Inkwell: Authors and Artists

    
AFter I finish the book I'm working on now, if I can stomach going
back into the magazine biz, I'm going to do something about the effect
of the international drug war on the treatment of pain, especially in
terminal illnesses. It's terrible for everyone, but if you have the bad
luck to have cancer in a third world country, it's truly atrocious. 
  

    
That would be a really important article to write.  I was wondering what
could POSSIBLY have been going through the head of that nurse with my dad
-- that he'd have to go cold turkey in Heaven?  That morphine is just so
gosh-durned expensive?  That it "wouldn't look good" on the hospital's 
write-ups to have all this morphine going to someone about to die?

I ended up having a fascinating discussion with Oliver Sacks, which I wish 
I had taped for Gary's sake, about whether or not my dad had enough brain 
tissue left to constitute a "self."  In other words, while his body was 
clearly in excruciating agony, there may not have been a part of him in 
there saying "I am Don Silberman, at the end of a beautiful life, in 
hellish pain -- please get me out, oh God."  I have zero guilt about 
getting him out -- frankly, I thought of myself as leading a revolution 
against the stupid doctors (my dad was a Communist) to liberate my dad 
from his suffering.  When I told Sacks the extent of the brain damage, and 
that my dad's hemispheres were no longer firing in synchrony (but, you 
know, still firing, so nowhere even near "as dead" as the people in Gary's 
book), he told me he didn't think my dad's brain was capable of 
constituting a coherent sense of self.  But what a slight thread to hang 
on!  I hope he wasn't just trying to preempt more suffering on my part.
Who knows -- which is the point of Gary's book.
  

    
And jeez, so *what* if they don't think he has enough brain cells
firing to feel pain? You did, and it would make *you* feel better to
know for sure that he wasn't in pain.
  

    
Indeed.

And it now occurs to me that "Cold Turkey in Heaven" would make a fine 
country-western album title.  :)
  

    
Gary, where there any other examples of noble lies in medicine or science 
that came to mind only after you wrote the book?

And:  Can we talk about that cover illustration?  At first, of course, I 
didn't even notice it.  Then, when I did, I didn't like it.  Then, within 
a minute or two, I started to love it and think it's really edgy and 
cool and a perfect visual representation of the book.  How did that come 
to be?
  

    
> whether or not my dad had enough brain tissue
> left to constitute a "self."

Hard to see what difference this makes. I once spent a night after
major surgery on very insufficient doses of Demerol. I'm not sure I had
any sense of self. The pain devoured my entire consciousness, my
entire being, the whole universe -- and I think it would have done the
same as long as the outraged nerves were still firing. We don't condone
the torture of animals, however "dumb" we think they are. If a fellow
being exhibits signs of suffering, and we have the means to ease that
(apparent) suffering, I don't think we have to solve any questions of
metaphysics or psychobiology before we know what ought to be done.
  

    

Here's the cover:

<http://www.amazon.com/gp/reader/0470072776/ref=sib_dp_pop_fc?ie=UTF8&p=S00
1>
  

    

What *is* that?  I can see the stapler, but what's the rest of it??
  

    
You can see what it is here:

http://www.amazon.com/gp/reader/0470072776/ref=sib_dp_pop_fc?ie=UTF8&p=S00
1

My own impression of the cover is that it's a bunch of random office junk 
-- tape, a CD case, etc. -- that's been assembled to look like a 
microscope, which is a bold visual metaphor for the book's subject.
  

    
Yeah, that's right. No ideaq who thought it up. They sent it to me,
and I thought it was pretty cool. As Steve says, a nice visual
representation of the theme of the book.

One thing I learned by spending time with people in severely
brain-damaged states is how little we know about where the self lives
and waht it needs to be. But I also learned that there would appear to
be much worse things than dying. ANd finally, that even if the self we
are accustomed to being is simply the sum of certain electrochemical
outputs, there are other possible selves. I think what I saw in
Japan--and I met a whole group of women who take care of children and
husbands in persistent vegetative states--was a kind of joint self, a
shared subjectivity that is probably just an exaggeration of the less
bounded, less embodied, less individual selfhood that exists among many
Japanese people. That phenomenon has been well explored, but its
ramifications when it comes to PVS have not. On the other hand, the
different concdept of selfhood was, at least according to a couple of
Japanese ethicist I talked to, what stopped Japan from adopting brain
death until about ten years ago, and then only after fractious debate.
  

    
>were there any other examples of noble lies in medicine or science 
>that came to mind only after you wrote the book?

Post traumatic stress disorder is the one that got away. This would
have been really interesting, because it illustrates so well how much
good these fictions can do. The value of a medical diagnosis can't be
overestimated--a decent working definition of "disease" could well be
"a condition that, because doctors have validated it, justifies the
allocation of social resources to the relief of suffering." But I also
wish I could have written about it because the question of why PTSD
rates increase with each new war is a really interesting one. I mean, I
think Iraq is horrifying enough, but is it really that much more
horrifying than Vietnam? And could any war be more horrifying than WWI?
And yet rates of PTSD (f/k/a shell shock), if the numbers are to be
believed are higher by an order of magnitude. 

I think this is probably because the definition of what a human life
feels like, waht kind of story our lives are going to be, has changed
such that the horrors of war are more traumatizing than they once were.
I don't know if I could have made good on that argument, but it would
have been fun to try. But I ran out of time.

Another would have been the earlier mentioned global warming
situation. I suspect there is lots of that science that just wouldn't
stnd up to scrutiny. But again, in service of a good cause.

I could go on, but I have to get on my third plane of the day. 
  

    
That's a great definition for "disease".  Hope you don't mind if I
steal it?
  

    
> I also learned that there would appear to
 be much worse things than dying.

Indeed.  That was the thing with my dad.  I couldn't even get him a shot
of morphine, but if he'd been a dog in that condition, any decent human
being would have shot him right away.

I know I'm drilling too far down into my personal experience here, but my 
worst fear that week was that if there was any shred of selfhood left in 
my dad, his endless devotion to my mom would have tempted him to linger in 
that state.  I have no doubt that my mom would have spent the rest of her 
days bringing flowers to his room, until the money she needed to support 
herself ran out.  I guess that's what happens in Japan.  Who pays for 
those years of suspended animation?

Heaven forbid I should ever end up anywhere near that state.  Much, much,
much worse than death.
  

    
I was talking to an extremely good-humored elderly friend some years
back, and he told me, as we were talking about the trauma a mutual
friend had just gone through, that he came back from WWII and sat in a
lawn chair out front for a year. Rain or shine, tornado weather or
blizzard, he got up every morning, sat out there all day, for one year.


He then related the list of local boys who'd come home "not right" and
every one of them was clearly damaged; we just didn't have a name for
it in 1945, and a small town offered shelter and acceptance that
allowed these guys to find something to do and be left alone. 
  

    
To tie the Laurie Anderson thread back there into this one, another thing 
she told me in the "Homeland" interview was this:

"One of my first memories was of my uncle, who went crazy.  I was born in 
'47, and he came back from the war the year before I was born, crazy -- he 
was shell-shocked in the trenches in France.  He lived with us, because 
that was the therapy at the time -- to live with the family.  He lived in 
the attic, and he would scream all night.  Nobody really talked about it 
but it was something about France.  So I always connected the French with 
going crazy and screaming -- something really bad would happen to you in 
France.  That had a very dark tone to me as a kid."
  

    
>That's a great definition for "disease".  Hope you don't mind if I
steal it?

Sure. That's how I got it. From an essat by Peter Sedgwick. 
  

    
Gary, from your own observations, do you think that ibogaine is a truly
promising treatment for the condition we call addiction?  I'm thinking of
LSD therapy for alcoholism in the '60s, when single, high-dose
transformative trips were reported as being enough to get some people off 
the booze.  Of course, the real tragedy is that research like that was cut 
off by pro-drug Learyian hype and anti-drug hysteria;  but as much as I've 
made constructive life changes of my own after a trip (we're talking a 
long time ago), I've always been a little skeptical about 
single-experience life changers.
  

    
>He then related the list of local boys who'd come home "not right"
>and every one of them was clearly damaged; we just didn't have a >name
for it in 1945, and a small town offered shelter and >acceptance that
allowed these guys to find something to do and be >left alone. 

WWII had a very big impact on American psychiatry. It galvanized
psychiatrists like William and Karl Menninger into creating a kind of
amalgam of Freudian psychology and American pragmatism. The basic idea
was that the returning vets with "war neuroses" were walking evidence
that Freud was right but just hadn't gone far enough. The fact that
otherwise normal people were freaked out by war proved that the
environment could be toxic not only in early childhood, but throughout
the life span. Which meant that psychiatrists should turn their
attention to the conditions of living, and shouldn't limit their
attempts at healing to individuals. Mainstream psychiatry became, for a
very brief time, a progressive movement. Robert Jay Lifton, who
deveoped the theory of psychic numbing based on his research with
Hiroshima survivors, was at the tail end of this movement. But by the
early 70s, after the controversy over homosexulaity and some other
embarrassments, psychiatrists began to blame their low esteem in the
eyes of other doctors and laypeople on the profession's attempt to
change the world. The solution, they thought, was to make psychiatry as
much like tjhe rest of medicine as possible.  
  

    
>Gary, from your own observations, do you think that ibogaine is a
>truly promising treatment for the condition we call addiction?  I'm
>thinking of LSD therapy for alcoholism in the '60s, when single,
>high-dose transformative trips were reported as being enough to get
>some people off  the booze.  

I don't have any question that Ibogaine is a promising treatment.
There's just too much evidence in its favor, including even biochemical
evidence. The most compelling part of that evidence is the nearly
universal experience people have of simply being uninterested in the
drug they are addicted to for a period of days or even weeks. In
animals addicted to opiates, that effect can easily be created with
doses of ibogaine.

The really interesting question that raises is whether or not the trip
is necessary to the cure. Therea re two scientists who have created
ibogaine-like drugs that they say distill the antiaddictive effect from
the hallucinogenic. Needless to say, this drug is not given once, for
a life-transforming experience, but every day, as a preventive against
craving. The treatment model is then the twelve-step program, with the
drug as additional insurance.

AT least one of those researchers would ahve preferred to stay with
the once-in-a-lifetime rather than the one-a-day model, but gave up on
trying to get DEA and FDA approval to do the research, and on a drug
company (or the Natl Institute on DRug Addiction) to support her. So
sjhe created a model that is in keeping with waht we already have. 

The problem with that, as far as I can see, is that the 12-step model,
for all the good it does, pivots on convincing people that they ahve a
chronic illness. In case that isn't clear, I just don't think this is
such a good idea, that the fewer existential conditions that get
transmuted into chronic diseases, the better. 



really interesting question is whether or not you can get the
antiaddictive effect without the hallucinogenic effect. The leading
researchers in ibogaine have turned all their attention there--to
distilling the medicine from the drug, so to speak. They think it's
possible to eliminate the serotonergic action from the other actions of
ibogaine
  

    
> the 12-step model,
 for all the good it does, pivots on convincing people that they ahve a
 chronic illness

This puts us right in the difficult core of the "noble lie."  Speaking
from personal experience with an alcoholic family member, I can say that
one of the most *illuminating* and *helpful* teachings of 12-step thinking
is to see alcoholism as not just a "disease" that afflicts not only the
individual, but the whole family of the alcoholic. When the bottoming out
of that family member sent me into AlAnon, the wisdom in their "Big Book"  
was a explanatory revelation to me -- as much as reading about being gay
had been when I was 12 or so.  It was like getting advice from someone who 
knew secrets about my family that I'd never told anyone, and really 
changed the way I thought about my role in my relative's alcoholism.
She is currently sober (I think?) without the help of 12-step, which also 
puts me at the heart of noble lie, because the first question almost 
everyone asks is, "Is she going to meetings?"  In this case, the answer is 
no, though she was in therapy and is obviously doing much better; my 
anxiety centers on whether or not it's possible to get sober without the 
help of the "leading brand" of sobriety.
  

    
Gary, in your chapter on sexual orientation, you talk about one of the 
dangers of the genetically-determined view of sexuality being that 
homosexuality could be "re-medicalized."  It seems like some of the new 
genetic research that opens the door to parents either opting to "treat" 
their children-to-be in utero, or simply abort "gay" fetuses, presents a 
huge challenge for our society.  I'd love to hear more about that.
  

    
STeve, your story about you & Al-Anon gets right at the heart of the
problems with the Twelve-Step movement. What Bill W. and Wm. Silkworth
and all the other founders got right is the phenomenology of addiction,
at least as it was experienced in America in the modern era. The utter
incapacity of the will to control either craving or using, the
solipsism of addiction, the unmanageability of life when addicted--when
they set this stuff down on paper, it did indeed help people
crystallize an experience and to do so without self-hatred. It made
them realize they were not alone, that being in the grip of something
bigger than they were was not a moral failing, that their addiction was
something that required a radical solution, and more. I can see the
connection between reading about the life of the family of an addict
and reading about being gay: in both cases, something speaks its name
that formerly could not. 

I would add that the Twelve-Step movement also creates the grounds for
community as a location of healing. People come together to help each
other and get helped. That fellowship is a rare and sometimes beautiful
thing. YOu can't help but be inspired by the stories of people whose
lives are saved and transformed in that fashion. If there is a weakness
in my chapter about ibogaine, and my other writing about addiction, it
is that I don't convey this well enough. 

The problem with AA is that it has been acquired by medicine and so
what is being "treated" at the meetings is a disease. The original
concept was quite different. AA came directly out of the Oxford Group,
a Lutheran splinter group that focused on fellowship, based on group
confession and absolute honesty, and turning one's life over to God on
the grounds that it is a big mistake to think of oneself as the source
of meaning and intention in one's life. The "disease" being treated in
the Oxford group is original sin compounded by modern selfhood into
hubris; the particular form of our fallenness is to see ourselves as
the authors of our own life stories. 

You can see how well this overlaps with certain religious
apprehensions, including, interestingly, Buddhism. I happen to find
this idea very appealing, except for the part about turning one's life
over to God. I prefer to turn my life over to the particular kind of
confusion known as negative capability, bu8t that's neither here nor
there. The point is that it is an explicitly (and historically)
religious perspective. Early AA leaders made the important decision to
make the movement ecumenical, which is why they adopted the Higher
Power idea in place of the Holy Trinity. 

But ecumenicism is not non-religion. And I think that when people are
confronted with a concept born of a religious ideology, no matter how
bland and ecumenical the religion in question, they consider it
differently from when they are confronted with a scientific (medical)
concept. So when you tell people they have a disease, meaning a medical
disease, the kind doctors treat, and that disease is best treated by a
religion, you've really muddied the waters, because eople in general
tend to think they have more flexibility when it comes to deciding what
church to join, or whether to join one, than they do about whether or
how to have their diseases treated.

That is exactly what has happened with AA, starting in the early
forties. AA arose at just the same time that doctors were trying to
figure out how to corner the addiction treatment market. (That's more
cynical than it needs to be; in post-Prohibition America, addicts were
left in limbo. Doctors were afraid addiction "treatment" would fall
back into the hands of the priests and the CArrie Nations.) They came
up with the idea, courtesy of a public relations expert, of diseasing
it; the best way to get it in therir hands, he told them, was to
convince the public that it was a disease, much like an allergy. And
then they encountered AA, realized that it was perfectly tailored to
their notion of addiction as a disease, and adopted it as their house
religion. And so the condition being treated by AA became not a
spiritual problem, our fallenness, but an illness, and its
solution--fellowship, prayer, confession, etc.--not a religion but a
medical technology.. 

To some extent, this is not really a problem. People who go to AA are
often there for the fellowship, and don't necessarioy think they are
sick. But if you ask them why they are still going after ten years,
they will generally tell you it's becasue they have a disease from
which they will never recover. And that's a lot different from saying
that they are sinners and this is their redemption. I think most people
would be less comfortable with this idea than the medical one. Indeed,
they might be motivated to lose the idea of being chronically ill if
you translated it back to being chronically broken. They might decide
that addiction is really in their past and move on to other things. Or
to treat their original sin differently. Or to do something besides
remaining in the Twelve STep group.

Which brings us to your relative's alcoholism, which evidently is
healed or being healed without benefit of AA. The fact is that most
people who get over addictions do it without AA, and relatively few
AA'ers go forever. But you wouldn't know that to talk to a clinician.
Indeed, the question that you say mjost people ask is the same question
a therapist asks, and the worry you have, the suspicion that she's not
really healing unless she's in AA, is exactly the one that motivates
the question. It's as if her choice not to turn her life over to her
Higher Power is also a choice not to get better, a refusal to treat her
illness--not unlike a diabetic who refuses insulin. That only makes
sense if you have already confused the medical with the spiritual.

I think if these were un-confused that AA would still serve a useful
purpose, but people might be much freer to consider the possibility
that they are not lifelong sufferers of a chronic illness. There would
also be more room to consider the social and political determinants of
addiction--funny, isn't it, that the most self-cetnered society in the
history of the world is ridden with addiction?--rather than worrying
about genes and neurons.
  

    
>It seems like some of the new genetic research that opens the door to
parents either opting to "treat" 
their children-to-be in utero, or simply abort "gay" fetuses, presents
a 
huge challenge for our society.  I'd love to hear more about that.

Well, it's not just genetic research. The leading theories these days
have to do also with the uterine environment, something that changes as
a woman has more babies that makes homosexuality, especially male
homosexuality, more likely as mothers have more children. 

One of the leading theorists in this area is a guy named Michael
Bailey at NOrthwestern. He was the head of their psychology department
when he started his research, which has included extensive twin studies
and other statistical/epidemiological approaches aimed at genetics (he
thinks homosexuality is an evolutionary glitch--not, he says, that
there's anythign wrong with that), and now focuses on neurology. He
puts people in fMRI machines, shows them erotic pictures and watches
their brains light up. The photos show only solo and homoerotic scenes.
So, he claims, your brain is responding only to the gender. And he
says he can predict with more than 90^% accuracy who is straight and
who is gay just by looking at the blood flow in their brains. (And yes,
he has also looked at blood flow down there, but that's a whole lot
less impressive.) He is most famous for saying that no one is bisexual,
which strikes me as a perfect example of the way neuroscientists over
reach--as if your brain somehow registers exactly what your experience
is, and the MRI becomes a big lie detector (a story Steve did in Wired,
which everyone should read). 

Anyway, Bailey got in huge trouble for writing an article about how
there is no reason that parents confronted with knowledge that their in
utero children are gay ought to be able to do whatever they like and
is legal--abortion, prenatal intervention, etc.--to change the outcome.
HIs argument was tendentious and, I think, a paradigm of trolling, and
he got the reaction he should have anticipated. Eventually, he was
removed from his post as head of the psychology department. 

But what was interesting about this was that no one attacked the logic
or science of his argument. Because it was pretty much unassailable.
The only reason not to allow such a thing is political. It's the other
side of the coin of not allowing stem cell research--because the idea
violates some deeply held notion of human rights. And, of course,
practically speaking, you can't ban this kind of therapy. If someone
finds a biological cause of homosexuality, you can be sure someone will
be looking for a cure, and that even if they ahve to go to Thailand to
get it, people will do so. 

I have no idea how to address this issue other than to hope that being
gay becomes so normalized that there will be no incentive to do the
research because no one will give a rat's ass whom you want to make
love with. The race is on. 

But one thing that this issue highlights that we don't normally see is
that every time medicine creates a disease out of suffering it is
implicitly making a statement: that the suffering is unnecessary, and
that the condition in question is soemthing that should be banished,
that we would all be better off without. That's why I think that at the
very least, gay rights activists would do well to back off the
biological claims. Indeed, I think they already have, the lawyers
anyway. I think they're trying to reshape the jurisprudence such that
immutability is less of a threshold issue for the Supreme Court's
determination that a group is protected from all forms of
discrimination.
  

    
Fascinating stuff, Gary.  I wonder how Bailey rationalizes the notion that 
homosexual behavior is an "evolutionary glitch" when it appears in 
thousands of animal species, and certainly not only as an adaptive 
response to deprivation (Bruce Bagamihl's vast book on the subject is 
called "Biological Exuberance").  If it's a "glitch," it's one that 
evolution keeps making, over and over again, and seems unable to 
eliminate.  Interesting.
  

    
It is interesting that even "noble" lies have (unforeseen?)
consequences.  It also appears that there is a rather durable demand
for lies (noble and otherwise) in that we seem to demand explanations. 


Is there a way for the aging citizen to sort out the lies they have
accumulated over the years so as to convey mostly the "better" lies
across the generations?  (An inquiring grandparent wants to know.)

BTW, I have treated most if not all of my "knowledge" thus far as
having some substantial amount of horse hockey.

In the meantime, I work on "negative capability".