Abstract
Although typically implicit, clinicians face an inherent conflict between their roles as medical healers and as providers of technical biomedicine (Scott et al. in Philos Ethics Humanit Med 4:11, 2009). This conflict arises from the tension between the physicalist model which still predominates in medical training and practice and the extra-physicalist dimensions of medical practice as epitomised in the concept of patient-centred care. More specifically, the problem is that, as grounded in a “borrowed” physicalist philosophy, the dominant “applied scientist” model exhibits a number of limitations which severely restrict its ability to underwrite the effective practice of care. Moreover, being structural in character, these problems cannot be resolved by piecemeal modifications of the existing model, nor by an appeal to evidence-based medicine (Miles in J Eval Clin Pract 15(6):887–890, 2009; Miles in Folia Med 55(1):5–24, 2013; Miles et al. in J Eval Clin Pract 14(5):621–649, 2008). Hence, the need for medical theorists to “partner with experts in the humanities to build a sui generis philosophy of medicine” (Whatley in J Eval Clin Pract 20(6):961–964, 2014, p. 961). In response, the present paper seeks to vindicate the merits of hermeneutically-informed template in providing the requisite grounding. While capable of correcting for the limitations of the applied scientist model, a hermeneutically-informed template is a “both/and” approach, which seeks to complement rather than exclude the physicalist dimension, and thereby aspires to reconcile technical mastery with patient-centred care, rather than eschew one in favour of the other. As such, it can provide a cogent philosophical template for current best practice, which does justice to the art as well as the science of medical care.
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Notes
Thus, as Tymieniecka and Agazzi put it, the aim is to foster “a more mature consciousness” oriented toward the development of “a medicine better in keeping with its task of taking care of the patients in the global perception of their needs” (2001, p. xiii).
While Polkinghorne’s area of specialisation is psychological counselling, his book addresses philosophical issues pertaining to the practice of care more generally, including medical practice.
In delineating a hermeneutic template appropriate for the medical context, I draw on the work of Hans-Georg Gadamer, with particular reference to concepts developed in his major work, Truth and Method (Gadamer 1989). In so doing, I go beyond Gadamer himself in seeking to crystallise their application to patient-centred care. Moreover, like other hermeneutically-informed commentators (e.g., Árnason 2000; Landes 2015; Svenaeus 2003; Widdershoven 2000), I find the themes developed in Gadamer’s major work (such as I–Thou relations, phronesis, and dialogue) more directly relevant in this connection than the ideas proffered in his later collection of essays entitled The Enigma of Health (Gadamer 1996).
As Svenaeus puts it: “The clinical encounter can be viewed as a coming-together of the two different attitudes and lifeworlds of doctor and patient—in the language of Gadamer, of their different horizons of understanding—aimed at establishing a mutual understanding, which can benefit the health of the ill party” (2003, p. 416).
This could be further explicated in terms of the “transformative” use of power and knowledge whereby, as elaborated by Wartenberg (1990, chap. 10), the imbalance is used productively to enhance the well-being of the relatively disempowered participant (here, the patient).
Hence, although from a positivistic EBM perspective uncertainty is typically regarded as an untenable limitation, with Popper, a hermeneutic approach endorses uncertainty as an ineliminable hallmark of scientific inquiry, and embraces its potential to stimulate an investigative, discovery-oriented form of inquiry (cf. Buetow 2001; Sturmberg and Martin 2008).
Ruitenberg epitomises what is at issue as follows:
“… the technically skilful application of scientific and technological resources alone does not make one a doctor; for that, one also needs to be able to reach a thoughtful professional judgement about what the patient needs are that this skilful application purportedly serves, and whether the various needs of the patient—as there is never just one—are relatively better served with this, or another, or perhaps a combination of skilful applications of scientific and technological resources. …the acquisition of scientific knowledge and training in technical skills are necessary but not sufficient for the preparation of doctors” (2013, p. 957).
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Healy, P. Rethinking the doctor–patient relationship: toward a hermeneutically-informed epistemology of medical practice. Med Health Care and Philos 22, 287–295 (2019). https://doi.org/10.1007/s11019-018-9875-5
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DOI: https://doi.org/10.1007/s11019-018-9875-5