What medicine do we want: automated or humanist?
In the 1960s, Gene Roddenberry, author of Star Trek, dreamed up the medical tricorder, a device which detects and analyses vital signs and then generates a diagnosis using pooled medical data. This futuristic device seems close to becoming a reality with the rise of data driven health, which makes it possible to automate certain elements of medicine (diagnosis, analysis, etc.), alongside the robotization of certain medical techniques or treatments. Nanites were another accurate Star Trek prediction: “Submicroscopic robots which work on the molecular level to fight different injuries and diseases.”
At the same time as techno-medicine is developing (without quite reaching the levels of 1960s science fiction TV), another form of medicine, which we could call “clinical and humanist,” persists. This approach puts the patient-provider relationship at the heart of care, as we see in therapeutic education and more broadly in clinical medicine as a whole. It takes into account patients’ changing expectations and levels of information (cf. Who are the patients of the future?), focusing on a more collaborative approach, perhaps more patient-centric than disease-centric, although that distinction does tend to remain theoretical.
Techno-medicine vs. humanist medicine: cure or care?
These two approaches to medicine seek to take individuality into account, to the point that they both fall under the common expression “personalised medicine,” despite their often opposite paths.
Observing or listening? In fact, these two approaches do not share a common definition of the term “personalised.” “Automated” medicine uses the collection of allegedly “objective” data, which can be genetic or statistical, while “humanist” medicine looks for statements and feelings and studies behaviours. Techno-medicine employs an exclusively biological and molecular understanding of patients, while clinical medicine examines “the mental and collective aspects of the human person,” according to philosopher Xavier Guchet.
To cure or to care? These approaches also operate differently. “Automated” medicine acts while “humanist” medicine supports. Techno-medicine aims, for example, to develop medical devices that react to physiological measurements, like automated insulin release based on glucose readings for diabetics. It is effective and responsive, offering certain patients the ability to live a “normal” life by minimising the day-to-day impact of their disease. “Clinical and humanist” medicine, on the other hand, seeks to work with the patient to co-construct a treatment approach, and to teach the patient to listen to him or herself. It aims to help patients live with and “tame” their disease, and to help them become more independent and resilient, by encouraging them to take control of themselves and preparing them for the progression of the disease.
Body or mind? This duality corresponds to another one: denial or acceptance. It emerges in patients’ fear of pain. On the one hand, “automated medicine” mainly uses chemistry to act on the body, with pain medications that inhibit the nervous signals between the affected area and the brain or trigger an artificial euphoria. On the other hand, “humanist” medicine seeks out alternatives or non-medical supplements to alter the patient’s consciousness: massages, relaxation, hypnosis, sophrology, etc. “Since physical pain paralyses the mind, why not use the mind to help the body?” says Luc Plassais, the medical ethicist behind the palliative care unit at Cognacq-Jay Hospital in the 15th arrondissement of Paris.
Digitising hospitals or making them more social?
These two forms of medicine exist in very different environments. “Automated” medicine leads to extensive digitisation and “softwarisation” of medical care and settings. Telemedco, for example, is developing a digital platform based on elements like Watson, IBM’s artificial intelligence, to manage emergency room intake. “Humanist” medicine, on the other hand, focuses on the relationship between patients and society. “Patients are full members of society,” says Plassais, when discussing the design of the new Cognacq-Jay hospital, “so our initial idea was to keep them a part of it. A small public street, which neighbourhood residents use every day, actually runs through the hospital.” Another example is the chair of philosophy which the ENS and APHP have created at the Hôtel-Dieu hospital in Paris, to make it “a place where knowledge is circulated and shared.”
From technical efficiency to virtualised patients?
The opposition between “technical” and “clinical” medicine is nothing new. The late Professor Jean-Charles Sournia wrote in A History of Medicine that, “The final decades of the 19th century saw the start of a debate - which is far from over - between the doctor who asks his patients questions, examines them and maintains personal relationships with them, relationships which have a therapeutic value in their own right, and the other side, the anonymous laboratory whose devices dose and quantify physio-chemical alterations.” Medical imaging technologies, and now new genome evaluation technologies, are further reducing the need for direct contact between doctors and patients (palpation, manipulation). Even surgeons are increasingly transferring patient contact to machines.
The virtualisation of patients lies at the heart of the debate: “The more the presence of medicine is based on technique, the more the subject it addresses is fictional,” says professor Didier Sicard. “How can we draw out the person behind this medical approach, which turns him or her into a totally abstract identity, a dot in a cloud of dots?” adds Jean-Claude Ameisen, former president of the French National Consultative Ethics Committee. Xavier Guchet worries that automated medicine carries with it a highly ironic risk, that of depersonalising a form of medicine which claims to be personalised, on the grounds that “the true singularity of an individual - his or her history, hopes, and fears, is seen as a nuisance, an interference in a process which aims to establish standard profiles for the groups they are classified into.”
The financial issues at play
This opposition might not be so problematic if techno-medicine were not virtually monopolising funding, according to journalist Hubert Guillaud. He notes that “automated” medicine is generating significant increases in healthcare costs, and unless new business models are developed our healthcare systems may go broke. He concludes that, “Medical innovation needs social innovation to respond to these challenges and develop new healthcare and support structures, which go beyond the ideas of rationalisation. Medicine is a field of patents, intellectual property and regulatory monitoring. But we are seeing the emergence of more and more alternative approaches, which encourage a different approach to research and the development of more accessible devices: low-tech, open, replicable, public domain... Like the release of the recipe for hand sanitizer, the open source low cost EchoPen ultrasound project incubated at la Paillasse, or the Bionico prosthetics project.” On a similar note, makers are appearing in hospitals with the Maker Nurse digital platform, which connects healthcare providers’ bright ideas with fablab DIY specialists.
Two approaches which go hand-in-hand in practice
The increased use of open source and commons could free up funding and shift the balance between cure and care, particularly since in practice automated medicine and clinical medicine often work together, and are sometimes indissociable, as Lourdes Mounien, a physiology researcher at Aix-Marseille University, who is diabetic himself, has observed: “Automated insulin injections based on the amount of sugar consumed can make life much easier for a child who has diabetes. However, if you don’t teach him to eat a balanced diet, he risks developing another, equally dangerous disease: obesity, because insulin is a hormone which stimulates the storage of lipids in fatty tissue.”
Automated and clinical medicine can work together to develop a care plan. For example, therapeutic education can be provided before surgery, as seen in the care provided to women who undergo a mastectomy and face debilitating post-op conditions. They can also balance one another’s excesses: when techno-medicine turns us into an object during treatments, clinical medicine can help us reconstruct ourselves as subjects. These two forms of medicine can thus work together in different stages or for different purposes.
And what about doctors?
Techno-medicine is helping to “make man transparent, ultimately eliminating the cultural and traditional need for human relationships and interpersonal clinical contact,” says Dr Vincent Fouques-Duparc, who believes that clinical doctors will be replaced by medical engineers. Therapeutic education, for instance, gives pride of place to patients’ feelings and choices, putting doctors in the role of coach and initiator, rather than that of the all-knowing healer. As they find themselves caught between omnipresent technology and omnipotent patients, what role will remain for doctors?
Their clinical experience should remain vital, because it feeds technical analyses and confirms, refines, and invalidates diagnoses. And doctors, unlike machines, can break the rules, an ability which is vital in the case of new pathologies or diseases which are difficult to diagnose or treat. The ability to think outside the box, or even to go against standard procedure, was already key in traditional medicine, which is highly institutionalised and hostile to questioning itself; it will be all the more so in a data-based society which only believes in what it can measure. Professor Guy Vallancien says, “I believe in practitioner’s ability not to systematically submit to the recommendations of learned societies and healthcare organisations.”
Faced with this double injunction (even when imbalanced) to cure and to care, to focus on technology and society, we will, more than ever before, need an irreverent regard which is neither fascinated by technology nor imbued with compassion for patients, but focused on saving their lives.