An Introductory Philosophy of Medicine

Chapter 3. Patient as Body or Person

One of the most important components of any medical worldview is the nature of the patient. The patient is and should be the center and focus of a medical worldview, for without the patient there literally is no need for medicine. Consequently, a medical worldview is important for perceiving the patient and that perception in turn shapes other components of a medical worldview, such as the nature of disease and health. The biomedical model envisions the patient as a mechanical body composed of separate parts that interact for functional purposes. Although there is interaction among the parts, it is minimal in nature and limited only to body parts. This view of the patient is, of course, a major reason for the quality-of-care crisis in modern medicine.

Humanistic or humane models, however, envision the patient as an embodied subject in terms of mind and body or mind/body integration, or as a unique person or self. In addition, the patient qua subject, person, or self, is located within a cultural and social environment or lifeworld. This view of the patient, according to humane practitioners, can help to resolve the quality-of-care crisis by taking into consideration the patient as a person rather than simply as a body part. In this chapter, the biomedical and humanistic conceptions of the patient are examined in terms of these differences.

3.1 Patient as Mechanical Body

Descartes is considered the traditional source for the mechanization of the human body. He split the mind from the body, and on the one hand he imparted to the mind a person's identity and vitality while on the other hand he reduced the body to a machine made from inanimate material. For example, Descartes stated in the Treatise on Man: "I suppose the body to be just a statue or a machine made of earth" (1998, p. 99). Drew Leder compares the Cartesian body to a corpse and argues that the Cartesian corpse has had an acute impact upon the practice of modern medicine: "Modern medicine, profoundly Cartesian in spirit, has continued to use the corpse as a methodological tool and regulative ideal" (1990, p. 146).

The acme of the human body's mechanization vis-n-vis medical practice was achieved by physicians motivated by Isaac Newton (1643-1728) and his mechanical philosophy. For example, Archibald Pitcairn (1652-1713)-one of the earliest physicians to appropriate Newton's mechanical philosophy-argued for a "mathematical physick" or medicine: "Physicians ought to propose the method of Astronomers as a pattern for their Imitation" (Brown, 1981, p. 216). After Newton, iatromechanism became the dominant approach to medical practice and increasingly influenced its practice until the present. Today, the standard model for medical knowledge and practice is simply an extension and application of the Newtonian mechanical worldview. For example, the Newtonian mechanical model is extended in terms of genetic and cybernetic bodies.

Based on the Newtonian mechanical worldview, the body is transformed into a scientific object that is reduced to a collection of separate body parts. In other words, it is just a machine with interchangeable components. For the biomedical practitioner the patient is assumed to be a material object or machine, which can be reduced to a collection of physical parts that can then be assembled to form a mechanical system. As Fredrik Svenaeus observes: "The body becomes a hierarchical structure-an organism framed in a special language" (2000, p. 49).

The body qua parts is composed of different anatomical systems, such as the respiratory or cardiovascular systems. These systems are, in turn, composed of various organs, such as lungs and hearts, which are made up of epithelial, muscular, nervous, and glandular tissues. Finally, to complete the hierarchy, these tissues are composed of diverse cellular types that are made up of a variety of molecules. Moreover, it is critical to note that the patient's body is generally stripped of its lived context: for the mechanized, scientific body is an abstract, universal object that obeys or is subject only to the physical and chemical laws of the natural sciences.

An important component in the development of the biomechanical model's view of the body is the rise of medical technology. Modern medical technology provides important objective and quantitative data concerning the patient's disease state. According to Ian McWhinney, "a constant theme [of medical technology] is the tendency for medicine to be dominated by the mechanistic values of objectivity, precision, and standardization" (1978, p. 299). This tendency fosters mechanization of the patient's body on two accounts. First, it provides the artificial parts and pieces that replace or substitute for the macro (organs) or micro (molecules) parts of the patient's body. Second, it provides a cadre of machines to which the patient's body is connected, forming body-machine hybrids. Technology, then, contributes significantly to the development of a medical machine-world-a world that physicians utilize to diagnose a diseased body part and to mend or replace it through pharmaceutical drugs or surgical procedures (Marcum, 2004b).

The medical machine-world in which the patient's body is located has developed tremendously over the last half of the twentieth century, from the stethoscope and microscope of an earlier era to today's heart-lung or dialysis machine and computerized or positron emission tomography (Jennett, 1986; Reiser, 1984). This machine-world approach also assisted the development of a number ofpharmaceutical drugs, such as insulin, heparin, and various antibiotics, for treating disease. Certainly, these technological advances are responsible for many of the "miracles"like open heart surgery and the management of childhood leukemia-in modern medicine. Moreover, advocates of the machine-world approach also used the approach to redefine the patient's body as mechanical.

The result of this mechanization is fourfold, with respect to the patient's body. The first is the fragmented body-the division of the body into individual, isolated parts. The next result is the standardized body, which is a generic body to which the patient's body qua clinical data is compared. The physician's task is to shape or reshape the patient's body to conform to the standard body deemed appropriate by the medical community. Often that body is the male body and only recently is a female standard body utilized for women. The third result is the transparent body. Medical technology, particularly imagining technology, allows physicians to peer into the inner reaches of the patient's body. However, the transparent body is not unproblematic: "Imaging technologies claim to make the body transparent, yet their ubiquitous use renders the interior body more technologically complex" (van Dijck, 2005, pp. 3-4). Imaging technologies often raise ethical dilemmas for both the patient and physician.

The final result of mechanization, and the most bothersome for the patient, is the estranged body-the alienation of the patient's body from the self and lived context and from other people. The patient no longer controls the body; rather, the medical profession takes ownership of the sick body or body part in an attempt to cure it. The patient or the patient's body becomes colonized by physicians: "When a person becomes a patient, physicians take over her body, and their understanding of the body separates it from the rest of life" (Frank, 2002, p. 52). Besides the colonization in which the physician assumes "center stage," the patient is also disembodied: "the person within my body was sent out into the audience to watch passively" (Frank, 2002, p. 53). The end result of colonization and disembodiment is loss of the patient's self and lived context.

The impact of the biomechanical model of the body for medical knowledge and practice is all too familiar. The patient's body qua machine is separated from the patient's self and lived context. The chief value of the biomedical model is the principle of separation, which "states that things are better understood outside their context, that is, divorced from related objects and persons" (Davis-Floyd and St. John, 1998, p. 17).

The aim of scientific medicine vis-a-vis the patient's objectified and mechanized body is to fix or replace the broken or missing part, generally without reference to the patient's lived context-for patients' bodies are nearly or basically the same. By splitting the body into a collection of parts, the patient as a person vanishes before the physician's gaze: "to view the human being as an assemblage of bodily parts and processes is to deprive the patient qua patient of every moral as well as every social dimension" (Maclntyre, 1979, p. 90).

The biomedical machine world is an abstract, scientific world made up of technological devices. Through fragmentation, standardization, transparency, and estrangement, the patient's body recedes into the background of this machine-world. Patients as body parts become cogs in a medical machine-world-a world of interconnected machines in which the patient's body is but another anonymous and exchangeable device. For example, a kidney dialysis machine is used to treat multiple patients under similar conditions; for patients are exchangeable mechanical devices within this machine-world.

Since the patient as assembled body parts is just one more mechanical device in the medical machine-world, the patient becomes disembodied or invisible-for the patient's body recedes into the background of this machine-world. For example, physicians often trust the outputs of machines used to monitor a patient rather than the patient's account of the illness experience.' Rather than being an embodied person, the patient often becomes a collection of test results derived from the employment of medical technology.

The biomechanical model of the body is developing towards two hybrid forms of the human body: the genetic body and the cyborg body. As mentioned above, the patient's body is not only reduced to individual macro parts (organs) but also to micro parts (molecules). Of course the most important molecule, which has achieved iconic stature in western society, is the macromolecule responsible for the transfer of genetic information-DNA. The analysis of DNA and of the genes it composes has ushered in a new era of medicine, genomic medicine, especially in terms of the human genome project (Guttmacher and Collins, 2002). Since diseases are now genetic, treatment will consist of fixing or replacing defective genes. For example, medical scientists can now introduce foreign genes into the body to treat diseases, such as in gene therapy, thereby producing bodies that are genetic hybrids (Marcum, 2005b).

Besides the genetic hybrid body, there is also the hybrid that is part machine and part human-the cyborg. For example, a silicon chip transponder was implanted into Kevin Warwick's arm on 24 August 1998 (Warwick, 2000). The chip allowed him to be connected to a computer, which was able to identify his position as he traveled through out the Department of Cybernetics at the University of Reading, U.K., and which then opened doors and turned on lights for him as he moved about the department. According to Donna Haraway, people are already cyborgs: "By the late twentieth century, our time, a mythic time, we are all chimeras, theorized and fabricated hybrids of machine and organism; in short, we are cyborgs" (1991, p. 150). We have become cyborgs in the sense that the line between human and machine is indistinct and blurred, especially in terms of medicine: "Modern medicine is also full of cyborgs, of couplings between organism and machine, each conceived as coded devices" (Haraway, 1991, p. 150). Both the cyborg and genetic hybrids represent important means by which to enhance the capabilities of the human body.

3.2 Patient as Person

In humanistic or humane models of medicine the patient is viewed as an organism, composed generally of two separate parts: one physical and the other psychological or mental. The patient as organism is differentiated both as constituting body and mind and also as embedded within an environment. Moreover, the organism is more than simply the sum of its parts but has features that emerge from the organization of those parts. Instead of reducing the patient to the physical body alone, the humanistic practitioner encounters the patient as an organism composed of both body and mind within an environmental context: "the embodying organism is a complex whole-an entire series of differently interrelated sets of members, structures, and patterns of interfunctioning, evincing multiple and multiply connected contextures" (Zaner, 1981, p. 45).

Rather than being just a machine composed of individual parts separate from any background or framework, the patient is an organism within a socioeconomic environment; and as an organism the patient exhibits properties that surpass the aggregation of those parts. For other humane practitioners, the patient is more than an organism and its environment, which are still reducible scientific objects. Rather, the patient is an embodied subject, a person, or a self. In this section, the phenomenologist's notion of embodied subject, Eric Cassell's notion of personhood, and Alfred Tauber's notion of selfhood are explored to provide a richer concept of patient than simply the biomedical model's mechanical object.

3.2.1 Phenomenology's Notion of Embodied Subject

For those humanistic or humane practitioners utilizing phenomenological insights, the patient is a subject who occupies a lived context or, in Husserlian terms, a lifeworld.' In other words, the patient is physically embodied, for the phenomenologist, as a subject in a unique lifeworld. "The lifeworld," according to Michael Schwartz and Osborne Wiggins, "is the sphere of prescientific activity... the realm of everyday social interaction and practical projects ... The human being who inhabits and acts in the life-world is the embodied subject" (1985, p. 341). This world is not the physical universe that science depicts; rather, it is the world of the everyday that is made up by our personal activities and projects. It is the world that is lived bodily, through which we impart meaning to our lives. The patient is embodied concretely in the here and now (phenomenological space and time) and not abstractly in a universal world that occupies no specific place and occurs at no particular time (physical space and time).

During the twentieth century, phenomenologists, such as Edmund Husserl (1859-1938), Martin Heidegger (1889-1976), Jean-Paul Sartre (1905-1980), and Maurice Merleau-Ponty (1908-1961), among others, radicalized life's everyday experiences by making them explicit and by so doing explicated the meaning of such experiences through an analysis of their intentional structure. According to Husserl, western science was facing a major crisis: positivist natural science fails to answer or even to address fundamental questions about human nature and existence. He argued that we must return to the "things themselves"-to concrete phenomena-instead of turning towards their scientific and theoretical abstractions, in order to uncover their meaning. For what makes possible such abstractions is the concrete world in which we daily live. This everyday world or lifeworld is the ground or foundation upon which the meaning of human existence rests. According to Richard Baron, "phenomenologists seek to reunite science with life and to explore the relationship between the abstract world of the sciences and the concrete world of human experience" (1985, p. 608).

Modern medicine is also facing a crisis similar to that faced earlier by science. However, for medicine the crisis revolves around the separation between the patient's concrete world of illness and the physician's abstract world of disease. Modern medicine's crisis is one of quality-of-care; for the clinician's gaze, listening, or touch is generally towards the patient's diseased body and only derivatively towards the patient's suffering. Since the current quality-of-care crisis is largely due to the biomechanical model of the body it can only be addressed by resituating the patient within the context of an everyday lifeworld, instead of thrusting just the body into an artificial machine-world. Again to quote Baron: "If we can adopt a phenomenological perspective, we can try to enter the world of illness as lived by patients rather than confining ourselves to the world of disease as described by physicians" (1985, p. 609).

As embodied subjects or lived bodies, patients create individual, unique lifeworlds. The body is personalized in a lived context or environment; for the subject is not composed of separate Cartesian body parts but is an integrated bodily unit that is situated in a specific location and time. Patients, as embodied subjects, "have bodies to the degree to which they appropriate the physical conditions of their individuality and become integrated (and not merely unified) psychological beings" (Deutsch, 1993, p. 5). At the pre-reflective level, the embodied subject "ex-ists" the body: "I am `embodied' in the sense... that I am my body" (Toombs, 1993, p. 52). In other words, the body is the medium in which a subject carries out daily tasks and activities intentionally and through which a subject comes to know the body not through abstracting it but through living it.

The body, then, is not some thing that a subject possesses as an object; rather, it is a lived, integrated unity that is not readily divisible into a body on the one hand and a mind on the other. At the reflective level, the body may be grasped as an object distinct from the self; but it is still an object within a lifeworld. It need not be simply an object of scientific investigation, i.e. as a theoretical or an abstract thing. In other words, the body is not experienced as molecules, cells, tissues, etc.; rather, it is experienced as an integrated unity through which a subject "in-habits" a lifeworld 3

The phenomenological model of the body has developed in two directions visa-vis modem medical practice. The first is towards transformation of the mechanized body-whether in its molecular or cyborg manifestations-into an integrated body. Embodiment is stretched to include and integrate the artificial enhancements of, or additions to, the body. As the mechanical body becomes more artificial, e.g. computer chips or foreign genes, the integrated body strives to incorporate modifications of and additions to the body into a unique lifeworld. Patients must reclaim their identity as embodied, not abstracted, subjects and as integrated bodily units embedded in unique lifeworlds.

The second development is the transformation of the empirical text body-as represented by the texts obtained from the medical history and examination-into a lived body. Besides reducing the patient to a mechanized body, scientific medicine also reduces the patient to an empirical text body that often replaces the physical presence of the patient (Daniel, 1986). For example, the medical history represents the patient as an empirical text in which the physician gathers data by asking questions of the patient, who then answers them with little extraneous input concerning the illness experience. The medical examination also represents the patient as an empirical text, i.e. as a set of numbers obtained from laboratory tests or as a set of written descriptive phrases obtained from the physician's prodding and poking the patient's body.' "If the body is a meaningful phenomenon... this is so because," argues Svenaeus, "it is lived, an aspect of our being-in-the-world, and not because it is written" (2000, p. 139).

In contrast to the story of territory-and the reduced, mechanized body it assumes-the approach to the patient's body should be one of wonder (Frank, 2002). "Wondering at the body," according to Frank, "means trusting it and acknowledging its control" (2002, p. 59). Wonderment is not meant to replace therapy, but rather to reorient the relationship between the two: "wonder is an attitude in which treatment can best proceed" (Frank, 2002, p. 59). Through this wonderment at the body, the patient regains the self: "Illness taught me that beyond anything I can do, the body simply is. In the wisdom of my body's being I find myself, over and over again" (Frank, 2002, p. 63). Wonderment at the body, then, allows a patient to apprehend that he or she is an embodied subject, who brings meaning to his or her lifeworld- whether in health or in illness. To reduce the body at any time to body parts, is to lose the integrity of lived experience as an embodied subject.

3.2.2 Cassell's Notion of Person

"Unlike other objects of science," argues Cassell, "persons cannot be reduced to their parts in order to better understand them" (1991, p. 37). According to him, "what is lacking in twentieth-century medicine is an adequate consideration of the place of the person of the patient" (Cassell, 1991, p. viii). The reason for this lack is that contemporary medicine focuses on the disease and not the sick person and subscribes to the myth that different persons who have the same disease basically have the same illness or sickness. But different persons who have the same illness can have vastly different illness experiences. "The job of the twenty-first century," claims Cassell, "is the discovery of the person-finding the sources of illness and suffering within the person, and with that knowledge developing methods for their relief, while at the same time revealing the power within the person as the nineteenth and twentieth centuries revealed the power of the body" (1991, p. x). To that end he proposes a different notion of what constitutes the nature of the person, especially as it relates to understanding the patient.

Cassell rejects traditional substance or interactionist dualism, as well as reductive monism. The question of how the mind affects the body is the wrong question, "because it presumes that there is a thing called the mind which is separate from the body, that the body is passive to the mind, and that the mind's essential nature is that it can cause changes" (Cassell, 2004, pp. 221-222). Cassell begins with different presumptions: (1) the person is a single entity and (2) distinctions among mind, body, and environmental context are artificial. What connects these artificial distinctions for Cassell is meaning: "meaning is the medium through which thought flows into body and the body flows into thought" (2004, p. 223).

Specifically, meaning is mediated through emotions and feelings. In other words, people attach various meanings to their life experiences though their emotions and feelings. Importantly, "the emotions or the meanings of which the emotions are a part do not cause the physical phenomena; the physiological responses are part of the emotion and the meaning" (Cassell, 2004, p. 236). Meanings, and the values upon which they depend, are important for understanding a patient's illness and the suffering associated with it.

What is a person? Cassell initially treats the question as two separate questions, one concerning the particularity of the person qua person and the other in terms of the measure of a person. Importantly, the initial discussion is embedded in terms of the nature of suffering, especially with respect to the illness experience. Although Cassell discusses over a dozen features that constitute the notion of person in the initial description, they can be grouped together into two categories: the first is composed of those features that pertain to the person as an individual, the second of those features of the person within a social context.

The features that make up Cassell's first category of person in terms of his or her individuality include an individual's body, personality or character, regular behaviors, activities, public and secret life, past, future, and transcendent dimension. Each of these features has an important impact on how a person responds to illness, especially in terms of suffering, or may be destroyed by an illness. For example, people vary greatly in their response to illness based on their personality or character traits. Also, a person's past is particularly important in providing a context for the experience of illness: "Life experiences-previous illness, experiences with doctors, hospitals, medications, deformities and disabilities, pleasures and successes, or miseries and failures-form the background for illness" (Cassell, 1991, p. 38). Finally, illness may not only destroy the public life but also the secret life lived in unrealistic fantasies, as well as a person's creativity and ability to lead a productive life.

Cassell's second category of person involves an individual's personal and cultural context and relationships and includes relationships with self, family, and social and political institutions. Again, these features have a tremendous impact on the experience of illness and illness can compromise or destroy these features. According to Cassell, "the extent and nature of a sick person's relationships strongly influence the degree of suffering that a disease may produce" (1991, p. 40). For example, the experience of illness may be exacerbated if the patient feels that he or she does not live up to personal or family expectations. Of course, cultural norms play a critical role in how society treats the sick. "Cultural norms and social rules," observes Cassell, "regulate whether someone can be among others or will be isolated, whether the sick will be considered foul or acceptable, and whether they are to be pitied or censured" (1991, p. 39).

With this general description of the nature of person in the background, Cassell addresses the question, especially relevant for clinical medicine, "Who is this person?" (1991, p. 158). For Cassell, this question is what demarcates the clinical medicine from medical science. Clinical medicine must be concerned with the particular patient qua person before the physician's gaze, not with an abstraction or generalization of a diseased body part as envisioned by medical science. To that end, the physician must enter into the patient's world or context and especially the meaning or value structure that under girds the patient's world.

Access to the patient's world, for Cassell, is through letting the patient tell the physician his or her illness story. The patient as person is not an intrusion into the patient-physician relationship but its foundation. The physician must also act as an authentic person towards the patient. Finally, another important source for accessing the patient's story is the physician's own knowledge of people: "the doctor's personal knowledge of people-their language, behaviors, emotions, and values-provides the foundation for knowing about the individual person" (Cassell, 1991, p. 172).

Finally, Cassell addresses the question of the measure of a person. A person and particularly the patient cannot be measured simply in terms of quantified data, especially in terms of numerical values or brute laboratory facts. "I believe," confesses Cassell, "that the objective facts which are the basis of medical science, as necessary as they are, are in themselves insufficient to the clinician's task" (1991, p. 179). Rather, the true measure of a person or patient must also include moral values and personal aesthetics. It is these values and aesthetics, and not simply an abstracted body part or quantified data, which make the patient who stands before the physician unique. For, "clinicians treat particular patients in particular circumstances at a particular moment in time, and thus they require information that particularizes the individual and the moment" (Cassell, 1991, p. 179).1

Since scientists consider science to be value-free, clinicians follow suit for medicine in order to justify their epistemic claims. "For all its apparent attractiveness, however," claims Cassell, "a value-free medicine is a contradiction in terms" (1991, p. 185). Values are critical in the practice of medicine: "applying medical science to particular patients mandates thinking in terms of values as much as in terms of the objective facts of the body" (Cassell, 1991, p. 107).

According to Cassell, there are at least five sources of values. The first is society in terms of the values it holds, especially in terms of the health of its members. The next source is the medical profession and its values, which often reflect its own goals in treating illness. The third source is the physician, both in terms of his or her personal and professional values. The next source is the individual, whether sick or not, with the final source being the "wholes and wholeness" that constitute "systems"

There is no algorithm by which to identify values and to utilize them in treating patients. For Cassell, however, there are three steps involved in identifying values. The first is to recognize that "people do display their values in their presentation to the world, their language use, or in other behaviors" (Cassell, 1991, p. 190). Importantly, the physician must realize that the patient's values may not be consistent with other values he or she holds. The next step is "to access this information in a manner that both accurately and precisely reflects the patients' values" (Cassell, 1991, p. 190). Physicians must be open to the patient, in order to allow the patient to teach the physician about the patient's values. Accessing the patient's values is demanding work, but the reward is the capability "to care for this person" (Cassell, 1991, p. 192). The last step is to learn "to reason about values in a logical manner" (Cassell, 1991, p. 190). Just because a patient's values are personal and subjective does not mean that a physician cannot evaluate them in a rational manner.

Besides values, the measure of a person is taken in terms of personal aesthetics. Although aesthetics is subjective and often based on feeling, it does not mean it is "idiosyncratic" Aesthetics are important with respect to measuring a person because it functions in terms of the self-creative process by which a person matures. A person is always in the process of becoming. Aesthetics also provides information that helps a physician to evaluate the veracity of a patient's story of the illness experience. "There is a knowledge of person," according to Cassell, "that can only be considered in aesthetic terms, the `correctness' of the story of the patient's life" (1991, p. 202). Without that knowledge, the physician may fail to know this patient and to alleviate his or her suffering.

3.2.3 Tauber's Notion of Self

In Confessions of a Medicine Man, Alfred Tauber develops a notion of the patient in terms of self. He too rejects the traditional dualistic model of separate mind and body, as well as the reductionist model of contemporary medicine that treats only the physical body. The problem with mind-body dualism is that there is no adequate means to connect mind and body for the practice of medicine: "In the medical context, the mind/body split is perhaps useful for a scientific approach, but curing illness is not exclusively an epistemological problem" (Tauber, 1999, p. 111). Rather, curing illness is fundamentally an ethical issue that requires a richer conception of the patient than simply a body part here or a mind there. Tauber's approach to the patient is in terms of a self, and not simply an isolated self but one in relationship to other selves.

Tauber defines the self not in terms of an autonomous agent independent of other autonomous agents, as has been the tradition in western society since the Enlightenment, but rather in terms of the other. For Tauber, "a person is not a selfcontained entity, self-defined or in any sense independently `established,' but [a person] rather becomes authenticated in his encounters with others, whether physical, social, or divine" (1999, pp. 23-24). Thus, the person qua self always comes with a context that includes the other. The self and other are intimately connected, serving as two poles which constitutes a relational whole. In fact, "the other serves a constitutive role in defining the self' (Tauber, 1999, p. 43). For a self realizes itself when in relationship with the other. Alone, a self cannot realize itself: "when one attempts to arrest that experiencing subject by reflecting on its experiences, we lose our own subjectivity and substitute an alien objectivity that is fundamentally incapable of capturing what we intuitively refer to as our inner identity, the experiencing self" (Tauber, 1999, pp. 52-53). The self is not experienced objectively or subjectively but reflexively.

Because of the relational basis between the self and the other, the self is a moral class. "'Moral' pertains," Tauber insists, "to the general domain of human relationships, and in this regard the Self is the moral vehicle that we employ to discuss how we ought to interact" (1999, p. 81). He founds the notion of self as a moral class on the philosophy of the "Other," as expounded by Emmanuel Levinas (1906-1995). According to Levinas, an individual's beingness is part of otherness or alterity: "The Self is not only defined in relation to the Other, but the very nature of our being resides in that intersubjectivity" (Tauber, 1999, p. 85). The other's response to one's self provides occasion for accessing the nature of one's self. This is especially true as one goes about acting in the world; an other's response to one's actions help to define one's self. Thus, the self emerges as part of a dialectical process. And since this process is relational, its actions are fundamentally moral, i.e. we are first ethical animals before we are knowing animals. This moral nature of the self is evident in the call of the other vis-n-vis responsibility: "The Self is defined not simply by the Other, but by its responsibility to the Other" (Tauber, 1999, p. 90).

Tauber further develops the notion of self, especially with respect to reforming medical ethics and with respect to the patient-physician relationship, in Patient Autonomy and the Ethics of Responsibility. He proposes a moral epistemology, in which the facts of scientific medicine are balanced with the values of both the patient and the medical profession. The medical profession's primary value should be a responsibility to care for the autonomous patient in a humane manner. "I am seeking a construction of selfhood and autonomy," claims Tauber, "that allows for a balance of rights and responsibilities consistent with the deeper moral agenda of an ethics of care" (Tauber, 2005, p. 85). To that end, he distinguishes between the atomistic and social self, especially in terms of the role of reason and passion in autonomous choice and of individual and communal rights and responsibilities.

The social self is "fundamentally what our social identifications confer on us" (Tauber, 2005, p. 86). Although there is a distinct biological substrate that makes up each self, there is no "core" self. Socialization is what forms the self from the biological substrate. In other words there is no self apart from one's social experience. The atomistic self, however, represents the unique and individual identity that can be distinguished from the social self, which the world bestows upon us. The atomistic self "occupies no special place or unique focus of understanding, for each individual possesses a secure objectivity to survey the world from any perspective, and by tapping into a universal reason, to see the world rationally and objectively as all others would" (Tauber, 2005, p. 89). The notion of an atomistic self is critical for the scientific enterprise, since it provides a separate identity, the "core" self, independent of the world required for investigating that world. The atomistic self is best represented by American individualism, in which the person qua individual is self-contained and independent of others.

Finally, Tauber explores Kant's notion of the rational self in counter-distinction to Hume's notion of the passionate self, as a basis for ethical or responsible action. For Kant, the self is a rational agent to which all other characteristics are subject. The consequence of this position is that the person becomes an objectified core: "comparable to a natural object, `the self' or the ego could not be directly perceived and our self-consciousness then became another natural object for scrutiny" (Tauber, 2005, p. 96). Kant's rational self is in response to Hume's passionate self. "Hume," according to Tauber, "gave up the search for a continuous self, or a core identity or ego, and settled for a bunch of perceptions, linked by memory as sufficient for the psychological ease of identifying our personhood" (2005, p. 96).

The issue, according to Tauber, is how to resolve the tension between these notions of self in order to rescue autonomy from being simply individual rights. The resolution is to balance such individual rights with an ethics of responsibility to achieve a "relational autonomy" based on a "relational self." To that end, he proposes a synthesis of the atomistic and social selves and the rational and passionate selves to preserve the autonomous self in medicine. These facts of selfhood complement each other in terms of providing a richer notion of the self.

3.3 Summary

The predominant model of the patient in modern biomedicine is the machine. Practitioners of the biomechanical model reduce the patient to separate, individual body parts in order to diagnose and treat diseased body parts. Utilization of this model leads, in part, to a quality-of-care crisis in medicine, in which patients perceive physicians as not sufficiently compassionate or empathetic towards their physical and existential suffering.

Humanistic or humane models of the patient, such as the phenomenologist's notion of embodied subject, Cassell's notion of person, and Tauber's notion of self, are proposed to address the reduction of the patient to body parts and consequently to alleviate the quality-of-care crisis. According to these notions, the patient is viewed as an embodied subject within a lived context, or a person in terms of individual and social features, or a self in relation to the "other" and in response to the call of the "other." Through these views the physician comes to understand the disruption illness causes in terms of existential suffering, in the patient's everyday world of meaning.

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