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History of Western Medicine
At all times and in all cultures, attempts have been made and still are made, to cure diseases and alleviate suffering. In medicine in its narrow sense, the physician’s appropriate action is derived from medico-scientific knowledge. Thus medicine developed as soon as diseases came to be explained ‘according to nature’ and were treated with scientific rationality. In the European context this took place in the fourth century BC in ancient Greece. We speak of ‘medicine’ and ‘physician’ only in contexts where diseases are not primarily seen in magical, mythical, religious, or purely empirical references. From ancient scientific beginnings in humoral pathology, different historical concepts of medicine have been generated via iatro-astrology, iatro-physics, iatro-chemistry, and iatro-morphology to the modern concept of iatro-technology. Concepts of medicine comprise a continuous causal interrelation between a particular physiology, a particular pathology, and its deducible therapy. This inner perspective of the scientific and conceptual history of Western medicine is broadened by an outer perspective. Guided by socio-historical, historico-sociological, and anthropological approaches, the institutional and organizational history of Western medicine is focused. In recent decades the leading concept of iatro-technological medicine is in transition to the molecular concept of medicine. The scientific medicine of the late nineteenth and early twentieth centuries was the reproductive rearguard of industrialization. By contrast, the medicine of the late twentieth and early twenty-first centuries is a forerunner of the ongoing scientific, economic, and social change. The transition to molecular medicine will reshape the concept of the human body and thus change individual life and the social world accordingly.
- The Scientific and Conceptual History of Modern Western Medicine
- The Institutional and Organizational History of Western Medicine
- The Recent Transition to Molecular Medicine
At all times and in all cultures attempts have been made to cure diseases and alleviate suffering. Healing methods nowadays range from experience-based medical treatment within the family and the lay-world to the theories and methods of experts. Medicine in a narrow sense refers to ‘scientific’ knowledge. Such special knowledge is distinct from other forms of knowledge following culturally characteristic criteria. The physician’s appropriate action is derived from medicoscientific knowledge: We may only speak of ‘medicine’ and the ‘physician’ when diseases are not primarily seen in magical, mythical, religious, or empirical contexts. Medicine developed as soon as diseases came to be explained ‘according to nature’ and were treated with scientific rationality. Historically, this took place in the fourth century BC in ancient Greece. Scientific medicine generated subsequently from these ancient beginnings. This concept of modern Western medicine has come to be the leading concept of medicine world-wide. At the same time, there have always been alternative understandings and methods of medicine, which will also be mentioned briefly. Concepts of medicine comprise a continuous causal interrelation between a particular physiology, a particular pathology, and its deducible therapy. The inner perspective of the scientific and conceptual history of Western medicine (=1) will afterward be broadened by an outer perspective guided by sociohistorical, historico-sociological, and anthropological approaches (=2). As we face a paradigmatic change of the concept of medicine in recent decades, the transition from the iatrotechnological to the molecular concept of medicine will be analyzed profoundly (=3).
The Scientific and Conceptual History of Modern Western Medicine
The magical-mythical art of healing in indigenous cultures has been part of a world in which the human relationships both toward nature and toward societal structures have not been understood as independent in their own right. In a society of hunters and gatherers and in the early agriculturally determined cultures, diseases were the results of violated taboos, offended demons, or neglected ancestors. Therapies aimed at restoring the good old order: exorcism was practiced, demons and ancestors were pacified and with this, the spiritual, physical, and social order were restored. The animistic-demonic medicine presented a closed rational system of thinking and acting. As the trepanations (perforations of the skull, which were disseminated world-wide) indicate, fairly complex surgical procedures were performed within this magical-mythical thinking.
Magical conceptions of the world not only had their effects on notions of disease and therapeutic methods of pre-scientific times but iatro-magic (‘iatro’ from ancient Greek ‘iatros’: the physician) influenced medical theory and even practical medical action far into the seventeenth century AD. Even today, ‘simile-magic’ (e.g., ginseng-roots) or ‘singularity-magic’ (e.g., charms, symbols, spells) determine popular medicine, nature healing, and the so-called complementary medicine.
A religious world order characterized the highly developed medicine of the archaic cultures of Mesopotamia, Egypt, and Asia Minor. This order was guaranteed by (national) deities and the (divine) ruler. Diseases were seen as conscious or unconscious violations of the world order with which the healers were familiar. These healers were characterized by practical as well as prophetic skills. Thus physician and priest are hardly distinguishable. There was an abundance of empirical practices both in magical-mythical medicine and in the archaic art of healing. The one criterion that clearly distinguishes the latter from medicine in the narrow sense was that the entire art of healing remained metaphysically oriented. Even those treatments that worked also in the modern sense, were in their time assigned to a magical-mythical, i.e., religious domain. This also applied to rules of hygiene such as sanitary and dietary laws.
It was Hippocrates of Kos (c.460–375 BC) who took the decisive step toward scientific medicine in Classical Antiquity. Hippocrates and his school emancipated medicine from religious concepts. Diseases came to be explained ‘according to nature.’ Natural philosophical elements (fire, water, air, soil) and their qualities (warm, humid, cold, dry) were combined with the teachings of the body fluids (blood, phlegm, yellow and black bile) to become humoral pathology. Apart from this concept, ancient medicine developed in its progress a large spectrum of theories and methods in association with the respective philosophical schools. The spectrum ranged from the pathology of the body fluids (humoral pathology, humoralism) to the pathology of solid body parts (solid pathology). This included (functional) anatomy (including vivisections), surgery (e.g., vascular ligatures), and pharmacy (The Greek Herbal of Dioscorides Pedanius was written in the first century BC). The Alexandrine medical schools (Herophilus of Chalcedon, c.330–250 BC; and Erasistratus of Kos, c.320– 245 BC) followed empirical, partly experimental concepts in the modern sense. With this, almost all the possible patterns of modern medical thinking were in nuce already put into practice, or at least, anticipated in Classical Antiquity.
Galen of Pergamum (AD 130–200) subsumed theory and practice of ancient medicine under a humoral pathological view. The authoritative Hippocratic–Galenian medicine entered Persian and Arabian medicine via Byzantium (e.g., Oribasius of Pergamum, c.325–400 BC, and Alexander of Tralles, c.525–600 BC). As a result of Islamization, Persian- Arabian medicine spread eastward to South East Asia and westward to the Iberian Peninsula. In the heyday of the Arabian-Islamic culture (AD seventh to twelfth centuries), ancient medicine was transformed into practice-oriented compendia in a process of independent scientific work. Far beyond the High Middle Ages, the ‘Canon Medicinae’ of Ibn Sina Avicenna (AD 980–1037) became the handbook even of Western European physicians.
For approximately 1500 years, humoralism was the dominating medical concept from India to Europe. The original theory of the four body fluids, qualities, and elements was constantly expanded: by the four temperaments (sanguine, phlegmatic, choleric, melancholic), by the four seasons, the 12 signs of the zodiac, then later by the four evangelists, certain musical scales etc. This concept allowed the physician to put the patient with his/her respective symptoms into the center of a comprehensive model: Continuously, the powers of the macrocosm and the microcosm mutually influenced each other within the individual. By means of thorough anamnesis, prognoses, and dietary instructions (‘contraria contrariis’; allopathy) physicians supported the healing powers of nature (‘vis medicatrix naturae’; ‘medicus curat, natura sanat’), a model which (though according to the principle of ‘similia similibus’) is still valid today in homeopathy.
With the political decline of the Western Roman Empire during the fifth and sixth centuries, a Christian art of healing came to the fore in Western Europe. In this, the traditions of ancient practice (Cassiodor, AD 487–583) mingled with a magic-influenced popular art of healing and Christian cosmology to create the world of Christus Medicus. Such a theological- soteriological concept of medicine was able to take up the ancient cult of Asclepius. In early Christian and medieval ‘iatro-theology,’ diseases were interpreted as the result of sin or as a divine act of Providence. This still continues to have an effect on today’s religious practices (votive tablets, intercessions, pilgrimages). In her medical writings (e.g., Physica; Causae et Curae), Hildegard of Bingen (AD 1098–1179) left abundant evidence of the medieval art of healing.
The so-called monastic medicine or presalernitarian medicine (AD sixth to twelfth centuries) was superseded in Southern Italy and Spain by the adoption of ancient traditions from Arabian medicine. With Salerno in the eleventh century (Constantinus Africanus, AD 1018–87) and Toledo in the twelfth century (Gerhard of Cremona, AD 1114–87 et al.), the era of scientifically oriented medicine taught at universities began (Northern Italy; Montpellier; Paris). Hippocratic– Galenian medicine became the all-embracing and generally binding concept.
Neoplatonism and astrology (e.g., Marsilius Ficino, 1433– 99) contributed to shaping Hippocratic–Galenian medicine into an all-encompassing model of microcosm/macrocosm during the Renaissance. Though initially not directly critical of the authorities but of corrupted textual transmission, modern medicine has been gradually developing since the Renaissance. This development was furthered by numerous text discoveries (e.g., Celsus, approx. AD 40; De Re Medicina, discovered in AD 1455). Andreas Vesal (AD 1514–64) in his secular anatomical work ‘De Humani Corporis Fabrica’ (AD 1543) wanted to rid the old authorities of bad transmissions. More and more, medicine based itself on its own experience, on its own theories and on its own experiments (‘experimenta ac ratio’). Theophrast of Hohenheim, known by the name of Paracelsus (AD 1493/94–1541) introduced a chemistry-oriented way of thinking into medicine, while Rene Descartes (AD 1596–1650) contributed a mathematical- mechanical thought pattern; both were complemented by Francis Bacon’s (AD 1561–1626) empirical thinking. The human body was released from religious cosmology and gradually became the outstanding subject of scientific, i.e., (in the first place) anatomical examinations.
A secular step was taken at the end of the eighteenth and the beginning of nineteenth centuries in English and French hospitals: the focus of medicine and the physicians turned from the patient to his/her disease. The sick man disappeared from medical cosmology. Seventeenth century attempts at scientific systematization led to extensive nosologies (Thomas Sydenham, AD 1624–89) in medicine. The Hippocratic–Galenian symptomatology, which was directed at the individual patient, was replaced by described syndromes. These syndromes became detached from the individual sick person who turned into a mere case. With this, a scientific-experimental field of separate research of disease entities opened up for medicine.
The man–machine model of iatro-physics and the man– reagent model of iatro-chemistry finally introduced modern scientific thinking into medicine. As medicine was being progressively freed from any religious or metaphysical reasoning, the question of the source of life was raised. It was answered by dynamic concepts of disease, by psychodynamism and bio-dynamism. These concepts finally led, via Brownianism, to modern psychopathology and psychotherapy. In contrast, iatro-morphology was built on the visible and observable. Georgio Baglivi (AD 1668–1708) paved the way from humoral to solid pathology. Pathology improved from Giovanni Battista Morgagni’s (AD 1682–1771) organ pathology via Francois-Xavier Bichat’s (AD 1771–1802) tissue pathology to the functional cellular pathology of Rudolf Virchow (AD 1821–1902). Cellular pathology established the physiological and pathological fundamentals of scientific medicine in a modern sense.
The actual step toward modern scientific medicine was taken in the late eighteenth and early nineteenth centuries. Initially chemical and physical, then biological thinking – which was gradually mathematically-statistically tested – has been determining the theories of medicine ever since. Deliberately reproducible (research) results led to a ‘triumphal victory’ of modern medicine in the second half of the nineteenth century. The development of anesthesia (nitric oxide AD 1844/46; AD 1846 ether; AD 1847 chloroform); antisepsis (Joseph Lister, AD 1827–1912); asepsis (AD 1886/1891: Ernst von Bergmann, AD 1836–1907; Curt Schimmelbusch, AD 1860–95); immunology; serum therapy; and the diagnostic (AD 1895/96) and therapeutic (AD 1896) possibilities of X-rays must be acknowledged for the surgical disciplines. With acetylsalicylic acid, the first chemically representable fever-reducing drug was introduced into medicine in 1873. Along with chemistry, industry with its economic concerns, became involved in medicine.
Modern scientific medicine follows the iatro-technical concept; pathophysiology, causal analysis of distinguishable disease entities, objectifying and gauging methods, and causal therapy characterize such medicine. The driving force of this scientifically and technically oriented medicine is its endeavor to put physiology, pathology, and therapy on a scientific footing; first chemistry, then physics became central guiding sciences; laboratories and experiments were introduced even into clinical practice. With the animal model, bacteriology launched a biological experimental situation. From the start, the iatro-technical concept created specific tensions in medicine: On the one hand, the scientific fundaments which aim at general insights get into the maelstrom of the physician’s need for action (consequence: the ‘autistic-indisciplined thinking’ and acting; Eugen Bleuler, AD 1857–1915). On the other hand, medical action directed at the sick individual patient as a subject gets caught in the maelstrom of generalized technical applications and scientifically justifiable therapies (consequence: the ‘therapeutic nihilism’ of the Second Viennese School; Josef Skoda, AD 1805–81). As a result, since the 1840s, both patients and medical practitioners have been turning to and from homeopathy and nature healing over and over again.
The Institutional and Organizational History of Western Medicine
Medicine is a science built neither on pure knowledge nor on mere empiricism. It is rather an ‘action-based science’ (Handlungswissenschaft), directed at the sick individual. As already formulated in Hippocrates’ first aphorism, the patient and his/her environment are granted equal importance in medicine. Therefore, a scientific and conceptional internal perspective can only partly explain the significance of medicine. From a historical perspective, diachronic questions are necessary, directed at medicine from outside, i.e., from society. Consequently, a comprehensive history of medicine also demands socio-historical, historico-sociological and anthropological perspectives.
The dialectics of scientific knowledge and practical experience has been part of medicine ever since. Due to the category of experience, history in medicine has presented a significant argument since the existence of the earliest written evidence (such as: ‘On Ancient Medicine’ in the Corpus Hippocraticum). In the course of making medicine ‘scientific’ during the nineteenth century, the historical argument simply disappeared from scientific reasoning. As a well aimed counterreaction against the purely scientific-technical concept, the history of medicine was reintroduced into the medical curriculum in the early twentieth century. Far into the 1990s, the history of medicine was considered in medical faculties and schools to be the substantial representative of the humane aspects of medicine. Just as much as objects and methods of the historical sciences began to expand in the late twentieth century, medicine also became an object of general history, i.e., especially of social and cultural history.
Similar to the steadily growing specialization of the scientific and clinical aspects of medicine, the sciences that specialized more and more dealt with the aspects of medical practice in the interaction of doctor and patient and the psychological and social environment of this interaction. Since the 1970s a broad canon of disciplines developed besides the classical history of medicine, so that a group of ‘humanities in medicine’ emerged. These can be summarized as: medical history, medical sociology, medical psychology, psychosomatic medicine as a special subject, economy of health care etc. With the increasing technical possibilities of modern medicine, especially at the beginning and the end of life, questions of an ethical nature got ever greater importance both in theory and in the clinic. Since the 1990s, the ethics of medicine has grown into its own as a theoretical and practical subject. Due to the different tasks to be addressed – which partly refer to the current problems of legitimization and action, and partly to the debate about contents and methods in historiography – it is useful to distinguish between a ‘history of medicine’ and a ‘history in medicine.’ ‘History of medicine’ can be conceived as a part of general history – ‘history in medicine’ is a part of the theory of medical action in its historic settings.
Within the doctor–patient encounter, patients receive special attention due to their special need for help, as do doctors due to their specific need for action. From Antiquity to the beginnings of scientific-technical medicine, the conceptual world of medicine and patients’ lay interpretations have overlapped in large areas. Humoral pathological medicine lives on in popular medicine (Volksmedizin), in nature healing, and in alternative medicine (‘rheumatism,’ ‘blood poisoning,’ ‘diets,’ etc.). Due to the scientific concept, the world of medicine and that of the patient drifted apart. Since the eighteenth century, the physician as an expert began to face the patient as a lay person. At the same time, medicine came to hold the monopoly of definition and action over the human body. In the socio-genesis of health as a social good and value, medicine and the physicians were endowed with an exclusive task: They were given a special position in the society. The historical and sociological discussion of the 1970s called this process ‘the professionalization of medicine.’
The medical marketplace has always been characterized by enormous competition. Because of that, the healing professions have almost always depended on their clients, the patients. In medieval and early modern times, the patronage system made the academically trained physician subject to his socially superior patron–client. This was only inverted with the gradual scientification of medicine in the eighteenth century. With the compulsory linkage to scientific medicine, ‘orthodox medicine (Schulmedizin)’ has developed since the 1840s. Orthodox medicine was confronted with traditional or modern alternatives as a kind of ‘outsider medicine’; healers who applied these methods were both internally and externally discriminated against as quack doctors. Industrial societies with their various forms of social security systems and their general claim of social inclusion, opened up for medicine a new clientele of the working class and the lower economic strata for medicine.
A significant institution of medical help both in the Western and in the Islamic tradition is the hospital: Hospitals (from Latin ‘hospes,’ meaning ‘host’) were established partly for pilgrims and partly for anybody in need of help, in order to fulfill the Christian ideal of ‘caritas.’ When it migrated to the orient along with ancient medicine, the hospital became the place of training for physicians in Islam, around the turn of the millennium. Within the European tradition, the charitably oriented hospital changed only in the late eighteenth century: The modern hospital (German: Krankenhaus) came to be a place to which only sick people were admitted, with the purpose of discharging them after a well-directed treatment within a calculable period of time. Such was initially the responsibility of proficient ‘nursing.’ Around the same time, selected hospitals had become places of practical training for future physicians. Scientific-medical research has also been conducted in these university hospitals from the 1840s onwards. Only as a result of antisepsis, medicine entered the General Hospitals in the 1860s. This was the beginning of the history of modern nursing, of scientifically oriented medical training, of the many medical disciplines, of the modern Medical Departments and Schools, and of the hospitals which only then became medically oriented.
On first sight, diseases embody the biological reality in the encounter between physician and patient. As the examples of leprosy or plagues show, there are neither in one period nor over the periods, standardized terms to label diseases. Therefore it is hardly possible to determine with certainty which diseases were referred to in reports handed down to us (e.g., the so-called ‘plague’ of Thucydides). However, culturally interpreted diseases induce the encounter between physician and patient. It is therefore the sick human being who accounts for the existence of medicine. Over and above the conceptual and institutional interpretations, diseases have always been experienced as crises in human existence. In different cultures and eras sick people and their environments interpreted diseases always with reference to their metaphysical reasoning. Diseases are given a cultural meaning as a divine trial or as a retaliation for violated principles of life and nature. The scientific-analytical notion of disease in the iatro-technical concept is not suitable for taking the patient’s quest for meaning into account. The chronically ill, the terminally ill, and the dying, therefore, present a constant challenge for scientific-technical medicine – including its necessarily inherent thoughts of progress. The result is a continuous push toward alternative and complementary medicine as well as toward ‘lay’ and ‘self’ help.
From an historical and sociological point of view, even the interpretations of health take place in a repetitive processes. In antiquity, health resulted from the philosophical ideal of the beautiful and good human being (ancient Greek: ‘kalokagathia’). The Islam and the Christian Middle Ages assigned the health of the body to religious categories. In the sciences of early modern times, the nature-bound human body came to be understood as an objectified body (The dichotomy of German: ‘Leib/Korper’ is a differentiation in philosophical anthropology which is hardly possible to translate into English: ‘Leib’ means the self-given presence of the body; ‘Korper’ means the scientifically perceived and shaped part of body as a ‘living corpse’). In early rationalism, Gottfried Wilhelm Leibniz (AD 1646–1716) elevated medicine into a means of ordering private and public life according to scientific rules: the order of the soul, the order of the body, and the order of society corresponded with piety, health, and justice; they had to be guaranteed by the church, by medicine, and the judiciary. In critical rationalism, reason, physics, and morality were declared a unity (cp. Christoph Wilhelm Hufeland (AD 1762–1836), Macrobiotics). In the early nineteenth century, the interpretations of health joined the sciences. The question of the meaning of health was excluded from medicine. Within the iatro-technical concept, health as a chemical, physical, or statistical norm (percussion, auscultation, thermometer, etc.) became a negative definition of scientific notions of disease. Those values and ideas of order which were indispensably associated with the notion of health seem to have disappeared during the scientific-rational progress.
With the scientific notion of health and disease, modern medicine was finally granted the monopoly of interpretation and action for a rational design of the biological human resources in modern societies. Disease is the cause for medical action, health is its aim; via the societal value of health medical knowledge and medical action, it is integrated into the societal surroundings. The definition of health mediates in its valid interpretation of a particular civilization between the individual, the social, and the ‘natural’ nature of mankind. Thus, health integrates the ‘natural’ biological basis, the social basis, and the individuality – the ‘I’ and ‘me’ of human existence. In terms of philosophical anthropology, the valid notions of health mediate between the outer world/nature (= ‘Aussenwelt’), the social world/society (= ‘Mitwelt’) and the inner world/individuality (= ‘Innenwelt’) with regard to their body/living corpse. The place and the scope of medical action in society are defined via the interpretation and the effect of the valid definitions of health.
To the same extent to which the human relationship toward nature becomes more scientific and leads to a scientific– technological civilization, more and more aspects become scientific within the combined interplay of the body as a part of oneself (‘Leib’), and the body as an object (‘Korper’). The ‘homo hygienicus,’ i.e., mankind, who define themselves and are defined by others in terms of medical standards, are typical examples of the paradox of modernity: The autonomously progressing discoveries of scientifically oriented medicine liberated the person, the communities and society from the task of having to account for the values and norms of their bodily existence. From this position, the individual and public ‘rationalization of the body,’ as was stated by Max Weber (1864–1920), amongst others, at the turn of the century, could begin their widely welcomed and from all sides demanded ‘victory march of medicine.’ With the end of the belief in progress, the disadvantages of this process have been perceived since the 1970s. So in historical, sociological, and anthropological debates, medicine turned into an ‘institution of social control.’ ‘Medicalization’ – as Michel Foucault (1926–84), amongst many others, pointed out from the early seventies onwards – became the focus of a fundamental critique on the penetrating social impact of modern medicine.
The doctor–patient relationship is no anthropological constant. Rather, this relationship is an integral part of the economic and social organization of a community. This is especially true for public medicine and the health sciences. Early forms of the modern public health service developed at the end of the thirteenth and the beginning of the fourteenth century, in North Italian cities. The driving forces were the endemic plagues, which kept coming back at regular intervals after the Great Plague of 1347–51. In early modern times those public health measures evolved and became regular institutions of the cities of commerce: General regulations which also had health effects (such as food inspection and market orders etc.); municipal supervision of those practicing medicine; city hospitals for the infirm, and others for special isolation (leprosaria, plague hospitals, etc.); the beginnings of the municipal doctor and surgeon service.
When the territorial states were thoroughly consolidated on the legal and administrative level, the medical and sanitary supervision unfolded in the late seventeenth and early eighteenth centuries. During Enlightened Absolutism, the ‘medical police’ (German: ‘Medicinische Polizey’; e.g., Johann Peter Frank, 1745–1821) generated a public medicine which was linked to administrative and political goals. Within the framework of mercantilism, one intention in calculating power was to increase the population. The paternalistic welfare state toward the end of Absolutism developed ‘public health’ (German: Staatsarzneikunde) as part of its ‘populating policy’ (German: ‘Peuplierungs-Politik’). This is where the special, still heavily disputed relationship between state, medicine and women begins: to the extent to which women were made the ‘human capital’ of a welldirected population policy, their role came to be substantially determined by medicine (medicalised midwifery, medicalization of birth and childhood, medicalization of housekeeping, child-rearing, etc.)
Through the bourgeois revolutions the concept of the nation as sovereign made itself the object of public health. Besides the idea of a qualitative evaluation of the population the thought evolved to calculate ‘the value of a human being in terms of money.’ In a combined act of statistics, epidemiology, physics, geography, metereology, etc. and driven by a paternalistic idea of welfare, the first modern health sciences came into being. The nineteenth century cholera pandemics accelerated this development. With the beginning of industrialization, a comprehensive health care was promoted due to the recognition of the ‘public value’ of health. The modern health sciences finally defined, in a biological chain of causes and effects, a closed circle of human hygiene: the environment as conditional hygiene of Michel Levy (AD 1809–72), Jules Guerin (AD 1801–86), Edmund Parkes (AD 1819–76) or Max von Pettenkofer (AD 1818–1901); the concept of microbiology or bacteriology as infectious hygiene pioneered by Louis Pasteur (AD 1822–95) or Robert Koch (AD 1843–1910); the dynamic relation of exposition and disposition as constitutional hygiene; the classification of forthcoming human life through racial hygiene and eugenics; and finally the concept of health and society as social hygiene – all these combined approaches took hold of basically all areas of human existence in the late nineteenth and early twentieth centuries. This is especially true for the unborn life. At this point the historical reflection on public health care, medical statistics and epidemiology, health economics, health laws, and health systems etc. begins.
The idea of obligatory collective health has been developed since the turn of the twentieth century. In the biologistic ideology of National Socialism it was molded into a highly rational model of future-oriented health. The goal of National Socialist health care was a ‘genetically healthy’ and ‘racially pure’ population of ‘Arian-German blood.’ This genetically and racially cleansed ‘Volk’ would be fit to survive the secular ‘war of races.’ The goal of obligatory national – which really meant: racial – health was located beyond all individual rights. This model of a totalitarian program of health care was based categorically on exclusion. It was carried out in decisive areas: at first sterilization (at least 350 000 victims, all of them Germans), then ‘euthanasia’ (over 100 000 victims, including so-called ‘wild euthanasia,’ probably more than 250 000 victims; all of them Germans), and finally the determination of ‘Volkerparasiten’ during the Holocaust (approximately 6 million victims, approximately 180 000 Germans).
Medicine in National Socialism asks for special reference here, as it is historically unique in the world. Basically, there is always inherently an excluding function in medicine. In the daily routine of medicine this becomes apparent wherever decisions have to be made on scarce goods and services in short supply (e.g., transplantation medicine, assessment and social medicine, allocation of medical services). As to their forcefully carried out eugenic actions the National Socialists themselves referred to the examples of other countries, especially the United States. Indeed there had been, prior to 1933 and after 1945, an ‘Internationale’ of eugenicists. The National Socialist model of health serves as a historical example of the conflicting nature of the rationalization process on which modern times are based – a process which is irreversible. National Socialism is therefore to be seen as the janus-faced flipside of the modern era, which is just as much obsessed with progress as it is blinded by it. This means that National Socialism and medicine in the National Socialist era are not only a particular phenomena of German history. They are rather a problem of our times and thereby a problem of all societies, which have built on modernism.
The Recent Transition to Molecular Medicine
In the 1980s the concept of a natural-scientific and iatrotechnological medicine began to shift into the concept of molecular medicine. The transition to molecular medicine has important implications for medicine and health care in general. A concept of medicine is a self-containing compound of a physiology, a pathology and a therapy. The concept of natural-scientific medicine and the consequent iatrotechnological approach – starting with Johannes Muller (AD 1801–58) and continued by his famous disciples such as Emil du Bois-Reymond (AD 1818–96), Hermann (of) Helmholtz (AD 1821–94), Rudolf Virchow (AD 1821–1902) or Ernst Haeckel (AD 1834–1919) – regarded the natural sciences as exclusive referential disciplines of modern medicine. Diseases appear to be incidents of a machinery that, in principle, can be repaired by chemical or physical, and technological interventions. From the 1980s and intensifying in the 1990s, the reference disciplines of chemistry and physics were replaced by biology, and especially by genetics. The necessary background technology is electronic data processing, which has accelerated research significantly, e.g., during the Human Genome Project, and in fact has even been the factor that made research possible in the first place. The classical natural sciences will not disappear, but they vanish into the second row, in order to clarify the novel issues raised by molecular genetics.
The transition to molecular medicine was – as always in such secular processes – accompanied by mistrust and misunderstanding. At the turn of the twenty-first century, even some doctors did not admit that a change was ongoing, at the same level of importance as the cellular pathology of Rudolf Virchow to medicine in the 1850s or the microbiology of Louis Pasteur and the bacteriology of Robert Koch to medicine in the 1870s and 1880s. In molecular medicine the cell is not the smallest explanatory unit, which can optionally be influenced chemically or physically or removed surgically or by strong radiation. The cell rather appears as a separate universe of significant data storage, messages, processes, products, and features. These highly complex events of the cell are controlled by a self-regulating process of genes (genomics), proteins (proteomics), and metabolism (metabolimics) that are in constant interchange with the requirements given from the outside (epi-genetics). Molecular biology and the genotype take the place of the former morphology and phenotype of features and processes. Two examples may illustrate this fundamental change. In molecular physiology mice lacking the gene for hemoglobin and thus lacking red blood cells, do not differ in their phenotype from mice that possess hemoglobin. Inflammation in rheumatoid arthritis has been previously treated with steroids and nonsteroidal, antiinflammatory drugs. The body is flooded with these drugs, in order to access the areas where the drugs must discharge their chemical effects. Of course, the drugs will work in many other areas, too. In molecular antirheumatic treatment the so-called biologicals are given. These drugs imitate human proteins and stop the destructive anti-autoimmune process. Thus, the disease is interrupted in its causal process. The intervention with TNF-alpha antagonists, however, is not specific to rheumatic arthritis, and therefore also can lead to serious side effects. This was noticed in the development of this therapy. As a result, rheumatologists have recently learned to treat the so-called ‘nonresponders,’ a group of patients particularly difficult to medicate.
Molecular medicine is the medicine that investigates biochemical processes from messages encoded in genes referring to the respective production processes up to the products of the cell – in particular nucleic acids and proteins – for the physiology and pathology of organisms, in order to use the results for an appropriate therapy. A person’s genetic repertoire is a singular entity. Mankind is identified by its genes as individuals – today genetic fingerprints are customarily recognized in paternity or criminological studies (restriction enzymes, noncoding regions of DNA). Molecular medicine is a medicine that leads to an individualized, and personalized treatment. Ultimately drugs have to be prepared for the individual patient. This is already done in certain areas of medicine: for example, in hemat-oncology cytostatics are individually related to the specific surface marker of the individual patient. This explains the progress that has been achieved, particularly in children suffering from blood cancers.
The question that now arises is whether, when, and in what form molecular medicine gets relevance in health care and in society in general. All half-true, sensationalist, and imagined concerns against molecular medicine have to be excluded in advance. Cloning or genetic enhancement of humans are beyond biological possibility – if there should be some biological pathways, the results are unpredictable. These evil utopias reflect, however, the public fears and concern, which accompany this recent explosion of knowledge in medicine, just as it was in the case of cellular pathology in the 1850s or in bacteriology in the 1880s – impassioned conflicts that we have stored in (medical) history, and that we will similarly store in history in respect of molecular medicine, when it is taken for granted. These discussions are to be taken seriously, because they reveal a genetically transparent world. But these discussions also obscure the tasks arising from this new level of explanation of medicine. The connection to the classic discussions, especially of public health care, is obvious: wherever the genetic component of diseases seems to be known, since the development of eugenics in the 1880s, always a discussion arises about public interventions in medicine. Attached to molecular medicine are hopes and fears, which a society has to deal with openly. Individual rights, property rights on knowledge and ignorance, and the determination of the genetic self, sets the limits.
At this point individual and public medicine should be distinguished once more – on the one hand the individual and personal encounter between doctor and patient, on the other hand the public, mostly administrative, work of public medicine. Under the aspect of an anticipative health care – be it individual or public – molecular medicine reveals a new dimension. Risk assessments are carried out by statistical tests. These statistically calculated risks are always related to collectives, never to individuals. Molecular medicine differs insofar, as specific risks for a specified group of diseases can be clearly identified biologically – for example the recognition of the BRCA-1 or BRCA-2 genes as risks for developing breast cancer. As a result, two new risk groups have to be differentiated. Those that do not have these genes are still a risk group for breast cancer. Those who carry the gene, represent a risk group with a biologically manifest, higher probability, (but not total) risk of developing this cancer. Those that carry these particular dangerous genes, have the possibility of preventing the disease risk resolutely. These preventive measures may be early surgery – such as in hereditary colon cancer (HNPCC, Lynch-Syndrome) or hereditary thyroid cancer (MEP2); a permanent monitoring, generally with BRCA; certain rules, for instance provision of increased protection against radiation in BRCA II; and up to a fatal waiting – as is the case of Huntington’s disease. Generally, the new phenomenon of the ‘healthy ill’ emerges – the seemingly healthy patient who is exposed by hereditary features to an increased risk of disease and thus may have to live for decades facing this deleterious knowledge. This results in many other issues, such as the obligation to know and the right not to know at the individual level or risk-calculation in health or life insurances at a public level.
The task of a molecular medically oriented public health care would be to identify risk groups, to provide safe preventive measures, and to offer appropriate diagnosis and treatment if possible. This idea reveals the dilemma of a molecular, medically oriented, public health care. The basis of any effective public action of molecular medicine is a comprehensive genetic screening, or at least a systematic molecular epidemiology. The data should be stored in biobanks and made available to doctors and institutions of health care and the patient, respectively. Will this find public acceptance in view of the risk of data abuse, the possible violation of the right to personal data, and the chances of genetic identity leading to personal identifiability? Important for the consequences to organized medicine is the question of whether the data collected have, a priori, a clinical character. The collected data may directly lead to therapeutic interventions. This raises the question whether ‘public health genetics’ is a form of public health care or affiliated to curative medicine. A historic example is the transformation of the public mother and child care of the 1920s to individual peri-natal medicine since the 1960s. This raises the question of whether curative medicine has the perception and forms of public intervention. Public medicine can go out to vulnerable groups, while curative medicine is dependent on the demand of patients.
So on the one hand, there is the need to organize disease prevention, health promotion, and risk reduction based on molecular biological susceptibility to certain diseases. On the other hand, new forms of intervention are required for this new concept of public health genomics and protection, which unite the various areas of individualized medicine of gene testing, special interventions and preventive measures, to the necessary mass data and applied public health care measures. The facilities and measures that have been recently established, primarily take place at the level of research and the dissemination of available knowledge on international and national networks. Public interventions based on molecular medicine, such as in diabetology or in rheumatology, are as yet cohort studies or limited, research projects. Permanent forms of medical intervention of molecular public health care or of public health genetics have not yet been observed.
In the narrow scientific-practical sense, medicine is determined by the dialectics of medical knowledge and medical action. Such dialectics have accompanied medicine since its first historical steps to its scientific-rational establishment in Greek Antiquity. So the controversy between ‘dogmatists’ and ‘empiricists,’ between ‘medics’ and ‘doctors,’ has characterized the positions during the entire history of medicine. It is the patient who gives these dialectics a direction: The patient’s need for help constitutes medicine. Due to the patient and the special situation in which the patient and the doctor meet, medicine possesses a domain distinct from that of other sciences: In the encounter between doctor and patient medicine faces the necessity to take action. With this, the doctor–patient encounter is placed within a historical context. This is the starting point of historical reflection as an indispensable aspect, both of a ‘history in medicine’ and ‘a history of medicine.’
In recent decades, mankind has experienced a fundamental change in all aspects of human life. During the eighteenth and nineteenth centuries the production of power shifted from humans and animals to machinery, with the then unforseeable consequences of industrialization. Today the production and distribution of data is being transferred from humans to machines, still with unpredictable consequences, (which finally will probably be even more dramatic than industrialization). Medicine is also covered by these processes. The position and the role of medicine within society is changing fundamentally. The scientific medicine of the late nineteenth and early twentieth centuries was the reproductive rearguard of industrialization. By contrast, the medicine of the late twentieth and early twenty-first centuries is a forerunner of scientific, economic, and social change. Since the 1980s, molecular biology has become the referential discipline of medicine. Thus it has become possible to diagnose diseases in their genetic informational principles and their molecular mechanisms. The molecular transition means a secular change in the concept of medicine. The molecular–biological thought pattern transfers the process of health and disease into the informational bases of the production and function of proteins. With that, genetics and information-processing in the cellular and extra-cellular realm, step into the limelight.
The historical analysis has shown to what extent medical knowledge and medical action affect society. Thus, experimental hygiene and bacteriology have cleansed and pasteurized conditions and behavior since the middle of the nineteenth century. Since the 1960s the pharmacological possibilities of contraception have altered the self-definition and the role of women fundamentally. Molecular genetics and clinical reproductive medicine already show their effects on the generative behavior of mankind (in-vitro and in-vivo fertilization, pre-implantation diagnostics etc.). The transition to molecular medicine will also change individual life and the social world: Molecular medicine leads to a new image of humans. The medicine of the last decades followed the model of ‘exposition’: diseases had an external origin (e.g., bacteria, viruses, stress factors, etc.). Molecular medicine shifts the etiology from exposition (i.e., the outside world of all human beings) to disposition and therefore to the (genetic) inner world of the individual. Predispositions for certain diseases are internalized as an individual (biological) fate. The result is the ‘genetization’ of individual life and of its subsequent societal acts (e.g., life and health insurance). The interpretation of health including the notion of ‘normality’ of the body, will, in substance, be linked with knowledge of genetically determined dispositions. Such a genetic life world will be as ‘real’ for human beings of the coming decades as the bacteriological life world had been ‘real’ for the last century. The ‘genetization of society’ is the current aspect of the general ‘medicalization’ process and the continually progressing rationalization of corporeality.
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