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 Contents

Foreword iv
Preface v
Acknowledgements vii
Reprint permissions for copyrighted material viii

Part One Health and humanities

1 The philosophy of healthcare 3
2 The art of seeing 19
3 The politics of health 31

Part Two Suffering: the heart of medicine

4 Suffering and spirituality 53
5 The illness experience in literature 71
6 Chronic illness and the sociology of disability 87
7 Mental illness and the poetry of despair 105
8 Narratives of abuse 121
9 Dances with death 137

Part Three Healing: the soul of healthcare

10 The history of healing 153
11 The dynamics of healing 167
12 Uncertainty, bewilderment and mystery 189
13 Compassion 201
14 Professional fulfilment 215
15 Professional virtue 233

Index 243
 Foreword

Peter Barritt suffers from a condition that I recognise. He is so steeped in his work
as both general practitioner and teacher that in everything he reads he finds pas-
sages that resonate with his daily experience. He is trapped within a virtuous circle
as his reading enriches his practice and his practice deepens and sensitises his
reading.
The power of words to make us feel less alone is both astonishing and consoling.
They are both the means and the ends of the human compulsion to search for
meaning. They form the map that outlines our understanding and, at the same
time, guides our search for more. The private reading of words opens us to a range
of human experience far beyond the limitations of a single life. Words take us across
space and time, invoking the capacity of the imagination to identify with the
workings of other human minds. Skilled writers use words in ways that help us to
see the world and our own place within it in a new light – a light that falls from a
slightly different direction revealing subtly different detail. Words help us to make
sense of our daily experience of joy and suffering and make it absolutely clear that
those experiences are shared and that, to this extent, we are never truly alone.
Peter has read widely and deeply from the Dalai Lama to Aristotle and from John
Donne to Susan Sontag. This book is suffused with quotations from his reading so
that it becomes an anthology that sets healthcare squarely within its philosophical,
cultural and political context. It gives the reader the chance to revisit and refresh
the familiar and to make completely new discoveries. Every book leads the reader
on to other books and this one leads in a multiplicity of directions. There is much
to treasure but also much with which to disagree and it is this range that enables
readers to take their own bearings within the map of understanding and to clarify,
through their reactions, the nature of their own position. In so doing, the book
orientates each reader within a particular philosophical, cultural and political con-
text of his or her own and provides a firm base for further exploration and reflection.

Iona Heath
General Practitioner
Kentish Town
London
June 2005
 Preface

This book is intended to present ideas and develop themes that will stimulate the
reader. It is aimed at young health professionals with a particular gift, but hope-
fully it will resonate with experienced professionals who have remained young at
heart. The gift is a desire to use humanity in our work, and the task is to develop
this for the benefit of patients.
I hope that the ideas in this book are not seen as impracticable in the busy world
of helping those who suffer. In truth, I don’t believe that they are. Treating fellow
humans with dignity, empathy, understanding and respect generally takes no more
time, although it can be more demanding. The book includes an element of des-
cribing a counsel of perfection and how aiming to be good, rather than perfect,
should be our aim.
The book covers religious and philosophical themes, and at times I have set out
to be controversial but not hurtful. If personal prejudice or intolerance shines
through and causes offence I would like to apologise, as this was not my intention.
Health professionals will recognise black humour creeping into some sections of
the book. This was introduced to encourage the poor reader who has a mountain of
a book to climb, but not to sanction flippancy or lack of respect for patients. In a
similar vein, I have written conversationally in order to lighten the text, but I
accept that this may grate on some, particularly those of an academic disposition.
Readers will realise that this book is primarily a collection of ideas and thoughts
of others. For this I make no apologies, as the intention is to illustrate how disci-
plines outside the health professions can enrich our daily experience. I believe that
this is the key reason for studying humanities. In different chapters I have tried to
illustrate how various arts can contribute to the understanding of issues relating to
health. I have tried not to duplicate work that has already been well described in
standard texts used in the training of health professionals, and for this reason there
is scant mention of many important areas, such as patient-centred medicine, nar-
rative-based medicine, the reflective practitioner and communication skills training.
Many of the books used during the preparation of the text are now out of print
but can easily be purchased second-hand via the Internet. At the end of each chapter
I have recommended some key texts that I have found interesting and well written.
Many of these books were initially recommended by David Greaves and Martyn
Evans, or by my friend Arvind Patel.
Clearly there is a conflict between the scope of this topic, which is huge, and the
amount of time that a health professional can spare to read this book, which is not.
I hope I have done justice to the discipline of medical humanities and provided an
overview, but inevitably it can be no more than an introduction to the subject.
There is a long-running debate as to whether medicine is a science or an art. I
hope to persuade the reader that it should become an inseparable combination of
both. I would have no interest in being cared for by a health professional who was
kind, considerate, caring and empathic but knew nothing about the science of my
vi Preface

predicament. As circumstances have turned out, neither I, my wife nor my two

children would be alive today without the benefits that modern science has be-
stowed upon us. Those to whom we owe our lives have shown not only mastery of
science but also skill in the art of humanity. This book is about humanity in
medicine, but it is in no way a diatribe against science. The intention was to strike
a balance and to show how much the world outside medical science has to offer
those of us within it.
The motivation for inflicting yet another book on the weary world was not to be
proscriptive but to stimulate conversation, enthusiasm and ideas. I can do no better
than quote from Descartes:1

Let no one think I am here about to propound a method which everyone

ought to follow in order to govern his reason aright; for I have merely the
intention of expounding the method I have myself followed. . . . But no
sooner had I finished the course of study at the conclusion of which one
is ordinarily adopted into the ranks of the learned, than I began to think
of something very different from that. For I became aware that I was
involved in so many doubts, so many errors, that all efforts to learn were,
as I saw it, of no other help to me than I might more and more discover
my ignorance.
(p. 263)

Peter Barritt
April 2005

Reference
1 Descartes R (1644) Dissertatio de methodo, pp. 2–3, quoted in Kierkegaard
S (1843) Fear and Trembling, translated by Lowrie W (1941). Doubleday and
Co., New York.
 Acknowledgements

The idea for this book sprang from the teaching and learning I did as a course
organiser for the Shropshire General Practice Vocational Training Scheme between
1992 and 2002. I was keen to try to encapsulate some of the experience and wisdom
that was shared by young doctors and fellow course organisers about the humane
practice of medicine. My educational guru at that time was Jonas Miller, and he
pointed me in the direction of an MA Course in Medical Humanities at the Uni-
versity of Wales, Swansea. This course was set up by two luminaries of the medical
humanities world, David Greaves and Martyn Evans. It has provided the stimulus
for the bulk of this book, and I am very grateful to David and Martyn, who fostered
enthusiasm and pointed out key texts.
Sympathetic support from the West Midlands Deanery, Shropshire County PCT
and, most importantly, my partners Rob Laycock and Teresa Griffin, allowed me to
write this book during a 12-month period of prolonged study leave.
Medical heroes may be a disappearing breed, particularly in hospital medicine
where shift patterns mean that personal apprenticeship may no longer be viable.
Nonetheless, I would like to pay homage to those clinicians who demonstrated
humanity in medicine in my formative years. Professor John Malins and Dr Sadru
Jivani are sadly no longer alive but my long-suffering trainer David McKinlay is,
and so is my retired senior partner Keith Hodgson. My friend Simon Reid provided
much appreciated support and enthusiasm during our 15 years together in medical
education. In addition, most of the humanity I have learned in medicine has been
taught by the many patients I have listened to since starting medical school in
1971.
Finally, I would like to thank my wife, who has supported and tolerated yet
another madcap scheme with her usual fortitude and good humour. Curiously, like
many women, she has no need for a book on theoretical humanity, as the practical
form was presumably inserted at conception.
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 The Silver Swan
The silver swan, who living had no note,
When death approached unlocked her silent throat,
Leaning her breast against the reedy shore,
Thus sung her first and last, and sung no more:
Farewell all joys, O death come close mine eyes,
More geese than swans now live, more fools than wise.
Anon. (c.1600)

May my book teach you to care more for yourself than

for it – and then more for all the rest than for yourself.
André Gide (1926), Fruits of the Earth.
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 import-
ant 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 Lamb3

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 philoso-
phy 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:
4 Humanity in healthcare

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, physi-
otherapists, 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. hyperten-
sion, 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 relation-
ship 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:
 The philosophy of healthcare 5

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 scien-
tific – 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 becom-
ing 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 anec-
dotal 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 phy-

sician, 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)
6 Humanity in healthcare

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 pa-
tients 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 ‘pro-
found 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, hyperten-
sion, hypercholesterolaemia, ischaemic heart disease and heart failure have been
developed. Surgeons have developed open-heart surgery, joint replacement, cata-
ract 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 in-
tensive care. This is no mean achievement in a mere 50 years.
This is not to argue for smug satisfaction or the denial of important new prob-
lems to be confronted, but crisis may be overstating the case. There is and always
has been change, and probably the rate of change is ever increasing as a result of
man’s inventiveness. Healthcare could be viewed as a victim of its own success. As
treatments become increasingly skilled and the public expects the best possible
results, increasing specialisation becomes inevitable. The challenge is somehow to
coordinate and incorporate these technological advances in a way that preserves
dignity and celebrates individuality.
 The philosophy of healthcare 7

Humans love to revel in past glories. Arcadian dreams of a lost Golden Age are
as old as the Garden of Eden. Doctors dream of times when patients obeyed them
without demur. Patients dream of times before avaricious multi-national pharma-
ceutical companies poisoned the population and of times when a handful of pulses
and organic vegetables gave eternal life and freedom from suffering. We shall
return to these themes in Chapter 3.
When mankind is not looking fondly backwards, it gazes wistfully forwards and
dreams of Utopia. In The Mirage of Health, Rene Dubos argues that after Darwin,
science moved centre-stage as the discipline to deliver the New Jerusalem.14
Industrialisation in the nineteenth-century Western world created perfect con-
ditions for generating disease. The problems of social inequality, poverty and squalor
were alleviated by humanitarian and social reform which delivered pure air, clean
water, good food and better housing. As the microscope arrived and germ theory
got well under way, serums, vaccines and drugs became available to treat microbial
diseases. The massive decline in deaths from infectious diseases in the latter half of
the nineteenth century was attributed at the time to medical science, but we have
since realised that it was in fact related to better social conditions. Improvements
in life expectancy have resulted primarily from falling death rates due to infection
in infancy and childhood. Indeed, as we shall see in Chapter 3, good health has
almost nothing to do with good healthcare. All of these factors had a part to play
in exaggerating the benefits of medical science to the population. The explosion of
this myth caused much of the disenchantment with medical technology in the late
twentieth century, epitomised by the railings of Ivan Illich in Medical Nemesis.12

Healthcare as models
There have always been two major conflicting views about health and illness. Char-
acteristically the Ancient Greeks invented a God for each. Hygeia was a serene,
benevolent maiden who was the guardian of health and symbolised the belief that
men could remain well if they lived according to reason. This is the ‘healthy mind
in a healthy body’ school of thought. Asclepius, on the other hand, was a handsome,
self-assured, heroic young god who was the first physician according to Greek
legend. Asclepius treated disease and restored health by correcting imperfections
caused by accidents of birth or of life. Dubos argues that these two schools of
thought have existed simultaneously in all civilisations in one form or another.14
Alistair Campbell, writing in 1984, argued that these models led to the traditional
roles of doctors and nurses:
Doctors tend to have quite infrequent and fleeting contact with the
bodies of their patients. … The wish for cure dominates medicine, and
the routine tasks of caring are delegated to nurses, who are regarded as
more appropriate hourly companions for the patient. We might say that
doctors tend to serve the male God of interventionist medicine, Asclepius.
The more tranquil, nurturing role of Hygeia, the goddess of well-being,
is seen as a lesser task, suitable for the womanly patience of nurses.15
(p. 31)
These two models, of course, are not mutually exclusive and they may complement
each other well, but tension between the extremes is inevitable. As Dubos observes:
8 Humanity in healthcare

To ward off disease or recover health, men as a rule find it easier to

depend on healers than to attempt the more difficult task of living wisely.14
(p. 109)

Asclepius is represented in the drama of the operating theatre and the emergency
room, and is the stuff of soap opera and television documentary. Hygeia, in her
serene loveliness, is embodied in the yin and yang of Chinese medicine, physiology
and homeostasis, epidemiology, public health, much complementary therapy, veg-
etarianism, whole/organic foodism, the gymnasium and the ‘lofty hope that man
can some day achieve a state of harmony within himself and with the surrounding
world’.14
Hippocrates, in his wisdom, managed to incorporate both models and to be all
things to all men. Dubos describes his legacy as follows:

To the philosophically minded, Hippocrates stands for rational concepts

based on objective knowledge and for the liberation of science in general,
and of medicine in particular, from mystic and demonic influences. To
the student of public health, the Hippocratic writings provide classical
examples of the relation between the environments – physical and social
– and the prevalence and severity of various diseases. To the physician,
they offer objective description of symptoms, subtle methods of diagno-
sis, hints for dealing with the patient as a person and with his family –
in short, all aspects of the art of medicine.14
(p. 112)

Nonetheless, not even Hippocrates escapes criticism altogether. As divine faith and
demonic influence were replaced by scientific reason, Cassell believes that this
eroded the importance of the individual in the scheme of disease.6 The Spanish
historian Pedro Lain Entralgo lays the blame for lack of communication between
doctor and patient at Hippocrates’ door:

Hippocratic physicians were so eager to separate themselves from the

superstitious and popular medicine they superseded that they disavowed
the spoken or sung charms, chants and incantations that were formerly
the primary modes of treatment. The use of the word in treatment was
suspect, since it smacked of those earlier superstitions. The second source
of silence was the fact that the Hippocratic school based its diagnosis and
treatment on objective measurement. While objective measurement
included the information of the senses, it decidedly did not include
much of what the patient said, since this was merely opinion.6
(p. 56)

Hippocrates certainly helped to launch scientific medicine, albeit in a holistic

framework. He taught that anyone living reasonably in an environment to which
he was well adapted was not likely to fall ill, unless some accident or epidemic
occurred. He believed in the natural ability of the sick body to restore the disturbed
equilibrium, and he saw the physician’s task as being to help the body to heal.
The balance between the Hygeian and Asclepian models was drastically altered
by the arrival of the germ theory and the doctrine of specific aetiology of disease.
 The philosophy of healthcare 9

Edward Jenner could rightly claim to have ushered in this era. His experiments
using cows to develop smallpox vaccination commenced in 1796. However, it was
not until Robert Koch identified the tubercle bacillus in 1883 and Louis Pasteur
identified the streptococcus, staphylococcus and pneumococcus in the period 1877–
87 that the germ theory gained general credibility and widespread acclaim. Attention
was switched to identifying a specific cause for each disease, and treatment
involved attacking the causative agent or focusing treatment on the affected part of
the body. As the realisation grew that therapeutic serums and prophylactic vaccines
could not cure every disease, attention switched increasingly to the search for
specific therapeutic drugs – the so-called ‘Magic Bullet’ approach. Perhaps the
search for new drugs is about to be swept away by the latest revolution, namely
genetic engineering and immunotherapy. Dubos reflects as follows:

By equating disease with the effect of a precise cause – microbial invader,

biochemical lesion, or mental stress – the doctrine of specific aetiology
had appeared to negate the philosophical view of health as equilibrium
and to render obsolete the traditional art of medicine.14
(p. 99)

The public has become accustomed to miracles, and expectation of a ‘cure for every
ill’ is widespread. A further nail was hammered in the coffin of holism by Descartes
(1596–1650) with his theory of Cartesian dualism. He believed in a mechanical
body inhabited by a non-material soul. Clearly Descartes was deprived of pets in
childhood, because he argued that animals had no soul and were automatons. Con-
sciousness and the mind were related to the brain but were, he believed, separate
entities. His famous catchphrase ‘I think therefore I am’ was an idea that was first
committed to paper around 1200 years before Descartes thought of it, by Augus-
tine in his City of God:

Without any delusive representation of images and phantasms, I am

most certain that I am, and that I know and delight in this.16

Even dualism dates back to Ancient Greece. What is more, Descartes believed that
the soul and mind interacted with the brain and the body via the pineal gland.
Anyway, for reasons that are not immediately apparent, Descartes is considered to
be the father of psychology, physiology and the biomechanical model of the human
body. As secularism spread, his concept of soul was gradually dropped and the
mind/body schism was complete. In medicine this has led to the separate disci-
plines of psychiatry (minds) and medicine (bodies). If patients fall ill but Western
medicine can find no disease, the patient may be referred to a psychiatrist as a
punishment. Alternatively, the family physician may talk of ‘psychosomatic dis-
ease’. If successful treatments are found for psychosomatic diseases, the latter are
immediately de-classified. In my professional career this fate has befallen duodenal
ulcer, eczema, asthma, ulcerative colitis and epilepsy. The underlying text here is
‘If I can’t find anything wrong with you on my tests, you must be imagining it.’
Patients are, in my experience, under-whelmed by the concept!
The body as machine has been termed the biomechanical or ‘plumbing’ model.
This model involves regular checks for servicing, spare-part surgery and whole-
10 Humanity in healthcare

body scans to detect faults that are not immediately obvious. Making the machine
last for as long as possible, with as few breakdowns as is feasible, is part of the
mission statement. The mechanic is a hero so long as he finds and fixes problems
at the first attempt. Rewiring (pacemakers), pipe-cleaning (angioplasty), re-plumb-
ing (vascular surgery), removal of blockages (bowel surgery, trans-urethral resection
of the prostate) or new for old (hip replacement, heart transplant) may all be nec-
essary. When the machines are no longer road-worthy, they are put in scrapyards
(care homes) or are broken up for spare parts. Good engine oil is recommended (not
too greasy) and may need thinning (aspirin). Quality control (audit and clinical
governance) is imperative, and machines are tested under rigorous conditions (con-
trolled clinical trials). The machine is a passive recipient in the hands of the skilled
engineer. Profitability or, in a State-funded system, financial stringency is para-
mount.
The counterbalance to the biomechanical model has been termed by Peter Toon
the ‘humanist model’. The ethos here is well expressed by Cassell:

The experience of the clinician produces knowledge tainted by emotion

and passion. Science was meant to rescue medicine from this problem yet
science cannot solve this problem. There is no alternative to using this kind
of experiential knowledge in medical care – understanding and accepting that fact
is the beginning of the solution to the problem.
Only the physician as a person can empathically experience the expe-
rience of a sick person. It must finally be accepted, therefore, that there can be
no substitute for the physician as a person.9
(p. 227)

In this model the central figure is the sick person, and the healthcare professional
is seen as a friend, witness or guide. Dialogue between the parties is human and
interpretive, and feelings and emotions are valued and discussed. Human beings
are helped to heal and their spirit or soul is carefully considered.17
As Toon reminds us, we need to sit lightly on our models. Each model has value
in certain situations, and no one model is correct or complete. Rewiring is perfectly
appropriate for a patient with complete heart block, whereas empathic witnessing
may serve us well in a patient’s dying moments.

Healthcare as capitalism
In The Mirage of Health, Dubos argues that technology has displaced religion and
philosophy as the driving force in shaping the world and determining human fate.
He also puts the onus of responsibility on scientists to become involved in the
ethical debates that follow technological advances.14 Human cloning is a particu-
larly good example of the awesome ethical responsibility that can emanate from
scientific advance. Medical technology has saddled every country in the world with
intractable financial problems, as healthcare professionals find more and more ex-
pensive activities to perform. Jacob Needleman writes:

The whole of our culture is having a reaction against a long-standing

faith in the goodness of science and scientific technology, a kind of waking
 The philosophy of healthcare 11

up, a realisation that science has not lived up to what it promised.

Throughout the world, people are having second thoughts about scien-
tific technology, even as its influence and our dependency upon it continue
to grow.18
(p.116)

The issue of dependence is crucial. The abstract thoughts of a taxpayer are often
very different from the feelings of that same person some years later when their
child with Down’s syndrome needs open-heart surgery. One man’s rationing is
another man’s manslaughter, so to speak. In a secular society where death means
oblivion, medicine may be asked to preserve life whatever the cost and however
bizarre the rest of that life may be. Feeding very elderly patients, who are semi-
conscious following severe strokes, via gastrostomy for years on end is an example
of this. The patients I am thinking of here had decisions made for them by doctors
and relatives because they had lost the use of meaningful communication. Ethically
it is often easiest to ‘do everything possible’, and starting treatment is much easier
than stopping it. Alfred Tauber rejects the concept of ‘technology gone mad’,
arguing that humans invent technology and humans decide when and how ma-
chines and drugs are used.19
Of course, medical science is not just about technology. Clinical trials may ques-
tion established dogma and lead to a reduction in unnecessary treatment – for
example, routine episiotomy in childbirth and antibiotics for otitis media and
tonsillitis. Medical science includes public health and epidemiology and, as we
shall see in Chapter 3, these disciplines have uncovered fascinating insights into
disease prevention that demand changes to fairness and democracy in society, rather
than more money. Technology has raised expectations of health and happiness to
unimagined heights, primarily because of a good track record. Subsistence farming
may appeal to our notions of the ‘Noble Savage’, but most human beings cannot
wait to escape from its clutches.
Rationing on some basis is inherent in all healthcare and always will be. Progress
in sustaining the ageing or failing body, treating infections and cancer, and recon-
structing after injury or mutilation will continue and comes at a cost. No society will
be able to afford every treatment or procedure of which orthodox or complementary
healthcare is capable. Our strivings and our aspirations are human, and limitless.
Only spirituality, religion or philosophy can turn back that particular tide.
Certainly, materialism and capitalism stoke the public’s desire for youth, beauty,
happiness and immortality, because shifting commodities and making profit depend
on it. On the other hand, if people choose to pay for a new nose or a slimmer bottom,
who are we to object to this? Which of us accept the declines of old age with relish?
This is the price of freedom and the cult of the individual. Campbell argues in
Health as Liberation that our individualism leaves us only two ways of evaluating the
goodness of our lives – the criterion of ‘success’ and the criterion of ‘feeling good’.
As he remarks, ‘We live in a world in which each of us is the only significant
inhabitant’. This contrasts with life before the Reformation, when class, occu-
pation and religion defined us as people. Campbell writes:

Through science and technology, we have achieved an ever-increasing

mastery of the world around us. As a result, we no longer see suffering to
be pre-ordained or inevitable.