A Pragmatist Recovery of Health: Rethinking the Limits of Biomedicine
While recent years have seen an explosion in bioethics, pragmatist contributions to this rapidly growing field have been tardy and comparatively minimal. One problem pragmatists working in the tradition of John Dewey and George Herbert Mead face is that the biomedical model of health employs philosophical assumptions that pragmatists have consistently and forcefully criticized in other areas of inquiry. To apply the important ethical insights of their intellectual tradition to biomedical problems, pragmatists must first reconstruct the idea of health. For the very conception of health has significant bioethical implications, about which the biomedical model currently misleads us. This project – the first such pragmatist effort – is, therefore, an effort to “recover” the concept of health along pragmatist lines, in the first place, as a complement to current pragmatist biomedical ethics, and secondly as a basis for future reconstructive work in research models, public policy, and institutional design. As such, it begins with reconstructive critiques of both the dominant biomedical model and evidence based medicine (EBM) before offering an argument for rethinking the proper object of health in terms of embodied selves, rather then merely physiological bodies; it then uses this account of the embodied self as a basis for a recovery of the ideal of health, and finally concludes with an examination of how such a recovery applies to a practical case study.
In Chapter One I make a case for reading Christopher Boorse's biostatistical theory of health (BST) as the fullest and most significant expression of the primary theoretical underpinnings of current biomedicine,which involve important philosophical mistakes leading to significant misdirections in mainstream biomedicine. A careful reading of the BST reveals that Boorse reifies or ontologizes statistical data. When transferred into biomedical practice, this biostatistical ontologization takes a toll in three main ways: the fragmentation of the body and the eclipse of the self; devaluing of physician competence and the undermining of patient self-knowledge; and the reification of risk and creation of proto-patients. Against this view, I offer a Deweyan critique, arguing that concepts, ideas, and theories should be understood as intermediary, operational, and instrumental rather than ontological; they guide action by indicating operations to be performed if certain desired existential results are to be achieved. Thus, the Deweyan critique requires the rejection of the BST as an interpretive framework. Quantitative methods remain very useful tools that can help guide action for the satisfactory transformation of an unsatisfactory existential-qualitative situation, but they must be understood and used within a broader interpretive framework of the sort Dewey suggests.
Against the backdrop of this critical reframing of Boorse’s BST, Chapter Two examines evidence based medicine (EBM), the current dominant mode of biomedical practice. EBM seeks to apply to medical practice so-called "hard" research evidence: quantitative data generated by randomized controlled trials (RCTs). After showing how the theoretical implications of the BST underwrite the practice of EBM, I offer a critique of the latter, again along Deweyan instrumental lines. EBM either rejects outright, or else demotes to the lowest rung of the evidence hierarchy theexistential-qualitative data provided by patients, becausethese are viewed as the least "rational" in virtue of their non-quantitative character. I argue that patients' existential-qualitative data are essential as evidence, both because some lived existential-qualitative disruption sets the problem in the first place, and because a satisfactorily resolved existential-qualitative situation is the gauge of whether our interventions are successful. This critique suggests that the proper object of health is not merely the ahistorical, quantifiable physiological body depicted by the BST and EBM; rather, it is the whole person, the embodied self. Because quantitative evidence finds its genuine meaning and significance only in the light of patients' experienced existential-qualitative situations, the scope of sound evidence must be expanded to include and prioritize existential-quantitative data.
Chapter Three focuses on reframing the proper object of health in terms of an account of human selfhood that successfully accommodates and meaningfully incorporates both quantitative and qualitative-existential data. For this purpose, I turn to Mead's comprehensive account of selfhood, which I argue represents the satisfactory philosophical account that is needed. Mead sees embodied human selves as contextual and social, and thus historical in the thickest possible sense. Under the biomedical gaze, the self is separate from and eclipsed by the body, which alone counts as “objective” by virtue of being quantifiable. By contrast, at the heart of Mead’s pragmatism is a rich account of the embodied self that sees bodies as central to persons, but equally importantly, sees selves as irreducible merely to bodies. Mead’s theory of selfhood offers three important features crucial for a reconstruction of health which does justice to both quantitative and existential-qualitative dimensions: the continuity of body and self; the social-environmental nature of selves; and the self’s narrative structure and the centrality of meaningfulness to it. These features are important because it is embodied selves and not merely bodies who suffer as a result of illness and disease. Suffering is always a matter of meaning, and meaning in turn is always contextual and historical. Reframing biomedicine in light of Mead's account of the self allows for a shift away from a theory of abstract states of health to an account of human selves living healthily, in which neither the physiological body of biomedicine nor the social self of daily living has the sole word, but are instead each mutually informative for the other.
On this basis, Chapter Four makes the case for understanding the idea of living healthily as a Deweyan ideal. Ideals for Dewey are not fixed or absolute, but are imaginative projections of the best possibilities of the present, and therefore arise from within and remain in service of experience. As such, they are neither paradigms of a perfected antecedent reality, which mundane experience can never hope to embody, nor mere fantasies, but rather active instrumentalities of experience useful for the guidance of conduct and the meaningful enrichment of experience. More precisely, Dewey understands ideals as generalized ends-in-view. As generalized, ideals are broad enough in scope to guide and direct the particular aims of a variety of individuals and groups of individuals, and to endow their conduct with added significance. As ends-in-view, ideals remain connected to experience. Their ability to guide conduct is a function of their genesis in concrete particular aims and purposes. Rooted as it is in the embodied self, the ideal of living healthily entails meaningful narrative self-development, in which quantitative physiological values and existential-qualitative values are ordered along axes of individuals’ ongoing purposeful life-stories. The ideal of living healthily, then, requires the coordination of a variety of values representative of one’s total life situation and not merely those representative of one’s biophysiological status, although the latter are always relevant to one’s life situation. Health in the prevailing biomedical sense, then, is not an end in itself, but rather one set of values to be coordinated alongside several others for the sake of meaningful qualitative experience. Physiological perfection, or biostatistical normality is always in service of improved existential-qualitative experience.
Having laid out the theoretical parameters of living healthily, Chapter Five applies this ideal to a practical case study. The case in question involves a middle-aged single Haitian female immigrant living in a major northeastern metropolitan center. She is receiving nutritional counseling for high cholesterol, but she also has a variety of physiological risk factors, including elevated body mass index (BMI) and overweight. All of these are complicated by her race and gender, which put her at a higher risk, statistically. After weeks of reticence, the patient agrees to follow the nutritional recommendations of her counselor, but only on the condition that she does not lose weight. If she begins to lose weight, she claims, she will stop following her counselor’s recommendations. The reason for this ultimatum, it turns out, is that men in her community prefer women with fuller figures. Hence, she is concerned not to lose weight despite also being concerned to lower her cholesterol, so that she finds herself facing a potentially difficult choice. From a biomedical perspective, there is no choice, for the problem and consequent solution are clear: her cholesterol, overweight, and BMI all need to be lowered, and quickly, because, as a black woman, she is already at a higher risk for heart disease, and these other risk factors compound the danger seriously. This response prioritizes biophysiological values to the neglect of existential-qualitative values. A response guided by the ideal of living healthily, however, seeks to coordinate the woman’s biophysiological values with her personal and cultural values, so that physiological health does not come at the expense of living healthily. To further strengthen the case, a number of relevant recent studies are cited which support the recovery of health advocated.