The goal of medicine

and the paradox in modern healthcare

Dec 05, 2021

Medicine has existed for as long as humans can remember. Hippocrates began his scientific study of medicine in ~460 B.C. The Egyptian Imhotep, considered the god of medicine, is said to have worked on the diagnosis & treatment of more than 200 diseases in 2600 B.C. In India, the earliest treatise Rig Veda mentions that Dhanvantari 17th incarnation of Lord Vishnu was worshipped as God of medicine. It was also regarded as the source of Ayurveda. Ancient scholars of India like Atreya, and Agnivesa have dealt with principles of Ayurveda as long back as 800 BC.

This mention of history is just to ascertain that falling sick is an inherent part of human existence. We all feel sick at some point in life. No matter how much we may try to escape falling sick, it is something that happens to all of us. Illness is and will always remain a stark reality of our life.

Medicine has become even more ubiquitous in our life since the post-modern society and even more so in the 21st century. Our relationship with medicine has undergone a sea change with the advent of scientific breakthroughs and the transition of medicine from the human realm to that of technology. We have more complex surgical procedures now, medicines have been developed to address a variety of disease states, medical devices have penetrated hiterto unreachable parts of our body. The latest in neural research is now invading the realm of brain too.

One can write reams on the history of medicine and what the future of healthcare may look like. But I am more interested to explore the question: What is the goal of medicine? What should be the goal of modern healthcare? What is the role of healthcare practitioners namely the doctors, nurses and the likes, in administering the medicine & delivering the treatment?

The disease

Let us take the case of a middle-aged mother of 2 children, who has just been diagnosed with breast cancer. The suffering this mother experiences is beyond words and comprehension. With every chemotherapy session, there was physical discomfort and agonizing pain. She lost weight, her hair and her appetite for good food.

The doctors have informed her about the course of treatment and generally tend to be kind. However beyond a point she is another patient for them whose treatment pathway has to be followed albeit with her & family’s consent. They share with her only as much as they think she needs to know. They don’t inform her that the breast being treated will be disfigured for the rest of her life. They may even have to remove it. That the chemotherapy will make her bones so fragile & osteoporotic that a minor fall may lead to fractures. Her libido has disappeared, she has gained weight to the point of being obese and the radiotherapy and all the medicines have made her groggy & irritable. When she looked at the mirror, her losing hairline would tell her the truth that only a mirror could. The nursing staff is efficient but, as they say, are very ‘clinical’ with her. Sometimes the visiting nurse would go on changing her inners even when she had visitors making her feel that she was just an object for them…just someone whose physical body is not working as it is supposed to.

Goals as defined

At this point of time, I want to pause and ask what is the goal of medicine (read healthcare) in this woman’s daily battle? With what purpose do the doctors, nurses and other healthcare staff orient their actions around this mother?

I did some research around the goals of medicine. The Hastings Center’s consensus report (Callahan 1999)1 on its international project on this topic settles on a list of four goals of medicine:

The prevention of disease and injury and the promotion and maintenance of health
The relief of pain and suffering caused by maladies
The care and cure of those with a malady, and the care of those who cannot be cured
The avoidance of premature death and the pursuit of a peaceful death

Miller and Brody (1995, 1998, 2000, 2001) 2 drew their list defining “The goals of medicine are directed to a variety of ways in which physicians help patients who are confronting disease or injury”. Their list of goals are:
1. Reassuring the ‘worried well’ who have no disease or injury
2. Diagnosing the disease or injury
3. Helping the patient to understand the disease, its prognosis, and its effects on his or her life
4. Preventing disease or injury if possible
5. Curing the disease or repairing the injury if possible
6. Lessening the pain or disability caused by the disease or injury
7. Helping the patient to live with whatever pain or disability cannot be prevented
8. When all else fails, helping the patient to die with dignity and peace

Dr. Leon Kass, bio-ethicist and a physician, in his 1975 essay “Regarding the End of Medicine and the Pursuit of Health” defines the end of medicine as ‘preservation’ of health. He asserts that the doctor’s short-term role is to restore the bodily functions in a patient to a healthy condition and work on restoring them to the pre-disease condition as much possible, as much as medicine allows. Health, he defines, as the ‘working well’ of the whole body and to be ‘healthy’ is to be ‘whole’.

A closer look at the lists above reveal terms like disease, injury, disability, physical pain etc thus revealing the focus of medicine on the physiological illness and its restoration. Health is considered as the ‘working well’ of the body and good health, it seems, is the absence of a physiological illness.

Lets return to the case of the mother with breast cancer. Is her experience of the disease limited to only physical pain? What about her suffering in totality?

The patient

Every time her body responded to therapy and treatment, she felt victorious in the battle between hope & despair. Every day of hope was coupled with anxiety & misery of what if the treatment fails. There is also the never ending anxiety of paying for the treatment as her medical insurance is slowly getting exhausted and the miscellaneous costs have been piling up. She feels socially isolated as if her personal & family life had come to a grinding halt. The friends show concern for her condition, a concern which conceals a certain ‘pity’ making her feel as if suddenly she was less of a human being than before. Even their visits have become less frequent as they have ‘accustomed’ and ‘got used to’ her illness. To add agony to it all were the several hospital visits for treatment sessions, the endless time in the hospital corridors waiting for test reports, the struggle to understand the truth of her condition from the medical mumbo-jumbo of the doctors and what not.

She suffers from the fear of death, anxiety of her own existence - what will happen to her children if she dies? Who will take care of them in case their father remarried? Will they even remember her when they grow up? The daily anxiety & agony of this mother is severe and runs deep into her psyche. She suffers both physically and mentally.

Dr. Daisaku Ikeda (buddhist philosopher, peacebuilder & educator) mentions 3 types of human suffering arising from illness: 3

Physical pain (and discomfort) from the disease
Anxiety & fear arising from disruption & breakdown of one’s social & personal life related to family, work, position & property
Existential agony or fear of death

While Dr. Ikeda mentions the above in the context of terminal illnesses like cancer, they apply to commonly occurring human ailments in varying extent. Being ill doesn’t just make us suffer physically but emotionally, socially and spiritually too. It would be common sense to then think that patients want relief, in totality, from this suffering arising out of the illness.

According to the constitution of the World Health Organization (WHO), health is a state of complete physical, mental, and social well-being, not simply the absence of disease or infirmity.

Does the medical profession understand these expectations? Does it acknowledge ‘relief from suffering’ as its common goal shared with the patients? Is the medical profession thinking of the ‘actual’ experience of the patient undergoing medical treatment?

The paradox

Eric Cassell, an intensivist who has extensively written & researched on Medical Ethics for The Hastings Center, a bioethics think-tank, says: “The obligation of physicians to relieve human suffering stretches back into antiquity. Despite this fact, little attention is explicitly given to the problem of suffering in medical education, research, or practice. In discussing the matter of suffering with lay persons, I learned that they were shocked to discover that the problem of suffering was not directly addressed in medical education. My colleagues of a contemplative nature were surprised at how little they knew of the problem arid how little thought they had given it, whereas medical students tended to be unsure of the relevance of the issue to their work. The relief of suffering, it would appear, is considered one of the primary ends of medicine by patients & lay persons, but not by the medical profession.” 4

It seems that when medical professionals think of patient’s suffering, what they essentially think of is pain. Though physical pain is a major cause of human suffering especially in a medical/hospital setting, it is only one amongst the many sources of human suffering. The patient on the other hand suffers on many accounts as we have seen in the mother’s case.

That medicine has primarily concerned itself with physical ailments or the ‘physical’ manifestation of the symptoms has given rise to the biggest paradox in the world of healthcare especially in the modern era - the paradox that patients often suffer from their treatment as they suffer from their disease.

Even in the best of the hospital setting with excellent, well-intending physicians & staff, it is not uncommon, Dr. Cassell argues, for suffering to occur not only during the course of the treatment but as a result of the treatment.

This paradox is the reason why patients, the world over, continue to remain ‘dissatisfied’ with their healthcare despite all the advances in medical science & technology. It causes the patients to distrust their doctors & their hospitals. According to a survey conducted in 2019, 61% of patients in India believe that hospitals do not act in their best interests. 5

Poor trust & communication levels between patient-doctor also leads to treatment non-compliance in many cases which further affects the health outcomes. Additionally, in a country like India where healthcare spend is mostly out-of-pocket, this distrust has also given rise to a phenomenon similar to doctor/hospital shopping - where a patient consults with multiple doctors & hospitals to see the best ‘cost’ of treatment especially in case of a major surgery or a medical procedure.

This is truly a precarious situation for a country like India where healthcare, for many years, had been a neglected sector both at the government & at institutional level. With India’s burgeoning population and arguably poor healthcare insrastructure in rural & semi-urban areas, this patient paradox in the urban areas where health infrastrucure is advanced & well established, is unfortunate and dichotomic.

So what is the root cause of this paradox? Why, despite the advent of life-changing surgeries, drug breakthroughs & technological advances, patients keep suffering? Why is the medical profession missing the trees for the forest?

I will write about it in the next edition.

True Health

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