"Between Heaven and Earth: A Guide to Chinese Medicine" - Par Harriet Beinfield,Efrem Korngold (1991)

CHAPTER TWO

PHILOSOPHY IN THE WEST :

THE DOCTOR AS MECHANIC

Cartesianism is the unspoken philosophical substratum of contemporary medicine - the source of many of its great strengths and equally of its deficiencies.

Pellegrino and Thomasma

A Philosophical Basis of Medical Practice

BECAUSE OUR PERCEPTION OF THE WORLD INFLUENCES HOW WE LIVE IN it, our consciousness sculpts reality. Conversely, our experience shapes our thinking, so our reality molds consciousness. Our minds create what is real, and our lived experiences generate our thoughts. Our minds create what is real, and our lived experiences generate our thoughts. There is a reciprocity between beliefs and observations - what we look for affects what we see, so describing "just the way things are" from the Chinese and Western vantage point is not necessarily the same. Each makes sense of the body according to a different set of beliefs.

It became clear to us that to penetrate Chinese medicine we needed to examine how reality itself was defined, East and West. Because taken-for-granted assumptions are buried just beneath the skin of our conscious awareness, in this chapter we peel that skin back to expose our Western philosophic presumptions about how things are. Upon understanding our serves, we can approach the unfamiliar and proceed to probe the East on its own terms.

SCIENCE: THE NEW RELIGION OF THE WEST

During the Middle Ages, people in Western Europe had a unified view of their universe: seeing themselves as an integral part of everything that was both seen and unseen. They were connected with Heaven through God and with Earth through Nature. The break with this organic sensibility came with the decline of feudal society as cities grew where there were once feudal kingdoms. As the pervasive authority of the Roman Catholic church was undermined by the Protestant Reformation, the people of Europe believed they could attain mastery in the world through their own wilful efforts. No longer were they solely dependent on the spiritual community of the Church.

In the Christianity of this new era, the realm of Heaven existed outside of Nature, apart from it, barely within human reach. Earth and Heaven were decided into separate realms. The dar, sinister, mysterious forces of Earth were juxtaposed with the enlightened, righteous, and supernatural forces of Heaven. Instead of being an ally, Nature became an adversary to be overcome and conquered. Man stood outside of it, apart from and above it. The Earth was no longer intimately connected to the life of our own body, instead it became an object that could be manipulated and exploited. Human beings were the battleground in which Man and Nature, good and evil, spirit and body, wrestled with each other. A unified reality was sacrificed for dominion over Nature, for technology, for “progress.”

A schism occurred between the sacred and the secular, Heaven and Earth, life and death. Before this, with God for protection and guidance, it was unnecessary to question and understand Nature. But without divine providence, the unpredictable chaos of Nature was perceived as forbidding and dangerous. Death, associated with the dark forces, became irreconcilable with life, rather than an inevitable transition in the cycle of existence. The best protection against Nature was through domination and control : to gain power over Nature was to conquer each. A new set of values and beliefs was created to explain and organise the world. This new “religion” was that of science, and its priests were the mathematicians, physicists, and mechanical engineers.

DESCARTES : NATURE AND THE BODY AS MACHINE

In the West the philosophy of science is based on the premise that humans are separate from nature, and that the world, like a machine, can be dismantled and reduced into constituent parts. Reality is located in the tangible structure of matter : that which can be measured, quantified, and analyzed. Events occur according to unchanging laws. The foundation for this scientific thinking was buried in the soil of Aristotle’s “empirical materialism,” excavated during the Renaissance. With Aristotle, reality came to mean that which could be substantiated materially. Matter was understood to be fixed and unchanging, therefore real.

In the seventeenth century, the French mathematician Descartes ushered in the Western scientific revolution. His introduction of analytic, reductive reasoning formed the basis of a new philosophy of science, which became the philosophy of modern medicine as well. His thinking had such profound influence that the principles underpinning modern science came to be referred to as Cartesian.

Descartes believed there could be absolute, certain truth, commenting, “All science is certain, evident knowledge. We reject all knowledge which is merely probable and judge that only those things should be believed which are perfectly known and about which there can be no doubts. Through the use of reductive, deductive logic, Descartes felt on the verge of comprehending the fundamental workings of the universe. He conceptualised the world and everything in it as a machine, stating, “I do not recognize any difference between the machines made by craftsmen and various bodies that nature alone composes.” Mechanical laws were said to universally govern all phenomena. The exact sciences formulated to dominate and control nature were applied to human beings as well. Descartes considered the human body a machine, likening a healthy man to a  well-made clock. He also erected a firm division between mind and matter, asserting, “There is nothing in the concept of body that belongs to the mind; and nothing in that of mind that belongs to the body.”

This mechanistic view of nature led to the fixed and absolute physical laws devised by astronomer and mathematician Isaac Newton, which outlined the cause-and-effect method of explaining the material universe. This logic formed the basis of the scientific method, which even today remains essentially unchanged. Perhaps unaware that many logical systems of knowledge exist, most Westerners consider this to be the only valid way of understanding the world.

Within this worldview, nature and humains are machines governed by mechanical laws: systems that do work, tools of production. Western medicine, correspondingly, is the study of how the human machine works. When people are like machines, doctors become like mechanics. The mechanic occasionally performs routine maintenance but mostly intervenes to execute emergency repairs. He plunges into the working parts, replacing the non-functioning elements, and puts the machine back into working order. It follows that the doctor as mechanic fixes the broken body-machine.

In this schema, the body is reduced to structural parts, proceeding from organs to tissues, tissues to cells, cells to molecules. The doctor as mechanic separates the whole into parts in order to discern the nature, proportion, and function of each constituent. Sorting out the parts enabled early Western doctors to conceptualize a diseased entity as the faulty component and sever it from the organism as a whole. They could thereby remove it or treat it in isolation from other organ and tissue parts.

THE RISE OF WESTERN MEDICINE

The findings of the early anatomists validated the mechanistic view that the body is made out of distinct and separate parts, connected and yet autonomous. They divided the body into systems analogous to mechanical processes that corresponded precisely with structural descriptions of organs and tissues. The circulatory system comprises the heart as a mechanical pump that pushes the blood through the pipes of the veins and arteries. The lungs are like a bellows, the nervous system like an elaborate electrical telephone network.

For the mechanic, it is best if the parts of the machine are standardized and uniform. That way the parts are interchangeable, easily replaced, and the ways in which they break down become predictable from one body to the next. Standardized diseases develop from established causes, and protocols of treatment are fixed. Uniform parts sit on the shelf. This view focuses entirely on the ways in which all people are alike and tends to overlook the ways in which people are unique and dissimilar. When a group of people receives the same diagnosis, they receive the same treatment. Science and industry have enabled medicine to be practiced on a mass basis. The same mechanistic philosophy that inspired mass production in industry also inspired mass medicine and health care.

The marriage of science, industry, and medicine spawned an age of innovation and specialization. As a result the human body and mind were divided and reduced into ever more diverse and refined areas of investigation.

For example, chemists began to perceive the body as a chemical factory controlled and regulated through the balance of molecular compounds. The practice of pharmaceutical therapy was the by-product of the tremendous discoveries made in chemistry. Penicillin, aspirin, digitalis, cortisone, and smallpox vaccine were just a fraction of the wonder drugs discovered to treat specific diseases and remove specific pathogens or causative factors. The developed radiation technology for diagnosis and treatment. The X-ray machine furthered diagnostic precision and inhibited the spread of many cancers.

For their part, the engineers perceived the body as a mechanical structure composed of discrete parts. They invented surgical tools and methods for removing and replacing faulty parts. The body as a machine could be stopped, taken apart, repaired, and put back together. Remarkable developments in surgical technology enabled doctors to do open-heart repair, skin grafts, appendectomy cesarean section, attachment of severed limbs, and bone setting. These innovations contributed to the resolution of potentially devastating health-care crises and constituted the wonders of modern medicine.

THE NARROWING DEFINITION OF DISEASE

Another fundamental shift occurred in the mid-1800s, when Louis Pasteur located the origin of disease outside the body, in the form of germs. His analytic research isolated a particular prior cause, triggering a given effect. The germ theory of disease postulated that a single microorganism could produce specific symptoms of disease in healthy organisms. This theory helped to explain epidemics and plagues and to develop effective remedies against them.

However, this "doctrine of specific cause" became generally invoked to explain all diseases. And because only the single cause was sought, the multitude of contributing factors occurring simultaneously in any given sick person were ignored. That the total condition of the person profoundly affected his or her susceptibility to a disease was excluded by this conceptual model.

For example, insulin was discovered when experimenters were able to produce the high blood sugar symptoms of diabetes in healthy animals by damaging the pancreas. According to the doctrine of specific cause, it was then concluded that the cause of diabetes was a deficiency in the production of insulin by the pancreas. This was a major lifesaving discovery of modern medicine. As remarkable as it was, however, the belief that insulin was a cure prevented people from searching for the real basis of the disease, the degenerative course of which remained unaltered.

The narrow view of specific cause has limited the scope and effectiveness of modern medicine, which often equated the control of symptoms with the cure of the disease. This belief in single cause diverted medicine from an appreciation of the context and complexity of human process from which degenerative diseases emerged. Although many involved in health care are increasingly aware that disease is not separable from the human life that cradles it, the ideology of Western medicine does not accommodate this insight. Referring to the "crisis in health care," H.R. Holman, M.D., of Stanford University cites shortcomings and suggests the need for philosophical and social remedies:

"Longevity has changed little, and the major illnesses such as malignancy and cardiovascular disease remain unimpeded.... Illnesses disproportionately affect the poor, major environmental and occupational causes of illnesses receive little attention and less action... clearly, there is a crisis in health care, both in its effect upon health and in its cost... Some medical outcomes are inadequate not because appropriate technical interventions are lacking, but because our conceptual thinking is inadequate."

Modern medicine directs its gaze through a microscope so that detail is gained at the expense of a restricted visual field. Specialists look at smaller and smaller fragments, gaining more and more positive information in the form of descriptive data but losing a sense of the integrity of the system as a whole. How did this medical model gain exclusive ascendance in America?

NARROWING THE INSTITUTION OF MEDICINE

In the beginning of the century a survey of medical schools was subsidized by the Carnegie and Rockefeller foundations. Its purpose was to find out which schools would be most interested in promoting "scientific medicine," therefore promoting the newly developing drug- and hospital-based technology industries. The Flexner Report, issued in 1910 by the American Medical Association following this survey, recommended that financial support from the foundations be awarded only to medical schools committed to scientific research based on models in the nineteenth century. All therapies not based on the Cartesian model were considered unscientific and would therefore be disenfranchised. Only 20 percent of the existing medical schools survived. The other 80 percent adhered to the "vitalist doctrine," which asserted that "man assists, but nature heals." Naturopathy, homeopathy, and herbology were forced out of the mainstream and relegated to the status of folk medicine. They were ultimately driven under by lack of funds and political harassment.

Formerly the majority of physicians were helpers, allies, and comforters to people struggling with maladies in their daily life. The new doctor became the exclusive source of specialized knowledge and the heroic slayer of disease. Increasingly a delegation of authority and power went to the doctor. Patients were educated to believe that doctors alone knew what made them sick and that only their technology or drugs could make them well.

As the depth and breadth of scientific information about the body grew, both doctors and people lost faith in the capacity of the human organism to heal itself. How could anyone but an enlightened and sophisticated engineer run such an awesomely complex and vulnerable machine? This faith was withdrawn from the body's self-healing abilities and put into the hands of the "experts" - the physicians.

OUTCOMES OF THIS MEDICAL MODEL

Medicine was not set up to advise people on how to stay or become well. The doctor could only fix what had broken down. He could miraculously remove evil (tutors, infections, stones) with drugs and surgery. He could manipulate function (thyroid hormones, diuretics, steroids) and replace worn parts (plastic hips and hearts). As a heroic soldier he could wage a valiant short-term battle. He could remove the “evil,” but there was no mechanism built into the system to discern or promote the “good.” Medicine’s strengths were the source of its weakness. The research and clinical institutions of medicine are still defined by the existing conceptual model and more oriented toward intervention than prevention.

Furthermore, as doctors became the experts, they acquired a type of power over their patients. Mastery of medicine became a technically sophisticated and exclusive high priesthood. The common person could not possibly gain access to and interpret the data necessary to administer medical care. Even the medical profession itself diversified into more highly specialised fields: the general practitioner who cared for a whole person was replaced by the cardiologist, who cared for the heart; the orthopedist, who ministered to the bones; the neurologist for the nerves; the oncologist for the cancer; the psychiatrist for the mind; and so on.

When power was taken from the person by the neural practitioner, and from the general practitioner by the specialist, there was no longer one doctor who cared for the whole person and knew her in the context of her total environment. The once intimate relationship between helper and helped shifted to an impersonal one between strangers. Doctors lost knowledge of their patients as real people.

This shift in the organisation of medicine taught people to feel that science knew more about them than they could ever know or understand about themselves. People as patients began giving away the responsibility to care for their own health. The phrase “health-care delivery system” suggests the doctor is like a mail carrier who can deliver health at the doorstep. This situation is reminiscent of Plato’s image of a “household” in which the “master,” the mind, knows but does not act and the “slave,” the body, acts but does not know. Doctors function as the master (mind) and patients as the slave (body). Now divided, the body loses its intelligence and the mind loses its power to actualise: not only is self-understanding undermined, but possibilities for action are limited as well. people mistakenly feel that the power to cure comes from outside themselves, administered by an alien intelligence.

This distortion of power often instigates an antagonistic relationship between doctors and patients. When doctors cannot perform the heroic role and fix the broken machine, they sometimes blame the victim, judging patients guilty of not getting better. Isolated, abandoned, undermined, and invalidated, patients then feel condemned to a circle of pain with now escape. Along with their physical pain, they are frustrated and angered by their feelings of powerlessness. They then become quick to blame the doctor for their problems, jumping into malpractice litigation. Suing for malpractice becomes an act of revenge, an attempt on the part of the patient to gain power over the doctor, not a reclamation of true self-power. The doctor is either a hero or villain-heralded for recovery or blamed for poor outcomes.

OTHER PARADOXES

Power, no matter who has it, does not confer wisdom. Doctors sometimes equate their authority with sagacity. Some interventions produce disastrous long-term effects on health. latrogenesis, or doctor-induced illness, can result from drugs, surgery, radiation, and chemotherapy. iatrogenesis is one of the leading causes of fatal disease. Approximately one out of every five people admitted to a research hospital acquires an iatrogenic illness.

Nobel prize-winning microbiologist Rene Dubos describes the new threats to health arising out of technological innovation. He says it is a painful and richly documented paradox that every drug of proven worth can itself become a cause of disease.

“Some of the toxic effects are extremely indirect and delayed. They result from disturbances in the physiological and ecological equilibrium of the organism. Their mechanism does not reside in chemical or physiological reactions involving direct cause-effect relationships, but rather in complex interrelated responses made by the whole integrated organism, including its indigenous microbiota.”

Another consequence of focusing more attention on the disease than the patient is that the doctor can eradicate the tutor but has no means of promoting the health of the patient. This enables one to say, “The treatment was a success, but the patient died.” For example, chemotherapy claims success at treating the disease and yet cannot necessarily improve the longevity of the patient. John Cairns of the Harvard School of Public Health states:

“Each year about 3,000 patients under age 30 are being cured by chemotherapy who would otherwise have died. Only two percent of the patients who die of cancer are under 30, however. For the vast majority of cancers, which arise in older patients, the results of chemotherapy are much more controversial…. Apart from the success with Hodgkin’s disease, childhood leukemia and a few other cancers, it is not possible to detect any sudden change in death rates for any of the major cancers that could be credited to chemotherapy.”

The other major paradox of the Western medical model is that it separates the indivisible. Western medicine has so successfully dissected the human body that it suffers from "overseparation," where the whole is no longer perceived as a meaningful entity. What was one indivisible circle, an unbroken continuum, became a straight line of successive causality in which events became random, losing their intrinsic relationship to each other. The mind has been separated from the body; the disease process as a whole; the parts from each other; the symptoms from the source of the ailment; and the patients from their self-responsibility and self-power.

This over-separation occurred at the dawn of modern Western civilization when matter was severed from the immaterial, human from nature, and process was frozen in fixed and absolute laws. Dualism shattered unity. This division has made us susceptible to an inversion of process whereby the means (technological, industrial, and scientific innovation) governs our ends (human values) and people become the "objects" rather than the "subjects" of their own activity. This has distorted our image of what the world is and who we are within it. The world man has made is impressive but lacks integrity- it no longer fits together, and neither do we know our place within it. When people are like machines, modern medicine becomes obliged to keep the machine running. Its purpose is defined as avoiding death rather than enriching life. Bodies must be kept alive at all costs because to die is considered intrinsically evil-death is the enemy to be conquered. Life and death are no longer part of a continuous cycle.

In ancient culture nothing was intrinsically good or evil, it was simply a matter of how one stood in relation to it. For an old person, it could be a gift to die with grace and ceremony just as it had been a gift to live - to preserve the tissue without the spirit would have been an offense, an insult worse than death.

The center of Western civilization has been commerce, industry, and information- the proliferation of economic transactions, manufactured products, and data. As Westerners we have been able to produce the world we live in, to control it by archiving power over nature. But the Western model is exclusive. It excludes the mysterious and intangible from its reality because the immaterial cannot be termed, contained, and controlled. In an effort to archive mastery over the world, connectedness with nature and humanity often perish.

Physicist Roger Jones comments upon the legacy of Descartes: "His genius, which has cleanly cut through the dense web of primitive mystery, has also severed out felt connection to the universe." This is where the Chinese model, still based on ancient principles, can help the Cartesian separation become whole again. Science historian Joseph Needham tells us that "the mechanical view of the world simply did not develop in Chinese thought and the organicist view in which every phenomenon was connected with every other … was universal among Chinese thinkers. “Rather, he continues, “The harmonious co-operation of all beings arose, not from the orders of a superior authority external to themselves, but from the fact that they were all parts in a hierarchy of wholes forming a cosmic and organic pattern and what they obeyed were the internal dictates of their own natures.