C. D. Bessinger, Jr. MD
What is missing, and what we would do well to reclaim for mainstream medicine, is that quality called "soul". To reclaim it could profoundly influence our understanding of ourselves as healers, our approach to patient care, and patients' attitudes toward our work. A medical philosophy which is germane to our current problems,would foster integration of bioethics, humanities, general knowledge, depth psychology, and spirituality as it relates to patient experience. By being sensitive to the "soul" issues of patients, we improve our ability to "evoke the placebo response" and to reduce patient interest in unconventional therapies.
Journal of the SC Medical
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In a recent study, Eisenberg and others found that "The frequency of use of unconventional therapy in the United States is far higher than previously reported." [1] Since many patients seek both "alternative" and medical therapies without revealing the fact, the physician and non-medical healer are often "unwitting partners in health care." [2] The movement is clearly gaining public and political strength, for Congress recently established an Office of Alternative Medicine within the National Institutes of Health. [3] Campion has stated, "The public's expensive romance with unconventional medicine is cause for our profession to worry." [4]
There are many implications. Heretofore, the debate between science- based medicine and other approaches has been largely a philosophic one, motivated in part by concern that patients avoid harm. However, in view of its growing political appeal, surely there will be much pressure to include various alternative treatments in any new national health insurance system. That will starkly shift the issue to that of economic competition.
However, there are still deeper issues, which challenge our profession to examine itself. That could be painful to some extent, for any success for alternative medicine implies that, from the patient's point of view, something important is missing from the patient's encounter with the medical profession. But what could that be?
The answer I am suggesting will sound radical, perhaps even "alternative", and I broach the subject cautiously, gently, gingerly, fully acknowledging the risk that I may be misunderstood. Still, the answer begs to be heard. I suggest that what is missing, and what needs to be reclaimed for mainstream medicine, is that quality called "soul". To reclaim it could profoundly influence our understanding of ourselves as healers, our approach to patient care, and patients' attitudes toward our work.
What is soul? The usual connotation of the word is religious, denoting that aspect of the human which relates to the divine and is "saved" (from the Greek sozo -- sigma omega zeta omega) by religious faith and/or practice. That sozo referred also to healing and restoration of well-being seems largely to have been lost today, even in religious circles.
Within science-based medicine, the word soul "does not compute". A Medline search shows that the word is seldom used in recent medical literature, and then mostly in a religious or historical context. It is also seen occasionally in abstracts of German language articles, presumably translating Seele which means both psyche and soul.
Dr. Albert Schweitzer wrote,
No one can give a definition of the soul. But we know what it feels like. The soul is the sense of something higher than ourselves, something that stirs in us thoughts, hopes, and aspirations which go out to the world of goodness, truth and beauty. The soul is a burning desire to breathe in this world of light and never to lose it -- to remain children of light. [5]
Psychotherapist Thomas Moore writes, "It is impossible to define precisely what the soul is ... We know intuitively that soul has to do with genuineness and depth." He continues, "The great malady of the twentieth century, implicated in all of our troubles and affecting us individually and socially, is `loss of soul.'" [6] In that sentiment, he echoes the theme implicit in the title of Carl G. Jung's 1933 book, Modern Man in Search of a Soul. [7]
In this article, I use the word soul to refer especially to medicine's collective sense of being involved in that "something higher", deep, and genuine which daily gives purpose and meaning to our work, and which inspires us to communicate the same sense to patients in our healing practice. If such soul has been lost in society generally, it would not be surprising that it should be lost in medicine as well; if both are true, we could expect that healing the healing profession would, in the process, make a substantial contribution to healing our sorely stressed society.
Doctoring the soul is the literal meaning of the word psychiatry, but psychiatry's dominant view of itself now is as a "medical" rather than a "talking" specialty. In a recent review article, Michels and Marzuk [8] write of the "profound transformation" in psychiatry's "major shift of paradigm"; in psychiatry, "The focus of research has shifted from the mind to the brain ... ". In essence, the pharmacologic treatment of mental illness has become so successful that psychiatry no longer needs to focus on psyche.
Patients with a developed spiritual or religious sense often express a concern that most modern medicine is hostile, or at least insensitive, to the soul aspect of life. Whether or not they have a developed religious sense, patients often present with a sense of spiritual "emptiness", especially at times of confronting major surgery or grave disease. Of course, "emptiness" is not a clinical diagnosis, and usually such patients do not want referral to a psychiatrist.
The obvious place for such patients to turn is to a trusted member of the clergy; but for many patients in our society, there is no such relationship. Many have abandoned traditional faith because of difficulty in believing what literalist traditions require them to believe; and many others have rejected, or been rejected by, their traditional faiths for reasons of lifestyle, such as non-traditional family structures.
Unspoken "spiritual" problems are often a factor in non-compliance with recommended clinical treatments, or in seeking unconventional therapies. Sometimes, such concerns may not become evident until they become overt illness (e.g. depression or stress syndromes), or social pathology (e.g. violent behavior and victimization of others). Both categories of problem have substantially increased in society during the two and a half decades in which I have been in surgical practice.
If we as physicians individually, or as a profession, are truly to offer a return to health and well-being to such patients, we must develop an appropriate concept and language for discussing such abstractions as "spiritual emptiness" during a medical encounter, and prepare ourselves to deal with the patients' responses.
Most of us recognize the placebo effect of medication. However, as the emphasis of medical practice has shifted to technology-based specialization, we have come to discount the "placebo effect" of a physician's personality. In a newspaper interview, [9] medical historian and author Edward Shorter of the University of Toronto spoke of medicine's general loss of skill in "evoking the placebo response" in interactions with patients. He indicates that the physician is often unaware of having such an effect. He attributes the effect to a high regard by the patient for the physician, and to the amount of time the physician spends listening to the patient; the loss of these qualities in medical practice has been accompanied by "the loss of medicine's therapeutic power".
The transference mechanism by which patient and physician relate is a complicated high-level effect, mostly unconscious, with both intra- and inter-personal dimensions. The doctor-patient relationship cannot be examined or explained at the molecular level. If something is wrong in medicine's collective interactions with patients, it must be a "soul-level" problem, involving our philosophic worldview, our attitudes about life and healing, and the unconscious dynamics of our own psyches.
I have previously advocated that the "philosophic milieu" of medical practice, [10] and the basis of its ethical responses, should be the modern integrative whole-system worldview. [11] Yet, in today's intellectual climate, there are problems about calling such a worldview "holistic". The world of alternative medicine commonly describes itself as holistic, and places itself in opposition to medicine's reductive approach.
A true philosophy of the Whole cannot exclude reductive research, for it is research into detail which provides the data to compose the whole. A whole cannot exclude its parts. Usually, alternative medicine is not holistic at all, for it rejects or devalues the scientific and cognitive processes by which knowledge is gained and affirmed.
It must also be said that the medical profession, if it is to regain its soul, must not reject or devalue the intuitive "spiritual" element in composing its worldview. That human nature is based on soul is amply evident in the fullness of its expression in art and religion throughout all cultures and throughout all history. A psychology which deals only with the cognitive, behavioral, or molecular aspects of human functioning is a superficial psychology, devoid of the essence of being human.
Reason itself requires that medicine embrace the fullness of the human person and potential, and that it deal at depth with soul. If we do less, we fail to meet the imperatives of reason and of whole-system homeostatic process. In other words, we fail at healing. A healing approach which keeps both science and soul in homeostatic balance is fully holistic. A system which attempts to heal without soul is as out-of-balance as a system which attempts to heal without science.
Many corrective responses are already evident. There has been a wide expansion within the profession of awareness of bioethics issues. Engel [12] has advocated a multi-level biopsychosocial model of practice, which is being incorporated into patient-encounter training, especially by the American Academy on Physician and Patient. [13] Teaching of humanities [14] and interpersonal skills [15] is being successfully incorporated into medical school and post-graduate curricula, and many similar points could be cited.
What seems especially to be needed now is for the profession to bring these efforts into coherence under a common (and of course, non-sectarian) whole-systems worldview. If we are to adapt our healing approaches to meet the needs and expectations of modern people, we must consider that today, personal illness occurs within a complex and stressful society, which is more crowded, violent, and toxic than ever before.
In the past, it has been sufficient to apply the findings of reductive research to clinical practice. That remains essential, but now we must also learn to understand patients and ourselves in terms of the depth and breadth of large-system interactions, including those of that realm called psyche.
Reorientation of worldview, and finding both will and /soul/ to do it, are philosophical problems. Medical philosophy has usually defined its concerns in terms of the traditional philosophic specialties, such as theory of knowledge, logic, ethics, and philosophic anthropology. However, that classification is not directly clinically relevant, and most clinicians are only vaguely aware that medical philosophy is an area of study.
A medical philosophy more germane to our current problems, would foster synthesis of bioethics, humanities, general knowledge, depth psychology, and spirituality as they relate to patient experience, and would seek to expand such awareness throughout the profession. There are several important areas of knowledge which might especially help medical students and physicians prepare for "soul-full" practice:
This concept goes beyond psychosomatic medicine, though psychosomatic concerns are a subset within it. I do not suggest that a physician needs to be expert in each (or any) of these areas. However, there is reason to think that our relationships with patients would be substantially improved if we were sensitive to such issues, and looked for these dynamics at work in our practices and in our own lives.
By showing our interest, we would be "giving permission" for patients to discuss their soul concerns. We would be opening up new channels of communication and discussion, and would become better able to make appropriate prescriptive suggestions or referrals. We would better understand that many patients seeking alternative medicine are actually seeking "alternative spirituality". We might even cool their "romance" with unconventional therapies. Perhaps most importantly, we would find again that there is healing value in merely letting patients know that we care about all of their concerns.
1. Eisenberg DM et al. Unconventional medicine in the United States: Prevalence, costs, and patterns of use. New Eng J Med 1993; 328:246-252.
2. Murray RH and Rubel AJ. Physicians and healers -- Unwitting partners in health care. New Eng J Med 1992; 326:61-64.
3. Beardsley T. Fads and Feds: Holistic therapy collides with reductionist science (news item). Sci American (Sept) 1993; 269(3):39-44.
4. Edward W. Campion. Why unconventional medicine? (editorial). New Eng J Med 1993; 328:282-283.
5. Schweitzer A. The Words of Albert Schweitzer selected by Norman Cousins, Newmarket Press, 1984.
6. Moore T. Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life, HarperCollins, 1992. p. xi.
7. Jung CG. Modern Man in Search of a Soul (1933). Harcourt Brace Jovanovich (undated edition).
8. Michels R and Marzuk PM. Progress in psychiatry (in two parts). New Eng J Med 1993; 329:552-560,628-638.
9. Skelly, FJ. Decline and fall, an interview with Dr. Edward Shorter; Amer Med News, Aug 3, 1992.
10. Bessinger CD Jr. Doctoring: The philosophic milieu. Southern Med J 1988; 81:1558-1562.
11. Bessinger D (CD Jr.) Emerging From Chaos: Wholeness, Ethic, and New World Order. Orchard Park Press, 1993.
12. Engel GL. The need for a new medical model: A challenge for biomedicine. Science, 1977; 196:129-136.
13. Medical Encounter, newsletter of the American Academy on Physician and Patient (Baltimore), 1993; 10(1,Suppl):2-3.
14. Radwany SM and Adelson BH. The use of literary classics in teaching medical ethics to physicians. J Am Med Assoc 1987; 257:1629-1631.
15. Novack DH et al. Medical interviewing and interpersonal skills teaching in US medical schools. J Am Med Assoc 1993; 269:2101-2105.
Essays on Ethics and Healing
Unitive Healing
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20 Mar 1999