A new path for humanistic medicine

Abstract

According to recent approaches in the philosophy of medicine, biomedicine should be replaced or complemented by a humanistic medical model. Two humanistic approaches, narrative medicine and the phenomenology of medicine, have grown particularly popular in recent decades. This paper first suggests that these humanistic criticisms of biomedicine are insufficient. A central problem is that both approaches seem to offer a straw man definition of biomedicine. It then argues that the subsequent definition of humanism found in these approaches is problematically reduced to a compassionate or psychological understanding. My main claims are that humanism cannot be sought in the patient–physician relationship alone and that a broad definition of medicine should help to revisit humanism. With this end in view, I defend what I call an outcomes-oriented approach to humanistic medicine, where humanism is set upon the capacity for a health system to produce good health outcomes.

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Notes

  1. 1.

    Quoted by [14].

  2. 2.

    See also [19] for a detailed criticism of the use of conceptual analysis in the philosophy of medicine.

  3. 3.

    The reduction of science to biology alone is often found in the narrative medicine literature. Science is described as capable of dealing only with the biological aspect of disease.

  4. 4.

    By contrast, Ashrafunnesa Khanom et al. merely claim that narrative inquiry will lead to more “humane discourses in the context of health services research” [28, p. 555].

  5. 5.

    It should made be clear, however, that this critique does not aim to cast doubt on the whole narrative medicine enterprise: extremely well-done and interesting analyses of patients’ stories exist (see, e.g., [28]). My target is merely the key theoretical basis of the narrative approach: criticizing biomedicine. It should also be noted that narrative works do not have to make specific claims against biomedicine or in favor of humanism, although they often do.

  6. 6.

    The term “bald naturalism” is also found; see [34].

  7. 7.

    The terms “ontological” and “epistemic” are sometimes found in place of “metaphysical” and “epistemological,” respectively; see [35].

  8. 8.

    Although I agree that it is not clear, see below.

  9. 9.

    It should be noted that my argument here stands only against the criticism of biomedicine found in the current approaches to the phenomenology of medicine. The phenomenology of medicine encompasses a complex and rich bundle of claims, the descriptions and assessments of which are outside the scope of this paper.

  10. 10.

    I discard two other meanings: humanism as in the study of humanities, and humanism as in the intellectual movement during the Renaissance. Although less relevant, these two connotations are often implicitly present in the background, especially, for instance, in the case of narrative medicine and other types of medical humanities; see [17, pp. 31-32].

  11. 11.

    See also Carel [6, p. 54]: “The complaint that seems to appear near-universal in this context is: why am I not treated as a person?”.

  12. 12.

    Much of psychology, however, is not focused on the subjective experience, as elaborated below.

  13. 13.

    Daniel Sulmasy would also add patients’ spiritual needs [17].

  14. 14.

    Solomon sees in this theme the cultural importance of individuality in the Anglo-Saxon world, especially in the United States [14].

  15. 15.

    It should be noted that there is a whole movement in psychology called humanistic psychology. This movement, introduced by Carl Rogers [40] and Abraham Maslow [41], aims to emphasize the subjective individual and the importance of the self in psychology. Although humanistic psychology is beyond the scope of this paper, my argument against the compassionate use of humanism in narrative medicine and the phenomenology of medicine could probably be applied against the use of humanism in that movement as well. However, I see no reason to restrict medical humanism to what humanism means in that specific psychology movement.

  16. 16.

    Despite Carel’s insistence that she is not asking for warm fuzzy doctors, it is unclear how exactly she can avoid the criticism. “My revolt against the attitude towards illness that is common in the medical world is not a sentimental one. I am not suggesting that health professionals' precious time be wasted on feel-good chatting…. Could some genuine care be introduced to the exchange?” [6, p. 50].

  17. 17.

    Health systems are indeed extremely different from one country to another.

  18. 18.

    This question can be understood in different ways. Whether medicine’s aim is to treat illness or to promote health is not directly pertinent to my argument, so I will not address this here.

  19. 19.

    I refer to the naturalistic trend in the philosophy of science according to which, briefly speaking, science is what scientists do.

  20. 20.

    It is not necessary to defend Engel’s biopsychosocial here. It is enough to show that public health—albeit being a scientific approach that relies on statistics and the study of populations—does not reduce patients to their physical bodies. This also illustrates that focusing only on patients as individual psychological beings is insufficient even on humanistic approaches’ own terms as it clashes with their social environment.

  21. 21.

    The Institute is unique in French health policy. It is distinct from the government and open to private sector organizations like professional and patient associations as well as to health insurance funds.

  22. 22.

    Herceptin is used to treat breast cancer.

  23. 23.

    It should be noted that it is often administratively difficult for a patient to go through this protocol in cases where there is no political will to facilitate the procedure for one specific drug or in the case of early or pre-trial drugs.

  24. 24.

    The Pharmaceutical Benefits Scheme provides subsidies for prescription drugs to residents of Australia.

  25. 25.

    See [46, 47].

  26. 26.

    In fact, individual-centered approaches are traditionally suspicious from a humanistic point of view. For instance, Jean-Paul Sartre’s existentialism (and subjectivist approach) was strongly criticized by tenants of humanism. His famous short book, L’existentialisme est un humanisme was written precisely to address their attack.

  27. 27.

    This reformist and progressive view of humanism can be credited to Pierre-Joseph Proudhon and to later thinkers such as John Dewey, Charles Francis Potter, William James, Karl Jaspers, and Maurice Merleau-Ponty.

  28. 28.

    Article 11 of the Preamble to French Constitution of 27 October 1946, Fourth constitution of French Republic.

  29. 29.

    Article L11110-1 of French Public Health Code, law of 4 March 2002.

  30. 30.

    Compare this to the polemical compassionate use of drugs in the recent Ebola pandemic, where pre-experimental drugs were given in and out of clinical studies [50, 51]. In these cases, drugs were given not because they were the best drugs available but because no other drugs were available. Here “compassion” is taken in a strong emotional sense.

  31. 31.

    It goes without saying that the “best” treatments are determined by physicians based on scientific data and not by lawmakers. Furthermore, there are obviously limits to the resources that need to be compromised.

  32. 32.

    I do not mean to imply that doing so is easy, but it seems clearly possible.

  33. 33.

    However, Charon argues that narrative skills allow physicians to work faster.

  34. 34.

    It should be noted that ethics has already provided extensive analyses about how the clinical encounter should and should not occur.

  35. 35.

    The conditions and consequences of said blood testing in a particular situation could, however, be studied.

  36. 36.

    See WHO report on the performance of health systems [43].

  37. 37.

    Of course, defining what a good doctor or a good medicine should be is ambiguous between good as in “efficient” and good as in “morally good.” It seems that a morally good doctor should be as efficient as possible, but I will leave this question aside for now.

  38. 38.

    Examples have also shown that health systems are consistently built on difficult compromises and difficult decisions. Additionally, it should be noted that patient-centered care is one type of humanistic approach that has been successfully implemented in France and elsewhere. They can both emerge from local initiatives or from higher impulses.

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Acknowledgements

I would like to thank the two anonymous Theoretical Medicine and Bioethics reviewers for their comments. I would also like to thank the participants of the “Medical Knowledge in a Social World” workshop held in 2016 at University of California, Irvine for their helpful comments and encouragements. Special thanks go to Guillaume Didier and James Angove for proofreading earlier stages of this work. Finally, I extend my most sincere gratitude to the managing editor of the journal Katelyn MacDougald for her fabulous work on the final version of this paper.

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Correspondence to Juliette Ferry-Danini.

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Ferry-Danini, J. A new path for humanistic medicine. Theor Med Bioeth 39, 57–77 (2018). https://doi.org/10.1007/s11017-018-9433-4

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Keywords

  • Humanistic medicine
  • Narrative medicine
  • Phenomenology
  • Biomedicine
  • Health systemic
  • French cancer plans