Healing Values: What Matters in Health Care By Elliot Dacher

Disillusionment with the existing medical model, and efforts to revitalize and reconfigure approaches to health and healing, emerge from this pregnant historical moment. To understand this circumstance is to comprehend that the changes we must now envision are fundamental rather than cosmetic, and as much compelled as chosen. Yet through the uncertainties of our times, the elements of a postmodern worldview are slowly
becoming evident. A key characteristic of this emerging worldview-unlike previous paradigms-is an openness to multiple perspectives. No single perspective will be granted priority or preference over all others.  

Signs of Hope and Concern

New ideas, innovative programs, and hope are widespread in the health field, and today's rapid changes seem to have a momentum of their own. States are providing licensure to new categories of health practitioners, medical schools are offering programs in holistic healing, the NIH's Office of Alternative Medicine is funding research on complementary therapies, insurance carriers are beginning to offer reimbursement for these therapies, the Internet is overflowing with information and informal dialogues, and the state of Washington has passed legislation mandating that "Every health plan after January 1, 1996 shall permit every category of provider (chiropractors, acupuncturists, naturopaths, etc.) to provide health services or care for conditions included in the basic healthcare services (offered by the health plan) . . ."

Yet despite such signs of hope, we hear a growing chorus of concern that conventional medicine has finally reached its limits and new approaches are urgently needed. Aggravated by the complexities and often conflicting demands of modern life, "lifestyle pathologies" are increasing. These include, for example, stress-related degenerative diseases, addictive disorders, anxiety, depression, and their various physiological manifestations. In addition, mounting dissatisfaction with the overuse of pharmacological and interventionist therapies has led to a groundswell of antipathy toward professional elitism and authority.

Critical Questions

In the United States, as elsewhere, we now have a broad-based demand for high-level health coupled with a growing consensus that real change is necessary and desirable. The critical questions at this time are "What kinds of change do we want?" and "Is there any real fundamental progress involving a shift in values?" The current rapid pace of change has allowed little opportunity for reflection and evaluation among both practitioners and the general public.

Motivated by very real concerns yet conditioned by old patterns of thought, fired up with enthusiasm and hope yet compelled by complex professional and financial interests, and carried along by a seemingly unstoppable momentum, we simply assume that our current initiatives are taking us in a beneficial and innovative direction. Consequently, we have failed to ask the critical questions the answers to which can either reassure us about our current efforts, or cause us to reconsider them. Consider these two simple but basic questions:

•What values do we wish to see expressed in a reconfigured approach to health and healing?

•Do our current initiatives reflect and support the development of these values?

In response, I would like to offer four perspectives and associated values that I believe to be critical elements of the emerging postmodern worldview and which hold important implications for a postmodern medicine.

Multiple Ways of Knowing

The dominant, modern worldview requires that reality be objectified, sensory-based, impersonal, measurable, quantifiable, opaque, and collectively experienced and validated.

The postmodern view of reality is far more complex. It rejects the view that reality is limited to the receptive capacities of our five senses, and it validates the legitimacy of non-sensory, intuitive knowledge. Reality is extended, revitalized, and personalized. It is seen as multidimensional-a blend of sensory and non-sensory knowledge. This postmodern perspective values multiple ways of knowing, and in medicine it opens the way for intuitive and other nonsensory diagnostic mode.

Intentionality

The modern worldview assumes that all phenomena are caused by unchanging universal laws that exist independently of consciousness. In essence, causality is seen as physically based and upward in direction-from matter to brains to minds.

The postmodern perspective, on the other hand, validates and legitimizes the causal nature of consciousness which is individually willed and downward in direction. This perspective values intentionality and the causal nature of consciousness. Medicine working from within this perspective recognizes the crucial role mind plays in the health of the mind-body system.

Holism

The modern worldview assumes the distinct separateness of subjective and objective, external and internal, material and immaterial, mind and body, reason and intuition, and human and nature. At its essence, irrespective of its extraordinary accomplishments, this view is alienating.

The postmodern viewpoint, however, accepts the value of an analytic methodology within a larger context that comprehends and honors the unbroken unity of all life. This perspective values integration and holism. In medicine, it opens the way for a truly holistic body-mind-spirit approach.

Personal Authenticity

The dominant, modern worldview assigns great importance to the individual and his/her rights, an ideal that too often degrades to a self-indulgent, egoistic, and aggressive quest for power and material gain accompanied by personal alienation.

The postmodern worldview revitalizes and deepens the meaning of individualism by asserting the significance of the individual search for authenticity through self-knowledge; legitimizing the shift in authority from belief systems, institutions, and professionals to the individual (a shift in authority from external to internal); and recognizing that authentic individualism comes into being in the context of relationship. This perspective values self-responsibility, authentic self-exploration, self-expression, and the healing relationship. In medicine, this means the individual person plays an active, responsible role in his or her healing and preventive healthcare.

I believe these four perspectives and values should underlie, inform, and drive our current process of cultural change. They represent a fundamental shift in our view of reality, causality, bio-psychosocial interactions, and personal capacities. Together, they constitute the historical imperative of our times, an elastic worldview that unlike previous religious and empirical perspectives is both pluralistic and inclusive. These essential perspectives characterize one possible option for the postmodern world, and as such they could most appropriately guide and define an approach to health and healing that would be unique to the needs and character of our times-an approach that I have called postmodern medicine.

A Shift in Worldview . . .

With these perspectives and values in mind, let's ask: Are our current efforts expressing and supporting these perspectives and values? Consider the origins of recent attempts to expand our ideas about health and healing.

Holism: The idea of holism, first described by Jan Smuts in his 1920s book Holism and Evolution, was revived decades later by individuals and practitioners seeking a broader vision of health and healing. As a concept, holism expressed the view that life at all levels is organized as a unity. Although reductionism had been successful in explaining the mechanistic workings of nature, it was increasingly seen as a limited and partial approach to knowledge-an approach that distracted from a more comprehensive and ecological view of the human condition offering a more meaningful, and vital, view of nature.

Wellness: Medical doctor John Travis opened the first wellness center in the late 1970s in Mill Valley, California. Influenced by Halbert Dunn's book High Level Wellness, Travis' concept of wellness sought to expand our ideas about health beyond the customary focus on preventing and curing disease to include a concern for the promotion of well-being. Health and healing were seen as a personal affair, a psychosocial process of education and lifestyle change.

Complementary Medicine: In the 1980s alternative and complementary practices began to emerge as a further expression of the rapid changes in our ideas about healthcare. Naturopaths, chiropractors, acupuncturists and others sought and achieved state licensure, and began the initial steps toward full integration into the mainstream of institutionalized healthcare, a process aimed at achieving conventional acceptability and consensual validation. The Office of Alternative Medicine was established at the National Institutes of Health to examine the efficacy and appropriateness of these diverse approaches to health and healing.

These initiatives were honest attempts by sincere individuals and institutions to bring change to an entrenched healthcare system, one that no longer seemed effective in dealing with present-day problems and sensibilities, and was at odds with the emerging postmodern viewpoint. Let's examine the results of each of these efforts.

. . . or More of the Same?

•"Holism" Today: As a philosophy, holism evolved as a counterforce to atomistic and reductionistic perspectives. But sixty years after Smuts defined this concept, his vision was reduced to packaged commodities and services that could be bought and sold with labels such as "holistic medicine," "holistic dentistry," and so on. Here, the "holism" more often than not refers to some add-on practice, for example, the inclusion of hypnosis in dentistry. But a true holistic dentist is not someone who uses hypnosis rather than drugs to overcome the pain of pulling a tooth. He or she would examine the lifestyle of the patient to identify and address systemic causes-not just take a different approach to eliminating symptoms.

True holism, as I see it, is not so much conceptual as much as it is a given property of nature that can be experienced directly by each individual. Comprehensive or integrated care that concerns itself with the larger set of interactive systems is certainly a reflection of that understanding, but it is more the map than the territory.

Unfortunately, "holism" has become a marketable credential self-applied by a diverse group of practitioners who too often confuse humanism and an expanded repertoire of remedies and practices with genuine holism. And even in medical practices that evolved from a more comprehensive framework, the "holistic" components often rapidly recede in importance, or are completely discarded by being secularized and reduced to disease-oriented treatments. As we are discovering, this is the cost of integrating into and accommodating to the institutional structures of mainstream healthcare whose perspectives are solidly embedded in the traditions of the modern worldview. It is the price of cultural acceptability and third-party reimbursement. In short, the price we pay is the substitution of disease treatments for true holistic healing practices.

•"Wellness" Today: The idea of wellness has suffered a similar fate by being rapidly absorbed into our culture. As it entered the mainstream of existing healthcare institutions, wellness was reduced to four physically based issues: nutrition, smoking cessation, fitness, and stress management. Its fundamental emphasis on personal development and its psychosocial framework and values were largely jettisoned, and with its assimilation into the larger culture it was reshaped until it more resembled traditional preventive approaches, packaged as generic commodities carrying the "wellness" label, than the dramatic shift in perspective envisioned by Travis.

•"Complementary Medicine" Today: Alternative and complementary approaches to health and healing, however valuable in diversifying our treatment options, similarly do not yet significantly reflect a new set of values. Conventional and alternative practitioners, irrespective of their rhetoric or intentions, generally use their specific expertise to prescribe techniques, practices, drugs, or supplements for the purpose of repairing or fixing an abnormality. The professional typically defines the approach solely within the context of his or her professional domain, and the prescribed treatment is, typically, external rather than internal. The individual is a more or less passive recipient of the therapeutic process gaining little in the way of personal insight or additional self-healing capacities. Because our culture is conditioned to turn to authoritarian structures and external remedies at times of adversity, we often demand and easily accommodate to the disease treatment model.

Of course, there are always individual practitioners whose practices reflect a substantial shift in perspective toward healing (both conventional and alternative healers can access holistic principles within their traditions), but this remains an individual prerogative, as distinct from a cultural shift.

With few exceptions, efforts to integrate the perspectives of holism, wellness, and complementary medicine into mainstream practices have yet to live up to their original promise. Usually, this is because they fail to explicitly and consistently express the values that characterize a postmodern medicine-values that most of us would agree with and ones that would take us in the direction of fundamental change.

Why has this happened? Old perspectives and parochial interests are powerful and enduring. They silently and effectively reshape our efforts to more or less conform to existing conventions, incorporating and reshaping them until they accommodate to the assumptions of the existing worldview. Because each of these initiatives explored new approaches and perspectives, and in this way succeeded in expanding existing perspectives and stretching our imagination, they have been useful endeavors. But so far they have not yet brought about fundamental change because the new values have not become the guiding foundation to our efforts at change.

As a result, these initiatives have ultimately given way to the power of existing values, perspectives, and practices-falling far short of taking us in the direction of a postmodern medicine. Holism became an empty word, wellness became prevention, and alternative approaches became alternative disease treatments. The powerful influence of the existing worldview subtly but surely changes us, and our efforts fall short of animating the perspectives of the emerging postmodern viewpoint. Overcoming our deeply conditioned and often unconscious assumptions is a difficult task.

Elevating Values

How, then, do we move toward fundamental change, aligning with our vision of the future? First, let's clearly articulate the perspectives and values that we choose to assert, then carefully design innovative programs which embrace them, and, finally, measure the success of these programs by their demonstrated capacity to foster these values. The changes that result will not be merely an accumulation of new ideas and practices subtly reshaped to resemble the past, but rather a fundamental revision of our approach to health and healing.

Because the central perspectives of the postmodern worldview-multiple ways of knowing, intentionality, holism, and personal authenticity-are activated, animated, and validated through direct personal experience guided by an inquiring consciousness, the individual (in contrast to professionals and institutions) becomes the essential focus and primary healer of postmodern medicine. Health and healing become personal issues, uniquely defined and orchestrated by each individual.

In a sense, the individual is the healer, the healee, and the healing. Directly engaged in the historical process of actively integrating and living a new worldview, the individual experiences expanded personal consciousness, and a deepened sense of empowered autonomy.

Practitioners and their therapies will remain an important component of a person-centered postmodern medicine, but not a dominant one. They will be a valuable resource to individuals who are actively engaged in composing their lives, defining their personal visions of health, and learning from and responding to life's adversities.

The Role of the Individual

Because we are still living in the gap between worldviews, we can catch only glimpses of what the full flowering of postmodern medicine might look like (see below). It is difficult to be a midwife to a new worldview. Each of us was born, socialized, and educated to live within and to honor the existing viewpoint-a set of perspectives with basic assumptions that are unstated yet relentlessly compelling. The science, and particularly the medicine, associated with this viewpoint have taught us to seek remedies for our problems outside ourselves, to distrust our inherent healing capacities, and to look toward the professional as the singular authority on issues of health and healing.

And yet it is entirely appropriate that the impetus for fundamental change be nourished by an informed and conscious public. An understanding of our historical moment would suggest that this change will be neither defined nor directed by practitioners; rather, it will be defined and directed by the individual.

Thomas Kuhn, in The Structure of Scientific Revolutions, said,

It is time that we step back and begin to speak about fundamentals, about the values that define our lives and our work. Such a conversation will surely assist us in creating and successfully implementing the changes that are now awaiting us.

Elliott S. Dacher is a medical doctor, a former IONS Fellow, and the author of Whole Healing (Dutton/Plume) and Intentional Healing (Marlowe & Company). He can be contacted at 508-645 9058; email: esd@healthy.net