The person in medicine
International Journal of Integrated Care, 29 January 2010 - ISSN 1568-4156
Section on Personal Identity, Experience and Meaning in Health
The person in medicine
Cassell Eric J., Emeritus Professor of Public Health, Weill Medical College of Cornell University New York, New York, USA
Correspondence to: Eric J. Cassell, E-mail: eric@ericcassell.com
Introduction

A brief description of what is a person is followed by a brief description of what sickness is. It is apparent that virtually every aspect of the person is altered to some degree by serious illness. It is a circumstance of the ascendant theory of sickness (‘when a person is sick it is because of disease’), history, and a result of the development of science that the physical manifestations of sickness are so prominent. Because persons are of a piece, whatever happens to one part happens to the all. Because of this, if a determinant of the illness is personal, psychological, social, or spiritual there will necessarily be physical manifestations as well. If these are given the most attention (as at present) that might not be true to the patients experience or offer the best opportunities for intervention. Sickness makes itself known by interferences in functioning that prevent persons from pursuing their goals and purposes. Healing should be directed toward restoration of functioning and a consequent return of well-being

The person

This brief description of a person should be read with seriously ill persons in mind so as to be aware that serious illness has an impact on virtually all facets of personhood.

A person is an embodied, purposeful, thinking, feeling, emotional, reflective, relational, human individual always in action, responsive to meaning, and whose life in all spheres points both outward and inward. Virtually all of a person's actions—volitional, habitual, instinctual, or automatic—are based on meanings. Persons live at all times in a context of ever present relationships in which a variable degree of trust is necessary both in others and in the self. The communal nature of persons has been partly obscured by the cultural importance of and attention to individualism developed over the past number of centuries in Western European and American societies. Because it is essential for everyday life that people conform to the norms of their communities, behaviors that vary from those norms must be hidden. As a result of sometimes differences or even conflict between the lives of persons in a community and their individual nature and behaviors, all persons have one or more public, private and sometimes secret selves that are different and distinct to a greater or lesser degree.

All persons have a past and a future and both are part of the person today. All persons are marked by the ability to love from the greatest to the least degree. All persons have a spiritual life—a transcendent dimension that reaches beyond them. For some this is articulated only in religion. But spirituality is also present in the love of others and the connection to things larger than the person like country and profession. Spirituality is also expressed in relationships.

All persons have a body that can do some things but not others. Persons become habituated to the body's enormous range of capacities and inabilities. These capacities become accepted as part of the person. Things happen to bodies—they can be injured or get sick and are no longer as able as previously, a truth often hidden by feelings of omnipotence. Bodies sometimes bleed, smell bad, make embarrassing sounds, have embarrassing functions, create desires, sometimes look bad, become old and slow, and sometimes ugly. Most persons conceal this from themselves and they are not a part of dailiness. When these phenomena come to awareness they can be a source of embarrassment.

Relationships of persons to others are guided by enduring rules of behavior and by widely accepted meanings. Their behavior and thoughts in relationships to themselves are also durable and rule guided. Some of this is known to the person but other behavioral codes and thoughts with equal power are unapparent, unknown, and unacknowledged residing out of consciousness. Persons know themselves as authentically themselves by their appearance, the sound of their voice, the beliefs they hold, by their aptitudes, skills, accomplishments, and by their ability to make things, do things, and write things.

Although persons know themselves as enduring over long periods of time, to some extent persons re-create themselves every day—what they did yesterday or last week is not sufficient; this has to be confirmed by what they can do today. They are thus partially existential beings—it is today that matters—but so do the past and the future. Children are almost wholly existential—it is what is happening today that matters.

Self-regard or vanity is the place where relationships with the body, others, and ones-self interact. Everyone wants to be valued by others and by themselves. Everyone wants to be admired or liked by others and themselves. Everyone wants to be like those they admire. Vanity to a lesser or greater extent is present in all and a part of the relationship of persons to others and to themselves.

All persons die and their knowledge of that possibility is a defining characteristic of humans. This knowledge has a widespread effect on persons and their relations to others and themselves.

People go to doctors and become patients because they are sick or impaired, believe sickness looms, fear sickness or disability, or wish to prevent sickness or the consequences of impairment. They believe they are sick when they cannot pursue their purposes or goals because of impairments which they believe are in a doctor's realm.

The dominant theory of sickness for the past two centuries has been that when someone is sick it is because of disease or injury. As a consequence, the focus of physicians and patients alike has been on the disease or injury—what it is, what it is doing to the patient's body and what must be done for it. In the past 50 years, attention has shifted toward the patient—the sick person—but the perceived cause of the illness, the disease, has continued to be the primary interest of medicine. It is a circumstance of history and a consequence of the growth of science that the physical manifestations of sickness are best known, most thoroughly explicated, and most prominent in the thoughts of sick persons and their clinicians.

Sickness has an impact on the whole person whether minor illness or life threatening affliction. Sickness is not restricted to the physical derangements of disease, nor does it only include the psychological or social phenomenon that may accompany it. Sickness makes itself known by interference in functioning. Since sickness involves the whole person the impairments of functioning that characterize illness involve all aspects of the human condition—physical, personal, psychological, social, and spiritual. Which impairments will come to the person's awareness in any instance, be most intrusive or important, follows from the nature of the illness, the particular person, and context (context refers to the social, political, technological, religious, and physical environment that exists outside of us). Because humans are of a piece—whatever happens to or is done to one part affects the whole and whatever affects the whole affects every part. As a consequence, sickness inevitably involves the entire person, every single bit. If the determinant of the illness is personal, psychological, social, or spiritual it follows that there will also necessarily be physical manifestations as well. Pride of place has conventionally been given to physical aspects because those were the source of the development of contemporary knowledge and technology. In any particular instance of sickness, the known bodily dysfunctions considered as a whole are usually considered as the disease. In an instance of sickness giving priority to the disease may not be true to the patient's experience; if the illness has its source elsewhere that is where attention should ideally concentrate. It is equally important to understand what has happened to the other domains of the patient's life because this may provide healers with the opportunity to decisively influence the illness.

Healing should be directed towards restoring functioning; to helping the patient once again attain the state of well-being that comes from the ability to pursue achievable goals and purposes.

Sickness is personal and individual. It is related to the characteristics of the sick person and influenced by the particular individual whose sickness it is. It changes patients; it may affect their body, actions, thinking, behaviors, response to others, and to the world around them. These changes may occur without the patient's awareness. These changes also, in turn, alter the illness; it is a circular process. The actions of healers must also be personal to be true to illness. They are directed toward sick persons, the dysfunctions making them sick, the effects of sickness, and sick persons themselves. As a consequence, healers must learn as much about persons as they do about illness itself. Their knowledge should equip them with the skills to understand this particular sick person. When someone is seriously ill, that person's being includes the illness.

Sickness and its manifestations are inextricably bound up with the phenomenon of meaning. Everything that happens to people; objects, events, relationships, every sight and sound, everything that happens in or to the body is given meaning. Meaning has cognitive, physical, emotional, and spiritual aspects. Thus, meanings have an impact on every dimension of persons. Meaning is the medium, the intervening agency, which unites all aspects of sickness and its impairments with the sick person [1]. In other words, people do not act because of events, things, circumstances, or relationships; they act because of their meanings. The importance of the centrality of meaning is that meanings can be changed and with the change in meaning the patient's reality is changed.

In the US, person-centered medicine has come to denote medicine that is focused on the patient's goals, expectations, and needs as determined by the patient. In the words of the Institute of Medicine of the National Academy of Science, it is a medicine “that is respectful of and responsive to individual patient preferences, needs, and values.” This defines an accommodating and benevolent medicine but it is not the person-centered medicine that arises from consideration of both the nature of persons and of sickness. Consideration of sickness demonstrates that it has an influence on virtually every aspect of persons and vice versa. A medicine of persons seeks the origins of sickness wherever they may lie in the person recognizing that physical phenomenon may be known disproportionally because of the availability of previous knowledge and technology. The goal of intervention is the restoration of functioning in whatever domain it is impaired so that persons may pursue their purposes and goals.

Reference
1.
Cassell EJ. The nature of suffering and the goals of medicine. 2nd edition. Oxford: Oxford University Press; 2004.