To Fix or To Heal

Patient Care, Public Health, and the Limits of Biomedicine

Joseph E. Davis, Ana Marta Gonzalez

• Publisher: NYU Press
• Year: 2016
• ISBN:
  9781479866526
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Do doctors fix patients? Or do they heal them? For all of modern medicine’s many successes, discontent with the quality of patient care has combined with a host of new developments, from aging populations to the resurgence of infectious diseases, which challenge medicine’s overreliance on narrowly mechanistic and technical methods of explanation and intervention, or “fixing’ patients. The need for a better balance, for more humane “healing” rationales and practices that attend to the social and environmental aspects of health and illness and the experiencing person, is more urgent than ever. Yet, in public health and bioethics, the fields best positioned to offer countervailing values and orientations, the dominant approaches largely extend and reinforce the reductionism and individualism of biomedicine. The collected essays in To Fix or To Heal do more than document the persistence of reductionist approaches and the attendant extension of medicalization to more and more aspects of our lives. The contributors also shed valuable light on why reductionism has persisted and why more holistic models, incorporating social and environmental factors, have gained so little traction. The contributors examine the moral appeal of reductionism, the larger rationalist dream of technological mastery, the growing valuation of health, and the enshrining of individual responsibility as the seemingly non-coercive means of intervention and control. This paradigm-challenging volume advances new lines of criticism of our dominant medical regime, even while proposing ways of bringing medical practice, bioethics, and public health more closely into line with their original goals. Precisely because of the centrality of the biomedical approach to our society, the contributors argue, challenging the reductionist model and its ever-widening effects is perhaps the best way to press for a much-needed renewal of our ethical and political discourse.

Part I

Reductionist Medicine in Cultural Context

1

Reductionist Medicine and Its Cultural Authority

Joseph E. Davis

Criticism of medicine as centered in molecular biology and technology, and prone to neglect the personal and social dimensions of health and illness, has a long history. Already in the 1880s, at the very epoch-making moment in which medicine was being reconstituted by discoveries from laboratory science, there was pushback. In early 1886, just weeks after the public announcement of a breakthrough with regard to a vaccine for rabies, Puck, the famous American magazine of humor and political satire, ran a panel of cartoons about medicine. One has the caption “No Time for Common Sick Folks.” The drawing (see figure 1.1) shows a doctor in a lab coat leaving the bedside of a patient, hat in hand and rabbit in pocket, with the apology, “Excuse me, but I have an experiment to make.”1 In an 1899 address to the Massachusetts Medical Society, James J. Putnam observed that a concern to treat “not the disease only, but also the man” was a “familiar sentiment” among older members of the profession.2 On and off ever since, medicine has been hailed for its extraordinary explanatory and technical successes while at the same time generating considerable discontent. Against a narrow biologism and procedure-orientation, critics have argued for more socially oriented and humanistic approaches. These holistic approaches have always run counter to the mainstream and they have seldom sustained much traction.

Why not? Why have socially oriented and integrative approaches, despite their long and continuous appeal, remained marginal? Why, to turn the question around, does medicine continue on a course characterized by reductionism, mechanism-based explanations for clinical syndromes, and heavy reliance on technological solutions, despite important reasons to change? No answer can be remotely complete, but I want to frame a general explanation by considering the powerful appeal of two enduring legacies, one from the seventeenth century and one from the nineteenth. Each is familiar enough. Philosophers and theologians have often reflected on the implications of seventeenth-century natural philosophy, particularly the works of Francis Bacon and René Descartes, to understand the commitments of modern science and medicine. Historians more commonly concentrate on the nineteenth-century changes that joined medicine with the physical and life sciences and gave birth to a particular constellation of ideal-types—the “biomedical model”—that have structured and constrained thinking about disease and treatment ever since. The problem for integrative, holistic approaches, I hope to show, arises from these two legacies together. As interwoven with central contemporary values, these legacies have given reductionist medicine a distinct cultural authority.

Figure 1.1. “No Time for Common Sick Folks. Doctor.—‘Excuse me, but I have an experiment to make.’” A scene from “The Profession Gone Mad,” illustration by G. E. Ciani; Puck 18:462 (January 13, 1886), 314 (New York: Puck Publishing Co., 1877–1918). Courtesy of the Bert Hansen Collection, New York, New York.

This authority—the authority to “name the world”—is rooted in biological science and therapeutic optimism. Optimism is grounded, in part, in past technological success, but it is also rooted in particular modern preoccupations: the valuation of health, which has increasingly become an end in itself; the “war against all suffering,” to use Ivan Illich’s phrase; and the project of self-determination.3 These preoccupations lay down powerful moral imperatives and hopes that carry over into medicine and, paradoxically, imbue medicine with an image of objectivity and moral neutrality. These imperatives, I want to suggest, help to account for both the continued assertion of the reductionist biomedical model, despite reasons to move in a more holistic direction, and for its extension over more and more areas of our lives, an extension held back only by the available technologies.

The Baconian Legacy

The story of biomedicine begins with the birth of modern science in the seventeenth century. That birth was complex and included new discoveries, such as Kepler’s and Galileo’s observations of the solar system; the growing sophistication of the mechanical arts and workings of complex mechanisms, such as clocks and pumps; rapid advances in mathematics; and new ideas about man and nature. The ideas, the philosophical part of the story, are particularly relevant here. Seventeenth-century natural philosophy (the precursor of natural science) articulated a revolutionary new stance toward the world, elaborated with particular clarity and influence by Frances Bacon, René Descartes, and Isaac Newton. The new stance begins from a rejection of traditional understandings of final causes, and of the universe as a hierarchy of meaningful order. It affirms an objectified conception of nature, wherein the world is no longer a locus of meaning—the reflection of the divine plan or the embodiment of the Ideas4—but a neutral domain capable of mechanistic explanation and, most important, prediction and instrumental manipulation.

In what might be called, following the historian Stephen Gaukroger, “Bacon’s project,” true knowledge is not abstract and speculative, as it was for the ancients and scholastics, but practical and useful.5 It is painstakingly acquired through the application of systematic and disciplined analysis. This analysis is based on experiment and observation, moves from effects to causes, and seeks to discover the fundamental mechanisms and general laws by which all of nature is ordered. Its method is logical, reductionist, and rigorously empirical. Its reasoning is inductive but in a very controlled, machine-like way. As Bacon expressed the idea in a famous passage in his New Organon:

Now my method, though hard to practice, is easy to explain; and it is this. I propose to establish progressive stages of certainty. The evidence of the sense, helped and guarded by a certain process of correction, I retain. But the mental operation which follows the act of sense I for the most part reject; and instead of it I open and lay out a new and certain path for the mind to proceed in, starting directly from the simple sensuous perception. . . . There remains but one course for the recovery of a sound and healthy condition [of understanding]—namely, that the entire work of the understanding be commenced afresh, and the mind itself be from the very outset not left to take its own course, but guided at every step; and the business be done as if by machinery.6

For Bacon, as for Descartes, the new natural philosophy begins with skepticism—the setting aside of preconceived notions—and brings knowledge of and power over nature. And for both it originates in a deep moral imperative to serve human well-being and better the human condition.

Philosophers have interpreted this moral imperative in somewhat different ways, but it includes at least two principal directives. The first is an injunction to relieve suffering and conserve health, and the second is an injunction to extend emancipation—from fate, from social constraint, from the authority of tradition—and self-determination.7 These goals are particularly clear in the writings of Bacon and Descartes, who formulate their projects not in terms of the domination of nature but from a theological conviction that an instrumental approach to nature is required for the sake of God’s glory and human benefit.8 But even as these theological beliefs are slowly stripped away in the succeeding years, the humanitarian imperative remains, and in a sense expands, as the relief of suffering and freedom from necessity become ends in themselves and the yardstick by which every conception of order is subsequently measured.9

The cure of disease is integral to this enterprise from the beginning. The remediation of illness, the conserving of health, and the prolongation of life are central concerns of Bacon, especially in his later works, including New Atlantis (1620).10 So too for Descartes, who in the Discourse on the Method (1637) observes, “It is true that the medicine currently practiced contains few things whose usefulness is so noteworthy” and that “everything known in medicine is practically nothing in comparison with what remains to be known.” But he is confident that science will begin to determine the causes and uncover “all the remedies that nature has provided us” such that “one could rid oneself of an infinity of maladies, as much of the body as of the mind, and even perhaps also the frailty of old age. . . .”11 Despite the state of actual medical practice at the time, these heady ambitions, infused with the same moral purpose, decisively shaped the emerging scientific revolution. They are, in an important sense, what made the whole effort worthwhile.

The drivers of the revolution were the societies dedicated to scientific research that began to appear in the mid–seventeenth century. The society that emerged in England, the Royal Society, was directly animated by Bacon’s thinking. It grew out of informal meetings of educated men in London and Oxford in the mid-1640s who recognized, with Bacon, that the new science would be a public and collective endeavor. They called themselves an “invisible college” and met to discuss the new approach to investigating the natural world through experiment and observation. In 1660, the group, which included such leading figures as Christopher Wren and Robert Boyle, formally organized and was chartered in 1662 by Charles II as “The Royal Society of London for Improving Natural Knowledge.” Its motto was “Nullius in verba,” roughly “take nobody’s word for it,” a clear indicator of the break with traditional authority.12

Over the next century and more, the Royal Society and its journal the Philosophical Transactions, were the foremost institutions of experimental science in England. At its founding, most of the members were interested laymen (there were no female members until 1945), only a fraction of whom devoted themselves mainly to science.13 Over time, the Society helped to institutionalize the scientific enterprise, and many notable British scientists (and some early American ones; Benjamin Franklin was a member) were Fellows of the Royal Society, including Newton, who was president for more than twenty years. Similar organizations, inspired by the Royal Society, sprang up subsequently in France, Germany, and elsewhere. Collectively, they had a hand in most of the inventions that produced the Industrial Revolution. Later, Fellows of the Royal Society would be instrumental in two of the first great medical breakthroughs: Edward Jenner with the smallpox vaccine (1798) and Joseph Lister with antiseptic surgery (1860s).

Shortly after the founding of the Society, one of its members, Thomas Sprat, wrote a History of the Royal Society. In the book, published in 1667, Sprat provides the details of the Society’s founding, explains its scientific purposes, and describes some of the progress in experimental work. Heavily influenced by Bacon, whose image appears on the frontispiece, Sprat’s History provides a good window on Baconian assumptions at work with respect to medicine. Sprat also shares Bacon’s zeal for the immense and epoch-changing promise of the new natural philosophy, and his book is a bold apologia for the Society and all that it represents.

Sprat began his writing in 1664 but had to break it off because of the outbreak of the Great Plague in 1665, which was followed and partly stopped (the blaze consumed many infected rats) by the Great Fire of 1666. The Plague, an outbreak of bubonic plague, k...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction: Holism against Reductionism
• Part I. Reductionist Medicine in Cultural Context
• Part II. Reductionist Medicine and the Disease Burden
• Part III. The Need for a More Holistic Ethical Discourse
• About the Contributors
• Index