Malplaying

Eric Lis

Earlier this year, a doctor of my acquaintance had his license to practice limited by the government. The case highlights an interesting question of the philosophy of healing which might have interesting implications for deciding how a culture views medicine in a campaign setting. In brief, the doctor in question got into trouble for two separate issues. First, he was practicing a form of medicine for which there's limited scientific evidence and which, importantly, isn't actually legal here in Canada. Second, and equally importantly, he was found to be allowing patients to adjust their own medication. Both of these are serious allegations, but at the same time, are very similar, and only subtly different, from how physicians very commonly operate in some cases. Should he have gotten into trouble for his practices? Should he not have? And either way, does this inform the way healers do their jobs in a medieval setting, where sound scientific data rarely exists and medical ethics often hasn't yet been invented?

Let's look at the first concern: a physician following practices which aren't recognized  by the broader culture. The hope is that this should be a very different issue in a medieval era versus a modern era. In the modern scientific era, our widely held beliefs about which treatments work and which don't are, in theory, reliable and proven, although it must be admitted that there have been numerous examples where our widely held beliefs have turned out to be wrong, or based on inaccurate evidence, or founded on an incorrect understanding of how some body system works. In a medieval setting, medical understanding is probably based on prevailing religious beliefs, which tend not to be reliable sources of scientific knowledge, but then again, in medieval fantasy, religiously-inspired science may genuinely come from gods who know what they're talking about. In the modern era, a researcher going against the prevailing "truth" tends to face ridicule and scorn, but with time and persistence sometimes changes the way we understand our world, wheres in a medieval setting, someone going against the popular understanding could be burned at the stake or might be one of a thousand people practicing totally different medicine with just as much apparent justification. The doctor in the example above got into trouble because he was practicing a specific type of therapy which has been tested and which has failed to hold up to good-quality scrutiny; if he had been doing something which was merely inadequately supported by the literature, instead of something widely argued against, then he might not have faced as much criticism for going "off-label" or trying alternative therapies. In a setting where no treatment is adequately supported by evidence, a person who breaks with convention might not be at all unique, or might be seen as a dangerous heretic.

The second reason that the doctor got into trouble was for allowing patients to change their own dosage of medications based on how they were feeling. Specifically, he was treating a medical problem which we usually follow via blood tests, and giving the treatment based on how the person was feeling based on whether their blood tests said they needed higher or lower doses. On the one hand, this is clearly problematic; people playing with their own doses can get themselves into a lot of trouble, and the medications being used in this case could have serious health consequences if people gave themselves too much, even while such overdoses would probably have felt very good in the short term. On the other hand, there's an increasing push in medicine to "treat the patient, not the lab value." In some cases, we're recognizing that certain patients do best at surprisingly high or surprisingly low doses or blood levels of drugs, and according to that point of view, the most important guide for a dose should be the benefits and side effects, not the numbers. The idea of treating the symptom instead of the lab value is arguably a return to a more medieval way of doing things; when we couldn't check blood levels of thyroid hormones or anti-convulsant drug levels or whatever, it was necessary to go according to what the person told us they felt, and in some ways this probably worked better... albeit less predictably so. In a campaign setting where most healing is done via magic, this is probably much less of an issue, as wounds can be seen closing with cure spells  and a single casting of remove disease is always as effective as a second. Aside from the rare hypochondriac who comes to their temple demanding a new restoration spell each day, fantasy clerics don't have to over-think very much what "dose" of magic a person needs. Due to the costs involved, however, we know that most healing in fantasy probably isn't done magically, but instead, probably the same way we did it in our history: through some combination of herbs, rituals, and prayers. Should the doctor have been letting people adjust their own dose? From the surviving medical books throughout history, we know that if anything, doses probably used to be even more strictly controlled back then than now, so medieval healers probably didn't give their patients that sort of flexibility routinely, although the dose of prayer probably doesn't make that much difference. In some fantasy settings it's probably perfectly normal for an herbalist to tell someone to keep eating a mixture until they feel a certain way, but in most it's probably very uncommon. Whether that's good or bad might be up for a very valid debate. 

More than four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on March 13, 2016. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system