Background reading material by Professor Omar Hasan Kasule Sr. for Year 1 Semester 2 PPSD Session on April 25, 2007
1.0 INTRODUCTION
A comparison of holistic and biomedical models of medical practice could give a misleading impression that there are differences in the technology and instruments used. The essential difference lies in the underlying paradigms, basic philosophical assumptions, attitudes, and values. The technology used may be used in the same but the manner of its use and the therapeutic and overall health improvement may be different for the two approaches. This paper presents a critique of the concepts and practices of the biomedical model. We have already covered most concepts of holistic medical care emphasizing looking at the patient as a whole: psychological, social, spiritual, and cultural aspects.
2.0 PHILOSOPHICAL BACKGROUND
Understanding of the underlying biomedical model is necessary for assessing health policy alternatives. Current medical practice is based on the biomedical model. Biomedicine has achieved a lot in prevention and treatment of many diseases but is being challenged by chronic non-communicable diseases and the rising costs of curative medicine not accompanied by corresponding improvements in health. The biomedical model is the culmination of philosophical developments in Europe over the past 500 years that have transformed metaphysical medicine into scientific medicine. The philosophical changes were a materialization of life (empiricism), marginalization of spiritual and other considerations in health (secularism), and physical reductionism (i.e. understanding by breaking up into components).
3.0 BASIC CHARACTERISTICS OF THE BIOMEDICAL MODEL
Biomedicine is empirical. Empiricism is the basis for cause-effect relations. It uses the empirical methodology to minimize subjectivity. It considers facts and not dogmas. It relies on reason and not faith or myth. The empirical basis is accepted by Islam. Islam encourages empirical observation as the basis for evidence-based knowledge. It shuns all forms of superstition in medical practice.
The materialist background of biomedicine contradicts Islamic concepts. Materialism leads to consideration of health as a commodity that can be bought with money. The materialist background dehumanizes and demystifies the body and treating it like a ‘machine’, a ‘thing’ or a ‘physico-chemical phenomenon’. Besides dehumanization, it depersonalizes the patient who is looked at as a case of pathology and not as a human. It is more interested in the disease and not the person. A technical relation replaces the human physician-patient bond. Patients do not get emotional and psychological satisfaction from encounters with physicians even if their pathological disorders are resolved satisfactorily. Biomedicine relies exclusively on the scientific disease theory which asserts that symptoms reflect specific disease entities and that each disease entity has a unique cause and a unique therapy.[i] It asserts that disease is due to either pathological anatomy[ii] or patho-physiology.[iii] It assumes that causes of disease disturb the equilibrium and the purpose of medicine is to restore equilibrium. Biomedicine does not readily accept other causes of disease outside anatomical and physiological derangements. It therefore bases its diagnosis exclusively on physical assessments.[iv] It does not consider any other ways of defining and diagnosing disease. Definition of abnormality in biomedicine is inadequate since it focuses on biology and ignores culture and psyche. Biomedicine has no fixed criteria for distinguishing the normal from the abnormal in body structure and function. It relies on statistical measures to define the norms. It also considers points of equilibrium as the norm. Despite the claims of scientific objectivity, the biomedical model has not always been able to operate away from subjectivity in practice. Subjectivity can not be avoided in diagnostic and treatment decisions. Reality depends on the starting point.
Biomedicine is not holistic. It ignores cultural, social, spiritual, and psychological aspects of illness and concentrates only on somatic aspects. It de-emphasizes overall wellness and welfare and narrowly focuses on pathological anatomy and patho-physiology. Biomedicine has failed to handle psychosomatic disorders that have no obvious anatomical or physiological origin. In its approach to factors of disease it marginalizes environmental medicine [v] and behavioral medicine. Biomedicine equates illness with disease. Illness is wider and more holistic than disease. Illness is affected by both somatic and non-somatic factors whereas disease is affected by somatic factors alone. The elderly may for example be ill but with no specific disease. In the same way people with serious pathological conditions may not be aware of them or may not be concerned and they feel that they are in good health. Biomedicine fails to distinguish illness from disease because it concerns itself with the body and not the mind. It rejects the body-mind dualism that human traditions have accepted throughout history. It also rejects the dualism of soul and matter that is the unique characteristic of humans.
Biomedicine is not flexible. Biomedicine has not been able to respond effectively to the epidemiological shift from acute to chronic disease and the demographic shift from younger to older population distributions. Biomedicine is more applicable to acute than to chronic diseases. It has been very successful in curing acute infectious diseases by use of specific anti-microbials. It has not been flexible enough to performed equally well in cure of chronic and degenerative diseases
Biomedicine seeks to predict, control, and regiment. Biomedicine is not democratic. It gives all decision-making power to the physician and leaves the patient powerless. It has medicalized human life. It has distorted relations between humans and medicine. Pre-biomedicine humans controlled medicine and used it as they like. Post-biomedicine medicine controls human life and behavior.
4.0 FRAGMENTATION AS A MANIFESTATIONS OF THE BIOMEDICAL MODEL
Biomedicine is characterized by narrow specialization and fragmentation. Physicians know more and more about less and less. The trend toward specialization in medical practice has strongly influenced medical educators to diminish the practical content of the crowded undergraduate program and transfer some of it to post-graduate or vocational training. A new graduate from medical school is therefore unable to treat a patient on his own until he becomes a specialist. Specialty practice however has the great disadvantage of fragmenting patient care among several specialists such that there is no one doctor to care for the whole patient. The fragmentation of medicine is reflected in the balkanization of administration (by department), stages of education (pre-medical, pre-clinical, and clinical) and by discipline or specialty. Separate curricular tracks for research and practice have even been suggested. In many cases each department teaches independently of others. Specialist physicians find it difficult to teach students who are just being introduced to medicine.
The following attempts have been suggested to overcome the problem of fragmentation: interdepartmental or inter-disciplinary programs, integration of clinical and basic sciences, generalist and not specialist medical practice, vertical integration (linking early with later years in the same discipline), horizontal integration (linkage between different disciplines), teaching by organ systems, and using the problem-centered approach.
The concept of integration has been well accepted and propagated but not understood well when it came to practical application. Attempts at integration are a response to a felt problem and are certainly a step in the right direction however they have not solved all the problems; they even succeeded in creating a few new ones. Uncoordinated integration has succeeded in producing a hypertrophic curriculum. There is pressure from each discipline to ‘integrate’ its material into the curriculum. New disciplines such as genetics, statistics, epidemiology, demography, anthropology, and sociology are at the door claiming their share of the undergraduate curriculum. New disciplines have been created to ‘integrate’ or bridge the gap between pre-clinical and clinical disciplines e.g. clinical biochemistry, clinical pathology, and clinical epidemiology. Interdisciplinary teams have been used as a tool of ‘integration’ in community medicine.
If each of these demands and approaches to integration were to be fulfilled, the undergraduate medical curriculum will require a life-time to complete! There are, however, defenders of a crowded undergraduate curriculum. They argue that students should be exposed to all disciplines to enable them be informed choices about their future specialties. This reminds us of the story of an ’accomplished’ lawyer who knew a bit about every subject including law. The process of continuous additions to and pruning from the curriculum is going on and has been dramatically described as integration, re-integration, and disintegration.
Fragmentation is a reflection of an underlying European world-view and did not come about in medical education by accident. This world-view started with the renaissance when religion was separated from public life and science. This set in motion centripetal forces that continually separate, fragment and sub-divide. The body was separated from the soul. The mind was separated from the body. Science was separated from art in medical practice. Each disease or organ was isolated and was dealt with in isolation. It must however be recognized that specialization has been responsible for much of the progress in scientific medicine because of the concentration of the researcher’s energy on a narrow focused issue. It is not surprising that in a context of increasing fragmentation, the concepts of ‘total health’, ‘total disease’ are not easily accepted. It is not the ‘total human’ who gets sick but his organs or tissues. It is however very surprising that Claude Bernard’s concept of a harmonious ‘milieu interieur’ and the appreciation of the biochemical unity of all life did not motivate practice of ‘total medicine’. Many physicians in the west have recognized that fragmentation is a major problem and have set about attempting to achieve integration in medical treatment and medical education. Some of these attempts were described above. Their limited success is due to lack of a guiding vision.
Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based on a vision and a guiding paradigm. Only Islam can provide this paradigm. Criticism of the fragmented medical curriculum is actually criticism of the underlying European non-tauhid world-view. The fundamental reason for failure of integration efforts is that the European world-view is atomistic; it is good at analysis and not synthesis. It is incapable of synthesis because it lacks an integrating paradigm like tauhid.
5.0 LACK OF BALANCE AS A MANIFESTATION OF THE BIOMEDICAL MODEL
Lack of equilibrium is a secondary manifestation of lack of integration. A lot of human illness is due to lack of balance and equilibrium; for example excessive intake of some foods leads to disease just as inadequate intake leads to ill-health. The Qur’an calls for observing the equilibrium, al wastiyyat. Violating the rule of the golden middle is associated with many problems and lack of balance is condemned.
Ancient Muslim, Indian, Chinese, Greek medical systems understood the concept of equilibrium. Modern European medicine lacks the concept of equilibrium or balance. It is replete with examples of overdoing a good thing beyond the equilibrium point and creating even bigger problems. Some therapies are worse than the disease they are supposed to cure. The quality of life of terminal cancer patients is made worse by chemotherapy and radiotherapy than the original disease perhaps they could have been left to die in dignity. Pesticides were used to eradicate malaria but they led to human disease. The best treatments of yesterday are known causes of malignancies today. Some physicians trained in the European tradition recognize the problems of balance and integration but they can not propose a comprehensive solution because of lack of an underlying paradigm. A European symposium called for balance between technological development and social change within an integrated system, education and skill acquisition, general and specialized training, science and behavioral disciplines. The conference did not however have a comprehensive solution or paradigm.
NOTES
[i] This assertion is seriously challenged by chronic diseases
[ii] Disease is due to anatomical anomaly
[iii] Disease is due to deranged physiological or biochemical function
[iv] Clinical examination for signs, medical imaging, and medical chemistry
[v] Environmental medicine asserts that disease is related to the physical and social environments
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© Professor Omar Hasan Kasule April 2007
© Professor Omar Hasan Kasule April 2007
