What is Health?
Notes from a Family Meeting, Vol. 2, No. 2
I sat on my porch one day, drinking tea and reading. My daughter played in the driveway, spinning in her dress and drawing with chalk on the cement. A light breeze played through the leaves above us, bringing the first cool promises of autumn amidst the summer’s heat. Her effortless movements, a blessing as much for me in that moment as for her, reminded me that health exists to draw us outside of ourselves. The healthier we are, the more seamlessly we live through our bodies so that we might more fully throw ourselves into relationship with others and with the world. Some people can do that to a great extent, while others are very limited. Even still, those with limited health can still pursue it and medicine can still help them, if only we have eyes to see.
So what is health?
The vast majority of my medical education focused on pathology. I don’t think anyone ever defined “health.” All my training assumed that in treating pathology, I would foster health. I learned how medical interventions could improve creatinine, blood sugar, or the findings on a CT scan, but had little appreciation for how they fostered, or failed to foster, a patient’s overall health. I had become, as Alasdair MacIntyre described it, an applied (and, I would add, myopic) scientist:
Part of our inheritance from [the period of scientific advancement in medicine during the 20th century], in which successful medicine was successful applied science, is a view of the patient as essentially either an object for or an exemplification of the results of scientific research. Viewed thus, the patient is no longer envisaged as a whole person, but only as a body; and the body itself is envisaged as a collection of parts and subsystems, each of which may fruitfully be studied in isolation from the rest. According to this view of medicine, the physician reenacts with the parts of the patient’s body what the scientist had first achieved on the laboratory bench, and it follows that the specific complaints uttered by the patient and the care of the patient are not really part of the genuine practice of medicine at all.
Medicine has been immensely successful in helping people live longer, improving or avoiding disability, and easing symptoms because of the paradigm MacIntyre described. And yet that paradigm misses something too. It’s most apparent at the limits of medicine where our interventions come with significant trade-offs. Even before one reaches that precipice, though, people can feel like their doctor doesn’t actually care for them. They feel like they’re not being treated like a person, but like a number, object, or “case.” They feel diminished, even if their pathology is being treated. Clinicians manage diseases rather than care for people.
This is at the heart of suffering as Eric Cassel defined it: “suffering occurs when an impending destruction of the person is perceived; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner. … suffering can occur in relation to any aspect of the person, whether it is in the realm of social roles, group identification, the relation with self, body, or family, or the relation with a transpersonal, transcendent source of meaning.” There’s more to suffering than mere biology and more than medical interventions can address. Sometimes those interventions can make things worse.
That helps to better situate a point I made about the goals of care: although these are the only things upon which medicine can intervene to improve or sustain health, they don’t exhaust what health is. Recognizing the limits of medicine helps us appreciate that we need other things apart from medical interventions to pursue health. And health is only one good among many in life. But modern medicine pushes continually against this limit. Not that it just meets the limit, which it often does, but that it promises more, as Gerald McKenny wrote: “Modern medicine, with its immense capacities to intervene into and reorder the body, continually holds out the promise of fulfilling this imperative. The imperative is to eliminate suffering and to expand the realm of human choice - in short, to relieve the human condition of subjection to the whims of fortune or the bonds of natural necessity.” In our disorientation about health, we grope after that promise.
What Health Is Not
This is the easier portion of our work.
Health is not the mere absence of disease. The World Health Organization helpfully clarified this in the early and mid-20th century as medicine began to wield natural science with great success. What they saw was that we could cure someone’s pneumonia but that may not necessarily restore them to a state of health. Our lives are woven together with physical, mental, and social threads, and tugging on one distorts the whole tapestry. Just as peace is more than the mere absence of war, health is more than the mere absence of disease. However…
Health is not merely normal. Some argue that health is indeed the absence of disease; that “normal” is healthy. Map out characteristics on a bell curve and determine what’s present for most of the well-functioning population most of the time and that’s “health.” In a certain way, this is true: it’s normal for fish to live underwater, and so part of being a healthy fish is to do those things that are normal for fish. There are many things about health that are “normal.” However, this doesn’t account for excellence - people who aren’t normal but exceed the standard, e.g., athletes, geniuses, robust immune systems. Furthermore, given the diversity of the human population and our capacity to adapt in the face of hardship, it’s hard to jump from “normal” to some understanding of what it means for a person to be healthy on the whole. Like, what is a “normal” human in their entirety? If we could even define that, should it be the standard of health? Even still…
Health is not “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” That is how the WHO positively defines health. First, this means health is an unachievable ideal: no one has complete physical, mental, and social well-being. No one, so defined, experiences health. Second, this definition is totalizing: no area of life falls beyond medicine’s scrutiny or intervention. Third, the definition just kicks the can down the road: what’s “well-being?”
Health is not whatever I want. While our own perceptions of our bodies are important to appreciating our health or lack thereof, health isn’t reducible to whatever I say it is for myself. Just because someone doesn’t like how their body looks, for example, doesn’t necessarily mean they’re unhealthy. There is something off about their relationship with their body and therefore the experience of their own health, but we’d need more information than their own whim to see that. This becomes obvious when someone claims to suffer from an infestation of parasites when that isn’t the case (delusional parasitosis); they lack a measure of health but not for the reason they say they do. Nevertheless, in a world that sees the body as a product that belongs to its owner, health is increasingly viewed in these terms. What’s the matter with that? Well, we’ve been eating the fruit of such hyper-individualism as people push back against COVID-19 vaccination. Individual agency is an important component of health. Still, health is not reducible to that agency. It can’t be divorced from the relationships that make health possible and meaningful.
What Health Is
Part of what makes health difficult to define is that it’s invisible to us when we have it. I don’t dwell on moving my arm this way or swallowing that food - I just do it. “Health is not a condition that one introspectively feels in oneself,” Hans-Georg Gadamer observed, “Rather it is a condition of being there, of being in the world, of being together with other people, of being taken in by an active and rewarding engagement with the things that matter in life. It is the rhythm of life, a permanent process in which equilibrium re-establishes itself.” My health is the means through which I am present and have a relationship with the world and with others. This means that it’s difficult to talk about health as an end unto itself, though it is the end toward medicine aims. We have and use our health for something.
Health, then, has a subjective component which is best experienced when it isn’t; health is most present when we hardly perceive it, if at all. We most experience health when it allows us, through our quiet, cooperative bodies, to be present to and have a relationship with the world and others. There’s also an objective component that is the integrity of everything that makes us who we are - physically, cognitively, emotionally, socially, spiritually, and narratively. In a word, health is “the well-working of the organism as a whole.” Leon Kass labored to define “well-working” and “whole” in that definition which I won’t review here, but the phrase “well-working wholeness” is a fair summary of what I’m driving at in regard to this objective integration. When we experience disintegration, that’s suffering in Cassel’s view, but disintegration can still happen without our knowing it - a tumor may grow quietly in the abdomen, for example. On the flip side, growing pains - the ache after exercise, the mental strain of learning, the awkwardness of childhood development - aren’t species of suffering. Instead, growing pains are the discomfort that occurs when one moves from disintegration to greater integration.
A Medicine That Aims at Health
What does all this mean for medicine? Because our entire experience is mediated through our bodies, it’s easy for medicine to become totalizing as I mentioned above. Nothing escapes its scrutiny and therefore everything is subject to its intervention. An example of this is found in this advertisement for the anti-anxiety medication Serax.
There are many possible responses to this woman’s predicament - “beset by the seemingly insurmountable problems of raising a young family, and confined to the home most of the time, her symptoms reflect a sense of inadequacy and isolation.” Why choose medication? Well, because she’s sitting in a medical office and, given your training that constrains your vision and imagination, the expectations on her role and yours, and the bureaucracy that supports your work, you can’t do anything else but prescribe something. This problem becomes a medical problem by means of, in this case, psychiatric diagnosis. A diagnosis cannot be left without a plan, and clinicians are trained to believe that the best plans involve doing something. Hammer-wielding clinicians who see nails everywhere are going to break something sooner or later.
Medicine has a second, perhaps greater, challenge. Even when we limit it appropriately to the scope of the goals of care (longevity, function, and comfort), what medicine is attempting to do is to restore some of the invisibility of health. It’s trying to bring a little more integration. It’s like rebuilding an invisible wall using invisible bricks.
Now wait a minute, you might say, we know plenty about how our interventions work - this surgery removes that organ, or that medication alters this organ and cell function. Some of this we can’t perceive with the naked eye, but it’s not totally invisible. True though that may be, health isn’t reducible to anatomy and physiology. We may make the numbers move in the right direction or cut out the infected tissue but nevertheless fail to restore health. This is a testament to health’s bedeviling elusiveness. Someone may be suffering, even dying, behind a veil of healthy-appearing numbers.
Not only may medicine fail to restore health even if it improves physiology, but it might actually - and often does - exacerbate the visibility of health. That is, it further contributes to disintegration and suffering. I see this happen almost every day as medical interventions fail to help people become healthy again, but instead shift them into different experiences of disintegration. To return to Gadamer’s understanding of health as equilibrium, if you’re off-balance, you need a counter-balance to get you right again. The risk of applying a counter-balance (say, shifting your weight when you ride a bicycle) is that you over-correct and begin to fall the other way. So, too, with medical intervention. Not only does the subjective invisibility of health make this easy to do, but also because we’ve lost sight of the objective end of medicine as someone’s “well-working wholeness.” Without that end in view, the counter-balancing measures of medical intervention will usually be disproportionate or ill-timed. We’ve lost our vestibular sense for the telos of medicine and as a result stumble around, desperate for anything that promises to hold us upright. W.H. Auden lamented medicine’s capacity to desiccate living as a result:
They are and suffer; that is all they do;
A bandage hides the place where each is living,
His knowledge of the world restricted to
The treatment that the instruments are giving.
The best standard for the success of a medical intervention is how well it restores people to their lives. Someone is a marathon runner and has broken their leg. The healthcare team fixes the leg and in due time this person is back to running marathons. Medical intervention has succeeded in this case. But what about chronic, progressive, or life-limiting problems? Those, by definition, aren’t going to be resolved. The question then becomes, what is medicine’s role in helping patients to understand their new relationship with health? How can medicine help them find glimpses of health even amidst the suffering, symptoms, impairments, and possible impending death? Insofar as health is that capacity to be present to and to connect with the world and with others, it’s possible for this to happen even in extreme circumstances, but it’s fragile. Medical interventions risk throwing someone off balance in another direction, and so it requires wisdom to know when to act and how.
That endeavor also requires the courage recognize how intimate a relationship the clinician has with this person who comes to them for help. One needs courage to encounter someone else’s suffering with eyes, and heart, open. They need courage to assume responsibility for the work of co-authorship that occurs among clinicians, patients, and their families. The person isn’t able to be restored to the life they had before, but they must return to life - that is, not just some form of biological functioning, but the rituals and rhythms that infuse our days with vitality. Waiting rooms and lines at the pharmacy don’t do that, so what can? Figuring that out, even as frailty, vulnerability, and mortality close in, is the work of fostering health, of restoring someone to life even if they’re dying. For the applied scientist, on the other hand, there are only physiologic processes to alter. These processes are mere dead matter in motion anyway, so it makes little sense for the applied scientist to speak of health even as someone is dying.
Third, while the goals of care provide a useful framework for understanding the limits of medicine, there is another limit: proportionality. At any given time, we’re probably aware of our bodies in a way that is a very small harbinger of greater disintegration: we’ve stubbed a toe, for example, or strained our back with excessive labor. Or we’re hungry or tired. These are little reminders of our vulnerability, frailty, and, yes, our mortality. That doesn’t necessarily mean those things require medical intervention. The risks of counter-balancing disintegration are too great with minor bumps and ailments. We’re better off resting or finding other ways to cope with the discomfort. Understanding which bodily experiences require medical intervention is a matter of weighing burdens and benefits.
Fourth, understanding health and proportionality this way means clinicians have two major thresholds for acting. The first is if someone feels the loss of their health - they’re either suffering or sensing that impending disintegration. We know that’s happening because someone is having a symptom - chest pain brings them to the emergency department, for example. The second threshold is the objective loss of integration without awareness. This might be a silently growing tumor discovered incidentally, or a mental illness that diminishes one’s insight. Entities in this second threshold might also be surrogate markers, like blood pressure. Blood pressure, in and of itself, only matters insofar as it portends that loss of integration - specifically, bodily harm via a stroke or kidney damage, for example. Therefore a clinician can intervene on the blood pressure to avert something in the future, even if it’s not causing perceptible problems now.
Fifth, and admittedly this is a nuanced point: medicine is aimed at health and health is different from transhumanism. If the goals of care in medicine are longevity, function, and comfort, recognizing that we are nevertheless mortal, frail, and vulnerable, transhumanists hope that one day we can become immortal, or at least engineer negligible senescence, optimize our function, and induce contentment. Whether we, as a society, should aim for those things is another discussion, but even though transhumanists have the body in view, they aren’t discussing health. They’re wanting to transcend the human condition itself and therefore redefine health itself. This is another limit of medicine which acknowledges the human condition. Medicine focuses on health within the context of our inevitable and shared mortality, frailty, and vulnerability. Lots more to be said here, but I’ll save it for another time.
Sixth, and this is my final point for now: understanding health in this way means we need more than technique to pursue it. While a computer could generate a list of the appropriate antibiotics to treat certain infections, aiming toward and pursuing an end like health requires something more. Returning to MacIntyre, medicine is a practice aimed at the good of health, and requires certain qualities of character called virtues. The clinical encounter is fundamentally a human encounter and this need for virtue is inescapable. Clinicians need to cultivate within themselves the capacities to navigate the messy, disorienting, wild, human dimensions of the clinical encounter. Patients do too. MacIntyre understood virtues to be necessary in pursuing goods, like health, and also in sustaining relationships that would enable the same. Virtues also both sustain and require traditions in which their cultivation is possible and makes sense. I’ll save a broader meditation on virtues related to medicine for another time. Suffice it to say, a mere procedural focus on ethical principles is insufficient in the pursuit of health, but would suit us quite nicely if all we cared about was altered physiology at the consent of individual patients.
How does all this frame my day-to-day practice as a clinician?
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
Some claim there’s no slippery slope regarding assisted suicide but advocacy efforts suggest otherwise. The logical terminus of support for assisted suicide is either non-voluntary euthanasia or euthanasia on demand. Either the standard is suffering and euthanasia is owed those who can't consent for it, or the standard is autonomy and suffering is irrelevant. We’re seeing that advocacy efforts aren't intended to stop merely at assisted suicide for those who are capable of self-ingesting a lethal medication when they have a prognosis of < 6 months. Importantly, this is no "slippery slope fallacy." This is a clear demonstration of the power of precedent. Rather than fallaciously claiming that somehow A --> D, we're seeing in real time how A --> B --> C --> D. What once were safeguards are now seen as obstacles.
“I have been through this before”
Poignant comparisons between the experiences of a mother of a child with autism and our current social dynamics regarding COVID. This is one of the more cogent essays I’ve read expressing concern about how the whiplash changes in behavior we’re expected to implement, often with little or evolving evidence. The problem isn’t changing science; the problem is the religiosity with which many adhere to the recommendations: “Don’t wear a mask; you must wear a mask. Buy a pulse oximeter. Stock up on Tylenol, vitamin D, Pepcid. Whisper so you don’t spit. Stand six feet from others—no, 10. Wear gloves. Wear two masks! Open the windows. Close the schools. The dizzying madness of COVID, and the reliance on gurulike experts, has been eerily familiar.”
“Re-enchanting the body: overcoming the melancholy of medicine”
Joel Shuman, theologian and physical therapist, reflects on how an analytical understanding of the human body, breaking it down to its constituent parts to understand how it works, actually trains our eyes to miss the whole person. “The specialist whose attention focuses on a particular aspect of the patient’s body - an aspect about which she knows a great deal and over which she may have a great deal of control - may nonetheless be able to do little to heal the patient simply because she is unable to ‘see’ the patient who needs healing.” How do we avoid this? “…a body seen as a body - both more and other than the sum of its parts - is one seen as the manifest presence of a beloved human person instead of simply as an object to be manipulated or controlled.”
“The human-built world is not built for humans”
L.M. Sacasas reflects on how human behavior inevitably bends and transforms in response to technology, even though technology is meant to serve human purposes. What results is an environment, culture, and human identity that are different than what existed before the introduction of the technology. In the world of healthcare, what springs to mind is the electronic medical record (EMR). Common objections to the EMR is that it’s an unwelcome intrusion into the encounter between clinician and patient. The more insidious imposition is that it forms clinicians to believe that healthcare should be endlessly catalogued, analyzed, and billable. This changes how clinicians approach their encounters with patients, as their work is refined (or degraded?) into a search for mere symptoms that fit the checkboxes provided to them by the EMR.
Nitin Ahuja is a gastroenterologist writing here on the liminal space between the human body and our environment. How can we better understand this space to in turn better understand medically unexplained symptoms, many of the bearers of which are referred to Dr. Ahuja’s clinic? How we see the human body depends on the interpretative lens we use. Modern biomedicine offers one particular lens (that of the cadaver, as argued by Jeffrey Bishop; the body is merely dead matter in motion), but there are others. How do we glean wisdom from using these other lens without medicalizing every aspect of life?
“The messiness of medical decision-making in advanced illness”
GeriPal is always a rewarding podcast and this one with James Tulsky is a helpful overview of the some of the nuances around complex medical decision-making in those particularly with advanced cancer. They discuss the too often overlooked member of the healthcare team too: the caregiver. I did want to highlight one idea they discuss: why wouldn’t you want to continue a fairly benign treatment even if it was ineffective and the end of life was near? The treatment may be physiologically benign, but it's not at all existentially, financially, socially benign. That treatment symbolizes a hope for the patient that may impair their capacity to engage other meaningful things (a point Dr. Tulsky made earlier in the podcast). It may keep someone from engaging with their mortality. While I'm not here to twist arms in that regard, it's tragic when they don't say any of the four most important things because they thought they had more time when they didn't. It may cost them a lot of money. And a lot of time - in waiting rooms, in labs, in scanners. And when the desperate time comes at 3 AM when they wake up breathless, who will they call? Not hospice. They may or may not survive to the ED, to admission, when someone can diagnose them as dying and provide the appropriate symptom relief. Rather than newer cancer-directed therapies being better tolerated, they actually more effectively hide important existential tasks. Even if you're not facing the end of your life in the next 6 months or the next 10 years, important things can come from acknowledging your human frailty, mortality, and dependence. Add the lack of hospice and steep cost of these drugs, and it's not a straightforward deal.
“The weird, wonderful work of pandemic geropsychology”
Craig Libman writes humbly about how the pandemic transformed his practice as a palliative care psychologist. While we’ve heard a lot about the changes hospital units have had to undergo to accommodate COVID surges, and the incumbent changes imposed on healthcare staff to meet those acute needs, I’ve read little about how the emotional and social needs, particularly of those in nursing homes, have been met during the most isolated times in the pandemic. Dr. Libman recognized this deep need and the limitations of traditional psychotherapy in meeting it. Instead, he reached for more mundane, but also more effective, tools.
For patients with significant pain related to pancreatic cancer and poor tolerance for opioids, we sometimes reach for a nerve block. This RCT shines more light on the practice: the pain relief is temporary (on the order of months, which we knew), it’s barely clinically significant (decrease of 0.7 in the pain score), and it doesn’t impact overall quality of life. The doozy of a finding in this trial is that it may reduce survival. It was a secondary outcome and so wasn’t powered specifically for this, but it warrants further exploration and, perhaps, hesitation as one is considering using this intervention to manage someone’s pain.
“The Nocturnists: Burn the Map”
A story about how psychiatrist David Elkin used improv (despite his great trepidation) to become more aware of important things in the clinical encounter. One important principle of improv is “yes, and.” You build on what someone else is doing. As Dr. Elkin observes, so much of medicine is “yes, but.” Working to become more collaborative is hard but rewarding work; some of that work is undoing the formative influences of rigid medical training.
Jessica Stuart, having survived lymphoma in her adolescence, writes of her experience caring for someone with cancer who, acknowledging the “big stuff” of his treatment plan, just wants to be able to eat his wife’s hamburgers again. Dr. Stuart observes that it’s usually the “little things” that patients care most about, not the “big things” the physicians spend so much of their time considering. Medicine over-steps when it assumes that the interventions are the big stuff, rather than those things intended to get folks back to the big stuff (what some call "little stuff") of their lives.
Parting Thoughts
The view of illness as biographical disruption is illuminating. Becoming ill creates a need to find meaning for a new narrative: the narrative of health that has now been disrupted by illness.
Havi Carel, Illness: The Cry of the Flesh