Towards a definition of holism

At the recent World Conference of Family Doctors (WONCA) meeting in Orlando, I attended a session of presented papers related to medical education. One examined the degree to which Swedish GPs felt that a holistic approach was important to their work. Curiously, this paper was labeled in the programme as not eligible for CME credit. During the questions period, one attendee suggested that CME was not allowed because the programme committee had considered holism in the title to mean it was about alternative medicine, and thus not scientific. This raises a number of questions because, as the authors noted, the motivation for the study was that ‘holistic modelling’ is one of the ‘six core competencies of the GP/family doctor’ identified by EURACT, the European Academy of Teachers of General Practice, in 2002. Why would a paper containing one of the core competencies in its title be presumed to be about alternative medicine, or otherwise not of value? (Not to mention why a paper that was on alternative medicine would be presumed to be non-scientific and unworthy of CME credit.) I suggest that at least part of the reason is that many different definitions of holism, and holistic, are being used in health and the healthcare literature, and no one is quite sure what anyone else means when they use these terms.

Certainly, a brief review of the medical literature suggests that there are multiple understandings of holism — it is used for a variety of approaches that come under the heading of ‘complementary’ or ‘alternative’ medicine, spirituality in health, nursing practice, and the more compehensive style of allopathic care suggested by the biopsychosocial model of George Engel, now widely accepted in the general practice community.¹ The term is most common in non-biomedical journals, but also appears in more ‘mainstream’ journals, such as BMJ, British Journal of Nursing and Pediatrics. Definitions, however, are much harder to find; each author seems to presume an understanding by the reader of its meaning, despite the wide variations in usage.

The term ‘holism’ is generally conceded to have been coined by the South African Jan Smuts in 1926.² The Oxford English Dictionary definition is ‘the tendency in nature to form wholes, that are greater than the sum of its parts, through creative evolution’. Comprising a philosophical approach beyond medicine and health, holism developed into a variety of schools in the inter-war period. The impact of these approaches on medicine is examined extensively in the collection Greater than the Parts: Holism in Biomedicine edited by Christopher Lawrence and George Weisz.³ A response to reductionism, particularly biological reductionism in medicine, Lawrence states that:

‘Medical holism can address itself to individuals, the environment, or populations, either separately or in various combinations.’³

In the same volume Charles Rosenberg traces four ‘conceptual styles’ of holism, one of which, ‘ecological holism’ is most resonant with the public health/social medicine tradition. He notes that:

‘Thinkers … as diverse as Rudolf Virchow and Friedrich Engels, Henry Sigerist and Thomas McKeown have all seen social and material circumstances as a cause of ill health … Social medicine implies an emphasis on groups in context, not on particular individuals in particular clinical interactions.’³

This tradition seems closest to that suggested by EURACT's usage, for which the ‘core competency’ of ‘holistic modelling’ is defined as ‘the ability to use a biopsychosocial model taking into account cultural and existential dimensions’, and states, under the ‘characteristics of the discipline of general practice/family medicine’ that the model ‘deals with health problems in their physical, psychological, social, cultural, and existential dimensions’.⁴

To a certain extent, what is ‘holistic’ depends upon where you stand. The systems hierarchy proposed by Engel⁵ goes from the universe to subatomic particles, and few of us work at either extreme. For a cell biologist, holism might mean thinking about the whole liver. In various contexts, it might mean the whole person, the whole community, the whole of society, or the whole planet. Which environmental events you respond to depends on the scale at which you choose to observe (‘this person is obese’ versus ‘30% of the US population is obese’). So the largest scale that is relevant to you, that you pay attention to, is probably what you define as holism.

An approach to health and medicine that is not reductionist is an implicit part of the comprehensive care provided by GPs. We are not doctors for particular diseases, or particular organs, or particular stages in the life cycle — we are doctors for people. People are complex, and live in complex communities in a complex world. All aspects of this world have an impact on the health of the people in it. The EURACT definition recognises and emphasises this, adding both ‘cultural’ and ‘existential’ to the familiar biopsychosocial triad. The European use of ‘existential’ would seem to include, but be broader than, the typical US formulation ‘spiritual’. As such, I find it preferable, though undoubtedly some would disagree, choosing to focus explicitly on the ‘spiritual dimension’. Essentially, this means — correctly — that everything affects health, and as physicians dedicated to maintaining and improving health we must understand and honour the whole, in each of its parts and with the synergies that are created as they act together. As physicians we cannot treat all of these areas, and we must guard against defining health problems only as things we can treat.

Ironically, while allopathic medicine recognises the complex interplay of these conditions, some ‘alternative’ practitioners who claim to be ‘holistic’ are in fact far more biologically reductionist. Are you tired? Do you have headaches? Are you depressed? Gaining weight? Unhappy? Have decreased sex drive? Maybe it isn't because you have too little money, or work too hard, or feel unsafe in your neighbourhood, or have a mean boss, or a spouse who drinks to excess, or children who are in jail, or a close relation who has died. Maybe you just need less wheat in your diet, a high colonic enema, a few drops of a herbal remedy under your tongue. Undoubtedly, this is a large part of the attraction of so many of these therapies — that the miseries of life are biologically treatable. But no matter how attractive, it is not true. No simple therapy aimed at the body (or even the mind) will treat these problems, and it is neither fair nor right for any practitioner, whether allopathic or ‘alternative’, to hold out such false hope. It is also, in the most profound sense, not holistic. Holism does not mean ‘anything outside traditional allopathy’. In themselves, herbal healing or faith healing or exercise therapy or cultural therapies or shamanism are no more holistic than the use of pharmaceuticals or surgery. Indeed, the very concept of a single ‘holistic therapy’ is oxymoronic; at best there can be a holistic approach, combining, when needed, a variety of therapies.

The hope of a holistic approach is that we can employ many allies in the effort to bring better health to people. The tradition of social medicine, of physicians that help to demonstrate how social conditions can impact health and work to ameliorate them, is an excellent example. The EURACT definition of holism is quite a good one. And, by the way, the study presented in Orlando found that Swedish GPs, at least, subscribe to the importance of a holistic approach, as did the study of British patients and practitioners by Tarrant et al.⁶ We need to adhere to this sort of definition, and oppose efforts to highjack the term, and prevent modern day Humpty Dumptys from making the word mean whatever they wish it to.