Tuesday, March 6, 2012

Field Review - Medical Humanities

            In its earliest practice, before even alchemy was conceived as a discipline, approaches to medicine heavily depended on the humanities. Medical theories rested on a primeval kind of empiricism, with direct observation and patient’s narratives as key diagnostic tools. The philosopher Hippocrates, for example, used direct observation of patients to theorize about the body’s workings and the ethics of medicine. He coined many of the medical terms still in use today – “acute,” “chronic,” “epidemic” – and developed treatments based on the idea that the body’s function depended on the balance of four “humors” – black bile, yellow bile, phlegm, and blood. His philosophy extended beyond the body, however, as Hippocrates also produced a seminal body of literature, known as the “Hippocratic Corpus,” which contains some of the first writing on medical ethics, the Hippocratic Oath. For Hippocrates, as well as other physicians of both his time and time beyond, medical practice was inextricably linked to philosophy, literature, and the social sciences.
            The introduction of Aristotelian empiricism marks the beginning of a long shift in the medicine away from the humanities toward “evidenced-based” theories of diagnosis and treatment. By the twentieth century, medicine was essentially void of any discipline save for the hard sciences and technology. In “Writing at the Margin: Discourse Between Anthropology and Medicine,” Kleinman calls this kind of medicine “biomedicine,” reflecting “the overall trend . . . for the patient narrative gradually to disappear in favor of technical investigation, for symptom to give way to disease entity, and for treatment to become non-negotiable . . . [in response to] the humanities gradually retreat[ing] from medicine” (Ilora et al., 11).
            Beginning in the 1960s, a “perception” of a “crisis” rose in western medicine, which questioned the “underlying authority of modern scientific medicine” (13). Specifically,
. . . the emergence of the anti-psychiatry movement; the inability of science and technology to deal effectively with many chronic and disabling conditions, despite escalating levels of public expenditure on healthcare; and an awareness of the personal insensitivity of much of modern medicine and its failure to take account of the patient’s perspective (13)
all contributed to a growing movement toward reform of medical practice, which catalyzed the development of the medical humanities. David Greaves, in his chapter entitled, “The Nature and Role of the Medical Humanities,” defines the field as “a humanistic perspective . . . [that] embodies a mode of enquiry which is typical of philosophy in particular, but can also be discerned in every subject in its relationship with medicine” (16). Though there is no one agreed-upon definition of the medical humanities (7), Greaves’ definition encompasses both the narrower and broader views of the field, situating the narrow conception within the broader. The first (and narrower) view of the medical humanities “equates [the field] with the medical arts” (18), defined as a view that “subordinates” science and technology to the “art of medicine” by naming science and technology “arts” in and of themselves (14). This narrower view depicts the medical arts as being a counterbalance to biomedicine, allowing neither art nor traditional science to dominate medical practice (18). The second broader view
focuses on the human as relevant to the whole of medicine and so cuts across the traditional formulation of western medicine as comprising separate realms of art and science, with the human aspects restricted mainly, if not exclusively, to the former (18).
Greaves’ definition defies the binary between the sciences and the arts, thus allowing for “and innovative and unified approach” (19) to medicine, which allows both for a reconsideration of medical theory and for “practitioners to develop a more rounded and humane attitude to their practice” (19). For the purposes of this paper, I will use Greaves’ definition of the medical humanities to inform the work I will do on Hornbacher’s memoir.
            In “The Humanities’ Role in Improving Health and Clinical Care,” Richard Edwards describes the goals of the medical humanities, calling the field a response to theories of medicine that are generalized and impersonal. He states that the “study of the humanities . . . may provide valuable opportunities to bridge the ‘organism – mechanisms’ divide” (238). Greaves presents four possible definition of the humanities, but in my discussion of Edwards’ implications for the field of the medical humanities in medicine, I will use Greaves’ fourth definition of the humanities: “[s]ubjects concerned with the uniqueness of individuals rather than generalization” (15) . Edwards points out that evidence-based medicine leads to generalizations that do not necessarily match the needs or situation of the individual, and that “even in ideal circumstances” (238) where the individual does meet a generalized clinical picture of an illness, “it remains imperative to address and respond sympathetically to the emotional consequences of diagnosis and treatment” (238). Medical humanities, then, sets as its ultimate goal the remedying of these two probable situations that arise from clinical generalization.
            Edwards discusses a variety of ways by which the medical humanities works to reform medicine from within its existing structures. First, he argues, the medical humanities provides a language by which patients and physicians may communicate (241). This language allows patients to verbalize their emotions concerning diagnosis and treatment, and the creation of fictional narratives allows for possible courses of action to be explored (241). This discourse provides a frame in which evidence-based theory may situate itself – within fictional narratives and emotive depictions of disease is the decision to apply a particular evidence-based theory. In addition to providing a means of discourse, Edwards points out that, in “[e]stablishing a valid language for communication of issues of emotions” (241), the medical humanities creates space for physicians to express warmth and “human values” (241), thereby allowing them to reassure patients and to explore the benefits and drawbacks of a treatment from  both theoretical and emotional perspectives. Edwards continues that the ability to entirely evaluate a given treatment is conducive to the exploration of alternative and complementary therapies for illness, thus creating the opportunity for western medicine to consider treatments not empirically validated, such as those associated with eastern medicine (242). Expanding on his argument that the medical humanities allows medical professionals to consider complementary therapies, Edwards states that the medical humanities builds upon the “problem-based learning” (245) associated with western medicine in that the humanities beg for a “questioning” (242), critical approach that “promote[s] reflective practice and learning” (242).
            In returning to Edwards’ basic argument – that the discourse created by the medical humanities ultimately combats clinical generalization by establishing an empathetic, critical approach to treatment and diagnosis –, I will now discuss Edwards’ implications for narrative representations of illness. Edwards states:
It is [useful] . . . to employ published narratives or artistic representations of ill health as qualitative input alongside actual patients’ narrative, to widen perspective and facilitate a more sympathetic understanding of the ‘human condition’ (237).
Thus, published narratives of illness work, on a grader scale than oral, unpublished patients’ narratives, to promote the aforementioned ways by which the medical humanities influences change within western medicine. In publishing such a narrative, a patients develops a voice apart from medical generalization, fitting his or her own story into the framework already in place to create the space for a dialogue between reader and text that allows for clinical language to expand beyond the textbook. It is through this combination of clinical and personal narrative, interwoven so as to be inseparable, that the medical humanities is apparent in published personal discourses of illness, and it is in this space that I situate my own analysis of such a narrative. 

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