Recent scientific developments and the medical applications they have engendered, as well as the resulting expectations on the part of the patients and caregivers have shed a drastically modified light on medicine, its goals, the role of doctors and the nature of the relationships entered into and maintained with patients.
Curing and preventing the diseases are still the main priorities of medicine, but extending the biological life, enhancing the human capacities, interfacing man and machine, modifying the genome appear to be today objective and realistic goals also, which are susceptible to improve the therapeutic results. Then, the question raised is: are the present goals of medicine still what they should be or should we identify new ones?
But, how is the person of the patient perceived in the present medicine? The increasingly slicing up of the patient into systems, organs, receptors and malfunctioning genes tends to favor an analytical approach of the pathologies of the ‘sick individual’, at the cost of seeing him (or her) as a ‘person who is suffering’, that is to say, one who is affected by his illness in both body and mind.
The title of the book written by Paul Tournier in 1955, ‘The Meaning of Persons’ , is the English translation of ‘La Personne et le Personnage’. The French word ‘personnage’ comes from ‘persona’ in Greek, which is the mask of the actor, and the word ‘personne’ means all what is expressed by the personnage, which comes out through his mask. Then, the concept of the person includes also all what is expressed by an individual, a human specimen. The real danger pointed by Paul Tournier is still today to reduce ‘a suffering person’ to ‘a sick individual’.
The individual can be described as a static object, but the person is a constantly evolving reality, appearing in all his or her dimensions only when encountered by another person. Today, the technical developments and the economical restraints focus the attention of politicians and caregivers to what they call ‘health systems’, reducing doctors to their functions, and patients to their pathologies.
What is the patient expecting, from the physician? What is its representation in the mind of a suffering person? In ‘The strength for healing’ [‘La force de guérir’] [2, p. 71] E. Zafirian says that “the social and individual representation of the doctor comes from the earliest ages; he must be together a chaman, a sorcer, a healer, a wise man and a confident”.
It is also what C.-G. Jung evoked, when speaking of the ‘archetypal image of the physician’, issued from the collective unconscious, and which has generated the image of a healing person in the psyche of the man, since the beginning of humanity. Being outstanding or stupid, the physician has to be aware of this projection, of its utility, but also its dangers.
But what kind of identity will our faculty of medicine offer to their students today?
The medical training has been insidiously replaced by the teaching of medical knowledge, constantly changing and increasing in number. Of course, it is often recalled that the patient has to remain in the center of the process, but what is taken in account to graduate is first the acquisition of intellectual knowledge and of technical performance. The consequence is that in the student's mind the patient may become a specimen to cure, instead of a person to heal.
It is not the promise of the so-called personalized medicine that will avoid the trend to reduce the person to a specimen, since in fact it is individualized therapy, which allows the replacement of statistically efficient treatments for a group of pathologies by specifically effective treatments for a given patient. It will be a definite therapeutic improvement of the therapeutic acts, but this type of medicine scarcely takes into account the therapeutic relationship itself.
In ‘The strength for healing’, E. Zafirian emphasizes the true therapeutic power of the physician himself and of the patient's circle, namely family, friends, nurses, etc.: “When using identical techniques, the relationship can or cannot be fully therapeutic. In order to have a relationship there must be an interaction of two subjectivities. We could say in other words, there must be a meeting of two desires: curing and healing” [2, p. 125].
If the physician does not look at the evolution of health care system, he will become the medical technician expected by health economists, easily managed to get best cost effectiveness ratios, that is to say the less expensive ones, and supposed to offer by this way the best quality of care for the patients.
Indeed, politicians, economists and insurance companies claim they have to reduce the increasing cost of health, but they are concerned only, or at least in first priority, with the cost of the treatments of the diseases and not by the people health. What should they do if they were really firstly concerned with health?
The WHO definition of health is ‘A full physical, psychological and social state of well being’, which means that a healthy man should feel comfortable with his body, his mind and his environment, with also the mention that health is not equivalent to the absence of disease.
In English we say: ‘How are you?’ and in French: ‘Comment allez-vous’, which can be translated into ‘How are you going?’ And the answer is: ‘Je me porte bien’, which means ‘I am carrying myself well’, not ‘one carries me well’!
According to these expressions, promoting health would mean ‘to promote the conditions which will allow the patient to carry himself to go forward in his life’. To be healthy means ‘to be able to walk toward a goal, when taking upon oneself’. Some people believe they have a good health, as any good which might allow them to get and to act, and other people feel they are in good health, living an enriching relationship with their environment, even when they may have some biological dysfunction.
To take care of the patient during a personalized relationship, helping him to discover his strength for healing and for carrying himself in the direction of a goal, that is medicine of the whole person.
And now, a new challenge will be raised by the new technologies, a challenge for the humans who hope to remain so!
The present developments of biotechnologies are often unperceived by many people today, but it will raise weighty questions concerning the identity of caregivers and patients, and also the role of medicine itself.
Up to now medicine was mainly concerned with the correction of biological dysfunctions and defects, but now it will be able to modify human organisms and to enhance the capacities of normal subjects.
Enhancement of the physical strength and of the memory, addition of new sensitive perceptions, extension of the biological life by ageing suppression, replacement of deficient organs by the grafting of new ones generated from stem cells, discovering new virtual life experiences, re-writing the genomic code and including additional bases to it, creating chimeric or new organisms, developing humanoid robots capable of learning behaviors and actions by themselves, to learn how to learn, even reacting to gratification or frustration; and finally downloading on a hard disk all the information of the brain, are no longer belonging to fiction science, but already projects on course of realization.
Are we changing the person or the individual by increasing his memory capacity, by adding new perceptions, by increasing the emotional threshold? Who will take care of an intelligent robot, suffering from frustrations? The engineer or the physician?
The development of biotechnologies will not only provoke questions concerning the identity of caregivers and patients, but also the role of medicine itself. Today, it is already our individual and collective responsibility to anticipate the risks and possible drift toward a growing depersonalization of medicine.
To summarize: it is becoming increasingly difficult to practice a medicine of the whole person today, due to the pressure to offer the best technical attention through an efficient therapeutic relationship.
The inflation of the theoretical knowledge monopolizes the caregiver's attention, focusing it on an increasing number of sophisticated dysfunctions they must be able to recognize and cure. They risk identifying the patient firstly as a group of malfunctioning organs, and they lack of time and training to engage themselves in a true therapeutic relationship.
The development of biotechnologies confers to the physician new tasks deviating from his previous ones, that is to say restoring, protecting and promoting health, and he will have to be attentive not to become an accomplice of such pressures.
The meaning of persons. London: SCM Press; 1957. (Translated from the French by Edwin Hudson).
La force de guérir [The strength to heal]. Paris: Ed. Odile Jacob; 1999. [in French].