Raimo Puustinen

Voices to be heard—the many positions of a physician in Anton Chekhov's short story, A Case History

Anton Chekhov (1860-1904) dealt in many of his short stories and plays with various phenomena as encountered in everyday medical practice in late 19th century Russia. In A Case History (1898) Chekhov illustrates the physicians many positions in relation to his patient. According to Mikhail Bakhtins philosophy of language, a speaker occupies a certain position from which he or she addresses the listener. A phenomenon may gain different meanings depending on the position from which it is addressed. In his story Chekhov describes how the patient was at first addressed solely from a medical point of view, without any relief to her suffering. Only when the physician was able to shift his position in a manner which offered the patient an opportunity to be heard as a person was she able to express the true nature of her illness and to find new ways for palliation and cure.

Medicine and the humanities-theoretical and methodological issues

Engel’s biopsychosocial model, Cassell’s promotion of the concept “person” in medical thinking and Pellegrino’s and Thomasma’s philosophy of medicine are attempts to widen current biomedical theory of disease and to approach medicine as a form of human activity in pursuit of healing. To develop this approach further we would like to propose activity theory as a possible means for understanding the nature of medical practice. By “activity theory” we refer to developments which have evolved from Vygotsky’s research on socially mediated mental functions and processes. Analysing medicine as activity enforces the joint consideration of target and subject: who is doing what to whom. This requires the use of historical, linguistic, anthropological, and semiotic tools. Therefore, if we analyse medicine as an activity, humanities are both theoretically and methodologically “inbound” (or internal) to the analysis itself. On the other hand, literature studies or anthropological writings provide material for analysing the various forms of medical practices.

Clinical use of placebo treatments may undermine the trust of patients: a response to Gold and Lichtenberg

There is an obvious need for a critical discussion of the concepts ‘placebo’ and ‘placebo effect’. In a recent paper on the use of placebos in clinical medicine, Gold and Lichtenberg note the conceptual difficulties but use the terminology in a confused way throughout their paper. In our response, we demonstrate these problems with a few examples from their paper.

Impure placebo is a useless concept

Abstract Placebos are allegedly used widely in general practice. Surveys reporting high level usage, however, have combined two categories, ‘pure’ and ‘impure’ placebos. The wide use of placebos is explained by the high level usage of impure placebos. In contrast, the prevalence of the use of pure placebos has been low. Traditional pure placebos are clinically ineffective treatments, whereas impure placebos form an ambiguous group of diverse treatments that are not always ineffective. In this paper, we focus on the impure placebo concept and demonstrate problems related to it. We also show that the common examples of impure placebos are not meaningful from the point of view of clinical practice. We conclude that the impure placebo is a scientifically misleading concept and should not be used in scientific or medical literature. The issues behind the concept, however, deserve serious attention in future research.

From physical bodies to astral bodies – theoretical problems in anthroposophic medicine

Switzerland has recently adopted anthroposophic medicine into its health insurance system. This decision was partly based on the 2006 Health Technology Assessment Report on anthroposophic medicine, commissioned by the Swiss Federal Social Insurance Office, which claimed that anthroposophic treatments seem to be safe and, in terms of patient satisfaction, beneficial for the patients receiving them. The report does not, however, discuss the theoretical basis of anthroposophic medicine apart from noting that there are, according to anthroposophic thinking, formative forces acting in nature that are not acknowledged by contemporary natural science. This article discusses the theoretical fundamentals in anthroposophic theory such as astral bodies, incarnation and clairvoyance and their role in medical diagnosis and treatment. Politicians making decisions on spending public money on anthroposophic medicine should be fully aware of its theoretical basis, which is incompatible with contemporary scientific thinking.