Tuesday, June 23, 2015

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will “make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health” in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her golf swing, or a family physician might administer amphetamine injections to people who want to feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed, doctors daily witness death and terminal illness. If we know CPR, do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine, is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism ... composed of parts. It is a structure and not a heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes, “large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine and we would be remiss if we didn’t study this purpose carefully. Without a purpose, medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.

2 comments:

  • Aaron Rothstein,

    I found this article a fascinating read as I have lately been questioning the purpose of medicine. I also agree with many of your statements. The only point I beg to differ on is where you claim that psychiatrists deal with patients in a way that goes beyond health. While I completely agree with what you say about Botox and plastic surgeons, I feel like you are overlooking the importance of psychiatry. In this article, you claim that medicine is about making people whole, a structure rather than a heap. If this is true, is it not important the person not only resembles a human in appearance and bodily operations, but also in cognition and behavior? While it is the purpose of a traditional physician to make one physically well, the goal of making one psychologically well also seems essential to true health. If you disagree, please let me know what I'm overlooking.

    Thank you,
    Chandler Buchanan

  • Thanks very much for your comment, Chandler. I agree that psychiatric health is as important as, for example, cardiovascular health. However, I think that the border between psychiatric pathology and an appropriate psychological reaction is sometimes intentionally blurred by those who seek enhancement rather than treatment. I will clarify what I mean by this. Being upset over the death of a loved one is a natural reaction to a human event, a healthy reaction, I would say. Similarly, losing a job or a friend may elicit sadness or anger. Should physicians treat these patients with drugs just so they don't have to feel sad? I would argue that this is not an appropriate use of medical care, that this is beyond the realm of medicine. Those reactions are part of human experience and behavior that is not pathological but understandable and healthy. On the other hand, if someone is so depressed and so handicapped by that depression for months or years on end, then yes, this person needs therapy, whether that is pharmacologic or cognitive behavioral. The latter example falls within the realm of medicine. This patient needs treatment in order to be made whole again. I have chosen the clearest contrast between these two categories in order to make a point. Please let me know if you have other questions/disagreements!
    -Aaron

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