0 évaluation0% ont trouvé ce document utile (0 vote)
35 vues5 pages
The medical field is becoming the sphere of a
quite peculiar confrontation, a sort of test of tension
between two different approaches: on one side self-referencing,
the concept that the whole set of knowledge and
capabilities generated by medical science establishes selfsufficiency
of our field; on the other, the quest to broaden
our concept of reason overcoming this self-imposed limitation
of reason. At stake is the need to overcome the
dissatisfaction and the crisis our field is currently going
through. This article will go over some aspects of what we
believe to be a paradigm of a much general and crucial
cultural problem.
The medical field is becoming the sphere of a
quite peculiar confrontation, a sort of test of tension
between two different approaches: on one side self-referencing,
the concept that the whole set of knowledge and
capabilities generated by medical science establishes selfsufficiency
of our field; on the other, the quest to broaden
our concept of reason overcoming this self-imposed limitation
of reason. At stake is the need to overcome the
dissatisfaction and the crisis our field is currently going
through. This article will go over some aspects of what we
believe to be a paradigm of a much general and crucial
cultural problem.
The medical field is becoming the sphere of a
quite peculiar confrontation, a sort of test of tension
between two different approaches: on one side self-referencing,
the concept that the whole set of knowledge and
capabilities generated by medical science establishes selfsufficiency
of our field; on the other, the quest to broaden
our concept of reason overcoming this self-imposed limitation
of reason. At stake is the need to overcome the
dissatisfaction and the crisis our field is currently going
through. This article will go over some aspects of what we
believe to be a paradigm of a much general and crucial
cultural problem.
Raffaele Scarpa Received: 4 October 2010 / Accepted: 28 October 2010 / Published online: 25 November 2010 Springer-Verlag 2010 Abstract The medical eld is becoming the sphere of a quite peculiar confrontation, a sort of test of tension between two different approaches: on one side self-refer- encing, the concept that the whole set of knowledge and capabilities generated by medical science establishes self- sufciency of our eld; on the other, the quest to broaden our concept of reason overcoming this self-imposed limi- tation of reason. At stake is the need to overcome the dissatisfaction and the crisis our eld is currently going through. This article will go over some aspects of what we believe to be a paradigm of a much general and crucial cultural problem. Keywords Self-referencing Humanization of medicine Scientic culture Introduction One of the most debated issues today is the humanization of medicine [1, 2], a matter that reects the deep dissat- isfaction of both patients and health-care workers [3, 4]. This dissatisfaction cannot be reduced to a problem of available resources. Its origin should be sought elsewhere and clearly identied if we really want to try to humanize health care. Against this background, this report aims to investigate on what is likely the most seriousalbeit poorly acknowledgedproblem faced today by the medical community, something we may dene a cancer affecting medical professions: self-referencing. Denition of self-referencing and its rst root What do we mean by self-referencing? It is the concept that the whole set of knowledge and capabilities generated by medical science establishes self-sufciency of this eld. In other words, denying the existence of, and need for, an objective and committing reference context for medical professionalism: working in the medical eld need not to respond to anything other than its own internal dynamics. In truth, this problem is common to all aspects of human activities of current times, although in the medical eld this attitude has reached perhaps its highest expression and is where it may have the most severe consequences, as we will see. The claim for self-referencing is based on two main factors. The rst is the recall to the origins of our profes- sion and its ancient ideal reference points. The classic and obvious reference is the Hippocratic Oath [5]. This is considered a Magna Charta identifying on the one hand the extent and prole of professional deeds, and on the other expressing an exhaustive position regarding the need for ideal support of professional devotion. Indeed, the miracle of classic antiquities is the devel- opment to the extreme of all human faculties. We owe A. del Puente (&) A. Esposito R. Scarpa Rheumatology Unit, Federico II University, Via Pansini 5, 80131 Naples, Italy e-mail: delpuent@unina.it L. Savignano Avellino Local Health Unit, Avellino, Italy V. Lombardi Naples Local Health Unit No.1, Naples, Italy G. Lombardi Department of Endocrinology and Molecular and Clinical Oncology, Federico II University, Naples, Italy 1 3 J Med Pers (2010) 8:130134 DOI 10.1007/s12682-010-0070-6 them the deep human drive that was able to discover the value and dignity of medical care. However, this would have remained unaccomplished had it not been grafted by Christian civilization. This constitutive unaccomplishment and not just technical inadequacy is well illustrated by several considerations. In Platonic and Aristotelian ethics, medicine was sub- ordinated to the good of the polis; consequently, if a physician employed part of the communitys resources to treat someone who, destined to sure death, would never be able to return the benets to the community, that physician would have failed in his professional duty. Doctors were instructed to abandon a person affected by an incurable condition [6]. For Hippocratic doctorsbut we could simply say for doctors in classical antiquitiesthe guiding principle inspiring their actions was the necessity of nature, imposing abstention from practice in cases that were necessarily considered incurable. Philanthropia was subordinated to love for nature (physiophilia). If we shed ourselves of all prejudice, therefore, classical antiquities display a humane positiona consideration for medical practicethat explores for the rst time in the history of humanity such a profound position. The Oath represents the culmination of a natural attitude. And yet, the full correspondence to human expectation remains unaccomplished, unattainable. An expectation that within this context can be dened by the words charity, gra- tuitousness: they represent the human approach that everyone who is ill would want to experience in his/her relationship with the health carer. Therefore, the referral to the origins does not justify the claim for self-referencing of the medical eld because it does not recognize the need for the opening of the eld to other contributions, which has granted its growth. It dis- avows, for instance, the substantial debt toward the Christian experience. This, transplanted in a substrate prepared by the classical culture, has generated novelty and originality of expression for the human surge for attention and care for those who suffer, in a way that corresponds to the persons expectation. The second root of self-referencing: modern self-limitation of reason There is a second basis on which this claim lies: the technicalscientic culture asserts that it has rules of its own that do not respond to any other cultural eld or knowledge. Moreover, this culture claims to be the only approach which can generate reasonable conclusions (exclusive use of the principle of reasonableness). It deems rational only that which can be proven by experiments. This attitude draws its origins on the self-limitation of reason [7] that has gained ground in modern times: the objective and universal knowledge can only derive from the mathematicalscientic approach. All other forms of knowledge remain limited to the subjective sphere and have neither space nor saying in the debates and decisions that concern our professional eld. The medical profession, therefore, sees itself as dependent only on evaluations that are validated by experiments. This reductive approach is the object of discussion suggesting, instead, that technicalscientic culture has in its own nature the need to open up to other realms of knowledge: true knowledge cannot be attained by reducing the broadness of human reason. Consequences of self-referencing in the medical eld The severe consequences of this attitude and the applica- tion of self-limitation of reason in medical profession can be summarized as follows. Mechanistic reductionism The rst consequence is that the self-limitation of reason connes to subjectivity all the considerations on the complex unity of the human being and its absolute value, considerations that precede the evaluations that need to be validated by experiments. There is in fact existential human evidencesuch as the persons absolute value or the respect for life from conception to its natural end which is absolutely reasonable, although not demonstrable by experiments [8]. A self-limitation of reason denying this, instead, ends up considering man as a broken machine needing repair, and the physician as the engineer of a broken body, with an immediate negative fall-out on the professional act, as would say anyone who was so unlucky to experience it. The human being is considered a product of our action, a product that, therefore, can also be selected according to the exigencies established by ourselves, and loses its dignity and inviolability. In a world based on calculations, the only reasonable factor is the calculation of consequences. The claim for a neutral technique This purely functional rationality, this self-limitation, engenders another distortion: it claims to conne the medical action to a neutral technique. Such a technique does not respond to anything other than its inner dynamics. It only needs to be applied. No need for people capable of judging, of relating with the patient: there is only need for clerks applying guidelines. At this stage, the only J Med Pers (2010) 8:130134 131 1 3 protagonists are the user who makes requests and the arbitrator who veries the proper execution of the proce- dure. The unique dimension of the doctorpatient rela- tionship, the need for meaning expressed by such relation, these too are conned to the realm of the subjective. The medicine of desire and bureaucratization, which drive the doctor towards defensive medicine, become wide- spread, and the technical goodness of the medical act is again penalized. The claim for a neutral technique once again turns against man, even in its professional action. Applying this self-limitation of reason to the medical eld consequently produces results that go opposite to what is theoretically desirable; medical profession, to be ef- cient and effective, must consider the patient in its wholeness, as a person. Broadening the concept of reason Challenging the concept of self-referencing does not imply, then, moving away from experimental evidence: rather, it means being loyal and recognizing reality in view of all its richness. It implies considering a person not as a broken machine needing repair, it means considering our work as part of a wider task aiming to respect and accomplish the global aims of the human being. It implies facing in our work the responsibility of a confrontation with the questions posed by what we nd to be true in our human experience. This is the work we are called to by the quest to broaden our concept of reason, overcoming this self-imposed limitation. It means not conning to subjec- tivity (and basically declass or neglect as relative) such relevant issues, nor denying the problems engendered by the persisting claim for self-referencing: massication and merchandization of patientcare giver relation; massica- tion and merchandization of such sensitive domains involving human suffering, the education of young stu- dents, scientic research; and, last but not least, the crisis of professional roles, the dissatisfaction with ones own work, the dissatisfaction felt by patients [9]. Any technical action or scientic know-how, especially if related to medical care, cannot do without the acknowledgement of a reference context where the person and life are considered as absolute values. The purest of all technical and scientic actions, or the one remotest from any applicability or apparent relation with the individual, beyond the awareness of this reference horizon, loses its efcacy and its technical or cultural goodness. It does not generate civilization and turns against man. Outside this context, it is the technical goodness of any act that falls short. He who does not respect the other as a person and connes such need to the subjective realm, does not work well, cannot make products or technical actions that are adequate. Therefore, the point is not adding something to technicalscientic knowledge, a bit more humanity, but rather to place technicalscientic knowledge in the con- text that makes it more effective. Going back to the cancer that self-referencing represents, it is not a matter of adding liver cells to the lung, because the lung is designed to carry out its own function, but rather to relate the lung to the rest of the body according to nature, correcting and treating the cancer growth (the claim on autonomy) that is taking place in that organ, which not only is damaging the entire body, but is preventing that organ from carrying out the role it was meant for in a technically adequate way. Broadening the concept of reason: the delicate issue of common values How can we achieve the opening necessary for our work? The rst step in this direction is to loyally recognize that the various aspects of human reality are not self-referential and that, consequently, our profession does not have in itself the potential to make it. Which is not a drawback: rather, it equals to acknowledging the richness of reality, even professional reality. This acknowledgement relates itself to the delicate issue of trying to agree on the values or objectives of our profession, which, if misunderstood, can become a mere expression of the attitude of self-sufciency previously described, with the dire consequences we mentioned. As a matter of fact, if the reference to professional values or objectives (as a minimum common denominator) supports the attitude of self-sufciency, it falls prey of those who are stronger, i.e., those who will be able every time to redene the content of these values or objectives. This is the substantiation of the self-sufcient attitude. At times the specic reference to the professional values can also become an antiscientic attitude, as a suggestion to move away from the experimental method, out of nostalgia for the artistic or poetic profession that once used to be. The experimentalbiological model, the evidence-based medicine, remains a valid instrument. The point is placing the technicalscientic knowledge in the reference context that would make it effective, and that medical science alone is unable to generate. There is need for an a priori opening. Values and objectives are obviously necessary in our activity, but the exclusive ref- erence to them remains ambiguous and ends up reinforcing the attitude of self-referencing. 132 J Med Pers (2010) 8:130134 1 3 Opening up to essential resources: a question of proper laicity In order to overcome the self-referencing attitude, a simple fact needs to be acknowledged: what is true in our human experience is not alien or irrelevant in our work, and vice versa. This is an extremely important cultural step, with important operative consequences: in our work we need to open wide the doors to those resources, to the educa- tional relations that express the full extent of our human experience. It is a call to a proper laicity, meant as acknowledgement of full right of citizenship for positions that openly express their motivations, recognizing their value as resource and their social relevance [10]. This does not limit anyones freedom: rather, it represents the will- ingness to put at everyones disposal all the available energy. On the opposite, laicitymeant as indifference towards a process of argumentation sensitive to the truth [11], laicity meant as concealing personal motiva- tions, considered relative after allends up giving into supercial reference, to common values (without sup- port or criteria) or to objectives of a self-referencing professionalism. Opening wide the doors implies giving value to the possibilities and resources that are before our eyes. In particular, the Christian experience is undoubtedly an essential resource for the world of health care, both from a historical and a personal point of view. The contribution of the Christian experience to professionalism in the eld of health care is not a mere idea, it is rather an educational relationship, a fellowship that makes reasonableand, therefore, tends to make permanentwhat everyone hopes for in our eld: considering the other (patient, colleague) in its wholeness, as a person. Therefore, to face the problem of self-referencing and its consequences (mechanistic reductionism and claim for a neutral technique), it is important to promote encounters with such experiences and the consequent development of judgments in a spirit of proper laicity. From ward meetings to company training courses, the road to humanization of medicine needs to be paved by encounters with effective professional experiences that do not deny the relevance of motivations and their impact on the technical action, that do not disown them as subjective or irrelevant; otherwise, the risk is communicating only an impression of personal ability, which does not produce culture but cultivates self-referencing. Consequently, if we favor these encounters, we facilitate positive interaction among professionals, aimed at express- ing judgments and initiatives on issues dealing with our profession, having as starting point the broadness of reason, without conning to subjectivity the most important aspects of human experience (substantially declassing or excluding them as relative in the confrontations and the decisions that involve our professional domain). This represents the context in which the attitudes uni- versally claimed as indispensable for the technical goodness of our work [1]i.e., gratuitousness, devotion, sacricecan again become signicant because they do not rely on theoretical postulates or on ethical effort, but rather on the energy that stems from liaising with other people, from a current educational relation that one nds humanely fascinating and professionally effective. Some examples can suggest a path for this opening. In the rst place, it would be possible to take the opportunity offered by the educational spaces already available as optional courses, as it is being already done in our Medical School for students and for health-care professionals [12]. These lessons are not primarily courses on ethics, or just lessons, but opportunities to discuss and share experiences with health-care professionals who are interested in an educational path. These seminaries aim to document that a motivated person-oriented approach of the medical pro- fession improves medical care [13, 14]. This opening to educational relations implies being aware, in the relationship with patients and with patient associations, that health is part of an overall wellbeing. Therefore, promoting health includes, together with a passionate and sound care of the person in front of us, the suggestion towards opportunities to open up ones own life to a wider perspective [15]. In addition, the opening to educational relations means giving value to professional associations, not only in terms of representativeness, but also as an explicit call to a proper laicity, and as a domain where this opening can be expressed systematically and critically. Lastly, in our activity the confrontation that stems from the aperture to such resources should be made methodical, so that all our work could ourish again: it is in fact sup- ported and modulated in every details by the way we consider ourselves and the one before us, i.e., by our anthropological concept. This interaction and this opening are a conditio sine qua non to overcome self-referencing and its consequences, and recover our role, from mechanics of a broken body or clerks who apply guidelines, to professionals, i.e., people capable of bringing out in their work their complete humanity. Acknowledgments No funding was provided from any source. The characteristics of the manuscript did not require ethics committee approval. Conict of interest None of the authors had conicts of interest. J Med Pers (2010) 8:130134 133 1 3 References 1. Medical Professionalism Project (2002) Medical professionalism in the new millennium: a physicians charter. Lancet 359:520 522 (Ann Int Med 136:243246) 2. Royal College of Physicians (2005) Doctors in society. Medical professionalism in a changing world: main report. RCP, London 3. Smith R (2001) Why doctors are so unhappy. BMJ 322:1073 1074 4. Cole TR, Carlin N (2009) The art of medicine. The suffering of physicians. Lancet 374:14141415 5. Markel H (2004) I swear by Apolloon taking the Hippo- cratic Oath. N Engl J Med 350:20262029 6. Plato. Republic, 409e410a, Book III. http://www.perseus. tufts.edu 7. Ratzinger J (2005) Europes crisis of culture. Speech in Subiaco, Italy, April 1, 2005. http://www.catholiceducation.org/articles/ politics/pg0143.html 8. Giussani L (1997) The religious sense. McGill-Queens Univer- sity Press, Montreal, pp 1222 9. Hartzband P, Groopman J (2009) Money and the changing cul- ture of medicine. N Engl J Med 360:101103 10. Scola A (2007) Una nuova laicita`. Marsilio Editori, Venezia, pp 1525 11. Habermas J (1998) Reasonable vs. True, or the morality of worldviews. In: Habermas J (ed) The inclusion of the other: studies in political theory. MIT Press, Cambridge, pp 75101 12. List of optional courses (ADE) Medical School Federico II Naples, Italy. http://www.medicina.unina.it 13. Del Puente A, Esposito A (2002) Il contributo dellesperienza cristiana alla professionalita` medica. Edizioni di Pagina, Bari 14. Del Puente A (2008) Una occasione di collaborazione in Facolta e nei corsi di aggiornamento professionale. J Med Person 6:4041 (letter) 15. Federazione Italiana Osteoporosi e Malattie dello Scheletro (FEDIOS) Sezione Campania (2009) Una compagnia signica- tiva nella fatica e nel dolore. Booklet for the patients (pro- manuscripto). eticagraca@inwind.it 134 J Med Pers (2010) 8:130134 1 3