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A Systemic Approach to Heart Based Medicine

55 Minute Read

People are called to a life path in the healing professions because of a care for the quality of experience of other people and the actual sacredness of human life and human experience and wanting to be in service to and devotion to that. Daniel Schmachtenberger describes heart-based medicine where the entire system of medicine and all of the interactions were designed from and in service to that devotion and that sacredness.

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Jan Bonhoeffer:
Thank you, Daniel. Thank you for being with us today.

Daniel S.:
Thanks for putting this together.

Jan Bonhoeffer:
We had a chance today to talk about heart-based medicine in the board meeting and during the opening ceremony. I just wondered what does heart-based medicine look like for you if you would describe it in your own terms?

Daniel S.:
The first kind of sense that I have is that people are called to a life path in the healing professions because of a care for the quality of experience of other people and the actual sacredness of human life and human experience and wanting to be in service to and devotion to that. So heart-based medicine would be where the entire system of medicine and all of the interactions were designed from and in service to that devotion and that sacredness.

Jan Bonhoeffer:
So heart-based medicine is about a sacred space for you?

Daniel S.:
Yeah. I mean we think about medicine being preventing and correcting illness and promoting health. People’s experience of life and what they can do with their life to affect the experience of others is sacred, so then the medicine is what is in service to their capacity to experience life fully and contribute to life fully.

Jan Bonhoeffer:
Beautiful. In many ways this is where medicine is coming from, at least in our part of the world and our cultures. Medicine was very much in the domain of the religious missions. That was the understanding of care. That was the understanding of care given and of elevating the potential of the ones we serve.

Daniel S.:
Yeah.

Jan Bonhoeffer:
Is this something very specific to our cultures or is this something that you see as a principle beyond the cultural and religious backgrounds that we share in Western Europe?

Daniel S.:
I think this might be as unifying a thing across cultures as there is in terms of medicine, women and medicine, men and shamans, and Chinese medicine and ayurvedic medicine, early humans figuring out how do we care for each other, how do we care for ourselves, how do we prevent illness, how do we fix illness. Obviously, the whole focus to do that would be not just self-preservation, but also care for each other. So I think that’s probably as unifying a thing as there is.

Jan Bonhoeffer:
Yeah. So care is the unifying principle. If care is the unifying principle and we see that all the talk in healthcare about the importance of care and we see how it is delivered, what do you see as the current, the strongest obstacles if you like, those elements in our current healthcare system and the way that we go about healthcare? What do you see as the current obstacles to deliver the kind of care that we would perceive as sacred?

Daniel S.:
A lot, actually. I’m happy to unpack this, but there’s a lot of systemic factors. There’s obviously trillions of dollars flowing through the thing we call global healthcare, industrial complex writ large, and pharmaceuticals and hospitals and industries and insurance industries. There’s also all of the money in the world flowing through things that affect health. When we look at the burning of coal and oil and what that does to the environment that then we’re embedded in and breathing and drinking the water from, when we look at agriculture that depletes the topsoil or sprays glyphosate on all the food, upstream from someone being sick and coming to the hospital is do we actually have a civilization that’s promoting health?

Daniel S.:
And in how many places do we have a civilization that through structures that create ubiquitous psychological stress and structures that actually, again, expose us to ubiquitous pollution and poor forms of nutrition? When you just think about that, the goal of almost every business is to maximize the lifetime revenue of a customer and nothing does that better than addiction. Obviously, the supply side might be a multi-billion-dollar company relative to an individual consumer and so there’s a kind of asymmetric warfare in terms of their capacity to influence with commercial media so many things. So if we wanted a society that was promoting maximum health, we would want to be minimizing addiction everywhere, which would mean that any place where addiction was profitable we would have a fundamental conflict. We’d have a perverse incentive in the nature of that type of market dynamic.

Daniel S.:
So I think there’s a huge amount of perverse incentive. That’s one place where there are structure issues. I think that there are places where out of caution because of malpractice and whatever else, hospitals create policies. There are insurance guidelines that actually don’t allow doctors to do things that would demonstrate certain kinds of care. I think that we have a medical school system where the average amount of nutrition that is taught to a medical doctor is extraordinarily low relative to the importance of nutrition and health. But similarly, how much psychology should actually be taught so that the doctor can actually really understand the experience of the patient well and be able to relate and work through that should be a much bigger percentage of the training that occurs.

Daniel S.:
I think we also have a situation where you can’t actually measure the felt sense of love and care in the same way that you can measure cholesterol and blood pressure, and so you end up optimizing for the things that you measure. I think MRI machines are expensive and they’re important, so you make big hospitals that a lot of people go to as opposed to small county clinics because there’s economies of scale. But I think the economies of scale mean you don’t really know your doctor. Your doctor doesn’t know you. You’re one of maybe hundreds or thousands of people that they’re going to see. So I think, again, the economies of scale end up really damaging personal connection and personal rapport.

Daniel S.:
I think the most important diagnostic tool there is is really detailed medical intake and really having the time to think through and pay attention, and then a continuity of being able to think about that for the patient. There’s just that requires a certain amount of time being allocated. So I think there’s a lot of structural factors that are oriented to things like lowering liability and maximizing profit and economies of scale, all of which are not optimized for what supposedly the whole thing is in service to.

Jan Bonhoeffer:
Thank you. That makes a lot of sense. I can resonate very much with the importance of an intake that is based on a deep listening, really being present with a patient and understanding where they’re coming from and seeing their disease through their eyes. You were touching on many issues. But you were also touching on one of the points you were raising is that the person’s subjective experience of their disease and how they feel and what it means to their lives is something that is worth exploring and yet it is hard to measure. So the measures that we currently have available are, I think, too crude or is it just structurally impossible to measure the subjective experience?

Daniel S.:
Well, by definition, it is structurally impossible to measure subjective experience. A measurement means some needle move, means it’s in the domain of the objective or third person. I can measure a neural correlate. I can measure an endocrine correlate. Otherwise I have to actually listen to the person report their own experience. Then of course, we’re going to have all the biases that self-reporting has and someone having reasons that they don’t want to say how miserable they are or they want to exaggerate it for empathy or they have a limited vocabulary to express it.

Daniel S.:
So I do think that there is a need for a lot of question-asking of things that cannot be measured in blood tests.

Jan Bonhoeffer:
How do we deal with this approach? We know that when we talk to patients that we find out things, and as you say, there are biases. There are preferences. There’s recall. There’s all sorts of things that affect this. A lot of the approaches that we take in everyday, routine clinics is trying to insert some objectivity into this assessment, seeing to what degree can we rely on this. But in a way, what we do is we take our tests that we apply our observations of that person that we call objective observations. We take those as a reference point and whatever the patient says is measured against that.

Jan Bonhoeffer:
Yet when I hear you correctly, then what we really want to do is we want to improve on understanding the subjective experience better.

Daniel S.:
Okay. There’s a number of parts we can look at here. There’s the way that someone’s subjective experience affects their objective physiology, the whole domain of psychoneural immunology and the way that stress affects health and the way that better psychological disposition, placebo dynamics, et cetera, affect health. We want to actually be able to work with people’s subjective experience as part of medicine. That’s one thing. The other thing is that some people might have a disease that can’t be cured and actually still have a good subjective experience of life based on their focus and their meaning-making versus having a totally ruined experience of life.

Daniel S.:
So subjective experience is a terminal value in and of itself. It is both useful for supporting objective physiologic health and it is intrinsically valuable independent of physiologic health. There’s a bunch of other reasons to talk to a patient and ask them questions though. You and I were talking before that modern allopathic medicine does a really good job in places where we actually understand the causation clearly. Generally, that tends to be more in the direction of things that were acute, like an acute injury. It’s pretty clear there was a puncture wound. We’re going to sew up the puncture wound. Or there was an acute infection and we can see what type of infection it is. Maybe an antibiotic can treat it. Or there was acute poisoning and we’re going to do an acute kind of detox.

Daniel S.:
But there was an acute incident and then immediate symptomology and we can trace causation. But with autoimmune disease and with cognitive decline and neurodegenerative disease and psychiatric disease and cancer, that’s not the case. So for the most part, we don’t actually know why those things are happening. It happens to be my belief, similar to much of the functional medicine and naturopathic world, that most of those diseases are multifactorial. They don’t have one cause. They have a lot of causes. It’s not the same set of causes every time. So there actually isn’t one thing called rheumatoid arthritis or one thing called MS from a patho-ideology point of view.

Daniel S.:
There’s a system that’s being exposed to things that don’t create immediate symptomology, but that are dysregulating homeodynamics. Those dysregulated homeodynamics make one more susceptible to the additional stressors, dysregulating homeodynamics more until eventually we cross a threshold and now we get symptomology and biomarkers. A cluster of symptomology and biomarkers gets a disease name. But if I really start paying attention to those things and wanting to be able to trace a complex causal situation that’s multifactorial and maybe very delayed causation in time, then I want a totally different kind of intake. I might want to be asking really detailed questions to see when they’ve ever been exposed to mold or when they were ever exposed to industrial chemicals or they spent a lot of time with epoxy at a certain point or whatever it is or when they had third world travels where they got nasty infections.

Daniel S.:
I want a timeline of when different symptoms kicked on and a timeline of different kinds of stresses and exposures when there was a micro traumatic brain injury that didn’t show up in an MRI, but it doesn’t mean that there actually wasn’t a micro TBI that affected functional patterning in the brain. If I’m able to look at the current symptomology, the current labs, the progression of symptomology and the progression of exposures and have all of that fit together and make sense, then I might be informed as to how to start a treatment that is actually addressing more than just symptomology and disease manifestation. There’s no way I’m going to get that without asking a lot of questions.

Jan Bonhoeffer:
Yeah. Do you feel that this is an area of research that is developing?

Daniel S.:
I mean I think that the environmental medicine, functional medicine, naturopathic medicine communities have been focused on, with chronic complex illness in particular, where the best modern treatments are mostly symptomatic. Not just symptomatic, a biologic can actually decrease the total tissue damage from a connective tissue disorder. Obviously, if we’re cutting a cancer out or radiating it out or poisoning it out, that’s still better than leaving it there oftentimes. But why was there increased carcinogenesis in the first place? Why did the body’s immune system not deal with the carcinogenesis are still applying questions, especially if we don’t want this person to get cancer again and especially if the things that might have led to it might be signs of underlying dysregulation that affect other things.

Daniel S.:
I think there is an increasing awareness that chronic complex illness is not just stupid bodies. It is just deeper complexity where it’s not one disease, one cause, and we’re going to have one pill. It is radically complex regulatory systems, many different elements of causation that end up leading to things that present like a cluster of symptoms and biomarkers that we call a disease.

Jan Bonhoeffer:
That is very fascinating. I think in most of research that we see published today, most of the clinic research at least that we see published today, what I observe is that the schematic, the methodology is very much the same. We kind of have two points of observation, and between the two points of observation we assume a linear correlation. But what we don’t look at, if you look at the classical table one in a publication where we’re looking at the demographics, comparing the two groups, there are three or four or five different variables. So we’re looking at gender, ethnicity, age, really crude variables. At the end, everybody feels comfortable that both groups are comparable.

Jan Bonhoeffer:
What we’re not looking at is what happens before the trial. What are these life stories? What is the complex of homeodynamic regulatory systems interacting with each other and building up in a way that we have great difficulties to understand that. We certainly don’t have any measures or marker for this. When we establish these, let’s say, if we get better at asking questions and really getting at least a reported picture of what happened, do you feel that if we basically exploded the number of variables from age and sex and ethnicity to maybe, let’s say, 200 or 500 variables, so if we were compiling this index of measures or indicators, would we really learn more about what happened before an event?

Daniel S.:
What are the right methods to gain the kinds of insights we want in a domain as complex as human physiology is a very interesting question. If we look at a clinical trial, say, for drug research that’s trying to see does this drug do something beyond the placebo, we’re going to get something like a Gaussian distribution where it’s going to work pretty well for some people and it’s going to work not well for other people. There will be some range of effect for a lot of people and we just want to see it had some range of effect and maybe the front of the bell curve is better than what a placebo is.

Daniel S.:
But why it works really well for these people and not really well for these people or maybe even badly for these people is a bunch of other variables that are just hidden under the shape of a bell curve. So obviously we would like to find that out. That doesn’t mean that that is a worthless study. That’s an interesting study. If we go all the way to the other end, we get how can we get as much information about this one person as possible, rather than this one drug across all people? How can I get as much information about this person? Now we’re starting to do n=1 kinds of studies and optimization. So I totally think there are places for clinical trials.

Daniel S.:
Of course, if we have more metrics, if they’re appropriate metrics, additional insight comes because not just are you likely to be able to see more things, but you also start to get to see what are the relationships between these metrics. Are there combinatorial insights? But as soon as I realized that I’m not just looking at a genome, I’m looking at the combinatorics on all of the polymorphisms possible on all of the genes and then all the combinatorics on the epigenome and then the protium recursively changing it. We’re never going to be able to compute all that. It is actually not computable.

Daniel S.:
There are better ways we have to think about how do we actually understand what health is. If we think about health as the integrity of the regulatory systems, so the homeodynamics of how the body self-organizes and self-regulates and the homeodynamic, not just the homeodynamic state, but the homeodynamic capacity. Typically most of the tests that we do in medicine are testing state. So we’re testing cholesterol level or we’re testing blood sugar or whatever it is. But what’s really going to determine the overall health is much more related to under some kind of stress how does the body maintain being within a homeodynamic range? We do this sometimes with a glucose stress test or with a stress echocardiogram.

Daniel S.:
Those are super insightful, but there’s a lot of things we don’t do those with or it might be in range, but very fragile and could come out of range easily which means that the person doesn’t have a disease, but they’re very susceptible. Yet if I see very high homeodynamic capacity across lots of axes, that’s a measure of the robustness of health. Different types of interesting diagnostics in the future.

Jan Bonhoeffer:
Thank you. What I hear from you is assuming linear, unique, causal association is a degree of simplification that-

Daniel S.:
Silly.

Jan Bonhoeffer:
… is really not very helpful.

Daniel S.:
I mean for some things. In the knife wound case, it’s fine, except we need to ask are they clumsy or are they getting in knife fights for dumb reasons. So there might be something upstream. For some things, unique causal is fine. But for most anything that emerged not immediately following an obvious causation event, this is why we don’t actually have real cures. We have symptomatic treatments and ameliorative treatments for most complex chronic disease.

Jan Bonhoeffer:
The etiology of disease we will more likely find answers for what is the real cause of disease if we look at nonlinear models and we look at the period before the disease started, before the symptoms occurred and see what are the different factors that have built up and reached that threshold.

Daniel S.:
Yeah.

Jan Bonhoeffer:
When you speculate about what might be the areas that affect the human body, what are the areas that if they stuck up will lead to an imbalance, a dysregulation that becomes symptomatic? What do you believe are those areas?

Daniel S.:
There’s some actual pretty simple models we can start to look at this comprehensively through. In Chinese medicine and ayurvedic medicine actually had some kind of good holistic heuristics to start with even though they didn’t have all of the assessments we have. But say you take a roughly Chinese medicine point of view of where is there too much of something, where is there not enough of something, so toxicity and deficiency, this is a pretty good starting model for predispositions towards disease. You can think about that we evolved to be able to … Our genetics evolved to have a certain set of behaviors interacting with a certain set of environmental parameters.

Daniel S.:
Where our behaviors are very different then what we evolved to handle or where our environment is meaningfully different, those are going to be interesting things to look at. Too much can look like things that we shouldn’t have any amount of, like glyphosate and pesticides. We’re really kind of ubiquitously exposed to the volatile organic compounds coming out of this carpet and out of the paint. We have built a world that we’re actually not genetically fit for where there are externalities to our health and the ways that we do lots of things.

Daniel S.:
So when you look at all the volatile organic compounds or all of the petrochemicals that are in the environment, most of them are either endocrine disrupters or neurotoxins or carcinogens. So then we look at how many diseases fit into those being part of the underlying ideology. Too much of things that shouldn’t really have been there at all, but obviously too much sugar or there can be excesses of certain nutrients in relationship to other nutrients like zinc-copper balance or calcium-magnesium balance or things like that. Obviously, we’re not just limited to talking about environmental toxins that aren’t alive. We can also talk about things that are alive.

Daniel S.:
Infection would be kind of a subclass of too much of something. That can either be things that should be there but they’re overgrown, like [inaudible 00:26:14] and kinds of microbiome disorders or actual infections, the pathogens that are not normally part of our healthy microbiome. This is where the concept of a subclinical infection or a subclinical toxicity is important, which is let’s say that I have a level of mercury exposure or a level of lead exposure where we’re going to say, “Yes, I have lead poisoning.” Well, lead poisoning is at this threshold. But the ideal amount of lead that I would have would be down here. Well, there’s a whole level in here which is I don’t have the level that we would diagnose with acute lead poisoning, that is more than none. It has some effect.

Daniel S.:
That also ends up being true with infections that are not necessarily showing up as acute infection but are testable and that have effect. So we see Helicobacter pylori in the stomach being able to cause ulcers and cause stomach cancer over a very long time period or HPV in cervical cancer or throat cancer, things like that. For those few that we’ve found recently, it’s pretty safe to assume that there’s lots of more like that where the correlations are just not as clear yet. That’s one of the things that, again, some of the infectious study and environmental toxicology studies that functional medicine is doing, I think, are really interesting.

Daniel S.:
Too much of various things, not enough of, and obviously we can look at things like not enough exercise, not enough sleep, not enough human contact and not enough human contact is actually profound because that ends up being one of the most profound drivers of addiction which is then going to cause so many other health issues, but also not enough of specific nutrients. We see that we have a modern American diet or modern industrial world diet is very high in macronutrients and often low in really critical micronutrients. Longevity’s usually best optimized by lower macronutrients and higher micronutrients, which is closer to what evolutionary environments would have. So that’s like a skeleton framework.

Jan Bonhoeffer:
Thank you. Here you have identified areas or risk factors and they’re compiling, I might add. These are the areas that we would like to explore further and more deeply in an intake, as you described it, where we ask lots of questions and try and understand what happened before the patient has reached a state of disease.

Daniel S.:
Yeah.

Jan Bonhoeffer:
When we don’t have a lot of time when talking to the patient and you mentioned the systemic factors, the limiting factors of how we are setting up our healthcare system. Certainly I feel that limited time is a critical factor. We need to make choices. We need to make choices about what questions to ask. One way is to go through a protocol. One way is to go through a long list of questions and ask all the possible questions and then hope that either ourselves or some computer will be able to make sense of it. And then there’s another way to make choices. It involves the observer.

Jan Bonhoeffer:
It involves the healthcare provider. It involves the way we show up as a healthcare provider. We relate to the patient and ask these questions. You briefly touched on the subjective experience of the disease and you touched on homeodynamics as the key principle to understand behind disease evolution. Now, if we see that you are a homeodynamic system and I’m a homeodynamic system, is there a way that those two systems can come into resonance? Is there a way that I can tune my system into yours, and by doing so, I can actually ask the right questions?

Daniel S.:
I would ask you, as a clinician, have you had this experience?

Jan Bonhoeffer:
Yeah. That’s what it seems like.

Daniel S.:
I don’t think we have to get hung up on wondering what the mechanism of intuition is to acknowledge that there’s a reality to it. Is it some electromagnetic resonance that’s happening? Maybe. It’s a cool idea. Is it simply that I have a lot of experience and when I take the time to quiet, I process the information in my own internal, neurologic database better? That’s a fine idea too. I actually don’t want to attach to a mechanistic explanation of how intuition works that someone can say not well enough verified and reject, to say that increasing awareness and presence and perceptivity is valuable. It will lead to better insights from wherever that comes about what’s going on with the patient and how to ask the right questions.

Jan Bonhoeffer:
That’s interesting. You’re leaving care as a sacred space and you’re leaving intuition as a sacred space. So it feels like we need to talk about love, in a way, connecting the two, at least that what it feels like to me. There’s another sacred space and another question of can we measure or should we measure what might be the value of measuring how we relate and how we describe the phenomenon of love or resonance?

Daniel S.:
We talked about this earlier. We can’t measure love. We can measure things going on with the physiology when we say that we’re feeling something that we call love that may be statistically correlated to some degree. Whether I’m measuring oxytocin, and other kind of neuro hormones or neurotransmitters, or I’m measuring heart rate variability or measuring some kind of EEG coherence pattern, those aren’t useless things to do. That’s interesting. But I could just say, “Pick the right person to marry on paper, whether you have any feelings for them or not, and just snort oxytocin regularly because love is just oxytocin.”

Daniel S.:
Most people don’t resonate with that. Or do a particular kind of transcranial magnetic stimulation to the brain region that we identified as where love is happening, and there it is. When the parent wakes up who is sick and who hasn’t slept in a long time who has an infant who’s worn out as can be to take care of their infant, love is motivating them. But they might feel like shit in the moment. Love doesn’t really feel like a subjective emotion. It’s actually something deeper than emotion. It’s transcendent emotion. It can move them even through emotion. We might not see the particular great heart rate variability in that moment or whatever it is.

Daniel S.:
I think it’s interesting to study correlation between physiology and subjective states, but I think if we’re studying it through the method of science and we can do a lot more with the objective within the method of science because that’s what we study, things that are measurable and repeatable. Experience, subjective experience is neither measurable nor repeatable. Then the temptation is going to be to reduce subjectivity to being an epiphenomena of objectivity. In doing so, then consciousness is illusory and choice is illusory. Or their consciousness is real as an epiphenomena, but choice is illusory because everything that happens in the brain is controlled by particle physics of the voltage differentials of sodium ions.

Daniel S.:
That’s the exact opposite of heart-based anything. That is maximum reductionism. It’s not even epistemically well-founded. It’s a category error of seeing that there is some pretty low degree of information, theoretic correlation between objective and subjective, pretending that it’s perfect and then pretending that this is the epiphenomena of this one because this is the one that we know how to actually make causal sense of. Do I think it’s important to have some way of noticing how the doctor and how the nurse and how the practitioners feel before they’re with patients and that they are paying attention to how the patients are feeling and that they’re paying attention to the quality of the relationship? Totally.

Daniel S.:
I don’t think you can measure that. I think you can pay attention to it. I think that you might have some indices that are worth noticing. But there will be meaningful things that can’t be brought into an index, and the moment you do, you’re actually collapsing something very information-rich to something very not information-rich. You’re losing so much information in the process that if you make your decisions as a hospital or insurance company or a doctor based off the thing that lost all the information and then you normalize this is the thing we want to do, you’ll mess it up.

Jan Bonhoeffer:
It’s beautiful. Basically our attempt to simplify questions so that we feel comfortable to answer them, so this reductionist approach, limits our ability to see just by the fact that we’re setting targets to see them.

Daniel S.:
Yeah. The Tao that is namable is not the eternal Tao. Ultimately, good medicine is not purely algorithmic. Our job is not just to try and be robots that just get data that we just haven’t got good enough robots to do yet, but we’ll be replaced by them, and then do if-this, then-that programs. It’s actually not that. That’s not the job. That’s a part of the job, but that is definitely not the whole totality of the job. So there is something to what medicine is that is trans-algorithmic. So then you have to say, “Well, if we’re going to be training doctors and if we’re going to be evaluating them based on a set of metrics on a scorecard so then they are going to try and perform to the scorecard, they’re going to mess up the actual thing.”

Daniel S.:
This is how I interpret what the no false idols thing is about is that that kind of graven image of that set of metrics isn’t actually the thing that it’s pointing at. It’s not worthless to pay attention to those things, but you actually have to have your choice=making be bound to the actual reality, not the information-reduced model.

Jan Bonhoeffer:
That’s very interesting, particularly when we think of artificial intelligence entering the space of medicine. So when we look at now there are computers being built that are exhibiting some features that we would describe as compassionate, for example, nonjudgmental listening. Some of the robots are now able to listen to a human being in a way that there is a feedback to the one that is talking, but is nonjudgmental.

Daniel S.:
There’s a conflation of ideas in here. To say nonjudgmental assumes a binary with judgmental where we’re correlating our experience of a human that is judgmental or nonjudgmental. That computer is not being nonjudgmental nor judgmental. There’s actually no one home. There is no quality. It is doing an if-this, then-that kind of program. Even if it’s doing a deep learning program, it is simply a fully causal input-output through some set of program dynamic. So it’s not really fair to call that nonjudgmental. It is doing a function.

Jan Bonhoeffer:
It is doing what it’s told. I think the interesting observation is that when people with certain disease conditions, for example, autistic people, are interacting with these computers there seems to be a level of trust or acceptance that evolves and that those patients exhibiting features that we would describe as autistic disease spectrum will reduce and they will be able to open up and actually start a conversation.

Daniel S.:
I think that that is a statement of how shitty the parenting is and how shitty the doctors, nurses, and educators are that the person does better with a robot, like a fairly low-level robot, rather than it is something exciting about AI for me. If someone’s doing better with a robot because it simply doesn’t seem judgmental and it takes a little space even though it doesn’t love you or care about you, that’s just a really low bar. I’d rather the person have a dog to spend time with. The thing I’m excited about with AI in the medicine space and it’s confusing to even call it AI, machine learning.

Daniel S.:
Do we want to have machine learning run big datasets to find correlations that we can’t currently find? Of course. That’s awesome. Do we want to scan all the medical records in using image recognition and run massive big data so that we can see early disease indicators we don’t currently know? That’s awesome. Insofar as, of course, we should be augmenting just like we augment human memory with books and computers. We should augment human computational process with computational process. So the ability to take a picture of somebody and have image recognition be able to do better diagnose of skin conditions, all of that’s great. That actually allows, as that gets better, it allows the doctors to be less focused on just memory and computation and more focused on actual connection to then know how to use that system and to relate to the person.

Daniel S.:
But there’s going to be a pretty big gap between the doctor relating with the person using the system and the system acting on the person directly.

Jan Bonhoeffer:
You’re now juxtaposing the human experience and the development of machine learning or the availability of machine learning capacity. We can run this on databases, as you say, but we can also turn them into … We can inform objects that we call robots with machine learning abilities so they’re able to provide services. What we’re seeing is that increasingly now there are kind of robots evolving that are involved in what we typically would call services of care. For example, they would help in household activities. They would help in basic getting dressed, washing ourselves, very basic day-to-day activities.

Jan Bonhoeffer:
They are helpful for people who are somehow they don’t have the capacity to perform certain activities. But they’re fundamentally different to a nurse coming to the home and actually being with this person and providing that support.

Daniel S.:
Yeah. There’s something about the development of these technologies that is awesome and liberating and helpful. And there’s something about the way we are relating to it that is gruesome. It’s important to understand both. Insofar as we’re talking about a robotic exoskeleton that can allow a paralyzed person to walk, it’s just a better wheelchair. It’s an extension of the tooling we’ve already been using. You’re wearing eyeglasses. That’s a tool that helps you, your cyborg to some degree. If we had ones that could auto-focus and do cool stuff like … Okay, that’s fine. But something that does not actually have the capacity to care about you, replacing a dynamic where care used to occur, is tragic.

Daniel S.:
Now, if it’s simply helping you get some stuff done you couldn’t otherwise, and hopefully that increases your capacity for authentic human interaction, awesome. But the tendency of hyper-individualization that the modern world has had, modern West in particular has had, every time you see a mass shooter who shoots up a bunch of people at school or somewhere, almost all of the time when the news goes and checks, the neighbors say, “Yeah. He was super quiet. He kept to himself. Nobody ever saw him.” Because in a setting where you have a family or an extended family or a village where humans evolved for most of human history, before you’d go kill a bunch of people, you’re obviously not happy. If you’re interacting with other people to get your needs met, other people see that. They’ll actually be responding and keeping that psychopathology from progressing that far.

Daniel S.:
But if someone can be a shut-in and they can hardly ever interact with anyone and maybe get an Amazon drone delivery to their house so they actually never have to interact with anyone, now they can have some robotic care agent. They can progress in psychopathology both in ways that make them dangerous to society and in ways that just allow them to be suffering gruesomely for a long time. Humans are social primates. We evolved in social environments. We have a world that totally is getting this wrong right now. We have to turn that thing around for there, not just to have an optimal world. I actually don’t think we have any chance of having a world to continue to at all from the point of view of existential catastrophic risk, if we don’t solve this particular thing because say someone is progressing in psychopathology and they’re really upset.

Daniel S.:
The best technology for killing they have is a knife. They’re just not going to hurt that many people before somebody takes them out. But if it’s an AR-15, they can kill a lot more people. With decentralizing exponential technology, when that becomes a crisper [inaudible 00:46:17] pandemic weapon and weaponized drones and et cetera, we just can’t have really disaffected people. That means if I can get all of my needs met without interacting with other humans, then either I have to have some top-down state surveillance system, like the China method, which is already a dystopia or how do we have access to the level of technological power people will be getting and have us be safe vessels for having that much technological power?

Daniel S.:
Well, there have to be no psychologically really damaged people and if there are any, we have to know. The only way to have that kind of known that doesn’t involve top-down state surveillance is the kind of surveillance that a family does or a tribe does or a community does, where my resource provisioning requires interacting in healthy ways with people, where unlike the kind of asymmetric surveillance of the state that is just trying to make sure I’m not a bad guy. It’s a symmetric paying attention of people that I actually want to make sure I’m doing well.

Jan Bonhoeffer:
Part of what you’re proposing is a community surveillance in a way. So are you saying basically that doesn’t even have to be developed because it’s an innate function of building primate communities that we’re resonating with each other and that we’re realizing if somebody’s behaving kind of outside of the pack then that is something to be addressed? Would you argue that this is something that is like an existential interest of the group because of the potentials? Or is this like a risk detection system of a group?

Daniel S.:
Does this mean that nobody can be a hermit? No, of course it doesn’t mean nobody can be a hermit. But it does mean that in the presence of decentralizable catastrophe-level technology we have to think about some things differently than we did previously. The disposition and wellbeing of people matters more to everyone because the one-to-many capacity of a person is much, much higher and so the coupling is higher which means that the care needs to higher.

Jan Bonhoeffer:
We’re coming back to care again and again and again. So now we’re looking at care as a group phenomenon. A group caring for the group and caring for individuals for the sake of the group.

Daniel S.:
And for the sake of the individual.

Jan Bonhoeffer:
And for the sake of the individual. So if I’m just translating this to the healthcare setting now where we have a group of people working together and we have individuals walking in and out of this setting and we’re looking at the current, I want to call it, epidemic of suicides among our colleagues, where are we failing? Have we become numb? Has the system numbed ourselves? Have we lost a sensitivity?

Daniel S.:
You’re specifically talking about suicide amongst doctors? I don’t know. I haven’t studied this. I would want to really look at is suicide much higher amongst doctors than other professionals of the same pay grade and other types of similar stress level. I’m sure, again, there’s going to be complex causation that’s involved. It’s not one thing. We can talk about why there are epidemic suicide issues society-wide. But yeah, I wouldn’t want to speak to with doctors without knowing more. But I think it’s pretty easy to see at least some things. I think it’s pretty easy to see that the amount of stress doctors go through, even in med school, experiencing burnout or being on some kind of Wellbutrin or Adderall or Ritalin or some kind of upper just to make it through school.

Daniel S.:
By the time they’re just not even graduating and then they’re supposed to have a whole career of that and, like you mentioned, 72-hour shifts. I also think that not having a place to process the emotionality of it, the desensitization of, okay, so I just was a part of some kids dying today, this experience. Now I’m going to go do it tomorrow. Where’s the space for that? Yeah. I think there’s obviously a lot of stresses both that are unavoidably endemic to that profession that need to be processed in ways that they aren’t currently processed and ones that are avoidable by changing the way the system works.

Jan Bonhoeffer:
So we could, as a group, become more proficient in detecting the dynamics of the group in taking care of each other. We could become more proficient in the way that we show up as an individual in the group, and that showing up more proficient with our peer group, with our teams, and with the patient, will help us to see the patient better, see our colleagues better, and that might create a community that is mutually supportive in a way that we are not so much cluttered by knowledge and red tape, but we can actually allow ourselves to activate our natural capacity to care and our, I feel like, to allow ourselves to be authentic in our natural state of being and connect at that level.

Daniel S.:
Yeah. I mean it’s interesting when you’re talking about the group care between doctors, colleagues. When someone that we know commits suicide, it’s such an important inquiry, especially if we didn’t know they were close. It’s an important inquiry to recognize that you actually don’t know how close anyone you’re talking to ever is to committing suicide. You don’t know how close to threshold they are and how your interaction is going to affect their relationship to that threshold. Simply being aware of that changes the importance you put on how you show up in all the interactions so much.

Jan Bonhoeffer:
Well, we’ve come a long way in looking. We’ve taken a big circle, starting in what does heart-based medicine mean to you, and we’re ending on a note of how important it is to develop a sensitivity for each other and to be present with each other and how many ways this finds reflections in our diagnostic capacity and the way we devise treatments and the way we want to create a healthcare system that overcomes the many limitations that we’re facing at the moment towards a system where people feel seen and heard as human beings rather than being seen as a disease with some kind of background that really isn’t so important for us.

Daniel S.:
Yeah.

Jan Bonhoeffer:
Thank you. Thank you for taking the time being here.

Daniel S.:
Thanks for having me. Thanks for following the call to help this movement birth.

Jan Bonhoeffer:
We’re on it together. Thank you. Thank you.

Announcer:
This has been a Heart Based Medicine production. Thanks for listening.

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