Tackling the “hard problem”: consciousness in medicine

Why does the universe have conscious beings? The physical and biological laws of nature do not seem to explain the existence of conscious creatures such as humans.  Neuroscience has done well to explain many of our behaviors, illnesses, and medical therapies based on purely physical and observable rules.  But no one has ever measured consciousness.  And yet it appears fundamental to whether my patient will recover from their disease.

After 15 years as a physician I have become fairly proficient at the scientific aspects of treating complex medical conditions in the hospital.  I study hard, try to keep up-to-date, and read my journals.  Even so, I cannot account for patients who passively give up versus patients who fight an illness long past the reasonable time of acceptance.  I cannot account for the placebo effect.  In a nutshell, I cannot account for the consciousness of my patients that transcends their physical existence.

Philosophers and neuroscientists have divided their thinking about consciousness into the “easy” questions — an organism’s ability to react to environmental stimuli, access its own internal states, and control behavior — and the “hard problem”: explaining experience.  The “easy” questions are at least in principle answerable through measurement and study.  We use these “easy” questions clinically when we prescribe selective serotonin reuptake inhibitors to treat depression, or interpret an EEG to diagnose a seizure.  Neuroscience continues to advance these areas daily.  But the problem of subjective experience is trickier altogether.

What is the experience of being someone?  There is something it is like to be a conscious organism, as the issue has been stated.  There is something it is like to be my patient with heart failure.  Whatever this experience is, it determines her fate as much as the dilated cardiomyopathy I see on the echocardiogram.  The “hard” problem in neuroscience has not been explained by the purely physical process of neurons firing in complex networks.  How many neurons does it take to be conscious?  Humans are conscious, sure, but are cats?  What about trees, or the E. coli living in my colon?  Can you be a “little bit” conscious?  As an eager medical student I used to laugh at these questions, likening them to medieval monks debating how many angels could dance on the head of a pin; I had more important subjects to tackle, like the Na-K ATPase in the distal tubule of the nephron — concrete, physical, and measurable.  Now as I round on my patient with heart failure, or in the ICU on my patient who is in a persistently vegetative state after hypoxic brain injury, I see that the hard problem of consciousness haunts all my work.

Will we someday be able to explain consciousness via physical processes, when our science of complex systems has advanced far enough?  Or will we find that spirit, not matter, is the fundamental building block of the universe?  If so the problem of metaphysical consciousness will not be a problem at all, just a recognition of the true non-material nature of reality.  Many patients have already resolved these questions in their minds.  Some will have never even considered them.  The same is true for physicians.

We all know patients who have resolved the question of consciousness by deciding that everything is spiritual.  These patients resist material explanation of their condition and resort entirely to non-scientific therapies: gemstones, homeopathy and whatever is popular on Google.  We also know patients who have resolved the question entirely in favor of materalism.  These people want the studies, the facts and the percentages.  I find that they are usually deluding themselves into ignoring the impact of illness on their lives.  The best medical outcomes likely appear through balancing our physical processes with our consciousness.  Not too spiritual, not too material.

Good medical care takes into account the “easy” problems of the human body, correctly diagnosing the physical ailments, their etiologies and their remedies.  But excellent medical care tackles the “hard” problem: what is it like to be this patient?

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