Cassell's argument mainly focuses on a philosophical critique of scientific medicine, not using anecdotal evidence of practitioner/patient relationships. I think this is important to note. If we were to take his words as a critique of the people performing medicine, we could easily object. It is towards a method that he aims his criticism, not doctors who face suffering and console patients and their families, daily.
To better understand Cassell, we must first understand what he is against. The mechanistic worldview has its roots in the philosophy of Rene Descartes. Descartes' main contributions were dualism, and a theory of nervous function. Dualism separated body from mind and mind from brain. Instead of consciousness being the result of the firing of a complex network of neurons, it was an immortal soul which rested in the pineal gland. The pineal gland was chosen as the seat of the soul due to it being one of the few regions of the brain which is non-hemispheric. Dualism is a top-down interactionist theory, which means the mind/soul can act on the body, but not vice versa. To tie this in with his theory of nervous function, when we react reflexively to our hand coming into contact with fire it is due to “animal spirits” descending from the pineal gland through the nerves. These animal spirits are what cause our hand to recoil, hence top-down interaction. We know now it is quite the opposite and much more complex. To Descartes, the body was like a complex machine piloted by the soul from the pineal gland via animal spirits. Descartes view is biased towards the soul and diminishes the body as an object. His ideas were influential and shaped world views for hundreds of years.
This is the root of the scientific medicine Cassell is reacting against. As Descartes views the mind/body relationship as dualistic and top-down interactionist, scientific medicine also sees the patient as a separate mind and body, with little regard to the mind. The diseased body, or the damaged machine, is where scientific medicine focuses its efforts and sees any adjustment of the body as having little effect on the mind. Therefore, scientific medicine is reductionist, because its view of the patient is of a collection of parts instead of a whole.
Cassell seeks to reorient scientific medicine by intertwining his views on the nature suffering, the philosophical concept of personhood, and the paradox of treatment. Suffering is an experience separate from pain and is felt despite it. It is something influenced by many variables, all of which form what Cassell terms, “the background of illness.” These variables are essentially what makes up the patient as a person, things such as: culture and society, family, the past, private life, associations, relationships, politics, perceptions of the future, and the transcendent being. The paradox of treatment, where treatments of disease (e.g. chemotherapy) tend to cause suffering, is intensified by the background of illness. Certain treatments have side effects, such as: hair loss, fatigue, weight change, mood imbalance, changes in libido and sexual function. These side effects of treatment can interact with the background of illness, creating a cocktail of suffering. This suffering is due to changes in the patient’s relationships with partners, their place in society, their view of the future, and their own identities. Cassell illuminates these complexities which exist alongside diseases medicine seeks to cure. Is it the goal of medicine to cure disease? According to Cassell, the obligation of physicians is to relieve human suffering. It is the goal of medicine then to relieve suffering, and curing disease is contributory, not the end we seek.
Quiz Questions
1. What does this presentation focus on?
2. Who is Rene Descartes?
3. Cassell's argument seeks to reorient medicine away from....?
4. What does scientific medicine eschew? Objectivity or subjectivity?
5. What is the paradox of treatment?
6. According to Cassell, what is the obligation of physicians?
Discussion Questions
1. What do you guys think? Especially any pre-med students. In your courses, or how we discuss the practice of medicine, do you feel consideration is made to how a patient’s mental state and experience can influence their illness and suffering?
2. The simplistic critique is always, “doctors have bad bedside manners.” Could this be less about personality and more about how one may view the goal of medicine? (Do they see the goal as the eradication of a disease, of suffering, both or neither? Obviously, I believe doctors are overworked! But let's consider this philosophically.)
3. Just for fun….do you think the study of literature, history, and art, has a place in the broad study of medicine? If so, how so?
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