What is medicine? Is it an art or a science-or a combination thereof? The debate over the nature of medicine is an ancient and a spirited one, which has not abated even in modern times but has intensified since the beginning of the twentieth century when the fortunes of medicine were tied to those of the natural sciences. The current debate over the nature of medicine is in terms not so much of art or science but rather in terms of evidence-based or patient-centered medicine. Traditionally the biomedical model envisions medicine as a science and as evidence-based, while the humanistic or humane models perceive medicine as an art and patient-centered. Much of the quality-of-care crisis, as discussed earlier, is a result of establishing medical practice on the natural sciences or reducing it to a science. The humanistic or humane modifications, in terms of stressing the artistic dimensions of medical practice or founding it on the patient, are to enhance the quality of medical care.
In a final section of this chapter, the nature of medicine is explored in terms of the biomedical model, which focuses on the logos or rationality of medicine that in turn drives its ethos or character, and in terms of the humanistic or humane models, which focus on the ethos of medicine that in turn drives their logos. My proposal is that modern medicine must undergo a revolution in terms of transforming its logos and ethos by grounding them in pathos.
Specifically, pathos can transform the logos of a biomedical practitioner's objective knowledge or technique and of a humanistic or humane practitioner's subjective information into wisdom, a wisdom that discerns the best and appropriate way of being and acting for both the patient and the physician. Pathos can also transform the ethos of a biomedical physician's emotionally detached concern or a humane physician's empathic care into a compassionate love that is both tender and unrestricted. That love is not a mawkish sentimentality but a vigorous passion that enters into the suffering of illness. Only a wise and loving stance will relieve the quality-of-care crisis of American medicine, by transforming both the logos and ethos of the biomedical and humanistic models.
1 Art or Science?
The debate over whether medicine is an art or a science has a long history (Pellegrino, 1979b). However, it was most turbulent during the late nineteenth to early twentieth centuries, when the fate and fortune of medicine were tied to those of the natural sciences. The task for many scientifically minded physicians was to sever medicine from a vitalistic approach and to secure its foundation on scientific rationality (Welch, 1908). No longer was medicine an ineffectual discipline but throughout the twentieth century startling, if not miraculous, advances in terms of diagnostic and especially therapeutic procedures and protocols made scientific medicine a powerful and effective means of treating patients-or so the rhetoric ran. What was once medical ignorance under the guise of art was replaced by the certainty of the natural sciences.
As the twentieth century progressed, for many the art of medicine was eclipsed by or reduced to the science of medicine. But could, or even should, the art of medicine be reduced to the science of medicine? For example, physiology, with its emphasis on precision and the quantitative, became the backbone of medical practice, which was reserved historically for anatomy (Meltzer, 1904). But as J.R. Botkin (1992) fretted, the beauty of physiology is seductive and precaution must be taken to secure the humane treatment of the patient. In this section, the art of medicine is first explored followed then by the science of medicine. Two derivative questions concerning the reduction of art to science and the combination of art and science are examined next. Finally, the point of the debate, if there is one, is explored.
1.1 The Art of Medicine
For many physicians, medicine has always and foremost been an art with science ancillary to its main goal-to heal this patient. For example, "Overall medicine is as it has always been-not a science but an art. Science may help, but it must not be allowed to rule the art" (Bourns, 1983, p. 56). What was meant by the art of medicine is the establishment of a personal relationship between the patient and the physician that addresses the patient's emotional and psychological needs. Others included in the art of medicine the link between soul and body, especially in terms of the discipline of psychology (Rushmore, 1923).
Besides the patient's psychology others included as part of the art of medicine the physician's sympathy for the patient, as well as other features of the physician's personality including ambition and enthusiasm for medicine's intellectual development, confidence in training and imperturbability and courage in the face of disaster and disease, and intellectual honestly when confronted with the unknown (Riesman, 1931).' The art of medicine "concerns itself not only with the sick individual but with the totality of his environment-his family, his friends, his occupation, his social and pecuniary status; indeed with everything that can favor or retard his recovery from illness" (Riesman, 1931, p. 374). It is a skill, then, in which the physician attends to the total care of the patient and its goal is the healing of the whole person not simply the curing of a diseased organ.'
The art of medicine certainly involves the application of the science to medical practice, which is its objective side, and includes the technical dimensions of patient care. "Art," according to Homer Swift, "implies arrangement, a creation of special conditions or relationships from available material... art has a never-ending task in arranging new combinations of materials which are constantly increased by science" (1928, p. 168). Art then is a craft or a doing. And, the art of medicine is a craft based on and at times guided by scientific and technical knowledge. Pellegrino likened the art of medicine to Aristotle's techne: "art had to do with the making of things, encompassing the necessary techniques and skills as well as the reasons underlying them" (1979b, p. 48).
The art of medicine is concerned with the concrete and particular aspects of medical knowledge and practice as they pertain to the individual patient. It is "the application of useful knowledge to attain beneficial results" (Hundley, 1963, p. 53). For John Fulton (1933), the development and use of the physician's hands played an important part in the objective side of medicine. Moreover, Swift demarcated between two roles for art in medicine: "Although the art of medicine may indicate the manner in which that knowledge may be applied it should also assist in the technique for acquiring new knowledge" (1928, p. 171).
1.2 The Science of Medicine
What is the science of medicine? Although medicine has been connected to the natural sciences since antiquity, most commentators locate medical science's contemporary appearance with the scientific revolution of the seventeenth centuryespecially with William Harvey's discovery of circulation (Riesman, 1931). However, the identification of medicine as a science by the profession at large did not occur until the late nineteenth and early twentieth centuries. The issue at this time for many physicians and other scientists was whether life or living organisms could or should be explained simply in physico-chemical or in vitalistic terms. For William Welch, as for many other scientifically minded physicians, the former terms were adopted and medical knowledge and practice were viewed as "rational... observational and inductive, mainly physical, as distinguished from vitalistic, and nearly devoid of superstition and the supernatural" (1908, p. 53). During the first half of the twentieth century, definitions of medicine as a science reflected this perspective. "The science of medicine," according to Fulton, "has reference to the analysis and interpretation of normal and pathological processes of the body in terms of physical and chemical laws (in so far as this is possible) with the end in view of instituting sound therapy" (1933, p. 112).
Whether medicine is a science for many depended upon how science is defined, even though most admitted that there is no good definition for science. For example, Alfred Cohn adopted George Sarton's definition of science as "systematized human knowledge" (1928, p. 405). For Cohn, the science of medicine entails the systematic study of diseases, especially using Virchow's doctrine of the cellular pathology and the methods of physiological and pathological investigation. Others also viewed the science of medicine as the systematic study of disease: "medicine, the science that most intimately concerns man,...deals directly with his body in a state of disease" (Swift, 1928, p. 169).
Lee Forstrom utilized R.B. Braithwaite's characterization of science to identify two features of clinical science: domain of investigation and investigative function. "The domain of clinical medicine," according to Forstrom, "is the human organism, in its manifold environmental contexts, in health and disease" (1977, p. 9). An important constraint is the notion of human disease and health, which narrows the domain of clinical science and distinguishes it from other scientific disciplines. The investigative function of clinical medicine pertains to both the clinic and operating room, spaces in which clinicians investigate the complexities of human illness. In these "laboratories," clinicians advance medical knowledge for their practice: "In its observation, testing, and intervention in these complex phenomena, clinical medicine exercises investigative as well as the more immediately apparent `diagnostic' and `therapeutic' functions" (Forstrom, 1977, p. 11).
Many commentators viewed medicine as a science, based on the traditional canon of science. "That canon," according to Pellegrino, "contained three elements: a method, a body of knowledge built up by that method, and an ex post facto explanation of reality based on generalizable laws which related the facts acquired by scientific method to each other" (1979b, p. 46). The scientific method was generally considered the method by which physician-scientists diagnose the patient's disease and then determine the best means to treat it. The method, as Lester King defined it, is "the foundation, on the basis of raw data, of articulate hypotheses, through which definite predictions, subject to verification, can be made" (1952, p. 131). Again, Swift characterized the scientific method as empirical, which involves "a tripod of observation, reasoning and experiment" (1928, p. 169) 3
As for the second element of the canon, the method of medical research and investigation has delivered a specific body of knowledge, as well as its own technical language: "medicine has accumulated theoretical knowledge of its own and this has had its origins in age-long and varying experience" (Cohn, 1928, p. 405). Of course, this body of knowledge also reflects the knowledge obtained from the other natural sciences like biology, chemistry, and physics (Swift, 1928).
The final element of the canon is identification of generalizations based on particulars. Although medicine deals with individual patients, this does not preclude generalizations. "Each individual patient," according to Clouser, "is indeed a nexus of causal chains making a unique particular. But that by no means makes abstraction and generalization over these particulars impossible" (1977, p. 5). Rather, generalizations in clinical medicine are possible "in principle" but are currently prohibited because of the complexity of medicine's subject matter.
Although these definitions seem straight forward for many others the definition of science or natural science per se was problematic, thus making any definition of medical science also problematic. Commentators on the nature of medicine felt that identifying medicine as a science was, for example, reductionistic. They asked whether medicine, especially its art form, can be reduced to science. For example, Canby Robinson queried whether "it is not unlikely that medical practice can ever be reduced strictly to a state of applied science, such as engineering" (1929, p. 460).4 Moreover, Ronald Munson argued that medicine cannot be a science because of fundamental differences between them: "the aim of medicine is to promote health through the prevention and treatment of disease, while the aim of science is to acquire knowledge; medicine judges its cognitive formulations by their practical results in promoting health, while science evaluates its theories by the criterion of truth" (1981, p. 204).
Recently, Hunter has claimed that medicine is not a science. Although she is aware that the circumstantial evidence points to medicine as a science, she insists that "medicine is not a science as science is commonly understood: an invariant and predictive account of the physical world" (1991, p. xviii).s For Hunter, as for Cassell (1991), the goal of medicine is to relieve this patient's suffering and to accomplish that goal science is certainly drawn upon but "medicine is (as it always has been) a practical body of knowledge brought to bear on the understanding and treatment of particular cases" (1991, p. xviii). Medicine is not so much a science as it is an art of interpreting the patient as text.
Besides the natural sciences, some commentators have examined the sociological nature of medicine, i.e. "Is medicine a social science?" For example, Michael Martin (1981) explored three possible interpretations of this question. The first is that medicine is wholly or just a social science. He rejected this interpretation on prima facie grounds, since physicians engage in scientific or technical analysis of the patient's physical state. Patrick Heelan (1977) identified the picture of the patient from this analysis as a "scientific image."6 The second interpretation is that medicine is "in part" a social science. In other words, there are social factors that can influence a patient's health or disease. Martin certainly acknowledged that this interpretation is true but in a trivial sense.
Martin also proposed a third interpretation in that medicine as a social science is a "slogan" By this, he meant that "the social scientific dimension of medicine is larger and more important than is usually recognized" (Martin, 1981, p. 348). To substantiate this proposal, he discussed the social influences on the origins, explanation and prevention of disease. Again, Heelan (1977) denoted the social picture of the patient as a "manifest image."' This image of the patient provides the clinician with "access to resources for understanding of the social, cultural, and hermeneutical complexity of the life-worlds of man" (Heelan, 1977, p. 32). Thus, the scientific image of the patient requires the manifest or social image in order to provide the physician with a complete picture of the patient. Only with such a full image of the patient, then, is holistic healing possible.
1.3 Combination or Tertium Quid
Is medicine a combination of art and science? Many commentators on this question believe that medicine must combine both to be effective. For example, Fulton (1933) championed a "union" of art and science-while Hundley (1963) a "balance" between them-for a successful clinical practice. Many metaphors have been used to illustrate the connection between the art and science of medicine. For example, Riesman suggested: "The art and the science of medicine are like the two sides of a shield; neither can exist alone; neither by itself can achieve the grand goal for which medicine has been striving through the ages-to relieve suffering and to prevent disease" (1931, p. 373). In other words, the physician should not only be scientifically or technically competent but also a caring and compassionate person. "The art of medicine and the science of medicine," according to Peabody, "are not antagonistic but supplementary to each other" (1984, p. 813).
Blumgart (1964) also claimed that the science of medicine and the art of medicine are not "mutually antagonistic" but rather "complementary." For him the intersection of the science and art of medicine is the patient. "Without scientific knowledge," argued Blumgart, "a compassionate wish to serve mankind's health is meaningless. But scientific knowledge without wisdom," he stressed on the other hand, "is a frozen storehouse" (1964, p. 449). The wisdom necessary for efficacious application of medical knowledge from scientific endeavors is obtained from years of caring for patients as persons and not simply as diseased parts that are reduced to their physical and chemical states.
Finally, is medicine neither art nor science but something else? Some commentators agree that the art and science of medicine are necessary for medical knowledge and practice but insufficient for explicating the nature of medicine." For example, Marinker claims that "medicine should be regarded neither as an art nor as a science in itself, but as a special kind of relationship between two persons, a doctor and a patient" (1975, p. 83). For Pellegrino, what guides that relationship is the end or purpose of medicine-the healing bond. "Medicine in its function as medicine" argues Pellegrino, "resides in making of a prudent healing decision for a specific person" (1979b, p. 49). Although medicine cannot accomplish this end without both art and science, its practice is separate from both. Pellegrino and Thomasma claim that "medicine is a distinct intermediate discipline, a tertium quid" (1981 a, p. 59). They view medicine as a unitary and unique discipline, in which the science of medicine in terms of its healing technology is applied with a humane or an artistic touch.
Interestingly, Pellegrino (1979b) claims that the debate over whether medicine is an art or a science is pointless. However, having made this bold claim, he seems to retreat from it. "How science and art are construed, and how much of each we think we use in medicine" Pellegrino admits, "must be assessed by each of us. The physician's self-image, education and satisfaction are" he adds, "inextricably bound to these construals" (1979b, p. 51). He believes that each physician must come to a consensus concerning the role of art and science for how he or she is going to practice medicine. Indeed, earlier Swift argued that "the skill in which we mingle the two will determine our success" (1928, p. 171).
However, the above position on the point of the debate begs the larger normative question. How should the profession itself view or address the debate? Besides the standard interpretations of the debate, it is important for another reason-the temptation to reduce the art of medicine to its science and the patient to a machine. As John Hundley has warned: "It is the art of medicine, applying with reason and judgment the science on which much of medicine is based, which enables the discriminating and wise physician to make the distinction, and by so doing, avoid the apparently increasing risk of becoming only a scientific medical technician" (1963, p. 54). The distinction between the art of medicine and the science of medicine is an important distinction and one that is crucial for understanding the very nature of medical knowledge and practice.
2 Evidence-Based or Patient-Centered?
Although the debate over whether medicine is or should be an art or a science appears to have faded during the latter part of the twentieth century, it really took on a new form-the debate over whether medicine is or should be evidence-based or patient-centered. Evidence-based medicine (EBM) is driven by the metaphysical and epistemological dimensions of the biomedical model, i.e. the physician is to apply the latest therapy proven effective through RCTs. Patient-centered medicine (PCM), however, is based on the moral or humane nature of the patient-physician relationship, i.e. the physician takes into consideration the patient's emotional state and value structure. Besides PCM there are a host of closely related versions, such as "real-world medicine" (Hampton, 2002). However, two related versions include narrative-based medicine (NBM) and value-based medicine (VBM). In this section, EBM is discussed first, followed by PCM and finally by NBM and VBM.
2.1 Evidence-Based Medicine
Although the phrase EBM is recent in origin, the idea has a long history in medicine; at least this is the claim according to its proponents.' There are three historical periods to EBM, with one transition period (Claridge and Fabian, 2005). The first period, ancient era EBM, involved anecdotal accounts transmitted through authoritative teachings. The next period, Renaissance era EBM, began during the seventeenth century with challenges to popular therapies, such as bloodletting. For example, trials were conducted to evaluate the efficacy of bloodletting. The result was the abandonment of bloodletting by the end of the nineteenth century.
A transition period from the 1900s to the 1970s issued in the RCT, which made possible modern era EBM in the latter part of the twentieth century. The two framers of contemporary EBM are Archie Cochrane from the United Kingdom and the Evidence-Based Medicine Working Group chaired by Gordon Guyatt of Canada. The Cochrane Collaboration, founded in 1993, provides reviews of up-todate evidence from clinical trials (Chalmers, 1993). Contemporary EBM is an attempt to manage large amounts of medical research evidence, in order to help "patients and societies make better choices and thereby optimize patient outcomes and public health" (Woolf, 2001, p. 41).
The Evidence-Based Medicine Working Group provided one of the first comprehensive and most recognized articulations of EBM. EBM is often envisioned as a new paradigm in contrast to the old paradigm of traditional medicine. The old paradigm is predicated upon unsystematic observations and traditional medical training that focuses exclusively on pathophysiology and clinical experience. "This paradigm," according to the Working Group, "puts a high value on traditional scientific authority and adherence to community standard approaches, and answers are frequently sought from direct contact with local experts or reference to the writings of international experts" (Evidence-Based Medicine Working Group, 1992, p. 2421).
The new paradigm, EBM, puts less stock in traditional medical authority and more in systematic observations, especially obtained from RCTs, and interpretation of those observations though meta-analysis (MA). The outcome of this paradigm is that "physicians whose practice is based on an understanding of the underlying evidence will provide superior patient care" (Evidence-Based Medicine Working Group, 1992, p. 2421). According to the Working Group, the new paradigm represents a Kuhnian paradigm shift and the future of medical practice.
David Sackett, an original member of the Evidence-Based Medicine Working Group, and colleagues formulated one of the first and best known consensus definitions for EBM: "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett et al., 1996, p. 71).10 EBM is a combination of the best available research evidence from RCTs and MAs, along with the clinician's personal expertise and experience. The "good" physician requires both for practice since either alone is insufficient: "Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients" (Sackett et al., 1996, p. 72).
Besides identifying what EBM is, Sackett and colleagues also identify what it is not. EBM is certainly not "old hat" medicine, since the rise of evidence from RCT is rather recent. Moreover, it is not impractical, in that it is not impossible to practice EBM, as evident from studies demonstrating that clinicians and surgeons are successfully applying it. Finally, EBM is definitely not "cookbook" medicine since it requires the input of the clinician's expertise in applying a treatment established by the best available scientific and clinical evidence. EBM, then, provides the best possible medical care based on the latest technological advances, experimental and clinical data and observations, and the best theoretical explanations and logical thinking."
Sackett and colleagues have proposed five steps for the practice of EBM (Sackett et al., 1998). The first is the articulation of clinical question(s) concerning the patient's disease state. An important feature of these questions is that they must be clearly focused on the patient's problem and answerable by searching available literature databases. They propose that the question(s) should be structured in a PICO format: patient or problem, intervention, comparison of interventions, and outcome(s). The next step is finding the relevant evidence within a medical literature database, like PubMed, to answer the question(s). The success of such searches depends upon identifying the appropriate key words and databases. The third step is the appraisal of the evidence obtained from the search, with respect to its validity or soundness and its clinical usefulness. Appraisal is a skilled activity that requires training and experience. The next to last step is applying the evidence to the patient's problem, especially in terms of the patient's values. The decision is often the patient's obligation, given the evidence presented by the physician. The final step is formal evaluation of the four steps to determine the effectiveness of the process.`
There is generally little, if any, room in the biomedical model, especially in terms of EBM, for the intuitive dimensions of either the physician or patient. Indeed, the biomedical model of medical knowledge and practice strives to be strictly rational and evidence-based. According to Liberati and Vineis, "intuition and unsystematic clinical experience as well as a pathophysiological rationale are insufficient grounds for clinical decision making. On the contrary," they insist, "the modern practice of medicine finds its way by reliance on formal rules aimed at interpreting the results of clinical research effectively; these rules must complement the medical training and common sense of clinicians" (2004, p. 120). Moreover, EBM requires an extended commitment on the physician's part in terms of training: "The practice of evidence-based medicine is a process of life-long, self-directed learning in which caring for one's own patients creates the need for clinically important information about diagnosis, prognosis, therapy, and other clinical and health care issues" (Sackett, 1997, p. 4).
EBM also depends on advances in computer technology. The reliance of medicine on such technology was presaged in the early 1970s. At that time, the application of the computer to medicine was heralded to revolutionize medical practice in the near future: "it seems probable that in the not too distant future the physician and the computer will engage in frequent dialogue, the computer continuously taking note of history, physical findings, laboratory data, and the like, alerting the physician to the most probable diagnoses and suggesting the appropriate, safest course of action" (Schwartz, 1970, p. 1258). Although the application of the computer to medical practice took longer than originally anticipated, we now benefit from the use of computers in diagnostic procedures such as computerized tomography. Moreover, search engines, like PubMed, provide ready access to results from RCTs and MAs. Finally, the application of artificial intelligence holds great promise-or so its adherents claim-for tomorrow's medical knowledge and practice (Coiera, 1996).
Although no one argues with the rational basis of medicine or even with its evidentiary base, there is considerable discussion and debate over the notion of EBM. Consequently, EBM is severely criticized on several fronts. For example, an anonymous organization that calls itself Clinicians for the Restoration of Autonomous Practice provided a scathing attack on EBM in a 2002 issue of the British Medical Journal (CRAP Writing Group, 2002). This Writing Group claims to have "irrefutable proof that EBM is, indeed, a full-blown religious movement, complete with a priesthood, catechisms, a liturgy, religious symbols, and sacraments" (2002, p. 1496).
The above criticisms are in response to the aggressive claim made by EBM's proponents that EBM represents a "paradigmatic shift" in medicine, from a nonscientific medicine to a scientific one. It is this claim to which the defenders of the older, traditional medicine bristle and take umbrage. However, this claim is "not only simplistic but, as any closer scrutiny will reveal, profoundly wrong. The difference that needs to be marked is not that before EBM people did not use the evidence. Rather, the real failure was the lack of a framework and a set of rules to use the evidence in a systematic and explicit fashion" (Liberati and Vineis, 2004, p. 120).
Critics of EBM also raise other objections and concerns. For example, Abhaya Kulkarni (2005) identifies several empirical and conceptual problems, including differing opinions of MAs over evidence, conflicting results from RCTs, and threshold for accepting current evidence. Also, John Worrall (2002) raises the problem associated with EBM's dependence on randomization. He claims it only controls for selection bias.
In addition, Mark Tonelli (1998) distinguishes several philosophical limitations to EBM. The first limit is that evidence obtained from population-based studies like RCTs is not readily applicable to any individual patient, given the variation from one patient to another. This limit is epistemological in nature. Another limit is ethical, in that EBM cannot address the ethical question of whether the patient wants to undergo the treatment based on the best evidence. Finally, there is a tacit limit to medical judgment that outstrips the algorithmic approach of EBM. "Clinical judgment appears to contain a tacit element," Tonelli opines, "one that cannot be captured by decision analysis or any other explicit model" (1998, p. 1238). For him, clinical judgment is more akin to casuistry than to scientific rationality.
The proponents of EBM have responded to these criticisms. They certainly recognize that there are a number of limitations to EBM but believe that they can be addressed successfully. For example, "the elimination of individual difference in trials does not render trial data inapplicable to individuals; rather, it makes it applicable to the extent that individuals share relevant characteristics with trial participants" (Parker, 2002, p. 275). But critics counter that the patients corresponding to the test population represent only a small part of the larger "real world" patient population. Sharon Straus and Finlay McAlister (2000) acknowledge this problem but report that subgroup studies to the main RCTs are conducted to include patient values and particularities. Moreover, Malcolm Parker cautions that stressing the uniqueness of patients underestimates the commonality of patients: "Overweening particularism is a conceit as harmful as coercive scientific generalization" (2002, p. 279). Finally, Straus and McAlister (2000) address what they consider to be the predominant misperception: EBM is an "ivory-tower" notion, with little "real world" application. Clinical surveys, however, reveal otherwise.
2.2 Patient-Centered Medicine
Can EBM provide the necessary resources for comprehensive medical knowledge and practice? Although EBM is revolutionizing medicine and providing a solid empirical basis for medical knowledge and practice, especially in terms of RCT and MA, some commentators believe that EBM is unable to under gird modern medicine adequately or completely. "There is no doubt," according to Liberati and Vineis, "that EBM does not, and cannot, answer all the epistemological and practical questions surrounding the practice of medicine" (2004, p. 120).
EBM certainly provides physicians with the methodological skills to utilize current empirical evidence needed for medical knowledge and practice; but, claim many critics, what about the patient's personal information. In the last several decades, PCM arose to prominence in medicine to address this need (Stewart et al., 2003). It is based on the patient's personal information and history, especially information the biomedical model finds distracting: "in RCTs patient characteristics are considered a nuisance that might disturb the results of the study, instead of providing valuable extra information" (Bensing, 2000, p. 19). It is that information that is critical for the practice of patient-centered or humanistic medicine.
PCM is often contrasted with EBM. EBM is thought to represent the natural or "hard" sciences, while PCM the clinical or "soft" sciences (Stewart et al., 2003). Whereas EBM "has basically a positivistic, biomedical perspective... Patientcentered medicine.. .has basically a humanistic, biopsychosocial perspective" (Bensing, 2000, p. 17). According to Jozien Bensing PCM is also distinct from EBM's "diseased-centered" perspective, since "the patient is more than his or her disease" (2000, p. 21). PCM "deals with the content of the consultation, the choice of topics that should or could be addressed, according to the patients' needs and expectations" (Bensing, 2000, p. 21). It also "deals with the control over the consultation, with the question whose agenda is dealt with, who is expected and has the power to make decisions" (Bensing, 2000, p. 22). Moreover, PCM is distinct from EBM's "doctor-centered" tendency, particularly with an emphasis on patient autonomy. In PCM, the focus is shifted from diagnostic accuracy in the physician-centered consultation to the patient's illness experience.
The goal of PCM is to bring the patient's world into focus. "The physician," according to Ian McWhinney, "is enjoined to discover the patient's expectations, his feeling about illness, and his fears. He does this by trying to enter the patient's world and to see the illness through the patient's eyes" (1988, p. 225). Moreover, the patient-physician consultation is a "moral encounter, and the responsibilities that spring from it (for both parties), can then provide the framework within which any effective consultation can take place" (Evans, 2003, p. 9).
The means to achieve PCM's goal is effective communication. Bensing emphasizes that "the best way to know the patients' agenda is still, and will perhaps always be, listening to the patients' story and seeking the right balance in the decision making process" (2000, p. 23). Communication, then, is critical for the success of PCM: "communication is the royal pathway to patient-centered medicine" (Bensing, 2000, p. 23). There are three reasons why communication is essential for PCM: the patient is the expert in terms of the patient's illness experience, different patients have different preferences in terms of healthcare, and patient morbidity depends upon patient's adaptation and coping mechanisms (Bensing et al., 2000).
Moria Stewart and colleagues have identified six, interacting components to PCM (Stewart et al., 2003). The first is the assessment of the two elements of the patient's presenting complaint, in term of the physical disease itself and of the patient's illness experience. The first element is obtained through the traditional medical history and physical exam, while the second through communication with the patient in terms of the impact the illness has on the patient's lifestyle and emotional wellbeing. The next component is integrating the information obtained in the first component with an overall understanding of the patient as a whole person, including the patient's proximal and distal contexts.
The third component is uncovering a common ground between patient and physician, particularly with respect to identifying the patient's health problem, agreeing on the therapeutic modalities, and defining the roles played by both the patient and physician. The next component involves promoting patient-physician consultations as an opportunity to promote wellness and to prevent further health problems. The fifth component is the growth and establishment of the patientphysician relationship, especially through compassion on part of the physician and compliance on part of the patient. The final component is that both the patient and physician must be realistic about the limitations of modern medicine: the former cannot expect miracles and the latter cannot promise them.
Although EBM and PCM appear to be polar opposites of one another there is significant overlap between them, according to some commentators. For example, Stewart and colleagues claim that EBM and PCM are "synergistic," in that both approaches to the practice of medicine converge to produce "creative tension" between the physician's and the patient's perspectives (Stewart et al., 2003, p. 12). Bensing proposes an integration of EBM and PCM. He advocates improving PCM by developing more rigorous communication studies that mimic RCT, which would provide explanations for behavioral activities between patients and physicians during the clinical encounter. Bensing also proposes to bridge the gap between EBM and PCM through communication studies, particularly by incorporating patients' preferences into the design of RCTs, thereby making EBM more patient-centered. "The challenge for the near future," according to Bensing, "is to bring these separate worlds together" (2000, p. 17). The obvious benefit is a more robust medicine, in which the patient's health needs are met and the physician's role as healer confirmed.
2.3 Narrative-Based Medicine
Communication between physician and patient, as noted above, is critical for the success of humanistic or humane medicine. Besides PCM, another type of humanistic medicine-NBM-has also gained prominence in the last several decades. The physician enters the patient's world of illness and suffering and learns what it means to the patient, by listening sympathetically to the illness story. For example, Arthur Kleinman champions the importance of the patient's narrative and the physician's responsibility to take it into account, during the healing process:
The work of the practitioner includes the sensitive solicitation of the patient's and the family's stories of the illness, the assembling of a mini-ethnography of the changing contexts of chronicity, informed negotiation with alternative lay perspectives on care, and what amounts to a brief medical psychotherapy for the multiple, ongoing threats and losses that make chronic illness so profoundly disruptive (1988, p. 10).
The meaning that a patient attaches to illness and suffering, especially chronic or fatal illness, is critical for the healing process-and that meaning is readily accessible through the patient's illness story. Consequently, it is imperative that the physician take this story seriously when diagnosing and treating the patient. According to Rita Charon, "narrative medicine can give physicians and surgeons the skills, methods, and texts to learn how to imbue the facts and objects of health and illness with their consequences and meanings for individual patients and physicians" (2001, p. 1898).
Trisha Greenhalgh and Brian Hurwitz (1999) point out several important advantages of NBM. For diagnosis, NBM provides an atmosphere in which professional intimacy can be fostered between patient and physician and also assists both patient and physician in developing an understanding, respectively, the meaning of the illness. It also facilitates sympathy between the physician and patient by permitting the patient to tell the illness story and the physician to listen intently to it. Often by listening to the patient's illness narrative the patient reveals the diagnosis to the physician, since narrative represents the "phenomenal form" of the illness. For therapy, NBM provides the occasion for a holistic approach to healing. It also facilitates the analysis of alternative therapeutic modalities or for palliative care instead of an aggressive therapeutic modality. "The core clinical skills of listening, questioning, delineating, marshalling, explaining, and interpreting," claim Greenhalgh and Hurwitz, "may provide a way of mediating between the very different worlds of patients and health professionals" (1999, p. 50).
2.4 Value-Based Medicine
VBM is proposed not so much as an alternative to but more as an extension of EBM; and, it reflects the rise of consumerism in medicine (Kottow, 2002). VBM is pyramidal in structure, with EBM at its base and with an intermediate tier composed of patient-perceived values in terms of quality and/or length of life, and with a top tier in which the patient-perceived values are converted to economic values by cost-utility analysis. "Value-based medicine," as defined by Melissa Brown and colleagues, "integrates the best EBM data with the patient-perceived quality of life improvement conferred by a healthcare intervention" (Brown et al., 2005, p. 5).
Cost-utility analysis is the means by which to quantitate treatment outcome in units of monetary expense per gain in quality or length of life. This analysis is imperative for distinguishing between interventions that provide little, if any, gain from those that provide maximum gain at minimum cost. VBM is an "information system" that improves the quality of healthcare and, at the same time, makes healthcare more cost-effective or efficient. "VBM," according to Brown and associates, "allows clinicians to practice the highest quality of healthcare... Because it permits clinicians to selectively utilize interventions that deliver the greatest value from the viewpoints of patients who have lived in a health state" (Brown et al., 2005, p. 9).
3 From Logos and Ethos to Pathos
The earlier debate between the art and science of medicine and its contemporary manifestation in terms of EBM and PCM belie a deep problem with the nature of medicine, particularly with respect to the quality-of-care crisis. A complementary position or even a third alternative position to this debate is unlikely to resolve the crisis; rather, the resolution involves the connection of medicine with its pathos. For the underlying problem, especially for American medicine, is that its logos (rationality) and ethos (character) are severed from its pathos (passion).
The paradigmatic shift that American medicine must undergo is not just from the biomedical model to one of its humanistic or humane versions or even to one of the alternative models, but from a medicine concerned only with logos and/or ethos to a medicine rooted in pathos. For scientific knowledge or personal information and emotionally detached concern or empathic care to be effective, they must be rooted in passion.
Contemporary medicine must secure a sensitive and responsive pathos to guide its rationally oriented logos and character-driven ethos, before it can address the issues surrounding the quality-of-crisis facing it. This pathos reflects a way of being present in and to the patient's suffering and not just knowing accurately or acting appropriately in the presence of the disease or illness. Pathos implies here more than simple emotion or desire; rather, it reflects a passionate or ardent way of being fully present that makes possible both accurate knowing or understanding and right doing or acting. Fundamentally, humans are conscious and irritable persons that respond as self to their environment and to others in it and by such responding are responsible for that response. It is that self-conscious respondability or response-ability that makes possible rational and virtuous or passionate medical knowledge and practice.
But how can rooting of logos and ethos in pathos affect change in the healthcare industry, from a philosophical perspective? The answer is two-fold. First, pathos can transform the logos of technique, facts, objective knowledge, and subjective information into wisdom, a complete or comprehensive wisdom that can discern the best and appropriate way of being and acting for both the patient and the physician. Second, pathos can transform the ethos of the biomedical physician's emotionally detached concern or even the humanistic physician's empathic care into a love that is both tender and unrestricted. For: "Every illness is also a plea for love and attention" (Marinker, 1975, p. 82). And: "The prescription, love thy patient, is good medicine for the good doctor" (Rhodes, 1995, p. 441). This love is not a mawkish sentimentality but a vigorous passion that enters into the suffering of illness; it is a compassionate or suffering love.
In this final section, I explore the transformation of medicine's logos and ethos via pathos to produce a wise and loving medical stance and practice. To that end, the nature of pathos is first explicated, followed by its transformation of logos as knowledge or information into wisdom and of ethos as concern or care into compassionate love. For, only a wise and loving stance will resolve the quality-ofcare crisis in modern medicine, especially in America.
3.1 Pathos
What is pathos? Traditionally, pathos is associated with the emotions or passions. For example, pathos is a person's quality or state in which an emotion like kindness or mercy is evoked. It is often contrasted with ethos, which is associated with unflappable or unquestionable character, and with logos, which is concerned with an argument's strength or validity. Pathos involves the transient and deficient, while ethos the permanent and ideal.
Pathos is also one of the three proofs (pistesis), along with logos (logical validity) and ethos (credible character), which Aristotle (2001) delineated in the Rhetoric. The function of pathos is to persuade another through an emotional appeal. Pathos as used here, however, transcends the emotional or even the logical. It is a power or force that operates like an assumption in a metaphysical sense. Although emotion as pathos may represent a power, pathos per se is not limited to just an emotional force. It is a power or force that makes possible, especially in terms of creating or transforming, whether at the logical or ethical level.
The use of pathos as a power or force akin to a metaphysical assumption must also be distinguished from the notion of "metaphysical pathos," as developed by Arthur Lovejoy (1873-1962). "`Metaphysical pathos' is exemplified," according to Lovejoy, "in any description of the nature of things, any characterization of the world to which one belongs, in terms which, like the words of a poem, awaken through their associations, and through a sort of empathy which they engender, a congenial mood, or tone of feeling on the part of the philosopher or his readers" (1936, p. 11). In other words, a metaphysical pathos represents "the emotional `charge' of certain words and phrases" (Macksey, 2002, p. 1089).
Lovejoy distinguished five types of metaphysical pathos, including the pathos of obscurity, esoteric, eternalistic, monistic or pantheistic, and voluntaristic. Since Lovejoy published his notion in the mid 1930s, others have identified additional types of metaphysical pathos. For example, bureaucratization represents a metaphysical pathos that shaped post-World War II industrialization (Gouldner, 1954). And, "technicism" is a metaphysical pathos that has shaped much of contemporary social organization (McSwain and White, 1989). Interestingly, the fear over technicism is that it may result in a "broad-scale emotional anesthetization of the human race," unless accompanied by openness to a "caring commitment." Although Lovejoy's metaphysical pathos is different from my use of pathos, it is similar to the role pathos plays here in that both are critical for shaping philosophical systems, even their logic.
3.2 Wisdom
We live in an information age, an age in which we know more than ever, and yet, an age in which we face more problems than ever but fewer solutions to those problems. "We are saturated with information," according to shaman Kakkib li'Dthia Warrawee'a, "and lacking in the most vital ingredient: wisdom" (2004, p. 9). Many medical pundits comment especially on the glut of knowledge and information and yet on the dearth of wisdom for applying that knowledge and information in the biomedical sciences. For example, Robert Pollack queries: "Why is there not more wisdom in the application of scientific discoveries to the lives of sick and suffering people?" (1999, p. 1477). The issue for contemporary medicine is how to move beyond biomedical knowledge and information to wise application of that knowledge and information in clinical practice. Although Pollack and others attempt to answer this bothersome question, part of the problem in answering it is that wisdom itself is not well understood and difficult to explicate."
What is wisdom? The ancient Greeks defined it in terms of action with respect to virtue, whether intellectual or moral. The wise person acts in accordance with the virtues and the virtuous person acts in accordance with wisdom, especially to enhance a person's flourishing or eudaimonia. In the Nicomachean Ethics, Aristotle called wisdom "the most finished of the forms of knowledge" and divided it into the theoretical or philosophical (sophia) and the practical or political (phronesis) (2001, 1141a16). Theoretical wisdom is contemplative in nature and is sought for its own sake: "philosophic wisdom is scientific knowledge, combined with intuitive reason, of the things that are highest by nature" (Aristotle, 2001, 114 1 b3-4). The intuitive reason is nous or the ability to grasp the first principles, while the scientific knowledge is episteme that involves knowing the four causes.
"Practical wisdom on the other hand," according to Aristotle, "is concerned with things human and things about which it is possible to deliberate" (2001, 1141 b8-9). In other words, it is concerned with the pragmatic activities of life. Practical wisdom is concerned not only with universals, like theoretical wisdom, but also with particulars, unlike theoretical wisdom. Moreover, Aristotle argued that theoretical wisdom ranks higher than practical wisdom, since practical or political wisdom is concerned with man, who is "not the best thing in the world" (2001, 1141a23).
Contemporary approaches to wisdom are indebted to the ancient Greeks. "Wisdom in its broadest and commonest sense," according to Brand Blanshard, "denotes sound and serene judgment regarding the conduct of life" (1967, p. 322). There are several components inherent to this definition, including knowledge, reflectiveness, judgment, and self-trust (Blanshard, 1967; Kekes, 1983; Szawarski, 2004). The first component of wisdom is knowledge or facts (Szawarski, 2004). Drawing on John Kekes distinction between descriptive and interpretative knowledge, Zbigiew Szawarski claims that "if there is any knowledge relevant for wisdom it is knowledge of what matters, what is important, what has merit, and what is significant in the human predicament" (2004, p. 186). Wisdom, then, consists of interpretative, not descriptive, knowledge.
Interpretative knowledge is the product of "basic assumptions," which "mark the dimensions of human experience by setting limits to human possibility; variations and differences occur within these limits" (Kekes, 1983, p. 278). Basic assumptions are the universally held assumptions that are used to interpret facts and thereby yield interpretative knowledge. The use of these assumptions for making genuine and accurate interpretations depends on the "breadth and depth" of one's experience. The end result of interpretative knowledge is eudaimonia or the good life. "What a wise man knows, therefore," according to Kekes, "is how to construct a pattern that, given the human situation, is likely to lead to a good life" (1983, p. 280).
Another important component of wisdom is reflectiveness, which he defines as "the habit of considering events and beliefs in the light of their grounds and consequences" (Blanshard, 1967, p. 323). In other words, wisdom consists in foresight into the possible course of action that would result from certain beliefs about the way the world is or should be. If one subscribes to a particular set of beliefs, then a certain set of events is possible. The task of a wise person is to foresee which course of action is best or good, given a specific set of conditions.
Reflectiveness is critical then for gaining interpretative knowledge, which is required for presaging the consequences of a certain set of beliefs and actions. Besides foresight, reflectiveness is also necessary for correcting unwise behavior and choices. "Wisdom," according to Kekes, "is corrective. It reminds the unwise of the relevance of their own descriptive knowledge to their pursuits" (1983, p. 282). Wisdom obtained through reflectiveness informs the wise person as to what is possible and what is not, thus guarding a person against ideals that outstrip his or her moral and intellectual resources.
Both knowledge and reflectiveness are the bases for making a wise or good judgment. "Good judgment," as Szawarski defines it, "is a capacity of perceiving and deciding which value (or rule) is overriding in a conflict of values. It is also," he adds, "a capacity of applying general knowledge or general rules in particular situations" (2004, p. 186). A wise or good judgment often involves perceiving which value, among a set of competing values, applies to a particular case, and then making the most appropriate decision based on that value.
Often a very important value may be transgressed or inverted, resulting in a decision that would not be considered good or wise under alternative circumstances. As an example, Szawarski cites the general values of life (and also health) as good and death (and also disease) as bad. But, in medical care there are times when death is not bad but good; and a patient must be allowed to die in peace and with dignity rather than to be kept alive, through extraordinary means, in pain and ignobly. A wise or good judgment involves recognition of human limitations and possibilities, especially in terms of good ends and of appropriate means to those ends (Kekes, 1983). Without such recognition, wisdom devolves into platitudes.
Finally, wisdom also relies on trusting the beliefs that one accepts and the choices and preferences they inspire (Lehrer, 1997; Szawarski, 2004). This trust of one's beliefs, choices, and preferences is based on the fact that one's ability or capacity to reason correctly and accurately and to make good judgments is trustworthy. Even though one is limited in terms of one's knowledge and cognitive capacity, one must, at some point, trust that they are adequate to understand a difficult situation and to make a good and wise decision as how to proceed vis-n-vis that situation. Without such self-trust, one "can neither construct, nor critically evaluate the structure, content, coherence and practical implications of that general pattern of [one's] world defining values and beliefs" (Szawarski, 2004, p. 187).
Self-trust is the basis for a life of reason and wisdom. "I trust myself in what I accept and prefer, and I consider myself worthy of my trust in what I accept or prefer. Acceptance and preference are, after all," according to Keith Lehrer, "my best efforts to obtain truth and merit, and if they are not worthy of my trust, then I am not worthy of my trust, and reason is impotent" (1997, p. 5). Without self-trust wisdom again devolves into platitudes and the only path is skepticism, which Lehrer claims is "sterile"
Szawarski (2004) applies these traits of wisdom to medicine and the healing professions. First he distinguishes between medical and clinical knowledge, with the former derived from scientific knowledge and the latter from the individual patient. The wise physician is one who demarcates between them and in each medical case he or she "should be able to assess properly what the real importance of things is" (Szawarski, 2004, p. 191). Of course, this assessment depends on the physician's reflectiveness upon both medical and clinical information. Only a proper assessment of such information can lead to a good or wise clinical judgment.
For Szawarski, a physician "cannot acquire and develop good clinical judgment without gathering some experience and that is possible only through methodical and meticulous studies of this or her] patients. In this sense," he adds, "clinical judgment is indeed a fundamental principle of the art of medicine and involves several more specific arts such as: the art of logical and critical thinking, the art of seeing and understanding the meaning of signs and symptoms, the art of communication, and the art of collecting and interpreting clinical data" (2004, pp. 191-192). Finally, a physician must trust his or her medical and clinical knowledge, reflection on that knowledge, and judgment based on it, or the physician is simply impotent in his or her trade. Moreover, self-trust has a therapeutic value: "If you do not trust yourself, you cannot expect that your patient will trust you" (Szawarski, 2004, p. 192).
For the development of wisdom, then, pathos is necessary to transform facts, objective knowledge, and subjective information into wise judgments. As an authentic and a genuine way of being in the world, pathos makes accessible the necessary and sufficient power or force to transform biomedical facts into wise clinical insights. Lonergan recognizes five features of this transformation:
It is heuristic, for it brings to light the relevant data. It is ecstatic, for it leads the inquirer out of his original perspectives and into the perspectives proper to his object. It is selective, for out of the totality of data it selects those relevant to the understanding achieved. It is critical, for it removes from one use or context to another the data that might otherwise be thought relevant to present tasks. It is constructive, for the data that are selected are knotted together by the vast and intricate web of interconnecting links that cumulatively came to light as one's understanding progressed (1992, pp. 188-189).
Pathos allows the physician and patient to interpret the biomedical facts for a particular patient with respect to the general knowledge and information available through the biomedical sciences and then to negotiate a treatment plan, in light of what is best and good for the patient in terms of the patient's values and needs. It is the affective basis for empathic insights into a patient's suffering and for motivation to relieve that suffering. "Feelings for others provides," according to Rhodes, "compassionate insight into what is required and motivates us to muster the required effort to meet the genuine needs that morally demand our response" (1995, p. 442). Pathos reflects the very essence of human nature vis-d-vis human knowing, in making possible wise decision and action.
3.3 Love
What is love? Unfortunately, like wisdom love is not easily defined and has a multitude of meanings: "The word proves indispensable but notoriously imprecise" (Outka, 1992, p. 1017). Traditionally love is considered a feeling or an emotion. Definitions based on this understanding of love, envision it as an affective disposition or emotional state. For example, the British philosopher, Henry Sidgwick (1838-1900), defined love as "primarily a pleasurable emotion, which seems to depend upon a certain sense of union with another person" (1962, p. 244).
Edward Vacek (1994) has identified four components to the structure of love. The first is an openness of the heart, in that humans are made to love. Both the lover and the beloved must have open and receptive hearts. The next component is that the lover is conscious of the beloved's value. "Love," according to Vacek, "is an emotional cognition directed toward the whole value of the beloved" (1994, p. 44). The third component is that the lover is affected or changed by the beloved's value. The final component is the lover's response to the beloved's value. "In sum," concludes Vacek, "love is an actively receptive movement of the heart that creatively enhances the value of both the lover and the beloved through the union that affirms their respective dynamisms" (1994, p. 66). The ultimate goal is the full expression of both agents in a loving relationship.
Traditionally, there are several types or aspects of love. The ancient Greeks had several separate words for the notion of love, just as they did for wisdom, including eros, philia, and agape (Nussbaum, 2001; Outka, 1992). "Ancient Greek ergs," notes Martha Nussbaum, "is not mutual: it is an intense erotic longing for an object, which includes the thought of possession and control of the object" (2001, p. 164). Erotic love is not necessarily sexual as it is intense and passionate and often only one-way or not reciprocal. In contrast to eros, philia is both reciprocal and mutual in nature. Philia consists of a fondness for or a liking of the beloved and is best represented by friendship. Agape is the New Testament love for God and one's neighbor. It is a self-sacrificing or altruistic love, in that it is not dependent on the beloved's social status or monetary worth. "The basic feature of apage," claims Alan Mermann, "is regard for others" (1993, p. 270).
Besides these types others have been identified, such as libido, storge, and amor sui (Jackson, 1999; Mermann, 1993). Libido is a sensual love for the beloved, especially love that is driven by sexual reproduction. "Libido," according to Mermann, "is a vital part of any significant love relationship. Delight and desire and union with the objects of out loves are central to our knowing what love is" (1993, p. 270). Finally, storge is "affection for the less than fully personal" and amor sui is "self love" (Jackson, 1999, p. 54).
Which of these types of love is best for medical practice? Mermann insists that all three traditional Greek forms of love-eros, philia, and agape-play an important role in medical care, although pride of place goes to agape. "Caring for others in sickness and in health," according to Mermann, "offers full possibilities for the expression of our loves" (1993, p. 272). For example, the passion associated with eros can heighten the physician's technical skills and creativity to perform according to the best means for the patient. Again, philia is required for a robust medical practice, especially as expressed in terms of friendship with colleagues and others concerned for public health.
However, according to Mermann, "it is agape that will define the good health care professional. A life lived out for others, and a view of the needs of others as a welcome site for giving of our own resources, will determine us" (1993, p. 272). It is agape that under girds the other forms of loves and transforms them to achieve even greater benefits for the patient, as well as for the physician. "Agape, the love that qualifies all other loves," exhorts Mermann, "can define the life and the work of both the caregiver and the care seeker" (1993, p. 273).
Besides these more traditional forms of love, other forms have been proposed to describe the role of love in medical practice. For example, Lynn Underwood combines "compassion" and "love" to explicate clinical love. Compassion is a powerful emotional disposition that allows a person to pull along side a suffering other, in order to help that person. "Compassion," according to Lawrence Blum, "is not a simple feeling-state but a complex emotional attitude toward another, characteristically involving imaginative dwelling on the condition of the other person, an active regard for his good, a view of him as a fellow human being, and emotional responses of a certain degree of intensity" (1980, p. 509).
Importantly, compassion is not just heroic but mundane. It is often composed of simple common acts of mercy and understanding, e.g. "ways of listening and supporting others that [are] hard to describe because they of their seeming ordinariness" (Mitteness, 2001, p. 6). The root of compassion is our shared humanity; the realization that bad fortune may strike any of us at any time (Blum, 1980; Oreopoulos, 2001). For a physician or other healthcare provider, compassion is just as essential for medical practice as technical competency.
The combination of compassion and love "describes sympathy towards the other, in a way that is caring, respectful, and appropriately emotionally engaged, which leads to appropriate action in service of the other person" (Underwood, 2004, pp. 484-485). Compassionate love on the physician's part allows the patient to manifest a fullness of life and illness. "A person acting with compassionate love," according to Underwood, "perceives the suffering, needs, or potential of another, and chooses to act in ways that can better the condition of the other, placing the other's needs in high priority" (2004, p. 484).
Underwood distinguishes several features of compassionate love, including a free choice for the other, an understanding of the other's situation and of oneself, a valuing of the other at a basic level, openness and receptivity to the other, and a heartfelt response to the other. Moreover, proper motivation is critical for full expression of compassionate love, especially in the clinical setting (Underwood, 2002, 2004). One's motive must focus on the other's needs rather than one's own. Thus, the physician who expresses compassionate love "has the capacity to experience the suffering of another and to experience something of the total impact of the illness, that is, the associated fears, the anxiety, and the illness' assault on the whole person, reflected in loss of freedom and the patient's sense of utter vulnerability" (Oreopoulos, 2001, p. 540). A physician so moved cannot help but respond with compassion to the patient's suffering.
As for the conversion of facts, knowledge, and information to wisdom, so pathos allows for the transformation of emotionally detached concern and even empathic care to compassionate love. Pathos, as a suffering love, is the force that moves or motivates a physician to respond in a genuinely compassionate and selfless manner to a patient's illness experience and the suffering associated with it. Pathos as an authentic and a genuine way of being in the world permits physicians to access the necessary and sufficient power or force to transform either the biomedical or humanistic clinical gaze into a compassionate or loving one.
Compassionate love is unrestricted and akin to what Lonergan calls religious love: "Religious love is without conditions, qualifications, reservations; it is with all one's heart and all one's soul and all one's mind and all one's strength" (1979, p. 242). A chief feature of such love is its self-sacrificing nature. Pathos empowers a physician to respond to a particular patient in a deeply loving manner, to provide a treatment plan in light of what is best and good for the patient vis-h-vis the patient's values and needs. Pathos reflects the very essence of human nature in terms of human compassionate love, in making loving decision and action possible. Thus, pathos is the ultimate source that allows for a compassionate and loving medicine of authentic persons.
4 Summary
What, then, is medicine? The answer to that question depends upon one's perspective (Black, 1968). "Medicine," from the physician's perspective, "is very much what he cares to make it" (Black, 1968, p. 1). In other words, medicine is a profession in which the physician can specialize. "Medicine," from the patient's perspective, however, "should mean simply help in sickness-help which comes promptly, is given willingly, which is manifestly efficient, and which does not cripple him financially" (Black, 1968, p. 2).
There is also a third perspective, which consists of a broad and a narrow view. The broad view consists of medicine as an institution, arranged in terms of healthcare workers and their physical and intellectual resources, which are marshaled to treat the patient's disease. The narrow view is concerned "with those disturbances of well-being which are dealt with by physicians, rather than by surgeons or other specialists" (Black, 1968, p. 3). For instance, the narrow view may be associated with "internal medicine." Finally, there is a fourth perspective, in which the patient and physician act together to make up what is called medicine. With respect to that perspective, Pellegrino and Thomasma (198 la) provide one of the better known and discussed answers to the question of medicine's nature that incorporates the views of both the patient and physician. They embed their approach to the question of medicine's nature in terms of "clinical interaction," since medicine is a particular type of relationship-a healing relationship.
Pellegrino and Thomasma (1981a) explicate medicine's nature in terms of four modes. The first is responsibility, which, although mutual, poses a greater burden for the physician who has greater medical knowledge and expertise. Thus, the relationship is asymmetric in terms of responsibility. Medicine's next mode is trust, especially the patient's trust in the physician's skill and practice. Again, however, the basis of trust is an asymmetric relationship between physician and patient in which the healing relationship begins with the physician's extension of a "helping hand." The third mode is decision orientation or clinical judgment, which depends upon the physician's style of reasoning and the patient's values. The final mode is etiology, in which the physician is to identify the causal factors for the patient's disease.
Based on these four modes, Pellegrino and Thomasma (1981a) distinguish medicine's unique nature or form-a form composed of several dimensions that separate medicine from other disciplines. The first dimension involves the personal nature of medicine, comparable to Martin Burber's I-Thou relationship. The next dimension is mutual consent, in which the patient seeks help and the physician offers it. The third dimension is the craft-like nature of medicine. Again, this dimension reveals the asymmetric nature of the healing relationship. "The therapeutic intent of the clinical relationship," according to Pellegrino and Thomasma, "tends to place the patient in a passive role vis-d-vis the physician. The latter is expected to acquire and maintain a superior fund of knowledge and skill. Even the diagnostic ability of patients which brought them to the relationship is suspended by a more scientific attempt to categorize the complaint and search for causes" (1981a, p. 72).14 The next to last mode is didactic, in which both physician and patient teach each other.
Although the above modes are features of medicine, they do not necessarily distinguish medicine from other disciplines. It is the final mode, which demarcates medicine from other disciplines. That mode is the telos or goal of medicine, which includes both motives and ends. The motives center on the illness itself, with which the patient cannot cope effectively and requires assistance, while the ends consist of "a personal and organic restoration to a former or better state of perceived health or well-being" (Pellegrino and Thomasma, 1981a, p. 72).
The "personal" and "organic" dimensions of the restoring separate medicine from all other helping professions. "The distinguishing feature of medicine, therefore," claim Pellegrino and Thomasma, "is that it is a craftsmanship that involves healing of the body with the body" (1981a, p. 73). In other words, it is the direct physical intervention, such as touching, that makes medicine unique. Medicine, then, involves healing of a specific patient's body through the use of the physician's body, i.e. "the curative intent is also corporeal, not spiritual or mental" (Pellegrino and Thomasma, 1981a, p. 73).
Medicine is a "tekne iatrike" or craft-like technique of healing (Pellegrino and Thomasma, 198 1 a). Importantly, medicine's craft-like nature is based on compassion but a compassion that is exclusively corporeal in nature, i.e. compassion based on "a shared bodily structure." Moreover, medicine's craft-like nature is distinguishable from science, in that medicine attends to the individual patient. Indeed, medicine may be defined as "a relation of mutual consent to affect individualized well-being by working in, with, and through the body" (Pellegrino and Thomasma, 1981a, p. 80). Medicine at its root is relational and moral in that it interprets the patient's bodily facts vis-n-vis the patient's values. In the end, however, medicine is more a science than an art and focuses almost exclusively on the corporeal rather than the mental or spiritual. "Medicine as a disciplined body of knowledge," conclude Pellegrino and Thomasma, "is a science respecting the perfection of lived bodies concretized by skill in experiencing and effecting connections between corporeal symptoms and remedies" (198la, pp. 80-81).
Pellegrino and Thomasma's definition of medicine still labors under the Cartesian dualistic approach to life, which results in a technique that can become lifeless and devoid of passion. Humanistic or humane approaches to medicine attempt to reinstate that passion. For example, Jeanne Achterberg identifies passion as one of the qualities necessary for healing: "Regardless of diagnosis, pain and suffering, or the difficulty of treatment, passion for something-anything-seems to allow one to grow larger than the problem: larger than the fact that a death sentence may accompany the diagnosis" (1996, p. 60). Passion-in terms of its root as pathos-is strong motivation not only for the patient vis-d-vis healing but also for the physician vis-d-vis medical practice, especially in terms of professional transformation form physician qua medical mechanic to physician qua wise and loving healer.
In conclusion, pathos is critical for transforming medicine from a technical profession that addresses disease into a vocation that responds with wise and loving compassion to the patient's illness experience and the suffering it brings. True physicians are healers even in the absence of any technology, for they respond not simply to the disease per se but to the suffering that cripples not just the patient's body but also his or her life. Passionate physicians do not abandon their patients simply because no standard protocol is available. "The truly wise [and loving] response to suffering," according to Philip Overby, "may not be the righteous, indignant call for more science but acknowledgment that no matter the disease, the physician pledges to see the patient through to the end-come what may, cure or no cure, albeit with the best available resources at the present time" (2005, p. 22).
Medicine at its very root is centered in pathos, both the patient's suffering and the physician's suffering. "We all hurt from the task of living life;" observes Achterberg, "we all seek help for our suffering" (1996, p. 58). For contemporary medicine to resolve its quality-of-care crisis, it must connect with its pathos in terms of both the patient's suffering from illness and the physician's suffering to heal that illness.