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The Journal of Continuing Education in the Health Professions, Volume 21, pp. 170181. Printed in the U.S.A.

Copyright 2001 The Alliance


for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for
Hospital Medical Education. All rights reserved.

Innovations in Continuing Education

Existential Medicine:
Martin Buber and Physician-Patient Relationships
Felicia Cohn, PhD
Abstract
Martin Bubers (18781965) social existentialist thought offers a unique lens through which
physician-patient relationships may be interpreted. Buber develops concepts of relationships
and dialogue that provide insight into physician-patient relationships. His notions of I-Thou
and I-It relationships have relevance for contemporary medical education and practice. Current
medical practice is situated in the It-realm of order, objectivity, detachment, abstraction, and
experience. This perspective is necessary for medical education and practice but can result
in the progressive decline of the interhuman relationships that define medicine. I-Thou rela-
tionships, characterized by spontaneity, subjectivity, reciprocity, and recognition and acceptance
of the unique other, are essential for humanhood. However, physicians and patients may be
constrained from achieving I-Thou relationships by the very nature of their interactions, which
are planned and purposive. Buber describes the possibility of a therapeutic relationship that
approaches the I-Thou realm. Bubers thought suggests three conceptual shifts that facilitate
the development of therapeutic relationships in medical practice and have implications for
medical education: (1) from disease-centered to person-centered care, (2) from crisis to every-
day management, and (3) from principles and contracts to relationships.
Key Words: Communication, continuing medical education (CME), dialogue, existential
medicine, Martin Buber, medical education, physician-patient relationships

There are many different ways to look at the prac- existential thought suggests. For Buber, rela-
tice of medicine, with each perspective both high- tionship and dialogue are not issues for medi-
lighting and hiding various aspects. Existentialism cine; rather, medicine is a matter of relationship
provides one more lens through which to view and dialogue. Analysis from this perspective will
medicine, and Martin Bubers (18781965) challenge more traditional views of medicine and
thought lends a unique focus. This article explores will offer new insights for medical education and
Bubers thought in the context of physician- practice.
patient relationships and describes distinctive
images of interactions and communication within Martin Bubers Social Existentialist Vision
the medical setting that Bubers unique brand of
According to Buber, an individuals basic con-
nection to the world is an expression of his or her
own existence. Human beings have a dual char-
acter, formed by the relations in which they are
involved. The I alone is merely an abstraction
Reprint requests: Felicia Cohn, PhD, Director of Ethics
Education, University of CaliforniaIrvine, College of
that can be actualized only with another form.
Medicine, Medical Education Building 802, Irvine, CA That is, the I exists in connection with a Thou
92697-4089. or an It. Both types of relationships are necessary

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Cohn

for existence.* The major difference lies in how of the physician-patient relationship for healing,
another is recognized, either in concrete unique- the appropriate role of detachment in a therapeu-
ness (I-Thou) or as the content of ones experience tic relationship, and beliefs that the practice of med-
(I-It). icine needs to be and can be improved. The con-
I-Thou relationshipscharacterized by reci- ventional wisdom regarding inadequacy with
procity or mutuality, spontaneity, acceptance and physician-patient relationships stems primarily
confirmation of otherness or uniqueness, imme- from tertiary care medicine, where, it is important
diacy, wholeness, exclusiveness, inclusion, and to note, most medical education occurs. Certainly,
alternation of actuality and latency1,2are integral the stereotypes do not fully describe the practice
to humanhood, defining individuals. An individ- of medicine or how particular clinicians practice
ual is fully realized in a relationship with another medicine but are rooted in reality and indicate
unique being, a Thou. Bubers thought, then, sug- perceptions regarding problems in the practice of
gests that a physicians very being, like other indi- medicine.
viduals, depends on a relationship with others, Buber recognizes that the analytical method
patients. of the human sciences is indispensable.3 The I-
Physician-patient interactions, however, appear It relation is, for Buber, a necessary anthropo-
to occur primarily in what Buber calls the It- logic category, offering familiar order, reliable
world, one of abstraction, causality, detachment, experience, and continuity in space and time.
and utility. He notes, In our time there predom- Thus, as it is a necessity for human existence, it
inates an analytical, reductive, and deriving look is not inherently evil.
between man and man,3 indicating what he per- A problem with boundaries, however, exists.
ceived to be a significant problem of our time. Our Analysis is necessary wherever it furthers knowl-
need to understand is, to a certain extent, over- edge of a phenomenon without impairing the
whelming what we are trying to understand, scru- essentially different knowledge of its uniqueness
tinizing the subjects of our inquiry to the point of that transcends the valid circle of the method.3 In
objectification. This reflects a particular view of allowing the It-world to represent the totality of
medicine based on certain assumptions, stereo- human existence, knowledge of uniqueness is
types, and generalizations. Briefly stated, this impaired, and individuals are reduced to abstrac-
view of medicine involves concern about an tions or categories. According to Buber, When
overemphasis on technology in the clinical prac- man lets it have its way, the relentlessly growing
tice of medicine to the detriment of human rela- It-world grows over him like weeds, his own I loses
tionships, limited recognition of the significance its actuality, until the incubus over him and the
phantom inside him exchange the whispered con-
fession of their need for redemption.4 The It-
world becomes evil if people presume that it pos-
sesses the actualitythe concrete, immediate,
*The literal German translations of Beziehung and
Verhltnis are pulling, tugging and being held in
inclusive, relational qualitiesof the Thou-world.
place, respectively. Beziehung (relationship) occurs Buber suggests that loss of relationship is a
between an Ich and a Du (I and Thou/You), whereas danger of modern times. The history of the
Verhltnis (relation) describes a meeting of an Ich and an
Es (I and It). Ich-Du has been translated as both I-Thou
and I-You in English, but neither seems to capture the

full meaning Buber intended. Thou suggests an inappro- Although no evidence is provided for this concept of
priate air of formality in present-day English, whereas medicine, here it is supported in the writings of several
You fails to indicate the unique character of this rela- physicians and bioethicists, including Francis Peabody,
tionship. Thou is generally used throughout this article, Eric Cassell, Jay Katz, Melvin Konner, Howard Brody,
but the use of I-Thou or I-You is maintained in and Stanley Joel Reiser, several of whom are cited in this
quotations. article.

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Existential Medicine

individual and the history of society both signify unconfirmable, and inferior by compari-
a progressive increase in the It-world.4 This son. . . From the beginning of their
growth decreases the capacity for relationship and introduction in the mid-nineteenth century,
so, according to Buber, is a sickness of our age.4 automated machines that generated results
As people become more able to use and experi- in objective formats such as graphs and
ence, the possibility of I-Thou encounters becomes numbers were thought capable of purging
more remote, and individuals are less able to cre- from health care the distortions of subjec-
ate and maintain a balanced dialectic between the tive human opinion. They were supposed
Thou- and It-spheres. Buber explains: to produce facts free of personal bias, and
thus to reduce the uncertainty associated
When a culture is no longer centered in a with human choice. This view, held by prac-
living and continually renewed relational titioners and patients, stimulated the intense
process, it freezes into the It-world which use of these devices, sometimes to excess.
is broken only intermittently by the erup- This excess has been characterized by over-
tive, glowing deeds of solitary spirits. From reliance on technologically depicted
that point on, common causality, which features of illness, inadequate understand-
hitherto was never able to disturb the spir- ing of the capabilities and limits of
itual conception of the cosmos, grows into machines and the information they gener-
an oppressive and crushing doom.4 ate, and relative inattention to those aspects
of medicine learned by inquiry into the
The practice of medicine exemplifies a pro- patients experiences and views. . .
gressive augmentation of the It-world. Physician- [Machines] can make us forget the hands
patient relationships reflect a variety of changes: and minds behind their creation, they can
increased research and technology, growth in the make us forget ourselves.6
health care enterprise, shifts in medical practice
models, a more regulatory and litigious society, and Increased physical contact with patients has
development of the health insurance industry. His- not resulted in the development of interhuman
torian David Rothman notes this growth of the It- relationships; in fact, it appears to interfere with
World: Practically every development in medi- expression of the Thou-world. With technology,
cine in the post-World War II period distanced the human interaction may be sacrificed in the name
physician and the hospital from the patient and the of expediency, subordinated to another goal, or
community, disrupting personal connections and neglected entirely. Physician and patient may
severing bonds of trust.5 The introduction of cer- meet, but not encounter, speak but not reveal, and
tain medical tools and techniques, such as the hear but not listen. Two concurrent monologues
stethoscope and chest percussion, have reoriented masquerade as dialogue.
the practice of medicine, with physician bias shift- These are broad generalizations, and certainly
ing from a scholarly disdain for touching patients a number of solitary spirits remain. The med-
to an emphasis on manual examination. How- ical profession does not appear to have yet expe-
ever, physicians rienced a crushing doom, but it does seem prone
to the dogma of the gradual running down that
. . .became so enraptured by the evidence Buber claims represents mans abdication in the
produced by applying their own senses to face of the proliferating It-world. 4 Medical
the evaluation of illness that they increas- progress has made treating disease more effective
ingly disregarded the sensations experienced and successful, at least on a physiologic level,
and described by the patient as unreliable, but in the quest for better medicine, other aspects

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Cohn

of patient care may have been overlooked or mutuality.4 But because Buber believes that reci-
deemed unimportant. Physicians now often do procity can be achieved in degrees, it may be pos-
not know their patients, usually work in institu- sible to strive toward a relationship in the clinical
tional or office settings instead of attending patients setting.
in their homes, and rely on a barrage of tests for Buber depicts his notion of normative limits
examinations. Patients, anxious for treatment, in the context of a teacher-student relationship,
may tolerate a lack of personal interaction, sub- which he describes as a kind of dialogical rela-
mitting to a more mechanical and impersonal tionship. He asserts:
medical domain. Whether the image of the caring
doctor who visits individuals in their homes . . .however intense the mutuality of giving
throughout their lives is a myth or not, stories of and taking with which he [the teacher] is
such personal care often underlie the cries for bound to his pupil, inclusion cannot be
reform to practice and education now heard. mutual in this case. He experiences the
A lack of dialogue, in Bubers sense, appears pupil being educated, but the pupil cannot
central to the problems in medicine. What has experience the educating of the educator.
been true for the evolution of mankind has been The educator stands at both ends of the
equally true for the progress of medicine: We have common situation, the pupil only at one
spared no effort to make better tools but we have end. In the moment when the pupil is able
paid little attention to learning how to commu- to throw himself across and experience
nicate better with one another.7 For example, the from over there, the educative relation
SUPPORT study documented limited physician- would be burst asunder, or change into
patient communication, even after measures were friendship.10
taken to improve communication.8,9 If dialogue
serves as the basis of relationships, as Buber The physician, like the educator, sees the sit-
argues, limited communication in the medical set- uation from both sides, experiencing the treat-
ting may be the key to the predominance of It- ment of the patient. So the physician may gain
relations in that context. inclusive understanding of the patient, imagining
the patients situation while maintaining his or
Therapeutic Relationships her own perspective. The patient, like the pupil,
experiences the treatment but not what it is to
The implications of Bubers thought, however, treat. If a patient is able to understand from the
suggest that the relationships of physicians and physicians perspective, either the relationship
patients need not be limited to the I-It realm. The would end or change forms. Mutuality must remain
conditions of clinical practice are challenges to one sided or incomplete. Hence, a doctor-patient
legitimate the Buberian encounter: the physician- interaction is constrained by what it is or, in
patient relationship is kept from full mutuality by Bubers language, is normatively limited.
the very factors that occasion it, the meeting of doc- Such normative limits do not entirely pre-
tor and patient is purposive, and the relationship clude the clinical meeting from the I-Thou realm.
is not one of equals in a fully mutual partnership. To care for a patient, and not just a symptom, a
Some I-You relationships by their very nature may person-to-person encounter is important. As a
never unfold into complete mutuality if they are
to remain faithful to their nature.4 The patient
seeks assistance from a professional who is trained
This is one of three types of dialogical relationships. The
to do what the patient cannot. This imposes what other two are an instant connection between strangers and
Buber has described as a normative limit on a friendship.

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Existential Medicine

person is comprised of more than his or her illness, indeed afflicted with disease, but they are
a physician should recognize more than just the also afflicted by other circumstances
disease within the patient to care for the whole per- beyond their control. Who knows their
son. According to the normative limits, an element despair, their loneliness, their over-
of detachment in the meeting of physician and whelming frustrations? To send them away
patient remains necessary for the practical goal of cured of bodily maladies but still mired in
healing. However, the physician and patient should their stress and misery is to abdicate our
work as partners, discussing and negotiating a responsibility as healers.12
treatment plan, instead of issuing and adhering (or
not) to orders, respectively. With such efforts, the Healing entails attending to each patient, both
interaction may approach, although not reach, the symptoms and circumstances. In Buberian terms,
I-Thou pole (Fig. 1). the physician acknowledges the concrete other
before him or her and attempts to experience the
Facilitating Therapeutic Relationships situation from the patients side.
A physician who has personally experienced
Progress along the continuum from the It-pole to being a patient says of his colleagues,
the Thou-pole requires a paradigm shift in which
the relationship between physician and patient dis- We are often oblivious to our environment
places technical skills and knowledge of disease as and treat patients as though they were fur-
central to practice and education. Although the niture. Careless and unfeeling talk has a
therapeutic relationship, in accordance with its pervasive influence on the atmosphere of
nature, may be destined to fall short of the Thou- our institution. . . The practice of medi-
pole, a certain degree of mutuality would enhance cine is concerned with people not
the practice of medicine. A consideration of patients, molecules. There is no incompatibility
physicians, and the institution of medicine in light between the two, but it seems that only
of some Buberian premises provides insight into one is intensively taught.13
how to promote therapeutic relationships.
According to Bubers thought, a patient must Attention to medical needs overwhelms atten-
be seen foremost as a person, not a disease. Physi- tion to human needs so that physicians may see
cians, caught up in their obligation and desire to people, even those they are not treating, as patients
cure, may neglect the person in whom the illness first.11
resides.11 While attention to symptoms is critical Sharing his experience as a physician who
for medical practice, the patient is more than a became a patient, Oliver Sacks recounted his
medium for disease. By recognizing the whole per- thoughts prior to meeting the surgeon who would
son, treatment becomes more than efforts to cure operate on his leg:
the present symptoms:
I knew he was a good surgeon, but it was
We need to develop a more critical aware- not the surgeon but the person I would
ness of sickness, poverty, and lifes bad stand in relation to, or rather, the man in
deals. Many of our patients today are whom, I hoped, the surgeon and the person
would be wholly fused. . . If he were a sen-
sitive man he would be instantly aware of

Konner shares a poem entitled Please See My Need,


the distress and dispel it, with the quiet
which some nurses had taped to a wall in a surgical unit of
the hospital where he did his medical training. The poem voice of authority. . . I required only the
emphasizes a patients need to be recognized as a person. voice, the simplicity, the conviction, of

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Cohn

Figure 1 Buberian continuum of human relationships.

authority: Yes, I understand.. . .If he subjectivity in which the I apprehends simul-


could not, in truth, reassure me with such taneously its association and its detachment.4
words, I would want an honest acknowl-
edgment of the fact. . .I should respect Based on his experiences, the doctor endeavors to nor-
whatever he said so long as it was frank matively limited I-Thou relationships with his patients.
and showed respect for me, for my dig- In doing so, the doctor creates opportunities for
nity as a man.14 physicians-in-training to understand the distinction
between an It-relation and a Thou-relationship.
Sacks wanted more than truth telling and During rounds with a senior physician, a med-
disclosure from his surgeon. He wanted the sur- ical student recognizes a similar teaching moment,
geon to see him as more than a patient, to under- recognizing the meaning and importance of car-
stand what he was experiencing, and to demon- ing about patients:
strate respect. Or, as Buber might say, Sacks
wanted the surgeon to encounter him, imagine We visited the bedsides of four of Dr.
the experience from his side, and confirm him Nathans patients. . . He didnt miss a trick
as a person. Sacks, as both physician and patient, medically, and his visits were in that sense
was able to see the surgeon as more than a sur- equivalent to those of any other doctor on
geon and hoped that this would be mutual; he the ward. But there was a warmth in his
desired a relationship. voice, in his smile, in his hands. His
Similarly, Ed Rosenbaum wrote of an insen- patients believed he cared about them, and
sitive neurosurgeon who learned about relation- for the best possible reason: he did. He
ships through a personal experience with illness was real, that was all. Real. I figured that
and friendship.15 These events in his life became if I could get mastery of half of what he
teaching moments, from which he was ready to knew about how to be with patients, it
teach. Buber explained: would be worth more than all I could learn
from the famous physicians at Galen and
. . .the I that steps out of the event of the their minions.11
relation into detachment and the self-
consciousness accompanying that, does Using Bubers language, this sense of being
not lose its actuality. Participation remains real is authenticity or actuality and is both a basis
in it as a living potentiality. . .the seed for and a product of a relationship. Thus, not every
remains in him. This is the realm of physician needs to have the experience of being a

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Existential Medicine

patient to learn how to treat his or her own patients. rigid sense of hierarchy which is the enemy
Some efforts at recognizing the actualitythe con- of mutuality.1
crete, distinct reality and potentialof each patient
and imagining his or her situation through role Physicians may end up needing the same kind
modeling and emulation may be sufficient. of help they offer. Even if this is not the case, physi-
Medical training generally appears either to cians need help from their patients in determining
create a dichotomy between healing and curing, the diagnosis and working out treatment plans.
so that they appear to be mutually exclusive, or to Recognition of the other, even if not fully mutual,
suggest that curing is all there is.11ll# Bubers Thou- allows each to help the other in ways appropriate
and It-worlds help explain that dichotomy but to the normative limits of the relationship.
also reveal how the opposite poles are connected. A similar theme is apparent in the use of the
The It-world need not efface the Thou-world, just metaphor of covenant to describe medical rela-
as curing need not overcome caring. Movement tionships.16** With this image of mutual fidelity,
between the poles is possible.
According to Bubers thought, the physicians
humanity also requires recognition; personal iden-
tity is not lost under a white coat, although it may **See May W. The physicians covenant. Philadelphia:
be hidden. Recognizing both the physicians and Westminster Press, 1983. Other metaphors or models may
patients human identities offers common ground also capture the meaning of Bubers concept of relation-
ship. James Childress and Mark Siegler note that there are
on which to base interaction as partners. The several possible and appropriate types of physician-patient
physician relationships. They favor a metaphor of negotiations,
although they recognize its limits. They suggest that this
metaphor captures two important characteristics of med-
. . .in any relation is not an abstract, or the- ical relationships: (1) it accents the autonomy of both
oretical ideal type, but a human being, with patient and physician and (2) it suggests a process that
all the achievement, skill, awkwardness, occurs over time rather than an event that occurs at a par-
and error that characterizes even the most ticular moment. This metaphor reflects elements of
Bubers I-Thou relationship. Although the language of
competent professional. Such a recogni- autonomy is foreign to Bubers conception of relationship,
tion of the human dimension actually is the term suggests an acceptance and confirmation of the
quite consistent with the critical element concrete otherness of each, including a recognition of dis-
tinct perspectives and capacity to direct the course of ones
of dialogue. . . In all the situations defined life. In making the negotiations an ongoing process, each
by the working out of a purpose, the helper negotiator may be able to experience the position of the
also needs help, or at least should be under- other, making the relationship inclusive. The relationship
stood as potentially needing help. Living is exclusive in that the negotiations are limited to the
physician and patient and is immediate as it occurs without
out a purposive relationship in the light of mediation in the ongoing present. Mutual participation in
that recognition can empower the imple- the negotiations may contribute to the possibility of
mentation of the defining task without the achieving a therapeutic relationship. Buberian dialogue,
however, would be rooted in a connection between inde-
pendent persons, whereas for Childress and Siegler,
negotiations stem from autonomous choices made by the
parties to a negotiation. For Buber, a relationship is more
than a matter of autonomous choices made over time.
ll
Konner recalls the advice of a neurologist-clinical precep- Although the results of a negotiation or a Buberian dia-
tor from his first year of medical school: If you want to logue may be similar (e.g., comfortable agreement
be a fixer, dont go into neurology, but if you want to be a between the physician and the patient on a treatment plan),
healer, it may be the field for you. there are significant conceptual differences rooted in per-
# ceptions of human beings and interhuman relationships.
Eric Cassell distinguishes between humanistic healing
and scientific curing based on the distinction between ill- Childress JF, Siegler M. Metaphors and models of doctor-
ness and disease. Cassell E. The healers art. Cambridge, patient relationships: their implications for autonomy.
MA: MIT Press, 1976. Theor Med 1984;5:1730.

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Cohn

interaction, respect for individual dignity, and Lessons for Medical Education
acceptance as a gift, more is required of a physi-
cian than merely fulfilling the terms of a contract As the practice of medicine evolves, so does med-
or meeting certain medical standards; it estab- ical education, although the causal association
lishes professional responsibility within a broader therein is unclear. An emphasis on relationships
human context. Depiction as a covenant enriches is fundamental to the current phase of evolution:
the meaning of physician-patient interactions in
much the same way as the concept of a Buberian In our era, what is new in medicine is not
relationship. merely a new understanding of disease
In addition to the human context, institu- or new drugs or technologies. . . What is
tional context influences interactions between new is a fundamental shift in the focus
the physician and the patient. The organized of doctors away from a primary interest
realm of the It-world provides the continuity in disease toward a basic concern for the
needed for medical education, medical research, sick person. . . In this way of seeing the
and the general practice of medicine and offers world of the sick, medical science and
an environment in which relationships may spon- scientific knowledge of disease have not
taneously occur. Systematic order is an anthro- become unimportant; rather they have
pologic necessity that only becomes problematic taken their place in a larger, richer under-
when it precludes the possibility of encounter. standing of the sick and the human
Encounters in institutional settings need not be conditiononly one of the many kinds
inhibited by the organization and order of the of knowledge that doctors must have to
domain around them but instead can humanize do their job well.
the purposive associations between two people, I believe that the changes occurring
permitting mutuality within working relation- in medicine today are part of a larger social
ships.1 The health care delivery system can model transformation. . . In view of this social
social support, cohesion, and interdependency transformation, it is not surprising that
rather than only disinterest or detachment. Allow- Americans are changing their relationship
ing for the Thou does not mean sacrificing the It- to medicine and to their doctors, wanting
world elements necessary for the institution, such to be treated as the persons they are, not
as the depersonalization indispensable for physi- primarily as containers of disease; they see
cians to do their work (e.g., dissect human cadav- themselves as partners in, rather than
ers, avoid fainting at the sight of blood, cut into merely objects of, medical care. . .17
a living human body, and maintain white coat sex-
ual purity). But an overemphasis on the It-world, Bubers thought offers a framework for that
too much detachment, could result in a harmful larger, richer understanding of the human condi-
progression of the It-attitude against which Buber tion within which medicine is considered. This
warns. enhanced understanding of human relationships
Dialogue is vital in this environment to occa- offers a context that can facilitate physician
sion and nurture therapeutic relationships, espe- progress toward I-Thou relationships with the
cially when a physician and a patient are strangers. persons for whom they provide medical care.
The doctor cannot heal, in the broad sense of the To enable physicians to practice a more exis-
term, and the patient cannot be healed, without dia- tential medicine requires three conceptual shifts
logue. In addition to verbal exchange, dialogue in practice and education. First, medicine would
entails really listening to one another and even be centered on persons rather than preoccupied pri-
seeking the opportunity to listen. marily with disease; medicine would be person

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Existential Medicine

centered, in contrast even with the current empha- personal and medical goals, knowing that she
sis on patient-centered care. The application didnt live just to breathe, but breathed so that she
of Bubers thought to medicine constitutes just such could dance, the physician would not impose a
an effort, moving medicine from the It-pole to a medical goal, such as total control of the disease,
location on the continuum nearer to the Thou- that did not account for her personal identity.19
pole or shifting focus from diseased persons to per- Existential medical education would incor-
sons with disease. This has practical implications porate the lessons life teaches and use cases like
for education and practice: that of the ballet dancer, enabling students to learn
to see the meaning of illness for an individual. An
Ideally, physicians should define their diag- existential ethic would not abstract from the indi-
nostic and therapeutic goals in terms of vidual patient; instead, it would consider the patient
the everyday life and function of individ- in his or her individual context. Existentialism
ual patients. Unfortunately, that ideal is removes the either/or proposition, allowing med-
seldom met because of the difficulty of icine to be both art and science and physicians to
holding impersonal technical imperatives care and cure.
in check, and because doctors seem to be Second, the mundane everyday matters of
trained to focus on diseases almost to the patient care would garner as much attention as cri-
exclusion of how sick persons actually live sis situations. Bubers thought requires attention
their lives in families and communities. In to specific context and particular persons. So, a
part the problem arises because physicians Buberian approach would entail greater attention
are trained from the first days of medical to the everyday events of life and the particular-
school to disregard the knowledge they ity of the involved persons. Additionally, a rela-
bring with them of everyday life and tionship implies ongoing interaction rather than
human function as irrelevant to medicine. intervention under emergency circumstances.
Another obstacle is that doctors are not Human existence is a complex of many events, all
trained to include in their decision making of which form individual identity. It is that iden-
the kind of soft and often subjective tity that is presented in a relationship. Human life
information that is relevant to the every- cannot be reduced to particular incidents or the
day life and function of sick persons. moment of decision making. Bubers existential-
Correction of these educational errors ism recognizes the commonplace and the pivotal
would do much to help change physicians and would embrace both in medical practice and
priorities in patient care.18 ethical discussion. For medical education, attend-
ing to the everyday involves teaching students
For example, in treating a ballet dancer with how to engage in ongoing interaction with patients,
asthma, a Buberian physician would understand in addition to parading students in to witness acute
the ballerinas priority of continued career over situations or to identify an unusual diagnosis.
exemplary airways. Recognizing both the dancers Third, medical practice would be framed in
terms of relationships and codes. Bubers anthro-
pologic and ontologic thought does not translate

Although patient-centered care does seem a recognition into a systematic code of ethics for medical prac-
of the importance of the individual patient in the process tice but instead offers an alternative or supple-
and decisions of medical care, it only begins to approach mentary worldview. Existentialism would either
the Buberian notion of the I-Thou relationship. Focusing
on the patient still recognizes the person as a patient, a dis-
help to establish a conceptual shift or join an
eased entity, first. Buberian thought would suggest already existing movement away from an empha-
recognizing the person first. sis on governing principles, specifically benefi-

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Cohn

cence and autonomy, or contractual models toward This does not mean that all traditional ethi-
a focus on the persons involved, how they inter- cal values are to be rejected. They symbolize
act, and the impact of those interactions on med- how relationships are understood in the abstract
icine. This movement is a deviation away from the and can be useful in decision making. However,
mainstream of orthodox Western medicine of they should not precede the personal interaction
the twentieth century, [which] has its roots in the in the concrete situation. The suggestion here is
Hippocratic emphasis on astute empirical obser- not that medical ethics should rely on situation-
vation, rationality, the demystification of disease, ism in the spirit of Joseph Fletcher. 22 Buber
and what can be referred to as the scientific men- explains:
tality toward a recognition and incorporation of
patients values into medical care.20 No responsible person remains a stranger
Buberian existential values arise from recog- to norms. But the command inherent in a
nition of the actual relations that currently inhere genuine norm never becomes a maxim and
in medical practice and of the possible relation- the fulfillment of it never a habit. Any com-
ships that might exist. In this way, the ethics of mand that a great character takes to himself
medical practice would reflect living, dynamic, in the course of his development does not
human experience rather than metaphysical act in him as part of his consciousness or
abstractions, to some extent bridging the distinc- as material for building up his exercises,
tions between theory and practice: but remains latent in a basic layer of his
substance until it reveals itself to him in a
Bubers philosophy of dialogue not only concrete way. What it has to tell him is
finds the narrow ridge between the sub- revealed whenever a situation arises which
jectivist identification and the objectivist demands of him a solution of which till
sundering of the is and the ought, but then he had perhaps no idea. Even the most
it also radically shifts the whole ground of universal norm will at times be recognized
ethical discussion by moving from the uni- only in a very special situation. . . There
versal to the concrete and from the past to is a direction, a yes, a command, hidden
the presentin other words, from I-It to even in a prohibition, which is revealed to
I-Thou. Buber does not start from some us in moments like these. In moments like
external, absolutely valid ethical code these the command addresses us really in
which man is bound to apply as best as the second person, and the Thou in it is no
possible to each new situation. Instead he one else but ones own self. Maxims com-
starts with the situation.21 mand only the third person, the each and
the none.10

It is the context of a concrete relationship,

Although Veatch so characterizes Western medicine, his not the particular circumstances of the situation,
alternative also does not seem compatible with Bubers that is primary in determining the good.
thought. Veatch offers a contractual model in which a What existentialism helps avoid is disregard
physician and a patient construct a contract based on a par-
ticular list of principles. This contract is framed by a larger for persons in the name of rule following, an atti-
societal contract that is based on the same list of princi- tude that Konner displays:
ples. Such artificial structures appear antithetical to a
Buberian approach. A contract would seem to interfere
I have developed the impatience with the
with the development of a Buberian relationship as it
would situate the association between a physician and a ethical discussions characteristic of most
patient in the It-world. house officers. It isnt that I dont consider

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Existential Medicine

them important, its just that I dont con-


sider them my job. I follow the rules laid Lessons for Practice
down by the hospitalmeaning, the rules
laid down by society. Tell me in plain A conceptual shift is needed in medi-
English what the Do Not Resuscitate order cine from disease-centered and
means and exactly whom it applies to, and patient-centered medicine to person-
I will carry it out. . . Tell me the rules centered care.
define them as strictly as you canfor Person-centered care involves defin-
taking the heart out of patient A and putting ing diagnostic and therapeutic goals in
it into patient B, and I will go on with that terms of the everyday life and function
dazzling technical miracle; I wont have of each individual patient.
pangs of conscience, which I really dont The mundane everyday matters of
need and which only make my work patient care should garner as much
harder.11 attention as crisis situations so that
physician-patient interaction is ongo-
Medicine is an inherently moral profession ing rather than emergency focused.
[because it] has directly to do with the welfare Medical practice and education should
and the good of others.17 The pangs of con- be framed in terms of relationships
science that Melvin Konner hopes to avoid are and codes so that they focus on the
integral to the work, work that is not necessar- persons involved and personal interac-
ily supposed to be easy. An existential approach tions rather than the governing princi-
to medicine is based on the good of a specific ples of professional conduct and ethics
other, avoids blind recourse to any given set of codes or contractual models.
rules, and serves as a reminder of the complex-
ity of life.
One cannot come to an understanding of
the norms of medical ethics in the abstract. ingful in real situations. There is no complete
Stanley Hauerwas enjoins people to under- rule book for human interactions, and that may
stand what it is physicians and patients do when be the most difficult lesson for medical educa-
they make themselves available to one another tion and humanity. Perhaps through dialogue and
in times of illness and crisis.23 Medicine is not openness to relationships, the physician and
about having stock answers that may be applied patient can meet on the narrow ridge of the
to increasingly difficult situations. It is funda- I-Thou.10 ll ll
mentally about caring for patients; ethical prac-
tice and education should reflect this. The norms ll ll
Buber used the narrow ridge metaphor frequently in his
must be taught as practical action guides, but writings. It first appeared in The Legend of the Baal-Shem
medical education must also involve exercising (1908) (Buber M. The legend of the Baal-Shem. Friedman
judgment so that abstract norms become mean- M, trans. New York: Harper, 1955.) and was usually used
to describe the constant tension in human existence
between concreteness and abstraction. Human beings walk
this ridge with faltering steps, trying to avoid the abyss on

For Hauerwas, religious premises underlie the ethic of either side. Later, the narrow ridge came to represent the
care. Another question, outside the scope of this article, is dialogical relationship. According to Buber, even at the
the role of religion in improving the physician-patient rela- highest peak of a relationship, an essential difference
tionship. The theological implications of Bubers work between the partners persists unweakened, while even in
might also be helpful in examining the role of religion in such nearness the independence of man continues to be
medicine. preserved.

180
Cohn

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