Thus far, I have considered social phenomena that are supported in part by certain philosophical/culture assumptions and the psychological reactions they tend to produce. I will now turn to the profession of medicine and examine how it both attempts to address and falls short of responding to the societal/cultural milieu in which it is situated. Before proceeding, a caveat is in order.
Having worked as a medical educator for thirty years, I know from first-hand experience as well as the professional literature that the vast majority of students enter medicine motivated by idealism and the desire to help others. I also know that it is the conscious intention of most of the medical educators who are my colleagues within my own institution and around the country to produce graduates who are empathic and caring as well as competent. Further, I am aware that after emotional "peaks" of cynicism and disillusionment in third year and then again during internship, many physicians-in-training find their way to assuming an empathic stance toward their patients. I do not dispute or question any of this; and as a patient I am very glad for it. However, I do maintain that the philosophical structures and assumptions of medicine do not provide adequate guidance in this pursuit; and therefore trainees are often forced to stumble forward under the catch-as-catch-can mentorship of individual physicians who themselves have haphazardly discovered how to draw nearer to their patients. Therefore, my argument below is offered within the context of respect, affection, and esteem for practicing physicians on the front lines of medicine; and the conviction that the educational system can provide them with much better support and direction in cultivating a path toward empathy.
Modernist medical practice grounded in the assumptions of the scientific method addresses the contradictory human impulses of approach and avoidance toward illness and suffering in unique ways. The explicit goal of medicine has always been to prepare its practitioners to draw closer to their patients, with the intention of providing understanding and assistance. But in the modern era, "drawing closer" is mediated by technology: instead of observing and touching the patient directly, scientific advances often substitute technological intimacy for personal closeness. Understanding is translated as diagnosis and prognosis; and assistance becomes treatment and intervention.
It has been noted [77
] that science requires a high level of abstraction to successfully promote theory and the testing of theory. Yet such abstraction, while advancing scientific development, encourages a tendency to think about reality from an exclusively abstract perspective, and to overlook the fact that it necessarily omits other aspects of reality that cannot be accommodated by scientific theory. An inadvertent byproduct of this "spirit of abstraction" is that what is not encompassed by or derived from the scientific paradigm is viewed as secondary, subjective, and unreliable. In medicine, such "unimportant" dimensions usually include all the patient's subjective experiences and reactions. In this sense, modern medicine promotes a kind of scientific
altruism (cf. [78
], "cognate professionalism") that still encourages approaching the patient, albeit as an object of interest, rather than a sympathetic subject. The fear and vulnerability underlying withdrawal are addressed by efforts at mastery and control.
In some respects, the modernist discourse that shapes current medical practice challenges the moral meaning of illness. Modern biomedical discourse focuses on disease conceived in terms of pathophysiological mechanisms, not punishment from God, or signs of moral weakness. Working within the modernist paradigm, Susan Sontag famously exposed the damaging effects of the metaphors that attach to stigmatized illnesses such as cancer and AIDS [79
]. Modern medicine, by reducing illness to its scientific foundation, ostensibly removes moral judgment.
However, the reductionism and objective positivism that underpin medicine are not morally neutral. Its goals of solution, restitution, and restoration both emerge from and reflect western cultural fears of contamination, impurity, and death, Thus, the "cleanly mechanistic view" that science attempts to impose on suffering actually runs the risk of reducing the patient to a disease, an object, a practice that enhances controllability and safety but reduces empathy.
Obviously, infection and contagion have biomedical meanings, and in this regard, modernist contributions in the public health sector such as clean water, waste disposal, hand-washing, use of antiseptic, and even quarantine, have been invaluable in improving population and individual well-being. However, as with much in the modernist paradigm, conclusions that are sensible and useful from a scientific/medical perspective become unconsciously extended to the social sphere with more disturbing results.
The dichotomization of health from illness [81
], and the presumption that illness can be eradicated or cured, for example, have produced invaluable breakthroughs in terms of alleviating and ameliorating physical suffering. However, these assumptions have also inadvertently transformed medicine into a vast enterprise to protect the healthy from the ill, to reassure the healthy that they will not become ill; or if they do unfortunately cross over into the kingdom of the sick [79
], to ensure that they can be fixed and returned to normalcy. Disease that conforms to a modernist restitution story is more easily acceptable and less frightening. In the Parsonian view of illness [63
] productive workers who become ill are allowed a temporary respite from societal obligations while they are restored to their previous good health, and therefore are once again able to assume their productive function (work). Illnesses that do not fit this paradigm become frustrating and frightening because they suggest restitution is not always possible. Because of the increasingly large number of patients with chronic illness in the U.S. [82
], more and more individuals find themselves in this liminal state [83
]. It is patients in this category who are most at risk from withdrawal and separation by their physicians, especially physicians in training.