- 8 April 1977, Volume 196, Number 4286 b >. t. , C new discipline based on behavioral sci- The~~~~~~, i..*a. New Medical MO ence. Henceforth medicine would be re- A.ChlegefrBimd sponsible for the treatment and cure of disease, while the new discipline would * t;, 0 - ;:G orge L be concerned with the reeducation of people with ;"problems of living." Im- del: plicit in this argument is the premise that while the medical model constitutes a cjne sound framework within which to under- stand and treat disease, it is not relevant to the behavioral and psychological Engel problems classically deemed the domain of psychiatry. Disorders directly ascrib- able to brain disorder would be taken care of by neurologists, while psychiatry At asference on psychiatric the physician is app)ropriate for their as such would disappear as a medical ed_e c sychiatrists seemed to helping functions. Medicine's crisis discipline. be d icine, "Please take us stems from the logi4cal inference that The contrasting posture of strict ad- ba WWill never again deviate since "disease" is defined in terms of so- herence to the medical model is carica- .gg-1* 'medical model.' " For, as one matic parameters, phiysicians need not tured in Ludwig's view of the psychia- L -C ipsychiatrist put it, "Psychiatry be concerned with psychosocial issues trist as physician (1). According to Lul.i on March 13, 2014 0 m_ne a hodgepodge of unscientific which lie outside mediicine's responsibil- wig, the medical model premises "that i assorted philosophies and ity and authority. At a recent Rockefeller sufficient deviation from normal re:e- 0S00_of thought,' mixed metaphors, Foundation seminar 4on the concept of sents disease, that diseasel is; due to; AIIision, propaganda, and politick- health,. one authority urged that medi- known or unknown natural cause, aind i n ntal health' and other esoteric cine "concentrate on the 'real' diseases that elimination of these causes will e- '',). In contrast, the rest of medi- and not get lost in thejpsychosociological sult in cure or improvement in individual. d, -*ars neat and tidy. It has a firm underbrush. The physiician should not be patients" (Ludwig's italics). While ac-: 8t i the biological sciences, enor- saddled with problemIs that have arisen knowledging that most psychiatric diag ' +_ whnologic resources at its com- from the abdication ofthe theologian and noses have a lower level of confirmation www.sciencemag.org 1niMIM *nd a record of astonishing the philosopher." Ainothet participant than most medical diagnoses, he adds ent in elucidating mechanisms called for "a disentanrglement of the or- that they are not "qualitatively diffrentt and devising new treatments. ganic elements of dis Dase from the psy- provided that mental disease is assumed seem that psychiatry would do chosocial elements oif human malfunc- to arise largely from 'natural' rather tha #imulate its sister medical dis- tion," arguing that me4dicine should deal metapsycholo cal, interpersonal or so- jy finally embracing once and with the former only (2). cietal causes.'Natural" is de¢n4 as < medical model of disease. "biological brain dysfunctions jthor Downloaded from But I do not accept such a premise. biochemical or neurophysiological inna-W Rather, I contend that all medicine is in The Two Positions ture." On the other hand, 'disQ crisis! and, further, that medicine's crisis such as problems of living, social :a` derives from the same basic fault as psy- Psychiatrists have rresponded to their ment reactions, character disdrder(s- chiatry's, namely, adherence to a model crisis by embracing twro ostensibly oppo- pendency syndromes, existenti l depres- ofdisease no longer adequate for the sci- site positions. One woiuld simply exclude sions, and various social deviancy Condi- entific tasks and social responsibilities of psychiatry from the Ifield of medicine, tions [would] be excluded from the con- either medicine or psychiatry. The im- while the other would adhere strictly to cept of mental illness since these portance of how physicians conceptual- the "medical model" and limit psychia- disorders arise in individuals with pro ize disease derives from how such con- try's field to behavioiral disorders con- sumably intact neurophysiological fuac- cepts determine what are considered the sequent to brain dysfunction. The first is tioning and are produced primarily by proper boundaries of professional re- exemplified in the wriltings of Szasz and psychosocial variables.: Such "non- sponsibility and how they influence atti- others who advance the position that psychiatric disorders" are not properfy tudes toward and behavior with patients. "mental illness is a m,yth" since it does the concern of the physician-psychiatrisW.1 Psychiatry's crisis revolves around the not conform with the accepted concept and are more appropriately handled b question of whether the categories of hu- ofdisease (3). Supporters ofthis position nQnmedical professionals. man with it distress which is concerned advocate the removal1of the functions ._,.__ __ _ _ _ are properly considered "disease" as now perfornved by psychiatry from the X currently conceptualized and w her concepul 4 professional jurisdiction attheathUniversity ofeRochesterM, exercise of the traditional authty o of edice pd their reallocation to a Rochester, New York 14642. 8 APPIL 1977 In sum, psychiatry struggles to clarify ruptive or individually upsetting the phe- of derangement of underlying physical its status within the mainstream of medi- nomenon, the more pressing the need of mechanisms. This permits only two al- cine, if indeed it belongs in medicine at humans to devise explanatory systems. ternatives whereby behavior and disease all. The criterion by which this question Such efforts at explanation constitute de- can be reconciled: the reductionist, is supposed to be resolved rests on the vices for social adaptation. Disease par which says that all behavioral phenome- degree to which the field of activity of excellence exemplifies a category of nat- na of disease must be conceptualized in psychiatry is deemed congruent with the ural phenomena urgently demanding ex- terms ofphysicochemical principles; and existing medical model of disease. But planation (5). As Fabrega has pointed the exclusioni.t, which says that what- crucial to this problem is another, that of out, "disease" in its generic sense is a ever is not cap#ble of being so explained whether the contemporary model is, in linguistic term used to refer to a certain must be excluded from the category of fact, any longer adequate for medicine, class of phenomena that members of all disease. The reductionists concede that much less for psychiatry. For if it is not, social groups, at all times in the history some disturbances in behavior belong in then perhaps the crisis of psychiatry is of man, have been exposed to. "When the spectrum of disease. They categorize part and parcel of a larger crisis that has people of various intellectual and cultur- these as mental diseases and designate its roots in the model itself. Should that al persuasions use terms analogous to psychiatry as the relevant medical dis- be the case, then it would be imprudent 'disease,' they have in mind, among oth- cipline. The exclusionists regard mental for psychiatry prematurely to abandon er things, that the phenomena in ques- illness as a myth and would eliminate its models in favor of one that may also tion involve a person-centered, harmful, psychiatry from medicine. 4mpngphy- be flawed. and undesirable deviation or discontinu- cians and psychia ath uc- ity . associated with impairment or tionists are the trug.bheerspthe exclu- discomfort" (5). Since the condition is sionists are the apostates, while both The Biomedical Model not desired it gives rise to a need for cor- condemn as heretics those who dare to rective actions. The latter involve beliefs question the ultimate truth of the bio- The dominant model of disease today and explanations about disease as well as medical model and advocate a Fore use- is biomedical, with molecular biology its rules of conduct to rationalize treatment ful model. basic scientific discipline. It assumes dis- actions. These constitute socially adapt- ease to be fully accounted for by devia- ive devices to resolve, for the individual tions from the norm of measurable bio- as well as for the society in which the Historical Origins of the Reductionistic logical (somatic) variables. It leaves no sick person lives, the crises and uncer- Biomedical Model room within its framework for the social, tainties surrounding disease (6). psychological, and behavioral dimen- Such culturally derived belief systems In considering the requirements fdr a sions of illness. The biomedical model about disease also constitute models, but more inclusive scientific medical mode1 not only requires that disease be dealt they are not scientific models. These for the study of disease, an ethnomedica,l with as an entity independent of social may be referred to as popular or folk perspective is helpful (6). In all societies; behavior, it also demands that behavior- models. As efforts at social adaptation, ancient and modern,pEr ite r. al aberrations be explained on the basis they contrast with scientific models, ate, the major criteria for identification of disordered somatic (biochemical or which are primarily designed to promote of disease have always been behavioral, neurophysiological) processes. Thus the scientific investigation. rthe historical psychological, and social in nature. Clas- biomedical model embraces both reduc- fact we have to face is that in modem sically, the onset ofdisease is marked by tionism, the philosophic view that com- Western society biomedicine not only changes in physical appearance that plex phenomena are ultimately derived has provided a basis for the scientific frighten, puzzle, or awe, and by alter4- from a single primary principle, and study of disease, it has also become our tions in functioning, in feelings, in per.! T1nd:b94_dua1is m the doctrine that own culturally specific perspective about formance, in behavior, or in relation- separates the mental from the somatic.