An Introductory Philosophy of Medicine

Chapter 1. Medical Worldviews

A worldview or eine Weltanschauung, originally coined by Immanuel Kant (1724-1804) in the Critique of the Power of Judgment (2000), is a notion composed of beliefs that allow us to make sense of the world and to act in it.'Although Kant used the term to account for the sense perception of the world, it has since then taken on a more expansive meaning. For example, the German philosopher, Wilhelm Dilthey (1833-1911), defined a worldview in terms of what is known about the world and how that knowledge is judged and responded to.' Many contemporary definitions emphasize some facet of Dilthey's definition. The most common definition takes a worldview to be an all-encompassing philosophy of life, composed of a personal or a social ideology. For example, Ninian Smart (2000) uses the notion of worldview to examine traditional beliefs and feelings associated with various world religions. Although he avoids defining the term, he does discuss parameters essential to a worldview, such as the mythical, emotional, and ethical.

Philosophers of science have also proposed definitions of a worldview. For example, Michael Polanyi (1891-1976), in contradistinction to logical positivism, claimed that "all knowledge is shaped and guided by gestaltlike frameworks and is both tacit and personal" (Naugle, 2002, p. 187). Richard Dewitt provides a rather general definition of worldview: "a system of beliefs that are interconnected" (2004, p. 3). He then illustrates it with an example of the Aristotelian worldview that is made of interconnecting beliefs, such that the earth is located at the center of the universe and is stationary. Other examples of scientific worldviews include the Newtonian worldview in which the world is viewed as a giant machine or the Darwinian worldview in which the biological world is viewed as evolving entities. Thus, scientific worldviews are defined by their fundamental beliefs and commitments to how the world is and how to investigate its nature.

The philosopher of physics, Abner Shimony, has proposed another definition of worldview that is more precise from a metaphysical perspective: a worldview represents "a set of attitudes on a wide range of fundamental matters" (1993, p. 62). Attitude refers to a stance or position taken toward the world, especially in terms of a mental attitude and the assumptions associated with the world's ontological nature. For a scientific worldview, a set of attitudes includes the various stances or positions and assumptions or presuppositions that are important for formulating scientific theories, laws, and hypotheses to account for the ontological entities that compose the natural world. As such, then, worldview is a metaphysical notion and is analyzed herein in terms of metaphysical positions and presuppositions, as well as ontological commitments.

Modern medicine is certainly part of a larger worldview that constitutes western culture. In this chapter, the metaphysical positions, along with the metaphysical presuppositions and ontological commitments, which ground the biomedical and humanistic or humane models, are discussed, before examining the other metaphysical issues concerning these models. The metaphysical positions or stances that a physician may take towards a patient and other medical entities include monism, dualism, or holism. Associated with these positions or stances are the metaphysical presuppositions of reductionism and emergentism, as well as the ontological commitments of physicalism or materialism and organicism (Table 1.1). I begin with metaphysics, analyzing the positions, presuppositions and commitments upon which medical knowledge and practice are founded; for they influence and constrain the ontological entities-such as bodies, persons, and drugs-and the metaphysical concepts-such as causation, disease, and health-that compose medical worldviews.

1.1 Metaphysical Positions

A metaphysical position is an important component for constructing worldviews, since it defines the fundamental attitude or stance towards the world's constitution. In this section, the metaphysical positions of mechanistic monism that constitutes the biomedical worldview and of dualism/holism that compose humane models are discussed and analyzed.

1.1.1 Mechanistic Monism

The metaphysical position of the biomedical model is mechanistic monism. By monism is meant the notion or principle that there is one ultimate substance that constitutes the world (Pojman, 1998). For the biomedical model, this ultimate substance is matter and its attendant manifestation of energy and the forces that interact among and on material entities. Monism, in terms of what constitutes the world, must be distinguished from dualism, which holds that there are two ultimate substances, and from pluralism, which holds that there are three or more ultimate substances.

The monistic metaphysical position of the biomedical model in terms of its ontology is physicalism or, the older manifestation, materialism.' Physicalism or materialism, however, is but one type of monism. There is the traditional antithesis to materialism or physicalism, idealism, which holds that mind or spirit is the ultimate substance of the world (Pojman, 1998). Moreover, there is neutral monism, a position held by David Hume (1711-1776), Baruch Spinoza (1632-1677), and recently William James (1842-1910), in which the ultimate substance is neither matter nor mind but a third common substance (Pojman, 1998).

Besides the material or physical dimension to the biomedical model's monism, there is also its mechanistic dimension. The notion of mechanism refers to the parts and the relationship among them that go to make up an entity or a process. For many biomedical scientists and practitioners, a mechanism is the means by which to account for a natural entity or phenomenon. "A mechanism," according to Paul Thagard, "is a system of parts that operate or interact like those of a machine, transmitting forces, motion, and energy to one another" (1999, p. 106).

Peter Machamer, Lindley Darden, and Carl Craver provide a more specific definition: "Mechanisms are entities and activities organized such that they are productive of regular changes from start or set-up to finish or terminal conditions" (2000, p. 3). And, they offer the following illustration for a mechanism: A->B->C, in which the letters represent entities and the arrows represent activities that provide the continuity in change or process of the mechanism from start to finish. Based on this notion of mechanism, then, mechanistic monism of the biomedical model is a metaphysical position in which the patient is a collection of parts and specific functions are a result of a combination of these parts, much like a machine.

1.1.2 Dualism/Holism

Most proponents of humanistic or humane models of medicine recognize and appreciate the value of the biomedical model's mechanistic monism, especially in terms of the technical advances for medical knowledge and practice; however, this position is strongly tempered and, in some cases even rejected, by humane practitioners. Often they temper the mechanistic monism of the biomedical model, in which the mind is equated with the brain, by including the patient's psychological and social dimensions as separate, non-reducible, etiological factors in the diagnosis of an illness and as therapeutic factors in the patient's treatment and recovery. For example, George Engel argued that although the biochemistry behind a disease like diabetes is important in terms of treating the patient, the patient's experience of the symptoms of the illness is also critical: "how [the symptoms of diabetes] are experienced and how they are reported by any one individual, and how they effect him, all require consideration of psychological, social, and cultural factors" (1977, p. 132). By incorporating the psychological, the social, and the cultural dimensions of the patient, humanistic or humane models of medicine are grounded in dualism.

As noted above, dualism is the metaphysical position that there are two separate entities that compose reality (Pojman, 1998). Generally, these two entities are the body and the mind. For the more traditional position, which is attributed to Rene Descartes (1596-1650), the mind is a non-physical or thinking substance (res cogitans) while the body is a physical substance extended in space (res extensa). Whereas physical entities are extended in space and since the mind is not, then, concluded Descartes, it cannot be a physical entity. Although neither of these entities can be reduced to the other, they can interact with one another.' For example, the mind can give rise through an act of the will to bodily actions while the body can influence mental states through sensory perceptions. This type of dualism is traditionally called dualistic or Cartesian interactionism.

The body and mind can influence the behavior and the state of each other, i.e. their interactions are reciprocal. Importantly for many humane practitioners, the body and mind 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 but may also include the psychological and the informational. For example, Laurence Foss (2002) introduced a "new" dualism-"an information/ matter-energy dualism"-to ground a more compassionate "mindbody" medicine. By exploring the consequences of the conjunction of the body, mind, and information, he redefined the sociobiological idea of memes ("the carriers of our sociocultural inheritance") as "self-replicating, psychological information units" (Foss, 2002, p. 142). These memes form the basis of a new dualism in which metabolic processes are linked to the patient's cognitive and emotional states.

For most humanistic or humane medical models, the entities that comprise the dualistic position not only include the body and the mind but also the patient's environmental and social or cultural context. Robbie Davis-Floyd and Gloria St. John, for example, distinguish the basic principle of humanistic medicine in terms of connection, not only with respect to the mind-body connection, but also in terms of an expansive notion of dualism: "the connection of the patient to the multiple aspects of herself, her family, her society, and her health care practitioners" (1998, pp. 82-83). Although the metaphysic of humane medicine is generally dualism, the connection between the physical body and the mind can be material or it can be mental or psychological.

Irene Switankowsky (2000) identified four advantages of dualistic interactionism for the practice of medicine. The first is that the physician treats the patient as a whole person rather than simply as a diseased body part. The illness often affects more than simply some part of the patient's body but also other dimensions of the patient, especially in terms of existential concerns. This leads to another advantage of dualistic interactionism, which is the concern the physician exhibits for the "lived-experience" of the patient's illness. This "lived-experience" includes not only the physical disruption of illness but also the psychological and social disruption. According to Switankowsky, "the patient's body and self is an intrinsic aspect of the illness, and the treatment of the illness cannot be successful without treating both the body and the self' (2000, p. 575).

The third advantage pertains to the inclusion of both the objective and subjective dimensions of illness. Not only must a physician determine the objective evidence, including laboratory tests and accurate medical history, but also the subjective information on what the illness means to the patient. Without such information a physician may fail to communicate effectively with the patient, especially in terms of the patient's existential concerns. Finally, dualistic interactionism allows a physician to include the full range of the patient's narrative into both the diagnosis and treatment of the illness. "By attending to the dualistic aspects of illness," concludes Switankowsky, "the physician can understand the patient's illness which is an essential part of the humanistic approach to illness" (2000, p. 577).

There are several other types of dualism, besides interactionism, including epiphenomenalism, parallelism, and double or dual aspect, to which a humanistic or humane practitioner may or may not subscribe (Pojman, 1998). In epiphenomenalism, the body affects the mind but the mind does not affect the body. In other words, mental events are a residue of bodily processes but are not reducible to them. In parallelism, the mind and body are two comparable, non-reducible realities or entities that do not interact. Rather, they are two independent causal chains that operate next to or concurrently with respect to each other in a "pre-established harmony" Finally, there is the double or dual aspect theory in which body and mind are not two separate entities per se but two separate, non-reducible attributes or properties of the same reality or entity.

To some extent, Cassell (2004), for example, holds to the double aspect theory of dualism. Although he rejects the more classical dualistic interactionist position, in which the body and mind constitute a human person, he argues that a person is a combination or an integration of both the body and the mind. A person, then, is the single entity that exhibits the attributes of both body and mind. In this sense, he is closer to a dualistic position than the biomedical model's monistic position. However, Cassell also rejects the reductionist monistic position. These two attributes are so well integrated in the person-through the reciprocal flow of meaning between the mind and body-that they are not reducible to each other. There is a real sense in which his position is also holistic.

Holism is the metaphysical position that "the properties and behavior of `whole' systems or objects (cells, persons, societies, etc.) cannot be reduced to, or explained fully by reference to, the properties and behavior of their parts" (Woodhouse, 2000, p. 155) s In other words, the whole in terms of its properties cannot be reduced to the properties of its parts; rather, those properties emerge from the structure or configuration of the whole. Thus, the behavior of an organic being cannot be reduced to its inorganic elements but emerges from the unique structure of the organic being. For many humanistic models, then, medical entities such as patients and diseases are not reduced simply to their component parts alone. Rather, such entities are wholes that are embedded within a particular biological or social environment. Ontological holism then, in which entities are composed of parts that do not determine the properties of the whole entity, is an important metaphysical stance for many humane practitioners.'

1.2 Metaphysical Presuppositions

Metaphysics is also concerned with first principles or the basic presuppositions upon which an epistemic community investigates and ultimately understands or explains the world or reality. Such presuppositions play an important part in a natural science worldview. According to R.G. Collingwood (1889-1943), in Essay on Metaphysics (1998), the chief task of metaphysicians is to untangle the knot of presuppositions underpinning the natural sciences, in contrast to the logical positivists who denied a role for metaphysics in the generation of scientific knowledge.' That task involves the identification and explication of the presuppositions made by scientists to raise questions about the world. To that end, Collingwood divides presuppositions into relative and absolute.

Relative presuppositions act as both background assumptions for asking a question under one set of conditions and for answering a question under another set, whereas absolute presuppositions are always background assumptions for asking questions and never for answering them.' For example, a physician may presuppose a particular disease is associated with a patient's chief complaint and ask questions accordingly. This presupposition is relative since it is used to ask questions but abandoned if the diagnosis does not substantiate it. An absolute presupposition, such that the disease is reducible to a particular mechanistic causation, is not abandoned but rather frames the diagnostic process. Importantly the logical efficacy of these presuppositions, i.e. their ability to prompt questions about the world, is independent of their truth-value; rather, this efficacy depends upon their being supposed. Thus, absolute presuppositions are required for framing questions about the natural world and are thereby critical for an analysis of the natural sciences.

There are a number of important absolute presuppositions that ground the activity of practitioners in the biomedical sciences. These include reductionism, determinism, and emergentism, to name but a few. Although these presuppositions are important for the generation of scientific knowledge, they are neither unproblematic nor universally accepted by all biomedical scientists. For example, the reductionistic assumption for the prevalent theory of cancer, the somatic mutation theory, is currently challenged by proponents of another theory based on emergenistic assumptions.' Consequently, there is no single set of background assumptions to which biomedical scientists assent; rather, there is a wide range of assumptions and combinations of them utilized by these scientists to generate scientific knowledge.

However, there is one background assumption that almost all practitioners in the biomedical sciences agree upon and that is naturalism. Although defining naturalism is a daunting task, for present purposes the presupposition may be taken to assert that natural phenomena are the products of natural events and forces and that human reason can comprehend these events and forces. In other words, there is no need to posit forces outside the natural realm to explain natural phenomena. Naturalism, as well as other presuppositions, is often divided into two types that are relevant for the present discussion: methodological and theoretical (de Vries, 1986).

Methodological naturalism presupposes that biomedical scientists investigate only natural phenomena and formulate physical or mechanistic explanations for those phenomena. As such, this presupposition provides a limit for developing an experimental strategy or heuristics to guide research in the biomedical sciences." Since the naturalistic posture or attitude of biomedical scientists is confined only to investigation of the natural world the presupposition is impotent for raising questions about phenomena that outstrip the physical world, such as religious experience. Whether God intervenes in natural processes is an issue that simply cannot be addressed by supposing methodological naturalism."

Theoretical naturalism, on the other hand, is the presupposition that natural phenomena are all there is. As Francis Crick puts it rather crudely: "You, your joys and your sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behavior of a vast assembly of nerve cells and their associated molecules" (1994, p. 3). Underlying this statement is a belief that one's personal identity is the result of natural factors only.'' As such, theoretical naturalism denies the existence of anything that is not natural. And it goes well beyond the limit presupposed in terms of methodological naturalism, by making empirically unwarranted metaphysical claims about the nature of reality. However, it must also be noted that the theoretical presupposition of supernaturalism also makes empirically unwarranted metaphysical claims about the nature of reality.

1.2.1 Reductionism

As noted above, the chief absolute presupposition of the biomedical model is reductionism, which is intimately associated with an ontological commitment to physicalism or materialism. "Traditionally," according to Geoffrey Hellman and Frank Thompson, "physicalism has taken on the form of reductionism-roughly, that all scientific terms can be given explicit definitions in physical terms" (1975, p. 55l).' In this context, reductionism refers to the reduction of non-physical disciplinary terms and theories to the terms and theories of the physical sciences. Theoretical reductionism then involves the reduction of terms from different theories to the terms of a single or more basic theory (Marcum and Verschuuren, 1986). However, it is often not a straightforward process in that all the terms of the theory to be reduced are not reducible to physical terms of the reducing theory.

But reductionism also has different forms. For example, John Dupre defines it as "some range of phenomena [that] can be fully assimilated to some other, apparently distinct range of phenomena" (2000, p. 402). This is an ontological reductionism by which higher order phenomena are determined by lower order phenomena. "Ontological reductionism," claim James Marcum and Geert Verschuuren, "results in a simplification of processes by denying new properties for higher level phenomena" (1986, p. 125). Finally, there is a third form of reductionismmethodological. Whereas theoretical reductionism simplifies theories and ontological reductionism simplifies the phenomena, methodological reductionism simplifies research through dissecting higher order phenomena into their constitutive components at the lower order (Marcum and Verschuuren, 1986). For example, the investigation of intermediate metabolic pathways is conducted in terms of their separate molecular components. After such investigation, the individual components are connected to generate the various pathways.

Another important presupposition of the biomedical model, and one that is often associated with reductionism and so deserves brief consideration, is determinism (Pojman, 1998). According to the notion of determinism, an event or action is shaped or determined by its antecedent events or conditions. If those preceding events or conditions are known, then the consequent event or effect is known prior to its occurrence. In a scientific version of determinism, the initial conditions along with a governing law are sufficient to predict or determine a subsequent event or effect with precision. Determinists deny the operation of chance within the unfolding of events and effects in the world. For them, there is only one possible world as determined by a natural order. This notion is in contrast to a contingent worldview in which things could have been different, given other preceding events or conditions that could not have been predetermined. This is best illustrated by the free will problem. For determinists free will is an illusion. However, if this is so then how can people be held morally responsible for their actions? This presents a conundrum for the determinists, which is not so easily answered.

1.2.2 Emergentism

The main absolute presupposition of most humanistic or humane models is emergentism. The notion of emergentism refers to the appearance of a higher order property from lower order properties (Clayton, 2004). In contrast to reductionism, the higher order property is not reducible to or deducible from the lower order properties. In other words, a higher order property of a complex entity (E,) is emergent if it is conceivable for a different complex entity (E2) to lack the emergent property even though E, is composed of the same parts as E, and even though those parts resemble the same structure as El. For exmaple, E, and E2 may exhibit different behavioral patterns to a similar environmental cue.

Beginning in the mid nineteenth century, the British emergentists developed the contemporary notion of emergentism (McLaughlin, 1992). "According to British Emergentism," claims Brian McLaughlin, "there is a hierarchy of levels of organizational complexity of material particles that includes, in ascending order, the strictly physical, the chemical, the biological, and the psychological level" (1992, p. 50). Each level contains material substances specific to that level, and these substances exhibit the unique, emergent properties associated with a given level. For example, properties like digestion and reproduction emerge from the special structure of biological organisms. John Stuart Mill (1806-1873) was one of the first British emergentists, who developed the notion in his System of Logic (1875). According to Mill, the emergent property of an entity, especially a living entity, is not the result of simply summing up the properties of its parts.14

The notion of emergentism, as an alternative position, was also central to the mechanist-vitalist debate of the late nineteenth and early twentieth centuries (McLaughlin, 1992).15 For example, C.D. Broad (1887-1971), in The Mind and Its Place in Nature (1925), used the notion to address the debate. The issue was whether "vital behaviour" is essentially different from "non-vital behaviour." To resolve the debate, Broad postulated emergent or "trans-ordinal" laws in distinction from mechanistic or "intra-ordinal" laws. Emergent laws are irreducible, non-causal laws that account for higher order properties vis-n-vis lower order properties. These laws provide the same heuritic advantages as mechanistic laws. The only perculiarity is their unpredictability in terms of their discovery, i.e. even with exhaustive knowledge of lower order properties, emergent laws cannot be predicted."

From a historical development of the notion of emergentism, Achim Stephan (1999) proposed strong and weak forms of the notion.17 There are two strong forms that depend on the theses of irreducibility and of unpredictability. The first strong form, based on irreducibility, is synchronic emergentism. By irreducibility, Stephan claims, in agreement with Broad, that the systemic or emergent property "cannot be deduced from the arrangement of its system's parts and the properties they have `isolated' or in other (more simple) systems" (1999, p. 51). Embedded within this notion are two types of irreducibility. The first is that behavior of the system's components is not deducible from the components in isolation or in a simple arrangement. This type of irreducibility implies downward causation from the system's arrangement onto its parts. The second type involves unanalyzable properties of the system's micro or macro structure. These properties are not causal in any mechanistic sense but rather epiphenomenal in origin.

The second strong form of emergentism is diachronic emergentism, which is predicated upon the thesis of the unpredictability of systemic properties. In this form, systemic or emergent properties "could not have been predicted in principle before their first instantiation" (Stephan, 1999, p. 49). Such properties are considered to be novel. The thesis of novelty involves the emergence of new properties from the different assemblage of parts. The thesis of unpredictability may be the result of variability or indeterminacy in the structure generating the novel property or what Stephan calls the "unpredictability of structure" Structural unpredictability gives rise to novel properties, when their creation is shaped by "laws of deterministic chaos." Another reason for unpredictability is that, even for structures that are predictable, the property is irreducible. Since a novel property is irreducible, it is by definition, unpredictable in terms of its first occurrence.

There is one weak form of emergentism, which depends on the following three theses. The first, which is common to the strong forms, is that emergent properties are systemic properties. "A property is a systemic property if and only if a system possess it," asserts Stephan, "but no part of the system possesses it" (1999, p. 50). Also, in agreement with the irreducible strong forms, the weak form denies a strong sense of reductionism. The next two theses of the weak form, however, are distinct from the strong forms. The thesis of physical monism claims that all systems are composed of material parts, while the thesis of synchronic determination claims that systemic property depends on the system's structure or arrangements of the parts. The weak form then is compatible with property reductionism because certain emergent or systemic properties of the system do depend on the system's structure.

Finally, a controversial issue among proponents of emergentism is the possible interaction between emergent higher order properties and lower order properties, especially in terms of supervenience and causation. Supervenience refers to the relationship between families of properties, in which a family of properties P depends upon another family of properties N and in which P is not reducible to N (Kim, 1984). Given these conditions, P supervenes on N; and, for any two entities that share N they must also share P. The converse does not hold, however, so that for two entities that share P they need not share N. For example, if the psychological properties supervene on neurological properties then the neurological properties vary if the psychological properties do but the psychological properties need not vary if the neurological properties do. Some philosophers hold that there can be interaction between them, with the higher order properties supervening on the lower order properties in a causal manner. Other philosophers claim that the higher order properties supervene on the lower order properties without any direct causal interaction between them.

1.3 Ontological Commitments

A worldview, in terms of metaphysics, is also composed of our deepest ontological commitments about what the world is and what the world contains. Ontology, as it developed in western philosophy, is concerned with what makes up the world in a fundamental way. It provides a general framework by which to categorize the entities that make up the world. Different ontologies have different categories (Pojman, 1998). For example, one ontological system divides the world into the universal and the particular, while another into the abstract and the concrete. Although there is some similarity between the universal and the abstract and between the particular and the concrete, there is none between the universal and the concrete or between the abstract and the particular. Moreover, universals can be subdivided into properties, kinds, and relations, while the concrete can be divided into substances and non-substances.

Ontological commitments refer the nature of the entities, which a worldview presumes to exist in the world. Thus, various worldviews are committed to different ontologies. For example, it is consistent for a worldview that takes a stance of mechanistic monism and that presupposes reductionism to be committed ontologically to physicalism or materialism. Such a worldview could not be easily committed to organicism. On the other hand, it is consistent for a worldview that takes a dualistic or holistic stance and that presupposes emergentism to be committed to organicism. However, such a worldview could be committed to a non-reductive physicalism or materialism. The ontological commitment of the biomedical model is physicalism or its older manifestation of materialism, while humanistic or humane medicine is generally committed ontologically to organicism.

1.3.1 Physicalism/Materialism

Physicalism, as William Seager so succinctly puts it, is "the claim that everything is physical" (2000, p. 340). In other words, the world and everything in it is corporal or physical in nature and there is nothing in it that is not physical. For example, Thomas Nagel defines physicalism as "the thesis that a person, with all his psychological attributes, is nothing over and above his body, with all its physical attributes" (1965, p. 339). Indeed philosophers use physicalism to examine the relationship between the mind and the body, in which mind states are often equated with brain states-known as the identify theory (Pojman, 1998).18 The problem with this notion of physicalism is its naivete, in that experience reveals greater complexity than simply the physical. However, the notion is not as simple as it appears but comes in a variety of forms based on one's assumptions.

A more prevalent definition of physicalism, which avoids the problems associated with its naive form, is in terms of the physical sciences." For example, as Tim Crane and David Mellor note, physicalism is traditionally defined as "all entities and, properties, relations, and facts... which are studied by physics or other physical sciences" (1990, p. 394). Engel also claims that physicalism "assumes that the language of chemistry and physics will ultimately suffice to explain biological phenomena" (1977, p. 130). And for Hellman and Thompson (1975) mathematical physics best exemplifies the most "basic" physical science. By defining physicalism thusly, it is grounded in both rationalism and empiricism that confers a sense of authority to physicalism enjoyed by the natural sciences.

1.3.2 Organicism

Most humane or humanistic models of medical knowledge and practice recognize and appreciate the value of the biomedical model's reductive materialism, especially in terms of the technical advances for medical practice; however, this presupposition is strongly tempered and, in some cases even rejected, in these models. Often humanistic models temper or reject reductionism by including a patient's integrative system as an etiological factor in diagnosis of illness and as a therapeutic factor in recovery. By incorporating a system dimension of the patient, humane models of medicine are grounded by an ontological commitment to organicism.

Organicism is a notion that entails organic unity, especially in terms of the organismal unit. It emphasizes structure or organization in contrast to composition. In this sense, it is not necessarily dependent on physicalism or materialism, since emergent properties need not be reduced to material or physical components. In other words, the emergent property need not be physical or material. Moreover, a reductionistic materialist perceives entities from the bottom up while an emergenistic organicist perceives them from the top down 2°

Importantly, the rejection of physicalism or materialism does not mean that organicists embrace vitalism, especially the variety that envisions an elan vital or an entelechy as an emergent property. The nature of life, in non-reduced organicist terms, is not simply the summation of its material or vitalist components. Rather, it reflects the assemblage of its parts as a whole, especially with respect to its informational content (Foss, 2002). Consequently, properties emerge that cannot be derived or deduced from examining the individual parts in isolation; rather, only when the whole is examined can the emergent properties be explained.

Organicism, then, differs from reductionistic materialism and vitalism in terms of focusing on the inter-relationships of parts as a complex matrix, rather than a simple combination or collection of parts. No additional element is necessary to account for the whole as required for vitalist positions and the whole cannot be explained in terms of a simple analysis of the component parts in isolation, as sufficient for reductionistic materialism.

1.4 Summary

The worldviews in which the biomedical and humanistic models are situated exhibit very different metaphysical boundaries in terms of their metaphysical positions and presuppositions and ontological commitments (Table 1.1). Whereas the biomedical model is bounded by a metaphysical position of mechanistic monism and a metaphysical presupposition of reductionism, and an ontological commitment to physicalism or materialism, the humane models are bounded by a metaphysical position of dualism or holism and a metaphysical presupposition of emergentism, and an ontological commitment to organicism. Thus, there seems to be a major shift underway in the metaphysical boundaries for contemporary medicine. Part of the impetus for this shift is certainly the quality-of-care crisis. Many physicians, and patients too, realize that the biomedical model succeeds in delivering excellent technical cures for many diseases; but, it fails to deliver the quality of care that addresses the suffering a patient experiences from being ill.

Importantly, shifts in metaphysical positions and presuppositions, as well as in ontological commitments, are not uncommon in the history of the natural sciences. For example, Collingwood documented a shift in presuppositions from the Newtonian mechanistic universe to the Einsteinian relativistic universe. E.A. Burtt (1892-1989), in The Metaphysical Foundations ofModern Physical Science (1932), also mapped the changes in presuppositions from Copernicus and Kepler to Newton to frame physical conceptions of the universe. Bunt's thesis was that contemporary philosophical issues, particularly those associated with the displacement of humans from the physical and metaphysical center of the cosmos, reflect philosophers' uncritical acceptance of the shift from a medieval worldview to a Newtonian or modern scientific worldview. That shift is particularly evident in the metaphysical categories used to frame the modern perception of cosmology; specifically, the modern categories of space, time, and mass replaced the medieval categories of substance, essence, and form. Moreover, modern reality became atoms and their motions, efficient causality, and the identification of mind with the brain. Bunt's demonstration of the importance of metaphysical presuppositions in the development of scientific knowledge ran counter to the then prevalent logical positivist's view that metaphysics is superfluous for the natural sciences.

Finally, Thomas Kuhn (1922-1996) in The Structures of Scientific Revolutions (1996) located shifts in metaphysics to scientific revolutions, as part of the "disciplinary matrix" that makes up scientific practice under a given paradigm; for the community's "collective metaphysics" is an important part of this matrix. As a scientific community makes a transition from an old paradigm to a new one, the community revisits and reevaluates its metaphysical foundations. Debates over those foundations for the reigning and competing paradigms are intense and reflect the incommensurable foundations that under gird the two paradigms. Moreover, the debates also reflect the inability of the empirical data to resolve the competition between two incommensurable paradigms. Although the empirical data are necessary for the eventual resolution of a controversy, they are not sufficient. The metaphysical foundation of the particular worldview must first be in place before a paradigm shift can occur.

Models, according to Kuhn, are also part of the metaphysical component of scientific practice. This dimension includes beliefs, such as in models as heuristic devices for guiding research or as ontological formulae for carving up the world. Models within a metaphysical context also provide the community with permissible metaphors. "By doing so," argued Kuhn, "they help to determine what will be accepted as an explanation and as a puzzle-solution; conversely, they assist in the determination of the roster of unsolved puzzles and in the evaluation of the importance of each" (1996, p. 184).

The question that obviously surfaces is whether the introduction of humanistic or humane medical models vis-a-vis the biomedical model represents a paradigm shift. In other words, are the two models incommensurable? In a sense, the metaphors upon which the biomedical and humanistic models are based are incommensurable. While the biomedical model has a worldview based on a bottom-up approach to the world, the humane models are based on a top-down approach and there appears to be no intersection between them. This lack of apparent intersection is evident from an analysis of the various components that compose the two models, including the notions of the patient, disease, health, etc. However, this analysis also reveals that the lack of intersection is not global but often simply local. For some humanistic proponents, the humane models supervene on the biomedical model.

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