Professional Virtues in Modern Medicine
the 'person' of 'whole person' medicine
what is a person?
What is a ‘person’? How do different conceptions of ‘whole person’ or ‘person centred’ care conceive of the person, and does medical generalism presuppose a particular conception of personhood? Questions about the nature of persons have received the focused attention of philosophers over a long period of time. So have questions about the nature of the ‘self’. These questions are no less relevant to medical generalism, with its emphasis on respecting the person and integrity of the self in whole person care.
For present purposes, the four most directly relevant philosophical approaches to the self or person are the following:
the dualist view
This view of the self is associated with the French philosopher René Descartes (1596-1650). For Descartes, a person is a union of two distinct things: body and soul. The soul is the true self. It is one’s thinking self – the thinker of one’s thoughts – and wholly immaterial. The soul or thinking ‘I’ has none of the spatial properties of material objects like tables. It is not extended in space and has no shape. It is, however, intimately related to something that does have spatial properties: the thinker’s own body. One’s body is a material thing, a corporeal object among corporeal objects, but does not think. For Descartes, nothing material can think, not even a brain.
Although body and soul are distinct, Descartes realized that the two are intimately connected. Having a body with bodily sense organs and limbs enables the soul to perceive and act. The body is also where bodily sensations like pain are felt. Despite being tied to a particular body, the soul is a separate thing that can outlive the body. The soul is immortal, the body is not.
This view of the soul and its relationship to the body underpins many religions. The philosopher Derek Parfit argues that many non-philosophers believe something like Descartes’ view of the relationship between body and soul. In Parfit’s terminology, we tend to think of ourselves as separately existing entities, distinct from our brains and bodies. Parfit rejects this view on empirical grounds. Other philosophers argue that Descartes’ view is not just false but incoherent. Although Cartesian dualism has few takers nowadays in academic philosophy, it is still a significant view if Parfit is right about its popularity outside the academy. For among those who believe that they are embodied souls will be many of the medical generalist’s patients.
the mental capacity view
In his Essay Concerning Human Understanding (1689), John Locke proposes what is still the single most influential philosophical account of personhood and personal identity. For Locke, a person is a thinking, intelligent being that can reason and reflect and consider itself as itself. To be able to consider oneself as oneself is to have self-awareness, and this is essential to personhood as Locke conceives of it. To be a person, for Locke, is to have certain mental capacities. Anything that has those capacities is a person. Anything that lacks them is not.
Among the striking consequences of Locke’s view, one is that personhood is not confined to human beings. Any being, human or otherwise, that has the relevant mental capacities is a person. If a dolphin can reason and reflect and has self-awareness then it is a person. Locke’s approach also implies that not all humans are persons. A baby that has not yet acquired the necessary mental capacities is not yet a person and human beings who have lost the relevant mental capacities are no longer people. Here one might think of humans with severe brain damage or advanced dementia.
As Christopher Dowrick notes, if not all human beings are persons in Locke’s sense then we have a problem. One way out for Locke is to continue to define personhood in terms of mental capacities but to adopt a much less demanding view of what the relevant mental capacities might be. Dowrick argues, for example, that ‘all human beings have some degree of inner conscious presence, a sense of “being me”’ (p. 127) and ‘the continuous capacity to be conscious’ (p. 128). If all human beings, including infants and those with severe dementia, have at least these minimal mental capacities, and these are the very capacities that define personhood, then all human beings are persons. On the other hand, the weaker the mental capacity requirements on personhood, the more likely it is that many non-human animals will qualify as people. After all, many non-human animals have the continuous capacity to be conscious.
For Locke, person and human being are different concepts. To classify a being as a person is implicitly to say something about its mental capacities: if it is a person then it has certain mental capacities. The debate between different versions of Locke’s view is a debate about what the relevant mental capacities are, and whether they allow all human beings and any non-humans to qualify as persons. To classify a being as a human being is to say something about its species and its biology. A soul – if there is such a thing – would be a person by Locke’s lights, but not a human being. God would be a person but not a human being.
Another implication of Locke’s theory of personhood is that a person’s survival or continued existence is fundamentally a matter of psychological rather than physical continuity. Despite all the physical and psychological changes that a person undergoes throughout the course of her life there is still a sense in which it is one and the same person undergoing going these changes. What makes it true that it is the same person is that each stage of her life is mentally connected to preceding stages. Today she can remember what she did yesterday, yesterday she could remember what she did the day before, and so on. Amnesia is potentially a problem for Locke’s view it implies that the pre-amnesia person and the post-amnesia person are literally not the same person.
the biological view
The biological view of persons, also known as animalism, says that every person is identical with a particular biological entity, an animal. You are one human animal and I am another. We are different people because we are different human beings. A human being is, in Havi Carel’s words, ‘a perceiving, feeling, and thinking animal, rooted within a meaningful context and interacting with things and people within its surroundings’ (p. 27) Some animalists allow that non-human animals can be people. Other animalists restrict personhood to human animals. Either way, the one thing that animalists agree about is that personhood is restricted to animals. Robots, however capable, can’t be people on this view.
One reason for allowing human beings to count as persons is that they typically have the mental capacities described by Locke. On this account, a patient in an irreversible coma is still a person because he or she is a human being, and human beings are typically thinking intelligent beings who can reason and reflect and consider themselves as themselves. It is also relevant that the comatose person did once have these mental capacities.
The biological view implies that personal identity is fundamentally a matter of biological rather than mental continuity. There is no mental continuity between the comatose patient and the same person before he fell into a coma. What makes them the same person is not that the person in a coma can remember his past life but the fact that it is the same human being before and after. Personal identity is a matter of biological rather than mental continuity because sameness of human being is a matter of biological rather than psychological continuity, that is, continuity of brain, body, sense organs and nervous system.
How does animalism conceive of the relationship between a person and his or her own body? This is how Havi Carel describes the position:
‘On this view, the body is not an automaton operated by the person but the embodied person herself. We are our bodies; consciousness is not separate from the body. Disease, therefore, can no longer be understood as a merely physiological process that affects the person only secondarily’ (p. 16).
The body with which the person is identical is not a mere body but a bodily subject. As well as being an object an object among others, one’s body is also the subject of one’s experiences and the vehicle of one’s consciousness. This is what leads the philosopher Merleau-Ponty to describe it as a ‘subject-object’.
Yet, as Carel notes, in illness one feels betrayed by one’s body. The same sense of betrayal by one’s body can result from the ageing process. As one’s body decays and becomes increasingly uncooperative, one becomes increasingly alienated from it. Having previously been an expression of one’s agency, one’s malfunctioning body prevents one from doing the things one’s wants to do. In being experienced as a hindrance one’s body is experienced as alien, as not a part of one’s unchanged true self. The point at which one finds it difficult to recognize one’s body as one’s own is the point at which one begins to feel the full force of Descartes’ insistence on distinguishing between the body and the self.
the narrative view
This is how the philosopher Marya Schechtman introduces the narrative view of the self:
‘If the person sitting next to you on a long plane trip suddenly launches into the story of his life you may be amused, or annoyed, or simply glad for the distraction. Whatever your reaction, you are unlikely to be surprised that he has a story to tell. The idea that our lives are in some way story-like runs deep in our everyday thought’ (p. 394).
According to the narrative view, selves are inherently narrative in structure. In other words:
‘[W]e constitute ourselves as selves by understanding our lives as narrative in form and living accordingly. This view does not demand that we explicitly formulate our narratives (although we should be able, for the most part, to articulate them locally when appropriate) but rather that we experience and interpret our experiences as part of an ongoing story. The experience of winning the lottery will, for instance, be a different experience for someone immensely wealthy, someone who has lived a life of crushing poverty, and someone who has struggled unsuccessfully with a gambling addiction’ (p. 398).
On this account, it is not possible to explain or describe one’s own life in purely mechanical or biological terms. Human beings are animals, but they are also what Charles Taylor calls ‘self-interpreting animals’, animals who interpret and make sense of their experiences by relating them to an ongoing story, the story of their lives. Crucially, we are self-interpreting animals who interact with other self-interpreting animals in a social context.
Critics of the narrative view object that it is possible to live a rich and meaningful life without having any sense of its narrative structure. It is worth noting that the narrative view is an account of the inherent nature of selves rather than persons. There are many different ways that the narrative structure of a person’s life can be disrupted without calling into question his or her continued existence as a person. Alzheimer’s can put paid to the narrative integrity of one’s life without literally ending one’s life. There is a parallel in this respect between the narrative view and the mental capacity view. Both views face the challenge that the mental capacities that they identify as the essence of personhood or selfhood can be lost by human beings who do not thereby cease to be persons or selves. Loss of one’s ability to make sense of one’s life in narrative terms does not necessarily amount to the loss of one’s personhood.
the ‘person’ of whole person medicine
For all the talk of ‘person centred’ or ‘whole person’ care, the notion of the ‘self’ or ‘person’ is rarely explained. How does medical generalism conceive of the ‘person’? Is there a particular view of persons or personhood that underpins the generalist practice?
The ‘whole person’ orientation of medical generalism is often contrasted with a purely biomedical model of medicine. The latter conceives of patients primarily as biological rather than social organisms and their illnesses as fully accountable at the biological or biochemical level. This seems to fit the biological view of persons. By the same token, it would seem that medical generalists who reject the biomedical model must thereby also be rejecting the biological view of persons, whether they realise it or not.
In fact, this is a gross oversimplification of the actual position. In the first place, the biological view of persons is not committed to the idea that human beings can only be understood in biological or biochemical terms. Animalists can and do accept that people are animals with highly complex mental lives and sophisticated mental capacities, including the capacity to self-interpret. It is therefore only to be expected that an adequate understanding of patients must be biographical as well as biological. According to Iona Heath, medical generalists have to have a biographical understanding of their patients because ‘individual biography affects biology’ (p. 94). This is not something that any self-respecting animalist should want to deny.
At the same time, the whole person approach to medicine does not deny that the biomedical model has much to contribute to the generalist’s understanding of illness and disease. Hjörleifsson and Lea object to the notion that ‘biological approaches trump biographical interpretations of patients’ problems’ (p.28) but it is no more plausible that the biographical necessarily trumps the biological. The generalist should be in the business of integrating considerations of biology and biography, and does not need to conceive of people as anything other than highly sophisticated biological organisms.
It would be wrong to conclude from this that medical generalism has no use for mental capacity or narrative conceptions of personhood. The mental capacities that are characteristic of persons include both the capacities described by Locke and those identified by the narrative view. Consider this quotation from Toon:
‘Many people go to their GP not principally because they want to change what is happening to them but because they want to understand it. Is it serious or is it trivial? Will it get better, and how quickly? What impact will it have on their work, their family life, their social and sporting activities? Answering questions like these is an important aspect of health care for which clinicians are ill-equipped by their basic education. It is part of the third aspect of health care, the interpretive function – giving prognostic information and helping patients understand their illness’ (p. 45).
The questions that Toon identifies are ones that can only be asked by beings who can consider themselves as themselves, that is, by self-aware beings who are persons in Locke’s sense. The influential idea that generalism has an interpretive function is very much in keeping with the narrative view of the self. The understanding that patients seek from their GPs is an understanding of how their illness fits into the story of their lives and what impact it will have on that story as it unfolds. It is because the ‘person’ of ‘whole person’ care is a self-aware and narrative self that helping patients to achieve narrative self-understanding is such a major part of generalist medicine.
If this is right then there is no simple answer to the question ‘how does medical generalism conceive of the person?’. In truth, medical generalism takes on board insights from several different conceptions of what it is to be a person. However, one would not be far wrong if one were to say that the ‘person’ of ‘whole person’ medicine is first and foremost a self-interpreting animal.
references & further reading
The best thing to read on Descartes’ dualism is Descartes himself, especially his Meditations on First Philosophy.
Derek Parfit’s hugely influential account of personal identity can be found in chapters 10-13 of his masterpiece Reasons and Persons.
Locke gives his account of persons and personal identity in Book 2, chapter 27 of his Essay Concerning Human Understanding.
The quotations from Christopher Dowrick are from his paper ‘Patient, person, self’, which appears in his book Person-centred Primary Care.
The Havi Carel quotations are from her book Illness: The Cry of the Flesh.
Two influential defences of animalism are Persons, Animals, and Ourselves by Paul Snowdon and Eric Olson’s The Human Animal.
My views about the body and the self are set out in my book Self and World.
Marya Schechtman’s article is ‘The Narrative Self’, in The Oxford Handbook of the Self, edited by Shaun Gallagher.
Charles Taylor’s classic paper is ‘Self-interpreting animals’, which appears in his book Human Agency and Language.
The references to Hjörleifsson and Lea, Heath and Toon can all be found in Defining Medical Generalism.