Subjective Objectivity In Medicine

(countering the trend to cold detachment)

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If we are to heal sick and hurting people we must learn all over again how to combine a warm subjectivity with our cool objectivity. This was the core of a seminar series given some time ago for new medical students at the University of Buffalo NY and at McMaster University in Canada.

We shall now deal with a soft, fuzzy, but serious topic for all doctors, especially new medical students, that just has to be considered someplace in the curriculum. So I begin this little course in medical ‘philosophy’ with it. It is related to the quandary about where reason leaves off and passion begins.

As hot young medical initiates, full to brimming with science, many of you might react by thinking: No way. Passion is out. Objective reason is paramount. It’s the keystone of modern medicine. It must never leave off.

Let me counter that thought by asserting this: All experience is subjective!

OK. We tend to think that subjectivity has to do with feelings and things artistic. And that objectivity is the essence of science and logic. Well, this ‘separation’ tendency, when applied to living beings, needs some serious qualification. For the two words, objective and subjective, are somehow linked together in meaningful application. But how exactly? Here’s my little picture of it:

At the extreme left and right of this diagram are hypothetically complete degrees of objectivity and subjectivity respectively. As we move from both ends toward the middle each diminishes. And they do not join up at any one point – they always overlap. Dancing around almost as an afterthought in the graph are line representations of thinking and emotional feeling level.

Now feelings are a most integral part of our being. When we gaze up at the night sky, the dome of stars leaves us in awe. As we sit around a fireplace with our family on a cold winter’s day we feel comfort, security and warmth. The scientist looking through her microscope is interested and curious as well as cool and contemplative. The young doctor’s disgust (ugh!-reaction) at examining a homeless person’s suppurating sores quickly turns to compassion. The family therapist ‘cares‘ right from the start. If we don’t like what we are doing we may get unpleasantly bored. Each italicized word represents a feeling. Feelings – always subjective – are a most integral part of our being.

That being the case, how on earth then can we ever be objective? How can we be cool, detached and logical to the extent that we can perform a good physical or a well-tuned family examination? Without being biased. It’s a very good question.

My answer: Some people think that subjectivity and objectivity are absolute opposites. Not so. They are simply relative, not mutually exclusive, stances. They are not necessarily even coextensive stances. Less subjectivity doesn’t make us objective. More objectivity doesn’t require that we lose our passion. Subjectivity is a natural human quality, whereas we have to train ourselves to be objective.

That’s what we began kindergarten for. And now we’re all at medical school. Here we become super-objective. But, if we are to heal sick and hurting people we must learn all over again how to be a wondering and compassionate child. We will have to rediscover how to combine a warm subjectivity with our cool objectivity.

Actually, there are drawbacks to this. For example, those of you who decide to be family doctors will quickly discover that everything in a family group impinges upon us at once. The cacophony of data before our eyes can be overwhelming. But, in a house call (which I hope you will try), it is all nicely in one spot and remains in one spot. If we know what we see, we can sort it all out and be kind too. The specialist doctor, on the other hand, when doing a comprehensive assessment, is forced, by tradition and circumstances, to spread things out and sort them out over time, often in different places. Hence, s/he, while inconvenienced, is less likely to get bogged down with data or overwhelmed with emotion.

Our main medical saving grace is rigorous self-discipline. And that is – to force order upon the data and oneself by using a comprehensive, systematic, diagnostic approach. If we do this, being quite objective almost becomes simple! You’ll do that. But then we, yes we, and I repeat, will have to train ourselves all over again to do what comes naturally and what is absolutely essential in really helping sick people. And that is being warmly subjective.

Let’s now go back to the diagram. Here is the key to the letters along the O-S (objectivity-subjectivity) axis, each of which represents a distinct human, relationship type:

Mr = Material relationship (as with a physicist and atoms or a chemist and equations),

Those who deal professionally with material objects try hard to establish strong objectivity and low subjectivity. Their tools for ‘distancing’ (as well as closing in) are telescopes, electron microscopes, test tubes, math, etc. Scientific thinking is highly logical, inductive-deductive and in equations. Regardless, scientists still retain variable subjective feelings like interest and curiosity. Sometimes (in real masters) they dare to display real passion.

Everyone further to the right on the horizontal axis almost always is dealing with other humans. (But some love toy objects more.) Dealing with people, they cannot be other than spontaneously subjective and must really work at being objective. Children, for whom the world is almost always new in their own eyes, naturally are the most ebullient and spontaneous yet often surprise us with their capacity for clear objectivity.

Px = Diagnostic relationship (such as a medical or any other kind of consultant),

Medical doctors attempt to avoid excesses of objectivity or subjectivity by invoking the Hippocratic Oath. They don’t want to fall off either end of the horizontal scale. Those professionals doing marital and family examinations can always increase their objectivity by using ‘uncommon sense’ and religiously adhering to a defined diagnostic schema. It keeps their thinking organized while still enabling proper empathy. Psychoanalysts perhaps can afford to be coolly analytical, but marital-family workers and family doctors can only be warmly so.

Nr = Normal relationship (as is usual between healthy and well-adapted people in real life),

Ordinary well-functioning people in their families and at work naturally guard against excesses of both analytical logic or totally uncontrolled negative emotion. Ideally, their thinking is common sense and their feelings are appropriately varied but predominately loving, contented, friendly, etc. Thinking and feeling level off here (half way in between objectivity and subjectivity). They are stable. In the event of normal grief or fear ‘normal’ people maintain their warmth. Thus ‘normal’ people are unconsciously subjective in their surroundings and work at being objective as needed. They intelligently experience music, literature, dance and art with equal feeling.

Rx = Therapeutic relationship (as between doctor and patient or therapist and family),

The most ubiquitous quality of any effective therapist is caring. The same applies to effective doctors. Subjective feeling and empathy are absolutely essential to success. But high quality thinking (objectivity and ongoing assessment) should not be disregarded.

Dr = Dysfunctional (sick?) relationship.

In dysfunctional, badly working relationships the emotional line on the graph splits to show pathological levels of anger, fear, lust, disgust, hate, depression, mania, violence, etc. Thinking, where it mostly counts, is irrational. In short, subjectivity is all too intense while reason and objectivity have gone partly or completely on vacation.

But what really ties them, objectivity and subjectivity, together? Answer: Clearly, it’s the subtle balance between our reason and our passion. The way we think and how we feel vary in distinctive ways as we are more, or less, subjective or objective. That is to say, thought and emotion tend to vary inversely to each other as we move back and forth between being objective or being subjective. As we become less and less objective our thinking partly deteriorates. As we become too objectively rational, categorical? Well, here’s what the poet William Blake said about that:

Thought chang’d the infinite to a serpent, that which pitieth

To a devouring flame; and man fled from its face and hid

In forests of night: then all the eternal forests were divided

Into earths rolling in circles of space, that like an ocean rush’d

And overwhelmed all except this finite wall of flesh.

Then was the serpent temple formed, image of the infinite

Shut up in finite revolutions; and man became an Angel,

Heaven a mighty circle turning, God a tyrant crown’d.

The poem sounds terrible. It talks about the effect of objectivity upon the whole person or upon the whole of life. In the poem the word “thought” stands for objectivity. Thought should remain a part of the whole but instead spreads itself and meddles with the rest. It slices everything to bits. The first slice is between the objective thing (under scrutiny) and the rest. The world of the objective creature gets split into helpful things and hindering things. Helpful and hindering become Good and Evil. And the world is then split between God and the Serpent. And after that, more and more splits follow because the intellect is always classifying and dividing things up. The poem, thus, is a polemic against scientific pseudo-objectivity and rampant reductionism. By inference it extols the virtues of ecology, integration of the whole, of being holistic. It is very stern and serious. Blake, while in some ways right, was very angry, not a fun person.

OK boys and girls, did you get all that? If not, you’ll have to learn through hard personal experience and I’ll continue on in the serene sadness of acceptance. If you got it, now you know and will be able to see. See what’s important. So, in future when I suggest you be less subjective I mean tune up your critical thinking. When I suggest you be more objective I mean try to get your reason and your passion in better balance.

Now, finally, lest I sound like a crazed technocrat, I must say that some things are best said by great works of fiction. This is especially so when lovers and families and students are swept up in the sweep of cataclysmic events. Boris Pasternak’s masterpiece novel, Doctor Zhivago, (which I recommend you read and absorb in bits and pieces when tired with the study of anatomy and physiology) says it all. Lara (the heroine) describes how the Russian revolution destroyed the family life of so many. Yuri (the anti-hero and displaced poet-doctor), concerned with individual, one on one, intimate, personal, private things, asks, “But what went wrong with your married life, if you were so fond of each other?” And she replies,

That’s a terribly difficult thing to answer. I’ll try and tell you. But you know it’s absurd for me to try to explain to you who are so wise what is happening to human life in general, and to life in Russia, and why families get broken up, including yours and mine. Goodness, it isn’t as if it were a question of individuals, of being alike or different in character, of loving or not loving! Everything established, settled, everything to do with home and order and the common round, has crumbled into dust and been swept away in the general upheaval and reorganization of the whole of society. The whole human way of life has been destroyed and ruined. All that’s left is the bare shivering human soul, stripped to the last shred, the naked force of the human psyche for which nothing has changed because it was always cold and shivering and reaching out to its nearest neighbour, as cold and lonely as itself…”

We all are so fortunate to be alive and study and work in US-America or gentle Canada. All I can say about my little method of evaluation is, take reality in its own perspective. When you, as a full-fledged doctor, are faced with monumental tragedy, and you will, as the world gets increasingly smaller, be helping in a hurricane or a flood or in an earthquake, set it all aside and listen – and learn. Be active. And be thankfully subjectively objective.