Treating the Person
The Nature of Suffering and the Goals of Medicine.
by Eric J. Cassell.
Oxford University Press. 254 pp. $22.95.
My mother always said that Doctor B. was the best doctor ever to practice in the small town in Indiana where I grew up. In defense of that judgment she would invariably say, “He listened to mothers.” And then she would go on to point out that, eventually, he took a position at the Mayo Clinic. These two facts—his insight and sensitivity as a clinician into the needs of patients, and his ability to secure a position at a place like the Mayo Clinic—were, in her mind, mutually supporting reasons for her judgment about the excellence of Doctor B.
When we pin Eric Cassell down, he seems to believe pretty much the same. Scientific knowledge of the mechanisms of disease is essential for physicians, but doctoring is also an art, and “the truly successful clinician must respect both aspects.” These two kinds of knowledge must be “combined and brought to bear on the patient’s illness.”
Cassell is a well-known figure in the medical-ethics world, and himself bridges these two kinds of knowledge in his work as a clinical professor of public health at Cornell University Medical College and attending physician at New York Hospital. He develops his argument in twelve chapters which explain why our received understanding of disease is inadequate for the care of patients; discuss the importance of the doctor-patient relation in caring for those who suffer from illness; and put forward an enriched understanding of the person who becomes a recipient of medical care. The argument, though chiefly theoretical in nature, makes helpful use of case histories.
A reader may often be uncertain, however, whether Cassell is simply reasserting the truth that medicine is not only science but art, or whether he wants to claim more. At places he writes as if he were offering a bolder claim—that disease theory, whatever its scientific merits, has failed as a guide for physicians and that some kind of new framework or paradigm for the medical profession is needed. This new framework would focus chiefly on the sick person rather than the disease. Writing as a layman, I have to admit that I cannot find such a theory in this book. The book’s central and insightful claims—which have to do with the relation of doctor and patient—might have been made more succinctly and clearly if separated from some of the theoretical baggage aimed at supporting the new framework. Moreover, any reader who comes in search of deepened understanding of the meaning of suffering will probably conclude that he was misled by the book’s title. Nevertheless, there is much to be learned from this book—wisdom to be gained and worries to be pondered.
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Diseases do not exist apart from the persons who suffer them, and Cassell wants medicine to redirect its attention to those persons. On several occasions he notes, without really explaining, the peculiarity that medical education in recent years has attempted to give curricular attention to such humanistic concerns, but, in his judgment, without any real success. To doctors, diseases still seem more real than patients. What medicine needs—and what all of us who are potential patients therefore need—is a way of bridging the “two cultures” of the science and the art of medicine, of the scientist and the clinician, of universalizable knowledge about diseases and particular knowledge about the patient and his illness.
The relation between theory and practice—whether in medicine or in other endeavors—is, of course, a very old and complicated topic. Perhaps the relation must always remain somewhat mysterious. It is, therefore, no very great criticism to note that Cassell’s proposed solution is difficult to grasp. On some occasions he sounds as if he were simply reworking the old Kantian claim that percepts without concepts are blind, and concepts without percepts are empty. Thus, for example, he will say that the doctor needs experience of many patients over time so that “knowledge interprets our experience while experience enriches our knowledge.” Related to this is the book’s recurring distinction between a universal knowledge about disease that science offers and a particular knowledge of illness in patients. When Cassell is thinking in this manner, he suggests that the physician’s abstract, generalized knowledge of disease must be “applied” or “reparticularized” in his experience of the patient. And the experienced practitioner, with “knowledge amassed from years of experience treating similar patients,” is the person who can do this reparticularizing.
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However often he writes in this way, I do not think this is the real Cassell. I would say that what he really means to argue is the necessity for the doctor to have, not so much experience of many patients, but empathic experience of this patient now before him. And this is quite a different claim—more an argument for what once was called “knowledge by acquaintance” rather than “knowledge by description.” An understanding of the patient’s suffering that cannot be reduced to formulas. Something as close as we can come actually to experiencing the patient’s suffering from the inside, from the patient’s perspective. Not knowledge about the patient’s suffering, but a tasting of it. The clinician seeks an understanding so intimate that he “has experienced the patient’s experience.” This is why the physician is really his own instrument, why, as Cassell repeatedly emphasizes, there can be no substitute for the physician as person. Because he recommends such “empathic experiencing,” such “immersion in the clinical experience,” Cassell is aiming at something far more than the kind of application of theory that one learns through years of experience.
It will always be hard to describe the kind of knowledge Cassell is recommending. One might practice medicine for years and never have the ability to know in this way. Hence, I am a little doubtful about Cassell’s claim that the ability for such empathic experiencing can be taught. At the very least, I did not find here many clues about how it is taught or learned. At one point, he does grant that only the “basic attributes” of the physician’s virtues can be taught, while “in their best exemplification” they perhaps are not teachable. This emphasis does help to explain, however, one of the very interesting features of the book: Cassell’s stress on illness as a story. (It also helps account for the reluctance of clinicians to think in general terms; they always return quickly to cases.) Change any of the details and a story—hence, an illness—changes. That is Cassell’s argument. If he is correct, coming to know a patient’s suffering cannot be entirely unlike learning to read a story with insight. Here again, however, we may be a little baffled about how this should be taught. One may need the help of the Muses.
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Once we see that this is the real Cassell, we may start to worry that his new framework asks more of medical education—and physicians—than they can manage. That worry I set aside, however, in order to pay attention to another, related one. Cassell’s understanding of medicine is very expansive. In his concern to move us away from thinking simply in terms of the body and disease, and toward focusing on the patient and his suffering, on, that is, the whole story of the person’s life, Cassell begins to include almost everything under the rubric of medical care. (What a nightmare for a national-health program!) Granting the obvious, that my sickness may often not be entirely understandable apart from knowledge about the story of my life, there are reasons to be wary of this expansive vision. If everything is medical, we claim too much for medicine and doctors. Cassell specifically criticizes an “anachronistic division of the human condition into what is medical . . . and what is non-medical.” This division, he continues, “has given medicine too narrow a notion of its calling.”
But perhaps some modesty is in order. At first sight Cassell might seem to be turning us away from the hubris of modern medicine, away from its trust in technology’s ability to counteract disease, and toward a more modest goal of being present with patients in their suffering. But I do not think his is a modest vision of medicine at all. Consider his claims. Change any details in the patient’s story, and we effectively change that story. Proper treatment is whatever effectively changes the story. The active presence of the physician is the treatment, as the physician enters into the story, understands it, and seeks to bring some healing. This physician is a heroic figure—well nigh a savior.
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We get here some sense of what it would really mean to think of medicine as a calling, and there is something very appealing in such a vision. Cassell writes powerfully of the steps a doctor must take to see to it that patients do not entirely lose hope. Even knowing that death is coming, the doctor heroically stands in the breach, not abandoning the patient, continually taking steps to demonstrate that something—however small it seems—can still be done to relieve suffering. “When pain is absolutely intractable, the doctor will call a consultant; in another city or another country, if necessary.” In a time when euthanasia proponents are asking doctors to abandon such commitment, we ought to be grateful for what Cassell has to say, and it may seem unkind to quarrel. And, to be sure, there is great power in his depiction of the doctor’s commitment to nonabandonment of patients.
Despite all its appeal and importance, however, I think it claims too much and misidentifies the true healer. “The doctor-patient relationship is the vehicle through which the relief of suffering is achieved.” If that is the ground of our hope in the face of suffering, we are greatly to be pitied. And if we ask that of our physicians, we ask of them more than is within their power. Between a purely technical and contractual understanding of medicine, against which Cassell rebels, and the redemptive, salvific alternative he advocates, there ought to be some middle ground. As present and future sufferers, let us hope that it can be found.
