Medicine and the humanities--theoretical and methodological issues.

Engel's biopsychosocial model, Cassell's promotion of the concept "person" in medical thinking and Pellegrino's and Thomasma's philosophy of medicine are attempts to widen current biomedical theory of disease and to approach medicine as a form of human activity in pursuit of healing. To develop this approach further we would like to propose activity theory as a possible means for understanding the nature of medical practice. By "activity theory" we refer to developments which have evolved from Vygotsky's research on socially mediated mental functions and processes. Analysing medicine as activity enforces the joint consideration of target and subject: who is doing what to whom. This requires the use of historical, linguistic, anthropological, and semiotic tools. Therefore, if we analyse medicine as an activity, humanities are both theoretically and methodologically "inbound" (or internal) to the analysis itself. On the other hand, literature studies or anthropological writings provide material for analysing the various forms of medical practices.

The development of modern medicine has been closely tied to the development of biology and its subdisciplines. Theoretical debates in medicine have, therefore, echoed the conceptual problems encountered in the biological sciences. Until the 20th century the theoretical demarcation line in the study of living processes resided in the debate between physicalism and vitalism. The advocates of physicalism claimed there was no fundamental difference between living organisms and inanimate matter. Living phenomena could therefore be studied and explained with the methods and laws of physics. This approach was strongly opposed by vitalists who postulated that living organisms had properties that could not be reduced to physics or chemistry and, therefore, biological phenomena could not be analysed with the concepts or methods of those sciences. Instead, vitalists claimed, to explain the nature of living phenomena one needed to apply such concepts as "vital force" and "vital fluids" to the analysis.

With the development of cellular and evolutionary theories it became apparent, however, that living processes could not be satisfactorily explained either by Newtonian physics or by any non-material life forces. This fundamental theoretical dispute in biology was eventually resolved with the conceptual development in biology of organicism, where life processes were explained by physiochemical and evolutionary instead of physical or teleological concepts. (1)

This conceptual change had a profound impact also on the development of medicine. The cellular theory of disease and its biochemical explanatory principle displaced the physical, humoral, and vitalistic approaches to human health and illness, and formed the knowledge base of 20th century medicine.

In clinical medicine, however, there are many instances where the biological approach alone cannot address the various human phenomena that physicians encounter in their everyday practice. When abandoning vitalism and physicalism a new theoretical demarcation line in medicine was formed between reductionism and holism. (2)

The reductionist approach in medicine attempts to explain human illness through biological concepts, whereas the advocates of holism have tried to incorporate social and cultural issues as well as personal experience into medical theory. This demarcation has deepened in the latter half of the 20th century with the rapid development of molecular biology and genetics, together with more and more sophisticated medical technology. All this has given rise to the hope of finding the ultimate explanation for human illness in the elementary cellular structures and their dysfunctions, as discoded amino acids in genetic processes.

Since the 1960s the critical social movement has been questioning--among various other cultural and political issues--the predominance of science and technology in modern society. This intellectual climate has also influenced medical faculties, especially in the United States, where medical students …