A great chapter, Awais, thanks! Harking back to your April 28, 2014 piece on the "medical model", I commented at that time as follows--and perhaps it is still relevant to you chapter:
Thank you, Awais, for a very thoughtful discussion of this much maligned concept of "the medical model." You are spot-on in identifying a misplaced "essentialism" as the chief culprit in the misguided arguments against the "medical model." (Please note that Ludwig Wittgenstein warned us of this trap in his Philosophical Investigations).
In a piece I wrote over 7 years ago regarding "hearing voices" [1], I noted that there is no single, written-in-stone, "essential" definition of the "medical model." Nevertheless, to the extent the term is useful in clinical psychiatry, we can identify its six central features:
1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is
always an inherent biological foundation to dysfunctional states, such as clinical depression,
psychosis, etc
2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict)
the biological foundations of these experiences
3) Conversely, biological explanations of human experiences do not negate (and often complement)
valid psychosocial and cultural explanations and formulations
4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional,
cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural
explanations prove more relevant or informative
5) That certain human experiences or perceptions (e.g., “hearing voices”) have a discernible “meaning,”
symbolism, or psychological significance for the patient does not mean they have no
neuropathological etiology
6) All somatic and psychological treatment modalities—whether medication or “talk therapy”—have
meaningful (and sometimes measurable) effects on brain function and structure
It should be clear that there is nothing "reductive" in this understanding of the "medical model", and I believe these features--while not defining an "essence"--are useful, heuristic starting points for the understanding of how psychiatrists think about illness, disease, etc.
Thanks for what is a more comprehensive summary of the rhetorical medical model than anything I have read elsewhere. Either I, as a biologist, am hanging out with the wrong crowd or the people leading discussions of mental healthcare and public policy in my city are dominated by those who view the medical model of psychiatry as a pejorative. I think the latter explanation is more likely, and that is a problem, because it means discussions of public policy are not adequately informed by the full range of thinking about these complex issues. Perhaps it is fortunate in the case of my home city, where the unbalanced view is led mostly by judges and attorneys and social workers, that those discussions have rarely if ever led to any meaningful changes in policies.
2. This condition would be fine to live with if the external factors were different.
Suppose that someone uses a wheelchair after breaking their spine in a car accident. Everyone agrees that this is what happened. In this specific situation, no one argues that the person had some genetic vulnerability that made their spine break in the crash. Everyone agrees that the impact was enough. People might even agree that this is society's fault - maybe this happened in a society with really bad traffic, and we could prevent lots of similar accidents in the future by improving roads, traffic signs, more roundabouts instead of four-way crossroads etc.
People might still disagree on whether using a wheelchair necessarily is a problem in itself. Some argue that once you're in the chair, your biggest problem is lack of ramps and lifts, prejudice, etc. Others argue that using a chair remains a tragedy and ideally all such conditions should be cured and everyone should walk. The former will often be called the social model and the latter the medical model, in discussions about physical disabilities.
Of course, you can make that same distinction in the mental case. Someone might argue that mental disorder X is caused by traumatic experiences, not something inherent in the body, but once you have it, it's inherently bad and should ideally be cured so you can function normally again. Someone else might take the opposite stance on both and say no, it's caused by being born with a different kind of brain. But it's NOT bad in itself - people with this condition need accommodation and acceptance, not a cure.
Thank you for your comment. You make an important point; i.e., some conditions of the mind or body that are putatively "medical" may not cause serious problems for the person, if certain external factors are modified to accommodate the condition. That said, I do not see any contradiction between making efforts to accommodate the person's condition and what I view as the "medical model." Nor is the latter informed by highly evaluative, moralistic, or prescriptive terms like, "inherently bad" or "should be cured."
There are, of course, some physicians who would strongly urge treatment for a patient whose condition creates a high degree of suffering and incapacity, but, in principle, this judgment is always subject to, and constrained by, the four cornerstones of medical ethics; i.e., beneficence; non-malfeasance; autonomy; and justice.[1]. Thus, if the wheelchair-bound patient is reasonably comfortable with his or her condition by making use of various adaptations, such as wheelchair ramps, and does not wish to be "cured", there is nothing inherent in the medical model that would oppose that choice. (Yes, of course--there are very paternalistic physicians who do not sufficiently respect the patient's autonomy, but this does not bear on the medical model per se).
Let's take a practical, real-world example: the insertion of a cochlear implant for a subgroup of patients with deafness. There is legitimate and often intense controversy within the "deaf community" regarding this procedure; e.g.,
"Not only do many Deaf culturalists find the assumption that they need to be “fixed” or “cured” insulting, some contend that cochlear implant technology threatens to destroy their culture. Because 90 percent of deaf children have hearing parents, cultural transmission of Deaf culture does not occur within families, but rather, through Deaf institutions." [2]
I would contend that there is nothing inherent in the medical model per se that would tell a candidate for a cochlear implant, "You should get this procedure! Your condition is inherently bad and should be cured!" Nor would any ethically and culturally sensitive physician take such a moralistic stance, though there are indeed ethical arguments that urge this procedure on deaf patients.
My point is that the medical model--at least as I construe it [see my earlier comment]--is essentially neutral on what "should" or "should not" be done in such a case. Finally, a good physician will make every effort to modify the impediments and "external factors" you refer to; e.g., by advocating for the placement of wheelchair ramps in facilities that lack them. Such advocacy is not in any way contradicted by the medical model--and in my personal view, is actually an integral part of it.
Thank you again for your stimulating comment!
Best regards,
Ronald W. Pies, MD
1. Principles of Biomedical Ethics 7th Edition by Tom L. Beauchamp (Author), James F. Childress (Author)
2. Sparrow R. Defending Deaf Culture: The Case of Cochlear Implants*. Journal of Political Philosophy. 2005;13(2):135–52. Web. Nov 12. 2018. See: https://pmc.ncbi.nlm.nih.gov/articles/PMC6913847
Thank you, Sofia (if I may). I did not feel your comment was aimed at anyone. I saw it as a heuristic invitation to clarify the concept of the medical model, and to show how it is not at all incompatible with what you call the "social model." Indeed, I think the two approaches are complementary. That's why psychiatry is, at heart, a bio-psycho-social discipline, with its "legs" in both the biological sciences and the humanities.
A great chapter, Awais, thanks! Harking back to your April 28, 2014 piece on the "medical model", I commented at that time as follows--and perhaps it is still relevant to you chapter:
Thank you, Awais, for a very thoughtful discussion of this much maligned concept of "the medical model." You are spot-on in identifying a misplaced "essentialism" as the chief culprit in the misguided arguments against the "medical model." (Please note that Ludwig Wittgenstein warned us of this trap in his Philosophical Investigations).
In a piece I wrote over 7 years ago regarding "hearing voices" [1], I noted that there is no single, written-in-stone, "essential" definition of the "medical model." Nevertheless, to the extent the term is useful in clinical psychiatry, we can identify its six central features:
1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is
always an inherent biological foundation to dysfunctional states, such as clinical depression,
psychosis, etc
2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict)
the biological foundations of these experiences
3) Conversely, biological explanations of human experiences do not negate (and often complement)
valid psychosocial and cultural explanations and formulations
4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional,
cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural
explanations prove more relevant or informative
5) That certain human experiences or perceptions (e.g., “hearing voices”) have a discernible “meaning,”
symbolism, or psychological significance for the patient does not mean they have no
neuropathological etiology
6) All somatic and psychological treatment modalities—whether medication or “talk therapy”—have
meaningful (and sometimes measurable) effects on brain function and structure
It should be clear that there is nothing "reductive" in this understanding of the "medical model", and I believe these features--while not defining an "essence"--are useful, heuristic starting points for the understanding of how psychiatrists think about illness, disease, etc.
Regards,
Ron
[Ronald W. Pies, MD]
1. https://www.academia.edu/79032733/Hearing_Voices_and_Psychiatry_s_Real_Medical_Model?uc-sb-sw=38597480
https://www.psychiatrictimes.com/view/hearing-voices-and-psychiatrys-real-medical-model
Also see: Shah P, Mountain D. The medical model is dead – long live the medical model. Br J Psychiatry. 2007; 191:375-377.
Thanks for what is a more comprehensive summary of the rhetorical medical model than anything I have read elsewhere. Either I, as a biologist, am hanging out with the wrong crowd or the people leading discussions of mental healthcare and public policy in my city are dominated by those who view the medical model of psychiatry as a pejorative. I think the latter explanation is more likely, and that is a problem, because it means discussions of public policy are not adequately informed by the full range of thinking about these complex issues. Perhaps it is fortunate in the case of my home city, where the unbalanced view is led mostly by judges and attorneys and social workers, that those discussions have rarely if ever led to any meaningful changes in policies.
One distinction that people often fail to make:
1. This condition was caused by external factors.
2. This condition would be fine to live with if the external factors were different.
Suppose that someone uses a wheelchair after breaking their spine in a car accident. Everyone agrees that this is what happened. In this specific situation, no one argues that the person had some genetic vulnerability that made their spine break in the crash. Everyone agrees that the impact was enough. People might even agree that this is society's fault - maybe this happened in a society with really bad traffic, and we could prevent lots of similar accidents in the future by improving roads, traffic signs, more roundabouts instead of four-way crossroads etc.
People might still disagree on whether using a wheelchair necessarily is a problem in itself. Some argue that once you're in the chair, your biggest problem is lack of ramps and lifts, prejudice, etc. Others argue that using a chair remains a tragedy and ideally all such conditions should be cured and everyone should walk. The former will often be called the social model and the latter the medical model, in discussions about physical disabilities.
Of course, you can make that same distinction in the mental case. Someone might argue that mental disorder X is caused by traumatic experiences, not something inherent in the body, but once you have it, it's inherently bad and should ideally be cured so you can function normally again. Someone else might take the opposite stance on both and say no, it's caused by being born with a different kind of brain. But it's NOT bad in itself - people with this condition need accommodation and acceptance, not a cure.
Hi, Professor Jeppsson,
Thank you for your comment. You make an important point; i.e., some conditions of the mind or body that are putatively "medical" may not cause serious problems for the person, if certain external factors are modified to accommodate the condition. That said, I do not see any contradiction between making efforts to accommodate the person's condition and what I view as the "medical model." Nor is the latter informed by highly evaluative, moralistic, or prescriptive terms like, "inherently bad" or "should be cured."
There are, of course, some physicians who would strongly urge treatment for a patient whose condition creates a high degree of suffering and incapacity, but, in principle, this judgment is always subject to, and constrained by, the four cornerstones of medical ethics; i.e., beneficence; non-malfeasance; autonomy; and justice.[1]. Thus, if the wheelchair-bound patient is reasonably comfortable with his or her condition by making use of various adaptations, such as wheelchair ramps, and does not wish to be "cured", there is nothing inherent in the medical model that would oppose that choice. (Yes, of course--there are very paternalistic physicians who do not sufficiently respect the patient's autonomy, but this does not bear on the medical model per se).
Let's take a practical, real-world example: the insertion of a cochlear implant for a subgroup of patients with deafness. There is legitimate and often intense controversy within the "deaf community" regarding this procedure; e.g.,
"Not only do many Deaf culturalists find the assumption that they need to be “fixed” or “cured” insulting, some contend that cochlear implant technology threatens to destroy their culture. Because 90 percent of deaf children have hearing parents, cultural transmission of Deaf culture does not occur within families, but rather, through Deaf institutions." [2]
I would contend that there is nothing inherent in the medical model per se that would tell a candidate for a cochlear implant, "You should get this procedure! Your condition is inherently bad and should be cured!" Nor would any ethically and culturally sensitive physician take such a moralistic stance, though there are indeed ethical arguments that urge this procedure on deaf patients.
My point is that the medical model--at least as I construe it [see my earlier comment]--is essentially neutral on what "should" or "should not" be done in such a case. Finally, a good physician will make every effort to modify the impediments and "external factors" you refer to; e.g., by advocating for the placement of wheelchair ramps in facilities that lack them. Such advocacy is not in any way contradicted by the medical model--and in my personal view, is actually an integral part of it.
Thank you again for your stimulating comment!
Best regards,
Ronald W. Pies, MD
1. Principles of Biomedical Ethics 7th Edition by Tom L. Beauchamp (Author), James F. Childress (Author)
2. Sparrow R. Defending Deaf Culture: The Case of Cochlear Implants*. Journal of Political Philosophy. 2005;13(2):135–52. Web. Nov 12. 2018. See: https://pmc.ncbi.nlm.nih.gov/articles/PMC6913847
Short reply: My post wasn't aimed at you, it's just a distinction I think it's important to keep in mind.
Might write a longer comment to this later.
Thank you, Sofia (if I may). I did not feel your comment was aimed at anyone. I saw it as a heuristic invitation to clarify the concept of the medical model, and to show how it is not at all incompatible with what you call the "social model." Indeed, I think the two approaches are complementary. That's why psychiatry is, at heart, a bio-psycho-social discipline, with its "legs" in both the biological sciences and the humanities.
Best regards,
Ron