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THE SUBJECTIVE IN MEDICINE LEON EISENBERG* Recently, psychiatry has begun to attain a modicum of credibility among physicians and surgeons, at least to the extent that it has become a more biological specialty. As psychiatrists call on positron emission tomography and dexamethasone suppression tests for diagnosis and employ a profusion of neurotransmitter agonists and antagonists in therapy, they have begun to look more like "real" doctors. Thus, in considering what I should say, I was tempted to write as a neurobiologist. As one of a small company who, during the halcyon days of psychoanalysis, had insisted that the brain is in the skull for reasons other than for ballast to keep it from floating offinto space, I might have been expected to be an enthusiast for the "new" psychiatry. Unfortunately , biological psychiatry threatens to become so myopic in its clinical vision that it may well substitute a "mindless" psychiatry of the future for the "brainless" psychiatry of the past. In its zeal to emulate biomedicine, psychiatry has begun to rival it in its disregard for the psychological content and social context of sickness. Therefore, I have chosen to reemphasize the irreducible role ofthe subjective in medicine. Dr. Donald Seldin, the distinguished former president of the Association of American Physicians, has defined the goals of medicine as "the relief of pain, the prevention of disability, and the postponement of death by the application of the theoretical knowledge incorporated in medical science to individual patients" [I]. He emphasizes that medicine is a "narrow discipline" properly restricted to the correction of biomedical derangements and that its fundamental interactions are "face-to-face." He makes clear that his definition excludes from medicine the "aggregate disciplines which influence health through social and cultural forces." Although he acknowledges that a "priestly function" [2] is a vital component of medicine, he does not regard it as a formal domain of The William S. Paley Lecture at Cornell University Medical School, January 11, 1983. * Professor and chairman, Department of Social Medicine and Health Policy, Harvard Medical School, Twenty-five Shattuck Street, Boston, Massachusetts 02115.© 1983 by The University of Chicago. AU rights reserved. 0031-5982/84/2701-0375$01.00 48 I Leon Eisenberg ¦ The Subjective in Medicine learning. Rather, he contends, it is "acquired and transmitted more through role models and participation in morally healthy environments than through structural courses or abstract reasoning." Dr. Seldin writes persuasively. His conceptual distinctions are elegant. The question is how far they correspond to the actual practice of medicine. There can be no disputing the quite extraordinary power of the preventive and therapeutic measures which have resulted from the application of the biological sciences to medicine [3]. But is it true that the doctor is no more than, or even mostly, an applied biologist? Permit me to approach this question by means of the powerful metaphor provided by Kurosawa's film Rashomon (1950). The story, based on a tenth-century narrative, later transmuted for contemporary sensibility by the writer Ryunosuke Akutagawa, deals with three events: a rape, a robbery, and a murder. The events appear straightforward, but how they happened and what they mean is made enigmatic by the recursive mode of telling: the conflicting versions offered in turn by each of those implicated in the events. The film opens as a woodcutter, a priest, and a commoner take shelter from the rain at the massive Rasho Gate of Kyoto. The time is medieval Japan, the scene one of civil war and desolation. The three converse about the recent murder of a samurai and the rape of his wife by a bandit. As the priest and the woodcutter recount the testimony offered in court, each account is reenacted for the viewer. , The bandit freely confesses the rape but insists that he was enticed to it by the woman. He had tricked the samurai, tied him up, and returned to where the wife awaited. Now no longer receptive, she resisted "like a witch." After the rape, it was she who demanded that the reluctant bandit duel the husband for her honor. In the ensuing battle, the samurai was slain. Not so, testifies the wife. The bandit, after raping her, fled. She hastened...


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