Failure to HealPrint
Today’s medical industry thrives on diagnosing and curing, but it doesn’t reach the soul
By Philip Alcabes
March 4, 2015
It’s strange that healing is absent from medical discourse today. Cure, resolution, recovery, and rehabilitation retain semantic currency; you can find these words throughout the medical textbooks and professional health literature. But healing, with its resonance of renewal, has been banished to the precincts of so-called alternative medicine. Spurned, it seems.
I was struck by this expulsion recently when I witnessed an act that appeared, against the backdrop of modern medical practice, to be a phantom visitation. My father, nearly 90 years old, a veteran of a handful of different cancers and at that point losing blood uncontrollably from an aggressive new one, was in a hospital bed. “Scientists are always working on new things; maybe they’ll come up with a cure,” he said to me, more out of what I recognized as an irrepressible urge to bargain with the angels than out of any genuine optimism.
His doctor, a man of my generation, had seen my father through the trials of a lonesome old age. Now he came in, wearing street clothes and without mask or latex gloves. He sat on the bed. “Al, we’re going to send you to a hospice,” he said. Looking in the doctor’s eyes, my father asked one last time about treatments, by which he meant magic. The doctor put his hand on my father’s knee. “Any treatment at this point would kill you, and I won’t let them do that.”
This drama suddenly seemed intensely private to me, in a way that changing my father’s adult diaper had not. And, despite the setting—the oxygen tanks and masks, the beeping of various medical paraphernalia, the flashing electronic readouts of the physiologic systems monitors—the interaction in this 21st-century hospital room looked more like a religious rite than a medical encounter. A dance. A hand extended to the dangling man. Or a benediction.
Over the next few days, my father withered. His grandchildren came to say goodbye, he fell asleep, and by the next morning he had been pronounced dead.
The doctor, when I called with the news, said that he had “learned” from my father. I think he meant that he had discovered the man. He knew who my father was. They were linked. He didn’t cure my father, and yet he healed him at the last possible moment. When could healing be more important?
Yet, is healing important? Is it too New Agey or too fuzzy or too old-fashioned for today’s medical culture? Books on the history of medicine do tell of healing in the past, as if it were an antique aspiration, like thrift or sexual temperance. Healing still appears in treatises on complementary medicine, energy medicine, integrative medicine, holistic medicine, Islamic medicine, African medicine, music as medicine, and, significantly, faith. But, apart from a specific usage in regard to the physical process of knitting tissue that has been harmed (i.e., wound healing), the medical establishment does not speak of it.
Even the prestigious medical journal The Lancet struggles to grasp healing. In trying to understand the French philosopher of science Georges Canguilhem’s exposition on the essential disjunction between the axes of normality and disease in The Normal and the Pathological, the journal’s editor writes that doctors think of measurable outcomes or cures, but patients “may think in terms of healing, their subjective evaluation of the effects of treatment.” The implication is that a subjective evaluation is a partial evaluation at best, or a second-rate one. And that the point of medical treatment is to validate the doctor’s diagnosis—as if such findings have independent existence. And as if the disease, as defined by the doctor, were an essential flaw that happens to demand exactly the treatment the doctor offers.
How to account for this curious void? How has healing, the most central aspect of care for the ill, been banished from doctoring today?
I see two pieces to this puzzle. One, self-evident and much discussed, is the technical nature of medical practice. The other is subtler: the medical industry is an organizing force in our complex world, guiding us toward some (“healthy”) activities and away from (“risky”) others, defining roles in seeking diagnosis and getting care, and freighting healthfulness with moral import. As a result, the intimate, private relationship of doctor to patient fades into the background.
Health was once an acknowledged avenue of the spirit world. To be well was to have kept to the salubrious side. To be unhealthy was to have strayed, to have slipped or stumbled over the line and entered the realm of malign energies. Naturally, magic was needed to relieve ailments, which it would do by halting the spiritual decline through ritual: incantations, spells, potions and poultices, dance, dietary revision, prayer, priestly ministrations.
Healing involved the essential thing that we now call soul or spirit, and it invariably required help. The help had to be authoritative, and therefore the pursuit of health brought on a shaman, diviner, herbalist, vaidya, charm caster, or priest. Or healing was achieved through the touching of idols or statues, stand-ins for the gods. Christian saints could do this, too. Saint Valentine was said to heal epilepsy. Viewing the 16th-century Isenheim Altarpiece in Alsace promised salvation through faith, much as the faithful had earlier turned to Saint Anthony, subject of the altarpiece, to relieve ailments involving the skin. The discovery of Santa Rosalia’s bones, according to a legend depicted in a 1624 painting by Van Dyke, lifted plague from Palermo in Sicily.
For most of human history, physical afflictions were understood as merely the immediate source of pain or debility, not a fundamental cause of suffering. Scrolls from the second millennium BC already contain directions for setting broken bones and reversing night blindness, and they mention a host of physical afflictions. But a bodily ailment was of interest to the ancient physician-healers not only because they sought to relieve discomfort or disability: any affliction was a window into what might be amiss in the soul. The biblical skin eruptions constituting tzara’at were signals of spiritual impurity, and Leviticus contains prescriptions for its management by a priest. In general, bodily suffering was remarkable in that it bespoke essential malaise. As such, malaise required some kind of communication with the forces of nature or the universe—mediated by an authority figure who had special knowledge. Until very recently, this was healing.
In the fifth century BC, Hippocratic medicine in Greece famously revolutionized medical thinking by attributing ailments not to supernatural causes but to physical aspects of nature. But the Hippocratic approach changed nothing about the essential understanding of affliction. Illness continued to be an idiosyncratic result of the interplay between uncontrollable forces (swamp air, dry winds, and the like) and movements within the body that were not entirely detectable to the senses. Internal flows of bile, phlegm, or blood were reputedly congruent with irrepressible external ones—meaning that spring torrents had to do with blood flow and thus with nosebleeds, and so forth. Hippocratic thought moved medicine out of the realm of the gods, yes, but it was still about connections with the mysteries of the universe.
Historians of the medical profession attribute to the Persian physician Rhazes, in the ninth century AD, the tenet that physical illnesses fit general categories and are not idiosyncratic manifestations of malaise. Only after Rhazes could smallpox be described as a consistent disease, no matter which individual suffered from it, and no matter what he or she had done to summon affliction. It wasn’t until the Enlightenment, though, that the concept of diseases as categories really caught on. Medical men then spoke of diagnoses. At that point, sufferers could become patients.
Today’s medical centers, despite being called health care facilities, are temples of diagnosis. Their aim is to bring technical know-how to patients’ disabilities and infirmities—to correct disorders. The term is revealing. To have encountered and negotiated a medical center is to have been subjected to tests, been labeled with a diagnosis, undergone treatment, perhaps been cured or at any rate been pronounced fit, and instructed to return for a follow-up. To have been dismissed or discharged means we patients may prepare ourselves for the inevitable next round. The health-restoring system is ubiquitous, and staying away from it altogether is essentially impossible. The point of the medical system is to halt disorder, not to reawaken any innate connectedness of the patient’s soul with the nature of the world. Don’t expect to be healed.
Correcting disorders was an aim of spiritual healing even in the ancient world. But disorders lay within an interplay of internal and external forces that were presumed to be unfathomable, even when they were imputed to observable things like blood or tides. Spiritual malaise might be incurred by violating the standards that preserved societal order—some scholars say that tzara’at was a telling physical sign of speaking badly of others, for instance. But the point of healing was to restore the purity of the spirit. A sharp contrast exists between the suffering that once was met with healing and the modern disorder requiring diagnosis. The divergence captures the essence of the medical industry’s shaping influence on the culture today. The demands of modern wellness keep everyone in line.
Wellness means order, and so healthful living is required of us, constantly. The expectation to live healthfully is not just an occasionally annoying fact of contemporary American culture. It’s a statement about our essential vulnerability, about living in what the sociologist Ulrich Beck termed the “risk society.” The premise is that anyone might end up sick or injured at any moment, and the consequent encounter with the medical system will undoubtedly involve inquiry about the healthfulness of personal habits. Is your breathing difficulty really due to a blow you took to the sternum in a minor accident? Or have you been smoking?
We are essentially vulnerable, and technology should not only prolong life but also enhance it. These are articles of faith. We treat them as fixed truths (although they aren’t) because they offer us a sense that modernity confers orderliness on the fearsome randomness of the universe. Where once we turned to priests to redress disorder, now we empower medicine to do it. This pointed use of technique not just to solve problems but to create something of social value—healthy behavior, as it’s called—imparts a special political character to medicine today. Medicine brings new principles to our ways of living: risk avoidance, behavioral correction, the abnormality of impropriety.
The new precepts for dealing with risk on a personal basis become our truths, the tenets of contemporary civics. We buy into them because we really don’t want to forgo the promise of life extension or pain relief that the medical industry promises (and because the physicians’ guilds, notably the American Medical Association, have devoted themselves to defeating all competition, for instance from herbalists and chiro-practors). Our society is weakened, we are supposed to think, when movies show the good guys smoking cigarettes, when parents aren’t ashamed of letting their kids get fat, or when vendors are allowed to sell sugared beverages in large cups. The political aims of control and constraint hide behind the smiling face of treatment and cure.
Usefulness and effectiveness matter in today’s medical industry, and they matter not only to the staff of medical centers and clinics but to all of us. We are occasionally reminded that laughter can speed healing or that a positive attitude is important in fighting cancer, but these bromides are understood to be aspects of morale, not the main thrust of the perpetual effort to counteract the chaos of illness. Morale alone will not quell the disorder.
Achieving wellness ever more closely approaches military combat. Nobody may simply have cancer now: cancer is an enemy, and we are expected to go to war with it. To gain an advantage in attacking our cancers, the medical system proffers treatments that it calls weapons. Addiction, too, is always a struggle, alcoholism a fight, depression a battle. When anyone dies after a protracted illness, or even after a long period of mental instability, the eulogies and death notices unfailingly remind us that death arrived after long contest. This death is understood less as a defeat than as a calculated surrender after a siege by overwhelming force. Certainly, death is not to be understood as an inevitable aspect of living.
We know that the health-as-order, wellness-as-victory ways of thinking are illusions, yet they are national deceptions, widely practiced and everywhere reinforced. We must pretend that we don’t know that death is inevitable. To acknowledge as much would undermine the noble war for wellness.
Death in America today wears a costume of contingency. We forget the fundamental impossibility of understanding everything. In The Death of Adam: Essays on Modern Thought (1998), Marilynne Robinson observes,
We cling desperately to the idea that something is real and necessary, and we have chosen, oddly enough, competition and market forces, taking refuge from the wild epic of cosmic ontogeny by hiding our head in a ledger.
In this willful forgetting, we are supposed to believe that it is in our power to escape death. Which means that wherewithal is what matters, not spirit. Even when the abyss looms, the medical system is supposed to do everything possible to keep us alive. “To prolong life was not one of Ravelstein’s aims,” Saul Bellow tells us about the title character in his last novel. “Risk, limit, death’s blackout were present in every living moment.” Ravelstein was right, but he was sui generis (and that was Bellow’s point). The rest of us dutifully act as if the blackout can be put off.
Not long ago, a physician friend recounted to me a visit she had made to the Cinque Terre on the Italian Riviera, where old men and women go about daily chores with manifold latent infirmities—diabetes perhaps, indolent malignancies, respiratory distress—none of them diagnosed. And then, when something finally upsets the balance of what had been a robust organism, they seem simply to accept death as an inevitable outcome of living their lives. The transition from the old style of those Ligurians—warding off or curing illness, which was a matter of refraining from forbidden activities and eschewing taboo foods, honoring moral exhortations, and otherwise letting nature take its course—to the new style, obtained and maintained by the martial force of industrialized medicine, seems irreversible. And no doubt it is. We’re unlikely to give up our life-prolonging technologies.
A grand paradox sits at the heart of today’s medicine. It claims to be scientific and modern, depending as it does on the deployment of technology. Yet, it grew from an ancient art, the cult practices of healing.
When it comes to tumor removal or heart valve replacement, most of us will sensibly choose science and technology over art. We can never be certain that the surgical procedure that was effective for other patients will also work in our case (after all, human bodies are not interchangeable). Yet, we have confidence that the procedure is likely to work—and to outperform magic. Even those who pray to the saints or supplement medical treatment with herbs will say go ahead and cut. Progress might mean the loss of some deep humane awareness, but effectiveness is a good thing.
A hallmark of medicine today is that effectiveness extends to all sorts of activities in the medical system, not to surgery alone. Even in nursing care, dietetics, and primary care, interactions in which the patient should least be regarded as spiritless, supposedly measurable objectives must be achieved: patient satisfaction, body mass index reduction, serum electrolyte level control, the number of tests carried out, prescribed dosages taken, referrals to specialists properly issued, diagnostic errors avoided, patient contact time elapsed, time from diagnosis to cure minimized, and so forth. This account goes beyond the industrial: it makes care into a reproducible commodity and medical service a matter of mechanics. Evidence confers authority. This is worth something, and cumulatively it is worth a lot: In 2013, the cost of medical care in the United States was estimated at $2.7 trillion per year, and rising.
Today’s medicine can boast real accomplishments—near eradication of paralytic polio, dramatic improvements in survival after heart attacks, life-extending cancer treatments, reductions in the chances of dying during childbirth or in the first year of life. But in its historical progress toward ever-greater measurability and reproducibility, medicine loses sight of what makes each of us most ourselves. The inevitable outgrowth of equating wellness with order is that, where we once knew ourselves as individuals through our infirmities, that aspect of authenticity is forgotten.
Many critics complain about our health care system, and rightly so: it costs a lot but denies care to many, and consequently Americans lose their lives because of failures of adequate illness detection and treatment at a rate similar to that of Portugal and far behind such other wealthy countries as France, Germany, and the United Kingdom, according to the Organisation for Economic Co-operation and Development. But it is not our faulty health care system that is responsible for the loss of individuality that mechanized medicine implies. Neither is it a consequence of the excessive influence of pharmaceutical companies, doctors’ increasing gravitation to specialty practice in lieu of primary care, or extra emphasis on high-tech forms of testing or treatment, although these are all valid targets for reform. Blame instead the abandonment of healing.
However mechanized our pursuit of wellness has become, the practice of medicine continues to rely on a human encounter. There remains the irreproducible dance between the patient and the physician. All of us who can afford to still go to doctors. Partly this is because doctors are gatekeepers to the specialized precincts of the treatment system. But not only that. The medical practitioner knows, or at least intuits, that wellness depends on a set of not fully apprehensible or measurable elements, and his or her practice is necessarily more than just the simple, technical act of removing diseased tissue.
Here is the seed of the contradiction within the system of technical medicine: we have a persistent yearning to interact with a sympathetic healer who knows our unique selves as reflected in our infirmities.
Might a reawakening of awareness come out of recognizing this contradiction? If art is at the heart of healing, then might some new authenticity emerge from recognizing that the system depends on the urge in us to connect with the art of a healer?
Already there are signs of this rediscovery, a heartening movement for narrative medicine, encouraging doctors to undertake active listening and recognize that the patient’s storytelling might provide excellent clues to diagnosis and effective therapy. (As long ago as 1927, writing in the Journal of the American Medical Association, Francis Peabody called on fellow physicians to see the patient not as an isolated sick person but as “an impressionistic painting … surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears.”) An effort has arisen to understand that the storytelling is a kind of ritual practice, not only valuable diagnostically but therapeutic in itself. And many physicians remain devoted to their patients, despite insurance companies’ demands that they speed up and become more efficient. Such devotion was on display in my father’s hospital room.
Also, efforts are under way to reunite somatic and psychic health, the coupling articulated in bio-psychosocial and mind-body medicine. The ancient sense of wellness as spiritual balance parallels a recognition today that no bright line separates the realms of psychic disruption and physical dysfunction. So-called alternative medical treatments are enjoying popularity, and they seem not really alternative in the sense of marginal, but fundamental. They seek a reunion of awareness and ritual. The realities that these efforts are not now mainstream, do not attract huge research grants, and don’t figure prominently in medical school curricula seem inconsequential compared with their significance as evidence of the continued thirst for healing in its magical or mystical sense.
If these movements are indeed signs that the seed of medicine’s contradiction is sprouting, then is it not reasonable to imagine the reemergence of the magical healer from within the technically equipped doctor? Perhaps we can continue to benefit from the surgeon’s skill, from the full armamentarium of modern medicine, and yet credit the mystery that is at the base of healing: a dance, an entanglement, a form of knowing. l
Philip Alcabes is visiting professor at Hunter College of the City University of New York and professor of public health at Adelphi University. He is writing a book on psychic distress, psychiatry, and medication.