The “Goldberg” Variations, Walden-And Informed Consent

“The unexamined life is not worth living,” as Socrates stated at his trial for heresy before drinking the hemlock, but it is the deliberative process by which life is examined that creates its value. This essay analyses that process in the thinking of the musical genius, Glenn Gould, the poet-philosopher, Henry David Thoreau, and in the brilliant humanitarian principle of informed consent.

Deliberate

Deliberate (from ME deliberare, to weigh well <de-, intens. + librare, to weigh < libra, a scale) has two (often overlapping) meanings:

1) to weigh in the mind; to consider the reasons for and against; to consider with full consciousness; to reflect upon; to ponder; and 
2) unhurried, leisurely and steady in action, movement, or manner.

Glenn Gould (1932-1982)

Gould, a world-class pianist, who rarely re-recorded a musical piece, did just that with the “Goldberg Variations.” Twenty six years after his remarkable first recording (1955), he decided that it “lacked deliberation.” His 1981 recording, which Gould never lived to hear (he died of a stroke at 50), was radically different. Their respective playing times, from an external point of view, went from a fast 38 minutes 27 seconds in the first compared to 51 minutes 15 seconds in the second. He explained the reasons for the tempo differences:

        I think that the great majority of the music that moves me very deeply is music that I want to hear  played or want to play myself, as the case may be, in a very ruminative, very deliberate tempo. . .
       Firm beat, a sense of rhythmic continuity has always been terribly important to me. But as I've grown older I find many performances, certainly the great majority of my own early performances, just too fast for comfort. 
       I guess part of the explanation is that all the music that really interests me, not just some of it, all of it, is contrapuntal music... and I think ...that with really complex contrapuntal textures one does need a certain deliberation, a certain deliberate-ness, and ... that it's the occasional or even the frequent lack of that deliberation that bothers me most in the first version of the Goldbergs." (Interview with Tim Page, NPR, 1981. Italics mine.)

Gould had in mind the second meaning (“unhurried”) although he arrived at his conclusion only by weighing it in the fully conscious mind.  Listening to both versions of what he termed the “Gouldberg Variations,” the 1981 rendition is played in a remarkably leisurely fashion, endowing it with great precision and clarity.

Henry David Thoreau (1817-1862)

Thoreau went to live in the woods to grieve and mourn his beloved older brother, which he partially accomplished by writing A Week on the Concord and Merrimack Rivers about their final 2 week effluvial excursion compressed into 7 days.

There was also another reason for the Walden Pond sojourn, which he explained in Walden.  Appalled by hurrying through life which led to its waste, he wrote:

              I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived. I do not wish to live what is not life, living is so dear.
             Nor do I wish to practice resignation, unless it is quite necessary. I want to live deep and suck out all the marrow of life, I want to cut a broad swath, to drive life into a corner, and reduce it to its lowest terms. If it proves to be mean, then to get the whole and genuine meanness of it, and publish its meanness to the world; Or if it is sublime, to know it by experience, and to be able to give a true account of it. (Thoreau, Henry David. Walden. "Where I Lived, and What I Lived For," Chapter 2. Italics mine.)

Thoreau, like Gould, emphasized the importance of an unhurried life, but the second meaning was also important to him-seeking to weigh life in the balance and discover its entire meanness or sublimity.

Informed Consent

Traditional Western medicine, beginning with Hippocrates 2500 years ago, was predicated on the concept that physicians should protect their patients from information about their diseases or treatment options. The Hippocratic oath clearly articulates clearly that the physician knows what is best for his or her patients. The physician was place in an almost Godlike position in terms of his or her wisdom to practice in the patient's best interest. Since the mid-twentieth century, however, there has been a trend toward patients rights, including the right to know what the physician intends to do and why, the essence of informed consent. 

This is more than simply getting a patient to sign a written consent form. It is the process in which the physician or person performing the treatment and/or procedure (not a delegated representative) discusses with the patient the diagnosis, if known, and the nature and purpose of a proposed treatment or procedure.  

Then the deliberative begins. The risks and benefits of the proposed treatment and its alternatives (regardless of cost) and the risks and benefits of not receiving or undergoing a treatment or procedure are provided. The patient is given the opportunity to ask questions to elicit a better understanding of the treatment or procedure to decide whether or not to proceed with a particular course of medical intervention.

The movement toward informed consent began after World War II with the 1947 Nuremberg trials when it was revealed that physicians conducted abhorrent medical research experiments on concentration camp victims.

The Nuremberg Code, which emerged from the trials, abandoned the earlier paternalistic perspective of medicine and replaced it with the practice of patient self-determination, asserting that voluntary consent of the human subject is necessary under all circumstances. Thus began the modern era of biomedical ethics based on informed consent.

 “Live Deliberately”

As psychiatrists, we are the role model for our patients, students, colleagues and friends, who often look to us for guidance. An antidote to the ubiquitous arrogance, impulsivity, and knee-jerk reactivity surrounding us is to gather as much information as possible, weigh the pros and cons of any intervention, think critically and act mindfully. We can, as Thoreau decided to do, “live deliberately.”