LOOK at health-care reform through a philosopher's eyes.
What if the task of genuine health reform involves not only the way we finance it, but the way we think about it? And while we're at it, the way we think about the self, the soul, the human body and its diseases? What if the entrenched interests in this domain stretch back some 350 years? It's enough to give one a headache. But let me explain.
President Clinton's proposals primarily seek to change the way in which health care is insured, distributed and financed. Change is badly needed here.
But something key is still missing from the reform agenda because people are not only frustrated over their difficulties in getting and paying for doctors, but over how doctors treat them once they are found. We have all heard or voiced the complaints: "I was treated like a piece of meat . . . poked and prodded . . . like I was just an organ, not a person . . . he was more interested in the X-ray than me . . . she didn't answer my questions, didn't even really hear them" . . . and on and on. What's going on?
We need to turn back to the 17th century for an answer. The French philosopher, Rene Descartes, in light of the achievements of Copernicus, Kepler, Galileo and others, served as a powerful advocate for the new world-view of modern science. The natural world, Descartes said, was not filled with purpose, spirit or consciousness -- it was mechanical. That is, it operated blindly, driven only by physical forces. Even animals, as a part of physical nature, were soulless robots. Their seeming subjectivity was an illusion created by intricate machinery; we are fooled in the way children are fooled by a wind-up toy.
Within such a universe, only the human soul is genuinely conscious -- not the human body. According to Cartesian dualism, soul and body are completely different kinds of substances, uneasily joined. The human body is nothing but a machine, obeying the same mechanical laws that govern all physical matter.
From this point of view, which has dominated our modern world, physical disease can be understood as the breakdown of a machine. The doctor's job, then, is to fix the body-machine like any good mechanic. How do you do this? First you have to understand how the machine works. This helps to clarify what part or function is broken, so you can do something about it. Perhaps you can help the machine run better by giving it something it needs, or by removing something damaging. If a part isn't working, you can go in and fix it, or else you can replace it with a new part.
Sound familiar? Though put in a very reductionist way, this is how a lot of modern medicine works. Kidney problem? Thanks to scientific research we have figured out how to use medications or adjust the diet in order to help the kidney perform better. Won't help? Too far gone? How about dialysis -- hooking you up to an artificial kidney -- or even transplantation with a donor organ.
This mechanistic approach to medicine has done wonders and saved many lives. Viewing the body as a complex machine governed by physical laws has enabled us to arrive at a deeper understanding of human physiology, and to pioneer a powerful array of diagnostic and therapeutic techniques.
But it has also made something of a mess of things. When the patient is seen as mechanism, the doctor as mechanic, communication between the two tends to break down. No wonder people complain of being treated like an object, an organ or disease entity, rather than a person. By and large, this is how doctors are trained to see things. Medical textbooks are filled with physiological diagrams, not suffering people. The first "patient contact" in medical school is often with the anatomy lab corpse -- the ideal patient, one might say: quiet, a non-complainer, easy to investigate. We don't expect auto mechanics to converse sensitively with their cars, and it is all too easy for doctors, steeped in our mechanistic mind-set, to neglect the humane skills of health care.
But where, then, is the care and the healing? The word "heal" comes from the same root as the words "holy" and "whole." But we have seen how our philosophical mind-set tends to fragment the self, separating ill people from their social context, isolating body from soul, even shattering the body itself into separate organ systems. The result is a neglect within our medicine of the mind's healing powers, and of alternative therapies richly used in other cultures. The result is also a heck of a lot of angry patients who don't feel very well-treated by their doctors. But these doctors are only doing what we've taught them to do.
How can we reform this aspect of health care? President Clinton's plan has little to say here. But this is not the problem or task of one man. It is the task of a culture seeking to retain what is valuable about its heritage, but also to supplement or re-form it when necessary. This is a task for all of us as we struggle toward a health-care system for the 21st century, perhaps more integrated and humane than the one we have now. Our task is to heal the very way we heal.
Drew Leder, a medical doctor and philosophy professor at Loyola College, is coordinator of Loyola's new program in health care ethics, designed for the general public and beginning in October.