Sholom Glouberman is philosopher in residence at Baycrest Health Sciences in Toronto and the founder of Patients Canada. His latest book is The Mechanical Patient: Finding a More Human Model of Health.
The medical model that informs the training of doctors and the care of patients – a model that modern medicine has followed for 300 years – considers people to be machines with organs, limbs and chemical processes. A widely accepted definition says that health is “the level of functional and metabolic efficiency of a living organism.” Here, health is seen to depend on the extent to which our limbs and organs work well and the degree to which the mechanical systems of our bodies are in good repair. According to this, we are mechanical patients.
But we are not mechanical. How we are treated by doctors is at odds with much of our understanding of human beings. We are not individual mechanical systems, but social animals, closely connected to other people from birth. Unlike many other animals, we cannot survive in isolation. We are utterly dependent on others to care for us as infants – to feed us, to dress us, to protect us from ordinary dangers. We cannot learn to speak without interacting with other people, and we can only think in a language that we learn from them.
But when it comes to our health, we fall back on the notion that somehow we are isolated individuals whose health is understood as the proper functioning of our limbs and organs and the maintenance of appropriate bodily fluids. We are constantly advised to eat healthy food and exercise the right amount in order to be healthy, which is all well and good in maintaining the mechanics of the human body. But very little is said about the social and relational contributors to our individual health.
This is not surprising. Seventeenth-century mechanical philosophers such as René Descartes and scientists and chemical researchers such as Robert Boyle declared that the body was a chemical/mechanical entity. They made a strong distinction between the spiritual, non-material mind and the physical, mechanistic body. The distinction remains deeply embedded in our thinking – even when we know it is mistaken.
Some recent changes have made this mistake more critical. A good example of such a change is the significant reduction in deaths from communicable diseases between the late 19th century and the end of the 20th century. By 2012, according to the World Health Organization, more than 95 per cent of deaths in developed countries were due to non-communicable, mostly chronic diseases such as cancer, heart disease and type 2 diabetes. There is good, growing evidence that many chronic conditions are correlated with a wide variety of social/relational factors, many of them outside the parameters of the chemical/mechanical aspects of the patient, but it has so far proved difficult to change the medical research agenda to include them. So our treatments continue to be largely confined to drugs and surgery – chemical or mechanical interventions.
This, too, is not surprising. The traditional model that forms the basis of medical education remains that of the chemical/mechanical patient. Formal medical diagnosis and treatment of most non-communicable diseases remain either chemical – largely through the use of chemical tests and pharmaceutical agents – or mechanical, by means of imaging and functional tests or surgery. In fact, very little of patient diagnosis and treatment by conventional physicians includes an investigation of the social and relational situation of patients or their families.
An excellent test for overall health is longevity. Longitudinal studies in Britain starting in the 1970s recognized that social and relational factors contribute to health and illness. The National Child Development Study, for example, considered the lives of more than 17,000 people born in Britain during the week beginning March 3, 1958. It looked at the cohort soon after birth, then again at nine additional times from 1965 to 2014. The results are significant. They confirm that the health of this population is closely related to social and relational factors. They showed that those who overcame social disadvantages did so as a result of a wide variety of relational resources, including familial support, such as parental determination to assure proper schooling; behavioral resources, such as having a stable bedtime; and personal resources, such as gaining pleasure from recreational reading.
The Harvard Study of Adult Development began in 1938 and followed 700 men and some of their spouses for more than 75 years. Those subjects who are still alive are in their 90s. A major conclusion is that the greatest contributor to health into old age is strong, loving relationships. People who maintained close family ties and good friendships for a very long time remained healthier and happier into old age than those who did not. The Harvard study is of the social/relational resources of a particularly privileged group. Even at the top of the socio-economic scale, there are dramatic differences in health that are dependent on the quality of relational interactions.
A social/relational model of health asserts that healthy human beings are not isolated minds in chemical/mechanical bodies, but people in the world who engage with others in many ways, in a wide array of settings and with multiple purposes. This view is reinforced by scientific research about the need for connections with others for healthy human development. Everything from brain development to emotional maturity depends on connections to other people. Our medical model must change.