Humanity in Healthcare

The Heart and Soul of Medicine

Peter Barritt

• Publisher: CRC Press
• Year: 2017
• eBook ISBN: 9781315344768
• Edition: 1
• Topic: Business
• Subtopic: Medical Theory, Practice & Reference
• Index: Business

The impressive progress of medical science over the nineteenth and twentieth centuries has tended to overshadow the art of caring for the patient and their families. This book aims to restore the balance by examining practical ways in which the arts can help health professionals to understand the experience of suffering and illness. Written by a family physician with 25 years experience, Humanity in Healthcare offers a broad perspective on the potential contribution of the arts toward fostering a humane approach to the care of those who are ill or suffering. It refers to a wide range of literature from prose and poetry, sociology, history, philosophy, politics, religion and spirituality. This book is an invaluable resource for all medical and healthcare professionals as well as students of the medical humanities.

PART ONE

Health and humanities

CHAPTER 1

The philosophy of healthcare

A good physician comes to thee in the shape of an Angell, and therefore let him boldly take thee by the hand, for he has been in God’s garden, gathering herbs: and soveraine rootes to cure thee: A good Physician deals in simples, and will be simply honest with thee in thy preservation.

Thomas Dekker (1570–1641), London Looks Backe¹

What is the use of studying philosophy if all that it does for you is to enable you to talk with some plausibility about some abstruse questions of logic, etc., and if it does not improve your thinking about the important questions of everyday life?

Ludwig Wittgenstein (1889–1951)²

‘But that’s medicine, the art of prolonging disease.’

‘Jesus,’ I said, with a laugh. ‘Why would anyone want to prolong it?’

‘In order to postpone grief.’

Peter DeVries (1969), The Blood of the Lamb

Introduction

We live, dear reader, in strange times. Our cathedrals are shopping centres (once a week and twice on Sundays), our dreams are Disney, our reality is television and our ambition is material. I make no apology, therefore, for beginning with philosophy, the study of meaning. I warm to Wittgenstein, who detested professional philosophy and referred to it as ‘a kind of living death.’² Wittgenstein worked in a hospital in World War Two and considered giving up philosophy to study medicine, so his thoughts are steeped in relevant experience. This book is not primarily about ethics in the usual sense. However, it does aim to raise awareness of the human dimension in our daily contacts with those who suffer, and to highlight the sanctity of the tasks associated with occupations that care for the ill. In this regard, I am with Wittgenstein, for whom ethics was an intensely personal and deeply serious affair. He believed that ethics was not simply about good conduct and good character, but about the sense of life, the state of one’s soul or, as he often put it, about being decent.²

What do we mean by meaning? In Philosophical Investigations Wittgenstein had this to say:

For a large class of cases — though not for all — in which we employ the word ‘meaning’ it can be defined thus: the meaning of a word is its use in the language.⁵

(p. 43)

In my view, ethics should be our constant companion when we care for others. Youngsters who are employed as carers for those with advanced dementia, for example, face a constant stream of ethical challenges. So this book is very much about how we can develop understanding and compassion in our work and how we can maintain the dignity of those who suffer.

Terminology is a problem. Medicine has come to be associated primarily with doctoring, and I hope that this book will be of interest to anyone who works with the sick and suffering. In view of this, I have used ‘healthcare’ as the best of a bad bunch of terms which refer to the industry of caring for the sick, and ‘healthcare professional’ as the term that best incorporates all those who work within it. In fact I believe that our job should be primarily concerned with care for the sick, rather than interference with the healthy — but that is another chapter! Many of the references quoted refer to doctors or physicians, but apply equally to nurses, physiotherapists, counsellors and others involved in care for the sick.

The terms illness, disease and sickness need to be defined, and again I have gone with the meanings most commonly ascribed in current usage. Eric Cassell uses the following definitions:

From this point on, let us use the word ‘illness’ to stand for what the patient feels when he goes to the doctor, and ‘disease’ for what he has on the way home from the doctor’s office. Disease, then, is something an organ has; illness is something a man has.⁶

(p. 48)

Using this definition, it is possible to have disease without illness (e.g. hypertension, hyperlipidaemia, HIV infection) and illness without disease (e.g. undiagnosed illness, chronic fatigue). Cecil Helman expands this concept:

Illness is the subjective response of the patient, and of those around him, to his being unwell; particularly how he, and they, interpret the origin and significance of this event; how it affects his behaviour, and his relationship with other people; and the various steps he takes to remedy the situation. It not only includes his experience of ill-health, but also the meaning he gives to that experience.

Illness therefore often shares the psychological, moral and social dimensions associated with other forms of adversity within a particular culture.⁷

(p. 91)

What of sickness? Sickness is usually taken to mean the acceptance by others that a person is ill, even (as in some forms of mental illness) if that person is unaware of being ill. Marshall Marinker had this to say of sickness:

Sickness is a social role, a status, a negotiated position in the world, a bargain struck between the person henceforth called ‘sick’ and a society which is prepared to recognise and sustain him (or her). The security of that role depends on ... the possession of that much treasured gift, the disease. Sickness based on illness alone is a most uncertain status. But even the possession of disease does not guarantee equity in sickness. . Best is an acute physical disease in a young man quickly determined by recovery or death — either will do, both are equally regarded.⁸

(pp. 81–4)

Scientific medicine is only comfortable with measurable phenomena. Humanities, arts and illness are based on individual experience of life and are therefore, by definition, anecdotal and unmeasurable. In The Nature of Suffering, Cassell writes:

The dominance and success of science in our time has led to the widely held and crippling prejudice that no knowledge is real unless it is scientific — objective and measurable. From this perspective, suffering and its dominion in the sick person are themselves unreal.⁹

(p. xi)

Healthcare demands that professionals use their humanity to apply the benefits of medical science wisely. Without humanity, medical science is in danger of becoming a headless monster. Here is Cassell again:

Since individual experience is inevitably anecdotal (one can have no other kind) and individual clinical judgements contain subjective elements (they are the product of a subject), banishing the subjective and anecdotal from medicine necessarily demotes the individuality of the physician to the level of the contaminant.⁹

(p. 19)

Scientific knowledge is crucial to healthcare, but it has limitations. The art of interpretation (or hermeneutic inquiry, as Western philosophers prefer to call it) is equally important, as McWhinney points out in A Textbook of Family Medicine:

Hermeneutic inquiry is inter-subjective. One person, in this case a physician, reaches an understanding of another’s thoughts, feelings and sensations by entering into a dialogue in which the meaning of words and other symbols is progressively clarified. In an inter-subjective inquiry, neither party is unchanged by the process. In this case, the patient may gain a deeper level of self-knowledge as well as a resolution of her existential crisis; the physician also may learn something about the human condition and perhaps about himself.¹⁰

(p. 72)

This two-way dialogue is the fundamental means of learning about others (and ourselves), and we shall return to this in Chapter 2. Cassell expresses it thus:

Physicians may remain objective; they may (in fact, must) retain their boundaries in order to remain private persons. But, as the sick are in bondage to them, they are in bondage to the sick, who provide the basis of their power and the source of personal reward and status. Physicians are also bound to their patients in another way, for it is from their patients that they learn, understand, and improve what they are and what they know.⁹

(p. 72)

Let us start then with some philosophical inquiry. How should healthcare be viewed in the twenty-first century?

Healthcare as crisis

Many have argued that Western medicine faces Armageddon. Iona Heath perceives a crisis,¹¹ Ivan Illich perceives a nemesis,¹² and Bernard Lown moved from a ‘profound crisis’ to a ‘meltdown’ between editions.¹³ It may be wise, as with the man carrying a billboard proclaiming the End of the World, not to hold one’s breath until the event finally occurs.

After 30 years in medicine, the changes I notice are relatively slight. Patients continue to suffer and need our help. People are born, learn to love and to lose, become ill and die. The main changes I notice are longer consultation times, fewer prima donna specialists, more democracy in the consultation, much less on-call and an improved range of treatments on offer. Healthcare professionals have certainly lost some of the public’s automatic trust and admiration, but there is plenty of gratitude and respect left for those who merit it. In my lifetime have come the prevention of congenital rubella and of rhesus incompatibility, immunisation against polio, diphtheria, measles, mumps, pneumonia, influenza, haemophilus A and hepatitis A and B, and the elimination of smallpox. The cure for peptic ulcer has been discovered, and well-tolerated treatments for asthma, depression, hypertension, hypercholesterolaemia, ischaemic heart disease and heart failure have been developed. Surgeons have developed open-heart surgery, joint replacement, cataract extraction, keyhole surgery and organ transplants. Gynaecologists have made great strides in the treatment of subfertility, paediatricians have saved many lives in special-care units, and anaesthetists have invented epidurals and pioneered intensive care. This is no mean achievement in a mere 50 years.

This is not to argue for smug satisfaction or the d...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Acknowledgements
• Reprint permissions for copyrighted material
• Dedication
• Part One Health and humanities
• Part Two Suffering: the heart of medicine
• Part Three Healing: the soul of healthcare
• Index