided" that it should no longer be regarded a disease. However, when this medical decision starts being analysed with the hard-edged precision of philosophical analysis, some rather painful politically incorrect problems begin to surface.
Whatever the reason brought to bear for not classing homosexuals as diseased and in need of medical attention, there are difficult implications, because exactly the same set of arguments could be employed for removing a host of currently listed paraphilias or perversions from the diagnostic manuals as well. These perversions and paraphilias range from the familiar, such as sexual masochism and fetishism, to the more exotic, such as klismaphilia - sexual enjoyment derived from enemas.
Many of these do not cause distress to others, and any upset caused to the "patient" appears often largely exogenous - in other words, if wider society accepted the perversion and didn't condemn or discriminate against it, then personal suffering supposedly engendered by the "condition" might disappear altogether.
Another example of the difficulty in deciding what should be treated or corrected by medicine and what should be outside of the remit of the health service is depression. Some forms of depression may be understandable reactions to genuine quandaries, a form of "existential alienation"; a reasonable, even desirable response to calling into question one's own values. It's not a new idea; Aristotle pointed out: "Why is it that all men who have become outstanding in philosophy, statesmanship, poetry or the arts are melancholic, and some to such an extent that they are infected by the diseases arising from black bile?"
It might be that the reduction of depression to faulty brain hardwiring or chemical imbalance is actually an impoverished understanding of the breadth and depth of the human predicament. The New Yorker magazine, in a tongue-in-cheek take on the medicalisation of life, began publishing a series of cartoons entitled "If they had Prozac in the Nineteenth Century", featuring Karl Marx remarking: "Sure! Capitalism can work out its kinks!" and Friedrich Nietzsche saying to his mother after church: "Me, too, Mom. I really liked what the priest said about the little people."
The implication is clear: if stress and dysfunction are "natural" reactions to difficulties, and if Immanuel Kant is even partly right about melancholia being a result of the mind's imagination run riot, then what might we have lost as a culture if psychopharmacology had prevailed in earlier times?
My point is that the boundary between suffering that requires the ministrations of nurses and distress that should be coped with without professional intervention is blurred, with massive financial and professional stress implications.
Indeed, with the remorseless advance of medical technology, it is likely our ability to interfere with states of being that are statistically extremely common is always going to be on the increase, meaning that nurses are going to be involved more and more with demands from the public to help them alleviate suffering when it might be that in many instances these are problems the "patient" should actually sort out themselves.
The problem is that nurses are used to saying yes and trying to help, and are very uncomfortable saying no and refusing care. But if this strategy opens up an infinite demand on nurses' time and physical and emotional resources, leading to breakdown or poor job satisfaction, maybe the time has come for nursing as a profession to demand a clearer boundary between what states of suffering fall under their professional remit and those which are the public's own responsibility to resolve.