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Rational Medicine,
Medical Rationing
by Marc S. Micozzi '74, M.D., Ph.D., and Dick Levinson (CMC '76)

The nature of Sir Francis Bacon's death speaks volumes about his life. Bacon was a statesman, lawyer, writer and philosopher, but science was his passion. During the winter of 1626, Bacon was undertaking a carriage ride when an idea occurred to him: Would subjecting a body to icy temperatures delay the process of putrefaction? On impulse, he left the comfort of his coach to purchase a chicken, which he packed with snow. While the scientific results of this experiment were never recorded, the medical consequences were unmistakable: Bacon contracted bronchopneumonia and died.

With today's treatments, Bacon might have survived that illness, thanks, in fact, to the scientific approach to medicine that his ideas helped shape. But even as he was helping to formulate an empirical approach to scientific research in 17th century England, such therapeutic modalities as acupuncture, herbal remedies, manual therapies, spiritual healing and the traditional medicine of India (Ayurveda) had been widely practiced for thousands of years. Today, we refer to these approaches collectively as "complementary" or "alternative" medicine. But if the world has changed greatly since Bacon's day, one thing that hasn't is that these "alternative" therapeutic approaches still constitute primary health care for 80% of the world's people, according to the World Health Organization.

Bacon's ideas of empiricism, as ultimately reflected in the Scottish Enlightenment, reached American medicine in the person of John Morgan, M.D., a graduate of the University of Edinburgh who founded America's first medical school at the College of Philadelphia (now the University of Pennsylvania) in 1765. Morgan's guiding principles are best described by the phrase "rational medicine"--an empirical system designed to provide a rational basis for medical practice by observing whether medical treatment alleviated human suffering and/or extended human life. Rational medicine was intended to supplant, in an enlightened way, medieval theories of medical mechanisms that were not linked to disciplined observations of outcome. It may have been the first articulation in English of today's "evidence-based medicine."

With the dawning of the 19th century came a series of brutal continental wars, which, ironically, served as an engine of medical progress. The physicians who treated Napoleon Bonaparte's troops were guided by a set of well-defined principles that emphasized " la terrain," or host factors. Today, we might describe this school as both vitalist and holistic. As Napoleon's empire expanded, these medical ideas spread across the European continent. However, while the French school of medicine survived the emperor's fall and remained the envy of Europe for decades to come, by the 1850s momentum had shifted to the German school, which--a bit like the Iron Chancellor Otto von Bismarck himself--was reductionist, materialist and focused on repelling invaders from without. At the time, with a host of infectious diseases then posing the most serious threat to public health, the German school's search for clinically proven "magic bullets" to combat germs made sense.

Today, however, the primary challenge confronting our health care system is different and more complex. Physicians are now being asked to manage a variety of chronic conditions for which "cures" may be decades away or may ultimately elude us. In the June 4, 2001, issue of The New Yorker, Dr. Jerome Groopman reviewed the relatively meager results of a "Thirty Years War" to find a cure for cancer. This initiative, launched by the Nixon Administration in the 1970s, seemed destined for failure. Cancer is not a single disease, but a multitude of different diseases with very different characteristics. In such cases, where "magic bullets" are hard to come by, expanding the range of therapeutic approaches available for use in disease management is of vital importance.

One problem is that both our current medical paradigm and the present standard of clinical evidence are too inflexible. Explaining the mechanism by which a given approach works has sometimes become more important than the empirical observation that it does work.

To see this more clearly, consider the example of bio-energy. Every physician who has ever taken a pulse, interpreted an EKG or studied a brain scan knows that there is a vital energetic component in the functioning of the human body. Using acupuncture to direct the flow of this energy for therapeutic purposes has been an essential element of the traditional medicine of China for thousands of years. During this period, hosts of practitioners have used acupuncture to treat millions of patients. A few years ago, the federal Food and Drug Administration officially reclassified the acupuncture needle as a therapeutic device after years of describing it as "experimental." Yet, bio-energy still remains outside the existing medical paradigm because Western science can't explain how it works. This is one of the few areas of scientific inquiry where we may actually be moving backwards, compared to the explorations of early 19th-century physicians and scientists.

There are other examples of phenomena that have an impact on patients even though we do not know how they work. This list would include the "placebo effect," a process in which a patient feels better after a treatment with no known medicinal value; the "laying on of hands," where a physician offers support and reassurance to a patient by touching him or her in an appropriate manner; and "undertaking to treat," in which a physician communicates intentionality in manner, tone and message, that he or she will do everything possible to restore the patient to health.

The impact of these approaches has been noted by physicians and researchers for many years. Since the attitude and psychological mind-set of the patient are important elements of the healing process, it would be counterproductive to dismiss the value of these healing phenomena.

If other cultures have discovered aspects of the healing abilities of the human organism that remain unknown, unexplained and officially unused by biomedicine, these could be seen as physiologic and not just dismissed as "placebo." So in this sense, the "placebo effect" may only point to the limits of our present knowledge of the physiology of the human body. As we learn more about the functioning of individual brain centers, the evidence in support of such conventional beliefs as "mind over matter" is growing.

For example, faith has traditionally been seen as the polar opposite of science. How do we measure the strength of religious conviction? How can we experimentally replicate the physiological impact of one person's spiritual experience? Yet new evidence indicates a closer link between spirituality and neurophysiology than we had previously expected. The work of my colleagues at the University of Pennsylvania has helped pinpoint the brain centers active when nuns pray and Buddhists meditate. And if we study accounts of deeply moving religious experiences across cultural, religious and historical lines, the descriptions are so similar that a link to core physiologic brain functions is strongly suggested.

There was a time when medicine was both an art and a science. Has modern medicine become too scientific for its own good? Until relatively recently, a physician knew his or her patients well enough to have a sense of an individual's personality, interests and place in both a family and societal context. If the physician wanted to change a patient's behavior, he or she could often intuit which approach was likely to be most effective.

In an insightful article in the May 2001 issue of Commentary, titled "Why Doctors Are Down," my colleague, Ron Dworkin, a physician, writer and social critic, notes that physicians were once responsible for the care of the total person. Beginning in the 1920s, many practitioners of the new "scientific medicine" could not or did not want to treat the emotional and spiritual problems of those who sought their help. This aspect of patient care was frequently messy and certainly "unscientific." Increasingly, these patients were farmed out to psychologists and psychiatrists. Immigrants and poor patients often faced problems that had to be addressed by the school system, judicial system or city hall. Over time, these patients became clients of the public hospital and social work systems.

Before the late 20th century, physicians functioned as independent professionals responsible for all aspects of patient care. In a truly free market, it was difficult to regulate or control them. After all, both the demands of their profession and their responsibilities made medicine a unique calling. As physicians became mere technicians of the body, with employers and government (the proverbial "third party") sharing the cost, medicine became easy prey for regulation. Physicians eventually may come to lead more balanced, less stressful lives than their predecessors, but what was once a special calling is now becoming merely another job. The economic realities of today have transformed physicians from healers to "providers," where time, care and costs are carefully rationed. I fear that rational medicine has become medical rationing. This is a circumstance welcomed neither by patients nor by physicians.

Today in America, complementary medicine is the one remaining area of health care that has not been reduced to a technical craft and rationed out on a "space-available" basis. While contemporary science increasingly demonstrates the value of these therapeutic approaches deeply rooted in ancient cultural or spiritual traditions, the demands of science have yet to overwhelm the art of caring for patients in body and soul. This is an irony Francis Bacon would have appreciated.

--Marc Micozzi '74, M.D., Ph.D., is executive director of The College of Physicians of Philadelphia, founding editor-in-chief of the first medical journal on complementary and alternative medicine, and author of Fundamentals of Complementary and Alternative Medicine. Dick Levinson (CMC '76) is director of public relations for The College of Physicians of Philadelphia.