In recent years medicine has increasingly recognized a connection between mind and body and how the interaction between the two can affect our health. But in its effort to avoid a problematic separation between mind and body, medicine has been led astray. Due to misunderstanding what in philosophy is called mind-body dualism, trained medical doctors end up over-diagnosing conditions as psychosomatic, automatically construing medically unexplained symptoms as psychiatric problems. This is a philosophical error that ends up putting the health of patients at risk, argues Diane O’Leary.
Medicine and philosophy have an uneasy relationship. Medicine is a practical endeavor, aiming for concrete results. Philosophy, on the other hand, has been construed as a head-in-the-clouds kind of thing since antiquity. Today, outside of medical ethics (which has taken a rightful place within the profession), it’s hard to see how philosophy’s abstractions could make a real difference to the nuts and bolts of diagnosis and treatment.
If medicine were just an applied science of the body, all of this would make good sense. But in the late twentieth century, western medicine reconsidered its exclusive focus on the body and emphatically rejected it. Patients, it turns out, are not just bodies, we’re people. And persons have minds, as well as bodies. This shift raised one modern philosophy’s most intractable issues: the mind-body problem: How do our subjective, mental experiences relate to our objective, physical bodies?
The world would be a very different place if right at that point – in 1977, when George Engel wrote “The need for a new medical model: A challenge for biomedicine” – some philosophers had been called in. The new focus on persons traded heavily on talk about dualism, Descartes, and reductionism. These ideas were invoked to characterize a new form of medical practice, one that recognized the mind’s role in disease, one that understood subjective experience well enough to draw the most objective data from patients’ subjective reports.
Since Engel, medicine has understood dualism as something we do, or choose not to do.
But the philosophers were not summoned, and elementary mistakes were made. George Engel and his colleagues mis-defined dualism in a way that would fail an intro to philosophy exam. More than that, on the basis of this misunderstanding, they drew misguided conclusions about what philosophy demands of medicine when it comes to mind and body. All of this was accepted without review or challenge by philosophers themselves. Fifty years later these misunderstandings have been woven into the fabric of medicine. Most importantly, in everyday clinical medicine, Engel’s confusions about dualism continue to play a substantial role in patient diagnosis and treatment.
While in philosophy these misunderstandings would not amount to much beyond poor grades or rejected papers, medicine is actually using them as the basis for clinical practice, that is, as tools for addressing the bodily suffering of real people. When they fail – and evidence suggests they do fail as a matter of routine – those people are harmed. All of us are threatened by this problem.
Since Engel, medicine has understood dualism as something we do, or choose not to do. When we separate mind and body in our thinking, language, or medical practice, we bring dualism to life, and when we stop separating them, dualism disappears. If we want to recognize the whole person rather than focusing just on the body, dualism in this sense would have to be rejected. In fact, on the basis of this definition, medicine understands its effort to recognize mind as a campaign to eradicate dualism.
Once you understand what dualism means, you understand that when we insist that medicine should recognize the mind, we advocate for dualism.
But dualism is not the separation of mind and body in our language or practice. It is not something we do, and it is not something that can be avoided by simply changing the words we use. Dualism is the view that the world contains both physical things and mental things, or at least mental properties in the form of experiences. Once you understand what dualism means, you understand that when we insist that medicine should recognize the mind, we advocate for dualism. It’s simply incoherent to insist that medical professionals must recognize the mind, or experience, as well as the body, and at the same time try to eradicate dualism.
This confused campaign does real damage in diagnostic practice. One of the most powerful clinical changes that arose from the new perspective was the idea that just as problems in the body impact our mental experience, problems in the mind impact the body. Most of us know what it’s like for some tiny bodily discomfort to be amplified in our experience when something stressful is going on, only to have the sensation disappear when things calm down. Medicine’s new openness to the role the mind can play, made it possible to incorporate psychological causes for bodily symptoms into everyday diagnosis and treatment. The term for symptoms caused by the mind, but manifested in the body, is psychosomatic.
Given that many of us have first-hand experience of how our minds can make our bodies feel a certain way, what’s the problem with medicine recognizing this as a genuine phenomenon? The trouble comes when doctors are forced to decide whether the problem is in the mind or in the body. In cases where diagnostic tests fail to explain symptoms, the question arises: is the cause a psychological problem or a purely biological problem that hasn’t been diagnosed yet?Unfortunately, doctors don’t have rigorous criteria for answering that question because the confused definition of dualism gets in the way. Because medicine understands dualism as the separation of mind and body, and it is committed to a campaign to eradicate dualism, medicine must discourage any diagnostic effort that separates problems in the mind from problems in the body.
Based on this confused philosophical anxiety, a doctor who follows her training will automatically construe medically unexplained symptoms as psychiatric problems.
For this reason, in cases of diagnostic uncertainty, doctors are advised to let go of their usual commitment to making sure that every case of disease is diagnosed and treated. Instead, because of fear of embracing dualism, they’re advised to stop investigating and just name the symptoms as a hybrid mind-body problem - a psychosomatic condition. Based on this confused philosophical anxiety, then, a doctor who follows her training will automatically construe medically unexplained symptoms as psychiatric problems.
This approach to uncertainty is problematic both philosophically and clinically. At the philosophical level, philosophy of mind just does not support the idea that we should avoid separating mind and body in our language and practice. In fact, if philosophers of mind can be said to have reached any consensus at this time, it would be that it’s important to separate talk of mental states and physical states: to recognize that while mental, subjective experiences are always correlated with physical, brain states, those two are in fact distinct.
In this sense, dualism is no longer a dirty word – it doesn’t mean what it meant to Descartes, that we are made of two separate kind of stuff, a body and a soul. Property dualism suggests that while persons are physical substances, we have both physical properties and experiential properties. This makes it possible to have our cake and eat it too, to accept that persons have subjective experiences without giving up our commitment to science. In the end of the day, there’s really no way to understand medicine’s perspective on the whole person except through some form of property dualism.
For the great many people who suffer from diseases not readily diagnosed, bad philosophy is an obstacle to health, to safety, to pain relief, and to full participation in life.
On a clinical level, the trouble with medicine’s approach to uncertainty seems obvious – and quite threatening. Even if there were just a few patients whose symptoms remain undiagnosed after clinical tests, disease is possible for all of those patients, so it is irresponsible to train doctors to assume the problem is psychosomatic. The fact is, though, that according to the NHS, an astonishing 50% of outpatients’ symptoms are medically unexplained. Purely on the basis of a philosophical misunderstanding, the NHS mistakenly classifies, and treats all of these symptoms as though they were psychiatric problems. Though half of the time patients’ conditions are undiagnosed, the NHS insists that instead of further medical inquiry, all of these patients need mental health support.
Because this problem demands two areas of expertise that we usually don’t put together, it’s been almost impossible to see. On the one hand, at the level of philosophy’s abstractions, medicine has mangled basic philosophy of mind to such an extent that it believes its effort to recognize mind is an effort to eradicate dualism. That’s a fact, and it’s one for the philosophical books. On the other hand, at the level of the nuts and bolts of medical practice, this mangling of philosophy is a mangling of people’s lives. For the great many people who suffer from diseases not readily diagnosed, bad philosophy is an obstacle to health, to safety, to pain relief, and to full participation in life.
It’s time for medicine to stop flying by the seat of its philosophical pants. To improve everyday diagnosis, and indeed the foundations for bioethics and psychiatry, it’s time to mend that uneasy relationship and summon the philosophers.