THE DOCTOR HIMSELF and the Human Condition - Chapter 2

CHAPTER 2

On Treating the Whole Man *¹

It has been my privilege and pleasure to be an observer of the Profession now for some 45 years. It has been a most fascinating occupation. Although I left Medicine officially in the year 1927, I did not cease to be interested, and applied myself to keep up my reading. Some may be surprised at the form which this reading took. I have made it my custom throughout the years to read on Saturday nights the British Medical Journal. Let me explain why I made this my practice. I used to prepare sermons on Fridays and Saturdays. When I have thought over material in this way, my mind tends to be over-active with it. So I had to find something which would divert my mind to more leisurely pursuits; and I have revealed the method employed. It worked!

Let me add that I am not commending to you the practice of reading the B.M.J. on a Saturday night, though I think it would do some of you good. For, on the basis of my experience in staying with different medical practitioners, I have noticed that not infrequently I see by the side of the desks quite a pile of unopened copies of the British Medical Journal! There is another medical publication that for some years I have read, and which I would put into a different category. I did not read The Practitioner on a Saturday night. I read it when I was at my best – not as a kind of mild sedative, but as a stimulus. I am very happy to pay tribute to the Editor for his monthly notes which I have found to be most stimulating and helpful. They have often given me suggestions for sermons. *²

THREE ASPECTS OF RECENT CHANGE

I desire to speak now about the changes which have taken place since the formation of this Fellowship twenty-five years ago. We have been passing through one of the most extraordinary periods in the whole history of the human race. This applies also to the practice of Medicine in common with so much else in the national and world spheres. I was reading recently a remark by Peter Drucker, the great American authority on business management. He had explained that the change in the management and running of businesses during the last twenty-five years has been quite astonishing. Up until that time the greatest requisite in the top management in business had been experience. But that is no longer the case. The greatest requirement now is knowledge. This, of course, because of the extraordinary speed of technological development. So now you do not look so much for experience and wisdom in your top men. You must look for knowledge of the latest advances and developments in the application of scientific methods to the conduct of business. Now it seems to me that this fact in many ways has become true in Medicine also, and for very much the same reasons.

Then, there is a second change. It is in the kind of problem which is now confronting us. I would subscribe to the view put forward so clearly in a recent book by Sir McFarlane Burnett, Genes, Dreams and Reality. I think that he has established the case that the fundamental change which has taken place in the last twenty-five years has been that (with the advent of antibiotics and developments in this department) the diseases which attack men from the outside now are under control. He gives as instances various types of infection. These, he would claim, are more or less under control. The diseases that are not under control, and which are going to constitute the main challenge to medical men in the future are the internal and degenerative diseases. Most of them are on the increase. They are such diseases as the various forms of malignancy, coronary thrombosis, arteriosclerosis, raised blood pressure and the like. In the future these will constitute the chief problem for medical men.

The third big factor is the advent of State Medicine. The National Health Service has been clearly a revolutionary factor – particularly in the realm of general practice. I have had occasion at a previous meeting of this Fellowship to refer to that, and expressed some fears at the changes that are taking place. I have become somewhat more alarmed about these. No longer – speaking generally – can you be sure that a general practitioner will pay a house visit. Everybody has to go to the surgery or to the clinic. At times it seems to me to be very bad medicine. I happened to be staying with a doctor on one occasion, when a phone call came in that a child was running a high fever. There was at the time, I understood, a mild epidemic of measles in that area. Nevertheless the doctor’s message was that they should bring this child up to the clinic. The thought which occurred to me was, ‘What a good way of spreading the epidemic of measles!’ Only today when I was talking about these matters to some friends, one man broke in to the conversation with – ‘Ah, but, you must add something to that. It is the impossibility of getting any medical attention at the weekend!’ Such are some of the changes which have been taking place during these last twenty-five years.

UNWELCOME TRENDS

As a result of such considerations I feel there are certain dangers which face the Profession at the present time. The first is professionalism. It has been an endemic disease, of course, within the Profession for many years. The tendency is going to be greater.

There are a number of reasons, but one of the chief is the great increase in technological knowledge which leads to an ever increasing specialization. I regard this as a positive danger. As detailed knowledge increases, specialization – and with it professionalism – is going to increase also. A few days ago I was very interested by a striking article by Marshall McLuhan, that extraordinary Canadian, who stimulates us so much at the present time. He gave us a new definition of a ‘specialist’. I am sure that he was thinking of no one here, and that it does not apply to either physicians or surgeons! But he declared that a specialist is ‘one who never makes small mistakes, while moving towards the grand fallacy’. I commend that definition. It is a salutary reminder.

Technological advance and development is obviously raising a number of problems which must concern any medical man who has any kind of religion, and particularly the Christian religion. I mean that there is a point at which your experimentation should stop. We must remind ourselves of the second part of the Great Commandment that you should love your neighbour as yourself. Is there not a danger perhaps of our forgetting that in the interest of science and the acquisition of new knowledge? The poor patient is the one who tends to be forgotten. What right have we to use another human being for the sake of ‘the advancement of Medicine’? Would we ourselves submit always to the procedure which is sometimes applied to a particular patient? Presumably it is never done without the consent of the patient. Is every patient in some situations capable of giving his consent? Does he know enough?

OVERLOOKING THE PATIENT

Too many practitioners know more about some detail in the anatomy or pathology of a person than they do about the person himself. While we may talk more of, and pay lip service to, the concept of ‘the whole man’ and ‘the complete patient’, we must be very careful that in fact and in practice we do not forget him. It is something which we need continually to bear in mind. The patient, the total patient and all that happens to him, is rarely being fully remembered in contemporary practice. Let me quote McFarlane Burnett again. He says, ‘An important part of the technological and social crisis of our time is this. The social problems of drug addiction and the more subtle influences of the need of alcohol, tobacco, sedatives, tranquillizers, and the rest, to make intolerable situations acceptable, are tolerated instead of making an effort to change them.’ I think that is a very profound remark. Our tendency is to tolerate, just to make these things - these intolerable situations - acceptable without any real thought of radical attempts to change them.

MORAL RESPONSIBILITY

Then, thirdly, there is the question of our attitude to immorality and crime. It is important in the following way. You will notice that it is the medical man who is generally called in as the arbiter in these matters. He is regarded as the authority, for example, on the question of ‘diminished responsibility’ and similar matters. At this point the doctor is regarded as the man who can speak with a special authority.

In the past, of course, a kind of general wisdom was deemed, and seemed, to be sufficient. The experienced medical practitioner was a wise old man. Everybody went to him and consulted him. He was a friend of the family and knew everyone. But does his successor still know them? It is at such points that our recent developments may be dangerous. It could be argued that one man is as good as another so long as the infective organism has been accurately identified. I suppose that one man is also as good as another in prescribing an antibiotic so long as it is handled with due care. But the point here is that with those diseases which we have mentioned as now increasingly prevalent, it is important to know your patient. You must ascertain the family history and the more you know about him and his background environment the better you will be able to treat him. But now another idea is with us. It would seem that you need not even see the patient. Or a doctor may go to a patient whom he has never seen before because he is doing duty this particular weekend. The matter to be dealt with is not so much a patient as the technical point of the particular organism. As for the prescription, I suppose that the computers will soon be doing that for us. The point of our present interest is – where does good medicine come in?

What is it, therefore, that at this point the doctor needs? Clearly he must have a true view of man. At this juncture mere knowledge of medicine is not enough. He must know what man – the whole man – really is. He must know the meaning and nature of life. He must have clear views about death. These are bare essentials. But how are these essentials to be obtained? That is the vital question. And I would not hesitate to assert that it is only a man who is a Christian who conforms to this ideal and who possesses this knowledge.

THE BANKRUPTCY OF HUMANISM AND FREUDIANISM

For general wisdom is no longer enough. It has gone out of fashion, it is not now accepted. It is outmoded. Humanism and moralism are obviously failing completely. It is not difficult to see why. According to the teaching of humanism each man is his own authority, his own standard in the matter of morals. The case against the humanists has been stated perhaps most perfectly by the late Bertrand Russell, who admitted that he could see no sense nor meaning in life whatsoever. That is inevitably the final position of a humanist. But I feel that humanism and moralism fail supremely at the point where they virtually leave it all to me to solve my own problems. All they seem able to do is to show me the folly of doing certain things, and conversely to commend to me certain other more rational courses of action.

But man’s real problem is not that he suffers from lack of knowledge. Man is not only an intellect. There are the ultimate problems. To give good advice does not necessarily touch the real problem at all. I would suggest that the contemporary modern world is showing this very plainly.

What, then, of psychology and psychiatry – Freudianism in particular? I would say of Freudianism and, indeed, also of learning therapy and certain other views of psychology – that they share equally in the general hopelessness. I would quote Freud to establish my point here. The following is what he once wrote – ‘In all that follows I take up the standpoint that the tendency to aggression is an innate, independent, instinctual disposition in man. The natural instinct of aggression in man - the hostility of each against all and all against the one - opposes the programme of civilisation.’ But, then, we would ask, where is there any help? There is none at all. It is a state of complete hopelessness, for he declares, ‘Man, being what he is, instinctively opposes the programme of civilisation!’ In the same context he goes on to say that the instinct of aggression is derived from the death instinct, ‘the death wish’, which he says ‘we have already found alongside Eros sharing his rule on the earth’. Well, surely, that is complete bankruptcy.

I would say that the same applies to many of the non-Christian religions of the world. They are ultimately pessimistic and, similarly, offer no real hope. Now this is where the Christian faith seems to me to be absolutely unique. It offers the only hope both for the physician and for the patient. On what grounds can I make such a statement? It is because of its authority. Perhaps the greatest need in the world at the moment is that of true authority. It is the key to what is lacking. Every man is doing that which is right in his own eyes. Authority in all forms is being flouted. It is hated. Where are we to find the necessary authority! Time does not permit, but it would be easy to demonstrate that there is no authoritative view of life other than that which you will find in the Bible. The Bible never said that the world would of itself get better and better. No! It was philosophy which said that, and also the pseudo-science of Charles Darwin and T. H. Huxley. The Bible constantly affirms that men would remain what they are until they are willing to come under the Christian influence.

It is widely suggested today that there is no such thing as sin, and that everything may be explained away in medical terms. Such a fallacy will endanger the very foundations of the whole of our society and of life throughout the world. We must realistically face the fact that there is positive evil in men. There are some men with whom there is nothing wrong medically, but they are evil and they delight in doing evil. For example, they will do anything for the sake of money and what it can purchase. We must be prepared to assert these things. We must not allow false notions to gain further currency and to ruin the whole of life.

THE RESULTS

Turning to the future, when you come to consider the question of hope, what hope is there for man? It is here, it seems to me, that is seen the unique message of the Christian faith. It is not merely good advice, it is not mere morality or ethics, nor is it simply a higher view of life. It is a doctrine that gives due place to the real nature and state of mankind. To use biblical terminology, it declares that a man can be ‘born again’, that there can be a radical change in a man’s soul. He can become a new man. It is amazing, but it is true. History has its endless examples of it – its striking examples. It is not confined to an élite class – it happens amongst the common people. Here is hope for the drug addict, the alcoholic, or any kind of individual who has become an utter slave to some particular kind of sin. It has its dynamic – it is ‘the power of God unto salvation’. This is something which is wholly relevant to our calling. As we face the unknown future, we can see the kind of problem which is going to arise and to arise increasingly. And I argue that this will become a part of medicine. For we are dealing with a ‘whole man’.

I remember some forty-eight years ago, my old chief, Lord Horder, asked me one afternoon whether I would do something for him during his summer vacation. It proved to be this. He had at the time a card index of his patients which was classified solely under their surnames. He was constantly called upon to give a lecture or an address. His problem was that when he wanted to refer to cases he had to rely on his memory. As it happened he had a prodigious memory and he could remember not only the particular cases but often their names, and look the details up on the cards. But he felt that as he was now in his early fifties his memory might fail him. The request was that I would go through his entire system of card indices and make a new supplementary card index beginning with the diseases and passing to the names. In future, when asked to lecture he would refer to the disease references and from the names to the patients’ records.

I did this for him. It was one of the best bits of education that I ever received. But what appalled me – and what astounded me – was this. Even in this practice (and he was very often a consultant to a consultant) the diagnosis in well over 50% of his cases was ‘eats too much’, ‘drinks too much’, ‘dances too much’, ‘does not get enough sleep’, or ‘is unhappy at home’. He was usually right! I remember raising with him my views about this whole question when I was spending a weekend with him at his home near Petersfield. After I had mentioned it, we argued for the whole of the weekend! My contention was that we should be treating all these people. ‘Ah,’ said Horder, ‘that is where you are wrong! If these people like to pay us our fees for more or less doing nothing, then let them do so. We can then concentrate on the 35% or so of real Medicine.’ But my contention was that to treat these other people was ‘real Medicine’ also. All of them were really sick. They certainly were not well! They have gone to the doctor – perhaps to more than one – in quest of help.

It was – I know – an elementary anticipation of what today is known as psychosomatic medicine. But I am seriously suggesting that this situation will in the future become increasingly true. Medical men must realize that more and more they will have on their hands the whole person to deal with. The various types of new antibiotics and the installation of computers will no doubt be doing a good deal for doctors. But I cannot quite envisage a day when the computer will replace the surgeon. It will clearly never replace the physician! This is an absolute certainty. So the great call to us is that we should become whole men ourselves and thereby be in a position to deal with ‘the whole man’ when patients come to us. Let us really understand what is basically wrong. Let us go beyond what technical medicine and the most modern therapy can offer and point men to the Way, the only way in which they can become whole men.

*¹ Part of an address given at the Quarter-centenary Dinner of the Christian Medical Fellowship held at the Royal College of Physicians of London on Friday, January 21st, 1972.

*² The Editor of The Practitioner was present on this occasion.