The field of medicine has a long and rich tradition in human history. The need and desire to heal the body would seem to be natural and basic to the human condition in which we find ourselves. The human body is subject to an apparently almost endless variety of injuries and diseases. Almost from the first moment of consciousness a child begins to experience, without fully understanding what is happening, the possibility of pain, injury, and illness--in short, the possibility of a lack of wholeness (health) in the body. However, the child also experiences a corresponding reality: pain can go away, injuries can heal, and the body can overcome illness. Being from the beginning within human community, in the presence of the other, the child also experiences the possibility that an "other" sometimes can "make it better." Already in this primitive experience we can see the roots of the vast area of human endeavor we think of as the field of medicine. Moreover, also revealed in this experience is the truth that from the very beginning we can see the art of healing taking place precisely in the context of human relationship. It therefore should not surprise us that the personal relation of the healer and the one to be healed, the physician and the patient, has taken such a foundational, and almost sacred, place in the tradition of medicine.
The roots of modern medicine in the West are generally traced to the ancient Greeks. Hippocrates is often identified as "the father of medicine." Thus, even though on the surface the practice of medicine today obviously looks very different from the practice of the Greeks, modern medicine still tends to be seen as in some sense participating in a tradition and a line of work in basic continuity with ancient Greek medicine, as well as those who worked in and developed the field in the centuries between the ancient world and the present day.
However, much has changed between the world of the Greeks and the modern world. The changes are not limited to things such as the development of new methods in healing, or the expansion of scientific knowledge. The philosophies that ground the modern world, including modern medicine, are very different from the philosophical tradition of the ancient Greeks. In light of this, it is reasonable to question whether or to what extent modern man can be and act in continuity with the Greeks in any area. Is the medicine of today truly in continuity with the tradition of medicine rooted in the Greeks, or is it a new product of modernity? Furthermore, to whatever extent medicine is inevitably shaped by modern philosophical presuppositions, can the relationship of physician and patient maintain its significance in the context of modern medicine?
The word "physician" comes to us from the Greek word φυσις (physis), generally translated as "nature." In this case, etymology does not mislead us. For the ancient Greeks, the concept of physis became key for the field of medicine. The physician exists fundamentally at the service of nature. Werner Jaeger speaks of physis as the "dominating conception" of Greek medicine. [1] The concept of nature grounded a number of important aspects of Greek medicine. Perhaps most importantly, physis implied something universally given. For the Greeks there is a sense of the natural, and in that sense normative, in the universe as a whole, and in the human body. There is something which the human being simultaneously already is, and ought to be, and is interiorly moved towards at all times, and physis is the source of this motion. There is thus a notion of health as a normal wholeness to which medicine as a field is subordinate. For Plato, the task of the physician is the restoration of the normal state of the body, guided by an understanding of the nature of the body. [2] Health is natural, and the state towards which nature tends. Plato refers to an eros for health in the body, the promotion of which is the work of medicine. [3] For the Greeks generally, the "doctor does not treat a sick man by interfering with nature. Symptoms of illness ... are actually the beginning of the process by which the normal state is restored. The process is initiated by the body itself, and all that the doctor need do is to watch for the point where he can step in to help the natural urge of self-healing. Then nature will help herself." [4] Thus there is an intrinsic end, a telos, for medicine. Nature herself has purpose. The physician is to assist, and in that sense participate in, the movement drawn toward that purpose in the body. [5]
Physis, as understood by Aristotle, is a source of movement and rest interior to the thing itself. Nature indicates a oneness and wholeness based on interiority in the thing itself. (Ultimately form accounts for this in all things in Aristotle, but for him it clearly is living things that have natures that possess interiority and wholeness in the most proper sense.) [6] Therefore, if the physician is to serve physis in the human body, he can only do so properly by respecting human interiority and wholeness. The body is an organism, and an organism is not just a collection of parts. Thus, the human being must be treated as a unified whole, and health in its fullest sense applies only to the full human. The mission of the physician, then, must be understood as directed to the human as bodily, not to separate physical parts. This holistic understanding of the body, in turn, can only be based on an understanding that there is something interior to the body that unifies it as a body. The human body only is the human body by virtue of this interiority. Therefore, the physician who serves nature, even as he enters fully into the countless details of the body, never leaves behind the relevance, and indeed the primacy, of interiority.
In light of what has been said about the role of the physician, what is the role of the patient? Here, too, etymology seems to open the door to insights. The word "patient" derives originally from the Latin verb patior (and a set of related words), which itself was connected to the Greek πασχω. These words carry meanings of suffering, enduring, bearing, undergoing, experiencing, permitting and allowing, as well as patience in the English sense. [7] That same Latin root also gave us the word "passive," but the meanings of the original Latin word here word obviously cannot be reduced to mere activity or passivity in the modern sense. (It is interesting to note in passing that in Latin this is a deponent verb, so that the active verb has a passive form.) The medical patient is, of course, one who undergoes treatment. However, this undergoing is not merely a passive "being done to." The patient receives from the physician, and permits the physician to act, and such reception and permission are not simply passive. Most fundamentally, of course, the patient is also active in the sense that the whole motion involved in healing originates interiorly in the patient. The whole field of medicine, in a certain sense, begins and ends in the patient. Indeed, the physis which the physician is to serve is not only nature in general, but the nature of the patient. It is therefore obvious that the patient participates in the work of medicine. In fact, it might be truer-more respectful of the priority in reality-to say that medicine participates in the work of the patient. The physician is more perfectly a physician the more completely he places himself and his action at the service of the patient, precisely as patient, and a fortiori as a human being with a nature.
The focus to this point has been, and will continue to be, on the physician-patient relationship in medicine. This is not intended to emphasize this relationship in an isolated way. Obviously many people may foster the health of others in a variety of ways, and in this sense participate in the physician-patient relationship. The physician-patient relationship is emphasized here as paradigmatic, not exclusionary. At the same time, it has already been indicated that it is natural for healing to take place in the context of human relationship, and such a relationship must be personal. The physician-patient relationship cannot be duplicated through a physician-physician-physician-nurse-physician's assistant-nurse-nurse-nurse-patient "relationship." In fact, it is perhaps the unified care that the physician can give to the patient as a whole that is most distinctive about the traditional role of the physician. However, throughout the reflections here, it should be remembered that the roles of the physicians and patient as they have been defined here in a certain sense represent broader roles, in which everyone can, and perhaps must, participate in some ways It would seem that everyone needs human assistance in some way in healing and in maintaining health, and certainly everyone is to serve physis not only in themselves but also in others.
Everything that has been said to this point about physicians, patients, and the nature of medicine depends on a philosophy based in an understanding and appreciation of nature as given interior source of wholeness and movement. However, in modernity there has been a progressive loss of any sense of nature. Already with Isaac Newton, there is a general reduction of the sense of motion to mechanical locomotion. The difference between movement which is natural and movement which is against nature (in other words, violent movement) is lost. From this point on, "Nature is no longer the inner principle out of which motion follows." [8] In contemporary thought, where any meaning is attributed to nature, it is often assumed to refer to the world of "stuff" as opposed to an unrelated (and perhaps non-existent) spiritual or supernatural world. As such, nature can no longer refer to anything normative in any sense of the word. From such a perspective, it no longer makes any sense to speak of serving nature. Such a phrase becomes meaningless. Indeed, even those who wish to speak meaningfully about respect for nature find themselves unable to do so, because the "nature" they describe has clearly departed from the Greek conception of physis. Thus, even with the best of intentions, modern attempts to articulate a position that takes account of nature may end up speaking somewhat vaguely of a "respectful attitude" towards nature as given. One can hardly blame those behind such attempts for failing to commit themselves to the service of nature when one finds that their understanding of what is given as natural apparently includes "smallpox and malaria, cancer and Alzheimer disease, decline and decay," as just as natural from a human perspective as a healthy human body. [9] It seems to be impossible within the terms of modernity to speak of any sense of a given human nature, carrying an "ought to be" within itself and corresponding to the Greek notion of physis. The consequences of this for medicine are catastrophic. Indeed, if medicine is understood as the Greeks understood it, the consequence of a loss of the sense of nature is the self-annihilation of medicine. Medicine itself becomes meaningless in some sense, because it has lost the basis for its inherent worth and direction.
If there is no nature for medicine to serve, then the physician is not truly engaged in healing, as in making whole, the patient. The physician and patient are no longer united in a common mission. Rather, the physician is providing the patient with a product which the patient wants. (In contemporary language one could say that the physician is providing a "service" the patient wants, but this language is already somewhat misleading. When the grounding for a sense of serving someone or something is lost, even those things which are called services are in reality products.) To put it in Aristotelian terms, neither formal nor final causality remains operative in the practice of medicine. The patient is no longer a patient, but a consumer. The devastating impact of this shift must not be underestimated. If the patient is a consumer, then the physician is no longer a physician at all, but a provider of an undefined product or service designed to meet a market demand. Thus, the modern (dare one say depressingly modern) term "health care provider" is tragically accurate, except that the words "health care" no longer have any real foundation. The fact that physicians provide products related to the body is ultimately only a function of what happens to be their area of expertise. With the redefinition of the physician-patient relationship as a producer-consumer relationship as described here, the physician or producer no longer has any defined mission.
In light of this loss of specific mission it seems it can hardly be a coincidence that one of the most common modern replacements for the Hippocratic Oath is, compared to the original, so lacking in specifics of what a physician should or should not do, precisely as a physician. The Hippocratic Oath commits the physician to avoiding certain actions, even if there is a demand for them: "I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy." [10] The modern oath has a passage which seems intended to correspond to this section of the Hippocratic Oath: "Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty." [11] The relative vagueness of this passage can hardly be unintentional, and it is all the more striking because it presumably represents an ambiguity in the medical field itself. This modern oath was written in 1964, years before the Roe v. Wade decision, and long before any serious consideration of the legalization of euthanasia. It would be easy to descend immediately into ethical analysis of why abortion and euthanasia or assisted suicide are wrong, and perhaps proceed from there to moral outrage that these practices have become or are becoming part of the medical profession, of all things. Indeed, such reactions may well be necessary and appropriate in their own way and their own place. After all, as Justice Antonin Scalia remarked in his dissent from a recent United States Supreme Court decision related to euthanasia, "if the term legitimate medical purpose has any meaning, it surely excludes the prescription of drugs to produce death." [12] This seems to exemplify a common argument among those with ethical objections to euthanasia, abortion, and so forth. However, such an argument precisely relies on a premise that is impossible to maintain without an acceptance of a philosophy of nature. It is of paramount importance to recognize the deeper philosophical problem, and thus to understand that modernity leaves no foundation on which such actions can be separated from the work of medicine, let alone morally condemned. In modernity, the phrase "legitimate medical purpose" does not and cannot have any meaning, although admittedly most medical providers and medical consumers presumably do not understand this yet, or have not realized its full implications. Abortion and euthanasia are procedures involving the human body, and from a purely technical perspective medical doctors are clearly the best-qualified people to perform these procedures competently. If there is a consumer demand for these products, then why should doctors not provide them?
As has already been indicated, the loss of the sense of nature radically changes the role of the patient as well as the physician. If the original relation between physician and patient is a real relation that involved the depths of their being, then it is inevitable that both roles must always change together, and if one role is destroyed the other dies as well. Indeed, the philosophical difficulties in modern medicine which have been articulated in terms of a loss of the sense of nature perhaps can almost be summed up entirely in terms of a loss of the sense of the dignity of being patient. A liberal perspective (taking "liberal" here in the broad sense, including classical liberals) might expect that patients, by becoming consumers, are actually elevated. After all, they now become more fully choosing agents. In practical terms, the type of service they can get from a physician is now no longer limited by some concept of nature. It has already been mentioned that abortion and euthanasia are now potentially products which can be obtained from doctors, and perhaps from a liberal point of view that is appropriate. However, admittedly these two examples are widely controversial moral issues. There obviously can be other instances of the triumph of consumer choice which, at least at first glance, seem far more benign. One could choose any number of examples here, and with the advancement of biotechnological possibilities for "improving" human beings there will doubtless be many more in the future, but perhaps the most obvious illustration from the perspective of the consumerization of medicine is a simple one: the explosive growth of the elective plastic surgery industry. In the traditional Greek conception of medicine, plastic surgery would clearly be a departure from the proper role of the physician, except perhaps in the case of certain injuries, burns, perhaps major deformities, and so forth. If the person is already whole in their human nature, the only proper work for the physician is to assist in maintaining that state of wholeness, not to interfere with nature to provide a body shaped to order. The modern medical consumer, though, can easily obtain this product from a modern physician as producer. The patient is thus empowered, in the sense of being able to fulfill a greater range of possible choices. Thus, individuals can get what they want from modern medicine while, from the point of view of many, no one is hurt. However, this assessment that no one is hurt already assumes that the loss of the dignity of that which is patient is not a loss at all.
The example of plastic surgery also illustrates another aspect of what has happened to the patient in modern medicine, by indicating a new conception of the patient in terms of mechanical "stuff," which may be shaped and manipulated at will. There is no interior nature with which the action of the physician must cooperate. Thus, in a sense the patient now truly is "passive" in the modern meaning of the word. The patient contributes nothing other than the material on which the doctor acts. The patient is now only "being done to," as it were, because the physician is not participating in a movement rooted interiorly in the patient. Such an approach, even if it is in some sense serving the choice of the patient, utterly destroys the intrinsic value of the person who is the patient. Instead of affirming the being of the patient as already good, this view sees the patient primarily as an object which can be made good. The patient can be engineered as a machine would be. The role of one who works with the human body is thus essentially the same as that of the engineer. This is consistent with the increasing tendency in modernity to understand the reality of the human being explicitly as a machine. Thus, as Wendell Berry points out, biologist and self-identified "humanist" E.O. Wilson can write without recognizing any inconsistency that "people ... are just extremely complicated machines," and the "surest way to grasp complexity in the brain, as in any other biological system, is to think of it as an engineering problem." [13]
Within the logic of modernity, medicine is thus radically transformed into a consumer industry dealing with engineered products. This new version of the field of medicine finds its dominant form in the modern hospital. The very fact that the hospital has become the primary location associated with the practice of medicine is in complete accord with the logic of modern medicine which has already been laid out here as it relates to the physician-patient relationship. It can hardly be a coincidence that the encounter of one physician with one patient, in the home of the patient, has almost disappeared. If the patient is only a consumer, and on another level only a machine, there is no reason any importance should be attached to personal encounter. The loss of personal encounter is also part of the structure of hospital medicine in terms of efficiency and economies of scale, which are values that very logically dominate in a consumer engineering industry. In this context it is also unsurprising that the scale ultimately goes beyond even the level of the hospital, and there is nothing inconsistent about the dictation of medical decisions by "health maintenance organizations" or others who are not even in a position to be in contact with the patient as person.
A predictable consequence of the industrial nature of the modern hospital is the lack of regard for elements which are placed artificially outside the realm of medicine, particularly elements which contribute to a natural setting for human life. For example, Wendell Berry has noted the odd lack of concern with the quality of food served in hospitals. Doubtless many hospitals have professional nutritionists on staff. However, the fact remains that the food in hospitals is generally expected to be bad; "hospital food" is not a complimentary term. Of course, one could dismiss this as a typical characteristic of large institutions, but this does not really explain the issue, but only confirms that we generally choose to treat human health as something that can be handled on the terms of massive institutions. In light of the obvious centrality of nutrition for health, it seems inexplicable in human terms that account would not be taken of the importance making nutrition not only available but naturally attractive to the patient. This simple point, which may seem laughably minor by itself, is one aspect of a much broader truth. The hospital as we experience it is not hospitable. It is not welcoming. It is not a natural human environment. Indeed, it is difficult to imagine a more artificial environment. It seems to be in the very nature of the hospital that people are not truly comfortable there, and not merely because they may be ill. No one feels at home in a hospital. Only with a mechanized understanding of the person can such concerns be dismissed as irrelevant to the health of the person as a whole. [14]
A particularly significant, indeed perhaps paradigmatic, realization of the depersonalization of the patient in the modern hospital is the disregard for patient modesty. This of course is both a symbol and logical consequence of an attitude that regards the body as mere stuff. If medicine need only concern itself with the body understood in a mechanized way, then in the context of the consumerization of the medical field, it is perfectly logical in a sense that concern for patient modesty would fall by the wayside. Modesty is specifically a reality which protects the well-being of the person as a whole. A dualistic view of the person, or any view of the person which reduces the person to only a body in the modern sense, cannot provide a proper grounding for claims about the importance of modesty. From such a perspective, any time, effort or attention given to modesty, or for that matter to the dignity of the patient in any respect, is a useless inefficiency, utterly pointless unless it is absolutely demanded by the patient. In a consumer industry governed by a logic of delivering the minimal acceptable product at a profit, such inefficiencies are not only unnecessary but unacceptable. (It is interesting to note that this is not mere theory. This issue has been treated in exactly this way when the medical disregard for modesty has been challenged, not by modern Christians, but by Muslims. Notice was taken of the challenge only when it became apparent that some potential patients were simply refusing to enter the hospital, and at that point it was framed in terms of individual embarrassment, not an issue affecting human dignity. Moreover, of course the priorities of the industry remain primary, as a reporter dutifully noted with a revealing choice of words: "In some situations ... it's more important to put the interests of doctors and nurses ahead of the interests of patients.") [15]
It also seems that modesty has a specific link to respect for that which is characteristically patient. The roots of the word "patient" examined earlier imply a sense of vulnerability, and modesty seems to be particularly associated with reverence for and protection of a vulnerability involved in the receptivity of the body. (This is perhaps why concern for modesty has generally been associated more with the feminine.) The medical patient, as patient, is in a role of receptivity, and certainly in an obvious way of vulnerability. Attacks on modesty in a hospital setting, however unintentional they may be, powerfully symbolize and embody the destruction of the dignity of that which is patient.
There seems to be some contemporary recognition that the primacy of the patient has been lost and needs to be restored. Thus, at first glance it may seem that the problem of protecting the dignity of the patient is one that is already being addressed in discussions within the medical field. One can certainly find literature on the importance of the role of the patient in medicine. However, this is not in fact as encouraging as it may seem. Popular advice can be found recommending that patients assert themselves more in the process of their care, reclaim power from doctors, and control their own destinies. [16] A recent cover story in a national magazine offered tips on knowledge doctors have which patients can use to "work the system" (the words of the article) more knowledgably to ensure that they get effective care. [17] Regardless of whether such measures may sometimes be necessary for persons within the medical system today, they are not "patient." One finds physicians as well, when discussing the importance of respect for the primacy of the patient, interpreting such respect in terms of a need to "empower patients," to create more autonomy for patients in making decisions, and to educate patients so that patients can "make informed choices" rather than give "passive consent." [18] Of course, educating patients is a worthy goal and a legitimate part of the work of a physician. After all, Plato himself describes the free doctor treating free patients as educating his patients on their condition, while the slave-doctor explains nothing. However, for Plato the aim of this is true education, not the production of a more informed agent of choice. [19] The dignity of the patient is not based on the ability to exercise consumer choice, so the solution for a lack of respect for the patient cannot be that the patient should become a better consumer. Approaches which seek a solution by that path cannot solve the problem, but rather end up embodying the problem, by implicitly rejecting any consideration of a notion that patients need to be patients, and need to be allowed to be patients, treated as patients, respected as patients, and served as patients.
There are also purported attempts in society to protect patients from a legal or juridical perspective. Anyone who follows contemporary political debates will be familiar with the notion of "patients' rights," and efforts to establish a "patient's bill of rights." However, such immediate appeals to the language of rights indicate that we have already left the realm of the patient properly speaking. These approaches imply that a proper relation between physician and patient can be restored by defining it in terms of some type of contract. Contracts obviously are a reality of this world, and presumably have a valid place in human life. However, any relation which is understood to be defined exhaustively as contractual is necessarily reduced. In fact, it is reduced to a relation which is not real, a relation understood in nominalist terms as posited arbitrarily by individuals. Such a "relation" can be defined in any way agreed upon, and thus intrinsically it is not equipped to resurrect a real relationship that has been undermined philosophically.
It also should at least be acknowledged briefly here that various contemporary streams of "natural" or "holistic" medicine may sound as if they would offer precisely what modern medicine lacks in itself. It is true that the field of medicine needs to be natural and holistic, in the proper sense of those words. However, using these words is not the same as participating in these realities. Much of what passes for natural and holistic medicine today, whatever positive aspects it may offer, itself clearly appears to be participating in what is primarily a consumer industry. As such, it is not a restoration of a sense of serving the authentic physis of a patient. To put it in concrete terms, if the primary response to human depression is a pill, there is no fundamental change in approach merely because that pill is the St. John's wort herb rather than Prozac.
The objection will no doubt be made by some that this entire critique of modern medicine is patently nonsense. Countless doctors and others involved in the medical field clearly are seeking to heal people, to "make people better." Moreover, in modern medicine perhaps more than any other field, any critique of the presuppositions and methods of modernity will inevitably be met by the objection, "But it works." Indeed, it would seem that it does work, and works spectacularly well. The accomplishments of modern medicine can be awe-inspiring, particularly when contrasted with the comparatively tiny scope of the knowledge and abilities of pre-modernity in this area. It seems that nowhere have the methods of the modern sciences delivered on their promises as impressively as in the field of medicine. If the doctor of today is in some sense a technician or engineer, he is nevertheless one who performs great wonders. To his pre-modern counterpart, the modern doctor might well appear more like a magician performing unimaginable feats that resemble miracles. Moreover, the end result of all this advancement seems clear. More people live longer lives in this new era than beforehand. Whatever one says about nature, surely the body cannot participate in its nature if the body is dead, and no longer exists as a body. If the end of medicine lies in the life of the patient, is not the field of medicine today fulfilling its mission more perfectly than ever?
The response to such objections is not simple. First of all, they are not simply false. No one should wish to deny the sincerity, not to mention the enormous value, of the efforts of modern medical professionals. However, this does not change the reality that modernity lacks the grounding for any notion of healing. The signs of this absence are ever more abundant. It is true that much good has come in the modern technological development of medicine. However, it has been argued here that by its very nature the modern approach to medicine also gives rise to serious problems, and perhaps to its own disintegration. Nor are such problems invisible, or confined to the minds of philosophers. Everyone recognizes that the "health care system," which in many respects seems so capable, is itself severely ill. (One may pause here to note in passing the fact that in the contemporary debate we commonly use mechanistic words such as "system" and "broken" to describe our health care, indicating an instinctive recognition of our understanding of medicine.) Even a casual observer can notice symptoms such as the almost universal inability to afford health care, the continual litigation of medicine in malpractice lawsuits, the emergence of diseases resistant to the very antibiotics that were so important to the success story of modern medicine, and dissatisfaction among doctors and patients alike with the dominance of bureaucracy in medicine. The list could go on.
In regard to the advances which a mechanical view of medicine has brought, these too should not be denied, and are not surprising when one remembers that, since nature truly is a given, human beings continue to participate in nature even as we deny it. No one who has had a loved one cured of a disease, perhaps given a longer life, through the methods of modern medicine, can refuse to acknowledge an incalculable debt to this form of medicine. At the same time, as Martin Heidegger wrote, "the fact of not dying, in the sense of prolonging one's life, is not yet necessarily the recovery of health. The fact that people live longer today is no proof that they are healthier." [20] As important as prolonging life can be, medicine must aim at health, as in a natural human wholeness, and refuse to settle for a definition of medicine that reduces it only to prolonging life.
Even some of those inside medicine today have come to a realization that the methods most characteristic of modern health care can themselves be problematic on their own terms. Donald Berwick, a pediatrician who heads the Institute for Health Care Improvement, has noted that "the areas in the U.S. with the highest rates of use of hospital beds, intensive-care units, specialist consultations and invasive testing don't have the best quality of care and outcomes ... In fact, they often have the worst. ... new technologies and hospital stays can sometimes harm more than they help." [21] However, while such problems are widely recognized, they are just as widely conceived as individual problems, to be addressed within the terms set by modernity. The solutions proposed for these problems are almost inevitably superficial, and typically political and juridical. For the most part, the problems do not provoke any recognition that the philosophy behind modern medicine may need to be re-examined. Such a recognition, of course, would require a prior understanding that there must be a philosophy underlying modern medicine in the first place.
If modern philosophy dismisses nature, and thus destroys the dignity of the patient, and the mission of the physician, how should we move forward? What would medicine look like if physicians were once more servants of physis? In one sense, it is impossible to answer this question. Such a question can only be answered in the reality of human history, and it is impossible to describe in detail in advance what such a conversion would look like. However, certain indications of directions are apparent from the critique of modern medicine up to this point. Clearly, healthy ways of being are to be found in the direction of the personal rather than the institutional, an understanding that is natural rather than one that is mechanistic, the holistic rather than the fragmented, and the relational rather than the isolated. Wendell Berry speaks of the modern hospital as a place where the world of love meets the world of efficiency. [22] In those terms, despite the benefits that the world of efficiency can offer, whether real or apparent, the rediscovery of an authentic medicine will require a primacy of the world of love.
It may seem at first glance (or perhaps even at second and third glance), that to suggest such directions is wildly unrealistic. Our society has enough difficulty paying for health care as it is, even with a high priority placed on efficiency. It seems that we must move in the direction of an even greater emphasis on efficiency in medicine. Of course, one might respond that it appears to be the world of efficiency that has given us this unaffordable system. Nevertheless, the claim can be made that basic economic realities seem to dictate the triumph of the efficient. As Berry points out, such claims are part of a common theme in contemporary culture, but they are ultimately opposed to serious thinking:
When you read or hear those words "larger" and "more efficient" you may expect soon to encounter the word "inevitable" ... This way of talking is now commonplace among supposedly intelligent people, and it has only one motive: the avoidance of difficult thought. Or one might as well say that the motive is the avoidance of thought, for that use of the word "inevitable" obviates the need to consider any alternative, and a person confronting only a single possibility is well beyond any need to think. [23]
Thus, such talk of inevitability ultimately only attempts to ignore the necessity of first finding the truth, and then living the truth as best one can in the setting in which one is called to live. This effort must be prior to a consideration of what seems "necessary" from the perspective of the world of efficiency.
Each person involved in some way with the field of medicine (which will be almost every person at some point and in some way) must attempt to live out a cooperation with physis in his or her own circumstances. This can only be carried out in a fruitful way through the prudence of individual persons. Of course, part of the tragedy of the situation in the field of modern medicine is that a particular person entering the contemporary medical system literally cannot be either a physician or a patient in the fullest sense. It is simply impossible within the terms of the system. The physician and the patient are both realities defined in terms of relation, and when the grounding for that relation disappears both realities of necessity disappear with it. However, this does not mean that one cannot participate in these realities to a point. Physicians in particular, of course, can try to live out, to the extent possible within modern medicine, a service of physis and a respect for the truly patient.
In the end, what is needed in modern medicine is not so much any one specific action, as change in the philosophical approach to the world, and ultimately the theological approach to the world. Perhaps the most apparently irrelevant passage of the classical Hippocratic Oath in the contemporary world is the beginning, with its invocation of ancient pagan gods: "I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses ...."[24] However, this opening line is fundamental to the meaning of the oath, not just as a generic oath, but specifically in its significance for medicine. Moderns would not necessarily duplicate the significance of this passage even if they swore before "God," as a way of affirming the truth of their statements. The point here is not to suggest that physicians should swear by pagan gods. Obviously, the Greeks were wrong in recognizing a variety of gods corresponding to various aspects of reality. However, beneath their ultimately incoherent polytheism, their appeal to specific gods here reflects the recognition of a fundamental truth: the immediate relationship of the divine, of the "greater-than-I," to every aspect of reality. These words locate medicine directly within a reality greater than itself, subject to authority above itself. It is within this context that physis can take on the significance it does as what is given in reality as we experience it. The sense of nature present in the Greeks which was discussed earlier is only coherent within an understanding of the world such as this, where there can be something given which no person, doctor or patient, can violate while still remaining true to their own being. What one believes about God and the relationship between God and the world has an intrinsic relationship to how one conceives of medicine, and of the physician, and of the patient.
Bibliography
Berry, Wendell. "Health is Membership." In The Art of the Commonplace: The Agrarian Essays of Wendell Berry. Edited by Norman Wirzba. Washington, DC: Shoemaker & Hoard, 2002.
________. Life Is a Miracle: An Essay Against Modern Superstition. Washington, DC: Counterpoint, 2001.
Beyond Therapy: Biotechnology and the Pursuit of Happiness. A Report of the President's Council on Bioethics. New York: Dana Press, 2003.
Coulter, Angela. "After Bristol: Putting Patients at the Centre." BMJ (British Medical Journal) 324, 16 March 2002, 648-651. Available at
Edelstein, Ludwig. The Hippocratic Oath: Text, Translation, and Interpretation. Baltimore: Johns Hopkins Press, 1943.
Foreman, Judy, "How to Retain Control While in the Hospital." 18 December 2001.
Gibbs, Nancy and Bower, Amanda. "Q: What Scares Doctors? A: Being the Patient." TIME 167:18, 1 May 2006, 43-47.
Heidegger, Martin. "On the Essence and Concept of Φυσις in Aristotle's Physics B, I." Translated by Thomas Sheehan. In Pathmarks. Edited by William McNeill. Cambridge: Cambridge University Press, 1998.
Jaeger, Werner. Paideia: the Ideals of Greek Culture. Translated by Gilbert Highet. Volume III. The Conflict of Cultural Ideals in the Age of Plato. New York: Oxford University Press, 1986.
Plato. Symposium. Translated by Robin Waterfield. Oxford: Oxford University Press, 1994.
Sachs, Joe. Aristotle's Physics: A Guided Study. New Brunswick, NJ: Rutgers University Press, 1995.
Simpson, D.P. Cassell's Latin Dictionary. Fifth Edition. New York: MacMillan Publishing Company, 1968.
Notes
[1] Werner Jaeger, Paideia: the Ideals of Greek Culture, trans. Gilbert Highet, vol. III, The Conflict of Cultural Ideals in the Age of Plato (New York: Oxford University Press, 1986), 6.
[2] Ibid., 22.
[3] Plato, Symposium, tr. Robin Waterfield, in Plato Symposium (Oxford: Oxford University Press, 1994), 188c.
[4] Jaeger, 28.
[5] Ibid., 27-29.
[6] Aristotle, Physics II:1, trans. Joe Sachs, in Aristotle's Physics:A Guided Study (New Brunswick, NJ: Rutgers University Press, 1995), 49-51.
[7] D.P. Simpson, Cassell's Latin Dictionary, fifth ed. (New York: MacMillan Publishing Company, 1968), 427; Online Etymology Dictionary
[8] Martin Heidegger, "Modern Science, Metaphysics, and Mathematics," in Basic Writings, ed. David Farrell Krell, second ed., (New York: HarperCollins, 1964), 288.
[9] BeyondTherapy: Biotechnology and the Pursuit of Happiness, A Report of the President's Council on Bioethics (New York: Dana Press, 2003), 325-326.
[10] Hippocrates, "Hippocratic Oath," translation from Ludwig Edelstein, The Hippocratic Oath: Text, Translation, and Interpretation (Baltimore: Johns Hopkins Press, 1943). Available at
[11] Louis Lasagna, "Oath of Lasagna," Hippocratic Oath-Modern Version
[12] Antonin Scalia, Gonzales v. Oregon, dissent, Supreme Court of the United States, 17 January 2006, available at Legal Information Institute:
[13] E.O. Wilson, Consilience, quoted in Wendell Berry, Life Is a Miracle: An Essay Against Modern Superstition (Washington, DC: Counterpoint), 46-47.
[14] Wendell Berry, "Health is Membership," in The Art of the Commonplace: The Agrarian Essays of Wendell Berry, ed. Norman Wirzba (Washington, DC: Shoemaker & Hoard, 2002), 150-151.
[15] "Revealing Hospital Gowns Redesigned," Associated Press, 17 August 2004,
[16] Judy Foreman, "How to Retain Control While in the Hospital," 18 December 2001,
[17] Nancy Gibbs and Amanda Bower, "Q: What Scares Doctors? A: Being the Patient," (TIME 167:18, 1 May 2006), 44.
[18] Angela Coulter, "After Bristol: Putting Patients at the Centre," (BMJ (British Medical Journal) 324, 16 March 2002, 648-651). Available at
[19] Jaeger, 12.
[20] Martin Heidegger, "On the Essence and Concept of Φυσις in Aristotle's Physics B, I," trans. Thomas Sheehan, in Pathmarks, ed. William McNeill (Cambridge: Cambridge University Press, 1998), 197.
[21] Gibbs and Bower, "What Scares Doctors," 46.
[22] Berry, "Health is Membership,"153.
[23] Berry, Life Is a Miracle, 53.
[24] Edelstein, Hippocratic Oath.