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SPECIALISTS WITHOUT THE MECHANISTIC

SPIRIT: LIMITATIONS OF BIOMEDICAL

MODEL

S O M A H E W A a A N D R O B E R T W. H E T H E R I N G T O N b

a Department of Behavioral Sciences, Mount Royal College, Calgary, Alberta, Canada b Department of Sociology, University of Alberta, Edmonton, Alberta, Canada

ABSTRACT. This paper examines the origin and the development of the mechanistic model of the human body and health in terms of Max Weber's theory of rationalization. It is argued that the development of Western scientific medicine is a part of the broad process of rationalization that began in sixteenth century Europe as a result of the Reformation. The development of the mechanistic view of the human body in Western medicine is consistent with the ideas of calculability, predictability, and control - the major tenets of the process of rationalization as described by Weber. In recent years, however, the limitations of the mechanistic model have been the topic of many discussions. George Engel, a leading advocate of general systems theory, is one of the leading proponents of a new medical model which includes the general quality of life, clean environment, and psychological, or spiritual stability of life. The paper concludes with consideration of the potential of Engel's proposed new model in the context of the current state of rationalization in modern industrialized society.

Key words: rationalization, biomedical model, medical history, biopsychosocial model, iron cage

1.

INTRODUCTION

Critics of the biomedical m o d e l ~'2'3'4'5 argue that the mechanistic approach t o h u m a n 1'2'3'4'5 health is incomplete or useless. According to George Engel, medicine today is in crisis because of its adherence to a particular disease model "that is no longer adequate for the scientific task and social responsibilities" of medicine. Arthur Schafter goes even further to suggest that about ninety percent of medical procedures based on purety technological medicine produce very few benefits, even though such procedures are given very high priority in medicine. During the last few decades many people, including some members of the medical profession itself, have agreed with such observations. These critics have suggested that the health and wellbeing of people must be defined in terms of a new medical model which includes the general quality of life (e.g., housing and education), clean environment, and psychological or spiritual quality of life. The purpose of this paper is to seek an answer to the question: Why did the mechanistic paradigm become the only model in modern medicine

Theoretical Medicine 16: 129-139, 1995. © 1995 Kluwer Academic Publishers. Printed in the Netherlands.

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despite the growing perception of its apparent limitations? Clearly, one cannot answer this question only in terms of better meeting the health needs of the people. While initially it appeared that the mechanistic model contributed to the improvement of health, its failure to meet changing health care needs resulted in a growing dissatisfaction with the model. Hence, this paper will attempt to explain the dominance of the mechanistic paradigm in terms of historical and philosophical circumstances surrounding its original development, and subsequent influence on medical practice. It is argued that developments in medicine should not be seen as isolated incidents, but rather as part of broad social and historical changes in Western civilization. Such changes have been interpreted by Max Weber as a process of "rationalization," in which the central theme is the persistent emphasis on calculable and predictable concrete evidence as opposed to metaphysical and mystical speculations. Within this general historical background, the philosophical and theoretical foundations for the bio-medical model were laid by Ren6 Descartes (1596-1650) and William Harvey (1578-1657). The mechanistic concept of the human body developed in their works was compatible with other scientific and technological developments of the time. Moreover, the rising demand for a calculable and predictable interpretation of the world soon led to the development of anatomy as the technique for studying the human body. Our argument closes with consideration of the potential of Engel's proposed "new" biopsychosocial model of health care. It appears that the basis of this new model involves a return to the recognition of the unity of the body and mind. However, the concept of "mind" involved in this model must encompass psychological, social, and cultural aspects of human existence. We question whether a model incorporating these elements is compatible with the current stage of rationalization which Weber foresaw for modern industrialized society.

2. THE PROCESS OF RATIONALIZATION According to Max Weber, 6 the sixteenth century Reformation marked a radical 6 departure from the medieval understanding of the world and the universe. Rejection of Roman Catholic teachings by Calvin and Luther not only inspired a new world religious movement, but also liberated individuals from religious domination. New ways of thinking promulgated by the new religious movement encouraged the individual to seek rational and logical interpretations of the world. For Weber, this was the beginning

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of the process of rationalization, or as he called it, "instrumental rational action." Weber 7 defined instrumental rational action in terms of predictability and calculability - that is, the goal and the means are methodically and rationally linked: "Action is instrumentally rational when the end, the means, and the results are all rationally taken into account and weighed."s Weber argued that the process of rationalization has penetrated into almost every aspect of life - medicine, science, arts, music, and commerce, to mention a few - and produced an unparalleled development in the West. Communication among nations was facilitated by the development of the printing press, and long considered obstacles in reaching distant lands by sea were swept away by the development of the mariner's compass, assisted by gunpowder which had already demolished the local feudal frontiers in sixteenth century Europe. While the new religion - Protestantism - liberated the individual from the old bonds, new Republican political systems recognized individuals' rights, such as the freedom of speech and the freedom of choice, as paramount to human progress. Influenced by the emphasis on rational and logical explanation, medicine and the arts became concerned with morphology and motion. Dynamic motion, emotional expression, and profuse ornamentation that became popular in the arts also influenced medicine, turning Vesalius's static anatomy and Paracelsus's mystical nosology into something dynamic and rational. The Copernican universe was re-invented by Kepler, Galileo, and Newton whose discoveries in physics, astronomy, and mathematics laid the foundation for modem scientific disciplines. 9 The liberation of the individual from traditional ways of thinking and the emphasis on empirical observations opened up a whole range of new developments and discoveries that became the cornerstones of Western industrial society. The scientific research of Robert Boyle elevated ancient alchemy to modem chemistry which along with anatomy contributed to the rapid growth of new knowledge in the structure and function of the human body. I° Although this new scientific and rational thinking brought about many social and economic benefits, it undermined the traditional moral and spiritual values in society. The ultimate result of this process of rationalization, for Weber, is the total alienation of the human spirit from the scientific and rational world. In this regard, Weber argued that the rational scientific paradigm "trapped" humankind forever in an "iron cage" striving for efficient means in attaining all objectives with little or no concern for the spirit of humanity. Being pessimistic about the future of modem Western societies, Weber concluded his seminal work The Protestant Ethic and the Spirit of Capitalism, with the following remarks:

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No one knows who will live in this [iron] cage in the future, or whether at the end of this tremendous development entirely new prophets will arise, or there will be a great rebirth of old ideas and ideals, or, if neither, mechanized petrification, embellished with a sort of convulsive self-importance. For of the last stage of this cultural development, it might well be truly said: Specialists without spirit, sensualists without heart; this nullity imagines that it has attained a level of civilization never before achieved.H Beneath the surface of Weber's fatalistic interpretation of modern Western rationalization, he implied that "modernity" or "progress" is multidimensional and that the practical orientation of "human will" can overcome the irrational outcome of purposive rational action. Weber did not elaborate on this practical orientation as he was fascinated by the enormous power of technological and scientific rationalization in modern Western society. Therefore, Weber's interpretation left the impression that the process of rationalization is irreversible and leads modern Western society to an "iron cage" or to a "dead end." As some recent interpretations of W e b e r 12'13'14'15'16 have clearly pointed out, it is incorrect to conclude that the "disenchantment of the world" in Weber's interpretation of the process of rationalization is the ultimate fate of modern Western society. The process of rationalization, as Johannes Weiss 17 argued, does not necessarily lead to an "iron cage," or an irrational end; understanding of the limitations of instrumental rational action would lead to alternative solutions to problems. Hence, the process of rationalization is multidimensional, and it offers alternative directions for unfolding developments in modern civilizations. Technological rationality (instrumental rational action) is only one aspect of the progress that Weber discussed in extensive detail. Practical rationality, according to Weiss, 18 includes moral, ethical, and cultural progress (value rational) of society that often competes with technical rationality in economic and political spheres. As Habermas 19 points out, the process of rationalization, for Weber, is the extension of instrumental rational action, first to the process of production, and gradually to other spheres of society. Instrumental rationality not only liberates the individual from the mysterious and religious world view that dominated the medieval period, but also it contradicts the moral and ethical values of society. Therefore, the growing realization of the limitations of technological rationalization should not be seen as an irrational outcome of the process of rationalization; rather it must be seen as a part of cultural progress that grows along with technological progress. In order to reduce the tension between instrumental rational action (technological rationality) and value rational action (moral and ethical process) in post-modern society, technological progress must be incorporated with cultural progress. 2°

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3. THE IMPACT OF RATIONALIZATION ON MEDICINE The foundation for the mechanistic m o d e l in medicine was laid in the seventeenth century by William H a r v e y and Ren6 Descartes. H a r v e y ' s discovery of the circulation of the blood (De Motu Cordis) 2~ in 1628 revolutionized thinking about the human body. Harvey stressed that blood circulated in the body in a mechanical manner, thus eliminating the need for metaphysical explanations which were c o m m o n at one time. Harvey... opposed the Femelian 'spirits' which bad been given a leading role as offspring of the s t a r s . . . Fernel had referred to the empty spaces of the heart, the arteries and the brain as receptacles suitable for an extremely subtle aura or vapour... Harvey can see no truth in this.22 Furthermore, H a r v e y ' s conclusions were based on direct observation, rather than on speculation. The c o m b i n a t i o n of a mechanical interpretation of the body and the observational technique, was a result of the increasing tendency of the historical period to emphasize calculability and predictability. H a r v e y ' s discovery was reinforced by the publication of De homine in 1662 by Ren6 Descartes, in which the human body was clearly separated from the mind. This Cartesian dualism recognized the h u m a n body as analogous to a machine which is c o m p o s e d of separate but interdependent parts, directed by a rational soul located in the pineal gland. As Descartes described it: I must describe to you first the body by itself... I assume the body is nothing else than a statue or machine.., indeed, the nerves of the machine I am describing to you may very well be compared to the pipes of the machinery of [the] fountains, its muscles and its tendons to various other engines and devices which serve to move t h e m . . , its heart is the spring. • . . Moreover, respiration and other such functions of a clock or a millY •

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This mechanistic view of the human body grew apace with subsequent discoveries in medicine which reinforced the idea that illnesses are a result of the failure of mechanical functions of various parts of the human body. Within this p a r a d i g m it is believed that medicine is a science that has concrete answers to everything that goes wrong with the body. This idea was further strengthened by the successful achievements in bacteriological research by Louis Pasteur, Robert Koch, and others during the eighteenth century. Their research directly contributed to the development of the germ theory of disease which, along with significant progress made in internal medicine, anaesthesiology, pathology, immunology, and surgical techniques, convinced physicians to focus heavily on clinical medicine based on biochemical discoveries. As Ren6 Dubos 24 argues, the practice of modern medicine became dominated by the idea that the human body

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can be manipulated and cured either by introducing chemical compounds into the mechanical system of the body, or by replacing and repairing parts. Therefore, medical research turned largely to finding new drugs and better surgical procedures. This emphasis in medical research is a direct result of subscription to the mechanistic model, which, as well as promoting a "way of seeing" and understanding the human body, is also a "way of not seeing" other aspects of human existence such as the psychological, cultural, and social dimensions. In addition to its influence on research and medical practice, the mechanistic model became deeply rooted in fundamental assumptions of medical education. This model has developed a unique culture within medical education. Ideas associated with it have now acquired the status of dogma so that attitudes and beliefs of physicians are subtly molded during their education and professional training, z5 For example, interns spend much of their time preparing patient charts. They are overwhelmed by laboratory tests and technical procedures which in turn produce very complex figures and graphs. Interns call this "laboratory medicine," as opposed to "clinical medicine" in which the diagnosis of illness and the selection of treatments are determined by the physician through examination and communication with the patient. 26 As Terry Mizrahi27noted, there is a strong desire among medical students to gain as much experience as possible in the use of technical medical procedures, as opposed to patient management. Whenever they contact a patient, it is to collect additional technical information. Psychology, spirituality, and emotions are not regarded as part of medical education and training, nor are they part of medical jargon, although spirituality and emotions are important aspects of death and illness. Medical students are taught to be emotionally detached from their patients; such detachment is heavily rewarded during their training. A resident who fails to cope with emotional circumstances would be reprimanded. It is a common belief among medical educators that in order to become successful physicians, medical students must be able to transcend all emotional and psychological feelings.28 The inevitable outcome of this process of training is the dehumanization of students who see social and emotional aspects of patients as nuisances. Patients who present complex medical, psychological, and social problems in the technologically oriented acute health care setting are called by nicknames such as "gomer," crock," and "gork. ''29

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4. TOWARDS A NEW MEDICAL MODEL Weber's failure to focus explicitly on cultural and moral rationalization in modern society left the impression that scientific and technological progress may produce experts in scientific disciplines such as medicine, but it could not produce scientifically ascertainable ideals. Therefore, the process of rationalization was primarily characterized by scientific and technological progress that eventually led to an "iron cage" or "dead end." For modern philosophers like Thomas Kuhn,3° however, revolutionary social changes occur when the dominant social paradigms can no longer provide satisfactory solutions to emerging problems. The exhaustion of an existing model, according to Kuhn, leads to a major social crisis that goes beyond the scientific community and has political, social, and cultural ramifications. As many social scientists, e.g. 31"32'33argued, the crisis in health care in advanced industrial societies is a widespread one and questioning of the mechanistic biomedical model stems from a broad spectrum of society. There are proposals for alternate medical models that involve a fundamental paradigm shift in modern medicine. The concept of the whole person or the "holistic" view of human life, according to some critics, e.g., 34'35'36is not only a matter of re-establishing the relationship between the body and mind, but also involves a revolutionary change of our understanding about human existence. As Barry Commoner37 argues, medicine needs to develop a new model that will respect the integrity of natural systems; a model that integrates what is known about nature. Among the critics of the biomedical model, Enge138'39'4°provides the most comprehensive set of ideas in constructing a new medical model that he described as the biopsychosocial model. Enge141 maintains that this new model will "take into account the missing dimensions of the biomedical model. To the extent that it succeeds it also serves to define the educational tasks of medicine . . . . " I n Engel's view, the distinction between health and disease cannot be described clearly as they are diffused by cultural, social, and psychological considerations. As the biomedical model diagnoses disease in terms of biological criteria, it inevitably defines health as the absence of disease. This approach creates fundamental problems when some people with positive laboratory findings are told they do not need medical treatment while others, who feel well, are told they need medical attention. By contrast, because the biopsychosocial model does not define health in terms of mere absence of disease, it can easily explain both situations as it takes into account not only the biological criteria, but also the social, cultural, and psychological variables of disease causation. Engel's biopsychosocial model is based on systems theory which explains nature both as

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a hierarchy and a continuum. The components of both a hierarchy and a continuum represent a system. While each system operates independently, they interact with one another when they act as a whole. Consider the following hypothetical situation. A low income individual may not seriously consider the quality of food that he/she consumes in daily life and that is a personal decision. However, this independent decision may eventually influence that person's health which would have direct implication for his or her employment, family life, and in the end, the health care system. A physician trained in the biomedical model can identify this problem only as a "biochemical disorder" when a particular illness caused by poor quality food is diagnosed by laboratory tests. This understanding of the physician is incomplete because his/her explanation of disease causation does not take into account the level of income of that person, the quality of food, stress, and other associated factors of health. Nor does the physician's remedy to the problem address the whole spectrum of socioeconomic conditions of the patient. This problem, however, can be well addressed by a physician whose training is based on the biopsychosocial model because of his biochemical knowledge, as well as his social and political skills. The components of the biopsychosocial model become evident when medical practitioners, themselves, today are continually being confronted by patients with "problems in living." Many of the health disorders involve multiple factors which are not responsive to biomedical treatment. Therefore, they find themselves under pressure to take into account a whole range of interrelated aspects of an individual's life, such as life-style, social interactions, economic conditions, living environment, cultural beliefs, and emotional stability. Of course, such an approach to health problems biopsychosocial - asks the physician to go beyond boundaries established by existing medical education and training. A physician trained in the biopsychosocial model is asked not simply to be a practitioner of medicine, but also an activist on many frontiers relevant to the well-being of people. For example, within the biopsychosocial model, physicians would take an active role in the prevention of disease and the promotion of healthy lifestyles, clean environment, and social programs designed to alleviate poverty and deprivation. Equally important, the physician would also be required to advance and propose social policies which are directed toward protecting the environment as part of preventive medicine. Already, some physicians have taken an active role in anti-smoking campaigns in many parts of the world. To return to our original question: Why has the mechanistic model persisted throughout the centuries with little alteration, despite the growing

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perception of its limitations? Part of the answer is associated with the legitimation of the medical profession in terms of the biomedical model. As we have said, the model involves elements of predictability, calculability, control, and understanding which are the benchmarks of science, and, in Weber's terms, purposive rational action or rationalization. The world has progressively moved from Harvey's time to greater and greater dominance of this view of humankind and its affairs. Factors such as psychological, social, and cultural unfortunately do not have these qualities: very little progress has been made over the centuries toward a greater understanding of these elements of human existence. However, as Kuhn points out, paradigm shifts over time do not simply occur because an existing paradigm is found to be inadequate - as has the mechanistic medical model. Other factors are equally important in determining such shifts: social, political, and economic. The medical model continues to be dominant - indeed the only model - in medical practice because to adopt a more encompassing model would tend to erode the exclusive authority of medical practioners in the field of health care. However, it is not only the medical profession which holds to the scientific basis of practice, it is also the general public which believes - and rightly so - that social, psychological, and cultural factors which are involved in illness and health are really very little understood, and cannot, therefore, be systematically "applied" by practitioners. Although the proposed new model may have significant implications for the health and wellbeing of people, the adoption of such a model is not an easy task. The process of rationalization in modern Western societies is still an ongoing one; predictability, calculability, and psychological elements of human existence. Therefore, if the Kuhnian paradigm shift is to occur in modern Western societies, there needs to be a major cultural and social change in these societies. In other words, the scientific revolution that was described by Kuhn must be preceded by a social and cultural revolution. Thus, we argue, at the present time, as in the historical past, significant changes in medical theory and practice will not occur as singular, unique events. Rather, they will reflect more general changes in the larger society. Despite Weber's dire prediction that rational calculability was the end-stage of Western industrial civilization, there are subtle indications in contemporary society of a widespread "dis-ease" with rationalization, bureaucracy, technology, and ramifications thereof. Such generalized malaise appears to be reflecting the Kuhnian theory of change rather than the Weberian view of end-stage. That is, continuous aggressive developments in science and medicine are meeting with serious questioning by those who are able to stand back and view the overall consequences - philosophers, sociolo-

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gists, ethicists, religious, and political leaders. As Kuhn argued, "anomalies" created by the continued application of the dominant scientific paradigm create "crises" in the larger society, which eventually lead to a "scientific revolution" or a "new way of seeing" reality. The change which results is not only a scientific revolution, but a true revolution, since it involves confrontation of major, entrenched ideologies which become institutionalized in the social system.

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