Should self-care and cultivation of the self be included as an essential dimension of medicine?
If medicine is ‘the art of preserving and restoring health’ (little oxford dictionary 1986:336) what is to be included within the remit of a doctor’s art and what ends must be gone to achieve this aim? I will be talking in this essay specifically about the doctor’s role in providing for his patients. It is a discussion about boundaries, between doctor and patient responsibilities, between self and other and more fundamentally the boundaries that lie within each person. In exploring these boundaries it becomes evident that they are not distinct, they move with changing perspective and can even disappear. We will see that recognition of this ambiguity, although at times disconcerting, is necessary for effective medical practice.
Medicine Today and the Socratic Imperative
The march of scientific progress continues; producing an ever-increasing number and complexity of medical technologies as well as an ever-expanding body of knowledge through the production and application of evidence based medicine. Despite its success in these fields, modern medicine is facing many problems. Litigation rates continue to increase as patient trust in doctors diminishes, many complain of the ‘human’ aspect having disappeared from medicine. There continues to be poor patient compliance with treatment and health promotion advice often falls on deaf ears. Doctors, in an increasingly pressurised environment, spend less and less time with each patient leaving little time for meaningful communication or to build a trusting relationship. System specialisation compromises continuity of care and categorises patients according to body parts – ‘a cardiac patient’, ‘psychological problems’.
In this climate it may appear that ‘self care as an essential dimension of medicine’, is an idealistic ambition. But I will show that it is the key to solving many of these issues. We will begin by looking at the ideal of self-care in Ancient Greece, followed by an analysis of ‘the self’. This will lead onto concepts of self-care and how these notions contribute to a redefinition of the everyday practice of medicine. We will then look at the approach to self-cultivation in the medical systems of India and China.
‘…Why are we concerned with truth and more so than with the self? And why do we care for ourselves only through the care for truth? I think we are touching on a question which is very fundamental and which is, I would say, the question of the Western world. What causes all Western culture to begin to turn around this obligation of truth…?’ Foucault (1984:15).
Foucault describes our society, in which the quest for truth is paramount and for our interests the truth of science, of understanding the cause and meaning of illness through the eyes of rationality and reason. We examine and live in the world empirically, objectively. ‘We will admit as human only those aspects of ourselves that seem to be reflected in physical laws or biochemical processes… By broad contrast, the classical Greek worldview was human-centred’ (Gregory, 1984:17). Foucault recounts ‘the Socratic imperative: ‘‘be concerned with yourself, i.e., ground yourself in liberty, through the mastery of self’’ ‘(1984:20). He describes the society of Ancient Greece, in which value was placed on truth, but of a different kind, the subjective truth discovered in care for self. This was achieved through self-knowledge, self-reflection and self-improvement. These practices were seen as an expression of liberty, and as the duty of a free man.
There are many and complex reasons for the change of focus in our society, not least the advent of Christianity and the future focus that this and the ideals of scientific progress brought (Gregory, 1984). But where are we today in our conceptions of self and self-care and what might help us to move forward to a better place?
Definitions of ‘the self’
The notion of self-hood is a somewhat problematic one in contemporary society. ‘The very category of person, it seems, has become parcelled out among expert discourses. All facts contain, imply or exclude categories of persons’ (Dumit 1997:86). Dumit argues that we have become dependent on scientific ‘facts’ in forming our identities and that they therefore ‘play a key role in how we experience our selves, our bodies and others’ (1997:87). This method of self-formation and self-understanding places emphasis on the objective and also on the responsibility of faceless ‘expert opinions’ or ‘other’ (as opposed to self) in telling us who we are.
This disembodied and fractured conception of self is compounded by the dominant ideologies of dualism in our society. We oppose mind and body, spirit and matter, and this leads to a mechanistic conception of the body (Scheper-Hughes and Lock, 1987); further compounding the sense of ‘other’ as formative in our self-identity. As quoted by Scheper-Hughes and Lock (1987), ‘the rise of science propelled man into tunnels of specialized knowledge. With every step forward in scientific knowledge, the less clearly he could see the world as a whole or his own self’ (Kundera, 1984). Nowhere is this more keenly felt than in the practice of modern medicine where humanity and science collide. The question is how to move beyond this disembodied and fractured self to a more, cohesive, holistic notion of identity.
‘The general condition of this concern with self is that contemporary society has approached the limits of rationalisation of the body, emotional experience and styles of moral evaluation and legitimation, limits at which there is a change in the very practices by which self is symbolized shaped and expressed’ (Csordas, 1994:20).
Csordas (1994) states that ‘the self’ is not an empirical entity; it is a theoretical construct and therefore can be understood in many ways. He describes it as an orientational process, a way of being in the world, but he also sees that it only has existence and meaning in its relation to the world. ‘Self is neither substance nor entity, but an indeterminate capacity to engage or become orientated in the world’ (1994:5). He recounts the writings of two other thinkers in his definition. The first is Merleau-Ponty (1962) who wrote about perception from a phenomenological perspective, stating that perception begins not with objective reality but with the perceiver. The body is first a perceiving subject and only after perception and reflection does it become an object. It is therefore also pre-objective. Perception becomes, not observation of objective reality, but a process of objectification or reflexivity. The second thinker is Bordieu (1977) and his theory of practice. He describes a ‘system of perjuring dispositions…’, habitus, (Csordas, 1994:9) within each person, an amalgamation of behaviour and environment, which guides our actions and is informed by society. The body is the medium through which these dispositions are coordinated.
So from the phenomenological perspective subject-object duality is no longer a clear dichotomy, and neither is the mind-body divide; ‘it is in the immediacy of lived experience that… dualities are collapsed, but also out of which they are generated in the first place’ (Csordas, 1994:278). It is when these dualities are objectified that they become problematic, in the indeterminacy of experience they remain fluid. In Csordas’ account of perception and practice we see a self which is ‘grounded in embodiment’ (1994:10), not a self which can be fixed in space or time or defined by ‘facts’. It is a self that is constituted of process rather than substance; it is never fully formed, continually developing. This interpretation allows us to escape from defining ourselves objectively and therefore loosing a sense of self as immediate and present reality.
Self-care and Cultivation
Recent discourse in medical anthropology has criticised orthodox medicine for its ‘’biomedical’’ perspective, its loss of touch with the social, psychological and emotional constituents of disease. This has led to Eisenberg’s disease and illness classification, where ‘disease’ is the structural or functional abnormality of the body, and ‘illness’ describes the subjective experience of that disease (1977). Engel’s Biopsychosocial model (1977) as described by Altenberg (1992) attempts to combat the same problem, stating that we must address psychosocial elements of illness in order to create a more cohesive and functional health system. Dr Engel also places great importance on the relationship between doctor and patient in effective treatment. He saw the role of doctor as that of educator. It is this role, which is lacking in many modern medical encounters and if it exists it is often didactic and paternalistic. This desired educational role is similar to the role of philosopher that Foucault describes in Ancient Greece, ‘the one who cares for the care of others’ (1984:7). He states that ‘in order to really care for self… one needs a guide, a counsellor, a friend’ (Foucault, 1984:7). But one who will direct without a sense of dominion.
This brings us to the idea of self-care as a part of medicine. If we accept the discourse of Engel and Eisenberg then we can no longer see bodies as existing in isolation and therefore medicine can no longer be responsible for healing only bodies. We are aiming for a more holistic and inclusive approach to medical care. This approach is patient centred and in caring for patients we must encourage them to care for themselves. If they do not, our efforts are futile. Self-care is therefore the fundamental building block in creation of effective health care.
If, as Csordas (1994) states, the self is processual and indeterminate, then it is open to change. The therapeutic process becomes a transformative process in which notions of self undergo change. Csordas talks of healing in the Charismatic church in terms of ‘subtle modulations of the self’ and ‘transformation of self’ (1994:71). But in order for this to be effective the participant must be existentially engaged in the process, on the level of their self – both ‘body and mind’ to apply current terminology. The same processes can be undergone in the setting of the secular medical consultation, through encouraging self-recognition and self-cohesion and by involving the patient as himself/herself in the decision making process. It is the doctor’s responsibility to instil a sense of responsibility in the patient, but through empowerment not coercion. Csordas’s cultural phenomenology allows us to exist experientially, as ourselves, in the present moment. From this perspective any change is possible. So the argument here is that if medicine is to care for all aspects of the patient and to provide an effective and lasting change through healing, then by definition health care must include self-care.
Listening to patient narrative and addressing psychosocial aspects of illness experience goes a long way to improving relationships between doctors and patients and therefore reducing litigation, complaints, mistrust and the dehumanising elements of biomedicine. Simply informing patients of health risks and beneficial lifestyle changes seems to do little for public health. These changes must be embodied, incorporated into people’s lives. They are not moments but processes that must be encouraged and maintained. It is through embodiment that these changes can be made and it is the role of the doctor to encourage these changes. As Thomasma (1984) states the goal of medicine must be to ‘heal the body, the self and the social side of a person by working in and through the body’ (1984:46). This approach has been used for some time in the medical systems of other cultures.
Non-Western approaches to Self-Care
The question of whether self-care should be included as an essential dimension of medicine is entirely redundant in the context of Traditional Chinese and Ayurvedic medicine. Self-care is central to these disciplines, self-care IS medicine. Alter (1999) would go so far as to say that our conception of medicine as a remedial discipline, is not universal. So what is the approach of Ayurvedic and Chinese medicine? And what can we learn about self-care from these ancient disciplines?
Ayurveda sees a person’s constitution and lifestyle as major contributors to disease (Lad, 1984). It therefore follows that modification of the way that we live can prevent illness. It prescribes changes beyond orthodox medicine’s ‘don’t smoke, eat well, exercise’ and provides a detailed framework within which to achieve its aims. The patient is more responsible for his/her own health and therefore plays an active role in treatment rather than simply receiving it.
In the west, hospitals, doctors and medical treatments and procedures hold negative associations for most people and medical knowledge is something that’s felt ‘’best left to the experts’’. So health is not something people think about on a day-to-day basis. As Blaxter (1990) found, people only really consider health when they don’t have it. Ayurveda is not just for the sick; it is a system for staying well that becomes part of the patient’s lifestyle. The basic concepts can be easily understood and applied by anyone. It encourages patients towards physical and mental self-knowledge.
Orthodox medicine is based on scientific method and clinical trial. It defines universal guidelines of best practice and makes broad policy decisions on this basis. So treatment begins with a statistic stating ‘what works best for Mr.Average’ and if that doesn’t work an educated guess is made about what might be the next best thing. Ayurveda does not use a standard treatment for a standard disease in a standard patient. It begins with a detailed assessment of the individual patient, addressing all aspects of their life. So each person is unique, there is no homogeneity. The therapeutic process begins with the patient, their ‘self’ not their objective body. As our analysis above led us to conclude, this is the best method for effective healthcare.
The Ayurvedic ‘perspective is proactive and concerned with overall fitness rather than reactive and primarily concerned with either illness or disease’ (Alter, 1999:S43). It challenges our definition of medicine as ‘the art of preserving and restoring health’ creating a notion not of restoring what is missing or fixing what has gone wrong but of going beyond wellness to a state of hyper fitness. Rather than seeing the body as naturally healthy and therefore prone to illness, it sees the body as naturally imperfect and therefore perfectible (Alter, 1999).
In comparison with Orthodox medicine, this kind of approach is not seen as preventative medicine ‘but rather… vigorous self-development’ (Alter, 1999:S51). Perhaps this is where the focus of public health messages has gone wrong – in using possible, negative, future, events to try to dissuade people from certain behaviours and encourage others. In removing the focus from the future self to the present self and using the positive language of proactive medicine rather than that of negative reactive medicine, Ayurveda creates an environment conducive to change. Additionally these life changes are encouraged to be slow, but steady; there is no instruction to ‘do this now’ (e.g. stop smoking). Ayurveda encourages people to listen to their bodies and become in tune with its rhythms, not just to pay attention to it when something is drastically wrong.
Many of these themes are reiterated in the theories and practice of Chinese medicine, such as striving for positive good health and person centred medicine. Self cultivation is a theme running throughout the history of Chinese medicine, there are texts dating to 200 B.C. dedicated to the four main branches of self-cultivation practices, sexual cultivation, breath cultivation, exercise and diet modification (Harper 1998). Farquhar (1994) describes these as ‘technologies of embodied knowledge’ (1994:472), reiterating our message of embodied knowledge and change. The close relationship between patient and practitioner cultivates an ‘attentiveness to symptoms and a willingness to report subtle changes’. This encourages the kind of attentiveness to the self that we have been discussing throughout. In Orthodox medicine any symptoms deemed unimportant to the doctor will be dismissed, so discouraging this kind of divulgence. Farquhar again touches on the positive reframing of healthful practices, saying that it is not a means to an end i.e. health but an end in itself – balancing the trials and tribulations of daily life, a kind of sanctuary from it. A sanctuary, which, I think, many in the west would welcome.
Dumit (1997) states that in Western civilisation the person has become an amalgamation of often-contradictory facts, an entity divided by specialists into sections. We live compartmentalised lives, each person having multiple identities to fit with the multiple roles in the multiple sub-cultures we are part of (Mellor and Shilling, 1997). It is this sense of division of self, of identity and of community that is at the heart of many of the problems facing orthodox medicine and society today. Medical science disconnects people from their bodies, breaking them down into parts, objectifying them through imaging and tests.
It is possible to combat this sense of disparity and body alienation and begin a process of change. If embodiment is the foundation of the self and therapy a process of embodied change, then we must begin by re-embodying our patients. We must bring them into the present moment, into their experiential rather than objectified bodies, through a process of self-knowledge, self-care and self-cultivation.
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