- Michael Cheng-tek Tai, M.D.
Chungshan Medical & Dental College, Taichung, Taiwan
The progress of medicine in the last few decades has brought profound changes on human life. Not only are people healthier, they actually live longer. The role of medicine has changed from mainly caring to curing (1) and now, prevention. The impact of the advances of medical science on human beings is tremendous.
In talking about modern medical
technology, Bernard Haring, a well respected and world renowned
theologian/ethicist suggested that medicine has to pay attention
from the present to the future, from an individual personalism
of the patient-doctor relationship to a social-collective accountability
of medicine and to the whole human society. In his words,
"we are forced to take a courageous step towards an understanding
of freedom expressed in terms of social responsibility for the
whole of humanity and for the world environment." (2). Arthur
Parsons, a Canadian bioethicist echoed this view by saying "
we need to move away from the strictly individual patient-centered
ethics.and considers the broader context of the common good and
our responsibility to society as a whole " (3). The impact
of modern medicine on human life and his society has been so profound
that medical educators in the 21st century must re-design a curriculum
that will respond to the new reality it confronts.
2. The Change of Medical Paradigm
The main concern of medicine used to be human physical condition as it was believed that a person's illness was due to physical problems, something was wrong with his body. But this understanding has been challenged and, thus, a new understanding developed which motivated medicine to move from a simple body-centered paradigm to a holistic approach to human health.(4)
A paradigm is a model of how science is to be conducted. It identifies the questions that can be studied and it determines the research methods that may be used(5). We can see three different paradigms:
1. The Biomedical paradigm. The dominant paradigm of medical science in the 20th century is the biomedical model. This paradigm has been strongly influenced by Cartesian dualism. Cartesian dualism defines mind and body as separate substances. In the 17th century, René Descartes thought our bodies were like machines and our minds were a different kind of spiritual entity. Functions of the mind and the body were believed to be radically different. The body is treated like a machine that is fixed by removing or replacing the ailing part or destroying the foreign body that is causing the problem (6). Images and emotions which belong to the mind, cannot affect the body. The discovery of external agents of diseases such as bacterium, viruses, and chemical and vitamin deficiencies fortified the strength of this belief. Within this understanding, only the biomedical factors are considered. Social, psychological and behavioural dimensions being outside the physical functioning component are therefore ignored.
2. Psychosomatic medicine. Psychosomatic medicine is the study of the interaction of psychosocial and biological factors in health and disease. It emphasizes the involvement of both mind and body in a person's health. This approach considers that not everyone becomes ill because of the viral or bacterial infection. The biological factors are assumed as causing only a limited number of illnesses. Ader suggested that all disorders might be called psychosomatic (7) because the brain receives and interprets all sensory input. Biological, psychological and social factors interact to influence health and illness. Mind and body are connected.
3. Biopsychosocial model. The biopsychosocial
model does not suggest that we disregard biomedical influences.
George Englel stated "we are now faced with the necessity
and the challenge to broaden the approach to disease to include
the psychosocial without sacrificing the enormous advantages of
the biomedical approach.( 8 ) Social, environmental and behavioural
factors are taken into consideration to determine the cause of
illness. It sees the important role peoples' lifestyle plays
in 20th century modern diseases. The biopsychosocial model is
based on the theory that nothing exists in isolation. It compels
physicians to consider the effects of external factors in health
and attempt to treat the "whole" patient.
3. A Teaching That Responds To Needs of the Time
In order to respond to the new reality of medicine and to a new understanding of health from a biopsychosocial perspective, the content of medical education needs to be re-evaluated. The Harvard Medical School's New Pathway model is a good example of this attempt. Medical Colleges in Taiwan had started contemplating a new curriculum since the early 90's. A Conference on Medical Education was convened in 1993. All deans of medical colleges in Taiwan along with many professors and students participated in this three days seminars to reflect on a medical education that would respond to the challenges and needs of the new century. Eleven Taiwanese scholars involved in medical teaching in the U.S. and Canada were invited to share their views. A conviction that bioethics must be required and emphasized was shared by all.. The final day of the conference was devoted to the discussion of how to implement the teaching of bioethics in Taiwan. Some suggested that exemplary teaching, that is instructors setting examples for students, could be more effective than simply lecturing. Others voiced the concern that medical training had been too much clinically-oriented, thus, missing the humanistic connection. Although no formal recommendation was presented at the conference, many colleges responded in requiring medical students to take bioethics in addition to offering other related courses in the following years.
Since bioethics encompasses several disciplines, the term medical humanity was first used by the National Taiwan University Medical College to pinpoint that the discourse on bioethics must also include other related subjects such as medical psychology, medical sociology, thanatology, medical anthropology, history of medicine, philosophy of life, human dialogue and religions.etc. This corresponds to the Harvard University Medical School's concern. Dr.Mary Jo DelVecchio Good indicated in her sharing of Harvard experience in the Medical Ethics Education Conference of Taiwan in April, 98, that "the department faculty (Harvard Medical School) favors a bioethics that is grounded in the social sciences and that examines moral action and reasoning as well as ethical principles. It also favors a bioethics that is situational and cognizant not only of clinical realities but of the social context in which health care is carried out". (9 ). Out of the similar concern the medical colleges in Taiwan began using the term medical humanity. It stresses the importance of human value in the practice of medicine in a technological age. Science and technology are value free. They can be either constructive or destructive, or both, or neither to human kind. To ensure that new medical knowledge and technology serve to further human health, well-being and dignity, medical students must be given the opportunity to study the complexity of human situation and his being. The purposes of this emphasis can be summarized as follows: (10)
1. to cultivate a holistic understanding of personhood
2. to enable medical students/physicians to know the human side of medicine and the effect of environment including life style on health
3. to provide a continuing reflection on medical students/physicians themselves as they grow in medical knowledge
4 to foster a sense of "Medicine as Vocation" in the minds of medical students and physicians
5. to study ethical theories and their applications to clinical decision-makings thereby enabling students/physicians to solve day-to-day problems ethically
6..to promote a consciousness of physician's social responsibility.
In one word, medical humanity attempts to equip students with a better understanding of human being so as to produce physicians of tomorrow who are not only effective healers of diseases, but also restorers of human wholeness (a person of body, mind and spirit) and promoter of social justice.
To achieve these goals, the National Taiwan University Medical College launched a new curriculum commencing in 1995. Courses on medical humanity are offered and the teaching style changed from mainly one-way lecturing to students' participation in presenting research findings. The class is divided into several small groups of 16-22 from which 4 students at a time are given the task to present their research result followed by a whole class discussion. Two to three professors are present in each session to povide guidance. Sixteen units of discussion have been slated ranging from biomedical ethics, medical law, clinical behaviour, benefit and conflict, medical Declarations, the right and obligation in medicine, ethics of medical research, reproduction technology, life and death, prolongation and termination of life ...etc
This new model may not address
to the ever-growing issues we face, but it is a beginning. Other
medical colleges in Taiwan also amended their curriculums and
established departments of medical humanity (or social medicine)
in hope that students will realize that medicine deals with not
only body but also a complex unity of body, mind and spirit. To
name a few of this change : the China Medical College in Taichung
offered elective courses on medical psychology, medicine and society,
and thanatology since 1997. Chungshan Medical college offered
the same courses as well as philosophy of religion. Buddhist Tzu-chi
College of Medicine, in addition to the course on biomedical
ethics, medical psychology and physician-patient dialogue, also
requires students to get to know those willed to donate their
bodies for medical research while they were still living so that
when students anatomize them in the class of anatomy will realize
that every human body, living or dead is sanctitious and learn
to respect life. Among all these new courses, bioethics is still
regarded as the basis of medical humanity.
4. Socially Responsible
The goal of introducing medical humanity courses is no other than to instill a sense of empathy in the mind of students while training them to be competent physician responsible to himself, his patients and to the whole society.
Traditionally, physicians in Taiwan served not only to enhance health, but were also active as social justice maintainer. People came to see physicians not only because they were ill but also sought advice to solve community conflicts, social problems etc. Physicians who were usually the highest educated and respected persons in a village were often elected to civil offices. Physicians were expected to be socially active and responsible besides being health care givers.
Responsibility is about accountability and commitment. Responsible persons conscientiously and consciously commit themselves to a task of life and readily accept accountability for its success and failure. They enter into the task, aware of its potential and its risks. Responsibility is not a thing but a relationship between people, or a person to a situation. There are different models as how responsibility is understood and carried out (11).
1. Man-the Maker: my duty as a physician is to treat patients and in exchange, my patients reward me for my service.. As long as my goal is reached, my job is done. This is a teleological response emphasizing on end. I will make thing happen and it happened, so to speak..
2. Man-the -citizen: my primary duty as physician is to treat my patients. This is my calling and even though my patient may not afford to pay me, I will still fulfil my duty as a physician to treat him. This is a deontological ethics which emphasizes obligations. Certain rules define right conduct and the moral life consists of the obligation to obey them.
3. Man-the-answerer; my patients are persons with problems and my duty is not only to help them out but also to make sure they are cared. They are just like my brothers or children who need a father to look after them and I am their father or a brother extending my hand of concern to them. This man is in dialogue with his clients. His concern, however is not limited to his own immediate surrendering, but to the whole society.
A socially responsible person is the one who answers the call and sees his patients as his close friends. He acts not selfishly, but for the welfare of the whole society. He acts in relationship to others not for making his own goals or simply serving his obligation. He goes beyond himself to meet people and serve the need of society. Such a socially responsible physician is what traditional Taiwanese refers to as a superior physicians. The saying goes as this:
"A superior physician heals
the ills of a nation. An ordinary physician heals the brokeness
of a person. An inferior physicians heals disease " meaning
that a physician's role is threefold, namely, to care and cure
diseases, to mend a person's brokenness and to promote justice
in society. Such a physician is a deputyship such as father acts
for children. Thus, he is their deputy never being an isolated
individual but always combining in himself the services of others..
physician is hard to come by. Our world may have changed so much
that such an expectation is regarded as unrealistic. Yet with
physicians' traditional high social image, medical education must
set a noble goal to pursue. Can a physician heal and in the meantime
be conccerned with social harmony and justice ? It depends on
the exemplary role of instructors and the content of our educational
program. The dean of Taiwan University Medical College said it
best: " Medical education is to pass on a humanized medicine
so that medical students may understand, experience and grasp
the humanistic philosophy of medicine and thus establish their
own value theory, ethical standard and eventually their own life
philosophy. Only when we reach this goal can we say our education
has succeeded." (12)
1.Shorter E: Health Century.
New York: Doubleday, 1987
2. Parsons AH, Parsons PH: Health Care Ethics. Toronto: Wall & Emerson Inc,1992: xiii
3. Haring B: Medical Ethics. Notre Dame, Indiana: Fides Publishers, 1973:5
4. Sheridan CL, Radmacher SA: Health Psychology : Challenging the Biomedical Model. New York: John Wiley & Sons, 1992:3-5
5. Kuhn TS: The Structure of Scientific Revolutions. Chicago: University of Chicago Press, 1962
6. McCelland DC: the Social Mandate of Health Psychology in American Behavioural Science, 28,1985:452
7. Ader R: Psychosomatic and Psychoimmunoloic Research, Psychosomatic Medicine, 42, 1980:307-321
8. Engel GL: The Need for a New Medical Model: A Challenge for Biomedicine. Science, 196, 1977:130
9. Good MJD: Medical Ethics Education: World Trends and the Harvard Experience in 101st Anniversary of medical Education in Taiwan, Taipei: Taiwan University Medical College, 1998:4-5
10.Tai MC: Biomedical Ethics, Medical Education and the Making of a Socially Responsible Health Professional in Medical Education, Special Issue on Conference on Medical Education 1993. Taipei,Taiwan: Taiwan University Medical College, 1993:162; Lee MB, LEE YC: The Current Situation of Medical Education in Taiwan, in 101st Anniversary of Medical Education in Taiwan. Taipei,Taiwan: Taiwan University Medical College, 1998:15
11. Niebuhr HR: The Responsible Self. New York: Harper & Row, 1963: 47-68
12. Hsieh BS: Introduction to Medicine. Taipei: Taiwan University Medical College, 1997:85.