Academic journal article The Hastings Center Report

Practical Aims and Applications

Academic journal article The Hastings Center Report

Practical Aims and Applications

Article excerpt

Rethinking the goals of medicine should help address three important practical questions: what should be the future priorities of biomedical research? What are the implications of the goals of medicine for the design of health care systems? How should physicians be trained to better serve the goals of medicine?

Medical Ends, Research Means. For well over a century, the dominant model for medical research has been biomedical: analytic, biochemical, and sometimes reductionistic, seeking to determine the causes and mechanisms of physical and mental pathology at the deepest possible biological level. As a model, it has been highly successful. It was particularly effective in an earlier generation in greatly reducing infectious diseases (its most important target), and holds out the possibility of doing the same in the future with molecular genetics for all disease. When it works well, the biomedical model not only can be applied clinically, but also makes sense for the clinician coping with particular diseases.

For all its power, however, the biomedical mode, has too dominant a place in modern medicine. In the developed countries, it has shown itself inadequate to many medical needs and possibilities. In some developing countries, it has stimulated an unbalanced emphasis on the medical sciences, often at the expense of the quality of medical services. Two general shortcomings, at different ends of the spectrum, are particularly obvious. At the clinical end, a purely biomedical model too often leads to a reductionistic approach to patients, encouraging clinicians to treat them not as whole persons but as collections of organ or molecular systems. This approach can fail to capture the nuances even of single organ or system failure, which may have a profound affect on a patient's entire fife as well as other aspects of a patient's health. It will be all the more inadequate in the case of multi-organ failure, characteristic of many elderly patients, and of patients with chronic illness or disability, who must fashion a new self capable of living indefinitely with illness. A reductionistic model can too readily fail to meet the needs of patients as full and complex persons. When that model is, moreover, thought to be most importantly applied in a struggle against death as the greatest enemy, a medicine becomes dominant that fails to see the organic and (for some) religious inevitability of death. A model of research that focused on the interaction of different conditions and on their effects in the aggregate, as well as the interaction of the macro- and micro-levels of human organisms, would be more helpful.

At the population and public health end of the research spectrum, a biomedical, reductionistic model shows itself no less wanting. For one thing, the fact that the expression of disease will be profoundly affected by context and environment shows that far more than biochemical causes and pathways are usually at work. For another, epidemiological research has shown, in ways too poorly understood, that class, income, education, and a variety of other social factors powerfully affect the incidence and prevalence of disease, suggesting that the causal pathways of disease have many dimensions. Such findings call into question many of the assumptions of what counts as valuable research. Epidemiology helps make clear the overall pattern of various diseases in society, something that the biomedical model - or the singlemindedness of disease-oriented research - cannot do. Most particularly, it reveals patterns of mortality that show the way in which causes of death are not eliminated but moved from one set of diseases to another (death rates from heart disease down in the elderly, but cancer rates up), and patterns of morbidity that help explain the different more or less successful ways in which people age and adapt to chronic disease.

Two imperative research reforms. Two fundamental reforms in research seem imperative. …

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