An Introductory Philosophy of Medicine

Philosophy of Medicine: Models of Medical Knowledge and Practice

As evident from the title of the book I opt for the philosophy of medicine relationship, which I hold to be a sub-discipline of philosophy. The relationship between the two disciplines is more than simply philosophy and medicine in that they share more than common problems and is more than philosophy in medicine in that philosophers use medicine not just to do philosophy but to understand the nature of medicine itself. I define philosophy of medicine specifically as the metaphysical and ontological, the epistemological, and the axiological and ethical analyses of different models for medical knowledge and practice. Such a definition is rooted in a standard topology for philosophical analysis. The aim of this analysis is to unpack the nature of medicine itself as articulated in the question: What is medicine? This question is at the center of the quality-of-care crisis facing modern western medicine and represents the primary issue for my philosophy of medicine.

By model is meant an idealized notion or representation of a system or phenomenon that is proposed as a theoretical explanation or a construct.' In other words, models are idealizations and not the real thing, i.e. they are notional. They represent a phenomenon or system and are used to explain it, often from an abstract perspective. As such models are constantly in flux and are either advancing or degenerating, in terms of their explanatory power. Part of that power is the ability to predict future events. Models then can assist in visualizing how the natural and social worlds operate and in manipulating those worlds for better or worse. The two models of modern western medicine analyzed herein are the biomedical and the humanistic or humane models. Their histories are intertwined and a brief examination of them provides a necessary background for conducting the philosophical analysis found within this book.

Many histories of modern western medicine trace medicine's origins to the dawn of human history (Ackerknecht, 1982; Porter, 1998). Certainly the first chief figure in western medicine was Hippocrates. The Hippocratic corpus influenced western medicine for over a millennium. Even today, medical students often recite in unison a version of the Hippocratic Oath as part of their graduation exercises. The next major figure in the western medicine was Galen, whose influence again was also felt for over a millennium. Not until the scientific revolution of the sixteenth and seventeenth centuries, especially with the anatomical work of Andreas Vesalius on the human body and the experimental work of William Harvey on the circulation of the blood, was Galen's approach to medical knowledge and practice challenged. By the end of the nineteenth century and the beginning of the twentieth century, the biomedical or allopathic model of medicine became the dominant model for medical knowledge and practice.

In the United States the biomedical model had its origins in the late nineteenth century, especially with the importation of physiology or experimental medicine from Europe (Duffy, 1993). One of the chief figures-if not the chief figure-in the development of experimental medicine was Claude Bernard in Paris (Olmsted and Olmsted, 1952). American physicians traveled to Europe and returned to introduce the latest in scientific advances (Fye, 1987). Bernard had a major impact on the development of American medical science through several students, including William Henry Anderson, John Call Dalton, Jr., Frank Donaldson, and Silas Weir Mitchell (Carmichael, 1972; Marcum, 2004a). Bernard's influence was keenly felt in American education, where the use of animals to illustrate physiological principles during lectures revolutionized medical pedagogy: "We venture to say that demonstrative teaching in physiology in [America] is to be attributed to the influence of Bernard's works" (Flint, 1878, p. 173). Besides Bernard other European scientists, including Michael Foster in Cambridge and Carl Ludwig in Leipzig, also influenced the development of experimental medicine in the United States (Fye, 1987; Geison, 1978).

A major event in the origins of the biomedical model in the United States is traditionally claimed to be the opening of The Johns Hopkins Hospital in 1889, followed four years later with the launching of the Hopkins medical school (Chesney, 1943). Entrance into the new medical school required a rigorous scientific undergraduate education and the Hopkins faculty taught its medical students a medicine shaped by current scientific knowledge. Hopkins set a standard that became the benchmark for medical education and practice in the United States, if not the world (Ludmerer, 1985). Besides Hopkins, the founding of the Rockefeller Institute for Medical Research in 1901 also contributed significantly to the development and establishment of the biomedical model in American medicine (Corner, 1964). Finally, Abraham Flexner's 1910 Report to the Carnegie Foundation was influential in promoting pedagogical changes in medical education to reflect the focus on scientific medicine (Flexner, 1910; Boelen, 2002).

Today, the biomedical model is the prevailing model of medical knowledge and practice within the United States of America, as well as in other western and developed countries, and is also becoming the dominant model in eastern and underdeveloped countries. In this model, the patient is reduced to a physical body composed of separate body parts that occupy a machine-world. The physician's emotionally detached concern is to identify the patient's diseased body part and to treat or replace it, using the latest scientific and technological advances in medical knowledge sanctioned by the medical community. The outcome of this intervention is to cure the patient, thereby saving the patient from permanent injury or possibly death.

Although the biomedical model provides major advances in American medicine, one of its chief underlying problems is the alienation of the patient from the physician. "The public perceives medicine," claims Miles Little, "to be too impersonal" (1995, p. 2). Moreover, by reducing the patient to a collection of body parts, the patient as a person disappears before the physician's clinical gaze (Maclntyre, 1979). The loss of the patient as a person from the physician's clinical gaze has led to a quality-of-care crisis, which afflicts American medicine today, and has eroded the intimacy of today's patient-physician relationship from a perceived intimacy of an earlier age in the United States.' For example, much of the infrastructure supporting current American medical practice favors the physician's schedule at the expense of the patient's lifestyle and at times the patient's health and wellbeing. Importantly, Engel identified the origins of this crisis in the "adherence to a [biomedical] model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry" (1977, p. 129). In other words, the crisis arose over bracketing the psychological and social dimensions associated with the patient's experience of illness and the physician's inability to understand the patient as an ill person.

In response to the quality-of-care crisis, some practitioners of modern medicine have proposed over the past several decades humanistic modifications of the biomedical model, in order to reinstate the humanity of both patient and physician into medical knowledge and practice. Michael Schwartz and Osborne Wiggins broadly define humanistic or humane medicine accordingly: "medical practice that focuses on the whole person and not solely on the patient's disease" (1988, p. 159). They do not reject scientific medicine but enlarge its scope to include the patient's psychological and social dimensions. Davis-Floyd and St. John concur with this assessment of the humanistic models: "Humanists wish simply to humanize technomedicine [biomedicine]-that is, to make it relational, partnership-oriented, individually responsive, and compassionate" (1998, p. 82).

Humanistic or humane modifications of the biomedical model range from more conventional efforts to reform the biomedical model, such as Engel's biopsychosocial model, to the more unconventional efforts by phenomenologists to replace it (Toombs, 2001). In humanistic models, the patient is recognized as a person (or self) or at least an organism composed of body and mind occupying a lived context or a socioeconomic environment. Under the practitioner's empathic gaze and care, the informed and autonomous patient is cured and at times even healed using generally scientific evidence-based or traditional medical therapies but possiblyand then only as a last resort-nontraditional therapies.

In the first part of this book I examine initially the metaphysical boundaries of the biomedical and humanistic models, in terms of medical worldviews in which the models are embedded (Table 1). Specifically, I analyze the biomedical worldview in terms of its metaphysical position of mechanistic monism and its metaphysical presupposition of reductionism, and its ontological commitment to physicalism or materialism. For the practitioner of this model the patient is a material object that is reduced to a collection of physical parts. Importantly the mind is not a separate non-material entity but a functional property of the brain, as the pumping of blood is the functional property of the heart.

According to the biomedical model, the patient is a machine composed of individual body parts that, when broken or lost, can be fixed or replaced by new parts. Moreover disease, whose cause can be identified by scientific analysis, is an objective entity. It is often organic and seldom, if ever, psychological or mental. The notion of health involves the absence of disease or the normal functioning of body parts. Physicians are interested in identifying only the physical causes or entities that are responsible for a patient's disease. Once identified by objective diagnostic procedures, treatment then is generally based on some type of drug or surgical procedure. Appropriation of the proper therapeutic modality, selected by the physician, is based on statistical analysis of data obtained from randomized clinical trials. Thus, the physician is a mechanic or technician, whose task is to determine which part of a patient's body is broken or diseased and to mend or replace it.

The biomedical worldview is modified in humanistic or humane models, with a metaphysical position that is often dualistic, composed of two non-reducible entities-the body and the mind. Other humanistic models operate from a holistic position, in which the person (or self) represents an integrated whole not only in terms of the individual but with the person's environmental context or lifeworld. Although practitioners of humanistic models of medical knowledge and practice appreciate biomedical model's metaphysical presupposition of reductionism and the gains it provides for the technical side of western medicine, they often reject it as an insufficient presupposition for medical knowledge and practice. They generally subscribe to some form of emergentism, in which properties of the system are not determined by the properties of the individual parts but transcend them. Practitioners of humanistic models share to some extent the biomedical model's ontological commitment to physicalism or materialism; however, this commitment is tempered in the humane models by including the patient's psychological or mental state-and for some, the spiritual state.

Instead of reducing the patient to the physical body alone, the humanistic or humane practitioner, who is not just a mechanic, encounters the patient as a person composed of both mind and body. Importantly, the mind and body often influence the behavior and state of each other in a reciprocal manner. Thus, the mind and body are complementary aspects of the patient and both must be considered when making a diagnosis or choosing a therapy. For the patient's illness may be more than simply organic (a disease) but may also include the psychological and social (an illness or a sickness, respectively). Causation then is more than physical but also includes information concerning the individual patient qua person. Moreover, rather than being considered just a machine composed of individual parts separate from any background or framework, the patient is viewed as an organism or a person within a socioeconomic environment or cultural background. And as an organism or a person the patient is more than simply the sum of separate body parts but also exhibits properties that surpass the aggregation of those parts. Thus, an important ontological commitment for some humanistic models is organicism.

In the second part of the book, I examine the epistemological boundaries of the biomedical and humanistic or humane models (Table 1). Medical practice within the biomedical model is based on objective or scientific knowledge and relies on the technological developments in the natural sciences, especially the biomedical sciences. The acquisition and implementation of medical knowledge reflects the techniques and procedures of these sciences. For example, the randomized, double-blind, concurrently controlled trial is considered the primary or "gold" standard for determining the efficacy of a new drug or surgical procedure. Such scientific practice defines acceptable knowledge and practice of medicine within the biomedical model. Medical knowledge in this model is generally based on mechanistic causation. Finally, epistemic claims in the biomedical model depend on the logical relationship of propositional statements obtained from empirical laboratory experiments and clinical studies. The trajectory of medical knowledge and practice is from the laboratory to the bedside. There is often little, if any, room in this model for the intuitive or emotional dimensions of either the physician or patient and medical knowledge is therefore generally impersonal.

Although the humanistic or humane models share many epistemological features with the biomedical model, they also rely on a practitioner's emotions and intuitions. Emotions and intuitions are not necessarily impediments to sound medical judgment and practice; but when judiciously utilized and constrained by the epistemic and empirical boundaries of the biomedical model, they enable a physician to access information about a patient's illness that may exceed quantified data, e.g. laboratory test results. This information obtained from a practitioner's use of emotional and intuitional resources is subjective and human. Behind such information is the face of the "Other" (Tauber, 1995). The type of knowledge obtained in this model depends on informational causation, where a patient's psychosocial dimension is an important factor in diagnosing and treating illness. Moreover, the patient is not simply a compliant or passive agent during diagnosis or treatment but can also be an active participant. The patient as an informed cognitive agent is part of the process of humanistic medicine.

In the third part of the book, I explore the axiological and ethical boundaries of the biomedical and humanistic or humane models (Table 1).' The biomedical model stresses the scientific problem-solving aspect of medical practice and is based on a value of objectivity. Diagnosis and treatment of a patient's disease are puzzles that concern the physician-scientist qua mechanic or technician. Diagnosis of the disease depends on a technology that reduces the patient to a set of objective data, from which the physician diagnoses the patient's disease. And from that diagnosis, the physician then chooses the appropriate therapeutic modality, often with little patient consultation. The ethical stance of the physician is a concern to save the patient from the disease and ultimately from death. According to the biomedical model, death is defeat and is generally avoided at all costs. The physician's concern for the patient is detached from the emotions of either the physician or patient. Moreover, the patient's relationship to a physician is passive. The physician is the authority figure with the knowledge and power to save the patient. Thus, the physician's relationship to a patient is one of dominance, as represented by paternalism.

Instead of the physician being rationally concerned in an emotionally detached manner for the patient's diseased body part, the humanistic or humane practitioner cares both rationally and emotionally for the health of the patient qua person. The underlying value of this type of medical practice is empathy, which shapes a physician's stance. Through this stance, the physician may become aware of the "eidetic" features of a patient's illness, including losses of wholeness, certainty, control, freedom to act, and the familiar world (Toombs, 1993). The physician is no longer the locus of supreme authority and power in curing a patient but a firstamong-equals, a co-participant with a patient and other healthcare providers. In other words, the patient is an autonomous person who deserves respect for helping to make the choice as how to proceed therapeutically. Moreover, the physician recognizes that a patient's mind/body often cures itself and that often the role of both the physician and patient is to assist in that process and not to hinder it. The patient-physician relationship is one of mutual respect, for the role and contribution of each other in the healing process. Finally, death is not necessarily a defeat according to this model but another or possibly final stage in the patient's life.

In a concluding chapter, I examine the nature of medicine by addressing the question, "What is medicine?"-certainly the chief question for any philosophy of medicine. The answer to this question is examined first in terms of the historical debate over the art and the science of medicine, followed by the contemporary debate between evidence-based and patient-centered medicine. In a final section, I explore the nature of medicine in terms of the biomedical model, which focuses on the logos of medicine that in turn drives its ethos, and of the humanistic or humane models, which focus on the ethos of medicine that in turn drives their logos. My proposal is that modern medicine must undergo a revolution not in terms of its logos or ethos but in terms of its pathos. Specifically, pathos can transform the logos of technique and information into wisdom, a wisdom that can discern the best and appropriate way of being and acting for both the patient and the physician. Pathos can also transform the ethos of the biomedical physician's emotionally detached concern or the humane physician's empathic care into a compassionate love that is both tender and unrestricted. This love is not a mawkish sentimentality but a vigorous passion that enters the suffering of illness. Only a wise and loving stance will relieve American medicine of its quality-of-care crisis.

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