Eric Cassell on the Goals of Medicine
A doctor argues against the duality of “mind/ body”
BY MAGAZINE EDITOR SUSAN MAIER-MOUL
Eric J. Cassell, The Nature of Suffering and the Goals of Medicine 2nd edition
New York, Oxford University Press 2004.
It is as though no matter how hard physicians try to see the patient and the disease as inextricably bound together – each causally related to the state of the other – they keep being pulled back to the old dualism of the disease as object and patient as subject.
Eric J. Cassell is an attending physician at The New York Presbyterian Hospital and Clinical Professor of Public Health at Weill Medical College at Cornell University. His book The Nature of Suffering and the Goals of Medicine is a poetic and lucid examination of one the troubling tensions at the heart of modern medicine: should doctors treat diseases or patients?
This paradox is the contemporary form of one of medicine’s oldest questions, a mystery that remains unanswered to this day.
What is the cause of disease?
Throughout the history of medicine a dispute has existed between those who see disease as a generalized phenomenon and those who hold that diseases are localized entities. The first idea, often called physiological conception of disease was embraced by the Hippocratic school which saw the origins of disease in an imbalance between the forces of nature within and outside the sick person. The second viewpoint, the ontological conception of disease, understands diseases to be entities, things that invade and are localized in parts of the body.
How we think of disease determines how we as a culture think of healing, and what we accept as a practice of medicine. Cassell is laudable for his willingness as a physician to take on the foundation of modern science – its often unexamined faith in something described as objectivity, which, in the practice of medicine, leaves aside the subjective experience of the person who is unwell.
The secret of the success of medical science has been to focus on the description of objectively measurable phenomena, seeing all phenomena as essentially separate form one from another, and avoiding entanglements with the spiritual and other metaphysical concepts.
Does science interfere with medicine?
This avoidance of entanglement results in medicine that does not assume or recognize whole persons as subjects for treatment. Medicine instead relies upon classification and categorization. Foucault’s The Birth of the Clinic is an obvious predecessor to some of the thought given in The Nature of Suffering, but Cassell is far more concerned with actual patients than abstract theory. His desire is to engage medical practitioners; though his condensing of medical history assumes some familiarity with the territory he pauses to collect all of us who may know less the lay of the land of his arguments.
The history of the era of scientific medicine really starts with the “discovery” of diseases by the French school of physicians in the 1830’s, the first to provide clinicopathological correlation. The enormous success of modern medicine appears to rest completely on the combination of disease theory and science. Thus physicians came to believe that to know the disease and its treatment is to know the illness and the treatment of the ill person.
Is there a medicine for suffering?
As Cassell brings his experience to bear on the question of the goals of medicine, he also takes on one of the great mysteries of how bodies work: pain. Doctors are distracted from accepting pain management as the critical key to healing, Cassell says, in part because of pain’s exceedingly ambiguous nature.
I believe there are two things that continue to hold back an appreciation of suffering and its relief. The first is a continuing failure to accord subjective knowledge and subjectivity the same status as objective knowledge and objectivity. The second is increasing denial of the inevitable uncertainties in medicine and a quest for certainty.
An outdated formulation of duality
This adamance about an unattainable certainty causes medicine to miss the mark, asserts Cassell, when it attempts to deal with the complexities of how bodies work, the nature of suffering itself, and therefore how medicine actually works.
How does the mind act on the body? That is the wrong question because it presumes that there is a thing called the mind which is separate from the body, the body is passive to the mind, and that part of the mind’s essential nature is that it can cause changes – even symptoms or sickness – in the body. All of these statements, I believe, are incorrect.
Ultimately, Cassell’s The Nature of Suffering is satisfying for the lay reader because of his determinedly humanistic view of the mission of medicine, one he exhorts his colleagues to place before safe distance of laboratory style medicine. His critique, then, of our current practice of medicine is an argument framed directly to the purpose of rescuing the doctor-patient relationship, and reestablishing doctors as healers once more.
The uncomfortable fact remains that doctors cannot get at diseases without dealing with patients – doctors do not treat diseases, they treat patients. Further, the same disease in different individuals may have a different presentation course, and outcome depending on individual and group differences among patients – from personal idiosyncrasies to genetic or anatomic variations. The scientific basis of medicine does not recognize nor provide a methodology to deal with such individual variations on the level of patient-doctor interactions.
What should we ask of health care?
Engaging the problematic failure of medicine makes Cassell’s philosophy of the body a compelling and thought provoking book for all readers, not merely those who’ve completed medical school. As such it is invaluable to the entire conversation between citizens and the medical community in the funding and policies of public health and the practice of 21st century medicine.
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© 2011, The Magazine of Yoga, LLC.