Sick or sickness? The importance of person centred healthcare and medicine paradigm

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  • ABSTRACT

    When you act for a good or just when you make a choice, you should ask yourself if the result of your action coincides with the principle that has generated it. Health and respect for our own individuality are two essential goods for the human being and also values that medicine itself should guard carefully remembering that its goal is to take care for a person and not only to cure a sick body. The means to achieve all this can only be a person-centered medicine which has the honor and the burden of considering the person (in the Kantian sense) and his health as an end, not a means. The current mainstream concept of health defined in 1948 by the World Health Organization as a state of complete mental, physical and social wellbeing and not merely the absence of disease and infirmity remind us that medical reasoning, based on the pathogenesis operator, is no longer sufficient in dealing with requests from the citizens: is now the right time to shift the focus from sickness to health giving emphasis to the salutogenic medicine approach.


  • KEYWORD

    Person-Centered Medicine , salutogenesis , health

  • Why to believe the Person-Centered Medicine is fundamentally important in the course of a medical treatment? The answer is implicit in the question; who should be in fact at the center of attention (not only of the doctor but also of the institutions) if not the person to whom the health system has been created for? We use the term person and not patient to avoid a distorted interpretation of the paradigm in question: the person-centered medicine is not resolved in fact as a polite attitude and empathy with the patient, giving him all the attention he requires. Identifying the person-centered medicine through these terms is without a doubt a deficit and reductionistic vision of the paradigm, limiting in this sense his potential and effects. It must be a person-centered medicine even before the patient for compliance with substantive and not merely formal dignity of every human being, contributing to the self-determination of the suffering person paying attention to the professed beliefs and cults, cultural belonging and personal sensitivity.

    The value of a thing cannot be determined by the mediocrity of what that thing is surrounded: kindness is not a virtue of some physicians. On the contrary, it should be a basic skill of an individual who feels that he wanted to be a doctor. It’s deontology, nothing more.

    Person-centered medicine means so much more. It means to fight the high conflict of interest present in medicine (Anderson et al., 2014), to require safety protocols studies on drugs most ethical and effective, to use data on patient experience to really improve care (Coulter et al., 2014).

    When we are ill, we feel that the freedom that characterizes us when we are well vanishes, as if the disease was undermining not only our physicality but also our autonomy. As Galimberti claims: “The body from operating power in the world, subject of intentions, it becomes, when we are gripped by the disease intentioned object, and I, that before I was living in my world, I suddenly find myself living for my body.” (Jaspers, 1986).

    We attend therefore to an objectification of the body that becomes from active agent to object, and is perceived by the patient as something apart, a source of pain which is not recognized as belonging to himself. The disease overwhelms the knowledge that you normally have of yourself, and your position in the world, causing a paradoxical estrangement.

    Because of the state of loss and incomprehension in which the patient lies, must refocus attention on him, developing a new paradigm for the treatment of the person, who has to be placed at the top of the attention of the medical and health personnel. On the basis of what is stated in the article “Person-centered Medicine: Towards a definition” (Roberti di Sarsina et al., 2010) published in Forshende Komplementärmedizin, numerous surveys on the quality of health care, conducted in Europe and the USA, have shown that if one were to ask a patient to evaluate the quality of medical treatments, the priorities expressed concern the humanization of treatment, which should be adapted to the individual, the need to be heard by public institutions and finally take advantage of adequate information in order to assert its freedom of treatment.

    The current mainstream concept of health was defined in 1948 by the World Health Organization as a state of complete mental, physical and social wellbeing and not merely the absence of disease and infirmity. This is the official version of one of the many interpretations through which the concept of health can be declined. In fact, in addition to the definition promoted by the WHO, there are other kinds of visions like that ethymological, biomedical, ecological, cultural and organisational, critical medical antropology, public health concept and at last an holistic one. Health could also be considered as an ideal state, as mental and physical fitness, as commodity or as a personal streght (Kaur and Sinha, 2013). However, common sense may probably designs health on the basis of an analytical perspective, defining it as absence of disease.

    This response leads to two possible interpretations of the nature of this concept: on a first level of analysis health co uld be considered as something the value of which we are a ble to appreciate in a negative way, that is when the disease appears and we have the perception of having lost what wa s previously silently allowing us to live a normal life. On a second level, however, we can analyze a similar response as related to the time of medicalization in which we live, whe re health promotion is based on the absence of disease.

    The many different interpretations to which the concept of health is subject indicate the hermeneutic nature inherent in the concept which is reflected in a normative and not onl y descriptive way. In fact to believe health “a complete phy sical and psychic wellbeing” rather than “a state of dynamic equilibrium between man and environment” has consequence s that go beyond the language field. What we detect proble matic is that health is something that concerns the sick pers on. We do not agree: health is the problem of the healthy p eople. Modern medicine has allowed to transform normal ph ysiological conditions like menopause, PMS, andropause, fea r, into diseases (Moynihan et al., 2007), (Dover, 2014) which yield a considerable profit for the pharmaceutical industries (Edgar, 2013). The main purpose of the WHO is believed to be the extension of this concept beyond the medical point o f view, judging, in a truly holistic perspective, health as a g ood, including aspects of life far more extensively than thos e included by medicine. When it comes to well-being it can no longer refer exclusively to diseases, otherwise you are lik ely to exchange a part, which is still of considerable import ance, for the whole. The very character of health is measure d, the health of a person is the ability to achieve their goals. Well-being can’t be turned into an absolute and incontestabl e value because individuals’ desires and goals are heterogene ous.

    In fact we think that health is not categorized as an end the individual tends toward, but rather a means that allows him to have a dignified life. A blind man can respect the statement of WHO, whereas a man who has just lost his job cannot. It is highly questionable whether the definition not concerns only scientific aspect; it is clear that medical reasoning, based on the pathogenesis operator, is no longer sufficient in dealing with requests from the citizens and that is why I think it is now the right time to shift the focus from sickness to health. The concept of Salutogenesis (Alivia et al., 2009) was developed by the medical sociologist Aaron Antonovsky (Antonovsky, 1979). His study fully reflects the attention he gives to the dynamics of the interaction between society and individual, his condition of life, social role and mortality. Thus, the state of health of a person is not limited to the medical field but is implied by the complex web of factors that intervene in the life of every man. One’s kind of job, intellectual capacity, economic resources, etc., greatly affect the level of health of each of us. Antonovsky understood all this and put it in a program of study aimed at making posters mechanisms. Thanks to a work commissioned by the Israeli government focused to assess the health of the elderly population of Israel, he found that the majority of healthy people had suffered the dramatic experience of the extermination camps.

    On the basis of this constant, he realized that the focus of his investigation was not to be paid to discover the factors that exposed most individuals to diseases but rather to investigate the causes that made the elderly immune to diseases: in fact, as the term indicates, the focus is on the research of the origin of health. This point recalls the concept of organic soil described by the famous histologist Claude Bernard, who said that the primary cause of the development of a disease should not be attributed to the presence of the bacterium but to the favorable conditions that able him to reproduce. Similarly, in the process concerning the development of a pathology it becomes necessary to understand what are the dynamics involved in the maintenance of health, rather than seeking the causes of the disease. In order to avoid misunderstandings it is necessary to consider what has been said not only from a preventive perspective (if so we would be in fact still within the vision pathogenic) but also from a predictive one (Alivia et al., 2011), the reasons for which it has occurred, despite the exposure to the same pathogens, that some individuals have contracted the disease while others have remained healthy. In the concept of Salutogenesis illness and health are not two conditions which are mutually exclusive, but they represent the two extreme points of a single process. If the medicine used to categorize health as a state of equilibrium, for the Israeli sociologist it is the result of a dynamic interaction between factors that maintain and factors that aggravate the condition of the individual.

    The concept of Salutogenesis (Lindström et al., 2005) strongly agrees with the definition of health, formulated by the WHO which has already been discussed, since in its challenge of health promotion gives a practical meaning to the discourse of international authority, which, in its theoretical formulation turns out to be indefinite and imprecise. Indeed, there are basic prerequisites, such as food, peace, shelter, education etc, that individuals must meet and that can be applied to the concept of health. What in fact does not allow a precise explanation is the absence of a corollary of practical references which be able to bring the discussion to a sphere that is not only theoretical: in fact, in reading, we have the impression that doctors are attributed more responsibility with respect to that imposed by his work ethic. The requirement of the creation of “complete physical, mental and social wellbeing” certainly goes beyond the tasks of medicine, even in a system like the Italian one, in which health is not considered, as in the USA, as an individual responsibility, but, first of all, a right. This is one reason why the Government must assume the task of promoting and safeguarding the health of its citizens, medicine must be reserved for the task of considering the patient as a whole, as a person living with the disease that affects in a given social context, through a heightened sensitivity to an aching body.

    In fact there are studies showing the effects of emotions on the health of the individual. One of these has analyzed data from the Women's Health Initiative, which has tracked about 100,000 women in post-menopausal, showing that women with the highest optimism index had 30% less chance of dying from coronary arteries’ diseases, compared to pessimistic peers. Another research was instead directed to the therapeutic use of positive emotions in pain management: 18 children, aged between 7 and 16, showed a higher tolerance to physical suffering while watching funny videos, compared to those who conveyed a sense of sadness or anger. Other studies have proven that laughter helps cancer patients to increase the desire to live and love felt towards you. The same happens with sense of humor, which is considered an excellent complementary therapy to be used to mitigate the level of epinephrine and cortisol in subjects in which the high stress is due to arrhythmias, and hypertension (Diener et al., 2011). All this justifies the claim of an attitude addressed, as much as possible, to the human being in its entirety. The body works closely with the mind, interferes greatly on health and the course of disease. Not understanding this is an act of intellectual blindness.

    The ultimate goal of health promotion is to increase the quality of life of individuals. A happy life, with a sense and perceived by the subject as this enables it to prepare their lives fighting for the achievement of the goals.

    Often the medical field tends to confer a secondary role to the mood prevailing in the patient, marginalization and alienation felt during his illness, hoping to regain their autonomy as soon as possible. However, I think it is not possible to draw up a hierarchy of the factors involved in a disease; individual is synonymous with totality. For these reasons, the quality of life is a parameter that can’t be deemed secondary, considering its involvement in the dynamics of health. Randomized controlled trials performed in order to evaluate the effectiveness of music on the living conditions of the elderly or research on the association between green spaces and quality of life have produced important evidence. It has been also suggested that the quality of life could serve as a medicine; the salutogenic effect of interventions whose aim is to improve the living conditions and therefore health has been tested as we have seen in numerous studies in the field. There are reviews of analysis that the overall quality of life in chronically ill patients has improved regardless of subjective factors such as income, level of education, self-esteem, etc (Höchwalder, 2011).

    This is also supported by the American philosopher Ronald Dworkin who sadly passed away recently. In “The domain of life” (Dworkin, 1993) he claimed the existence of” an interpretation of secular as well as religious, the idea that human life is sacred.”

    Despite his discussion was more directed to secularism of abortion and euthanasia, the fundamental basis of his discourse regard also this opportunity. Dworkin attributes to the Kantian thesis presented in the Critique of Practical Reason on the need to treat the person not as a means but as an end, a value that goes beyond strictly Catholic interpretation, recognizing that life is sacred because of the presence within itself of intrinsic and non-instrumental value. The response to a therapy, pain tolerance, the conditions of the environment in which the patient lives, the sufferance around him, eating habits and religious beliefs are aspects that affect the lives of every individual and this is the reason why it becomes a strong need to recognize and include them in a program designed to education and health promotion.

    This aim is pursued strongly by the Charity Association for Person-Centered Medicine founded in 2007 in Bologna which was founded with the goal of promoting the health of people in a global sense, through sustainable and person centred healthcare and therapies, as much humanized as possible. The person-centered approach considers the patient as ultimate and exclusive for a cure, and as an extension of the medical practice itself, conventional or not (Roberti di Sarsina et al., 2012).

    A patient is a person. The human being is a complex being and only if we respect that unity in the therapeutic medical conception of the disease, it will match that of the patient.

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