The Old Age Challenge to the Biomedical Model

Paradigm Strain and Health Policy

Charles F. Longino

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781351862820
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Central to this book is the idea that the United States is in the midst of a health care crisis, one that will be exacerbated as the population continues to age. Longino and Murphy trace the philosophical and technological development of the biomedical model and show its inadequacy to deal with the massive chronic disease demand of the present and the future. They argue that the delivery of health care will meet and survive the old age challenge only if the medical system is thoroughly democratized. A more inclusive system must be devised that encourages a more reasonable allocation of resources, gives more attention to prevention, adopts a wider range of non-medical interventions, and invites citizens to become more involved in their own health care and the planning of services.

CHAPTER
1

Introduction

THE BIOMEDICAL MODEL AND REDUCTIONISM

A juggernaut is driving the health care system to a predicament affording no obvious escape. On the one hand, biomedicine is sustained by a set of assumptions that guide the medical enterprise. On the other, these presuppositions are incompatible with treating chronic illness. The problem is that as the population ages, this sort of malady will become even more prevalent. As a result, the prevailing medical system may become irrelevant and rapidly outmoded.

At this time, the rise of chronicity is receiving much attention. Most persons seem to recognize that as the “baby boom” generation ages, for example, a variety of social changes will occur. But the impact on the medical system has been underestimated. Practitioners have begun to recognize that perhaps some new services will be required. These additions, however, are planned to be introduced at the periphery of the traditional medical enterprise. Little awareness seems to be present about how the philosophy that underpins biomedicine may render this approach to medical practice ineffective in the near future. The key point in this book is that a complete philosophical shift will be necessary, if chronicity is to be dealt with adequately. In other words, the core of current medicine will have to be altered, or chronic problems will be misconstrued and mistreated.

In this discussion the biomedical model is understood to have five components. These are 1) the mind and body are essentially different and medicine is restricted to considerations related to the body; 2) the body can be understood as analogous to a machine; 3) medical answers are thought to be more reliable when they are founded on basic sciences, and thus biophysical answers are preferred to all others; 4) a singular and specific cause exists for every disease, and through biomedical science each cause can be discovered and a cure provided for every illness; and 5) a patient’s physiology is the proper focus of the regimen and control enacted by the physician [1]. The principal shortcoming of this model is that it is too narrow to handle the complex nature of chronic medical problems. In short, the biomedical model is reductionistic.

This pronouncement is hardly new; the restrictive character of biomedicine has been debated for quite some time. Nonetheless, the overall effectiveness of biomedicine was not called into question. Indeed, most acute illnesses responded nicely to biomedical interventions, and those who criticized the biomedical model were considered to be misguided or uninformed. The precipitous increase in chronic disease that is expected, however, will likely alter this assessment. As never before, widespread chronicity may shake the foundations of biomedicine. Criticism of biomedicine may be essential if medical treatment is to have any positive effects in the near future.

A distinction has always been made between those afflictions that have a sudden onset, rage briefly, and then leave abruptly, such as most infectious diseases, and those that begin slowly and lead to gradually increasing disability. The former afflictions have been thought of as “acute” and the latter as “chronic.” Before this century, there were some prevalent disabling infectious diseases, too, such as tuberculosis and syphilis, that by this distinction should be considered as chronic. Nevertheless, as Fox writes, “The phrase chronic disease came to be used … as a loose descriptor for illnesses of slow onset and long course, for which a singular and specific cause had not yet been discovered” [2, p. 23]. When advocates of biomedicine are reminded that they have not discovered a cure for cancer or diabetes, “promissory notes,” such as “We’re working on it,” are issued to salvage the biomedical model [3]. In this way, the inconsistency between the biomedical model and chronicity is concealed.

The impact of acute and chronic disease on the patient is different because an acute disorder is distinct and limited, and its cause and treatment are understood. In a chronic condition, however, the whole person is tormented, and where the malady came from and where it will go is not well understood. Therefore, clear and concise cures are not readily available. As Cassell affirms, “When suffering occurs in the course of acute disease, medical understandings of the body and categories of disease seem adequate to explain why the threat to the integrity of person exists” [4, p. 48]. This is not so with a chronic disease that grinds away at the person, his or her associates and family, or even the community.

Distinctions are made in the medical community between primary, secondary, and tertiary prevention. Primary prevention pertains to the diagnosis and treatment of a disease before it is manifest. Inoculation and education to avoid a disease are primary strategies and are associated with public health approaches to illness, or calcium supplementation and exercise in young women to offset later postmenopausal osteoporotic bone loss.

Secondary prevention is defined as treating a disease to prevent recurrence or progression once manifest. For example, the earliest manifestations of arteriosclerotic heart disease can be found even in the arteries of children. Lifestyle changes to slow or even stop the progress of early heart disease are examples of secondary prevention. In terms of acute manifestation, as after a heart attack, prevention aimed at postponing a second heart attack would also fall into this category. One would expect primary and secondary prevention to expand greatly as managed care systems come to dominate the organization of clinical medicine. In the past, however, these sorts of strategies have been aimed primarily at preventing the reoccurrance of acute disease manifestations.

Tertiary prevention is aimed at restoration of function once disease has caused dysfunction. Nearly all rehabilitation strategies fall into this category, including the work of physical and occupational therapists.

Levels of preventive strategies should not be confused with levels of care or services. Primary care is considered to be the first encounter with a practitioner when the patient presents his or her health concerns. Secondary and tertiary care services are a matter of degree of complexity and the sophistication of technology, generally delivered by specialists and subspecialists. Ostensibly, tertiary services treat severe disorders to save the patient’s life, at least in the short run; heart bypass surgery or a cancer operation are examples. As Pelletier argues, “most of the medical care given today is tertiary care …, care which attempts to bring about curative results, alleviate suffering, restore the maximum possible degree of function and prolong life at any cost” [5]. Tertiary care is aimed at treatment and thus tends to deal with chronic disease only after manifestation, and often in its final stages. This strategy is heroic. And, in keeping with the American national character, it embodies crises-management rather than planning. Further, tertiary care is considered to be “scientific medicine,” and thus the medical profession is reluctant to invest a lot of time, effort, and money in the care associated with primary prevention, which is considered to use low-tech and less interesting forms of mediation. But as should be noted, primary prevention applies well to chronic illness. Chronicity requires that serious attention be extended to prevention and that care be broadened or made more holistic. In short, prevention, maintenance, and management must receive greater emphasis.

There is a continuing aspect of care involving maintenance and management that is especially important to older patients. This is care for persons with disabilities that result from chronic disorders, and takes the form of “long-term care.” Delegated to medical social workers and nurses by the medical establishment, long-term care has tended to be devalued by the medical subspecialists. This practice is viewed only as custodial and thus unworthy of biomedicine. Hence, in the past, little attention has been given by physicians to the rehabilitative potentialities of long-term care patients. As the older population in the United States continues to grow, however, long-term care will likely come to dominate a broader version of medicine than now exists.

HOLISTIC MEDICINE AND CHRONIC ILLNESS

Other writers, such as Knowles [6], Graubard [7], and Waldovski [8] have tried to illustrate this emergence of chronic illness, but their efforts were not critical enough. These have been mostly instrumental responses that do not challenge the basic philosophy of biomedicine. An adequate response will require a shift away from the curative bias of traditional medicine, so that emphasis can be placed on the whole person. As part of this change, interaction will have to be understood to exist between the mind and body, patient and the environment, and physiology and culture. Persons, in short, must be viewed as actively involved in the promotion of health. Stated differently, they are not the passive recipients of disease agents or medical knowledge. With regard to chronicity, a social context exists that should not be ignored when formulating an intervention. A plethora of social and cultural factors should receive attention, which have minimal importance in the use of biomedicine.

Attention will have to be broadened so that holistic approaches will gain legitimacy and be used more widely, thereby breaking free of the monopoly that grants to biomedicine hegemony in all health matters. (See pp. 76-78 for definitions.) But critics should recognize that the ideology of medicine and its structure are linked. For example, legislation and organizational rules have justified the rewards and narrow focus of the medical profession. But the stress on physiology originates from the primacy that is given in the biomedical model to biological theory. As a result, the health care system is hierarchical; at the center of traditional medicine are issues of power, territoriality and exclusiveness [9, pp. 33, 47]. In feminist terms, the medical system is patriarchal. In post-modernist terms, it is dualistic. The point is that the structure of health care cannot be divorced from the philosophy of biomedicine. They are mutually reinforcing. Accordingly, changing one without the other will probably be unproductive. Yet at this juncture in the development of health care policy in the United States, this interplay between philosophy and practice is receiving scant attention.

Scientific medicine cannot approach chronicity because of the dualistic way in which disease is defined. Furthermore, dualism legitimizes the hierarchical practices that are adopted to provide care. In fact, essential to the biomedical model is a dualism that rationalizes transforming persons into physiological objects. This same dualism, accordingly, plays an instrumental role in elevating medical opinions over all others, and in excluding patients from their own treatment [10, pp. 9-10].

Cassell contends that practitioners of scientific medicine are more interested in pursuing a disease than caring for a sick person. According to the dictates of biomedicine, the person, sick or otherwise, is not the focus of inquiry, but the body of a patient. And within the body the physician seeks out a disease which is given an ontological status through classification. Stated simply, a disease is a discrete entity that can be discovered, treated, and cured.

Thus far, there are two interlocking dualistic distinctions: first, the body delimits the parameters of medical inquiry, while, second, intervention is restricted to disease. As might be expected, these dualistic distinctions have far reaching implications. For instance, in the diagnostic process there are symptoms and perceptions of the patient that are considered to be subjective by the physician, and signs and observations made by the physician, using today’s medical technology, that are considered objective [11]. And as Cassell notes, in the scientific era of medicine “the word objective [has] come to have the connotation of real, in contrast to subjective things which are only mental and therefore unreal” [4, p. 96]. Because the body is grounded in nature and thus real, physiological indices of disease are treated as factual. Insights offered by patients, because this information is deemed subjective, are downplayed in importance. But suffering is not found in the physiology of a person. In point of fact, health and illness are human constructs. And given this insensitivity to the human condition, biomedicine has little chance of dealing productively with chronic disease. More holistic approaches are needed to deal with chronicity because relief from the suffering associated with this problem often resides outside of the body.

Good reports that chronic pain is often embedded in repressed symbolism, performance failure, and fear [12]. Chronicity, in this sense, is linked inextricably to social conditions. This is regularly the case with acute illness. But in the example of chronic disease, ignoring this relationship becomes very difficult. In a sense, chronicity exemplifies the tie that is present between the mind and body, and the self and Umwelt.

Furthermore, chronic disease is dynamic rather than static. This kind of malady lies dormant as “potential”—present in a pre-clinical form—and then is finally manifested. In the end, this condition progresses to a crisis, which can at best be managed. Usually pregnancy is characterized as an either-or situation, but heart disease cannot be identified this simply. Chronic diseases operate on a continuum, one that, in some cases, can increase or decrease depending on a host of conditions. The conceptual basis of biomedicine, with its ontological demands, makes it difficult to conceptualize, assess, and predict chronic disease. In biomedicine, disease must be present physiologically or it does not exist. Talk about potential, pre-clinical status, and situational contingencies is not concise enough for scientists. Like dualistic conceptions in general, this one is far too limiting.

The dualism written into state laws, and the structure of the medical profession, is also restrictive. Structural dualism, in this case, defines who is permitted to treat patients. Practicing medicine without a license, for example, is a crime. The purpose of such laws is ostensibly to protect the public. The result, however, is that the power, privilege, and resources of biomedicine are protected. In effect, these values block the legitimate use of other, non-specific, approaches to healing, especially by persons...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Foreword
• Acknowledgments
• Table of Contents
• Chapter 1 Introduction
• Chapter 2 The Shift from Speculation to Science
• Chapter 3 Major Components of the Biomedical Model
• Chapter 4 The Rise of Scientific Medicine
• Chapter 5 Aging and Paradigm Strain
• Chapter 6 The Emerging Paradigm
• Chapter 7 The New Paradigm and Public Policy
• Chapter 8 Conclusion
• Index