Doctoring:

The Philosophic Milieu

To understand fully a physician's role in society, and to deal successfully with the current sense of crisis, the medical profession must evolve a world-view that appropriately relates a physician to the patient, to the practice environment, to the base of knowledge, and to the physician's own sense of self. Such a world-view would be multi-level and inter-disciplinary, and would be based on interactions and adaptations of physicians to life systems. Medicine's world-view must provide a philosophical "milieu interieur" which leads to a proper equilibrium between medicine's technologic skills and its humanistic concerns.

There is wide acknowledgement that the practice of medicine is currently undergoing a substantial upheaval. In economic terms, we are seeing a "monetarization" [1] and a "destablization" [2] of medical care, and the rise of a "medical-industrial complex." [3] Medicine is "undergoing some sort of crisis". [4] "Something has gone wrong ... and we all know it." [5] The sentiment often heard in hospital lounges, that "medicine is no fun anymore", has "trickled down" to medical students, to be heard in the Dean's office, [6] and there are even hints of a sense of "helplessness". [7]

The lustre of the medical edifice and the esteem of its practitioners, much like the art work on the facades of ancient buildings, show signs of corrosion in an "anti-scientific" environment, in which the public is seen as at least ambivalent toward science. [8] There is a perception that medicine's science is at odds with medicine's art, and with its sense of humanism. Scientific medicine is often seen as arrogant. [9,10] Patient dissatisfaction is seen in such statements as, "I left my doctor's office feeling worse than when I came." [11]

The profession's adaptive response includes the "striking phenomenon" of "the resurgence of biomedical ethics" [12] and a marked upswing in interest in the interface between medicine and the humanities. [4,5,13] There also seems to be a restructuring of the classic views of science and human function.

Engel has stated the case for a restructuring of the classic "biomedical" model of disease, [14] a model which focuses on a disease as a specific entity which "attacks" a patient. He offers a "biopsychosocial" model, in which a patient is seen in the context of life systems, affected by influences at multiple interactive levels. The biopsychosocial model focuses on the patient in the life system, rather than only on an identifiable disease. In the context of patient care, that of course is the appropriate focus.

Just as the cells of the body live in a fluid "milieu interieur", so does the physician work in a philosophical milieu which governs interpretations of and responses to situations encountered in practice. If we are to understand fully a physician's role in society, and if we are to deal successfully with our professional sense of crisis, we must go beyond a patient-disease model. We must achieve a sythesis which relates the physician to the entire practice environment and to the base of knowledge. Indeed, our world-view must also relate the physician to the physician's own sense of self.

Such a system of thought must encompass the multiple levels of life experience, and thus must be systems oriented. However, it must also be inter-disciplinary, and must provide the links to harmonize physiology, pathology, psychology, anthropology, history, sociology, and philosophy, to name a few of the pertinent types of studies.

Further, it must harmonize the humanistic and the scientific aspects of medicine, and deal with the complexities of medical ethics. Our philosophical system must be sufficiently in focus to project clearly to medical students, and sufficiently bright to illuminate the way of weary practitioners in the field.

In this study, we outline the scope of such a medical world-view, in a search for a better understanding of the physician in an always-evolving health care environment.

In computer science, a model is a program which behaves in a way that is analogous to some physical process. While a metaphor may appropriately express image and analogy, a model must appropriately demonstrate function. On the other hand, one's world-view expresses one's overall concept of reality and determines one's response to that reality. The world-view may be composed of many conceptual models and metaphors which help interpret reality in human terms.

In the history of mankind, there have been many different world-views expressed. In present-day society, many co-exist concurrently, and that accounts in no small measure for the differences in expectations between medicine and society. For purposes of discussion, we might roughly classify world views as "mythic", "alchemical", "scientific", and "systems".

The ancient myths were not consciously composed, but emerged in oral tradition as inner truths perceived unconsciously and expressed symbolically. [15] Such inner experience has also been the major determinant of the rise of religions, all of which communicate in symbolic language and symbolic image. [16] The mythic world view serves to give expression to inner human aspirations, but is quite limited as a means of describing and interpreting phenomena in the outer material world.

The alchemical world-view is a transitional type. In their search for transformations which could lead to ordinary gold, the alchemists' tinkerings laid the foundations for modern experimental chemistry. However, they were also concerned with psychological transformations, expressed in the search for "philosopher's gold".

As "natural philosophy" and the experimental method became established in the wake of Descartes' Discourse on Method, the scientific world-view became ascendant, and rapidly moved away from metaphysical and mythic concerns. Only a century ago did clinical science seek to come to terms again with inner experience, in the work of Freud, Jung, and others. Even then, the tedium of its empirical method made it difficult for science to deal convincingly with its findings regarding the unconscious. Further, Descartes' explicit metaphor of the animal organism as a machine persisted in the prevailing reductionist view of life as a mechanistic process, and gave no basis for interpreting the symbolic language of the unconscious. Reductionist tendencies have been encouraged and intensified by specialization in all of the sciences.

The impetus to reconsider the classical view of science came primarily from quantum physics, for subatomic particles failed to behave in accordance with the laws of classical mechanics. These new "quantum realities" [17] require a reexamination of reality itself. Some observers consider that, at the particle level, it is more appropriate to view the universe as built of energy interactions rather than of minute building blocks. [18]

In the life sciences, the restructuring of classic views derives largely from an evolving theory of evolution [19] and from studies of ecologic systems. These indicate life's interactive complexity, and require a consideration of systems theory. Systems theory may be seen as the study of complexity.

A system (whether concrete or conceptual) is a complex of operations in which the processes of multiple components (subsystems) interact in a self-regulated way as a functional whole. The system yields a product greater than can be accounted for by considering its constituent operations independantly. [20] The biosphere is a hierarchy of life-systems extending from the level of the individual cell to encompass all life on, within, and above the globe.

Thought, and the world of knowledge, emerge at the human level within the life system. Thought is itself a natural systems phenomenon, characterized by Teilhard de Chardin [21] as the "noosphere". The systems world-view must properly encompass the whole of knowledge, harmonizing the experimental science of the material world with the empirical science of the human unconscious world. The systems world-view seeks the proper balance between technology and human aspirations. In seeking to go beyond the "scientific world-view", however, the systems world-view in no sense seeks to go beyond science.

The process of confirmation by reason and experience must be applied rigorously to all observations, preserving a careful distinction between knowledge and opinion. The alternative "holistic medicine" [22,23] often offers only a pseudo-holism that, in its zeal to affirm the realities of inner aspirations, rejects the rigorous tests of reason and experiment. By contrast, a true holism preserves true science.

All knowledge must form a consistent whole. The term "false knowledge" is a contradiction, for knowledge is that which is known to be true. [24] New information must be constantly reviewed in the light of all other knowledge. That requires the establishment of interdisciplinary links, so that the departments of knowledge are brought back into relationship in a true "university" of knowledge. Education must emphasize the process of "drawing out" understanding from all the disciplines.

Understanding of human experience requires study of both the unconscious and conscious aspects of life systems. At the unconscious level, the dominant life-systems phenomenon is autonomic self-regulation, characterized by Cannon [25] as homeostasis. In his famous declaration, "I dress the wound; God heals it", Pare in effect affirms the healing power of homeostasis. The physician can not regulate life systems, but can only seek to tip the balance toward the recovery of homeostasis. The systems view sees disease, not as an attacking entity fended off by an armamentarium, but as a strain condition within a flux equilibrium. Such a strain may be the result of causal factors operating at several levels concurrently, and usually affects the organism at many levels simultaneously.

Carl Jung's model of the psyche [26,27] also places great emphasis on unconscious homeostatic function. He finds that the total psyche functions as if regulated by a unconscious nuclear center (the "self") which seeks to integrate the unconscious and the conscious (the "ego"). He advances a theory of "archetypes" which are a part of the inheritance of human nature, and which account for the highly consistant way humans process symbols and express feelings. That consistency is apparent in all cultures, and throughout history in all "mythic" systems. The theory provides an empirical basis for harmonizing the outer and inner dimensions of human experience, and for understanding the human realities behind the symbolic language of various belief systems.

In the conscious world, one may also find evidence of systems organization, with function regulated through various feedback mechanisms. At the origins of sociology as a discipline, Comte [28] and especially Spencer [29] drew parallels between social systems and the multi-level function of the organism. System interactions are present at the levels of family, community, nation, and global civilization. The social organism also seeks its balance (its equilibrium), which the analysis of social systems must take into account.

The systems view makes clear that the physician interacts with the world in many ways and at many levels. The "problem" of a physician's action is much larger than the patient's "problem list". Even though the primary and immediate focus of a physician's consciousness may be on the patient's disease process, there will still be interactions (unconscious, perhaps) with the physician's own self, with the medical knowledge system, with the patient's unconscious, with the patient's (conscious) system of beliefs, with the patient's family, etc.

Further, a physician's actions also have effects on the profession as a whole and on society at large, even though these effects may seem "weak" or may be imperceptible. The systems view makes clear that even at the large-system level of global issues, though the physician may not have a sense of control, at least there is a measure of influence. A medical philosophy must seek to bring these interactions to the conscious level, so that reason and the lessons of life experience may be applied to problem solving at all levels.

The systems view also makes clear that the world of knowledge is complex indeed. Specialization in practice is thus an appropriate adaptive response. The systems view is also an evolutionary view. Life process is a process of change. The requirement for survival adaptations is not limited to genetic or other unconscious levels.

Over a lifetime, economic, social, cultural, geographic, and philosophical adaptations may be expected as a normal consequence of life process, even for physicians. However, change as process does not necessarily imply change as progress. A medical philosophy must be concerned with identifying maladaptive, as well as adaptive, responses.

Though the profession has become highly specialized, all medical specialists are physicians first. All specialists find in the historical view of doctoring a basis for continuing unity of purpose. [30] While Hippocrates is seen as the father both of scientific medicine and of its ethical commitment, the first physician identified in history (indeed, the first person named in ancient records [31]) was Imhotep, a physician-priest of ancient Egypt, later venerated as the god of medicine. [32]

The ancient view of healing is the view of the restoring of wholeness, or in system terms, restoring equilibrium. A composite historical view of the physician combines the image of the "mythic" priest who manipulates symbols for healing transformations, with that of the "physiker" who manipulates materials. In its concern for equilibrium, the systems world-view reaches across the "alchemical" bridge to bring forward a modernized understanding of healing transformations.

While the modern physician may not feel comfortable functioning as a priest, professional symbols and mythic sensitivities nonetheless have a proper role in humanistic medicine. [33] In the systems view, the physician comes to be conversant with and respectful of the many belief systems of patients, without sacrificing one's own belief system. Regardless of one's belief system, one may relate to the beliefs of others at the "generic" level, the level called by Einstein "cosmic religious feeling". [34] At that level, the physician finds bridges, not barriers, in dealing with the belief systems of individual patients.

In the study so far, we have gleaned lessons from many different disciplines. In the systems view, it is clear that all knowledge is an extension of humanity and that the "humanities" include all science. Our philosophy and our practice must be grounded in our knowledge of life systems. It would not do to attempt to shape our practice by some philosophy formulated in isolation. [35]

The physician's understanding of life systems provides an especially valuable perspective from which to view the large-system issues faced in the global society. This author has previously advocated that physicians play a role in "seeking to heal civilization", an activity that might be called the "new specialty" of "humanitology". [36] Such a "specialty" is not, of course, a field of limited practice, but a basic concern which, like physiology, pervades all practice.

Classical ethics seeks to define the good through (conscious) reason alone. The systems view shows that in the unconscious world, nature has already defined the good as homeostasis, as the "wholeness" of equilibrium. According to Schweitzer, ethics consist in "thinking sincerely" to become aware of and act in response to that homeostatic equilibrium.

Writing six years before Cannon "named" homeostasis, Schweitzer called that equilibrium "will-to-live", and he called the natural ethical principle "reverence for life". [37] That "natural ethic", deriving from a systems world-view, has direct and immediate application to current issues in medical ethics. [38,39]

The present dis-ease widely felt in medical practice may indeed represent a disease which threatens our health systems equilibrium. If so, the disease is not defined by the existance of change, for change is the normal state of life systems. Such disease would be defined by the barriers which impair understanding, and which impair adaptive reaction.

A recent basic science article is entitled "Tumors: wounds that do not heal". [40] That title illustrates crossing disciplinary lines to express new understandings. It also provides an apt metaphor for our professional dilemma. Medical philosophy must diagnose centers of destructive change. It must also help define the healing response. In the study of medical philosophy, the profession can renew its sense of meaning in its work. It can find the means to heal its wounds.

As Moore recently pointed out, [41] and as Imhotep undoubtedly would agree, "the discovery that mind and body go together" is not all that new. Medical philosophy is not a new study. It must however generate a renewed interest in the study of the physician's relationship to science, that is, to all knowledge. It is from that broad base that we must synthesize a world-view that guides our doctoring toward a balanced expression of both humanistic concerns and technical skill.

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Essays on Ethics and Healing