Primary health care is in a process of rapid change driven principally by the government, the pharmaceutical industry and the medical science establishment (the professional colleges and academic research establishments). Their dominant agendas are political, commercial, and scientific respectively. Special interest groups have some influence at all levels but these organisations generally speak for disadvantaged minorities and sufferers from specific diseases and do not challenge the dominant paradigm.
This leaves an important area of health care without a decisive voice. It is even difficult to give this area a name that will have a similar meaning to all readers. It could be called whole person care, or holistic care, or practice in which humanity and context are given first priority. It is about a way of thinking that cuts across the dominant conceptions of health and suffering. It once had the central place in general practice and I believe that its relative omission from the terms of the current debate is a source of frustration and unhappiness amongst many primary care practitioners. This contributes to poor recruitment and retention, much unnecessary suffering of patients, the wastage of valuable resources, and an overwhelmed NHS.
Western biomedicine helps people to live longer but not necessarily to feel healthier. In fact, a morbid curiosity about disease and the likelihood of developing it has become a national pastime. Furthermore, people are encouraged to strive for perfect health and to equate this with idealized images of happiness, comfort and prosperity that are unattainable. Natural biological variation, life’s inevitable ups and downs and the aging process are translated into demands for a technological fix. In the words of Per Fugelli this ‘may result in a malignant combination of learned helplessness and perfectionist expectations.’ (Fugelli 1998) He says ‘malignant’ because the imperative of health produces stress and disease. We are in the vicious cycle predicted by Ivan Illich (Illich 1975).
Underlying much of this is the fundamental nature of our image-obsessed, materialistic and consumerist society. If we try to address the problems using a health care system with the same underlying features we create several new problems for every ‘solution’. To transcend this vicious cycle we must have a health care system that is not subject to these problems. Such a system should not rely exclusively on a consumerist system for the application of technologies to biomechanical faults, but instead be based primarily on our mutual humanity – of patients and clinicians alike. Humanity here means those aspects of our being that provide us with meaning and that seem to disappear in the face of science and technology: our place in the natural world, our need for community and cooperation; the dramatic narrative of life and relationship; our dignity, humility, compassion, love, suffering and joy. It means understanding that a rounded life has all of these in good measure. It means we cannot understand illness unless we share this human world with our patients. Medical scientists go to great lengths to control these human factors out of their research – in effect sacrificing relevance on the altar of rigor. In striving for generalisable evidence, the unique and particular has no place, yet it is in that very uniqueness and particularity that the human person resides; and it is the whole human person that seeks relief of suffering. Suffering is intensely personal yet occurs in a context of relationships to others, to our culture and to Nature. (Cassell p211). Herein lies the art of medicine. It is the art of knowing the predicament of man, of understanding how life unfolds its story; the art of knowing how life can be improved and when it should be accepted. ‘The [holistic] clinical practitioner understands that imperfection is the lot of man and that a sound health culture must accept the unavoidability of pain, trouble, malfunction. The clinical practitioner can advocate the human right to be imperfect.’ (Fugelli 1998). Of course, this right to imperfection applies to both the human beings who are collaborating in the healing relationship, otherwise there will be treatment but little healing – an outcome often unsatisfying for both parties. Pain and trouble become meaningful when we see ourselves not as masters of the world, but as tiny parts of it. As Oscar Wilde famously wrote “..we are all in the gutter, but some of us are looking at the stars.”4 Used in this context the wonderful technologies now available are more likely to fulfil their potential within an health service that has high morale and is not overwhelmed.
Dr William House
St Augustine’s Practice
Fugelli P Clinical Practice: between Aristotle and Cochrane Schweiz Med Wochenschr 1998; 128, 184-8
Illich I Medical Nemesis 1975
Cassell EJ The Nature of Suffering and the Goals of Medicine New York: Oxford University Press, 1991
Wilde O Lady Windermere’s Fan Act 3