To reveal disease or to promote function – that is the question

Abstract

Medicine faces challenges that indicate that it may not be sustainable. A descriptive disease concept is apt to what philosopher of science Ian Hacking called "looping effects”, which can explain why health care is faced with insatiable demands. Diseases are not only indifferent objects with an objective existence in the biology of individuals. They are often interactive identities that have attractive properties. We suggest a shift in medical practice where descriptive perspectives are complemented with functional perspectives to enable clinicians better to help people from merging with dysfunctional disease identities.

Keywords:

• Medical ethics
• psychotherapy
• biopsychosocial
• functionalism

Thomas (aged 34) is an engineer. It is important to Thomas to be in good shape, and he has an ambitious, scrupulously planned, exercise program. He is in training for a triathlon. Although very fit, Thomas has become worried about his health. His motivation has dwindled, and he feels he is not progressing optimally. Thomas visits his general practitioner (GP) for a check-up and brings with him a colour printout of his in- and post-training stats. Amber readings indicate sessions that are sub-optimal.

T: Doctor, look at these figures. Something must be wrong. I am worried that it is my heart.

GP: You make me curious. Can you explain for me why this is important for you, and how you think I can help you?

T: Well, I guess the only way to sort this out is that you refer me to a cardiologist.

In this paper we describe two ways of understanding health and disease that have different consequences when meeting patients like Thomas. The first is the prevailing objectivist understanding in Western biomedicine, whereas the second is a functionalist understanding. We suggest the latter perspective as a useful supplement in situations where objectivist approaches alone are insufficient or even problematic.

The descriptive paradigm

Descriptive paradigms come in two main versions. The most prevalent, following the biomedical scientific revolution from the mid-18th century, is objective essentialism. Diseases exist as objectively observable phenomena that aberrate from normal anatomy and physiology. As they are constant objects, independent of our observations, diseases are indifferent entities. From this perspective medical knowledge is value neutral, in the sense that it pertains to facts that are objectively verifiable and have nothing to do with value judgments and political governance.

Acknowledging that clinical judgement is fallible, and disease often does not reveal itself unequivocally, this descriptive paradigm has been modified by the clinical epidemiology movement to acknowledge the probabilistic nature of medical judgement and thus the possibility of false positive or false negative diagnoses [1]. Despite this probabilistic element, there is still a presupposition that disease is a deviation from the normal anatomy and physiology of the body.

The second, contextually oriented rendering of the descriptive paradigm has its foothold mainly in academic family medicine and rehabilitation medicine. From this viewpoint, disease is not an isolated object but a phenomenon that is interpreted by a person in a context. Interpretation depends on a person’s earlier experiences and their biography. Some patients have experienced overwhelming challenges and, as a result, their beliefs can be dominated by helplessness and hopelessness [2]. By considering whether patients experience their ailments from the standpoint of mastery or hopelessness, doctors could help patients to manage better and promote a supportive doctor-patient relationship.

GP: I understand that you are worried about your cardiovascular system, and that you put much effort into keeping fit. I will do what I can to rule out disease. However – and I hope this does not sound too strange – I wonder if you could explain how all this relates to your life goals and life values.

The functionalist paradigm

To help a patient like Thomas, it may be useful to widen our focus of interest. On the one hand, it is not impossible that there is a clinically relevant aberration in Thomas’ heart, e.g. Wolff-Parkinson-White syndrome. On the other hand, heart disease is not only an indifferent entity, but also interactive to the extent that it is affected by human self-awareness. Interactive entities are prone to what Hacking called ‘looping effects’, as when the classification of people as patients with an illness changes their self-perception and behavior. A diagnosis may be the point of departure for identity formations that stimulate either sickness behavior and dysfunction, or adaptive identities that accommodate illness. A person can also oppose an identity that they do not want to accept [3].

Looping effects are often involved when patients either seek or avoid a certain diagnosis, and they are typical of complex adaptive systems of which humans are a prime example [4]. An understanding of health and illness that corresponds to this functionalist paradigm is proposed by the French philosopher Canguilhem, who maintained that a sick person is someone who is unable to overcome and transform their identities and, correspondingly, health is the ability to transform one’s self-identity by being flexible [5].

In today’s culture, each person carries a strong moral responsibility to keep fit, manage their health, and seek expert advice when there is an indication that their bodily or mental status deviates from predefined standards. One of this paper’s authors (SH) has previously explored how overwhelming the external obligations of health and self-surveillance are on the individual in modern societies [6]. These obligations are a crucial backdrop against which the GP’s interaction with Thomas should be interpreted.

Training in specialist health care often leaves young doctors with a mandate to search for objective disease, without regard for the unintended harms the search may incur [7]. Although it can sometimes be useful to view diseases and deviations as indifferent entities, doctors should not ignore the interactive properties of health complaints and medical diagnoses. In situations where the likelihood of health benefit from pursuing objective disease is low, and the chances of harm are high, it becomes more pertinent to ask how far the patient’s illness and the search for disease can be interpreted as human communication and an expression of human agency.

Within rehabilitation medicine this functionalist approach has long been acknowledged, and WHO has recently suggested that it could become a new paradigm for medicine as a whole [8]. In general practice in northern Europe the patient-centered clinical method and biopsychosocial model are at the core of most academic teaching. The methods include, in their original version, the agency of both patients and providers [9,10]. However, the methods are frequently misinterpreted as one-way, causal, and descriptive models, whereas the founders of these methods took their theoretical point of departure in functionalism and general systems theory. Ludwig von Bertalanffy was highly critical of one-way causal models in medicine and psychology, saying they amounted to a ‘robot view’ [10]. Engel similarly underscored that his biopsychosocial model was mistakenly interpreted as a one-way, multifactorial, causal model [11]. The main point for the founders of these models, as Canguilhem also suggested, is that causal factors operate within complex adaptive systems where patients can have the agency to modify and overcome self-identities as sick.

T: You ask what is important to me? Obviously to see the cardiologist. Words like “life goals and life values” are much too lofty when all I need is to establish the concrete facts about my cardiovascular health.

GP: I see your point. So, I need to understand what might be wrong with your heart or your lungs. I will examine you and then order some complementary tests that will help me decide if you need to see a specialist. Let’s meet again in two weeks when we have the results. Meanwhile, could you reflect on another question: Suppose this lack of progress from your training was a signal from your body trying to tell you something important – what could that be?

Morality or moralism

When symptoms and complaints are not manifestations of indifferent disease entities, we suggest that it can be useful to regard them as corrective messages from our minds and bodies. According to the Danish moral philosopher, Løgstrup, people are by nature equipped with an ability to appreciate such messages and reflect upon them in order to judge what is morally true in their lives [12]. Ascertaining what is the right action to take is not straightforward, however, and Løgstrup emphasized that moral norms are important in this reflection. To help someone like Thomas, providers need to balance respect for the autonomy of the patient with the demand of not doing harm, and with due respect for the professional autonomy of the doctor.

We suggest that medicine is a moral activity in the sense that we impact patients’ self-perceptions and motivation. If we, e.g., notice a borderline increased PQ-interval in Thomas’ ECG and communicate this result to him with a recommendation to be more cautious when exercising, this could entrench his self-identity as a sick person.

We are, however, aware that morality can be mistaken for moralism. Responsibility and guilt are confused in the western world. We suggest, therefore, that respectful curiosity should guide our interaction with patients. Løgstrup recommended both frank speech and humble respect for the integrity of the other person, so as not to conflate helping with pleasing [12]. It would not be helpful to comply with the patient’s consumer expectations in encounters like the one with Thomas.

T: Well, since you mention it, my workout has become like an obsession for me. I don’t allow myself to recuperate between the sessions. It has struck me that that might be the reason for insufficient progress. What do you think?

GP: As I said, I will do a physical examination and order some tests before concluding, but it might well be that your suspicion is true. Try it out yourself as you wait for the next appointment. An obsession often arises when you lose track of what you want to achieve. Is it possible that training has become a life goal on its own rather than a means to an end? It could be relevant to reflect upon how your training relates to your life values.

Advances in psychotherapy

With the introduction of cognitive therapy, human agency and ethical deliberation became central to psychological practice [13]. Initially, the boundaries between morality and moralism were unclear as clinicians considered certain life rules (cognitive schemas) to be inherently dysfunctional, and the client was asked to execute self-propaganda to substitute such rules with others that were held to be more functional [14]. However, with the third generation of cognitive therapy, and especially in the form of ‘acceptance and commitment therapy’ (ACT) [15], morality was introduced from an inner growth perspective as maintained in humanistic psychology [16].

A core principle of ACT is that clients should be self-determined in their choice of life values [15], and that humans are innately apt to healthy flourishing as long as their needs for autonomy, relatedness, and competence are met [16]. The ACT therapist, therefore, offers unconditional respect for the person and understands that symptoms and suffering are well-intended attempts to master. Suffering is not a manifestation that we are broken, rather that we are stuck [15]. Clients are stuck, according to ACT, by dysfunctional attempts to eliminate suffering.

Suffering may obviously be caused by indifferent diseases, e.g. cardiomyopathy. Frequently, however, ignoring the interactive nature of symptoms and suffering leads to further problems. When health care providers indicate that suffering can be ended, they may offer a disservice by recommending that patients avoid work, social relations, or physical exertion. In ACT, avoidance is considered one of the main dysfunctional mastering attempts, along with fusion and fight. ACT therapists, therefore, engage with the patient to understand the functional and communicative meaning of physical and mental symptoms. Instead of eradication, they recommend self-compassionate acceptance. They warn against the ‘eradication trap’ [15], as no human being can be wholly without symptoms before death.

ACT offers different metaphors to help patients understand and master suffering. These metaphors are often introduced as guided, mindful meditations involving the patient’s self-determined values. The aim is not to get rid of symptoms and suffering, but to live as upright, morally responsible individuals with compassion for our fellow humans and ourselves [17].

T: Well, since last time, I have been thinking about my priorities. I love exercise, but I guess I have come to realize that the deep reason why I love it is that it gives me this feeling of purpose and it is the only thing that enables me to really relax. Afterwards, I mean. But my family is also important to me. Actually, more important than exercise. When I manage to be present and mindful together with my children and wife without purpose and expectations, I have experienced joy and peace of mind.

It seems that Thomas in this case history benefits from an increased awareness of his values and priorities, as this allows him to act more flexibly and in accordance with his values. The approach of Thomas's GP illustrates a shift in clinical practice, emphasizing function and values, that is already gaining foothold. Interventions that are not too effort-intensive, conducted by GPs employing work-focused cognitive therapy and ACT, can improve functional ability and quality of life [18,19]. Sustainable medical practice is possible and realistic.

Disclosure statement

No potential conflict of interest was reported by the author(s).