Theology Today - Vol 38, No. 1 - April 1981 - CRITICSCORNER - Holistic Care and Conventional Therapy

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Holistic Care and Conventional Therapy
By Bernard Towers

ORTHODOX MEDICINE is unquestionably under challenge today by those practitioners of "alternative therapies" known collectively, and often without obvious validity, as "holistic." The term itself is a euphemistic catchall. Because of the deep psychologial appeal and etymological similarities of words such as whole, health, heal, and holy, it gives one the "good" feeling that those who offer themselves as 'holistic health practitioners" are likely to have your (the patient's) interests closer to their hearts than your regular doctor has. Though that conclusion would clearly be justified in some instances, it is by no means generalizable. The maxim caveat emptor is particularly applicable when one is suffering and therefore both most vulnerable and least likely to be able to exercise good judgment. How are we to assess the new wave of enthusiasm by and for practitioners of holistic medicine?

It is a curious paradox that modern scientific medicine has been and continues to be extraordinarily successful in the treatment and cure of many diseases that hitherto were lethal or severely crippling. And yet the application of the very technologies on which that success depends draws heavy criticism from a consumer-oriented and increasingly knowledgeable general public and its representatives in government and law. The problem is philosophical at its roots.

Science is essentially objective and analytical. The aim in medical science is always to identify and analyze specific variables in order to manipulate them for the benefit of individuals and of society as a whole. The methods of science work well with relatively simple projects such as (to be provocative) space-exploration, where both the variables and the techniques to analyze them are for the most part well understood. By comparison, the complexity of the physical and psychic inner space of the human organism is mind-boggling. A measure of uncertainty is inevitable in medicine. But science demands certainty as its goal. Orthodox medicine has pretended to be much nearer to that goal than it possibly can be. Society has "demanded" it, and we in medicine have been too ready to pretend that we can meet the demand. Disappointment

Bernard Towers, M. B., Ch.B, is Professor of Pediatrics and Anatomy at the University of California at Los Angeles and serves as co-director of the UCLA Program in Medicine, Law and Human values. A native of England. Dr. Towers taught for several years and served as Director of Medical Studies at Jesus College, University of Cambridge, before coming to UCLA. He is the author of numerous articles in the fields of medicine and medical ethics, and he has served as the President of the Society for Health and Human Values, the principle national medical ethics organization concerned with medical education.

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is inevitable, particularly when the biomedical model, with its purely physical and chemical therapies, leaves out the most important element in all therapy, namely the human values inseparable from all human encounters. Modern medical technology has tended to neglect that specifically human factor, personhood, which is difficult to quantify in the way science requires.

The underlying philosophy of holism implies that the "whole" is greater than the sum of its parts. Orthodox twentieth-century biomedical philosophy implies that the whole is nothing but the sum of its parts. There are appropriate times and places for the application of each philosophy. This is a truism that used to be well-recognized in medicine throughout the twenty-five centuries since Hippocrates first subjected disease-processes to rational inquiry. There is nothing new about holistic health except that its current exponents have recognized the patient's need to be treated as a whole person and not as an assemblage of functional and dysfunctional parts. The movement also emphasizes the importance of the patient's share of responsibility for getting and staying well.

These elements represent something of a return to the best of medical tradition, where the patient is seen as primarily a person. It was expressed by Francis Peabody over fifty years ago: "The secret of caring for the patient is to care for the patient." Sir William Osler used to tell his students that it is just as important to know the patient who has the disease as to know the disease from which the patient suffers. Earlier in this century, medicine was holistic. It was oriented toward the study of disease but always also, and primarily, toward the study of the person. Only in the last fifty years have diseases come to seem more important. in orthodox medicine, than persons.

There are, in holistic practice, dozens of exotic "therapies" in vogue. Many of their exponents make the ludicrous mistake of calling themselves "holistic" when in fact their claim is that the one part of the psychophysical unity that they emphasize really constitutes the whole. It may be the sole of the foot, or the constellation of planets at one's birth, or the acupuncture points, or megavitamins, or any one of the other modalities currently in vogue. The holistic health movement is itself fragmented into dozens of sects. Just as each religious sect has something valid to offer, so do holistic sects. The common element may well be faith. The well-known placebo effect of orthodox medicine surely comes from "faith." Since more than three-quarters of all sickness is naturally self-limiting and self-healing, reputations for exotic therapies are easily made. The difficulty for all diagnosticians is to distinguish those fifteen to twenty percent of conditions that require more than placebo and encouragement to effect a cure or at least relief. Holistic health workers are often good therapists but poor diagnosticians.

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It is essential to recognize that accurate diagnosis must always come first.

The modern protest movement has demonstrated many evident deficiencies of the established medical-industrial complex. Medical technology has its own outstanding record of achievement. Both groups now need to recognize the importance of the other. What we clearly need is a diagnostic system that will accurately identify those persons whose pain and suffering will best be relieved by therapy based on scientific technology and those persons who will benefit more from alternative modes of therapy. One day perhaps they will all be housed together in health centers where a both-and rather than an either-or philosophy prevails.

Meanwhile one should tread warily, suspicious of all enthusiasms. Systems that purport to be, or that behave as if inspired or possessed by some form of god (which is what being enthused literally means) are likely to be up to mischief whether they know it or not. People are especially at risk of deception when they are sick. Patients need to be protected from deception both inside and outside the orthodox profession of medicine. By the same token they need to be encouraged to seek the help of real "healers." genuine helpers. They, too, are to be found both within and without the ranks of current orthodoxy.

III

Technology-based medicine is at its best when it can offer the hope for cure of, or at least alleviation of the suffering produced by, disease. So many pathological states have proven to be amenable to cure by the use of modern technology - and this even when the patient has been close to death or even "dead" according to some definitions - that it is easy to see how practitioners become committed to interventionist, aggressive, invasive methods. The results are sometimes so dramatic and so rewarding that it is difficult for the doctor not to believe that one more aggressive intervention might succeed. The physician's own fear of death, and fear of the failure that death too often represents, lead to internal conflicts between three cardinal precepts of medicine, namely to save life, to relieve suffering, and above all, to do no harm. When the patient is in fact dying, then all attempts to -save life" cause harm and suffering, thus offending against the other two precepts.

The ability to recognize the facts of the situation depends far more on experienced clinical judgment than it does on the knowledge of detail the medical student spends so much time acquiring. A data-base of factual information about the structure and function of the body in both health and disease is necessary but not sufficient for the development of sound clinical judgment. That comes only with time, and with clinical experience. Once it is recognized that the patient has moved into "the dying role" then all therapy, whether "conventional" or "holistic," should be oriented toward the relief of pain and suffering. The injunction

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to do no harm, whether by acts of commission or omission, is paramount throughout, and patients have a right to expect that therapists (of whatever persuasion) will respect their integrity until the end.

The fear of pain in terminal illness is often more disturbing than the fear of death. Pain itself is a necessary and useful attribute of living for all animals. Without it, living forms would quickly destroy themselves through neglect of symptoms. At the human level, the psychological component of pain assumes increasing dominance over the physical. If it is negative, one's emotional state can exacerbate physical pain far beyond utility.

It has recently been discovered that the brain has the capacity to produce its own morphine-like substances, the endorphins, which are far more potent that any exogenous pain-relieving drug. The scientific quest for understanding the mechanisms of production and action of endorphins will, when completed, give a high-level technological breakthrough of the utmost significance, namely the knowledge of how best to stimulate the body's own pain-relieving mechanisms. It is already clear that positive emotional states can lead to increase in production of a host of natural defences of the patient. Fear and anxiety (often experienced as panic in face of the impersonal machines of modern medicine) must be allayed. What should be encouraged, as holistic health practitioners demonstrate so "ell, is the development of faith and hope and the giving and receiving of love. That is what real caring demands. It is often difficult to find such care within the hustle and bustle of modern hospitals.

For the control and alleviation of pain and suffering, good practice demands the skilled use both of "orthodox" treatments such as painrelieving drugs, chemotherapy, radiation-therapy and surgery; and also "alternative" therapies as appropriate to the patient's needs and belief-system. Acupuncture, biofeedback, meditation, psychological and spiritual counselling, and a host of other holistic therapies are suitable for the relief of pain and to ease the passage from life to death. The process of dying is rarely if ever painful, if it is left to nature and to caring companions. Nature has a way of easing the pain if we will only allow ourselves to "flow with the stream." But first of all the fear of pain, or the fear of the fear of pain, must be assuaged. In the best of the modern hospices, pain-relieving drugs are given prophylactically and in carefully-controlled doses so as to produce relief of symptoms without clouding of consciousness. This then allows for other (holistic) supportive therapies to be employed, and for reduction in the drug-dosages that were previously required.

Holistic medicine has great benefits to confer when its practitioners give themselves, in non-exploitative ways, to care of the dying. Wholeness is never so important, and never so "holy" as when one is preparing for that "good death" which should be a principal aim of life.