Medicine and medical ethics have come a long way since then. What has not changed, however, is the idea that the special concerns of medicine still must be rigorously distinguished from ‘unscientific’ affairs, again citing Dr. Hellegers, such as “personhood, value, dignity, or [other] words denoting societal attitudes toward biological life” (Hellegers 1973, p. 11). I say this while recognizing that most medical schools in the U. S. no longer agree with him, but have for decades offered at least something in ethics and ‘values;’ that hospitals, nursing homes, and other health care institutions must now have ‘ethics committees;’ and that some of these institutions even provide for what is called ‘clinical ethics consultation.’ Biomedical ethics has been a veritable growth industry since its modest beginnings in the middle 1960s—now more than ever, Arthur Caplan stated several decades later.² Some progress has occurred during this period, for instance, as regards certain ethical and legal issues at the end of life—formal recognition of the right of self-determination, withdrawal and withholding of life supports, ‘do-not-resuscitate’ orders, advance directives such as living wills, and even, in some states, ‘assisted suicide’—as distinct from ‘euthanasia.’

Even so, on some issues there seems to have been somewhat less progress. A glance at current discussions about what to do when medical treatments are ‘futile’ is sufficient to make the point. Despite some clarity achieved concerning permissible withdrawal of life supports, even these discussions often remain caught in intractable ambiguity. What should be done in a situation where the physician regards further treatment as ‘futile,’ but the patient or significant others insist that ‘everything must be done’ and all treatments continued? Should the physician override the patient’s or family’s wishes, in effect limiting or even voiding their ‘autonomous choice’ to continue treatment? How, after all, should ‘futility’ be understood—as ‘physiological’ or ‘personal’? Whose goals, the patient’s, the family’s, or the doctor’s, should govern? And who should define ‘benefit’—the doctor? the patient? the family? the court?

So far as issues at the beginning of life involve more than medical and scientific facts, what role do the individual’s ethical (or religious, at times even legal) beliefs play in abortion, embryo research, fetal tissue transplantation, stem cell or genetic research? When we ask, ‘When does life begin?’ which meaning of ‘life’ is or should be operative? Which meaning is most important, and for whom and why? Now profoundly shaped by developments in the field of genetics—whose impact on clinical practice is perhaps its greatest hope (and surely its principal public justification)—one finds the same anomalies and disturbing questions and discussions about the human body and human person still going on: even if an embryo and a fetus are human, what is their moral status and what is the best way to define that? Which actions follow from which set of beliefs? Are things different at different stages of life? What governs (and ought to govern) the decision, for instance, about experimentation on human fetuses or embryos? What is supposed to be done in the (very common) event of serious disagreement?

These questions are not completely novel. Centuries ago, for example, Galen, the physician who more than any in Western medicine’s long history left his own decisive mark on the discipline, had urged (and lamented) as he struggled (and, he thought, failed) to comprehend Plato’s idea of “psyche.” The only viewpoint that made sense to him was the medical materialism long advocated by those in the ancient Greek “Rationalist” or “Dogmatic” traditions: ‘soul’ is a ‘temperament of the body’ (Edelstein 1967, pp. 173–397). If one wishes to influence the soul, one can do so only through the body. The idea that considerations other than the corporeal body lay outside the sphere of medicine is both ancient and enduring.

Although widely supported even today, the dominant medical materialism view is nevertheless peculiar. Many doctors still try to avoid confusing ‘biological’ notions with ‘unscientific’ ones such as personhood, dignity, soul, and value, for these ideas are still thought to express mainly personal, sometimes social, attitudes about biological life. Yet, doctors cannot act without being with, talking and listening to, taking care of, and helping individual patients: human beings who are persons in whatever sense one wishes. And how could it be otherwise, if a doctor really does wish to help not simply a body, but an embodied person become better, get well, or at the very least feel more comfortable?

It is of course true that many doctors do not concern themselves with these matters, but simply go about their clinical practice without thinking about such things. Thus, despite the emergence of managed-care institutions and their already notorious intrusions into clinical situations, not to mention the always-increasing presence of governmental and insurance regulations and rules, one frequently hears about the ‘doctor-patient relationship’ as if it were still not much different from what it was in an early, mythic day of personal visits.

These relationships remain intimate even while largely between strangers, to be sure, and the idea that the heart of medicine is this one-on-one relation is still an article of faith among physicians, usually along with something about the Hippocratic tradition: acting on behalf of patients’ best interests and doing no harm. Not without reason: not only in early times when the abilities of doctors to heal or help was highly limited, but also in contemporary societies where technologically sophisticated drugs, surgeries, and regimens are readily available, much of a doctor’s daily work still occurs in such intimate relationships with patients—even if that relationship is often very brief and temporary. What Edmund Pellegrino calls the “clinical event” remains the organizing principle of medicine, (Pellegrino 1983) but has become increasingly difficult to sustain in the face of burgeoning technology and the bureaucratic structures that frame practice and research.

These peculiarities of modern medicine are probably due in large part to the fact that, since the late nineteenth century—even more since World War II—as the widely acknowledged basis for training in medicine became empirical science, especially the biomedical sciences. Despite that, however, the clinical practitioner’s concrete work is still for the most part with individual patients. Eric Cassell, for example, points to the gradual but clear shift in medicine in recent times, from an enterprise focused mainly on scientific discovery to one where intervention into some patient’s life is the key moment. Cassell’s point is well-taken: the clinical event is still vaunted as the core point of the medical enterprise, as often by those whose practice is as much bench science as it is clinical care of patients.

It is true as well that current economic and related considerations in the United States and elsewhere tend to support the point with an increased emphasis on family practice, nurse practitioners, and the like. Despite that, however, the very success of scientifically based, technology-driven and bureaucratically organized health care makes available to even the most modest practitioner a truly awesome array of diagnostic, therapeutic and prognostic techniques and abilities—a genuine cornucopia revealing a technical complexity whose mastery and use on and for patients requires a high level of scientific knowledge was well as expert technical skills. Inevitably, this also brought about basic changes in the nature of the clinical encounter.

It was not for nothing that over the same period of time there has been a great deal of criticism that, for all its newly won abilities to counteract the ravages of so many hitherto untreatable diseases and injuries, medicine is said to have lost sight of the ‘patient as person,’ in Paul Ramsey’s well-known phrase (Ramsey 1970). Instead, many critics charge, it focused on disease processes, pathological lesions, biologic processes, and organ systems—more recently, genetic underpinnings, causes, statistical links and tendencies toward disease conditions. Coupled with that is the impact on medical practice and health care generally of a bureaucratic organization that encourages as much attention and time to institutional continuance as to the care of patients.

Since Max Weber’s seminal writings, (Weber 1991) it has been recognized that the social, institutional organization of human social activities affects not only patients but also professional practitioners—physicians, nurses, the wide array of technicians, the institution itself and the broader social nexus—and that these organized bureaucracies tend, as has been widely observed, to ‘dehumanize’ and alienate, and thereby erode the governing purpose of the physician-patient relation (Pellegrino 1979). Indeed, the psychologist, Peter Lenrow, emphasized decades ago that the bureaucratic organization of human efforts to provide help to those who need help (and cannot help themselves) incorporates a deep value-conflict: while the institution is guided by mainly utilitarian values (such as efficiency and productivity), helping patients is guided by such radically different values (such as nurturing and caring)—and inevitably, it seems, the grounds for dehumanization and alienation are there as well (Lenrow 1982).

These considerations should be taken along another prominent facet of social life in those societies that provide scientific and technology-driven medicine to individuals. For the most part, doctors and patients are and tend to remain relative strangers to one another—while, however, they are, ironically and somewhat paradoxically, within a relationship that is intensely intimate and oftentimes involves profound interventions into the lives of sick and injured people. In a word, ethically speaking, the centerpiece of that relationship—reliance of the patient on the doctor’s knowledge and actions—presupposes the greatest form of trust but is at the same time precisely what is most compromised and threatened by the socio-economic organization of modern medicine: situations that require a maximum of trust too often promote little grounds for trust (Zaner 1991).

Indeed, while in a sense the cherished doctor-patient relation does continue in this new world of health care, it seems to persist increasingly as a kind of vestige, more like an archeological relic than the daily reality often touted. The very words—‘doctor,’ ‘patient’ and ‘relationship’—may then seem merely hollow shells, more nostalgic evocation than accurate description of what patients most need and physicians most want to provide.

This is only a first step in an effort to understand what the clinical encounter is all about; more needs to be said especially about the pressing issues occurring at the beginning and at the end of life—two of the most significant clusters of issues that are posed in the ‘new medicine.’ In a scientifically based, technologically sophisticated enterprise designed to cure, heal or at least ameliorate pathological conditions and processes—but driven by the urge to know (research) and socially organized in bureaucratic forms—there is not much space or place for the ‘patient as person.’ To talk about the ‘patient as person,’ in other words, is a plea for more ‘humanity’ in medicine, an appeal already recognized in 1927 by Francis Peabody (1927) and made into a veritable icon much later by Ramsey.

A second step should at least be suggested here. Consider a typical encounter between physician and patient in a hospital. To make things manageable, we can ignore here many of its features—the specific ailment, whether the patient is self-admitted or transported by ambulance, whether the patient has a family, friends, and so on. The situation is still considerably complex. To explain a particular procedure to a patient involves specific people, each with what Alfred Schutz termed his or her own “autobiographical situation,” (Schutz and Luckmann 1973, 1989) each of whom is actively engaged in an ongoing conversation at a specific time and in specific circumstances. The encounter occurs within a particular hospital and within only one of its units (emergency room, intensive care, cardiac unit, surgical ward) that includes other providers (nurses, consultants, residents, technicians, clerks), and which is only one of many units in the hospital. That hospital, moreover, is itself only one of several, sometimes many hospitals in that region, in a particular state, and in a particular country. Each of these units and hospitals operates under certain written and unwritten guidelines, protocols, regulations, and laws, the totality of which lies within the broader society with its own characteristic patterns of prevailing values (about, among other things, doctors, hospitals, sickness and health) (Fig. 3.1).

Each of the providers has his or her respective personal biographical situation, including values, beliefs, habits, and so on, and each works within a specialty or sub-specialty that has its accepted norms, codes and practices. Each practices within a specific hospital unit which has its own rules and protocols regarding resuscitation, accepted therapeutic regimens, written and unwritten rules and codes of conduct, and so on. As a socially legitimated institution, the hospital has its various rules, committees, and policies; each particular hospital region and state has its body of regulations, licensure policies, and laws; the national government has its regulations, policies, and laws; and the medical profession and specialty and subspecialty organizations have their accepted standards of admission, licensure and practice—all of which are components of the current culture with its complex folkways, mores, laws, institutions, and history. There are thus personal, professional, institutional, and prevailing social value-contexts that impact and configure each medical encounter.

There is, of course, a different but complementary complexity on the side of the patient. None of us are atoms in a void but are unique, embodied individuals with our own individual histories and biographies as well as multiple relationships, beliefs, values, and styles of life all involving other people—actions, language, situations—in a wide variety of ways. What is clear from even this brief overview, however, is that the usual way of understanding the clinical event—one person relating to another—has never been wholly true and, in any case, is not at all accurate in the context of any contemporary society.

Furthermore, with the most recent developments in the realm of medicine—specifically, the remarkable announcement in June, 2000,³ that for all intents and purposes, the fabulous de-coding of the human genome sponsored by the Human Genome Project is now all but completed—the genome identified, its strands sequenced, and increasingly understood—the clinical event is itself becoming fundamentally transformed, even as the face of medicine’s new promissory note about our genetic makeup and history is a coordinate transformation.

Such terms as these, increasingly common though they surely are, nonetheless betray a common thematic undercurrent, a structural feature of the clinical event. However, even while this event endures as the core of what doctors’ work is all about, it is more and more in danger of becoming ever more obscure and hard to define, concealing the persistent core of the doctor-patient relationship (Zaner 2005). The point deserves greater attention.

There are obviously different types of clinical encounter between helper and person needing help—whether for prevention, routine check-up, acute-care or chronic issues. Such differences are variations on an underlying thematic core. In the most straightforward terms, everyone caught up in the relationship is an embodied individual. Each person is embodied by an animate organism that is subject at once to the worldly and biological conditions affecting any such organism—illness and injury are the most obvious—and (within certain limits) to the complex strivings, efforts and wishes of the embodied person, soul or self whose body it is, who ‘has’ and ‘lives in’ that embodying body. There is nothing mysterious here; it takes no treasure-hunt to seek and find what is at issue here, for the words express precisely what each of us experiences and knows in the merest move of a finger, twitch of an eyebrow, or growl of hunger, whether any of these is specifically willed or not.

This phenomenon of embodiment is even more awesomely complex—surely as much as, in some respects even more than, the wonderful organic and genetic complexity exhibited by the human body touted by the different biological sciences. ‘As much as:’ after all, whatever else ‘it’ is, my body embodies ‘me,’ and in some perhaps obscure ways (Zaner 1964, 1992, 2006) is the basis for, and is itself part of, what each of us experiences at every moment of life. ‘More than:’ for even appreciating the marvelous intricacies of human anatomy, neurology, or physiology, there is the additional fact that must never be ignored or forgotten—that, in whatever sense may be given to the words, this one organism is experienced by me as ‘mine’ (Zaner 1984). It is experienced by the embodied person as uniquely singled out from among the vast universe of objects as ‘uniquely belonging to me,’ as uniquely that whereby ‘I’ enact ‘my’ wishes, aims, actions, and the like. If therefore we truly wished to discover the actual ground for such highly touted ‘ethical principles’ as autonomy, privacy, beneficence, non-malificence, respect, and others, then surely one must begin with this remarkable phenomenon—at the very least, this peculiarity of this animate organism, that it is ‘mine,’ cannot be ignored.

At this point, I want merely to note several of its facets. First, my body is, like any other biological entity, subject to certain of the conditions of a biological nature. As significant as that, second, is the fact that wherever ‘my body’ is, there am I; whatever is done to my body is done to me. In simplest terms, not only is my body susceptible to literal changes arising from the world, but it couldn’t be otherwise. To say alive, I must tend to my own body: to eat, breathe, drink, move about, at once affecting and being affected by things in the world, and thus each of us always lives within profoundly intimate and ongoing interrelationships with the surrounding world and its myriad constituents—thanks to ‘my’ embodying organism. What can happen to objects and organisms in the world can and does happen to my embodying body. Injury, illness, handicap, compromise—all are part of what embodiment means.

Third, to be injured or become ill is to undergo personal disruption, whether trivial or more serious: if I break a leg, I can no longer ‘do’ as I’ve done before but must now ‘do’ differently; if I become ill, I must ‘do’ differently than before. If anything is truly universal about human life, then surely these must qualify: that each of us becomes ill or injured, at some point and in some manner, no matter how apparently trivial, and that we each experience ourselves as ill or injured. Moreover, to be sick or injured means that the affected person must do something about it: ignore it (but only after noting it!) and let ‘nature take its course,’ treat myself if I can, or turn to another for help. Whether primitive or urban, in ancient times or today, old or young, male or female, we each become ill or injured in some way, and in response very often seek the help of others—most often, someone who at least professes the ability and means to help. We become ill or injured, and we seek help to be restored, to whatever extent possible.

Drawing the sphere of attention more narrowly now—ignoring, for instance, whether the one who professes to help really can—we must note that even the simplest appeal for help is quite complex. To appeal, even if motivated by serious illness, does not mean that the sick person will accept the help offered by the other (friend, acquaintance, shaman, or physician). But if accepted, the appeal is marked by an initial, singular act of trust. And this act, it should be emphasized, even while it may be thought to require some basis, some reason for giving one’s trust, yet is often enacted without that basis or reason, or with only the slightest one—perhaps, for instance, only the other’s words, or the word of a friend, or some chance noticing of an ad stating someone’s claim to help. If time permitted, this remarkable act should be carefully explicated, for too often nowadays not only are doctor and patient strangers, but their relationship is thought to be primarily fiduciary, with the emphasis placed on the pledge or vow of the physician (one professing the ability to help), solely on his or her trustworthiness. Clearly, however, trust must be earned, demonstrated or confirmed, and the initiating, positional act by the sick person is too often simply presupposed, passed over. The sick person turns to the physician first, and only later learns whether he or she is trustworthy; the fiduciary relation depends on that initial act of trust.

In any event, the relationship is one that is strikingly similar to a dialogue: an appeal by one who needs but does not know what to do, a response from one who professes to know and to be able to help, and the consequent opening-up of an ongoing relational interaction including discourse wherein the initial problem is progressively explored, continuously checked and tested, and, hopefully if at all, brought to some resolution. There are also genuine differences between these relations: the doctor’s attention is understandably focused by the illness or injury that initiates the relationship in the first place, and what ‘dialogue’ there is may often seem merely between the doctor(s) and the patient’s body, while the patient is passed over. Hence, it seems to me clear that the temptation for the physician to pay attention more to the body than the embodied person—more to the body as a biological entity than to the body as the patient’s embodiment, and thus more to the disease than to the one who is ill—is not due simply to prevailing medical training or ways of organizing the doctor’s work. It is, rather, a structural feature of the relationship itself: appeals by the sick, responses by the doctor—even though it is of course true that the training and institutional organization of health care enhances that temptation.

What has thus far been said is in any case sufficient to bring out what I take to be the key structural feature of the relationship: that it is, in essence, a structural asymmetry of power in favor of the physician, to paraphrase Lenrow (1982, p. 48). More specifically, the doctor, not the patient, has the knowledge and skills to help; the doctor, not the patient, has access to the vast array of available medical, diagnostic and therapeutic resources (consultants, equipment, medicines, drugs, procedures, etc.) to respond to the appeal. These are, moreover, typically backed up by considerable social legitimation (we are socially encouraged to take the doctor’s word for what’s wrong and what should be done about it), and legal authorization (only certain people are permitted to practice medicine).

This imbalance toward the physician is apparent in contemporary societies in the ways health care is promoted and organized, as by the relative social value these societies place on scientific research, technological devices, and formal training of health professionals. As contrasted to the power of the physician, there is what Pellegrino calls “the peculiarly vulnerable existential state” of the patient, (Pellegrino 1982) or what I’ve termed the multiple disadvantages inherent to the patient’s place in the asymmetrical relation. This vulnerability, moreover, is quite unique, as Pellegrino underscores:

The poor, the imprisoned, the lonely, and the rejected are also deprived of the full expression of their humanity, so much so, that men [sic] in these conditions may long for death to liberate them. But none save saints seeks illness as the road to liberation. In no other deprivation is the dissolution of the person so intimate that it impair the capacity to deal with all other deprivations. The poor man can still hope for a change of fortune, the prisoner for a reprieve, the lonely for a friend. But the ill person remains impaired even when freed of these other constraints on the free exercise of his humanity. (Pellegrino 1982, p. 159)

This asymmetry of power and vulnerability is vital for understanding medicine, especially in its modern-day forms. Properly understood, it is also central for apprehending the at times avidly pursued political maneuverings among different medical traditions during the nineteenth and early twentieth centuries, a rivalry that eventually resulted in the endorsement of allopathic medicine and the demise or decline and continuing struggle of so-called ‘alternative’ medicine—osteopathy, chiropractic, homeopathy, for instance. In different terms, while the structural asymmetry pertains to any form of medicine, it obviously takes on different emphases depending on the particular medical model.

This was already understood within the Hippocratic tradition. The essential feature of the initial act of trust by the patient forms one of its central themes: “What about the patient who is putting himself and ‘his all’ into the hands of the physician?” (Edelstein 1967, p. 329). The patient then no less than today is “in the hands” of the healer, whether chiropractor, osteopath or homeopath, surgeon or allopathic physician. To be sure, the specific possibilities of intervention, social acceptance, and legal authorization will obviously differ, at times considerably, for each of them.