Inclusion of medical humanities as a staple in medical curriculum

Wednesday, April 2, 2014

by Dr Ashok Jahnavi Prasad 

To conceptualize medicine purely in scientific terms is the biggest disservice that can be done to this discipline. Medicine has an inbuilt humanistic dimension, removal of which is akin to a body without a soul. — Sir William Osler

Dr Ashok Jahnavi Prasad

How true the words of this all-time great ring today. I recall Dr S S Singhal, one of my teachers during my medical school days, describing Osler as the greatest clinician that ever lived. While we may debate this assessment, the consensus is that Osler’s words of wisdom have had an enormous impact on contemporary medical practice. Sadly though, we seem to have completely overlooked this particular advice of the genius.

Any scientific discipline requires a humanistic base to sustain itself and none more so than medicine. Yet the cruel irony remains that the humanistic dimension is almost completely ignored in contemporary medical practice at very level.

There is no credible emphasis on training medical students to develop a humanistic dimension. By and large this is a worldwide problem but is certainly more pronounced in India and other developing countries. The neglect has resulted in a multitude of problems not just for the physicians but the patients we serve — small wonder then a large percentage of sufferers have started taking refuge in alternative medicine modalities available all over the world.

While this problem is obvious to all concerned there has been no credible effort to institute measures to curtail its deleterious consequences. Admittedly some major centres in North America and Europe have established Medical Humanities departments, by and large they are viewed as esoteric appendages to the medical curricula and their importance is not emphasized in the medical examinations. (One notable exception is the Harvard Medical School where giants like my mentor Leon Eisenberg and later Arthur Kleinman conducted pioneering work.)

The salient question that should bedevil us is:
a) What is the scope of medical humanities?
b) What is its importance to merit its inclusion in the already overburdened medical curricula?

To respond to these legitimate queries, we have to delve a little into the history of medicine and I believe that late Roy Porter’s marvellous and eminently readable volume viz. ‘The Greatest Benefit to Mankind: A Medical History of Humanity’, which details the development of the medical profession over centuries is an elegant eye opener. I was privileged to associate with Roy and was delighted to have earned his professional friendship when I recommended him for the Fellowship of the Royal Historical Society where he played a seminal role. Roy adumbrates how during the ancient times in Greece, philosophers and physicians enjoyed a mutually symbiotic relationship — one could not aspire to be a physician unless he was a qualified philosopher. Galen and Paracelsus had their primary identity as philosophers. It was only when scientific pioneers like Claude Bernard, Koch and Pasteur presented their findings that humanities was almost completely sidelined and Elisha Bartlett in 1844 contended that Medical Philosophy should be seen as a completely distinct discipline to medicine — and that is the general trend that seems to have dominated the medical ethos as it exists today.

The time has come for us to take stock and reflect whether this trend has benefitted us or are we losing a vital part of our therapeutic armamentarium by persisting with the existing arrangement.

To understand what medical humanities, in particular philosophical medicine, offers we have to view our profession through metaphysical, epistemological and ethical prisms.

Metaphysics

One branch of metaphysics, denoted ontology, investigates problems and questions concerning the nature and existence of objects or events and their associated forces or factors. For philosophy of medicine in the twenty-first century, the two chief objects are the patient’s disease and health, along with the forces or factors responsible for causing them. “What is/causes health?” and “What is/causes disease?” are contentious questions for philosophers of medicine. Reductionism, broadly construed, is the diminution of complex objects or events to their component parts. For the life sciences vis-à-vis reductionism, an organism is made of component parts like bio-macromolecules and cells, whose properties are sufficient for investigating and explaining the organism, if not life itself. Life scientists often sort these parts into a descending hierarchy. Beginning with the organism, they proceed downward through organ systems, individual organs, tissues, cells, and macromolecules until reaching the atomic and subatomic levels. Albert Szent-Gyorgyi once remarked, as he descended this hierarchy in his quest for understanding living organisms, “life slipped between his fingers.” Holism, however, is the position that the properties of the whole are not reducible to properties of its individual components. Jan Smuts (1926) introduced the term in the early part of the twentieth century, especially with respect to biological evolution, to account for living processes — without the need for immaterial components.

Reductionism influences not only how a biomedical scientist investigates and explains disease, but also how a clinician diagnoses and treats it. For example, if a biomedical researcher believes that the underlying cause of a mental disease is dysfunction in brain processes or mechanisms, especially at the molecular level, then that disease is often investigated exclusively at that level. In turn, a clinician classifies mental diseases in terms of brain processes or mechanisms at the molecular level, such as depletion in levels of the neurotransmitter serotonin. Subsequently, the disease is treated pharmacologically by prescribing drugs to elevate the low levels of the neurotransmitter in the depressed brain to levels considered normal within the non-depressed brain. Although the assumption of reductionism produces a detailed understanding of diseases in molecular or mechanistic terms, many clinicians and patients are dissatisfied with the assumption. Both clinicians and patients feel that the assumption excludes important information concerning the nature of the disease, as it influences both the patient’s illness and life experience.

Realism is the philosophical notion that observable objects and events are actual objects and events, independent of the person observing them. Proponents of realism also espouse that even unobservable objects and events, like subatomic particles, exist. Anti-realism, on the other hand, is the philosophical notion that observable objects and events are not actual objects and events as observed by a person but rather they are dependent upon the person observing them. The debate among realists and anti-realists has important implications for philosophers of medicine, as well as for the practice of clinical medicine. For example, a contentious issue is whether disease entities or conditions for the expression of a disease are real or not. Realists argue that such entities or conditions are real and exist independent of medical researchers investigating them, while anti-realists deny their reality and existence. Take the example of depression. According to realists, the neurotransmitter serotonin is a real entity that exists in a real brain — apart from clinical investigations or investigators.

For philosophers of medicine, causation is another important notion for analysing both disease etiology and therapeutic efficacy. At the molecular level, causation operates physico-chemically to investigate and explain disease mechanisms. In the example of depression, serotonin is a neurotransmitter that binds specific receptors within certain brain locations, which in turn causes a cascade of molecular events in maintaining mental health. This underlying causal or physical mechanism is critical not only for understanding the disease, but also for treating it. Medical causation also operates at other levels. For infectious diseases, the Henle-Koch postulates are important in determining the causal relationship between an infectious microorganism and an infected host. To secure that relationship the microorganism must be associated with every occurrence of the disease, be isolated from the infected host, be grown under in vitro conditions, and be shown to elicit the disease upon infection of a healthy host. Finally, medical causation operates at the epidemiological or population level. Here, Austin Bradford Hill’s nine criteria are critical for establishing a causal relationship between environmental factors and disease incidence.

“What is disease?” is a contentious question among philosophers of medicine. These philosophers distinguish among four different notions of disease. The first is an ontological notion. According to its proponents, disease is a palpable object or entity whose existence is distinct from that of the diseased patient. For example, disease may be the condition brought on by the infection of a microorganism, such as a virus. Critics, who champion a physiological notion of disease, argue that advocates of the ontological notion confuse the disease condition, which is an abstract notion, with a concrete entity like a virus.

“What is health?” is an equally contentious question among philosophers of medicine. The most common notion of health is simply absence of disease. Health, according to proponents of this notion, represents a default state as opposed to pathology. In other words, if an organism is not sick then it must be healthy. Unfortunately, this notion does not distinguish between various grades of health or preconditions towards illness. For example, as cells responsible for serotonin stop producing the neurotransmitter a person is prone to depression. Such a person is not as healthful as a person who is making sufficient amounts of serotonin. An adequate understanding of health should account for such preconditions. Moreover, health as absence of disease often depends upon personal and social values of what is health.

Epistemology

Epistemology is the branch of philosophy concerned with the analysis of knowledge, in terms of both its origins and justification. The overarching question is, “What is knowing or knowledge?” Subsidiary questions include, “How do we know that we know?”; “Are we certain or confident in our knowing or knowledge?”; “What is it we know when we claim we know?” Philosophers generally distinguish three kinds or theories of knowledge. The first pertains to knowledge by acquaintance, in which a knowing or an epistemic agent is familiar with an object or event. It is descriptive in nature, that is, a knowing-about knowledge. For example, a surgeon is well acquainted with the body’s anatomy before performing an operation. The second is competence knowledge, which is the species of knowledge useful for performing a task skilfully. It is performative or procedural in nature, that is, a knowing-how knowledge. Again, by way of example, the surgeon must know how to perform a specific surgical procedure before executing it. The third, which interests philosophers most, is propositional knowledge. It pertains to certain truths or facts.

The rationalism-empiricism debate has a long history, beginning with the ancient Greeks, and focuses on the origins of knowledge and its justification. “Is that origin rational or empirical in nature?” The rationalism-empiricism debate originates specifically with ancient Greek and Roman medicine. The Dogmatic school of medicine, founded by Hippocrates’ son and son-in-law in the fourth century BCE, claimed that reason is sufficient for understanding the underlying causes of diseases and thereby for treating them. Dogmatics relied on theory, especially the humoral theory of health and disease, to practice medicine. The Empiric school of medicine, on the other hand, asserted that only observation and experience, not theory, is a sufficient foundation for medical knowledge and practice. Theory is an outcome of medical observation and experience, not their foundation. Empirics relied on palpable, not underlying, causes to explain health and disease and to practice medicine. Philinus of Cos and his successor Serapion of Alexandria, both third century BCE Greek physicians, are credited with founding the Empiric school, which included the influential Alexandrian school. A third school of medicine arose in response to the debate between the Dogmatics and Empirics, the Methodic school of medicine. In contrast to Dogmatics, and in agreement with Empirics, Methodics argued that underlying causes are superfluous to the practice of medicine. Rather, the patient’s immediate symptoms, along with common sense, are sufficient and provide the necessary information to treat the patient. Thus, in contrast to Empirics, Methodics argued that experience is unnecessary to treat disease and that the disease’s symptoms provide all the knowledge needed to practice medicine.

“How doctors think” is the title of two twenty-first century books on medical thinking. The first is by a medical humanities scholar, Kathryn Montgomery (2006). Montgomery addresses vital questions about how physicians go about making clinical decisions when often faced with tangible uncertainty. She argues for medical thinking based not on science but on Aristotelian phronesis, or practical or intuitive reasoning. The second book is by a practicing clinician, Jerome Groopman (2007). Groopman also addresses questions about medical thinking, and he too pleads for clinical reasoning based on practical or intuitive foundations. Both books call for introducing the art of medical thinking to offset the over dependence on the science of medical thinking. In general, medical thinking reflects the cognitive faculties of clinicians to make rational decisions about what ails patients and how best to go about treating them both safely and effectively. That thinking, during the twentieth century, mimicked the technical thinking of natural scientists — and, for good reason. As Paul Meehl (1954) convincingly demonstrated, statistical reasoning in the clinical setting out performs intuitive clinical thinking.

Georg Stahl’s De logico medica, published in 1702, is one of the first modern treatises on medical logic. However, not until the nineteenth century did logic of medicine become an important area of sustained analysis or have an impact on medical knowledge and practice. For example, Friedrich Oesterlen’s Medical Logic, published in English translation in 1855, promoted medical logic not only as a tool for assessing the formal relationship between propositional statements and thereby avoiding clinical error, but also for analysing the relationship among medical facts and evidence in the generation of medical knowledge. Oesterlen’s logic of medicine was indebted to the Paris school of clinical medicine, especially Pierre Louis’ numerical method.

Philosophers of medicine actively debate the best courses of action for making clinical decisions. For, clinical judgment is an informal process in which a clinician assesses a patient’s clinical signs and symptoms to come to an accurate judgment about what is ailing the patient. To make such a judgment requires an insight into the intelligibility of the clinical evidence. The issue for philosophers of medicine is what role intuition should play in clinical judgment when facing the ideals of objective scientific reasoning and judgment. Meehl’s work on clinical judgment, as noted earlier casted suspicion on the effectiveness of intuition in clinical judgment; and yet, some philosophers of medicine champion the understood dimension in such decision-making. The debate often reduces to whether clinical judgment is an art or a science; however, some, like Alvan Feinstein (1994), argue for a reconciliatory position between them. Once a physician comes to a judgment then the physician must make a decision as to how to proceed clinically.

Diagnostic knowledge pertains to the clinical judgments and decisions made about what ails a patient. Epistemologically, the issues concerned with such knowledge are its accuracy and certainty. Central to both these concerns are clinical symptoms and signs. Clinical symptoms are subjective manifestations of the disease that the patient articulates during the medical interview, while clinical signs are objective manifestations that the physician discovers during the physical examine. What is important for the clinician is how best to quantify those signs and symptoms, and then to classify them in a robust nosology or disease taxonomy. Philosophers of medicine especially dispute the role of tacit factors in the process. Finally, the heuristics of the process are an active area of philosophical investigation in terms of identifying rules for interpreting clinical evidence and observations.

Ethics

Ethics is the branch of philosophy concerned with the right or moral conduct or behaviour of a community and its members. Traditionally, philosophers divide ethics into descriptive, normative, and applied ethics. Descriptive ethics involves detailing ethical conduct without evaluating it in terms of moral codes of conduct, whereas normative ethics pertains to how a community and its members should act under given situations, generally in terms of an ethical code. This code is often a product of certain values held in common within a community. For example, ethical codes against murder reflect values community members place upon taking human life without just cause. Besides values, ethicists base normative ethics on a particular theoretical perspective. Within western culture, three such perspectives predominate. The first and historically oldest ethical theory — although it experienced a Renaissance in the late twentieth century — is virtue ethics. Virtue ethics claims that ethical conduct is the product of a moral agent who possesses certain virtues, such as prudence, courage, temperance, or justice — the traditional cardinal virtues. The second ethical theory is deontology and bases moral conduct on adherence to ethical precepts and rules reflecting moral duties and obligations. The third ethical theory is consequentialism, which founds moral conduct on the outcome or consequence of an action. The chief example of this theory is utilitarianism, or the maximization of an action’s utility, which claims that an action is moral if it realizes the greatest amount of happiness for the greatest number of community members. Finally, applied ethics is the practical use of ethics within a profession such as business or medicine. Medical or biomedical ethics reflects applied ethics and is a major feature within the landscape of twenty-first century medicine. Historically, ethical issues are a conspicuous component of medicine beginning with Hippocrates.

According to many philosophers of medicine, medicine is more than simply a natural or social science; it is a moral enterprise. What makes medicine moral is the patient-physician or therapeutic relationship. Although some philosophers of medicine criticize efforts to model the relationship, given the sheer number of contemporary models proposed to account for it, modelling the relationship has important ramifications for understanding and framing the moral demands of medicine and healthcare.

The traditional medical model within the industrialized West, especially in mid-twentieth century America, was paternalism or “doctor knows best.” The paternalistic model is doctor-centred in terms of power distribution, with the patient representing a passive agent who simply follows the doctor’s orders. The patient is not to question those orders, unless to clarify them. The source for this power distribution is the doctor’s extensive medical education and training relative to the patient’s lack of medical knowledge. In this model, the doctor represents a parent, generally a father figure and the patient a child — especially a sick child. The motivation of this model is to relieve a patient burdened with suffering from a disease, to benefit the patient from the doctor’s medical knowledge, and to affect a cure while returning the patient to health. In other words, the model’s guiding principle is beneficence.

Within the latter part of the twentieth century and the rise of patient autonomy as a guiding principle for medical practice, alternative patient-physician models challenged traditional medical paternalism. Instead of doctor-centred, one set of models are patient-centred in which patients are the locus of power. The most predominant patient-centred model is the business model, where the physician is a healthcare provider and the patient a consumer of healthcare goods and services. The business model is an exchange relationship and relies heavily on a free market system. Thus, the patient possesses the power to pick and choose among physicians until a suitable healthcare provider is found. The legal model is another patient-centred model, in which the patient is a client and the guiding forces are patient autonomy and justice. Patient and physician enter into a contract for healthcare services.

Philosophy of medicine is a vibrant field of exploration into the world of medicine in particular, and of healthcare in general. Along traditional lines of metaphysics, epistemology, and ethics, a cadre of questions and problems face philosophers of medicine and cry out for attention and resolution. In addition, many competing forces are vying for the soul of medicine today. Philosophy of medicine is an important resource for reflecting on those forces in order to forge a medicine that meets both physical and existence needs of patients and society.

To conclude, I must add that my own journey began as a medical scientist — my first doctorate and higher doctorate were in medical science. It was only after delving into the humanistic vacuum surrounding me that I started gravitating more and more into medical humanities and having worked towards doctorates in medical existentialism and history of medicine has considerably broadened my understanding. As an existential philosopher, I can state that we ignore the questions posed by philosophers of medicine at our own peril.

My fervent desire since my relocation (to India) has been to initiate a debate for the inclusion of medical humanities as a staple in medical curriculum and towards this end I have had several exchanges with the leaders of the medical fraternity. I firmly believe that humanistic insight is just as essential in contemporary medicine as scientific prism. It is interesting that orthodox Ayurvedic and Unani traditions also lay a very strong emphasis on this dimension.

Medical curriculum is overburdened and I would be the first to concede that. But can we remain silent spectators to the erosion of humanism from the profession of ours! The time for serious reflection is here!

(Some parts of this article constituted Galen Oration delivered by the author very recently in Zuerich.)

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