In medicine, just like in other disciplines, there is a distinction between “art” and “science”. A line is drawn between the humanistic and data, between subjective and objective, between mind and body, and what is personal and what is verifiable.
In the Journal of Evaluation in Clinical Practice Henrik Vogt et al. want to answer if systems medicine can bridge the gap between them.
The authors compare two particular views of medicine. In the humanist medicine camp is Eric Cassell, author of The Nature of Suffering and the Goals of Medicine and The Nature of Healing: The Modern Practice of Medicine. As a representative of systems medicine, the authors consult systems biologist Denis Noble and his works, like The Music of Life: Biology Beyond the Genome.
By contrasting these two ways of looking at the patient, medicine, and treatment, the authors illuminate how there is no one best way to look at a patient. They also flesh out why the idea of “personhood” is important in medicine at all, and also have something to teach us about how narrative can be used.
Broadly conceived, the authors write,
systems biology is a convergence of molecular biology and systems theory.1 Systems medicine tends to begin with the molecular chemistry of life, and study how those molecules interact in context with one another. Zooming out to a different “level” or “scale”, the molecular interactions are mathematically modeled. Those models are then used to study systems in increasing levels of complexity.
We as a civilization know quite a bit about our own genome, and how that genome translates to RNA and protein. These are the tiniest parts of the human, though.
The resulting massive amounts of information on parts have not in themselves yielded the sought-after understanding of wholes, predictive power or medical breakthroughs.2 Rather, it would seem that biology hashit the wall of bio-complexity…3
Using a mathematical understanding of modelling and how complex systems function, the goal of systems biology is to understand how exactly long chains of carbon give rise to what we see walking around everyday.
Cassell and Noble are complimentary representatives of their camps. Cassell (advocating for a humanistic medicine) is perfectly comfortable talking about the relationships of parts and wholes, mind and body. Noble (advocating for a systems medicine) stands out because of his rejection that the tiniest parts of a biological system are the most important.
Larger systems, Noble emphasizes, regulate and “constrain” smaller systems in important ways. Why do we assume that the molecular causes of things are the most important? If we only needed to study the smallest moving parts of a living thing to understand it completely, why not look to our parts that are smaller than a molecule?4
What is common to both of their work is that there is no one best “scale” to view a person or a patient’s pathology. What molecular biology teaches us about healing is absolutely important. Viewing each person, though, as a unique individual in their own natural and social environment who has a personal experience in addition to organs, tissues, cells, DNA, molecules, etc. is important. In reality, Cassell and Noble argue, a disease might stem from any one — or a mixture — of those “scales” of the person.
Viewing the person as a person and not an object is important. The patient understands themselves as a person (not as a collection of phenotypes). In addition, it is the interaction and blurring of all of these systems working together that make us alive and make the practice of medicine necessary.
What is the difference between a live [animal] and a dead one? … A dead [animal] is a collection of component parts. A live [animal] is the emergent behavior of the system incorporating those parts.5
This interaction moves forward in time. This is profoundly simple, but profoundly important. Cassell refers to our being not as a static snapshot, but as an activity. Noble calls human beings the instruments that
We can only understand the emergent nature of that system, that person, in time. Narratives were built for this: to communicate the unfolding of events in relation and opposition to one another.
What Cassell discusses that Noble doesn’t is an understanding of meaning. It is not a biological afterthought, but an inherent part of our existence as a species that we make meaning.
…this must mean that, in order to get a comprehensive understanding of human health, one must ultimately also consider specifically human constraints. In this regard, it is vital to remember that the evolutionarily derived and key defining features of human biology are in fact our cultural capacities of symbolic interaction and creation of narratives.7
Vogt et al. frame the entire article around challenges in modern medicine, including medically unexplained symptoms (MUS) and multi-morbidity. Whether an illness is routine, unexplained, or complex, narratives connect what is human with our understanding of how those biological systems work.
The article reviewed: Vogt, Henrik, Elling Ulvestad, Thor Eirik Eriksen, and Linn Getz. “Getting Personal: Can Systems Medicine Integrate Scientific and Humanistic Conceptions of the Patient?” Journal of Evaluation in Clinical Practice, 2014. https://doi.org/10.1111/jep.12251.
1 O’Malley, Maureen A., and John Dupré. “Fundamental Issues in Systems Biology.” BioEssays 27, no. 12 (December 1, 2005): 1270–76. https://doi.org/10.1002/bies.20323. ↑
2 Check Hayden, Erika. “Human Genome at Ten: Life Is Complicated.” Nature 464, no. 7289 (April 1, 2010): 664–67. https://doi.org/10.1038/464664a. ↑
3 Woese, Carl R. “A New Biology for a New Century.” Microbiology and Molecular Biology Reviews: MMBR 68, no. 2 (June 2004): 173–86. https://doi.org/10.1128/MMBR.68.2.173-186.2004. ↑
4 Noble, Denis. “A Biological Relativity View of the Relationships between Genomes and Phenotypes.” Progress in Biophysics and Molecular Biology 111, no. 2–3 (April 1, 2013): 59–65. https://doi.org/10.1016/J.PBIOMOLBIO.2012.09.004. ↑
5 Anonymous. “In Pursuit of Systems.” Nature. 435, no. 7038 (May 5, 2005): 1. https://doi.org/10.1038/435001a. ↑
6 Noble, Denis. “A Biological Relativity View of the Relationships between Genomes and Phenotypes.” Progress in Biophysics and Molecular Biology 111, no. 2–3 (April 1, 2013): 59–65. https://doi.org/10.1016/J.PBIOMOLBIO.2012.09.004. ↑
7 Pagel, Mark. “Adapted to Culture.” Nature 482, no. 7385 (February 16, 2012): 297–99. https://doi.org/10.1038/482297a. ↑
Featured Image: “Bubbling Up” by flikr user Neil Williamson under a CC BY-SA 2.0 license.