The Bioethical Mandala
A Reflection on the Moral Structure of Health Care (part 3)
Mapping the Maze
Some questions arise in the mapping of this health-care maze. Given that the practitioners at the medical "rockface" are at least nominally interested in caring for the suffering of others and that their armies of supporters and camp-followers are properly concerned with providing suitably constructed underpinnings for the provision of appropriate services, bioethics should first examine the epistemological issues that lie at the foundation of the edifice.
Having made sense of the structural paradigm, the next step should be an examination of the justifications for medical intervention that have been bandied around. So, in what Szasz terms the "paradigm of illness" there are three modalities of the need for health care.(7) The first is disease-oriented, inviting treatment because the patient may have fallen ill, while the second is treatment-oriented, because the patient may be able to be cured. The third strut of the paradigm is consent-oriented, because the patient has given her consent to be treated.
Three epistemological questions that follow from this analysis are:
- What is Disease?
- What is Treatment?
- What is Consent?
Developing appropriate guidance based on sound ethical principles for harried practitioners and other decision-makers concerned for the health and wellbeing of their fellows is the major raison d'être for the bioethics itself, so the ethical question that involves these three empirical concerns is: what is it that can adequately justify medical intervention in the cases of disease, treatment, consent and any combination of the three?
What is Disease?
Disease is suffering. Of that there can be little doubt, although the converse does not apply: pregnancy, for example is often accompanied by suffering, but although it has become increasingly medicalised, it could hardly be described as a disease. Old age itself is not a disease, although it too may be accompanied by suffering, perhaps from associated diseases; the sufferings of old age may be mainly felt in the persons of those who must care for the old ones. Moreover we experience suffering in the grief of bereavement, but the loss of a loved one is not a disease, although nowadays it seems to require counselling, a form of treatment, and even, in severe cases, drug therapy. Suffering arouses, by sympathetic identification the resolve to assist the sufferer, sometimes to an extent not necessarily contributing to their actual benefit.
The received medical position, grounded in atomistic, newtonian conceptions of the world, propounds the view that complex structures may be reduced to their component parts; organisms such as the human body may be understood by examining their components in isolation, seeing how they fit together and observing their function within an overall mechanism that may be studied, and analysed in detail, rather like a complicated piece of clockwork. Disease is thus thought to be a more or less simple breakdown in the mechanism, or in one or more of its parts, identifiable by characteristic symptoms reflecting the organism's divergence from the model of functional health.
A Human Being is not a Car
If a car throws a wheel bearing, it exhibits characteristic noises and other peculiarities at a particular location which identifies the problem for a qualified mechanic. The treatment is to isolate the cause of the symptom and replace or repair it before it does any more damage. But the car is a mechanism, not an organism; simply resting the machine and ensuring a supply of good quality gasoline is not going to allow it to sit back and quietly grow a new bearing. A human being is not a car.
One alternative popular among feminists and others wishing to rise up and abandon the creeping meatball of established medicine lies in the denial of the mind/body distinction and rejection of the concept of the autonomous, disembodied individual having ownership of a passive body-vehicle. These post-structuralist characterisations present disease as a discontinuity, a collapse of the seamless fabric of relationships comprising the experiential contour of the "lived body".
Disease, however, may be more truly characterised in a deep, holistic light. We can better describe "dis-ease" as the expression of a destabilising interference with the harmonious patterns of interactive support and mutual nourishment which are constantly undertaken between the living organism and its environment, the luminous source of energy and the focus of intent. The source of such interference may appear in diagnosis to lie within either the internal environment (the body/mind continuum), or the external environment, the habitat or milieu, although there is no fundamental difference between the two, for they are a constant interactive continuity.
What is Treatment?
For the doctor as bodymechanic and the patient as disordered machine, the treatment consists in the removal of symptoms as quickly and painlessly as possible. A new part (kidney; heart; blood transfusion), the adding of an accessory (IUD; spectacles; hearing aid), or the equivalent of a grease and oil change (blood test; gallstone removal; tranquillisers) will get the machine on the road again. Such a repair job is thought to serve the interests both of patient as consumer and practitioner as provider of health care, and to a point, so it does.
Nevertheless, such intervention often fails to address the underlying causes of the problem in the milieu or habitat of the patient and frequently results in complications arising from the therapy itself, as in the case of the Thalidomide debacle.(8) Moreover, the objective comparison of divergent cases with theoretical norms generates a misleading view of health and wellbeing (the operation was a success, but the patient died...).
Holistic practitioners seek to treat the body within the context of its relationships, avoiding the tendency to view the patient as an isolated object of medical interest. Such an approach has the advantage of minimising the potential damage of invasive, mechanistic techniques and rejecting any assumed property relations between the bodies of individuals.
Treatment of any kind requires the intervention of the medical practitioner and the surrender to some degree of the autonomy, however perceived, of the patient. This is the case within any medical framework, but less in the holistic case where interaction is intended to stimulate a mandalic relationship of mutual growth leading to the optimal blossoming of health and fulfilment of the whole person, rather than a mechanistic patch-up which fails to address the deeper issues of the bodily continuum's relationship with itself, its parts and its habitat. Admittedly the medical profession is changing; it has adopted many of the techniques of holistic medicine and has sought to incorporate them within a wider, scientific framework.
What is Consent?
Medical theory assumes the model of a self-present, autonomous individual, with at least potential access to her own motivations and desires. She is assumed to be capable of arriving at an informed decision regarding the needs of her body, which is seen as some sort of appendage to the self. Knowledge of her best interests is thus assumed to be accessible to her. In the event that she may be unable to determine them, it is assumed that the practitioner (or a guardian holding the medical power of attorney), standing in the place of the ethicist, will determine them for her.
The liberal theory of the individual underlying this idea of the consent between two persons tends to disregard the actual lived body schema of the patient, treating the whole transaction rather in the way that one might treat the disposal of a piece of property. Feminists dispute the concept of disembodied individuals arranging contractual invasions of passive bodily reality, but, in practice, the relevant decisions will usually be made on pragmatic considerations of availability of time, facilities and most importantly of all, funds. This process of consent may thus be hijacked by institutional considerations; nevertheless, such decisions, even in the context of Rule Utilitarianism should consider some fundamental rights of the person concerned, at least as a jumping off point for negotiations.
This is not the end of the story, however. Since the body is viewed as an item of property within the context of agreement between autonomous individuals, although modified to some degree by the principle of justice subject to a range of ethical considerations of the common good, once that person has surrendered the control of her bodily schema to a medical practitioner, she has undergone something of a religious act, devolving the responsibility for her own wellbeing onto those who may be only quite peripherally associated with her life, or who may merely perceive her body as an impersonal, statistical object, to be dealt with as one anonymous item among many, like so many faggots on a woodpile. This diminishes the right of the patient to experience the healing relationship in any deeply relevant way and tends to the alienation of her consciousness from its intimate involvement with the interchanging structure of bodily space.
It is the ethical duty of the practitioner to clarify the options available to the patient (or her guardian) in the treatment of the problem, without the issues of risk being obscured by any instrumental considerations, or at least with such considerations being clearly explained. Moreover, once the patient has consented to treatment, personal relationships struck between patient and therapist should not be allowed to slide into hierarchical impersonality and false objectivity. The healing process, even in the event of the patient's death, must also extend to the reconstruction of the gash in the web of her relationships as embodied in the people in her milieu. Healing is a continuum, not a technological feat -- and death, like birth is a process, not a moment.
This article goes on to consider the ethical positions, and the implications of harmony and wellbeing.
Read more about the Bioethical Mandala