What Is Health For?-Human Priorities in Health Care JAMES VARGIU, MA, and NAOMI REMEN, MD THE AMOUNT OF MONEY spent each year in the United States on products that are believed to enhance and promote health, and the amount of time spent by people in jogging, dieting, exercising and otherwise strengthening their bodies, suggest that physical health is something that most people see as extremely valuable. Useful as many of these activities are in maintaining health and preventing disease, the quantity of energy expended in this drive for health leads us to pause and wonder. Is health a quality so intrinsically valuable that it should be sought and possessed for its own sake? Or is health, like money, valuable only because it can be used for another purpose? Is being physically healthy an end or only a means? Why be healthy? Such questions offer an interesting opportunity for us as physicians to bring into clearer focus the principles which guide our professional decisions and the priorities which govern our therapeutic actions. Consider the following case history. Reginald Mitchell was an Englishman who died in 1937. At the time of his death, he was world famous as the designer of the airplanes that brought victory to England year after year in the international Schneider Cup air races. In 1933 he was found to have cancer and he underwent extensive surgical procedures from which he never fully recovered. A year later, during a trip to Germany, he became concerned about what he saw happening in that country. He spoke to people in the streets, met personally with Hermann Goering and, because of his expertise in the field, was shown the German air force. He was tremendously impressed with the advances Germany had made in the design of its planes. With Refer to: Vargiu J, Remen N: What is health for?-Human priorities in health care, In Orthodox medicine, humanistic medicine and holistic health care-A forum. West J Med 131:471-472, Dec 1979 From "Dimensions of Medical Synthesis," a lecture series given at the Synthesis Graduate School for the Study of Man, Fall 1978. Mr. Vargiu is President, Synthesis Graduate School for the Study of Man, and Founding Director, Psychosynthesis Institute, San Francisco; and Dr. Remen is on the faculty of the Synthesis Graduate School for the Study of Man, and Clinical Assistant Professor of Pediatrics, University of California, San Francisco, School of Medicine. Reprint requests to: Synthesis Graduate School, 3352 Sacramento Street, San Francisco, CA 94118.
a sinking heart, he realized that the technology evident in these German aircraft far exceeded anything comparable in England. He returned home and reported to Whitehall that he felt the safety of his country was in possible jeopardy because of Germany's advanced air capacity. He was able to convince the government of the danger and received clearance to design a plane that would allow England a chance of defense in the event of war with Nazi Germany. Soon after he started to work, relations between the two countries began to deteriorate. Mitchell worked 18 to 20 hours a day, seven days a week. Under this stress, his fragile health faltered and he consulted several physicians, all of whom advised that he must stop his work. He ignored their advice and pushed on, while his health continued to fail. Finally, he was told that he simply could not continue doing what he was doing; at his present pace, he would be dead within the year. His response was "I think a year is all that I need. Can you keep me going?" After much thought, his physician decided to give Mitchell the support he asked for, and barely 20 months after his return from Germany, the final designs were completed and emergency production of the plane had begun. On March 5, 1936, he watched its maiden flight from a wheelchair. The Spitfire performed exactly as he had planned and became the critical factor in England's successful defense against the Luftwaffe. Six months later, Mitchell died. He was 42 years old. Mitchell was a man who spent his health, who used it to do something that was more valuable to him than health itself. For him health was a personal resource which enabled him to express his priorities and sense of purpose. Mitchell and persons like him inspire us to reexamine the context in which health occurs, the subjective realm of purpose, aspiration, values and meaning. In some ways, Mitchell's life was healthier than that of persons who are physically healthy but who find life meaningless. He was a man who chose THE WESTERN JOURNAL OF MEDICINE
471
to live by his values and, in doing so, presented his physician with a difficult choice. In point of fact, his physician chose to help Mitchell live in this way, to keep him going so that he could act in keeping with something that gave him not only personal satisfaction but the opportunity to meet a need greater than his own. Technically, Mitchell was a noncompliant patient, and in the same class as a man with emphysema who smokes or a woman with pancreatitis who drinks. Yet, when he ignored his doctor's advice, his doctor responded not by refusing to condone such self-destructive behavior, but by using his medical knowledge to support his patient toward his goal. How many of us would be open to consider the appropriateness of responding in this way? It is difficult to reconcile this action with the traditional dictum that a physician's primary responsibility is to preserve physical health. When can this more orthodox approach justifiably be tempered by a consideration of a patient's individual sense of purpose and his wish to use his health in accordance with it? Patients like Mitchell may not be so rare. Many people value something that enhances the meaning and quality of their lives more than they value health itself. Mitchell's case is dramatic in that he gave his life as well, but less extreme cases frequently pass unnoticed in the daily practice of medicine. If we examine our own health care experiences we see that many of our patients choose to get a little less sleep, skip a meal or return to work before they are completely well to do something that is important to themselves and to others. Physicians use their own health in this way all the time. This seeming abuse of health may be common enough to raise some difficult issues for us in our professional role. What is the responsibility we have to people who use their health in this way? Is our traditional frame of reference broad enough to make such decisions, or does it need to be expanded? A sense of purpose is a distinctively human quality; in supporting it we support what is most essentially human in our patients.' Yet the spectrum of human purpose is broad; some people place the highest priority on their own personal comfort or pleasure, others on the welfare of those they love, still others on principles or causes which are of benefit to society in general. The diversity of this range presents a difficulty 472
DECEMBER 1979 * 131 * 6
in determining which of these many goals and purposes warrant our professional support. If we support someone like Mitchell in his goals are we also obligated to support a cardiac patient whose choice of an expensive life-style demands that he work a 70-hour week, or a professional athlete who demands periodic methandrostenolone (Dianabol) in order to lift weights more
effectively? The choice of individual purpose and direction is unquestionably the domain of each person. No one can tell another what this purpose is or should be. Yet in supporting this personal freedom of choice, are we also to support the choices
themselves, indiscriminately? The practical approach to such questions seems to require a perspective greater than that found within medicine itself. The individual sense of the meaning and purpose of human life which we bring to our medical practice deeply affects the way in which we respond to these issues. To see the prolonging of life as a goal sufficient in itself will probably lead us to see health as an end in itself. To see life in a larger frame of reference, as including a person's individual direction and purpose as well as a direction and purpose beyond this person, will enable us to see health as a means that can be used appropriately to reach these larger goals. The issues involved, therefore, encourage not only a reexamination of our responsibilities and priorities as physicians, but also point to the relevancy of our own world view to our
practice.
It appears that the perspective in which Mitchell and his doctor saw health is worthy of our consideration, as we attempt to act in ways that acknowledge the full humanity of our patients. Is human health indeed only an end in itself, or is it actually a means toward a greater goal? Should we, as physicians, consider the growing human need for meaning and purpose2-4 in the same careful and responsible way in which we presently address the needs of the body? Is the current drive towards physical health as the ultimate goal and defense against death at any cost really the best and most satisfying way to live? REFERENCES 1. Jonsen AR: Purposefulness in human life. west 3 Med 125: 5-7, Jul 1976 2. Maslow AH: The Farther Reaches of Human Nature. New York City, Viking Press, 1971 3. Frankl V: Man's Search for Meaning. New York, Washington Square Press, 1963 4. Vargiu R, Firman J: Dimensions of Growth. Synthesis; The Realization of the Self 3:59-121, 1977
a sinking heart, he realized that the technology evident in these German aircraft far exceeded anything comparable in England. He returned home and reported to Whitehall that he felt the safety of his country was in possible jeopardy because of Germany's advanced air capacity. He was able to convince the government of the danger and received clearance to design a plane that would allow England a chance of defense in the event of war with Nazi Germany. Soon after he started to work, relations between the two countries began to deteriorate. Mitchell worked 18 to 20 hours a day, seven days a week. Under this stress, his fragile health faltered and he consulted several physicians, all of whom advised that he must stop his work. He ignored their advice and pushed on, while his health continued to fail. Finally, he was told that he simply could not continue doing what he was doing; at his present pace, he would be dead within the year. His response was "I think a year is all that I need. Can you keep me going?" After much thought, his physician decided to give Mitchell the support he asked for, and barely 20 months after his return from Germany, the final designs were completed and emergency production of the plane had begun. On March 5, 1936, he watched its maiden flight from a wheelchair. The Spitfire performed exactly as he had planned and became the critical factor in England's successful defense against the Luftwaffe. Six months later, Mitchell died. He was 42 years old. Mitchell was a man who spent his health, who used it to do something that was more valuable to him than health itself. For him health was a personal resource which enabled him to express his priorities and sense of purpose. Mitchell and persons like him inspire us to reexamine the context in which health occurs, the subjective realm of purpose, aspiration, values and meaning. In some ways, Mitchell's life was healthier than that of persons who are physically healthy but who find life meaningless. He was a man who chose THE WESTERN JOURNAL OF MEDICINE
471
to live by his values and, in doing so, presented his physician with a difficult choice. In point of fact, his physician chose to help Mitchell live in this way, to keep him going so that he could act in keeping with something that gave him not only personal satisfaction but the opportunity to meet a need greater than his own. Technically, Mitchell was a noncompliant patient, and in the same class as a man with emphysema who smokes or a woman with pancreatitis who drinks. Yet, when he ignored his doctor's advice, his doctor responded not by refusing to condone such self-destructive behavior, but by using his medical knowledge to support his patient toward his goal. How many of us would be open to consider the appropriateness of responding in this way? It is difficult to reconcile this action with the traditional dictum that a physician's primary responsibility is to preserve physical health. When can this more orthodox approach justifiably be tempered by a consideration of a patient's individual sense of purpose and his wish to use his health in accordance with it? Patients like Mitchell may not be so rare. Many people value something that enhances the meaning and quality of their lives more than they value health itself. Mitchell's case is dramatic in that he gave his life as well, but less extreme cases frequently pass unnoticed in the daily practice of medicine. If we examine our own health care experiences we see that many of our patients choose to get a little less sleep, skip a meal or return to work before they are completely well to do something that is important to themselves and to others. Physicians use their own health in this way all the time. This seeming abuse of health may be common enough to raise some difficult issues for us in our professional role. What is the responsibility we have to people who use their health in this way? Is our traditional frame of reference broad enough to make such decisions, or does it need to be expanded? A sense of purpose is a distinctively human quality; in supporting it we support what is most essentially human in our patients.' Yet the spectrum of human purpose is broad; some people place the highest priority on their own personal comfort or pleasure, others on the welfare of those they love, still others on principles or causes which are of benefit to society in general. The diversity of this range presents a difficulty 472
DECEMBER 1979 * 131 * 6
in determining which of these many goals and purposes warrant our professional support. If we support someone like Mitchell in his goals are we also obligated to support a cardiac patient whose choice of an expensive life-style demands that he work a 70-hour week, or a professional athlete who demands periodic methandrostenolone (Dianabol) in order to lift weights more
effectively? The choice of individual purpose and direction is unquestionably the domain of each person. No one can tell another what this purpose is or should be. Yet in supporting this personal freedom of choice, are we also to support the choices
themselves, indiscriminately? The practical approach to such questions seems to require a perspective greater than that found within medicine itself. The individual sense of the meaning and purpose of human life which we bring to our medical practice deeply affects the way in which we respond to these issues. To see the prolonging of life as a goal sufficient in itself will probably lead us to see health as an end in itself. To see life in a larger frame of reference, as including a person's individual direction and purpose as well as a direction and purpose beyond this person, will enable us to see health as a means that can be used appropriately to reach these larger goals. The issues involved, therefore, encourage not only a reexamination of our responsibilities and priorities as physicians, but also point to the relevancy of our own world view to our
practice.
It appears that the perspective in which Mitchell and his doctor saw health is worthy of our consideration, as we attempt to act in ways that acknowledge the full humanity of our patients. Is human health indeed only an end in itself, or is it actually a means toward a greater goal? Should we, as physicians, consider the growing human need for meaning and purpose2-4 in the same careful and responsible way in which we presently address the needs of the body? Is the current drive towards physical health as the ultimate goal and defense against death at any cost really the best and most satisfying way to live? REFERENCES 1. Jonsen AR: Purposefulness in human life. west 3 Med 125: 5-7, Jul 1976 2. Maslow AH: The Farther Reaches of Human Nature. New York City, Viking Press, 1971 3. Frankl V: Man's Search for Meaning. New York, Washington Square Press, 1963 4. Vargiu R, Firman J: Dimensions of Growth. Synthesis; The Realization of the Self 3:59-121, 1977
