EXISTENTIAL MEDICINE

The total monopoly of the medical profession and its institutions on ‘knowledge’ of the body and of illness was radically and caustically challenged by Ivan Illich in his book entitled ‘Medical Nemesis: The Expropriation of Health’. In it he exposes the veritable epidemic of medically induced or ‘iatrogenic’ illness, a truth confirmed by the accepted evidence that medical ‘treatments’ are themselves the 3rd major clinical cause of death.

Hence Illich’s opening words:

“The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic. Iatrogenesis, the name for this new epidemic, comes from iatros, the Greek word for ‘physician’, and genesis, meaning ‘origin’.”

Illich identified three types of iatrogenesis – clinical, social and cultural.

“Iatrogenesis is clinical when pain, sickness and death result from medical care; it is social when health policies reinforce an industrial organization that generates ill-health; it is cultural and symbolic when medically sponsored behaviour and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other, and aging, or when medical intervention cripples personal responses to pain, disability, impairment, anguish and death.”

“People who are angered, sickened, and impaired by their industrial labour … can escape only into a life under medical supervision are thereby seduced or disqualified from political struggle for a healthier world.”

Today, more than ever, medical professionals, appealing to the evidence of biomedical science, research and technology, and believing in the effectiveness of medical treatments, maintain an almost absolute authority and monopoly on questions of health and illness. This is a monopoly that serves principally to maintain and bolster the profits of the corporate health industry and its products.  For make no mistake – today more than ever, not despite but precisely because of its high costs to the individual or state, Medicine is Big Money – and ‘Big Pharma’ the most profitable industrial sector of all.

Through its institutionalised monopoly, biological medicine, as Illich points out:

 “… has the authority to declare one man’s complaint a legitimate illness, to declare a second man sick though he himself does not complain, and to refuse a third social recognition of his pain, his disability, and even his death. It is medicine that stamps some pain as ‘merely subjective’, some impairment as malingering…”

The monopoly of biomedicine is sustained despite the plethora of ‘alternative’ or ‘complementary’ forms of medicine that continue to spring up as part of a global health industry  – whether in the form of vitamin treatments, herbal or homeopathic medicine, ‘integrative medicine’ or ‘energy medicine’, Ayurvedic medicine or Traditional Chinese Medicine. For however suspect the ‘scientific’ credentials of the latter in the eyes of  orthodox Western medicine, these complementary forms of medicine in fact offer no true ‘alternative’ at all – sharing as they all do the same unquestioned root assumptions of what is called the ‘biomedical’ model. This is the assumption that illnesses have biological ‘causes’ rather than existential meanings. Together with this goes a view of the human being as a function of the human body and brain – what I call ‘bio-ontology’ – rather than its converse, an onto-biological understanding of the human body as embodiment of the human being. 

The biomedical model leaves the patient in a hopeless situation – forced to choose between the false alternative of orthodox Western medicine, one or other form of non-Western or complementary medicine – or some mere admixture of the two. The problem is that none of the forms of medicine on offer in any way question or offer a true alternative to the basic ‘model’ shared by all forms of medicine today.

Certainly there have been notable thinkers such Thomas Szasz, who have questioned the relevance and applicability of the ‘medical model’ to so-called ‘mental illness’. What is questioned here however is only the application of this model within the realm of psychiatry and psychotherapy. Few have gone so far as to question the value and effectiveness of this model to medicine as such. 

Thus, as Illich remarks: “A number of authors have … tried to debunk the status of mental deviance as a ‘disease’. Paradoxically, they have rendered it more and not less difficult to raise the same kind of question about disease in general.”

Some people have of course heard of ‘Existential Philosophy’ and its expression in ‘Existential Psychotherapy’. Unfortunately however, the very term ‘psychotherapy’ reinforces a false theoretical, institutional, professional and personal separation between the realm of the ‘psychic’ and that of ‘somatic’ illness, between subjectively expressed ‘psychological’ distress  and ‘objective’ or ‘organic’  illness or between so-called ‘behaviourial’  disorders and bodily ‘dysfuncton’.  Since the forgotten era of Freudian-oriented ‘psychoanalytic medicine’, almost all schools of psychotherapy and psychoanalysis have effectively abnegated responsibility for exploring more deeply the subjective and psychological dimensions of all forms of human dis-ease – instead deferring to the authority of the medical profession and its ‘science’ when it comes to understanding the nature of somatic illness or ‘disease’.

Even practitioners of so-called ‘somatic’ or ‘body-oriented’ psychotherapies such as ‘biodynamics’, ‘bioenergetics’ or ‘biosynthesis’ fear to ‘stray’ into the territory of somatic medicine  –  despite the fact that their founder – Freud’s student Wilhelm Reich – offered an entirely different understanding of specific illnesses such as cancer, to those of orthodox biomedicine. And whilst acknowledgement of so-called ‘psychosomatic’ symptoms and of processes of ‘somatisation’ (people turning their problems into bodily symptoms and illnesses) has been a recognised part of psychotherapeutic and psychoanalytic theory since Freud, what is still not recognised is the fundamentally social character of ‘somatisation’ – the way it is effectively reinforced by the institutional beliefs and practices of biomedicine.

The fact remains that most people still express and ‘present’ their most currently acute or chronic ‘psychological’ problems to physicians rather than psychotherapists – biologically and culturally ‘coding’ them as somatic symptoms.  Even psychotherapists who get ill will tend to turn to doctors and the medical profession rather than to their own fellow psychotherapists. The false separation between ‘psychological’ and ‘medical’ problems is thus also reflected in a split between the professional and personal lives of psychotherapists themselves. 

For all these reasons, I believe it is high time for psychotherapists of all schools to stop simply bowing to the authority of biomedical science when it comes to knowledge of the human body and bodily disease, for as long as they do so this ‘science’ and its professional institutions will continue to claim a total monopoly on ‘authoritative’ knowledge of the human body – together with the ‘diagnosis’ and treatment of bodily illness.

Through the practice of biomedicine:

“The patient is reduced to an object – his body – being repaired; he is no longer a subject being helped to heal. If he is allowed to participate in the repair process, he acts as the lowest apprentice in a hierarch of repairmen.”  Illich

Yet to ignore the subjective dimension of the body – the ‘lived body’ or ‘subjective body’ – is to ignore what brings patients to doctors in the first place – not an ‘objectively’ measurable pain for example, but a subjective experience of pain, one which may have no identifiable cause, and may persist for a lifetime even if an ‘objective’ cause is found and treated. More fundamentally, how do we know we have a body in the first place except through a subjective awareness of it? And since subjective awareness is the most fundamental precondition for our experience of bodyhood,  how can it – in principle – be reduced a mere property of function of that body – or to that private, self-encapsulated ‘psyche’ mysteriously residing within the brain?

In contrast to both existential and somatic ‘psychotherapy’, ‘Existential Medicine’ questions – as Martin Heidegger did in the Zollikon seminars – the very concepts of psyche and soma in which this separation of psychotherapy from somatic medicine has its roots. Yet whilst the foundations for an thoroughgoing Existential Medicine have long since been laid by Martin Heidegger, Medard Boss and others, this groundwork has yet to be transformed into a means of radically challenging – both in principle and in practice – the unquestioned assumptions of  medical ‘science’. The concept of causation still governs this science – even and not least in all talk of ‘psychosomatic causation’. In contrast, the foundations of Existential Medicine lie in an essentially non-causal understanding of illness, and in a non-causal science of phenomena as such – in ‘phenomenology’ or ‘phenomenological science’.

A foundational principle of phenomenological science is that no phenomenon arising from or present within a given contextual field of emergence can be said to be ‘caused’ by any another phenomena present or arising within the same field. To even attempt such a form of causal explanation would be like attempting to find the ‘cause’ of something we dream of in some other phenomenon experienced in the same dream – thus ignoring the common source of both phenomena in the overall contextual field  of our dreaming consciousness and indeed of our waking consciousness as well.

Existential Medicine is both phenomenological and ‘hermeneutic’ in character – seeking the meaning rather than the cause of symptoms. Hermeneutics is the art of interpretation. The word derives form Hermes – the messenger gods and he who also leads souls to the ‘underworld’. Symptoms too are messengers bearing a message, and illnesses serve as one way of leading our souls to the afterlife.  A hermeneutic approach to the human body understands it as a living biological language – one whose fleshly ‘text’ is many-layered only to be understood in its existential context. Hermeneutics too, is a type of knowledge and science that has no place for the notion of causality. For no text – and no symptom – can ever give full expression to its larger context of emergence, let alone be said to be ‘caused’ by that context.  And whilst meaning finds expression in words, as it also finds expression in dreams and in bodily symptoms – this does not imply that a particular meaning ‘causes’ a particular mode of expression or embodiment, for meaning is above all characterised by a multiplicity of different possible modes of expression.    

Existential Medicine not only challenges the scientific foundations of orthodox medicine but also transgresses the taboo it imposes – the taboo on anyone who is not a qualified medical professional daring to suggest different understandings of illness to a patient. ‘Doctor knows best’ remains the motto – implying that physicians know the patient’s body better than the patient themselves. Yet the ‘body’ that doctors ‘know’ is not the lived or felt body – the body as felt from within by the patient themselves (German Leib) but the ‘clinical body’. This is the body as it is ‘objectively’ perceived and examined from without (German Körper) and understood solely through the language and body of clinical terminology that make up medical ‘science’. 

Through the theoretical framework and social practice of the biomedical model, any directly sensed significance or meaning latent in a patient’s felt dis-ease and its symptoms is immediately ‘enframed’ by the already signified senses posited in advance by medical-diagnostic terminology – with its notion of illnesses as autonomous disease ‘entities’ or  ‘things in themselves’. As a social practice, biomedicine reduces the physician’s professional role to one of identifying some purely biological or genetic cause for these symptoms – reducing them to the expression to some hypothetical disease entity to which the patient has inexplicably become victim. 

“Language is taken over by doctors: the sick person is deprived of meaningful words for his anguish, which is thus further increased by linguistic mysticification.” Illich

Biomedical ‘science’ is a science that does not even recognise that its own true foundation is not ‘hard facts’ but linguistic metaphors – in particular the military metaphors of immunology and immune ‘defences’.  Hence we have an entire medical industry and profession which sees itself militaristically engaged in a ‘war’ against disease and death – a war in which patients are the major victims of the ‘collateral damage’ it inflicts.

Both medically (iatrogenically) induced death and the medicalisation of death and dying deny the basic existential right asserted by Illich – to die without diagnosis. They also stand in direct opposition to Heidegger’s understanding that acknowledgement of mortality and ‘being toward death’ is the very foundation of authentic living. Thus, though Illich himself was diagnosed with cancer, he refused all but palliative care – and referred to his obvious facial tumour simply as “my mortality”. The biomedical model would have us believe that Illich himself died ‘of’ or ‘from’ cancer. Yet the very idea of ‘terminal’ illnesses assumes that people die from diseases, rather than through them. If there is such a thing as ‘premature’ death then it is largely a consequence of people not choosing to reject medical treatments of a sort which radically reduce their quality of life and with it, their will to live.  

Medicine had its roots in philosophy and not in ‘science’ as it is understood today. This has good reason – for profound questions to do with the nature of life and death, health and illness simply cannot be enframed within a biomedical model or made the subject of controlled scientific tests. Yet as Fredrik Svenaeus points out, historically “Medicine and philosophy enjoyed a rather close partnership until the emergence of modern medicine around 1800. What happened around that point can be envisioned as a radical philosophectomy in medicine. Philosophy is cut off as a useless and even dangerous speculative approach to questions of health …” (Svenaeus, F. The Hermeneutics of Medicine and the Phenomenology of Health: Steps Towards a Philosophy of Medical Practice, Kluwer Academic Publishers 2000).

Thus living as we do in a culture in which science has, as Heidegger recognised, effectively replaced philosophy as a path to knowledge and truth, the need for a new philosophical approach to medicine – for what he called “thinking physicians” – is now greater than ever.

What I call Existential Medicine is a philosophical revolution in our basic understanding of what constitutes ‘health’ and ‘illness’ – one which reveals and challenges countless core assumptions of current medical science in a way which even existential psychotherapy still fails to do – despite the decisive new understanding of the body offered by its founders. It needs to be emphasised however, that by its very nature, Existential Medicine cannot be reduce to yet another form of medical ‘treatment’ or ‘cure’. Instead it is essentially ‘medicine beyond medicine’ or ‘meta-medicine’. That is because it so radically undermines and challenges ‘the medical model’ in all its forms – whether in the guise of ‘biological’ and ‘genetic’ medicine, ‘traditional’ or ‘complementary’ medicine, ‘psychosomatic medicine’ and even so-called ‘spiritual healing’.

For again, the central question addressed by all these diverse forms of medicine is not the meaning of a patient’s illness but rather what ‘causes’ it and how best to ‘treat’ or ‘cure’ it.  The far more fundamental questions first posed by Martin Heidegger, taken up by Medard Boss and further developed through Existential Medicine are: ‘What is health?’ and ‘What is illness?’ Within these questions lie yet further fundamental questions of a sort totally excluded from the realm of current medical ‘research’.

Examples of such fundamental questions are:

Is illness an aberration from ‘natural’ health or is it a natural part of life and human existence – as natural as birth and death?  

Is illness some ‘thing’ that we ‘get’ or ‘have’ or is it a natural life process – comparable to the processes of being born, maturing and dying?  

Can the human body be separated from the human being or is it a living embodiment of our individuality as human beings? 

Do ‘somatic’ states, symptoms and diseases merely ‘affect’ our consciousness or ‘psychological’ state or is every somatic state itself and essentially a state of consciousness – an embodied state of being or ‘self-state’ – just as every ‘psychological’ or ‘mental’ state is at the same time a ‘somatic’ state, experienced not just ‘in the mind’ but as a mode of bodily self-experiencing and of bodying our self-experience? 

Is a particular illness something reducible to a set of biological ‘causes’ – or does the emergence of a particular illness at particular time in the life of an individual always have a definite meaning in the larger existential context of their life-world (Lebenswelt) as a whole – including not only their environment and relational world (Umwelt and Mitwelt) but also their ‘work world’ (Arbeitswelt)?  

Last but not least, does healing come about through medicating an illness and ‘treating its causes’ or through meditating its meaning?

The two-column table on the next page of this site  sets out in brief a series of fundamental contrasts between the unquestioned ‘Assumptions of Biomedicine’ and the ‘Foundations of Existential Medicine’.