Values of Reductionism and Values of Holism Tom Mason, Pete Hinman, Ruth Sadik, Doreen Collyer, Neil Hosker and Adam Keen

 Values of Reductionism and Values of Holism

Tom Mason, Pete Hinman, Ruth Sadik, Doreen Collyer, Neil Hosker and Adam Keen

 

Introduction

Many readers of this text may be concerned about what it is to be human in a world that is ever-changing, complex and dynamic – in short, what is the human condition? Part of being human, in evolutionary or developmental terms, involves attempting to understand where we fi t as mere ‘particles’ within the wider universe and where the atoms fi t within our own individual, sub-universal selves. In our search for this understanding, our ‘gaze’ has been drawn to the heavens (holism) (James, 1984) as well as to the depths of the Soul (reductionism) (Rosenberg, 2006). Although, for many of us, our search continues, we can begin to draw some tentative conclusions. In this chapter, we focus our attention on four interrelated concepts that contribute

to our humanistic perspective of health care delivery: reductionism, holism, value and humanism.

Reductionism

Reductionism is an ancient philosophy dating back, at least, to the early Greeks. It is a procedure that we employ to attempt to understand how a domain works by analysing its constituent parts. Domains can be any area of study from the physical sciences such as objects, planets, geography and biology to the social sciences of human behaviour, customs, rites, rituals and so on. Domains also traverse the philosophical sciences such as law, language and theology. In simple terms, we can apply reductionist procedures to the human body and, thus, arrive at an understanding of how the individual parts, for example the nervous system, alimentary system and endocrine system may function to maintain the integrity of the body in a state of what we know as ‘life’. Through modern technology, we can deconstruct the human body down to minute structures with electromagnetic microscopy and theorise about molecular interaction (Ideker and Sharan, 2008). Furthermore, during this procedure of reductionism through all levels, including the universe, the world, the human body, the nervous system, neurones, synaptic gaps, chemicals and atomic structures, it is said that each smaller theory is absorbed into the greater. Given that we have only used the one example of the nervous system, if this were applied to all domains, across all sciences, then all theories could ultimately be absorbed into a ‘global thesis’ or a ‘theory of everything’ (Hawking, 1995). However, there may be problems with reductionism.

Holism

Holism dates back at least to the early Greeks and was summarised in the Metaphysics by Aristotle as the whole being more than the sum of its parts (Aristotle, 1998). The idea of holism, which is often said to be the opposite of reductionism, is that the properties or parts of an overall system cannot be totally understood by its components alone. If we take an example from physics, we might be able to understand how an engine works from an appreciation of its constituent parts, but we need another form of thinking to appreciate what it is to have a car, to understand the transport system and to appreciate our contribution to pollution and global warming. Thus, holistically, the human being is more than the sum of its component atoms, molecules, cells, organs, systems and body and would embrace aspirations, drives, ambitions, beliefs, social interactions and so on. In scientific holism, it is argued that because the whole is greater than the sum of its parts, then the overall behaviour of the system cannot always be predicted and leads to higher levels of complexity. An example of this can be seen in meteorology and the weather. This notion of multifaceted interaction is referred to in systems theory, chaos theory and complexity theory and, we would argue, is resonant in human nature.

What we value

Values operate as standards by which our actions are selected. There is little agreement in the science of values. Psychologists, sociologists, anthropologists and philosophers all disagree as to the emergence, function and dynamics of values (Giddens, 1997). However, at an axiomatic level, we understand values to be part of our societal traditions, mores, beliefs and normative prescriptions that bind communities together. This is despite the fact that they may be different in differing sub-groups of a community, may change over time, are affected by circumstances and may be held rigidly or weakly. In terms of health and social care, we can note that values are held in relation to reductionist approaches to understanding how the body works and holistic approaches in relation to the bio-psycho-socio-spiritual functioning of the self in the world. These contrasting approaches are often complementary in our understanding of health and social care and most assuredly are interrelated in the human condition.

Humanism

For most of us, when the integrity of the body or mind is threatened through being in a state of ill health or social difficulty, there is an underpinning drive to return to a state of health equilibrium and in doing so we may draw on numerous humanistic qualities (Herrick, 2005). We may ascribe wholeheartedly to a reductionist approach in the rationalist notion of cause and effect or we may draw on a holistic belief system in the mystical sense of being greater than the sum of our parts. In the former, we may rely, for example, on modern surgical or pharmacological remedies whilst in the latter we may draw on complementary therapies which remain largely unexplained. Furthermore, in this latter mode, we may rely on a greater authority by invoking a more divine therapeutic involvement through spirituality. In any event, we can see the human impact of all modes of thinking in the human condition.

In this chapter, we will offer a critique of the contemporary reliance on evidence-based practice in Western health care systems and argue that this mode of thinking is merely one in a range of ‘sciences’. It is our view that by focusing on a reductionist perspective alone merely eradicates the humanness in health and social care, and that other modes of beliefs are complementary to the human condition.

The Nature of Value

Personal values are acquired and developed early on in our lives, shaping and influencing our thinking and behaviour (Warne and McAndrew, 2008). In relation to the bio-psycho-socio-spiritual functioning of the self in the world, values are neither identical with nor reducible to particular psychological phenomena: liking or disliking, preferring, evaluating, valuing or devaluing, whether taken singly or in various combinations (Lemos, 1995). By their individual disposition, personal values may never be articulated or shared. They indicate a belonging to different social groupings with a degree of homogeneity, such as our work, leisure activities or religious observance; they may or may not separate each grouping from others. Thus, heterogeneous groups with individual members with conflicting values may or may not be

disclosed.

Taking the view that it is false to assume that people know what their values are, identifying one’s values requires a person to decisively penetrate their moral index and form a values inventory. In reality, most people are living the values of others. Only when undertaking this conscious process and developing an inventory of personal values, identifying why these values are important to oneself and committing to them, are we able to live our own values. This exercise potentially reveals the ethical position of oneself and potentially the depth of self-indulgence or more sinisterly the extent of our immoral values. This account will incorporate a number of axiological studies and encompassing concepts which may include personal, organisational and societal notions of value and which also have correlated ethical and aesthetic features. These in turn will provide a distinct viewpoint on the nature of value and its influence on the human condition.

Values can constitute an individual’s identity and also be shared by groups of different individuals, and similar individuals in a broader societal and cultural order. Examples could be respect for others, justice, concern for others, self-discipline, loyalty, competence and cooperation. Societal values could include authority, equality, legal protection and education. Social groups generally have a set of values, held within a loose psycho-social framework, for example religious or patriotic beliefs. Yet an individual’s value of one concept may conflict or compete with another, creating a dissonance within that individual as shown in Vignette 4.1.

Vignette 4.1

My name is Pavel, I am a 54-year-old lorry driver, married with two young daughters, aged 9 and 11 years. I am in hospital with bad pain in my left leg. I am waiting for amputation due to insufficient blood supply caused partly by my smoking. Medication only dulls the pain and in an attempt to feel relaxed, I need to go out from the ward to smoke and the nearest place is the vestibule of the main pedestrian entrance to the hospital. I know that I should smoke in designated areas to reduce the passive smoking by those entering and leaving the hospital. Also, I should try to stop smoking to improve my health in light of my current problem and proposed surgery.

An elementary evaluation of the scenario could be that Pavel wants to smoke to help him relax from the sustained pain in his leg (the value of autonomy). Yet, he is aware that people using the main entrance will directly be affected by him smoking in a public area (maintaining the value of nonmalfeasance). Continuing to smoke, he could exacerbate his symptoms and potentially affect his chances of continuing to work to maintain an income for his family (again, the value of non-malfeasance). In this case, the locus of control on what individually is viewed as the more respected value or values at a given time, is internally deliberated by Pavel (autonomy versus nonmalfeasance). He views the use of smoking as his means of coping whilst in an acute stage of his condition. It could be claimed controversially by those accessing the hospital that his actions are universally harmful and antagonistic (malicious); also, from an emotive position, that he is jeopardising his employment status and the means to support his family (self-determination).

Further, discarding the lit cigarette into a general waste bin or onto the carpeted floor in the main entrance as a careless act graphically illustrates the position Pavel selfishly takes. Taking an extreme view that there exists an increased risk of fire which could affect staff, service users and visitors, Pavel may fleetingly acknowledge his behaviour as an irresponsible act. Would he then excuse it by admitting that he was preoccupied by the pain in his leg, the prospect of his worsening health or the possibility of losing his job? Arguably, he had the choice of two courses of action, both of which he could view as morally right, but only one choice to make, a classic ethical dilemma (Purtilo, 1993). His choosing to take one course of action upholds his values at that time, though compromises and challenges the values of another (Beauchamp and Childress, 1994). Which of those values should override the other? Is it the true nature of a human being to act in their personal interests first, and then respond altruistically when publicly exposed? Ethics can be defined as thinking and reasoning about morality (Rowson, 1990: 3), though it is also about being human and living in today’s world: acknowledging that people have different views, values and experiences. Tschudin and Marks-Maran (1993: 3) suggest the view that ‘it is not a question of who is right or wrong, but of how you can know what you believe is valuable, and stand by that value, and respect other people’s values’. Further, they add that it is ‘about understanding how your feelings and society’s norms relate to each other, and how you decide for yourself and others’.

Although a powerfully influential and diverse concept, the nature of value, controversially, could be viewed as almost indeterminate. Furthermore, when value is described, an assumption is that it provides only a vague indication of its universal worth. If we take the view of Frankl (cited in Wirth, 2007), there are three central values in life: the experiential, or that which happens to us; the creative, or that which we bring into existence; and the attitudinal, or our response in difficult or challenging circumstances. Employing all three simultaneously in our activities is ultimately how we thrive as human beings, both altruistically and egocentrically, with competing beliefs.

Schwartz (1992, 1994) used his ‘Schwartz Value Inventory’ (SVI) for a wide survey of over 60,000 people to identify common values that acted as guiding principles for their lives, depicted here as a circular representation of the value types (Figure 4.1). The value type domains are ‘super grouped’ into four higherorder value types: on one side, ‘openness to change’ and ‘self-enhancement’; on the opposite side of the circle, ‘conservation’ and ‘self-transcendence’. On examination, the values form something of a spectrum with successive values often having a close relationship.

Described in detail within his published work (1992, 1994), Schwartz’s domains of his inventory include following value types:

• ‘power’ – those individuals that value social status, prestige and dominance over people and resources

• ‘achievement’ – relating to personal success and admiration

• (benevolence) – advocating an ethical virtue of non-malfeasance, promoting the welfare of others

• ‘tradition’ – representing a respect of traditions and customs.

Other value types identified by Schwartz et al. (2002) reveal more indulgent characteristics, such as ‘hedonism’ representing a value type where preference is given to pleasure and self-gratification; ‘stimulation’ representing a group of values that express a preference for an exciting life; and ‘self-direction’, a distinct group of values that value independence, creativity and freedom. Along with more principled value types noted within the inventory, is a ‘conformity’ value type containing values that represent obedience, with ‘universalism’ representing a value type whose preference is for social justice and tolerance, and, finally, ‘security’ as a value orientation containing values relating to the safety, harmony and welfare of society and of oneself. It could be argued that exposure to the value types endorsed by Schwartz et al. (2002), as elements of our moral index, will enhance the development of oneself. We grow from infancy, learning and rehearsing, executing learned behaviours, employing numerous value dimensions.

These signify our status as an individual along with a profound set of psychosociological and spiritual principles, be they inhibited by custom or expressed creatively without bounds. By tacit adherence to one’s own value code, it is the expression of oneself.

Return to Task Orientation

From value to task

In the reductionist ideology, there is a tendency to focus on the individual part, which has the potential for the overall picture to become confused. For example, in the development of the industrialised world, in relation to the modes of production, factories were designed for individuals to work on one small component of an overall product. This mechanistic approach ensured the effective use of labour, but at a cost of tedium for the workers. Employees working on a conveyor-belt production line may have the reductionist task of putting a particular bolt on a specific part of the construction but the overall end-product of a car, for example, is merely a distant figment. Throughout the last century, this conveyor-belt industrialisation became known as Fordism, after the Ford factory production of cars, with its focus on task orientation, efficient modes of production (at a physical and psychological cost to the workers) and consumerism (Bakker and Miller, 1996; Lundy, 2007). It is not surprising that in the post-Second World War era and the inception of the NHS in the UK, the medical model and numerous nursing models were reductionist in nature, viewing parts of the body and mind as ‘broken’ and requiring health services to ‘fix’ them (Shaw and Mountain, 2007). This mechanistic approach to health care saw hospitals as factories with input, throughput and output recorded as admission rates (Richman, 1987). This led to a concentration on the human being as a set of sub-components that if all are working effectively constitutes the overall state of being human. Unfortunately (or fortunately), this falls short of understanding the essence of being human (Norman, 2004). Throughout the closing decades of the last century, and the early part of this century, two major factors have converged to influence our current health and social care services. These factors are technological advancements and political ideologies. The development of the microchip has led to the huge leap forward in information technologies with giant strides being made in health science. This, Foucault (1973) suggests, has produced a ‘medical gaze’ on the micro-aspects of the body with keyhole surgery, fibre-optics and mapping techniques revealing the previously hidden parts of the body as visible entities on TV screens. Whilst progression of health science is creditable and welcome, it comes at a potential cost to the service user at an individual level. The increase in technology, for all health care professionals, can lead to a focus on equipment rather than on the service user (Cooper, 1993). By necessity, complicated equipment requires careful and expert management, which centres the attention on the task at hand. The task, or job, is to ensure the effective functioning and operation of the technology rather than the service user. This has been noted in numerous health care arenas (Heath et al., 2003; Smith, 1997). The second factor or, more accurately, the second set of factors, involves political ideologies. The consumerist approaches within the capitalism

of Margaret Thatcher and the Conservative government of the 1980s and 1990s led to many health and social care reforms being set within a marketeconomy-driven structure. The values of care delivery were subsumed within the dominant force of profit. The drive for profit inevitably involves competition and the use of cheap labour. Although ideologically such a consumerist approach in businesses would suggest the evolution of waste reduction and increased quality of services, in health and social care organisations, these drives may well be misdirected (Smith, 1997). An example would be the placing of hospital cleaning services with private companies, who competed for the contracts in the open market. This resulted, as would be expected, in the use of cheap labour and cleaning materials, at a reduced cost to the company with the consequences of a poor cleaning service (Cooper et al., 2003). Some have suggested that the result of this is the high levels of infections (the Superbugs – MRSA, C. Diff.) seen in some of our contemporary hospitals (Greenstein et al., 2003). Over the past decade, New Labour policies have fared little better with Foundation Trusts and the implementation of the Modern Matron having little impact (Bolton, 2003). Although Tony Blair attempted to re-focus attention on the individual service user, the government appeared to lose sight of the holism of the person through an emphasis, even obsession, on quantifying the entire process of health and social care delivery. Indeed, there has also been the suggestion of measuring how much compassion a nurse shows and how often they smile at service users! (Carvel, 2008).

Tensions in health and social care

Emerging from the foregoing brief history of contemporary health and social care influences are a number of themes and these are: expectations, roles and accountability. Expectations refer to what can be realistically anticipated from health and social care services in relation to the limitations in resources and professional knowledge (Manser and Staender, 2005). For example, there is frequent debate concerning the expensive price of certain drugs and a care provider’s decision not to provide it on the NHS for individual service users suffering from cancer. Furthermore, we appreciate that despite modern treatments, service users continue to die, thus indicating the limits to medicine (Illich, 1976). However, expectations also involve the prediction of standards as a norm to be anticipated. In this sense, it is what we can expect from a service after we have balanced the tension between limitations and desires. Another tension involves the changing role dynamics of the professionals, the service users and their families. From the traditional accepted abdication of responsibility within the Parsonian sick role (Parsons, 1951), service users now share accountability for their illness or social situation, are partly responsible for recovery and are expected to contribute to their care (Fendrick et al., 2001; Holden, 2007). Professional roles have changed in response to the dynamic of contemporary health and social care services with a strong emphasis on the effective management of the infrastructure of the organisation. At a macro-organisational level, this focuses on waiting times, bed management, early discharge, case closure and so on, and at a micro-organisational level on care plans, birth plans, administrative forms and so on. Relatives’ roles have also changed as they expect the care services to function like any other service. Complaints have increased as the silent respect for professionals, particularly doctors and nurses, has evaporated (Blickstein, 2007; Cowan and Anthony, 2008; Floyd, 2008). It would appear that they are now just as likely to be threatened as thanked. Accountability has emerged as a powerful factor in modern health and social care with increases in litigation, compensation and out-of-court settlements (Blickstein, 2007; Floyd, 2008). The setting of targets by the government has allowed for the monitoring of results with the corollary of dismissal in the event of failure (Shaw et al., 2008). These factors, then, have coalesced to change the value structure within health and social care which encourages a focus on the reductionist parts and loses sight of the service user at a holistic level.

A few examples should now suffice to bring these factors into stark relief. Service users are expected to comply with the professionals’ request for early self-help and discharge. They are also expected to negotiate care and contribute through becoming autonomous. Relatives are now expected to be more fully involved in the service users’ care, for example in cooking and feeding, toileting, washing, cleaning and shopping. The move towards a closer relative involvement is reflected in partners attending childbirth, parents staying with their children in hospital over the 24-hour period and families being involved in the single assessment process for vulnerable people in the community. Professionals may shed these interactional and interpersonal aspects of care delivery as they expect service users and relatives to manage these holistic elements. If relatives are expected to provide this, then it allows the professionals to focus more on the management and operationalising aspects of the task. Seen in reductionist terms, task allocation is managed through assessing the requirements of the task (what needs to be done), operationalising it (doing it) and evaluating the outcome (reflecting on it) (Pearcey,2007). However, the skills and competencies required to undertake task management – even a health or social care task – may not be those required by a holistic professional. It may be that a manager has the skills of task allocation whilst the health or social care professional has the skills to perceive the service user in a holistic manner. In nursing, for example, the care role has come under scrutiny in recent times in relation to the skills and competencies that are required (Pearcey, 2008). The current move in the UK to provide nursing education at degree level only would suggest that qualified nurses will be a minority of the health care workforce in the future. The main caring role will likely be undertaken by a larger group of unregistered Health Care Assistants (HCAs), a highly skilled but smaller nursing group and a service user population expected to meet their own health care needs (Bach et al., 2008). This phenomenon is also seen in other professional areas with roles such as physician’s assistant and mental health worker developing. Vignette 4.2 illustrates the possible outcome for service users.

Vignette 4.2

Jim and Betty are both octogenarians, have been married for 63 years and have three children, the closest of whom lives 103 miles away. In order to assist Betty and Jim, a carer comes and showers Jim each morning. Early one morning Jim sustains a fall which results in admission to hospital after sustaining a fractured femur and cuts to his head and legs. He also has dementia which is made worse by unfamiliar surroundings. Betty accompanies Jim on his admission at 03.30 hours and as he is proving difficult to manage, chronic staff shortages and the fact that Betty and Jim have never spent a night apart, the staff encourage Betty to remain in a side room with her husband. The following morning a Healthcare Support Worker (HSW) arrives and presents Betty with a bowl in order to assist her husband with his hygiene. At 15.00 hours a Staff Nurse goes to check on Jim and finds him and his wife collapsed, surrounded by untouched breakfast and lunch trays.

The questions that should arise from this are twofold. First, would the outcomes of the scenario change if on admission there had been no chronic staff shortage? This is debatable given that the full staff complement would have predominantly been Healthcare Support Workers (HSWs), Second, if a qualified nurse had gone in with the bowl as opposed to the HSW, would she have noted that Betty appeared exhausted and had not been able to get a drink?

Structured Assessment

Plato deals with the notion of learning in his inimitable fashion within the Socratic dialogue Meno (Hutchinson, 1997) and this has an interesting perspective on the idea of ‘assessment’. Meno begins by asking Socrates to explain to him whether virtue is acquired by teaching or by practice; or if neither … then whether it comes to man by nature, or in what other way? The answer involves issues of education, learning and teaching within the overarching concept of what constitutes knowledge. To facilitate Socrates’ point, he invites a young slave boy over who represents ignorance and the uneducated in early Greek times. Socrates then asks the slave boy to draw a square in the sand and, through a series of questions and answers, leads the boy through some complex geometric examples dealing with squared numbers and angles. At the end of the session, he then sends the slave boy off to his work and turns to Meno to enquire whether the slave boy has learnt anything, is now educated or if the knowledge was always there and just needed to be brought out. A lengthy discussion takes place regarding the process of what had happened in the interaction between Socrates and the slave boy. What is relevant to us here is the issue that we do not actually know whether the slave boy is educated or not or has learnt anything from Socrates because he is not assessed, and he never returns in the dialogue to give any other indication, practical or theoretical, that he has learnt something. All we have to go on is the answers he gave to Socrates’ questions when asked. However, what is clear within the Meno dialogue is the ongoing formative assessment as Socrates continually gauges whether the boy understands as he does, indeed, frequently claim to do so. However, without a summative assessment, we do not actually know whether the value of the knowledge, education and learning is applied, either in practice or in theory. From this, we make an assumption that it would be a positive endeavour if we could assess the slave boy to see if he had learnt something. We could undertake this assessment through a number of formal instruments by examinations, assignments and projects, for example, or we could employ a structured evaluation by observing a practical test in which he would do a task to reveal his knowledge of geometry. Of course, we juxtapose this type of formal assessment with a more intuitive evaluation which would incorporate watching and listening to the interaction between Socrates and the slave boy with a belief in the process of the educational framework, in this case questioning and answer. The issue now turns to the underpinning values inherent in both formal and informal (or intuitive) assessments.

Formal and intuitive assessments

In contemporary health and social care, there is an emphasis on evidencebased practice and this is as much the case in the practice arena as it is in professional education itself. There is a reliance on the structured assessments that are considered to be scientific in the sense that they usually involve some degree of measurement. The growth in instruments to perform a degree of assessment is vast and continues to expand (Mason and Whitehead, 2003). This reliance on quantification reflects the belief in the hard science of numbers with statistics being the favoured religion. In clinical terms, there are APGAR scores at birth (Finster and Wood, 2005), percentiles through growth (Hemachandra et al., 2007), measures of quality of life (Rajmil et al., 2004) and all manner of scales of mental health, personality function, behavioural repertoires and the experience of pain (Williamson and Hoggart, 2005), to mention but a few. In professional education, we are familiar with unseen examinations, assignments, essays, objective, structured, clinical examinations, portfolios, multiple-choice exams and so on. In all these, the values pivot on the notion of hard evidence extracted by an array of measurement tools, some clearly quantitative but others most assuredly qualitative. Informal, or intuitive, assessments, on the other hand, are held to be more strictly qualitative and by dint of this term are devalued in relation to the evidence-based approaches. However, a brief foray into this intuitive assessment procedure reveals a different picture. Intuition is an internal and often subconscious process that is grounded in tradition, experience and instinct. Traditional values are those that have been passed on from generation to generation and have been formulated in evolutionary terms over hundreds and thousands of years. They form the basis of our collective unconscious and make up our cultural mosaic, which as we can see contributes to establishing differences between societies. However, despite these differences, there are consistent imperatives across cultures, perhaps in varying strengths, but none the less inherently established, such as caring for the sick and socially deprived. Experience can be said to emanate from an interaction with traditional values and also contributes in turn to maintaining them. Once exposed to, say, the values of caring for others, we then employ that experience to perpetuate those beliefs for future generations and teach others those values. Experience of those principles becomes established as the normative standards by which our culture functions and certain behavioural actions become expected, such as caring for the sick. This type of experience becomes respected and valued. Instinct refers to innate patterns of behaviour that occur in response to certain stimuli without necessarily any actual experience of how to act in a certain way. This can be said to be a way of intuitively acting or thinking in a pre-determined and natural way. For example, if an egg is hatched in an incubator, the caged bird will grow and have the skills to build a nest independently of the experience of seeing one built. Therefore, the assumption is that we, as humans, may have certain values (in our example, caring for the sick), even if we were born and raised on an island away from all other humans. In short, we would instinctively value caring for others.

Dehumanisation

In philosophical terms, humanism refers to a number of interrelated concepts that are concerned with what it is to be a human being in this world. It involves the nature, defining characteristics, abilities, powers, education, culture and, most notably, the values of being human. Humanism is both a simple and a complex concept. In simple terms, it is about the recognition of the value of others and sharing this world in a common community in which everyone has an equal place. It is also concerned with the ability to have empathy, in which we recognise the pains and pleasures in others and reflect them back into ourselves. In this way, we can ‘share’ and ‘know’ others’ feelings. However, humanism is also a complex, yet coherent, system of substantive, ontological, epistemological, anthropological, sociological and psychological perspectives. These bring in educational, aesthetic, political, ethical and moral claims, which contribute to the cultural mosaic that forms community structures (Kurtz, 2006; Norman, 2004). There are, of course, many more aspects to being human and most writers on this topic would include spirituality, poetry, art, history and morality, to name but a few. Seeing such aspects to being human is clearly a reductionist approach, which sub-divides human nature into ever more micro components and suggests that each part is separate from the other. In reality, all aspects are interrelated and have a dynamic affect on each other, with each contributing to the holistic nature of being human (Herrick, 2005). When we think of the self, we predominantly think of what it is like to be ‘me’ and we perceive our ‘self’ in relation to the world from the ‘I’ that is within us. However, as we live in this world with others, it is our relation to others that makes us human and this relation is known as the ‘I–Thou’ primary relation, in the classic text by Buber (1937). Within the ‘I–Thou’ relationship with others, each culture, community and society arranges a set of social norms that govern how we are to behave towards each other. These norms prescribe our social action and take into account the nature of being human, which outlines ways of acting towards each other with accompanying sanctions when they are transgressed (Giddens, 2000).

Difference and distance

The role of norms in regard to dehumanisation is exemplified in the works of Szasz (1974), Bauman (1996) and McPhail (1999). According to Szasz, mental illness is traditionally based on the medical ethic that a neurological cause lies behind each variance from normal behaviour and thought. Yet, the judgement of ‘normal’ is based on a complex interplay of sociological, ethical and political factors and this, therefore, has the potential to dehumanise. In order to dehumanise, we must be able to establish a difference between ‘them’ and ‘us’ and this difference then carries some element of a devaluation towards ‘them’. We are all aware of the many prejudices that occur around the world and we can name racial, religious and national as exemplars of such intolerances. Once such differences have been identified and devalued, we can then become detached from the commitment to the relationship with the ‘other’ and separate ourselves from empathy with them. ‘They’ become not like us and ‘They’ are thus distanced from us. However, before we turn our attention to health and social care issues, it is important to examine how we, as human beings, can now move beyond mere distancing of the ‘other’ to actually acting negatively towards them. Bauman (1996), in his study of the Holocaust, describes how some social theorists compare the processes required for the implementation of the ‘final solution’ to those of modern enterprises and bureaucracy. This gives the historical nature of the Holocaust analysis a modern relevance, particularly in relation to health and social care. During the Holocaust, some 6 to 12 million people were put to death (Bauman, 1996). Whilst the starting point of the Holocaust required a devaluation and alienation of the learning disabled, the mentally ill, the Gypsies, the homosexuals and the Jews, the ultimate outcome required the application of efficient business processes, modern technology and systematic surveillance techniques. Those involved in the process were arguably distanced from the moral implications of their actions through the ‘normality’ imposed by the organisational process itself. In short, the process of elimination becomes ‘normal’. Once the distance between ‘them’ and ‘us’ is established, ‘they’ have to all become the same. They become ‘The Jew’ (Lyotard, 1990). This is personified in the shaving of their heads and making them wear the same striped ‘pyjamas’ in order to maintain the detachment. There are many examples of dehumanisation and the Holocaust is probably in the extreme. However, we must remember that it was men of medicine, having taken the Hippocratic Oath, that performed the medical experiments in the Holocaust. Furthermore, their defence at the Nuremburg trials was largely not based on a denial of their involvement but that the experiments were legal (Hitler had changed the law) and had peer review acceptance. However difficult it is to understand how medical professionals can break such a code of morality, we should note that such transgressions have been observed in ‘normal’ people. We should compare the Eugenics movement in the UK, which saw the hospitalisation of thousands of people with learning disabilities and mental health problems over the previous century and the analogy of the communist witch hunts in the USA. Both these show how ‘normal’ people may lose sight of the individual in an overarching prejudice of belief. At the level of science, Milgram (1974) conducted a series of controversial experiments testing obedience (Blass, 2002). His experiments involved ‘normal’ subjects administering increasingly (perceived) painful electric shocks as a form of punishment to a distanced victim (the stooge). The results of the study showed that the various control mechanisms for moral agency can be disengaged in ‘normal’ people and that this disengagement is inversely correlated to the distance between the subject and the victim (Milgram, 1974). Haney et al. (1973) investigated the process of dehumanisation and de-individualisation in a controlled ‘total environment’. The two-week experiment, known as the Stanford Prison Experiment, in which 24 college students were assigned the roles of either prisoner or guard, was disbanded after only six days as altered behaviour within the study sample evoked serious ethical concerns. It was shown that individuals, who had been previously psychometrically tested for their ‘normality’ could, when placed in certain contrived situations, adopt roles beyond the boundaries of their previous norms, laws, ethics and morals (Zimbardo et al., 1999). The history of the Holocaust, therefore, demonstrates that dehumanisation can occur in people who are considered to be ‘normal’ and can take place in the monstrous event as well as the mundane of everyday life. In fact, it is quite surprising the extent to which it is occurring throughout our society – for example, in sport with the use of performance enhancement (Culbertson, 2007), in reality TV shows (Menon, 2006) and in the creation of the ‘enemyimage’ (Maiese, 2003). Therefore, it should come as no surprise to realise that in health and social care settings dehumanisation is also taking place.

Dehumanised values in health and social care

Health and social care settings are part of an overall system of services that form an industry of care. But, by the nature of the services that are delivered, they are usually constructed as large organisations. Here we will use hospitals as an example. Like most large organisations, they require systems of process to manage their productivity and these systems may well emerge to be the focus of scrutiny in themselves, rather than the product that they produce. When dealing with tangible products, such as motor cars, the systems that produce them can be quality assured in an effective and quantifiable way involving measures of performance-related outcomes. Furthermore, whilst the product of a good car is set within parameters of a quality assurance framework, a health condition transcends these boundaries to an existential level of meaning. In measuring a medical condition in terms of waiting times, inpatient admission rates, throughput and output, outcome data and discharge times, which are all necessary and appropriate, we can lose sight of the quality of that journey for the person concerned. The analogy of the construction of a car through the factory and the mechanistic process of reconstructing a human being through the hospital is, perhaps, a little hackneyed these days. However, it suffices to deliver the message that there is something beyond the human journey through ill health or social difficulty that modern health and social care services can miss if their focus is limited to these measures alone.Concentration on outcomes, such as inpatient days, can evade issues of the lived experience of the quality of that inpatient time, and the meaning that it has in the more holistic life journey for that person. This is part of the dehumanisation process of modern health and social care services which can focus on the system processes and outcomes rather than the individuals within it. Whilst most of us are advocates of science and the production of evidence, it is within the system of health and social care that we must remain vigilant in protecting the values and morals that underpin it. In focusing on the body and its reductionist parts, we can lose sight of the person within the care system. There are obvious areas in the care services in which dehumanisation can occur. For example, it has been noted that the effective application of what is considered to be best evidence-based practice in Intensive Care Units can lead to dehumanisation, even by the very best of caring practitioners (Calne, 1994; Corrigan et al., 2007). In surgical procedures, cradled within modern notions of science, there is a danger of dehumanisation but, thankfully, also a call for surgeons not only to be Homo sapiens but Homo moralis too (Likhterman, 2005). The advancement of medical technology itself, implicitly accepted as a good thing, is also a warning against dehumanisation (Heath, et al., 2003) as is the encroachment of modern information systems (Keen, 2006). These warnings serve to remind us that the values that underpin health and social care are more important than the mere process of application, as illustrated in Vignette 4.3.

Vignette 4.3

Kelly, a 24-year-old woman with severe learning disabilities, was admitted to the Accident and Emergency Department claiming to have swallowed several batteries. She had done this on several other occasions. She was difficult to manage and aggressive when approached by staff. Debates ensued as to the best approach to gathering information about the size and number of batteries she had ingested but Kelly was not amenable to rational discussions. She was refusing any treatment and demanded to be allowed to go home. The decision of the team following discussions between the medics and the nursing staff was to allow her to go home.

 

Here, the rationale for the decision was that as she had learning disabilities, and that she had brought this upon herself, she would not be able to learn not to do it again, so did not warrant valuable resources. The staff did not consider a psychiatric referral or compulsory admission under the Mental Health Act but rather focused on the severity of the learning disabilities. Thus, the individualised values of humanism gave way to overarching problems of management and the limitations of resources. It could be argued that, because Kelly had learning disabilities, she needed more resources to help her than someone who fully understood what he or she was doing.

Medical Model and Complementary Therapies

Modes of knowledge

For the purpose of this discussion, there can be said to be three modes of knowledge (or ways of thinking) concerning the world in which we live (Nachmias and Nachmias, 1981). These modes of knowledge are:

• Authoritarian: in this mode, the focus is upon sapient knowledge that is espoused from a source that is considered wise, and there is little questioning as to its truth, accuracy or alternatives. This mode can best be described in parent–child terms when the authority of the mother and father announce to the toddler the pending arrival of a new baby brother or sister delivered by a Stork. At that stage, it is unquestionably accepted as true and accurate by the young child. Whilst we may like to believe that we grow out of this mode of thinking, and indeed many do, for some it remains into adult life and knowledge is accepted when authority figures issue dictums which are unquestioned. These ‘authorities’ may be, for example, religions (doctrine), political persuasions (the Party line) or medical knowledge (‘the doctor said so’).

• Mystic: this mode is concerned with a state of consciousness that is said to be in tune with a higher order of reality, and access to this knowledge is achieved through prophets, divines, gods, mediums, clairvoyants and parapsychologists, to name but a few. In this mystic mode, there is a belief in a link between supernatural authorities and the bio-psycho state of the individual. Thus, for example, we look to astrology to inform us as to the effects on our earthly lives. We can recognise a wide array of strands of mysticism in many traditions and cultures and it is a notably powerful theme in both Islamic and Buddhist philosophy. Superstitions are based in this mode as we believe certain behaviours may invoke higher-order interventions, such as walking under a ladder bringing bad luck. Behaviour enacted from this mystical mode of knowledge is difficult to change as it requires many refutations before it affects the individual’s belief in the mode of thinking (Nachmias and Nachmias, 1981). An example is circumcision based on religious beliefs.

• Rationalistic: this mode is concerned with a philosophical belief in knowledge that is said to be gained through the process of logic. This process is based on two assumptions: first, that we can apprehend the world independently of the observed phenomena, and secondly that forms of knowledge exist prior to our experience of them. The cause-and-effect relationship is seen in isolation and understood as being independent of extraneous influences such as gods, prophets and devils. This mode of knowledge is known as the method of science and is held in high esteem in Western societies (Nachmias and Nachmias, 1981). For example, the perception that illnesses such as cancer or HIV are often related to behaviour such as smoking, drug abuse and sexual promiscuity results in less sympathy for sufferers, and demonisation of those who behave in these ways.

All three modes of knowledge can be seen independently but we can also note that there may be areas of overlap. In fact, there is nothing to negate a belief in all three modes at the same point in time. Numerous astronauts who walked upon the moon believed in the rationalistic mode of science through their knowledge of physics but also operated within the authoritarian and mystic modes through a belief that a divine being was safeguarding them on their journey (Nachmias and Nachmias, 1981).

The medical model

The medical model is a term that is widely employed but not well defined. Its basic premise is that it is focused on the physical aspects of the body, in terms of sickness and health, and the physical treatments that are available. This is based in the rationalistic mode of thinking in relation to the logic of cause and effect. However, it applies equally to issues of the mind, and to social situations where there is deemed to be an identifiable cause that leads to the situation the individual finds her- or himself to be in. The medical model assumes a power imbalance between doctor (or other care professional) and patient (or service user) with the former being the technical expert and the latter the passive recipient of services. Within this framework, the medical model attempts to explain disease or social difficulty by establishing its aetiology, its agent and its path of restoration. It views the person as a machine with reductionist parts that can be repaired. However, in viewing the person in these limited terms, it fails to appreciate the wider empirical diversity of the social and spiritual aspects of the human condition. Although the majority of Western medicine, and much of social care, is grounded in this model, there are some health and social care professionals who broaden their model to encompass the social and spiritual aspects, notably in the fields of mental health care. The notion of all medical models is underpinned by a process known as medicalisation.

The medicalisation process

The medicalisation process is concerned with how areas of life, or domains of the human condition, are brought within the framework of medicine. This is what Foucault (1973) called the medical ‘gaze’. Examples of this ‘gaze’ include childbirth, child-rearing, bereavement and dying (Clark, 2002), these being domains of traditional life that would previously be encompassed by the village midwife, families and religious orders respectively, but are now part of ‘medicine’. There are many other examples of this ever-encroaching ‘gaze’ in contemporary society, such as sexual behaviour (Hart and Wellings, 2002), misery (Pilgrim and Bentall, 1999) and rage (Fisher, 2006). The process by which this medicalisation occurs has five components:

• Identification – medicine must be able to establish a differencebetween normal and abnormal. It needs to know what constitutes normal (levels, functioning, behaviour, thoughts and so on) from which it can then establish someone who is operating outside the parameters of this normal. Thus, there is a need to identify the difference.

• Classification – once the difference is established, the ‘condition’ must be placed within a classification system which absorbs it into the theoretical structures of that particular nosological framework. Nosology is a branch of medicine that is concerned with classifying conditions according to whether they fit, for example, into physical systems such as the nervous system, or psychiatric systems such as psychoses. Classification gives the impression of knowledge of the condition.

• Diagnosis – this is concerned with a concept beyond classification and involves providing an aetiological explanation. The medicalisation process involves providing clarification on how the condition arose, where it comes from, how it happened, etc.

• Treatment – for the medicalisation process to continue, a treatment intervention must be offered. This may be merely palliative in cases of terminal illness or abstract in psychiatric conditions. Nonetheless, an intervention must be both suggested and accepted, at least by some.

• Prognosis – to complete the process, a prediction is required as to the anticipated outcome following treatment. Forecasting the progress of the condition is an extension of the cause-and-effect logic of science. The prognosis does not necessarily require accuracy, it merely needs to be predicted.

It should be noted that if the process cannot be completed, then the ‘condition’ is not likely to be accepted within the medical model and, similarly, if an established medical condition becomes unsupported in any of the components of the medicalisation process, then it is likely to fall out of the medical frame of reference. An example of this is homosexuality which was considered a psychiatric condition up to the 1960s but then abandoned as a medical entity thereafter. A more recent example is the acceptance of myalgic encephalomyelitis (ME) which prior to total medicalisation was known as Chronic Fatigue Syndrome (ME Association, 2009).

Health beliefs and complementary medicine

Health belief models take many forms, both within and across cultural groups. Numerous distinctions can be drawn, including (a) supernatural and natural, (b) personalistic and natural, (c) retribution and justice and (d) internalising and externalising (Richman, 1987). In all these, causes of ill health are sought through all modes of knowledge: authoritarian, mystical and rationalistic. Health belief models range from cosmopolitan (rationalistic) approaches to traditional approaches, which vary across cultures. We do not have space to outline the numerous health belief models but one will suffice as an example. The American Navaho Indians may spend a quarter of their time involved in healing rites and ‘to be cured means social reconciliation with kin, ancestors and nature. Treatment is family and community orientated therapy’ (Richman, 1987: 20). Complementary medicine is a more modern term for ‘alternative’, ‘marginal’, ‘fringe’, ‘quack’ and ‘traditional’ and the array of approaches within the terms is immense. There is an attempt to portray cosmopolitan medicine as scientific, and traditional medicine as unscientific, and similarly terms such as ‘orthodox’ and ‘unorthodox’ have been applied as value judgements. The modes of thinking outlined above can also be applied to health belief systems to give more or less credence to them. For example, claiming to be rationalistic implies being logical and scientific, having evidence of cause and effect, being testable and proven; whilst mystical suggests magic, witchcraft and being metaphysical, unproven and unscientific. Furthermore, we can note a value judgement being applied to medical approaches that claim to be reductionist (we understand the component parts) and holistic (we do not understand how the parts affect the whole). Consider Vignette 4.4 which provides an example of how two approaches can be successfully combined.

Vignette 4.4

Mariyah, a 14-year-old Indian girl living with her parents who emigrated to the UK four years ago, is admitted to the Intensive Care Unit in a serious state of septicaemia. Following tests and 48 hours of intravenous antibiotics, she is deteriorating and grave concerns for her life are expressed by the doctor. The family contact the local Shaman who arrives that evening with a small bottle containing a clear fluid. He informs everyone that the potion contains a secret ingredient that will cure Mariyah and wishes to give her a few drops immediately before she dies. The medical staff ask what the potion contains but the Sharman refuses to tell them, claiming that its secret is its potency and once revealed it will no longer be effective. The family agree but the medical staff do not. The Consultant is called and suggests that the potion be analysed in the laboratory. The Shaman refuses to hand the potion over and outlines the urgency of administering it to Mariyah. The medical staff are worried that the potion will harm Mariyah but as it is only a few drops they relent and agree once a disclaimer form is signed. The potion is given to Mariyah and by the following morning an improvement in her condition is noted. Prior to being discharged, a case conference is called during which the medical staff state that Mariyah was cured by the antibiotics and life support; the Shaman states that she was cured, as expected, by the secret potion and the smiling parents state that they were pleased that Mariyah was going home.

Conclusion

In this chapter, we note the interplay of numerous aspects that work together to form an understanding of what it means to be human in relation to states of health and illness. We choose to view ourselves and others either in reductionist terms or in a holistic manner, or sometimes in a combination of both. In any event, health and social care decisions are based on the underpinning values that govern our culture, with its beliefs, traditions and norms. Our belief in science tends towards an explanation of illness and social difficulty based on the logic of cause and effect. However, values we espouse in terms of the value of the individual urge us ever closer to a values-based approach to care.