HOLISM AND MEDICINE
Professor Titular e Livre Docente do Departamento de Clínica Médica
Universidade Federal de Uberlândia
Uberlândia (MG). Brasil
The word paradigm has frequently been used since the physicist and philosopher Thomas S. Khun1 wrote about it in his book The Structure of Scientific Revolutions. Paradigm is a model or a pattern to be followed in studying phenomena and reality. It represents a system of learning to learn and establishes rules for the development of future knowledge (Crema)2.
Science means human knowledge acquired mainly from observing nature, human intuition and more recently, from analytic research. It aims to provide comfort, peace and happiness for the human being. Science developed relatively sparsely and inordinately until the middle of the 16th century, without very established foundations of study and research. It was then strongly influenced by the thoughts of the great geniuses of that time, mainly Galileo Galilei (1564-1642), master of theoretical deduction, Francis Bacon (1561-1626), the creator of empiricism of investigation, René Descartes (1596-1650), creator of analytic geometry and Isaac Newton (1642-1727), creator of the principles of mechanics. Descartes developed the deductive rational scientific method and defended the dualism of nature, that is, matter (res extensa) and thought (res cogitans); in this way, he favored human being dualism (body and soul, both under the help of God, whose existence he judged to have been demonstrated from logical reasoning). He was capable of distinguishing two knowledge sources: intuition and deduction. However, for him all human knowledge would only depend on reason or on thought and never on sensation or imagination. He considered all material bodies including human bodies as machines which operations obey mechanical principles5. Newton consolidated the deductive rational method of Descartes5 and so the Cartesian-Newtonian paradigm was created, which influenced and still influences practically all the fields of human knowledge today. This paradigm basically presumes that to know the whole it is necessary to take apart all components and to study each one of them separately. The whole is then the result of the union and intertwine of the smaller parts. For instance, to know the operation of a machine it is necessary to disassemble its parts. Therefore, under this principle, dividing is knowing.
Medicine, as a science, has been developing mainly since Alcmaeon of Croton (6th century B.C.), who attributed the cause of diseases to the imbalance of the forces of nature, questioned the power of magic that was predominant in medical practice. Hippocrates (5th century B.C.) delve into Alcmaeon's concepts and denied the old one, that stated that disease was punishment by the gods, when he concluded 'each disease has its own nature and originates from external causes'. Among his greatest merits, was his stressing on ethics in medical practice. Galen, a Greek doctor who worked in Rome from 164 a.D., introduced innovative concepts of anatomy and physiology that are pertinent until today*. He is considered the creator of experimental physiology. He emphasized, above all, the organic nature of diseases3,4. The Cartesian-Newtonian paradigm also influenced the development of medical knowledge when it encouraged the study of the human body through the breaking down of its parts. Galeno had already initiated this work. Progress in physiology and pathophysiology was then made possible, while creating conditions for a formidable advance in prevention, diagnosis and treatment of diseases. The complexity of diseases was manifested in such a way that the emergence of different medical specialties occurred, in which the doctor deepens his knowledge in certain organs or organic systems, and almost always puts the approach of seeing the human being as a whole on the back burner. In other words, the specialist has deep vertical knowledge and limited horizontal knowledge. (A. Einstein, in a veiled critic to fragmentism, is said to be responsible for the observation that the specialist knows almost everything about almost nothing).
The Cartesian analytic method, without a doubt, was one of the pillars in the fantastic evolution of the modern world. However, it is equally undeniable that it contributed to the negligence of the human beings intimate feelings, by virtue of the emphasis on the mechanic approach. For instance, it was good for creating confusion between material wealth and individual happiness - and this explains, partly, why social imbalance exists (which is so well known everywhere) and the systematic destruction of our ecosystem, which on behalf of progress, threatens the existence of life, including human, on earth. These observations lead to a paradoxical verification: science, which objective is to provide man comfort, peace and happiness, in spite of its fantastic development was not capable of making man discover peace nor happiness and [overall] love! On the contrary, it arouse a world dominated by selfishness, cruelty, poverty, hunger, oppression, wars, indiscriminate destruction of nature and negligence for the true values of being. Knowledge as it appears today suffocates wisdom and is disastrously imposing.
In medicine, something similar happened and this is why modern and conscientious doctors are frequently and simultaneously euphoric and perplexed. Euphoric because they judge themselves as knowledgeable - due to medical science evolution - and perplexed for they feel that, even with so much knowledge, they are still unable to solve definitively most of their patients' problems. They note that their current knowledge is fragile and transitory, because it comes from the analytic scientific method (Cartesian), which is not always capable of revealing the truth in itself. For this reason, doctors are usually plenty of uncertainties4. (Some philosophical chains, unlike Descartes, admit that truth comes from intuition and that intuition is an absolute dimension of our being, therefore independent of analyses. However, we are not used to, with rare exceptions, being intuitive in our scientific studies).
Jiddu Krishnamurti6 (1895-1986), considered a wise Hindu, explains those paradoxes: "we have technical progress without equivalent psychological progress and, for this reason, there is a state of imbalance. Extraordinary scientific conquests have been made and, yet, human suffering continues to exist, empty hearts and empty minds continue to exist... An empty heart plus a technical mind do not make a creative human being..." F. Capra7 reports a dialogue in which Krishnamurti stresses: "first you are a human being and then you are a scientist. Before this you have to become free and that freedom cannot be reached through thought. It is reached by meditation - the understanding of the totality of life, in which all forms of fragmentation cease." (Krishnamurti argues that "thought… will never be able to renew itself..., because it is always the answer to antecedents - our conditionings, our traditions, our experiences, our personal and collective accumulations." For this reason, he completes, it is not capable of creating anything new. Moreover, it is an enemy of absolute truth, because it obstructs the capacity to meditate and to sense intuition. The truth surfaces when we have empty minds, that is, when we got rid of thoughts9!)...
When practicing medicine, we can consider that our relative (in)efficiency is due, at least partly, to the excessive emphasis that we usually dedicate to the disease (part) and relative negligence to the patient (whole). While we try to know the disease in his most intimate mechanisms and details, we do not realize that, beyond the sick organ, lies a highly complex person, who possesses a brain, feelings and mind, and this mind is constantly in tune with the universe, as it is part of the universe. In short, we are technicians that take care of human beings, but we do not use to pay attention to the human being himself - or we do in an insufficient way, imposed by a method we adopted. We in true hardly know ourselves.
The nature of human beings is usually not approached in medical curriculums. Generally this subject is only found in psychology synopses or in psychosomatic medicine4. However, how are we to practice human medicine appropriately if we do not know man in his totality?
According to the World Health Organization, man is biological, psychological and social (Fig. 1); health means a perfect balance among these three components and not simply absence of symptoms.
Mutatis mutandi, diseases can be considered, at least acquired ones, as a result of the imbalance in one or more of the individual's components. In other words, it is a manifestation of intimate disturbances in the person's physical, psychic and/or social sphere. A disturbance in one of theses components unavoidably contemplated the other two components, for they are interrelated and unseparable (individual), generating a sequence of events that will appear as symptoms and signs of a disease (Fig. 2).
Medical schools, as we pointed out, emphasize the disease in detriment of the patient and for his/her [disease], they address diagnostic and therapeutic resources. They do not take into account that the disease just represents a manifestation of internal problems of the human being4. They emphasize the part, and neglect the whole. Their view of being is mechanical or organical and lacks global evaluation. It is common to observe that modern doctors are more prepared to hear, to feel and to notice the organs better; however, old doctors noticed people better. Modern technology investigates disease well, but it is cold, impersonal, insensitive and unable to penetrate into the soul of the patient. This patient does not eagerly await modern conduct for his or/her case, but hopes to find a competent technician (doctor) that is also a confessor, a protector and a friend. From the technician, he/she expects solutions; to the confessor, he/she reveals his/her intimate problems, sometimes timidly, but courageously; to the protector, he/she surrenders his/her destiny; and from the friend, he/she expects solidarity, understanding and human warmth. It is then evident why the computer does not substitute the doctor in that role, because that is essentially human4. Another more complex approach of the human being visualizes four dimensions of the patient; soma, psyche, nous and pneuma and was developed by Philon of Alexandria and Karlfried Graf Dürckheim8. Figure 3 displays a graphical representation of the human being and its four dimensions:
The first dimension, soma, refers to the physical body which philosophically represents a vehicle for improving the following dimensions. In a purely materialistic perception, this would be the only significant dimension of man, hence truly equivalent to a machine. The role of the doctor would then be similar to that of a mechanic (Cartesian view). This perception restricts thought and mind to the neuronal activity of the brain, but, still inside the matter. Many doctors, although not necessarily materialists, behave in this linear way of viewing the human being as a single dimension. They are limited purely to the action in the material field. They use resources capable of providing more longevity to the body or to the sick organ -and nothing else. Once the body is extinct, the human being extinguishes as well.
The second dimension, psyche or soul or mind (according to different perceptions), comes from observing human beings, however not just by imagination, and derives from several philosophical chains since Aristotle (384-322 B.C.) to Thomas of Aquinas (1224-1274) and others. For the followers of Thomas, the soul or psyche can be understood as the set of the psychic, intellectual and moral skills which interact with animals, particularly man4. It represents a superior dimension to the sum of the parts and is in the Cartesian dual perception of human being: body and soul, corresponding the res cogitans and res extensa. The doctor who accepts this bidimensional thought is, in general, more attentive to the conflicts of psychic order and psychosomatic diseases.
The third dimension, nous (in Greek), can be translated approximately as conscience (some prefer spirit). Leloup8 explains: "It is not only analytic intelligence or rational intelligence. It is neither the world of emotion nor the world of feeling. It is a type of contemplative intelligence... It is a silent intelligence. It is an experience for humans that occurs in a place and silence beyond the mind, beyond the emotions and beyond the sensations." It thirsts intuition and can be reached through meditation and is hierarchically beyond the psyche.
The fourth and last dimension, pneuma, graphically represented by an arrow that points up and that joins the three precedent dimensions, without a doubt is the most noble and it means the essence of human beings, translated as wind or blowing [of life]. Some understand it as the true immortal spirit and that it develops, according to the laws of the universe, towards perfection. It is manifested in soma, psyche and nous, uniting them, improving them and taking them to superior landings of existence, in direction to the High, to God.
This last anthropological concept introduces the doctor to the holistic perception of the human being. It intends to be the basis of a new rationality by connecting man intimately to his interior (homeostasis) and exterior (ecology), and by considering him as not dissociable part of himself and unavoidably linked to his destiny. Holism (of holos: all) represents a system that has been thought of since Heraclito, in ancient Greece, but became more systematized after the publication of the book Holism and Evolution by Jan Smuts in 1921. It tries to be a scientific model based on the interrelation of the phenomena, where everything has to do with everything, not only in the human being, but in every part of universe, in an intertwine that unites everything to everything2,10. Boff11 clarifies that "holism does not mean the sum of the parts, but the reception of the organic totality, unites and is diversified in its parts, but always articulated to each other inside of the totality and being made up of this totality."
The perception of human being in its totality adopts this synthesis system or aggregation of the components of being, unlike the analytic, reduced or fragmentary Cartesian method. It is essential to join [the parts] in order to know [the whole]. It emphasizes the physical, but intimately interrelated with the mind, the conscience, the spirit and with the energies of the universe. It considers the acquired disease not as cause, but as consequence of the interior disturbance of being and it admits that the limited treatment to the disease is many times insufficient to reach the definitive cure (fig. 4). The diseases would have, necessarily, a foundation far beyond our current perception and certainly would go through the different dimensions of our being until manifesting themselves in our bodies, the most evident stage of the process. In our current evolutionary apprenticeship, we are far from clearly understanding the intimate phenomena of nature, be them macro (universe), or micro (human being). In that manner, we still do not have answers for the countless questions that come about.
Notwithstanding, good current medical practice demands that understanding the patient is necessary to explain his/her disease. This new reality can become a new paradigm, the holistic one, which is believed to be supplemental to the old Cartesian-Newtonian paradigm and increases the knowledge of the whole. Under this new paradigm, it is expected that the doctor will aim more toward the human being as a whole using existent means - or those yet to come - that can truly favor his/her global balance. Therapeutic means that are prone to take into account the human being as a whole, such as homeopathy and acupuncture among others, although are still seen as uncertain in some aspects, allied to transpessoal psychology and a transdisciplinar approach and complemented by effective medication for the disease, may mean a model of integral conduct before the ill individual. This type of model could result in real benefit for the patient. It is necessary to dare to progress, conscious that our destiny is beyond what we know today and that our essence, the spirit or pneuma, develops for the perfection of God.
Through the organization of UNESCO in 1986, 19 celebrities representing several areas of human knowledge from 16 different countries, including 2 Nobel Prize winners and the president of the Nobel Committee of Stockholm, met in Venice to discuss the future of science in the world. At the end of the Conference they published the conclusions of the work in a report that was known as Declaration of Veneza12, which content is reprinted below (in Portuguese and French)
Os participantes do colóquio "A Ciência Diante das Fronteiras do Conhecimento", organizado pela UNESCO, com a colaboração da Fundação Giorgio Cini (Veneza, 3-7 de março de 1986), animados por um espírito de abertura e de questionamento dos valores de nosso tempo, ficaram de acordo sobre os seguintes pontos:
Somos testemunhas de uma revolução muito importante no domínio da ciência, provocada pela ciência fundamental (em particular a física e a biologia), devido a transformação que ela traz à lógica, à epistemologia e também, através das aplicações tecnológicas, à vida de todos os dias. Mas, constatamos, ao mesmo tempo, a existência de uma importante defasagem entre a nova visão do mundo que emerge do estudo dos sistemas naturais e os valores que ainda predominam na filosofia, nas ciências do homem e na vida da sociedade moderna. Pois estes valores baseiam-se em grande parte no determinismo mecanicista, no positivismo ou no niilismo. Sentimos esta defasagem como fortemente nociva e portadora de grandes ameaças de destruição de nossa espécie.
O conhecimento científico, devido a seu próprio movimento interno, chegou aos limites onde pode começar o diálogo com outras formas de conhecimento. Neste sentido, reconhecendo as diferenças fundamentais entre a ciência e a tradição, constatamos não sua oposição, mas sua complementaridade. O encontro inesperado e enriquecedor entre a ciência e as diferentes tradições do mundo permite pensar no aparecimento de uma nova visão da humanidade, até mesmo num novo racionalismo, que poderia levar a uma nova perspectiva metafísica.
Recusando qualquer projeto globalizante, qualquer sistema fechado de pensamento, qualquer nova utopia, reconhecemos ao mesmo tempo a urgência de uma procura verdadeiramente transdisciplinar, de uma troca dinâmica entre as ciências "exatas", as ciências "humanas", a arte e a tradição. Pode-se dizer que este enfoque transdisciplinar está inscrito em nosso próprio cérebro, pela interação dinâmica entre seus dois hemisférios. O estudo conjunto da natureza e do imaginário, do universo e do homem, poderia assim nos aproximar mais do real e nos permitir enfrentar melhor os diferentes desafios de nossa época.
O ensino convencional da ciência, por uma apresentação linear dos conhecimentos, dissimula a ruptura entre a ciência contemporânea e as visões anteriores do mundo. Reconhecemos a urgência da busca de novos métodos de educação que levem em conta os avanços da ciência, que agora se harmonizam com as grandes tradições culturais, cuja preservação e estudo aprofundado parecem fundamentais. A UNESCO seria a organização apropriada para promover tais idéias.
Os desafios de nossa época: o desafio da autodestruição de nossa espécie, o desafio da informática, o desafio da genética, etc. mostram, de ua maneira nova, a responsabilidade social dos cientistas no que diz respeito à iniciativa e à aplicação da pesquisa. Se os cientistas não podem decidir sobre a aplicação da pesquisa, se não podem decidir sobre a aplicação de suas próprias descobertas, eles não devem assistir passivamente à aplicação cega destas descobertas. Em nossa opinião, a amplidão dos desafios contemporâneos exige, por um lado, a informação rigorosa e permanente da opinião pública e, por outro lado, a criação de organismos de orientação e até de decisão de natureza pluri e transdisciplinar.
Expressamos a esperança que a UNESCO dê prosseguimento a esta iniciativa, estimulando uma reflexão dirigida para a universalidade e a transdisciplinaridade. Agradecemos a UNESCO que tomou a iniciativa de organizar este encontro, de acordo com sua vocação de universalidade. Agradecemos também a Fundação Giorgio Cini por ter oferecido este local privilegiado para a realização deste fórum.
Les participants au colloque "La science face aux confins de la connaissance : Le prologue de notre passé culturel" organisé par l'UNESCO avec la collaboration de la Fondation Giorgio Cini (Venise, 3-7 mars 1986), animés par un esprit d'ouverture et de questionnement des valeurs de notre temps, sont tombés d'accord sur les points suivants:
Nous sommes témoins d'une très importante révolution dans le domaine de la science, engendrée par la science fondamentale (en particulier, par la physique et la biologie), par le bouleversement qu'elle apporte en logique, en épistémologie et aussi dans la vie de tous les jours à travers les applications technologiques. Mais nous constatons, en même temps, l'existence d'un important décalage entre la nouvelle vision du monde qui émerge de l'étude des systèmes naturels et les valeurs qui prédominent encore en philosophie, dans les sciences de l'homme et dans la vie de la société moderne. Car ces valeurs sont fondées dans une large mesure sur le déterminisme mécaniste, le positivisme ou le nihilisme. Nous ressentons ce décalage comme étant fortement nuisible et porteur de lourdes menaces de destruction de notre espèce.
La connaissance scientifique, de par son propre mouvement interne, est arrivée aux confins où elle peut commencer le dialogue avec d'autres formes de connaissance. Dans ce sens, tout en reconnaissant les différences fondamentales entre la science et la tradition, nous constatons non pas leur opposition mais leur complémentarité. La rencontre inattendue et enrichissante entre la science et les différentes traditions du monde permet de penser à l'apparition d'une vision nouvelle de l'humanité, voire d'un nouveau rationalisme, qui pourrait conduire à une nouvelle perspective métaphysique.
Tout en refusant tout projet globalisant, tout système fermé de pensée, toute nouvelle utopie, nous reconnaissons en même temps l'urgence d'une recherche véritablement transdisciplinaire dans un échange dynamique entre les sciences "exactes", les sciences "humaines", l'art et la tradition. Dans un sens, cette approche transdisciplinaire est inscrite dans notre propre cerveau par l'interaction dynamique entre ses deux hémisphères. L'étude conjointe de la nature et de l'imaginaire, de l'univers et de l'homme, pourrait ainsi mieux nous approcher du réel et nous permettre de mieux faire face aux différents défis de notre époque.
L'enseignement conventionnel de la science par une présentation linéaire des connaissances dissimule la rupture entre la science contemporaine et les visions dépassées du monde. Nous reconnaissons l'urgence de la recherche de nouvelles méthodes d'éducation, qui tiendront compte des avancées de la science qui s'harmonisent maintenant avec les grandes traditions culturelles, dont la préservation et l'étude approfondie paraissent fondamentales. L'UNESCO serait l'organisation appropriée pour promouvoir de telles idées.
Les défis de notre époque - le défi de l'auto-destruction de notre espèce, le défi informatique, le défi génétique, etc. - éclairent d'une manière nouvelle la responsabilité sociale des scientifiques, à la fois dans l'initiative et l'application de la recherche. Si les scientifiques ne peuvent pas décider de l'application de leurs propres découvertes, ils ne doivent pas assister passivement à l'application aveugle de ces découvertes. À notre avis, l'ampleur des défis contemporains demande, d'une part, l'information rigoureuse et permanente de l'opinion publique, et d'autre part, la création d'organes d'orientation et même de décision de nature pluri- et transdisciplinaire.
Nous exprimons l'espoir que l'UNESCO va poursuivre cette initiative, en stimulant une réflexion dirigée vers l'universalité et la transdisciplinarité.
Professor D. A. Akyeampong (Gana), físico-matemático, Universidade de Gana.
Professor Ubiratan D’Ambrosio (Brasil), matemático, coordenador geral dos Institutos, Universidade Estadual de Campinas.
Professor René Berger (Suíça), professor honorário, Universidade de Lausanne.
Professor Nicolo Dallaporta (Itália), professor honorário da Escola Internacional dos Altos Estudos em Trieste.
Professor Jean Dausset (França), Prêmio Nobel de Fisiologia e de Medicina (1980), Presidente do Movimento Universal da Responsabilidade Científica (MURS França).
Senhora Maîtraye Devi (Índia), poeta-escritora.
Professor Gilbert Durand (França), filósofo, fundador do Centro de Pesquisa sobre o Imaginário.
Dr. Santiago Genovès (México), pesquisador no Instituto de Pesquisa Antropológica, acadêmico titular da Academia Nacional de Medicina.
Dr. Susantha Goonatilake (Sri Lanka), pesquisador, antropologia cultural. Prof. Avishai Margalit (Israel), filósofo, Universidade Hebraica de Jerusalém.
Prof. Yujiro Nakamura (Japão), filósofo-escritor, professor na Universidade de Meiji.
Dr. Basarab Nicolescu (França), físico, C.N.R.S.
Prof. David Ottoson (Suécia), Presidente do Comitê Nobel pela Fisiologia ou Medicina, professor e diretor do Departamento de Fisiologia, Instituto Karolinska.
Sr. Michel Random (França), filósofo, escritor.
Sr. Facques G. Richardson (França - Estados Unidos), escritor científico. Prof. Abdus Salam (Paquistão), Prêmio Nobel de Física (1979), diretor do Centro Internacional de Física Teórica, Trieste, Itália, representado pelo Dr. L.K. Shayo (Nigéria), professor de matemáticas.
Dr. Rupert Sheldrake (Reino Unido), Ph.D. em bioquímica, Universidade de Cambridge.
Prof. Henry Stapp (Estados Unidos da América), físico, Laboratório Lawrence Berkeley, Universidade da Califórnia Berkeley.
Dr. David Suzuki (Canadá), geneticista, Universidade de British Columbia.
Obervadores (Observateurs intervenants) : Michel Random (France) et Jacques Richardson (France - États-Unis d'Amérique)
* The current practice of medicine observes the ethical principles of Hippocrates and the organic vision of diseases of Galen
* Hélio Teixeira Professor Titular e Livre Docente do Departamento de Clínica Médica
Universidade Federal de Uberlândia
Tel. + 55-34-3219-3311
Fax. + 55-34-3219-3311
Endereço Postal: Rua Carajás, 65
38400-076 - Uberlândia (MG)