Pediatric Bioethics: Better Medicine Through Philosophy - Improving Care for Patients With Medically Unexplained Symptoms

“The best physician is also a philosopher.” -Galen

Clinicians regularly encounter patients who believe they are sick (or, in pediatrics, children whose parents believe they are sick) but whose symptoms cannot be linked to a known organic pathology. Indeed, studies suggest that perhaps 30-50% of somatic symptoms are medically unexplained.¹ There is a familiar cyclical pattern to such medical encounters: (1) patients present with symptoms, (2) clinicians conduct a standard examination and order the usual tests and (3) everything from the exam and tests comes back “normal” (i.e., there is no indication of organic pathology), which then leads to (4) clinicians assuring patients, implicitly or explicitly, that “nothing is wrong with them.” Unfortunately, from the perspective of many patients in these encounters, there very much is something wrong with them—namely, the undesired symptoms that they are experiencing, which the familiar pattern above has done nothing to address. In addition to leaving patients with unresolved, or even exacerbated, symptoms, such encounters have many unfortunate consequences for patients and clinicians alike, including unnecessary tests and procedures (which can lead, in turn, to higher costs and greater risks of iatrogenic harm and false positive results), exam-room antagonism, clinician burnout/turnover, and loss of trust in the medical community.

At its roots, the “problem” of medically unexplained symptoms is philosophical, rather than clinical or biological, in nature. It arises from a historical shift in the dominant medical paradigm from a symptom-centric approach that viewed disease and illness as a holistic imbalance throughout the body (humoralism) to a sign-centric approach focused on ever more localized and specific pathologies in organs, tissues, and eventually cells and genes. While it has enabled many important medical advances, this shift in medical paradigms has strained medicine’s fundamental duty to respond with attention, care and a robust humanity to the concerns and suffering of the patient as a whole person. Philosopher and physician H. Tristram Engelhardt Jr. describes the ethical tension at the heart of this paradigm shift:

Patient problems came to be understood as bona fide problems only if they had a pathoanatomical or pathophysiological truth value. Absent a lesion or a physiological disturbance to account for the complaint, the complaint was likely to be regarded as male fide. The error lay in failing also to accent the goals and purposes of medicine. As an applied science, medicine remains focused on caring for human suffering. Clinical medicine begins from and returns to the problems of patients.^2(p216)

The American Medical Association (AMA) reinforces precisely this mandate for clinical medicine in its Code of Medical Ethics:

The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.³

What both Engelhardt and the AMA are asserting is the need for clinicians to engage philosophically with their practice and profession, reframing the clinical encounter from a consultation aimed at discovering or ruling out organic abnormality to a collaborative, holistic healing endeavor with a unique and complex person. By reconnecting medicine with its ends (i.e., “the imperative to care for patients and to alleviate suffering”) rather than its means (i.e., its preferred diagnostic and treatment tools), philosophy has much to offer clinicians serving this sizable patient population. There are at least four important philosophical insights that clinicians should incorporate into the clinical management of all patients, but which are especially vital when caring for patients with medically unexplained symptoms.

• Medicine is not a practice of diagnosing and treating a limited disease process in the abstract, let alone simply ruling out organic pathology, but rather of caring for a whole person in all their concrete and complex humanity. As Francis Peabody emphasizes in his seminal contribution to medical ethics, “it is one thing to write an examination paper on the treatment of gastric ulcer and quite another thing to treat John Smith who happens to have a gastric ulcer.”⁴ What Peabody is reminding us of here is that, even when there are classic presentations of organic pathology, there truly is no “textbook patient” in clinical practice.
• Building on this first insight, it is vital to appreciate that patients and families are not blank slates nor closed biological systems. They enter clinical spaces from a unique context, bringing with them particular histories and experiences (their own and others) as well as their own psychosocial realities, and too often these include trauma. Indeed, each patient is radically unique in this sense. Choosing to focus on symptoms in isolation from this larger picture is decidedly non-scientific and unlikely to lead to genuine and holistic healing for the patient.
• Appreciate that while, as medical historian Robert Aronowitz puts it, “biological and clinical factors set some boundaries,…social influences largely explain which symptom clusters have made it as diseases.”⁵ And, in the context of caring for patients with medically unexplained symptoms, this philosophical reframing requires clinicians to “recognize and accommodate the essential continuity between persons who have symptoms that have been given a name and disease-like status and persons whose suffering remains unnamed and unrecognized.”⁵
• Finally, recognize that communication—effective and empathic communication—is itself therapeutic. Even the most frustrated and difficult patients and families can be receptive to new ideas and approaches to their medically unexplained symptoms when they feel heard and valued as whole persons.

At minimum, there is a duty for clinicians to avoid being yet another stressor in the lives of their patients when they experience unexplained symptoms. But the opportunity is almost always there to offer more when the clinical encounter is framed by sympathy, understanding and a collaborative spirit.

References:

1. Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. 2014;161:579-586.
2. Engelhardt Jr, HT. The Foundations of Bioethics. 2nd ed. Oxford University Press; 1996.
3. American Medical Association. Opinion 1.1.1 Patient-physician relationships. Code of Medical Ethics. https://code-medical-ethics.ama-assn.org/sites/amacoedb/files/2022-08/1.1.1.pdf
4. Peabody FW. The care of the patient. JAMA. 1927;88(12):877-882.
5. Aronowitz RA. When do symptoms become a disease? Ann Intern Med. 2001;134:803-808.