“Understanding the sick person”

Towards a medicine of care

by Dr med Sabine Vuilleumier-Koch

After all his critical books on medicine in the recent years Giovanni Maio presents “book of encouragement” with his latest work. As a philosopher and physician with extensive clinical experience, it is a matter of great concern to him to give patients hope. Furthermore, he wants to encourage all those who care for people in outpatient and inpatient facilities day by day to focus on what is relevant and to encourage them to maintain their inner values and let them not be taken away by economisation and a one-sided technical-scientific medicine. For his presentation Maio chose an understandable language.

Giovanni Maio recognises that the greatest asset of medical professions is the inner commitment to serve suffering people. The current system of medicine increasingly degrades this intrinsic motivation. Maio wants to stop this degradation by raising the awareness of how valuable this inner commitment is. Based on encounters with patients, reports from medical students and experiences in public discussions he presents his reflections built on great accuracy and humaneness. In the first part of the book, he takes the reader to come quite close to the sick person and this way he enables him to sympathise with a “situation dropped out of normality”. The ability to sympathise is – in addition to the indispensable medical expertise – a basic requirement for success in medical treatment. In the second part of the book, Maio develops ways of coping with illness that are helpful and valuable for both patients and clinicians.

Core qualifications of a physician

In our time, the treatment of the sick person follows the theoretical demands of industrial production more and more, which does not correspond in any way to the reality of a successful treatment. With regard to this erroneous comparison between medical treatment and industrial process, Giovanni Maio response is that medicine is not about following operation instructions, but: “The core qualification of a physician is the skillful handling of complexity, dealing with uncertainty, the professional management of uncertainties and on the basis of these qualifications finally the careful exploration of what is best for the particular patient.” Already in the first part of the book, Giovanni Maio introduces a concept whose meaning will be more apparent later: the concept of dialogue. In medicine, good decisions can’t emerge without dialogue.

“Culture of care”

Giovanni Maio chose four major challenges of medicine as examples for many others. The treatment of pain, cancer, dementia and “dealing with the dying” shall refer to what is the core of the medical task, namely “taking care of people who suffer from symptoms and illnesses that cannot just be eradicated with an appropriate handling.” Especially these people run the risk of falling through the grid of a more economical approach to medicine. Maio develops approaches to people with these ailments that are encouraging and liberating both for the patient and for the helper. In a “culture of care” the own potential will be recognized and it can be learned how to cope with multiple symptoms in a life enabling way.

Anthropological preconditions

Maio as a doctor, is always taking a position based on binding anthropological basic requirements: “For man is not an egolocial being, but he is fundamentally aligned with the others and can’t do anything by himself, out of himself. And it is with the capacity to make another human being feel that he is not alone in his distress, that every person has the chance to give back what he received from others in many ways – and it is exactly this chance that medicine provides.” To cope with dementia which can’t be “rendered positive” by any means, requires to look at the whole human community: “So to challenge dementia can also be an opportunity for a new way to discover the concern for vulnerable people as a core cultural achievement of society.”

No to ethical resignation

Giovanni Maio takes a determined position to assisted suicide which is being increasingly propagated today: “Why do we ask primarily about freedom (of choice) in the case of an assisted suicide and not about the misery which has led to it?” Only to ask if somebody has well-considered his suicide or not is a reductionist approach to this essentially important subject and at the same time an ethical resignation.” People in need do not primarily wish their death but other conditions of their lives which however seem to be inaccessible to them. Only if the helper is willing to get involved into the sick person’s need, to listen very carefully, can he develop a way out together with the suffering patient.

“Ways of coping”

Every single passage of the chapter “Ways of Coping” entails precious advice for the encounter between helper and patient and the conduct in practice: “Learning to accept – the good life as the art of taking steps”, “Confidence – or why sueing for the essential is impossible”, “hope – what hope can mean for modern medicine” and “to understand the sick (person)”. Giovanni Maio here also questions much that made its way into hospitals and practices in the course of the last years dictated by economisation. The relationship of trust must not degenerate to become a contractual relationship. “It is the interpersonal relation which makes the encounter of a person in need and a qualified helper to be a sustainable relationship of confidence.” And: “If we succeed to create an encounter out of the physician-patient consultation in the proper sense of a true ‘encounter of togetherness’, a space for hope is opened.”
The reading of the book opens up new, pleasantly human perspectives with every sentence. The helping in the physician-patient relationship is inspired again and gives hope for a return of medicine to its true meaning. The book can be most warmly recommended.     •

“Today this orientation on the natural sciences receives an additional boost by coupling it with the economy, resulting in a far reaching orientation on economy. Economy and natural sciences are forming such a strong alliance that under the predominance of these two paradigms, the entire medicine is changed fundamentally. These changes pass almost unnoticed because they change attitudes. Maybe even more than external procedures it rather concerns the awareness of medicine, its inner identity. Performing, measuring, checking, certifying – all that is required today, and astonishingly not only where processes actually are running like in the industry, but also in areas solely concerning people. Even the treatment of ill people is increasingly following the conceptual standards of an industrial production. This is the actual entrance gate for a transvaluation of the values of medicine. Therefore, it is important to reflect in depth on the difference between the production of objects and the treatment of people. Why is medicine no process of production? In how far is the industrial thinking imposed on medicine so insufficient and harmful?“

From: Giovanni Maio: Den kranken Menschen verstehen. Für eine Medizin der Zuwendung(Understanding the sick person. Towards a medicine of care). p.13. ISBN: 978-3-451-30687-7

(Translation Current Concerns)

“Whether a person suffers from chronic pain, whether he or she has cancer or a beginning dementia – always the person is challenged to learn how to deal with this phenomenon which allows to discover a new space of creation for himself or herself and not to feel at the mercy of the disease despite of the associated restrictions. In the course of industrialisation and economisation of medicine nothing less has got lost but the awareness for the necessity of lending assistance and care. By this (attitude) we convey our appreciation to the ill person, and this allows the patient to develop a feeling of wholesome self-esteem. This is the true ‘agent’ of a medicine of devotion.
For a medicine of devotion – in this way we have circumscribed the plea of this book. It is a case for something which has lost its self-evidence in our streamlined health system but which has to be re-evaluated once again as the core of medical, nursing and psychotherapeutic practice. At present modern medicine is structured as if it was about the treatment of strong healthy persons and not of ill persons who are dependent, needy and often falling in despair. Because modern medicine omits to express an interpersonal connectedness with the suffering person which can rescue him or her, give him or her a new security and stabilization, not only by continuing support but by mobilisation of the inner strengths of the ill persons themselves. Devotion stimulates strengths, it mobilizes and evokes unexpected potentials of coping. Therefore it is simply irresponsible to silently rationalize away exactly this potential. Because thereby medicine exhausts the breeding ground of its core identity – and this is bound to go wrong in the long run.”

From: Giovanni Maio: “Den kranken Menschen verstehen”. p 206–208, ISBN: 978-3-451-30687-7

(Translation Current Concerns)