Healing & the...Word
April 28, 1998
[Editor's Note: The following essay forms part of the presentation by Charles B. Rodning, MD, Ph.D., FIGS, FACS, at the Harbinger symposium "Healing and the Spoken/Written Word" on April 23, 1998. Dr. Rodning is Professor and Vice-Chair of the Department of Surgery at the University of South Alabama.]
[Editor's note: The following essay was co-authored by Charles B. Rodning and Mark D. Williams, and appeared in Life on the Line: Selections on Words & Healing, an anthology co-edited by Sue Walker, Ph.D., and Rosally D. Roffman]
Homo sum; humani nihil a me alienum puto.
(I am a man; and nothing human is foreign to me.)
Heautontimaroumenos I, Terence (Publius Terentius Afer)
Vitruvian Man (Man in Circle and Square), created by Leonardo da Vinci, epitomizes a perception of humankind that existed during the Renaissance (Figure 1). The inherent harmony, measured proportions, and symmetry of a man are depicted, with the extended extremities subtending a circle and a square -- the most divine and perfect of geometric figures. The circle is centered on the umbilicus and is interpreted as the generative or maternal symbol. The square is centered on the symphysis pubis and is interpreted as the masculine or paternal symbol ("foursquare"). The widened stance forms a third geometric figure, an equilateral symbol bounded by the lower extremities. The balance and stability of this configuration, with the feet resting naturally on the surfaces and the hands stretched easily to the boundaries, depicts the reality of a human being, not an abstraction. It also depicts a vision of the incarnation of humankind -- harmoniously created in the image of the Divine, reaching to touch perfection.
The domain of the humanities (from the Latin humanus, "man") is broad and deep because it involves all the endeavors and relationships of humankind. Humanities denotes an attitude, a doctrine, or a way of life centered on human interests and values, especially a philosophy that asserts the dignity and worth of humankind and a capacity for self-realization by the application of reason and rationality. This capacity for self-realization occurs within interdependent cultural spheres of influence and interests, including artistic, economic, ethical, moral, historical, legal, literary, medical, philosophical, political, psychological, recreational, religious, and sociological.
Semiotically, humanitas can be interpreted as an entity and as a methodology. As an entity, humanitas ("humanism," "humanity," and "humanitarian") connotes a reaction to, and an attempt to interpret and explain, the multifarious world and universe in which humans are born, live, and die and in which they experience love and hate, triumph and defeat, joy and despair, hope and loss, pleasure and pain, health and disease, honor and humiliation, common sense and insanity, and wisdom and stupidity. As a methodology, humanitas ("humanize," "humane," "humanly," and "humanistic") connotes a system of nurture, education, development, and maturation employing reason and rationality for the benefit of humankind. Predicated on the evolution of sentience and linguistic, humans are qualitatively aware of their conditio humani and, by analogy, of that of other humans. These definitions and perspectives have substantial relevance to the relationships that form between patients and physicians vis-a-vis health and medical care.
The avowed goal of medical education is to develop a proper balance between the sciences and the humanities in preparing physicians to deliver that health and medical care. A study of the humanities enables physicians to develop what K.D. Clouster has referred to as "qualities of mind" or an awareness relevant to the nuance and subtlety of the patient-physician relationship. These qualities include incredulity, critical analytic skills, flexibility of perspective, discernment of values, nondogmatism, empathy, and self-knowledge. These skills are evermore required because of contemporary multicultural interactions. The dichotomy that currently exists between the sciences and the humanities has occurred because the ascendancy of science since the Middle Ages, and particularly during this century, has skewed this balance.
Life is short, art long, opportunity fleeting, experiment treacherous, judgment difficult.
"Aphorisms," Corpus Hippocraticum, Hippocrates
The ideational environment of contemporary physicians has been substantially influenced by the sciences. Physicians, unlike most persons, believe in science and that science can elucidate disease and illness. The fact that nonscientific variables may influence the content of the patient- physician relationship and may occasionally even supersede the ultimate therapeutic result poses a conundrum. This dilemma originates in and revolves around the distinction between the mechanistic reductionistic model of science and the biopsychological model of illness.
What are the humanities if not the study of scientific and nonscientific ideational environments? The language of the humanities, unlike the language of the sciences, is intensely personal and appeals to sensibilities. Ideational environments may be as real and as consequential for patients and physicians as biological, physical, and social environments. Knowledge of patients' ideational environments enables physicians to develop compassion, empathy, rapport, and understanding, which are essential components of the therapeutic milieu.
Study of the humanities also enables physicians to understand their own ideational environments and the subjective and objective philosophical scales underlying their value judgments that are rendered daily. An objective approach to an analysis of values, perhaps encouraged by scientific methodogic principles, implies an external value structure and a moral order of the world that can be judged as right or wrong, as typified by the formal ethics and morals espoused by Immanuel Kant and Judeo-Christian tradition. Most caregivers, including clinical medical ethicists and philosophers, prefer objectivity. In contrast, during this century, there has been a tremendous increase in the popularity of subjectivism, as expressed by the existentialist thought of Albert Camus and Jean-Paul Sartre. Values are perceived as idiosyncratic expressions of personal opinion and inner subjective feelings that cannot be evaluated as right or wrong. Cognizance, study, and discussion of these and other philosophical perspectives enable physicians to develop that attentiveness (from the Latin attendere, "to stretch toward") essential for the establishment of effective therapeutic relationships as they struggle intellectually with their attitudes regarding illness, the ill, scientific innovations, clinical productivity, and self-worth. Awareness and acknowledgment of these attitudes enable physicians to function with maturity and prudence.
If we have our own why of life, we shall get along with almost any how.
Twilight of the Idols
Friedrich Wilhelm Nietzche
Although the sciences and the humanities are linguistically and semiotically distinguished, the humanities actually encompass all human endeavors, including the sciences. The approach within each domain can be characterized as follows:
The goal of any discovery is to balance the scientific methodologic approach to answer how (what, when, where, and who) with the humanistic methodologic approach to answer why. It is axiomatic that the accretion of knowledge in the scientific domain has substantially influenced humankind's perception of its situation and status in relationship to the biosphere. This has been exemplified by the rendering of human anatomy by da Vinci, Vesalius, and Harvey; the heliocentric interpretation of the universe by Copernicus and Kepler; the chemistry of van Helmont, Priestly, and Lavoisier; the physics of Galileo, Newton, Farady, Gilbert, Bohr, Planck, and Einstein; the genetics of Mendel, Morgan, Watson, and Crick; the evolutionary theory of Darwin and Wallace; the introduction of vaccination by Jenner; the application of anesthesia by Long, Wells, and Morton; the concepts of asepsis and antisepsis by Semmelweis, Pasteur, and Koch; and the discovery of antibiotic medications by Ehrlich, Fleming and Waksman. The point to be emphasized is that the relationship between the sciences and the humanities is bi-directional, dynamic, and evolving.
Where is the wisdom we have lost in knowledge?
The Rock, Chorus I, T.S. Eliot
The intellectual or metaphorical gap or split that has developed between the sciences and the humanities is a characteristic of Occidental society since the Enlightenment. The split was the consequence of a search for certainty and universality of knowledge as a basis for social order and as a reaction to the irreconcilable and unresolvable conflicts in religious and political life that characterized the Reformation. This untethering of the sciences from overt ecclesiastical and political control resulted in unprecedented growth in the understanding of human biology and in the application of this knowledge to medicine. However, this metaphorical split between the sciences and the humanities, what C.P. Snow has referred to as a "two-culture gap," has been detrimental to the relationship between patients and physicians, between scientists and clinicians, and between the medical profession and the public. A scientific world suffused with professional norms, procedures, priorities, and standards is discordant with a humanistic world suffused with fears, hopes, opinions, and values.
This perceived gap, the isolation and separation of the sciences from culture such that science is a value-neutral cognitive system that produce universal truths, is an illusion. The sciences are and must be subservient to human values, as philosophical and sociological observations and studies have repeatedly demonstrated. Can society justify spending billions of dollars to determine the sequence of the human genome while children are suffering from and dying of malnutrition and preventable diseases? Which endeavor has greater beneficence and value, or are they equivalent? A failure to understand and apply humanistic as well as scientific principles to articulate answers to these and other questions exposes the medical profession to criticism for being complacent and self- serving.
Education, properly understood, is that which teaches discernment.
Meditations of a Parish Priest
Organized conventional medicine has been characterized as possessing an abundance of knowledge (sciences) and a paucity of wisdom (humanities); thus, it has been criticized for excessive reliance on scientific fact and insufficient emphasis on values, caring, personal relationships, and social skills. in addition, no universally accepted curriculum incorporating the humanities currently exists. Both perspectives have contributed to a consensus that curricula must be re-oriented properly to serve current and future social contingencies, constituencies, mandates, and requirements. The Edinburgh Declaration of the World Council on Medical Education is exemplary of this re-orientation and evolving philosophy to heighten emphasis on the humanities.
Several authorities have recommended formal education in the humanities at the undergraduate, graduate, or postgraduate levels. Bibliographies containing primary and secondary sources from our Occidental cultural heritage have been compiled that include science, economics, history, politics, literature, philosophy, religion, psychology, and sociology. Systematic and thorough study of such a curriculum is a challenge that would require substantial commitment, conscientiousness, dedication, and will by students and physicians. However, the intellectual rewards and enhanced ability to serve patients are potentially great if physicians would but recall the Oslerian perspective of medical education as "a life-course, ending only with death." Physicians must also counteract the tendency of modern industrial society to trivialize the literary masterpieces of our predecessors. Although it is impossible to prove scientifically, common sense suggests that the intellectual and cultural heritage of Occidental society is a correlatively valid source of information and insight within the realm of medical education, health and medical care, and patient- physician relationships. Study of the humanities enables physicians to place scientific and nonscientific issues in appropriate and relevant contexts. The literary masterpieces of our predecessors remain contextually meaningful and remind physicians that they do not function in a vacuum but rather serve as a part of the cultural heritage and tradition of contemporary society.
Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.
Humanism and the Physician
-- E.D. Pellegrino
A section of the Corpus Hippocraticum entitled "Of the epidemics" records that the practice of medicine "consists in three things: the patient, the disease, and the physician. The physician is the servant of the art...it is the patient who must combat the disease along with the physician." According to this tradition, physicians vow "first to do good and to do no harm." This celebrated summary of the practice of medicine is indicative of the accumulated knowledge and wisdom that a "compleat" physician must possess to achieve enpowerment, entitlement, and mastery of the discipline.
A physician must be scientific. A physician must know about diseases in general and be able to classify diseases according to their etiologies, symptoms and signs, pathophysiologies, and natural histories. Such knowledge underlies a physician's diagnosis of a patient's malady. This in turn facilitates assessment of the prognosis and the stages through which an illness will progress, from its onset, through various crises or turning points, to its sequelae or consequences. The accuracy of the diagnosis and the certainty of the prognosis influence the effectiveness of any remedy a physician prescribes to achieve cure or palliation.
However, a physician must also be humanistic. Patients are never identical. A physician must know a patient as an individual, and all the relevant circumstances of that individual's life, as well as the particular characteristics of the illness, must be discerned. The Hippocratic conception of a physician's work favors the practice of general medicine rather than divisive subspecialization. An individual, not the disease per se, is to be treated, and to treat that individual well, a physician must examine the patient as a whole, not merely the organ or system involved. The formula for obtaining a case history, for example, mandates an inquiry into the patient's life:
...his antecedents, his occupation, his temperament, habits, regimen, and pursuits; his conversation, manners, taciturnity, thoughts, sleep, and sometimes his dreams, what they are and when they occur; his picking and scratching; his tears -- from there as well as from symptoms and signs, we form our judgment.
A physician must recognize and attend to the patient as a unique individual.
Finally, a physician must be artistic. The practice of medicine requires more then scientific and humanistic knowledge of health and disease. It requires the sort of experience that can be acquired only from actual practice -- the arts of medicine. Physicians are called on to apply all the knowledge and wisdom they have acquired as they focus on the care of an individual patient. This integrative process introduces an element of artistry, mystery, and subjectivity into the entire endeavor because knowledge of the human organism, as sophisticated as it may currently be, remains elementary. Decisions about patient care are often rendered on the basis of incomplete, and occasionally even incorrect, information. It is prudence acquired by experience that enables physicians to cope with this burden and to help their patients cope with this burden.
Unto whomsoever much is given, of him shall be much required.
-- Luke, The Physician, 12:48 Bible
(King James Version)
Physicians can create a milieu for healing to occur, an incompletely understood physical and psychological biologic phenomenon; however, physicians cannot, no matter what their prowess, cause healing to occur. Physicians must recognize this distinction. Scientia can answer how something occurred, but it cannot answer why something occurred or the moral value of the occurrence. For the latter, physicians must apply humanitas. Physicians must guard against using the sciences to answer why, just as they must guard against using the humanities to answer how. Doctors (from the Latin docere, "to teach") must educate their patients and their students to address and understand this eternal dichotomy. In treating something as complex as the human organism, the sciences and the humanities serve bilateral, complementary, interdependent, and mutual roles.
Linkage between how and why and between the sciences and the humanities is needed. The art of medicine serves as the link. To speak of right action in medicine, to define disease and illness, or to enjoin the preservation of human health presupposes ideals of human well-being. Because medical therapies involve the manipulation of human nature, all the traditional philosophical questions about what one can know, what one ought to do, and how one should use technocratic power are raised in contexts intimately bound to human life, suffering, and death. Comprehending and explaining the workings of the human organism must be commensurate and compatible with a realistic and achievable goal of maximal restoration of health for patients. The sciences and the humanities should ideally inhabit the intellectual milieu, the ideational environment, of every physician if physicians are to serve their patients with authority, excellence, expertise, and foresight -- striving to achieve mastery, "reaching to touch perfection."
The aim of medical education is to produce doctors who will promote the health of all people, and that aim is not being realized in many places, despite the enormous progress that has been made during this century in the biomedical sciences. The individual patient should be able to expect a doctor trained as an attentive listener, a careful observer, a sensitive communicator, and an effective clinician; but it is no longer enough only to treat some of the sick. Thousands suffer and die every day from diseases which are preventable, curable, or self-inflicted, and millions have no ready access to health care of any kind...
Scientific research continues to bring rich rewards, but man needs more than science alone, and it is the health needs of the human race as a whole, and of the whole person, that medical education must affirm...
1. Enlarge the range of setting in which educational programs are conducted, to include all health resource of the community, not hospitals alone...
3. Ensure continuity of learning throughout life, shifting emphasis from the passive methods so widespread now to more active learning, including self-directed and independent study as well as tutorial methods.
4. Build both curriculum and examination systems to ensure the achievement of professional competence and social values, not merely the retention and recall of information.
5. Train teachers as educators, not solely experts in content, and reward educational excellence as fully as excellence in biomedical research or clinical practice...
Reform of medical education requires more than agreement; it requires a widespread commitment to action, vigorous leadership, and political will...
By this declaration we pledge ourselves and call on others to join us in a sustained and organized program to alter the character of medical education so that it truly meets the defined needs of the society in which it is situated. We also pledge ourselves to create the organizational framework required for these solemn words to be translated into sustained and effective action. The stage is set; the time for action is upon us.