Armand M. Nicholi, Jr., M.D.
Harvard Medical School
Response from Strahler
From Perspectives on Science and Christian Faith 41:4 (1989): 214-20.
This paper, originally given as an address at the Imago Dei symposium cojointly sponsored by the American Scientific Affiliation & the Christian Medical and Dental Society, explores the role of the scientist/clinician in relation to his personal world view. Does the world view of the scientist affect his results? This paper examines the influence of the investigator on his scientific observations and of the clinician on his work with his patients. Seeing the patient as an object created in the image of God influences the tone and attitude of a physician towards his patient.
Behavioral sciences comprise those disciplines that study man's development, interpersonal relationships, values, activities, experiences, institutions, etc. These sciences include ethenology, sociology, cultural anthropology, psychiatry, and many other fields. My remarks will focus on the field of psychiatry. Psychiatry is that branch of medicine that deals with the diagnosis, origin, treatment and prevention of the disorders of the mind. The human mind and that part of the body most directly related to it, the human brain, comprises the primary domain of psychiatry. I limit my remarks to psychiatry not only because it is my field and the only one I could discuss with any semblance of intelligence, but also because it's a medical specialty, and has specific relevance to our theme of relating man in the image of God to the health sciences. Our theme also mentions clinical implications, and I would like to focus specifically on clinical psychiatry, that is, that branch of psychiatry involved in the observation and treatment of patients.
If we begin with the proposition that man is created in the very image of God, we have taken a step toward embracing a world view based on the Old and New Testament documents. This world view, of course, suggests certain basic presuppositions; presuppositions about God's existence, about the origin and nature of the universe, about the nature of man, about meaning and purpose of life on this planet, and about ultimate destiny.
On the other hand, does the world view, the Weltanschauung, embraced by the scientist have any serious impact on his work? Does the world view of the clinician influence significantly his or her role both as investigator conducting research or as physician and therapist treating patients?
As modern research increases our understanding of the mind and of the brain, the question of the interrelationship of the mind and brain arises again and again. The mind-brain or mind-body problem dates back at least to the Ancient Greeks, to Democritus, Plato, and Aristotle. We cannot take time to focus on this problem in detail except to ask the question of whether current research in psychiatry takes us any closer to resolving this problem. A popular notion prevails that modern research has now demonstrated that all disorders of the mind can be traced to biological abnormalities and therefore has taken us a large step toward focusing entirely on the brain, of considering the brain not merely the biological substrate of the mind, but the actual mind itself.
Research on Mind & Brain
New knowledge in psychiatry comes from a variety of sources including the following.
(1) Recent clinical and laboratory research and new technology that facilitates this research such as the vastly improved brain scanning methods of computed tomography (CT), positron emission tomography (PET), and magnetic resource imaging (MRI); from the advances in molecular biology prompting the search for a specific gene in the transmission of schizophrenia and other of the major psychiatric disorders; computer brain electrical activity mapping (BEAM), and new biomedical techniques for assessing enzymes, metabolites and neurotransmitters in human tissues.
(2) The emergence of diseases such as Acquired Immune Deficiency Syndrome, or AIDS, whose first and sometimes only manifestation may be severe psychiatric symptoms.
(3) The increased incidence of disorders such as bulimia, and the recent intensive investigation of others such as Alzheimer's Disease and obsessive compulsive disorder.
(4) Environmental and cultural changes that result from or contribute to psychiatric disorder such as the current changes in family structure, the rapid rise in psychoactive drug use, and the epidemic in adolescent suicide.
Progress in psychiatry continues in many directions. More rigorously controlled studies have replaced the relatively unsophisticated research of the past. Investigations have focused on establishing the neurological substrates of psychiatric disorders; that is, on ascertaining the specific parts of the brain associated with disturbed thinking, feeling, and behavior of these disorders. A great deal of research today continues to search for metabolic and physiological abnormalities that may be clues to the cause and to the cure of particular illnesses. New discoveries have come from explorations both within cells, to find the gene or genes involved in genetic transmission of a disorder, and between cells, especially at "synaptic clefts," the name given to those spaces that exist between each of the billions of brain cells. We have focused a great deal of attention on these spaces because we have found that drugs that alleviate psychiatric symptoms, such as the neuroleptic drugs as well as drugs that imitate psychiatric symptoms like the amphetamines, act at the level of neurotransmitters--chemicals that carry impulses across these spaces. Although we have made great strides in the biochemistry and neurophysiology of the brain and an understanding of the neural basis and the localization of certain feelings and certain thought processes in the brain, we have as yet failed to find any metabolic or physiological abnormality consistently present in any of the major psychiatric illnesses. Even when and if we find this magic abnormal metabolite we will be only halfway home--for we still won't know whether the abnormality causes or results from the disorder.
Paradoxically, the more we learn about the mind the more we realize that we can never reduce human thought, feeling, or behavior to a biochemical reaction. Our knowledge of biology by no means rules out the significance of psychological factors, nor our knowledge of genetics the significance of environmental factors. The more we know about one area, the more significant the other area seems to become in explaining the whole picture. The more we develop and use psychopharmacologic drugs, the more we realize that these drugs usually must be combined with psychotherapy to be most effective. Perhaps once we discover the elusive abnormal metabolite, we may find it influenced by a combination of genetic, environmental, biological, and psychological factors. The integration of these factors certainly constitutes psychiatry's greatest challenge.1 One thing we can say for sure: All of the modern research and new technology has not altered significantly the statement by the famous neurosurgeon Penfield when he wrote in 1975, after a life's work of research on the brain, "In the end I conclude there is no good evidence in spite of new methods - that the brain alone can carry out the work that the mind does. I conclude that it is easier to rationalize man's being on the basis of two elements than on the basis of one."2 Though we have accumulated new and significant evidence of how the mind influences the body and the body the mind, we must still agree with Penfield that brain and mind are two distinct entities. We cannot reduce the mind of man to neurochemistry and neurophysiology.
What we can conclude is that new knowledge of the mind reveals not only its paradoxical nature but also its enormous complexity. Recent scientific research leaves us with an acute awareness of how little we really know. It reminds us of the statement by Dr. Lewis Thomas in the New England Journal of Medicine: "The only solid piece of scientific truth about which I feel totally competent is that we are profoundly ignorant about nature. Indeed, I regard this as the major discovery of the past one hundred years of biology . . . it is this sudden confrontation with the depth and scope of ignorance that represents the most noteworthy contribution of 20th century science to the human intellect."3 New knowledge, if kept in proper perspective, increases not our arrogance but our humility--perhaps because as our island of knowledge increases, so does our shoreline of ignorance.
The Influence of the World View of the Scientist
Does the world view of the scientist influence his work as an investigator conducting research and as a clinician treating patients? Many scholars in the history of science would answer that question with a resounding "Yes." Some, like Thomas Kuhn in his widely quoted "The Structure of Scientific Revolutions," have argued that the scientific process is less than an objective critical empirical investigation of the facts. They claim the work of scientists is greatly influenced by their culture, by social and psychological environment, by what Kuhn calls the "paradigm"--that is to say, the preferred or prevailing theories, methods and studies of that particular discipline, and above all by their world view--their specific beliefs about "the order of nature." Kuhn writes that two scientists with different views of the "order of nature" . . . see different things when they look from the same point in the same direction . . . they see different things and they see them in different relations to each other." And we might add that they tend to see and to accept those data that conform to or make sense in light of their world view. So evidence exists that the world view of scientists and the presuppositions that view implies may influence not only the problems scientists choose to investigate but also what they actually observe and fail to observe. Let me give a brief example from my discipline.
Sigmund Freud, the Viennese physician whose scientific contributions some historians have ranked with those of Planck and Einstein, founded psychoanalysis. Most of the basic concepts of dynamic psychiatry derive from Freud's theories. Psychoanalysis is: (1) a theory of the mind and of human development, (2) a method for investigating the unconscious, and (3) a system of treatment for certain emotional disorders. In addition to his scientific contributions, Freud embraced the world view which he called the "scientific Weltanschauung." His world view comprised an atheistic philosophy of life. He referred to himself as an "infidel Jew," and he rejected the religious view of the universe--especially the Christian world view. He attacked this view with all of his intellectual might and from every possible perspective. He observed in some of his patients the neurotic determinants of their religious beliefs, and a tendency for these beliefs to disappear once the neurotic need was resolved or once the authority of their father was no longer prevalent. Freud concluded that God was a projection of the childish wish for an all-powerful father who would protect one from the unpredictable, harsh elements of nature. Freud spent the last 30 years of his life writing about religious issues. This began as a serious endeavor with the publication of his Totem and Taboo, a study of the origins of primitive religions published in 1913, through to the publication of his last book, Moses and Monotheism, published in 1939. He just could not leave the subject alone. A great deal of evidence exists that Freud's world view was less than a comfortable one for him, that he continued to write about religious issues because he was looking for a more satisfying world view, that religious faith was by no means a closed issue for him, and that he was extraordinarily ambivalent about God's existence. Throughout Freud's letters you find statements such as, "If some day we meet above," statements about his "one quite secret prayer," about meeting his predecessors in "the next world," and about "God's grace." During these last 30 years of his life he carried on a continuous correspondence, an exchange of hundreds of letters, with a Swiss theologian, Oskar Pfister. He admired Pfister and wrote that Pfister was "a true servant of God, a man in the very idea of whom I should have had difficulty in believing, and that he feels the need to do spiritual good to everyone he meets. You did good in this way even to me." He later said that Pfister was in the fortunate position of being able to lead [men] to God.4
I might add here parenthetically that I have studied for many years the letters and writings of Freud in order to ascertain the basis of his intense antagonism toward religious faith. I have concluded that his main obstacle--one not uncommon among thinking intellectuals--is his inability to reconcile a benevolent, omnipotent creator with human suffering. In 1928, in a letter to Pfister, for the first time in any letter that I have ever read by him, Freud becomes quite angry and quite discourteous. He writes, "And finally--let me be impolite for once--how the devil do you reconcile all that we experience and have come to expect in this world with your assumption of a moral world order?5" And then, in a 1933 lecture called Eine Weltanschauung, he says:
It seems not to be the case that there is a Power in the universe which watches over the well-being of individuals with parental care and brings all their affairs to a happy ending. On the contrary the destinies of mankind can be brought into harmony neither with the hypothesis of a Universal Benevolence nor with the partly contradictory one of a Universal Justice. Earthquakes, tidal waves, conflagrations make no distinction between the virtuous and pious and the scoundrel or unbeliever. Even where what is in question is not inanimate nature but where an individual's fate depends on his relationships to other people, it is by no means the rule that virtue is rewarded and that evil finds its punishment. Often enough the violent, cunning or ruthless man seizes the envied good things of the world and the pious man goes away empty. Obscure, unfeeling and unloving powers determine man's fate. The system of rewards and punishments which religion describes to the government of the universe seems not to exist.6
Freud, of course, seemed to be unaware that in the Christian world view "the government of the universe" is temporarily in enemy hands. A few summers ago, before Freud's daughter Anna Freud died, I asked her about her father's difficulty with the problem of suffering. She expressed great curiosity about it. She asked "is there a God who sits there in heaven and decides who will get cancer and what specific adversity will affect each individual?" I expressed to her the notion that theologians such as Pfister would describe the presence of an evil power in the universe that might account for some of the suffering. She seemed unusually interested in this notion and came back to it several times during our discussion.
We must also remember that Freud suffered considerably; emotionally as a Jew growing up in an intensely Catholic society, and physically with an intractable cancer of the pallet that required an endless number of operations.
The Influence of Freud's World View on His Scientific Investigations
How did this world view of Freud influence his work as a scientific investigator? Did it in any way influence not only what data he observed, but how he interpreted this data? I think there is a great deal of evidence that it did. Let's look at the issue of religious faith. Freud saw only the neurotic determinants of religious faith in his patients. He appeared to be totally unaware of those who possessed a healthy faith, of those who had a positive transforming spiritual experience. He must have seen healthy expressions of faith in his patients. He certainly saw this in his close friend Pfister toward whom he expressed such affection and admiration, and with whom his friendship extended over 30 years. Pfister actually discussed this with him in his letters and said that Freud seemed to be aware only of "pathological forms of religion," while he himself had embraced a healthy form that he regarded "as the core and substance of evangelism." In 1928 Freud published a paper titled "A Religious Experience." In it he discusses a letter he received from an American physician telling Freud of his religious conversion. The physician had written to Freud because he read in an American newspaper an interview in which Freud said that he gave no thought to the subject of survival after death. The physician told of the shock he experienced in seeing a "sweet-faced woman who was being carried to the dissecting table." The physician wrote, "in the course of the next few days God made it clear to my soul that the Bible was His Word, that the teachings about Jesus Christ were true and that Jesus was our only hope. After such a revelation I accepted the Bible as God's Word and Jesus Christ as my personal saviour. Since then God has revealed himself to me by many infallible proofs." The letter continued, "I beg you as a brother physician to give thought to this most important matter, and I can assure you if you look into this subject with an open mind, God will reveal the truth to your soul, the same as he did to me and a multitude of others . . ." Freud sent a polite answer saying that he was glad to hear that this experience had enabled the physician to retain his faith. As for myself, Freud wrote, "God has not done so much for me. He had never allowed me to hear an inner voice; and if in view of my age he did not make haste it would not be my fault if I remained to the end of my life what I now am infidel--Jew." Freud said he received another letter from the physician saying the physician was offering prayers for Freud that God might grant Freud "faith to believe." Freud said he was still awaiting the outcome of this intercession. And then he went on to give a psychoanalytic explanation of the psychological factors involved in the physician's conversion.7
So we ask, how does one explain Freud's total inability to accept certain data concerning non-pathological faith that he must have observed clinically in his patients, in his friend Pfister, and even in correspondence from strangers? Perhaps the only explanation we can offer is that the data did not make sense in light of his world view and the presuppositions predicated on that view.
The Christian World View and the Clinician
Does the world view of scientists influence their work as clinicians? Does it have an impact on their roles in treating and caring for patients? If the clinician really believes the patient is made in the "image of God" he then realizes the patient, every patient, will transcend in time and significance every other institution on earth, and therefore cannot help but approach that patient not only with great respect, but also with a sense of reverence and wonder. The clinician who embraces the Christian world view has certain marching orders--broad, clear guidelines as to how to approach his patients. These guidelines include such simple directives as "be kind and compassionate," but also a whole new complex standard for conducting doctor-patient relationships. This standard--referred to as agape-- comprises a unique kind of love, a love devoid of sentimentality yet considerably more than kindness. A love based not on feeling but on the will, though as we carry it out by exertion of the will, it contributes to how we feel and to our sense of fulfillment. Agape involved stepping out of our own needs sufficiently to become aware of the needs of others and then acting to meet those needs, whether we feel like it or not. Agape therefore involves thought, effort, time, accessibility, and at times self-sacrifice and self-denial. It's a difficult kind of love to practice but it's the key to all successful relationships, especially the doctor-patient relationship.
The practical application of this standard in everyday practice is by no means easy or obvious. Close detailed attention must be given to how the physician can carry out this standard in establishing a successful doctor-patient relationship within the confines of a professional relationship and without patronizing or condescending.
Simple Standards for the Clinician
The physician's attitude toward the patient sets the tone for his whole relationship with that patient. Whether the patient is young or old, neatly groomed or disheveled, out-going or withdrawn, articulate or inarticulate, highly integrated or totally disintegrated, of high or low social economic status, the sensitive clinician realizes that the patient, as a fellow human being, is considerably more like himself than he is different and that even if he understands only a fraction of the patient's mind, the patient will contribute significantly to the physician's understanding of himself and of every other patient that he sees. The physician also realizes that each patient, regardless of how prosaic in appearance and background, is considerably more complex than can be grasped or described no matter how brilliantly detailed the diagnosis of the physician; that each patient offers the therapist the potential for increasing his own professional skills and understanding, as well as for contributing to the body of knowledge in his or her specialty. These realizations motivate the physician to approach each patient with no little degree of humility, care, and respect.
A patient consulting any physician suffers stress, not only because of symptoms prompting the consultation but also because of conditions inherent in the doctor-patient relationship. The patient, for example, is usually confused about the significance of his symptoms, unaware of their cause, apprehensive about what the doctor will recommend, and often embarrassed or humiliated at exposing what he considers exceedingly personal details of his life. Under such circumstances he is particularly vulnerable, and for this reason deserves even more consideration than in ordinary social interactions. Too often, however, he receives less. Even the simple introductory handshake is often neglected--perhaps because of the doctor's hectic schedule, perhaps because the doctor shares a common human tendency to withdraw from illness, or more likely because the clinician has never been formally taught to heed such issues.
The mundane, yet often neglected practice of simply shaking hands helps set the tone for the initial relationship between doctor and patient. Shaking hands firmly with the patient brings to the first moment of contact an element of personal warmth and respect. The simple gesture eases the tension preceding the initial interview, and reassures the patient who almost always approaches the doctor with a degree of apprehension. To the patient the physician represents not only an awesome stranger who will probe the most intimate aspects of his or her life, but also a highly knowledgeable authority with the power to make life and death decisions. Because so many people harbor this threatening image, a simple handshake at the beginning and at the end of the first session helps the doctor relieve initial anxiety.
How the physician addresses the patient ought to be given some consideration. Does the physician use the first or last name only, dispensing with the title of Mr., Miss, or Mrs. before the patient has granted that liberty? Does the physician dismiss these common courtesies as stuffy formality? Or does he use them to express respect for the patient as a fellow human being?
In essence, all that takes place in the initial stages of a physician-patient relationship can be measured against a single simple standard: Is the physician in his exchange of initial courtesies as warm and respectful to the patient as he would be to a dignitary visiting his home? Meeting such a visitor for the first time, the physician would introduce himself, offer his hand, and take pains to make the visitor welcome and comfortable. He would honor the visitor's title until given permission to dispense with it. He would strive to be relaxed and composed without being aloof or stilted, and to be warm and responsive without being familiar or effusive. He should do the same in his first meeting with a patient--especially if he considers that patient within the context of his Christian world view.
It's important to emphasize that although a professional relationship sets clearly defined limits and demands some restraint and reserve, it by no means precludes warmth and kindness. Furthermore, to the extent that most patients need to see the physician as a friend, as someone strongly "for" them- and to the extent that they consider a friend to be "a person with whom one is allied in a common struggle" or "a person whom one knows and trusts" (as the American Heritage Dictionary defines the term)--then to that extent a professional relationship also does not preclude friendship. These qualities are far too often missing in the physician's office today, and contribute in no small way to what appears to be a deteriorating relationship of the physician's image in our society. The office of Christian physicians ought to be a model for these kinds of relationships. One other point involves the capacity of the physician to listen to the patient. The physician's ability to convey a genuine interest in his or her patient, to facilitate the patient's telling of his story, and to establish a solid therapeutic alliance depends in large measure on the physician's capacity to listen effectively. Listening effectively involves first and foremost respecting the patient enough to keep out of the patient's way as he attempts to tell his story. To keep from obtruding, to keep quiet, to keep the spotlight focused completely on the patient--these are among the physician's most difficult tasks.
Humor can exert a wonderful humanizing influence in interpersonal relationships, easing tension and facilitating communication. It helps for the physician to maintain a sense of humor. A hearty laugh between physician and patient underscores Addison's comment that "mirth" is like a flash of lightning, that breaks through a gloom of clouds. One must carefully distinguish, however, between laughing with the patient and laughing at the patient. Laughing at the patient or making fun of symptoms through mockery, sarcasm, or irony will inevitably set a discordant tone and become an obstacle to the relationship.
Seeing the patient as a object created in the image of God automatically influences the tone and attitude of a physician toward his or her patient. It precludes approaching the patient merely as a "case," whose symptoms must be assessed in order to attach the appropriate diagnostic label. This view of the patient fosters an attitude that helps the physician look beyond the patient's pathology to observe the fellow human being with unique characteristics and with the same hopes, fears, aspirations, feelings, and perhaps the same conflicts as his own--a suffering human being whose illness has made him dependent on the physician and particularly vulnerable. This approach will ensure a degree of humility in the physician and prevent the patronizing arrogance afflicting some who held a measure of power over others. It will also facilitate giving the patient the same warmth and courtesy accorded a respected guest, a cherished relative, or, one would hope, the physician should he or she become a patient. More important, the physician will more likely have a desire to serve the patient--to give hope, to allay fears, to alleviate pain, and in short, to treat the patient as an object made in the image of God.
Wanting the best for the patient and acting accordingly--whether a particular patient evokes positive or negative feelings--necessitates no little degree of spiritual maturity on the part of the physician. It requires of the clinician, regardless of feelings he may have to the contrary and regardless of the particular status of the patient, always to act in the best interests of the patient. In my view, this encompasses all that we mean when we speak of "kindness and compassion," what we mean by agape, and what we mean by treating a patient as an object made in the "image of God."
Wilder. 1975. The Mystery of the Mind. Princeton, NJ: Princeton University Press.