Talk at the Summer Workshop of the Research Center Medical Humanities (University of Innsbruck), May 2018

 

Dr Noelia Bueno-Gómez (Assistant Professor, Department of Philosophy, University of Oviedo, buenonoelia@uniovi.es)

1.      How can philosophy contribute to the medical humanities?

Before focusing specifically on this question I would like to begin with a brief introduction about the content and the origin of the medical humanities.

The medical humanities include a number of disciplines in the humanities, arts and social sciences relating to medical issues and medicine. Literature, history, philosophy, sociology, anthropology and the arts all fall within the realm of medical humanities by contributing to a deeper understanding of the cultural, social, anthropological, ethical, existential and phenomenological dimensions of phenomena present today in medicine, such as pain, suffering, illness, death, birth, old age, health, risk prevention, security, mental health, etc. Since they bear tough-to-measure, subjective and cultural features, these phenomena are not “purely” biomedical phenomena. Although gerontology describes the characteristics common to old age, a better understanding of the lived experience of becoming old comes from reading La cérémonie des adieux by Simone de Beauvoir. In medical terms the process of dying is well described, but Oliver Sacks’s Gratitude provides a greater appreciation of the importance of assimilating the idea of the death in life itself. From a more philosophical point of view, it is also possible to consider how finitude (the fact that we are finite beings) affects our existence, Martin Heidegger’s Sein und Zeit does just that. This is something that medicine cannot do, it is something beyond the remit of medicine and we should not expect medicine to do so. In this regard, the medical humanities complement medicine by adding a more nuanced understanding of these phenomena and dealing with the questions arising from medicine as such. 

The medical humanities as a field took shape in the 1960s and the 1970s in the United States (Greaves & Evans, 2000), although there are precedents in past centuries. In Spain, three intellectuals advanced the medical humanities prior to institutionalization: Santiago Ramón y Cajal (a neuroscientist and humanist, who, together with Camillo Golgi, received the Nobel Prize in Medicine in 1906; 1852-1934), Pío Baroja y Nessi (physician and writer; 1872-1956) and Gregorio Marañón y Posadillo (physician, historian and writer; 1887-1960).

The institutionalization of the medical humanities coincided with the push for a “more human” form of medicine (the “humanistic turn”), which manifested itself in both theoretical approaches and social activism and sought to defy the methods, goals and consequences of medicine. The humanistic turn pushed back against the same features of the clinical, evidence-based medicine that had turned it into a science in the 18th century, as explained by Foucault in Naissance de la clinique (Foucault 1997), and brought under its umbrella the hospice movement, women’s rights movements, Ivan Illich’s Christianity-based humanistic criticism of medicalization (Illich 1976), bioethics and its attempts to resituate the ill person in medical contexts (Beauchamp and Childress 2008), the postmodern critique of medicine (Bauman 1992), “medical humanism” as exemplified by Cassell’s influential work The Nature of Suffering and the Goals of Medicine (Cassell 2004) and phenomenological as well as narrative approaches to medical practice and patient experience, in addition to the contributions of history, philosophy, anthropology, sociology, medicine and the arts (Bueno-Gómez 2017a). The medical humanities have been slowly incorporated into the educational programs of medical schools throughout the world and clinical medicine has begun to change, incorporating to a greater or lesser extent certain of the reforms called for (such as the hospice movement and its emphasis on the “palliative” goal of medicine, rather than the merely “healing” goal). At the same time, clinical medicine has expanded its techno-scientific scope, resulting in new challenges for humanistic disciplines, such as new ethical dilemma and new ontological problems dealing, for instance, with the possibility of changing human conditions by using genetic engineering (see, for example, Savulescu 2012).

With this in mind, I will try to answer the more specific question about the contribution of philosophy to the medical humanities. I propose classifying the philosophical contributions to the medical humanities into three different groups:

1)      Epistemological and ontological contributions in the field of philosophy of medicine.

Each discipline has its own language and its own way of classifying phenomena. Philosophy can compare the different categories or concepts of each discipline regarding the same phenomena. For example, a philosophical study about pain needs to take into account the biomedical knowledge about pain, historical studies that show how pain perception and the treatment of pain has changed over history, sociological studies that demonstrate the existence of a particular kind of pain caused by social institutions and anthropological studies showing the cultural variability in pain perception, the influence of rituals, etc. One philosophical task (among others) is to organize this map of approaches to pain in an attempt to offer an all-encompassing perspective.

Philosophy of science can reveal the social conditions that influence the apparently neutral scientific studies (gender studies, for instance).

Philosophy can examine the ontological assumptions of certain disciplines too (the mind-body dichotomy and its consequences for medical approaches, for instance).

2)      Critical/normative function (ethics and bioethics). Ethical and political dilemmas emerge in biomedical contexts, including those in the realms of environmental ethics, bioethics and research ethics. Moral and political philosophers argue in favor or against a solution for a dilemma, reveal problems (for example, power relations) that may remain hidden from the agents involved and try to provide them cultural and philosophical resources to deal with them. From my point of view, moral philosophers are not moralists. Their main role is to provide resources to students, professionals and citizens that they can use in their personal and professional lives and in public debates.

3)      Philosophical methodologies to investigate phenomena relating to or under the scope of medicine, such as the phenomenology of pain or the hermeneutics of autobiographical notes on illness. These are original contributions of philosophy.

 

2.      What is your contribution to medical humanities?

In my work on two topics -death and suffering- situated directly at the heart of medical interest, I have tried to take a philosophical point of view. In this attempt, I have found it crucial to understand and situate the particular view and mode of handling such phenomena by biomedicine. While it is clear that our society tends to legitimate purely techno-scientific approaches to such phenomena as the definitive and best ways to dealing with them, this tendency can at the same time disappoint those seeking a more comprehensive understanding. Biomedical approaches to death and suffering cannot encompass the broad complexity of the phenomena. Indeed, it is always a challenge for a philosopher to deal directly with phenomena (as opposed to another philosopher or another philosophical theory). That said, I think that our times demand that philosophers take on this particularly difficult challenge. We have to break the bones in our heads, as Sartre seemed to say. I try to assume this challenge.

The first question is: how to do it? The methodology…I think that philosophy nowadays needs to carefully take into account the results of the sciences. I see no way to study death philosophically without taking into consideration the medical definition of death or the fact that medicine has changed the nature of the phenomenon. However, philosophy is not a natural science and its view must be broader. My conclusions about the contemporary experience of death includes a classification of four different levels of characteristics that define such an experience, including the material, epistemological and bioethical consequences of the massive techno-scientific (medical) management of death, and the symbolic level, the idea that the traditional perception of death as a passage to a different state of living has come under question. As an alternative to the death-denying and death-hiding hypotheses (the generalized idea that contemporary Western society denies and hides death and the set of moral recommendations derived from it), I have held that modern Western society has created its own way of facing death, namely a techno-scientific approach that does not entail denying or hiding death, but rather implies a particular professionalized, techno-scientification of death with particular internal tensions, limitations and new relations of power (Bueno-Gómez 2017b). This is an example of a philosophical contribution to the study of death: situating the medical management of death in the context of other historical approaches, studying the new dilemmas and problems arising and proposing alternative solutions. For example, the new spatiality and language of death facilitate situations in which ill people feel displaced and confused and physicians may hold excessive power. In this regard, socio-empirical studies can identify the agents involved in each case to inform about their social positions, power relations, values and interests in an interplay of experts and professionals versus laypeople and facilitate a negotiated solution to a particular problem in which the non-professional agents involved are accepted as the ultimate experts on their own life and death. At this point philosophy once again proves its utility, as different philosophical arguments can, from an existential point of view, help assimilate finitude.

Regarding the phenomenon of suffering, I have designed a research project to study the consequences of the techno-scientification of suffering (the same methodology as in the case of death) and the religious (particularly the ascetic) handling of suffering. Again, it was clear from the outset that biomedical approaches to pain and suffering could not completely describe, explain and account for the phenomena. Of course, pain can be described in neurological terms, but there are other factors that influence pain perception, such as cognitive awareness, interpretation, behavioral dispositions and cultural and educational factors. Defined as an unpleasant or even anguishing experience, suffering can be caused by pain or other circumstances, severely affecting a person at a psychophysical and existential level (Bueno-Gómez 2017a). With this in mind, the first challenge was to conceptualize suffering and pain. Different authors coming from different traditions and working on different albeit related areas conceptualize the territory of pain and suffering differently, even if there is a universally accepted definition of pain given by the International Association for the Study of Pain.[1]

Two consequences of looking deeper into the medical definition of pain are (1) the uncovering of the ontological mind-body dichotomy underlying such definition and (2) the consideration of the advantages and limitations of the medical treatment of pain as a result of accepting the aforementioned dichotomy. Problems such as the placebo effect, chronic pain and non-somatic pain are still challenges to medical understanding and pain management. Such are the results of research in philosophy of medicine: uncovering ontological and epistemological assumptions and their consequences.

Due to their very nature, phenomena such as pain and suffering (also illness, health, death, birth, menopause, puberty, etc) cannot be dealt with exclusively in biomedical terms. Even if the need to reframe biomedicine by overcoming the classical mind-body distinction (which would indeed change the medical management and definition of pain and suffering) is accepted, pain and suffering do not only concern medicine, but also the social sciences and humanities, which contribute to the clarification of their cultural, social and cognitive dimensions. There are types and dimensions of suffering not managed in medicine (or at least, not exclusively). We cannot manage social problems that cause social suffering with medical resources only. The medical humanities contribute to understanding this kind of phenomena, with philosophy of medicine tasked particularly with showing the limits of medicine while remaining cognizant of the limits of philosophy as well.

A second part of my research about suffering is dedicated to the ascetic-mystic experience of suffering. I have assumed that Christian religion has an enormous influence in the European ethos, and this includes our conscious and unconscious assumptions about suffering. I realized that I cannot measure the exact impact of such influence by using philosophical methodologies, so I decided to concentrate on a philosophical (now hermeneutical) approach to the ascetic-mystic tradition, which incorporates a very radical view and handling of suffering (particularly shocking is its positive consideration of suffering and the phenomenon of self-inflicted pain) with the aim of understanding them (by situating them historically and culturally). With this aim I am working on Teresa of Avila, Gema Galgani, Marta Robin and Simone Weil.

 

3.      How do you manage the transdisciplinary challenge (methodology, concepts…)?

By reading the contributions of different fields. I have studied sociology and anthropology to understand the methodologies and kind of contributions these disciplines make. I read contributions from medicine, biology, history… it is difficult to stay abreast of new developments, so selecting readings is crucial.

 

4) What is particularly important regarding the MH? What are the risks/opportunities of the MH?

The medical humanities are a great opportunity for experts from different disciplines to collaborate to advance a better understanding of phenomena that are not exclusively biomedical, even if our techno-scientific society tries to impose a purely techno-scientific view of them. We all need to make an effort of mutual understanding but it’s worth it, positive outcomes have already been seen from the effort.

One more opportunity of the medical humanities is in education, with the chance to provide future healthcare practitioners with insight into the particular methodologies and resources of the humanities or at least with an appreciation that “medical phenomena” are usually, but not exclusively, medical. In parallel, students of the humanities (for example, in bioethics or philosophy of medicine) might profit from an outlook that takes into account current and foreseeable medical knowledge and techniques and their real possibilities and limitations.

 

Bibliography


Bueno-Gómez, Noelia (2017a), “Conceptualizing Suffering and Pain.” Philosophy, Ethics, and Humanities in Medicine 12 (7). Open access: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5621131/

Bueno-Gómez, Noelia (2017b), “The Experience of Death in Techno-Scientific Societies: Theoretical Discussion and Consequences for the End-of-Life Decision-Making Processes.” Illness, Crisis & Loss 25(2): 150-168. 
Bauman, Zygmunt (1992),     Mortality, Immortality and Other Life Strategies. Stanford: Stanford University Press.
Beauchamp, Tom L., and James F. Childress (2008), Principles of Biomedical Ethics. 6th edition. New York: Oxford University Press.
Cassell, Eric J. (2004), The Nature of Suffering and the Goals of Medicine. Oxford: Oxford University Press.
Foucault, Michel (1997), Naissance de La Clinique. Paris: Presses universitaires de France.

Greaves, D, and M. Evans (2000), “Medical Humanities.” Medical Humanities 26: 1-2.

Illich, Ivan (1976), Medical Nemesis. The Expropriation of Health. New York: Pantheon Books.

Savulescu, Julian (2012), ¿Decisiones peligrosas? Una bioética desafiante. Madrid: Tecnos.

 



 



[1] An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698 Accessed on 18/05/2018.