* Humanistic medicine was the theme of a seminar convened by the Center for Ideas and Society at the University of California – Riverside in 2001, where I presented a version of this article. It is not meant to be comprehensive, but a starting point for discussion, argument and disagreement about important values that sustain medicine.
The term "humanistic medicine"* has achieved a certain currency, particularly in North America. An Internet search for this term yielded 1260 "hits" in July 2002. But why might we need this term? What does it do for our understanding of medicine that terms like "evidence-based" or "care-based" medicine fail to do? Do we need a new term at all?
When a new term, like humanistic medicine, is launched, it forces us think about the old terms it may replace. Why should we be doing any rethinking? The answer to this question is unfortunately all too clear. Health services are in grave difficulties, and there are many things happening in most First World societies that should remind us of the crisis. These include:
Healthcare workers have high rates of stress-related illness and mental illness, and suicide is commoner among them than among other groups.1-3
Medical litigation continues to expand in countries like the United States and Australia, and litigation is becoming alarmingly expensive. In Australia, the largest litigation insurance group, United Medical Protection, has gone into voluntary liquidation because of the level of claims on its funds.
The costs of services and technology are spiralling upward toward a limit of tolerance for most Western societies. We can no longer afford ourselves. Rationing is already a fact of medical life.4-8
Human, physical and technological resources are unevenly distributed, and are sparsely available in many areas of need.9
Vast investments in technology produce diminishing returns in population health.10
People who perceive themselves to be ill turn increasingly to alternative medical practices, because they feel that they are listened to and cared for better than they are in conventional medicine.11
Despite these systemic symptoms of discontent and division, there are many who are more than happy with what they have experienced from modern healthcare. Similarly, there are many who work in healthcare who are happy enough with the way things are. Unfortunately, there are as many patients and clinicians who are not happy.
All the complaints levelled against modern healthcare seem to be directed against a medicine that is not humane. Perhaps "humanistic medicine" has been coined because "humane medicine" produced no revolution in medical attitudes or practice. But what does "humanistic" mean?
First appearing in the early 19th century, humanistic is the adjective derived from "humanism", the belief in the humanity, but not the divinity, of Christ. Later, humanism came to refer to "the quality of being human; devotion to human interests or welfare". Later still, in the early 20th century, humanism came to mean "a belief or outlook emphasising common human needs and seeking solely rational ways of solving human problems, and concerned with humankind as responsible and progressive intellectual beings". This understanding of humanism expresses a devotion to rationality as a means of understanding the human condition. Humanistic medicine might thus be seen as an Enlightenment project, a medicine devoted to the rational solution of the problems of human illness.
And yet, I doubt that this is what the term is meant to capture. Humanism, in the senses I have given, rejects the spiritual and supernatural, yet spirituality is one of the attributes that seems to be missing from modern medicine. Humanistic medicine seems to mean a medicine that is rooted in a concern for fellow humans, for their emotions, their suffering, their peace of mind. It is hard to find fault with such a concept. But what conventional wisdom is it challenging?
There are a number of other models of medicine that healthcare workers follow — for example, scientific, evidence-based, care-based or holistic medicine. Each paradigm can defend itself against challenges. All can claim "humanistic" elements. Scientific medicine and evidence-based medicine can claim the real advances in measurable outcomes of care. Scientific advance has an unstoppable momentum of its own. Society agrees to commit massive amounts of money to the scientific, evidence-based system we have. Holistic medicine has been claimed by "alternative" practitioners. Thus, the status quo seems defensible, and no real opponent appears against which to stand humanistic medicine.
We know, however, that there are things that are perceived to be wrong with modern healthcare practices. Therefore, it seems likely that there is some element common to the prevailing paradigms that does need to be interrogated and challenged. One element common to scientific, evidence-based and care-based medicine is one form of reductionism. Each seeks to ground medicine in something "good", but in doing so emphasises one element over others that are also good and important. Holistic medicine claims to be antireductionist, but holism suffers from a vagueness that limits its usefulness as a corrective to the problems of reductionist medicine.
But does humanistic medicine serve as an adequate corrective? In its current usage, humanistic medicine refers to a mode of practice that emphasises concern for the experiences of our fellow humans. It prescribes compassion, beneficence, concern, gentleness, careful communication, patience, fidelity to duty — all the virtues that are part of virtue-based ethics.12 This is helpful, but falls short of suggesting why we should attend to these virtues and put them into practice. To understand why, we need to ask more questions, to repeat the "Why" until there is no further answer, because we have reached the level beyond which we cannot reason.13 That level is the level of our values.
If we ask ourselves why we believe in having healthcare, we can answer perhaps that we need it to prevent and relieve human suffering, and to prevent untimely death. Then we can ask why we want these preventions, and answer that suffering is intrinsically bad, because it represents negative, destructive experience, and that untimely death is wasteful and a denial of potential. If we question why these things matter, we are forced to fall back on very general arguments about the intrinsic value of individual human life in quantity and quality, about human security and flourishing, about the values of living in stable and supportive communities. When we ask why these things are important, we realise that we have come to an end of reason. We can only reply that life can be no other way, that individuals and societies cannot flourish without the sense of security that comes from an acceptance that individual human life has significance, both for our own lives and the unique, individual lives of others.
These are the sorts of values that ultimately underpin the health endeavour. They justify, for example, the principles of principle-based ethics in medicine, the principles of respect for the autonomy of others, of beneficence, non-maleficence and justice. Principles do not simply emerge from nowhere. They are based on values and beliefs.14
At the deepest level, our values, both personal and societal, justify and sustain the medical endeavour. If we, in Western societies, did not place so high a value on individual human life in quantity and quality, we would rebel against the huge expenditures we commit to health services.15 Would it therefore be better to use "values-based" medicine as our therapeutic term rather than the somewhat unsatisfactory "humanistic" medicine? There are certainly arguments in favour of values-based medicine.
First and foremost, the term invites us to remember the ultimate, sustaining values-base for healthcare services. We do value individual human life. It is this value that justifies personal medicine, and public health services. The health of communities reflects the health of their individual members.
Second, acknowledging — and indeed welcoming back — the values-base of medicine allows us to acknowledge and welcome all the other paradigms of medicine, but not as the sole determinants or defining elements of medicine and its practice. Scientific medicine and evidence-based medicine become ways of extending the scope of medical care; of expressing the desire to deal better with suffering and to prevent it from happening, to extend good-quality life, and to provide a better environment in which our fellow humans can be secure and can flourish. Humanistic and humane medicine fit easily into values-based medicine, as do holistic and care-based medicine.
Third, and most importantly, values-based medicine seeks to go beyond any reductionist model, because it asks that we consult our values when we face dilemmas and problems of service delivery. It does not seek to reduce medicine to one of its components. Our values underpin all those component parts, and each component becomes important as a means of expressing those values.
There is enough evidence of stresses and strains within and around medicine and healthcare generally to justify attempts to change or refresh current paradigms of medicine. The invention of the term "humanistic medicine" is an attempt to achieve this. The use of the word "humanistic" is presumably meant to make us think of medicine's perceived deficiencies, and to address them by injecting "humanism" into medical thinking, education and practice. The associations of the word "humanism" with rationality and with a denial of the transcendental and spiritual are, however, problematic. The word "humane" might seem to be more appropriate, but it has been used before without the hoped-for reforming effect.
Attempts to change paradigms always assume the presence of something worth replacing among the prevailing paradigms. Scientific, evidence-based and care-based medicine, however, are difficult paradigms to challenge. All have "good" at their base; scientific and evidence-based medicine have huge achievements among their claims. Holistic medicine has been appropriated by alternative practitioners. If humanistic medicine has something to modify, it is probably a form of reductionism, by which medicine is reduced to one of its components (such as care or evidence). Humanistic medicine seeks to restore compassion, empathy and human concern to the reduced models of medicine created by the prevailing paradigms. But, in doing so, it runs the risk of itself reducing medicine to its human concerns, and belittling the great contributions of science and evidence.
Values-based medicine avoids some of these problems, because values are broad enough to allow the other paradigms to be assimilated within them. Science and evidence are valued because they contribute toward better ways of ensuring autonomous human security and flourishing within the communities in which we live and function. It is unlikely that simply introducing the term "values-based medicine" will produce any striking, revolutionary change in medical education, policy or practice. Nevertheless, it could serve as a focus for the development of a discourse of healthcare that might eventually be of some benefit, and a new discourse is one step towards reform.16
- J Miles Little
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW.
I am grateful to Kathleen Montgomery, Associate Professor, Organisations and Management, at the A Garry Anderson School of Management at Riverside, California, for suggesting this topic for discussion, for organising my visit to Riverside, and for her critical and constructive comments on the article.
None identified. I was paid travel expenses and a small honorarium for presenting this work at the University of California – Riverside, USA.
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Abstract
"Humanistic medicine" is a term compounded, for therapeutic purposes, with the good intent of reminding clinicians of their need to be compassionate and empathic. Although the expression is arresting, and demands thought, it does not go far enough.
"Values-based medicine" is a stronger term, reminding clinicians of the sustaining values that underpin the whole health endeavour. These values include an acceptance of the value of individual human life in quantity and quality, and of the importance to both individuals and communities of human security and flourishing.
Values-based medicine can incorporate all the other paradigms of medicine, including scientific and evidence-based medicine, within it, because it can include anything that contributes to human security and flourishing.
If we are to seek a new paradigm for a reconstructed view of healthcare, the term "values-based medicine" might have more power and relevance than "humanistic medicine".