ANTH110 response paper

Ž .International Journal of Gynecology & Obstetrics 75 2001 S5�S23

The technocratic, humanistic, and holistic paradigms of childbirth �

R. Davis-Floyd�

Department of Anthropology, Uni�ersity of Texas Austin, Austin, TX, USA

Abstract

This article describes three paradigms of health care that heavily influence contemporary childbirth, most particularly in the west, but increasingly around the world: the technocratic, humanistic, and holistic models of medicine. These models differ fundamentally in their definitions of the body and its relationship to the mind, and thus in the health care approaches they charter. The technocratic model stresses mind�body separation and sees the body as a machine; the humanistic model emphasizes mind�body connection and defines the body as an organism; the holistic model insists on the oneness of body, mind, and spirit and defines the body as an energy field in constant interaction with other energy fields. Based on many years of research into contemporary childbirth, most especially through interviews with physicians, midwives, nurses, and mothers, this article seeks to describe the 12 tenets of each paradigm as they apply to contemporary obstetrical and health care, and to point out their futuristic implications. I suggest that practitioners who combine elements of all three paradigms have a unique opportunity to create the most effective obstetrical system ever known. � 2001 International Federation of Gynecology and Obstetrics. All rights reserved.

Keywords: Childbirth; Humanism; Holism; Technomedicine; Obstetrics

1. The technocratic model of medicine

The way a society conceives of and uses tech- nology reflects and perpetuates the value and

� Certain portions of this article draw heavily on From � �Doctor to Healer: The Transformati�e Journey 35 and Birth as

� �an American Rite of Passage 1 . For more information, please � �see these works; see also Davis-Floyd 36,39 ; Davis-Floyd and

� �Davis 34 , and � www.davis-floyd.com� . �

Tel.: �1-512-263-2212.

belief system that underlies it. Despite its preten- ses to scientific rigor, the western medical system is less grounded in science than in its wider cultural context; like all health care systems, it embodies the biases and beliefs of the society that created it. Western society’s core value sys- tem is strongly oriented toward science, high technology, economic profit, and patriarchally

� �governed institutions 1 . Our medical system re- flects that core value system: its successes are founded in science, effected by technology, and

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( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S6

carried out through large institutions governed by patriarchal ideologies in a profit-driven economic context. Among these core values, in both medicine and the wider society, technology reigns supreme. As has been clear for over 20 years, most routine obstetrical procedures have little or no scientific evidence to justify them. They are routinely performed not because they make scien- tific sense but because they make cultural sense. As we shall see below, they exemplify certain fundamental aspects of technocratic life.

1.1. The 12 tenets of the technocratic model

( ) ( )1.1.1. 1 Mind�body separation and 2 the body as a machine

The main value underlying the technocratic paradigm of medicine is separation. The principle of separation states that things are better under- stood outside of their context, that is, divorced from related objects or persons. Technomedicine continually separates the individual into compo- nent parts, the process of reproduction into con- stituent elements, and experience of childbirth from the flow of life. However, first and foremost, it separates the human body from the human mind.

The body presents a profound conceptual para- dox to our society, for it is simultaneously a creation of nature and the focal point of culture. How can we be separate from nature when we are part of it? Descartes, Bacon, and others, neatly resolved this problem in the 1600s, when they established the philosophical separation of mind and body upon which the metaphor of the body-as-machine depends. This idea meant that the superior cultural essence of man, his mind � as well as the superior spiritual essence, his soul � could remain unaffected while the body, as a mere part of mechanical nature, could be taken apart, studied, and repaired.

This metaphor of the body-as-machine could have been inherently egalitarian, but the industri- alizing nations of the west were male-centered, patriarchal societies. Thus the male body came to be medically viewed as the prototype of the properly functioning body-machine. The female body, as it deviated from the male standard, was

regarded as inherently defective and dangerously under the influence of nature, which due to its unpredictability, was itself regarded as in need of

� �constant manipulation by man 1,2 . As a result, despite the growing acceptance of birth as me- chanical like all other bodily processes, it came to be viewed as an inherently imperfect and untrust- worthy mechanical process, and the metaphor of the female body as a defective machine eventu- ally formed the philosophical foundation of mod- ern obstetrics. Furthermore, as the factory pro- duction of goods became a central organizing metaphor for social life, it also became the domi- nant metaphor for birth: the hospital became the factory, the mother’s body became the machine, and the baby became the product of an industrial manufacturing process. Obstetrics was thereby enjoined to develop tools and technologies for the manipulation and improvement of the inherently defective process of birth, and to make birth conform to the assembly-line model of factory production.

( ) ( )1.1.2. 3 The patient as object, and 4 alienation of practitioner from patient

Mechanizing the human body and defining the body-machine as the proper object of medical treatment frees technomedical practitioners from any sense of responsibility for the patient’s mind or spirit. Thus, practitioners often see no need to engage with the individual who inhabits that body-machine, preferring instead to think of and talk about a patient as ‘the C-section in 112.’

� �Jordan 3 demonstrates how this tendency to objectify patients can extend to refusal to discuss any details of a case with the person who em- bodies it. This kind of alienation from their patients is often trained into physicians during medical school and residency, as they are taught to protect themselves by avoiding emotional in- volvement. It logically follows that there is no reason to deal with the patient’s emotions at all. Thus they are free to protect their own feelings from the pain of caring too much. Technocratic physicians do not value lengthy conversations with their patients, preferring to keep their visits short. Although it is well-known that touch and caring are powerful factors that can positively influence

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S7

both a woman’s experience of labor and the out- Ž .come of the birth see below , it is rare to see

obstetricians touching laboring women, holding their hands, or sheltering them in an embrace.

( )1.1.3. 5 Diagnosis and treatment from the outside in

When most machines break down, they do not repair themselves from the inside; they must be repaired from the outside, by someone else. Thus in technomedicine, it follows that one must at- tempt to diagnose problems, cure disease, and repair dysfunction from the outside. The most valued information is that which comes from the many high-tech diagnostic machines now con- sidered essential to good health care. Such diag- nostic technologies are pervasive in pregnancy and childbirth, from ultrasounds in early preg- nancy to electronic fetal monitoring during labor. And treatment too is from the outside in � when labor slows, the amniotic sack is pierced with a hook and pitocin is poured into a vein to speed it up; when a baby seems stuck, it is pulled out with forceps or cut out with a knife.

The routine administration of IVs to women in labor is a good example of the massive overuse of this outside-in approach. There is plenty of scien-

� �tific evidence 4�7 to indicate that it’s much healthier for a woman to eat and drink during labor. But the IV makes a powerful symbolic statement: it is the umbilical cord to the hospital. The IV places the woman in the same relation- ship of dependence on the institution for her life as the baby in the womb is dependent on her for

� �its life 1 . By extension, one can see IVs as a perfect symbolic expression of life in the tech- nocracy: we are all umbilically linked to institu- tions and through them, to society. As a vein is penetrated with a needle and then with the fluid flowing through the IV line, our homes are pene- trated by water, sewer, telephone, and electricity lines. The fullest symbolic extension of the IV lies in its expression and display of our ongoing fu- sions of ourselves with the technologies we cre- ate. A ‘cyborg’ is a cybernetic organism, a fusion of human with machine. In the cultural arena of reproduction, we are escalating the pace of our

� �own cyborgification 8 .

( ) ( )1.1.4. 6 Hierarchical organization and 7 standardization of care

Like its industrial predecessor, the technocracy is a hierarchically organized society. The term technocracy implies use of an ideology of techno-

� �logical progress as a source of political power 9 . It thus expresses not only the technological but also the hierarchical, bureaucratic and autocratic dimensions of this culturally dominant reality model. Even as many businesses seek to make a paradigm shift by transforming themselves into ‘organizational networks’ and ‘flat corporations,’ the medical system remains true to its role as society’s microcosm, rigidly hierarchical in terms of the power of physicians as a group, the empha- sis on specialty over primary care, and in terms of the subordination of individual needs to standard- ized institutional practices and routines.

The standardization in hospital birth is dramat- ically evident in most modern hospitals. Upon entering the hospital, the laboring woman is taken in a wheelchair to a ‘prep’ room. There her clothes are removed, she is asked to put on a hospital gown, and a vaginal exam is performed. Her access to food is limited or prohibited, and an intravenous needle is inserted in her hand or arm. The external fetal monitor is attached to the woman to monitor the strength of her contrac- tions and the baby’s heartbeat. Periodic vaginal exams are performed to check the degree of the baby’s descent. All of these procedures in most modern hospitals are routinely performed without

� �scientific justification 4�7 . As the moment of birth approaches, there is an

intensification of actions performed on the woman, as she is transferred to a delivery room, placed in the lithotomy position, covered with sterile sheets and doused with antiseptic, and an episiotomy is performed. After the birth, she is handed the baby for a certain amount of time, her placenta is extracted if it does not come out quickly on its own, her episiotomy is sewn up, and finally, she is cleaned up and transferred to a hospital bed. Or she may have a cesarean section; in countries like Brazil and Mexico, that opera-

� �tion seems to be rapidly becoming routine 10,11 . Of course, there are many variations on this

theme. Some procedures that used to be standard

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S8

in US hospitals in the 1940s, 1950s and 1960s such as handstrapping, the exclusion of fathers, and shaves and enemas are no longer used, al- though some are still common in developing countries. Other major changes since then have included the father’s presence and women re- maining conscious during birth. When possible, many women opt for delivery in a birthing suite

Ž .or LDR labor-delivery-recovery room , where they can wear their own clothes, do without the IV, and walk around during labor. Yet in spite of these concessions to consumer demand for more humanistic birth, a basic pattern of high-techno- logical intervention remains: most hospitals now require at least periodic electronic monitoring of all laboring women; analgesics, pitocin, and epidurals are widely administered; and cesarean section rates are increasing. Thus, although some medical procedures drop away, the use of the most powerful signifiers of the woman’s depen- dence on science and technology intensifies.

( )1.1.5. 7 Authority and responsibility inherent in practitioner, not patient

In line with its hierarchical structure, the tech- nocratic model invests authority in physicians and in institutions and their personnel. Obvious cues such as titles and white coats signal the authority of the physician, who can add to his status by withholding information, and using technical jar- gon the patient cannot understand. When the doctor is the authority, the patient lacks responsi- bility. Many doctors are able to present an option as the answer quite easily, by simply refusing to discuss non-paradigm alternatives. In this sce- nario, a patient’s most comfortable role is abdica- tion of personal preference in favor of the doctor’s choice.

In childbirth, one of the most graphic demon- strations of the power of ‘doctor’s choice’ is the lithotomy position so popular with doctors not because it is physiologically sound, but because it enables them to attend births standing up, with a clear field for maneuvering. We know very well that this position complicates childbirth, but the many good physiological reasons to allow women

Žto give birth in upright positions which include increased blood and oxygen supply to the baby,

.more effective pushing, and wider pelvic outlets are far less important to most physicians than their own comfort, convenience, and status. In the West, ‘up’ is good and ‘down is bad’: the person who is ‘on top’ has the status and the power, and rarely gives it up for the good of the laboring woman and child.

Technomedicine’s investment of both authority and responsibility in physicians and hospitals is a double-edged sword. Although medical personnel do have the power to give orders to patients and establish institutional policies and procedures, they can be and often are held to be accountable for deaths and outcomes that no mortal could prevent. The proliferation of lawsuits against obstetricians over the past two decades is testi- mony to the way citizens have turned this tenet of the technocratic model against its proponents.

( )1.1.6. 8 Super�aluation of science and technology The general public tends to assume that doc-

tors are scientists, but most medical students re- ceive little or no training in research methodology and analysis. A 1978 study carried out by the Office of Technology Assessment of the United States Congress reported that ‘only 10�20% of all procedures currently used in medical practice have been shown to be efficacious in controlled trials’; in the 1990s, it is still true that over half of the techniques physicians routinely employ have not been proven in rigorous testing. Yet the power of the technomedical paradigm is such that physi- cians will rapidly accept procedures and technolo- gies in keeping with it, while rejecting those that do not. So, while science is ‘supervalued’ as an ideology in this paradigm, its actual findings are often discounted or ignored.

Likewise, the technologies that predominate in medical treatment are those that support the ‘evolution through technology’ ethos of the tech- nocratic model, in which progress means the de- velopment of ever more sophisticated machines. When a doctor uses a ‘low-tech’ tool like a stethoscope, he touches the patient, speaks to her, listens with his own ears to hers or the baby’s heartbeats, interprets the sounds through his own bodily perceptions, and arrives at a diagnosis that depends in large part on his physical senses. When

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S9

the same doctor uses a computerized axial tomog- Ž .raphy CAT scanner or an electronic fetal moni-

Ž .tor EFM , only the machine touches or interacts with the patient during the procedure. The physi- cian’s role is to interpret the mechanically medi- ated results, which are regarded as more objective and reliable than his perceptions.

Such new technologies are usually introduced by their marketers, who tend to describe them solely in terms of their best-case use and minimize any detrimental effects. EFM is a case in point � �12 . Its manufacturers regularly paid physicians’ trips to medical conferences; upon arrival, they found themselves walking through elaborate EFM

� �displays to get to the meeting rooms 13 . Now pervasive in hospital birth, the EFM has resulted not in better outcomes but in higher costs and higher cesarean rates. Nevertheless, many hospi- tals in the US routinely employ these machines in more than 80% of labors.

Rapid diffusion and acceptance of a new tech- nology often has more to do with its symbolic value than its actual efficacy. Machines can mesmerize:

The amplified fetal heartbeat sounds like galloping horses . . . both the sound of the galloping and the vision of the needle traveling across the paper, making a blip with each heartbeat, are hypnotic, often giving one the illusion

� �that the machines are keeping the baby’s heart beating 14 Ž .p. 90 .

So powerful is this illusion that nurses Davis- Floyd has interviewed often become reluctant to detach the mother from the monitor because they fear that the baby’s heart will stop. While they know intellectually that this is nonsense, never- theless they are emotionally swayed by the sym- bolic power of these machines.

Once machines like the EFM, along with CAT Ž .and positron emission tomography PET scan-

ners and hundreds of others, are there, they must be reckoned with, and any decision not to use them begins to look like substandard care � a reality that reflects both the financial and the symbolic supervaluation of technology in the American medical system. Such machines serve the powerful symbolic purpose of ‘upgrading’ medical care in keeping with our notions of evo-

lutionary progress; indeed, our newest cultural value is the flow of massive amounts of informa- tion through sophisticated electronic systems � just the kind of option that the EFM provides.

( )1.1.7. 9 Aggressi�e inter�ention with emphasis on ( )short-term results, and 10 death as defeat

Since the dawn of the Industrial Revolution, western society has sought to dominate and con- trol nature. And the more we controlled nature, including our natural bodies, the more we feared the aspects of nature we could not control. This led to the emergence of a phenomenon that an-

� �thropologist Peter C. Reynolds 9 has labeled the ‘One-Two Punch’ of technological intervention. Take a natural process that seems to need fixing � say, a river in which salmon annually swim upstream to spawn. Punch One: ‘improve it’ with technology � build a dam and a power plant, generating the unfortunate byproduct that the salmon can no longer swim to their spawning grounds. Punch Two: fix the problem created with technology with more technology � take the salmon out of the water with machines, let them spawn and grow the eggs in trays, feed the babies through an elaborate system of pipes and tubes, then truck them back to the river and release them downstream. Reynolds’ brilliant insight was that, while most people see Punch Two as an accidental byproduct of Punch One, the deeper truth is that Punch Two is the point. We in the West have become convinced that altering natu- ral processes makes them better � more pre- dictable, more controllable, and therefore safer.

It is not hard to see how this One-Two punch of mutilation and prosthesis applies to birth. The birth process seems to us to be chaotic, uncon- trollable, and therefore dangerous. So we ‘im- prove’ it with technology. First we take it apart � deconstruct it � into identifiable segments. Then we control each segment with the obstetrical

Žequivalent of dams and floodgates EFM, pitocin, .drugs . When the unfortunate byproduct of this

technological reconstruction of birth is a baby in distress from a now-dysfunctional labor, we res-

Žcue that baby with more technology episiotomy, .forceps, cesarean section . Then we congratulate

ourselves on a job well done, just as the builders

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S10

of the salmon hatchery congratulate themselves for ‘saving the salmon.’

Reynolds’ One-Two Punch is a powerful moti- vating force in American society � I call it the technocratic imperati�e. This impetus to improve on nature through technology has as its ultimate aim to free us altogether from the limitations of nature. The more able we become to control nature, including our natural bodies, the more fearful we become of the aspects of nature we cannot control. Death becomes the ultimate sig- nifier of defeat, proof that in fact we have not succeeded in transcending nature’s limitations, and thus the ultimate enemy, to be defeated at all costs. Lifesaving procedures for low birth weight infants, often implemented without respect for their eventual quality of life, like high tech inter- vention for the terminally ill, represent attempts at sustaining the fragile thread of life against all odds. The underlying ethos behind the routine application of so many unnecessary procedures to birth is fear of death. These procedures keep fear at bay by giving both practitioners and birthing women the illusion of safety: they appear to minimize risk while in fact they often generate more problems than they solve.

( )1.1.8. Technomedical hegemony: 11 a profit-dri�en ( )system; and 12 intolerance of other modalities

The word ‘hegemony’ refers to an ideology espoused by the dominant group in a given soci- ety. In a multi-cultural society such as that of the United States in the late 20th century, no one set of ideas about medicine, religion, economics, or anything else is shared by everyone. Nevertheless, there are ideologies that are obviously dominant: in economics, the hegemonic ideology is capital- ism, and in health care, it is the technomedical model. When an ideology is hegemonic, all other competing ideologies become ‘alternative’ to it. Thus healing modalities such as midwifery, chi- ropractic, homeopathy, naturopathy, acupuncture, and so forth have been viewed as alternative to allopathy. While these modalities command in- creasing respect and usage, allopathic tech- nomedicine still sets the standards for care. Its hegemonic status works to ensure its profitability: pharmaceutical and medical technology compa-

nies constitute by far one of the most profitable industries in the United States. The median after-research profit rate in 1993 for the makers of the top-selling prescription drugs was more than five times higher than the median profit rate for all Fortune 500 companies in the same year � �15 . Any system � medical, economic, religious, or otherwise � that gains sociocultural ascen- dancy and then rigidifies, shutting out new infor- mation and refusing to incorporate contradictory evidence, is in mortal danger both to itself and to the public it serves. Such hegemonic systems can benefit from frontal attacks, which can serve to keep them flexible and responsive to the changing realities of changing times. It is in that spirit that I have presented this analysis.

2. The humanistic model of medicine

In the United States and elsewhere, the ex- cesses of technomedicine have long been the sub- ject of heated discussion and debate. Humanism arose in reaction to these excesses as an effort driven by nurses and physicians working within the medical system to reform it from the inside. Humanists wish simply to humanize tech- nomedicine � that is, to make it relational, part- nership-oriented, individually responsive, and compassionate. This caring, commonsensical ap- proach is garnering wide international apprecia- tion and support. Clearly less radical than holism, clearly more loving than technomedicine, this hu- manistic paradigm has the most potential to open the technocratic system, from the inside, to the possibility of widespread reform.

2.1. The 12 tenets of the humanistic model

2.1.1. Mind�body connection The humanistic approach neither demarcates a

total separation between mind and body, as does technomedicine, nor claims oneness for mind and body, as does the holistic model. Rather, it recog- nizes the influence of the mind on the body and advocates forms of healing that address both. Proponents of this paradigm see body and mind as being in constant communication, citing scien-

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S11

tific research in the field of psychoneuroim- munology and elsewhere. Thus the humanistic paradigm insists that it is impossible to treat physical symptoms without addressing their psy- chological components. Psychoneuroimmunol- ogist Candace Pert explains:

�Viruses use the same receptors as the neuropeptides that �carry emotions to enter into a cell, and depending on how

much of the natural juice, or the natural peptide for that receptor is around, the virus will have an easier or a harder time getting into the cell. So our emotional state will affect whether we’ll get sick from the same loading dose of a virus... Emotional fluctuations and emotional status directly influence the probability that the organism will get sick or

� � Ž .be well. 16 p. 190 .

The implications for childbirth of the notion that the mind affects what happens in the body are obvious and profound. Humanism in child- birth allows for the possibility that the laboring woman’s emotions can affect the progress of her labor, and that problems in labor may be more effectively dealt with through emotional support than through technological intervention.

( )2.1.2. 2 The body as an organism Although in some ways the human body is like

a machine, it is a fact of biological life that the body is not a machine but an organism. Such a conclusion has powerful repercussions for treat- ment, as the way the body is defined will shape the way it is treated by a culture’s health care system. ‘Even medical therapies that are the most machine-like would be ineffective without the in- nate healing powers of the organism,’ which has ‘properties that no machine has: those of growth, regeneration, healing, learning, and self-tran-

� �scendence’ 17 . Defining the body as an organism charters the

development of an array of treatments that may be irrelevant to a machine but matter a great deal to an organism. Unlike machines, mammalian organisms feel pain and respond emotionally to interactions with others and to changes in their environment. Most mammals respond positively to the comfort of a loving touch and shrink from contact that is harsh or punitive. Thus a paradigm of healing based on a definition of the human

body as an organism would logically stress the importance of kindness, of touch, and of caring. These dimensions have special significance for the care of laboring women, from the ways they are treated during labor to the need of mother and baby to remain together after birth. The best analog for the term humanism in the medical literature is the term bio-psycho-social, which ac- knowledges that this model takes in to account biology, psychology and the social environment.

( )2.1.3. 3 The patient as relational subject Most humanists are not afraid to establish a

real human connection with their patients, to come to know them not just as patients but as individuals, not as ‘the C-section in 112’ but as ‘the mother with twins whose sister just died.’

� �David Spiegel 18 showed that women with ad- vanced breast cancer who participated in weekly support groups not only felt better emotionally, but ultimately lived an average of 18 months longer than did women with comparable breast cancer and medical care who did not attend such groups. This added survival time was, according to

� �Spiegel 19 , ‘longer than any medication or other known medical treatment could be expected to provide for women with breast cancer so far ad- vanced.’ This study has been followed by a num- ber of large-scale studies showing that more and better social support from family and friends is associated with lower odds of dying and better odds of healing at any given age.

Starting in the 1970s, natural childbirth ac- tivists in large numbers in the US and other countries began to demand that fathers and sig- nificant others should be allowed into delivery rooms, that mother and baby should not be sepa- rated after birth, that friends and relatives be allowed to remain with the laboring woman if such was her desire. The effect of the presence of caring others during childbirth does far more than simply work toward a more pleasant labor experience; it can be central to the positive out- come of that experience.

( )2.1.4. 4 Connection and caring between practitioner and patient

Whereas the technomedical paradigm is based

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on the principle of separation, and the holistic model on integration, the principle underlying the humanistic approach is connection: the connec- tion of the patient to the multiple aspects of herself, her family, her society, and her health care practitioners. Humanism requires treating the patient in a connected, relational way as any human being would want to be treated � with consideration, kindness, and respect. This paradigm insists on the deep humanity of the individuals involved and stresses the importance of the patient-practitioner relationship to the healing process. The phrase ‘relationship-centered care’ has been suggested ‘to capture the impor- tance of the interaction among people as the foundation of any therapeutic or healing activity’ � �17 .

In childbirth the strongest evidence of the power of relationship-centered care comes from the doula research. A doula is a female compan- ion especially trained to give labor support. Sosa � � � �20 , Kennell and their associates 21,22 com- pared the results of normal hospital labors with labors of women attended one-on-one by a doula. They found that doula support dramatically re- duced problems of fetal asphyxia and labor dysto- cia, shortened length of labor, and enhanced

� �mother-infant interaction after delivery 23 .

( )2.1.5. 5 Diagnosis and healing from the outside in and from the inside out

Where the technomedical model emphasizes diagnosis and healing from the outside in, and the holistic model from the inside out, the humanistic model calls for a moderate application of both approaches. The physician �patient communica- tion it emphasizes allows physicians to elicit infor- mation from deep within the patient and combine it with objective findings. Accordingly, humanists find that how to listen is as important as knowing what to say. Listening skills are crucial for obtain- ing the correct mix of data required for diagnosis.

Noting that a clinician will perform from 120 000 to 160 000 interviews during a career,

� �Smith 24 points out that the biomedical model teaches students to elicit symptoms of disease using a ‘doctor-centered’ interviewing process. The physician elicits many bits of non-personal

data, starting with the patient’s chief complaint, then synthesizes them into a description of the patient’s disease. However, humanistic doctors know that the presenting complaint often masks an underlying problem. A woman complaining of fatigue, depression, and body aches may have lupus or may be despondent over a failed mar- riage. Practitioners must adopt an open-ended learning approach in order to create the space and time necessary to bring forth the underlying dynamic.

This open-ended learning approach forms an � �important part of what Smith 24 calls the ‘pa-

tient-centered interview.’ Instead of asking a se- ries of closed, rapid-fire questions, the physician simply encourages patients to express what is most important to them, which will usually come out as a combination of personal data and data about symptoms. Allowing patients to lead keeps their ideas and concerns paramount and en- hances their sense of autonomy. The patient- centered interview can form an invaluable part of the humanistic physician’s ability to be both tech- nically competent and humanistically caring.

( )2.1.6. 6 Balance between the needs of the institution and the indi�idual

Humanism counterbalances technomedicine with a softer approach, which can be anything from a superficial overlay to profoundly alterna- tive methods. It is superficially humanistic to dec- orate a technocratic labor room so the machines do not stand out so much; it is deeply humanistic to provide women with flexible spaces in which they have room to move around as much as they like, to be in water if they wish, to labor as they choose.

Most medical institutions are designed to sup- port and implement technocratic principles. These institutions are so highly regulated with respect to infection control, medical�surgical and nursing procedures, security, and liability that it is often not possible for one individual to effect significant change. So sometimes humanistically inclined physicians must content themselves with superfi- cial improvements; but very often, committed in- dividuals find they can do more. In the US, nurse-midwives have gained a reputation as the

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S13

practitioners who try the hardest to provide deeply � �humanistic care within hospitals 7,25 . Thus two

humanistic changes often sought by childbirth activists include convincing hospitals to give women the right to choose midwives as their birth attendants, and to have access to one-on-one doula care.

( )2.1.7. 7 Information, decision-making, and responsibility shared between patient and practitioner

The poles between empowerment and depen- dence form the framework within which doctors and patients make decisions. Most health profes- sionals are trained to bring linear information to bear in their decision-making; in addition, the humanistic paradigm allows non-linear, subjective processing to play a significant role. This is the balanced or empathic style of thinking. ‘Em- pathic’ refers to the ability of one person to understand another’s reality even if that reality is beyond their direct experience. Even when straightforward evidence of disease is present, doctors still have considerable latitude regarding how mutual they are willing to allow decision making to be. In the technomedical model, each situation seems to dictate a matching action. The humanistic model opens situations to multiple options.

The doctrine of informed consent establishes that patients have a right to understand their diagnosis and prognosis, their proposed treatment and its risks and benefits, and their treatment options. In the technocratic model the discussion of options outside of conventional medicine is generally impossible due to the doctor’s alle- giance to technocratic approaches and ignorance of alternatives. Discussing no treatment as an option is equally unlikely. But in humanism, open discussion of treatment choices leads naturally to an exploration and sharing of values, and doctors are more likely to respond favorably or at least neutrally to a patient’s wish to try alternative methods or to employ no treatments at all.

� �Arthur Kleinman 26 expands the notions of the patient’s right to information and the ‘pa- tient-centered interview’ to a more dialogic ap- proach. He suggests that the goal of the practi- tioner should be to enter into the experience of

illness as patients perceive it by listening carefully to their narratives. To more deeply understand a patient’s story, the physician can try to interpret the patient’s symptoms as symbols of deeper life issues and to grasp the influence of the patient’s cultural, personal, and family explanatory models. Like other humanistic and holistic physicians,

� �Kleinman 26 stresses the value and importance of the placebo effect, which can be activated purely through the strength of the physician-pa- tient relationship and thus should be tapped in every healing encounter.

� �Medical sociologist Eliot Freidson 27 asserts that the need for information is apt to result in conflict simply because a lay culture is encounter- ing a professional culture at a moment of crisis. To balance this, the doctor needs to communicate a trustworthiness to the patient so that the patient can accept or reject recommendations without feeling either bullied or negated. Although some physicians might fear liability with this level of information-sharing, the Consensus Conference on Doctor �Patient Communication held in Toronto in 1992 found that most lawsuits against doctors are the result of communication faults rather than errors in medical judgment.

( )2.1.8. 8 Science and technology counterbalanced with humanism

Humanistic physicians take science as their standard and use virtually the same tools and techniques as technomedical doctors. The differ- ence lies in timing and selection. Humanists may be more willing to wait, more apt to be conserva- tive, more open to mind�body approaches. Hu-

Žmanists who are primary care doctors family .physicians, internists, pediatricians, gynecologists

may delay referring to a specialist and attempt to resolve a problem using more conservative meth- ods, provided they have the consent of the patient to do so. Humanistic specialists will naturally be inclined to use the technology at their disposal, but will emphasize caring and relationship along-

� �side it, a combination John Naisbitt 28 captured in the phrase ‘high tech, high touch.’

A whole new class of birth technologies has been developed that can be considered humanis- tic, from portable tables that allow babies in

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S14

distress to be resuscitated at their mother’s sides to sophisticated birthing chairs that allow women to be in upright positions. But for such interven- tions to be truly humanistic, they should be used at a patient’s request or desire and their use should be soundly evidence-based. For example, epidural anesthesia can be considered a humanis- tic intervention because it takes away pain while allowing women to be ‘awake and aware.’ How- ever, there is nothing humanistic about forcing epidurals on women who do not want them. On the other side, how humanistic is it to allow women who arrive at the hospital demanding an epidural to have one in very early labor? A great deal of evidence now shows that if given before 5 cm dilation, epidurals can significantly slow labor. But when epidurals are given after five cm dila- tion, such problems are rare. Humanistic obstetri- cians and midwives try to evaluate the evidence and to make decisions that reflect the balance between what science shows to work and the needs and desires of the women they attend.

A good example of counterbalancing science and technology with humanistic principles stems from a birth Davis-Floyd once observed, in which a mother laboring in a hospital supported by her husband and a doula rejected the delivery table and asked to be allowed to give birth on the floor. The physician and nurses attending her asked themselves what science truly demanded in that situation. The answer was that there was nothing scientific at all about giving birth flat on one’s back on a delivery table; it was in fact much more evidence-based to give birth upright on the floor. What science did demand was a clean area for the delivery. So the nurses took the sheets off of the table and put them on the floor, and the woman, propped with pillows, cheerfully sat on top of them to give birth. In other words, ideally, humanistic care should be evidence-based care that reflects real science and not medical tradi- tion.

( )2.1.9. 9 Focus on disease pre�ention Most proponents of humanism are also strong

proponents of science-based public health initia- tives that stress prevention and deal sensibly with the public environment. They point out that pro-

viding a village or a country with a clean water supply will do far more good for the health of far more people than building high-tech hospitals, as will ensuring clean air, adequate nutrition, and access to primary health care.

Prevention has been limited to the public health arena presumably because it does not turn a profit, unlike the sale of high tech medical equip- ment and pharmaceuticals. No one benefits in any immediate sense when people stop smoking, but a model in which compassion, not profit, is the driving force, has room for prevention and for social programs that reflect political agendas that protect the disenfranchised. Thus the public health paradigm, which stresses long-term, large- scale disease prevention and health promotion, corresponds closely to the humanistic paradigm, which stresses long-term individual and family Ž .biopsychosocial disease prevention and health promotion. In fact, humanists often leave private medical practice for work in the wider arena of public health.

The implications of this prevention-based ap- proach in childbirth are enormous. True preven- tion of complications in childbirth would involve addressing the problems that lead to maternal and fetal deaths at their source. But often public health programs like the Safe Motherhood Initia- tive are heavily influenced by technomedical per- spectives. Technomedicine identifies hemorrhage, toxemia, anemia, and the like as the sources of maternal death. But the underlying causes of these problems are the interrelated factors of poverty, poor nutrition, contaminated food and drinking water, the lower status of women, and overwork. Initiatives that try to solve the problem of maternal mortality by building more hospitals and stocking them with more machines fail to address these core problems; instead, they perpe- trate the agenda of technomedicine.

Both the public health paradigm and the hu- manistic model are compassion-driven; both focus on disease prevention, health promotion, and public education. The public health paradigm takes a broadscale, population-wide approach, while the humanistic model focuses more specifi- cally on the individual relationships between family, patient, and provider and the effects of

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S15

these relationships on illness prevention, diagno- sis, and treatment.

( )2.1.10. 10 Death as an acceptable outcome In childbirth, where death usually arrives sud-

denly, the technocratic approach to the death of a baby is to whisk away the body, leaving the par- ents with empty arms. The humanistic way is to allow the parents all the time they need with that baby, so that the pain of death is not augmented by the pain of sudden separation. In the wider cultural arena, the humanistic approach to death is one of individual choice about the manner of dying. Individuals can sign living wills in advance, requesting that life-prolonging measures be limited. The hospice movement has brought death back into the home by supporting the dying indi- vidual and the family, not with major medical intervention but with the comfort of pain relief. This highly humanistic approach stem from a philosophy that profoundly honors a patient’s in- dividuality and freedom of choice. The process of conscious dying under both the humanistic and holistic paradigms becomes an opportunity to heal one’s relationships with spouses, lovers, children, friends, oneself, and God. Grievances can be for- given, old wounds mended, unmet needs and wishes fulfilled. In such cases, the death of an individual can provide tremendous opportunities for healing for families and entire communities.

( )2.1.11. 11 Compassion-dri�en care � �Byron and Mary Jo Good 29,30 suggest that

the juxtaposed ‘central symbols’ of competence and caring represent a cultural tension developed throughout medical education that is linked to a dualistic discourse characteristic of contemporary Western medicine. Competence is closely associ- ated with the natural sciences, caring with the humanities. Competence is a quality of knowledge and skills, caring a quality of persons. They also note that this juxtaposition of competence and caring, present throughout the history of western medicine, reflects the larger struggle between sci- ence and culture, technology and humanism, which in the West are often seen as opposing forces.

It is precisely these contradictions that the hu-

manistic approach to medicine seeks to resolve. Physicians faced with suffering are expected to process information quickly, arrive at, and often implement a course of treatment. In technomedi- cal circles, emotions are thought to interfere with such abilities. In both humanistic and holistic settings, feelings are accepted as part of the heal- ing response. The driving ethos of the humanist is compassion � the ability to sense and feel the needs of others even if they are outside of one’s own experience. When they sit down by a laboring woman’s bed and breathe with her through a contraction, humanistic physicians are working to re-create a place in medicine for the human val- ues of partnership, relationship, compassion, and caring. Only after three decades of scientific re- search documenting the benefits of this humanis- tic approach are technocratically trained physi- cians allowing themselves to be human, letting go of the fear that others will think them weak and incompetent if they open themselves to their own feelings and learn skills for processing their patients’ feelings without becoming emotionally overwhelmed.

( )2.1.12. 12 Open-mindedness toward other modalities

Most humanists have no intention of learning alternative healing techniques, although in gen- eral they are open-minded and support patients who chose to use alternatives � as long as the overall treatment program includes conventional care. While many humanists adopt a sort of be- mused tolerance to alternative modalities, some do advocate dietary and lifestyle changes that border on the holistic, and take a more proactive stance toward other healing alternatives. Physi- cians in transition to humanism need not undergo any noticeable change in beliefs about what causes or cures disease. Simply being nicer, more caring, more willing to touch and communicate reposi- tions them in the humanistic model. Most will not undergo the radical shift in values that permits them to go beyond compassion to employ the healing power of that mysterious thing called energy in overcoming disease. This is the realm of the holistic physician.

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S16

3. The holistic model of medicine

If the technocratic model of medicine is the ruling hegemony, the holistic model of medicine is the ultimate heresy. Of the three paradigms I discuss, the holistic model encompasses the rich- est variety of approaches, ranging from nutritio- nal therapy to traditional healing modalities such as Chinese medicine to various methods of di- rectly affecting personal energy. Some holistic practitioners study a particular modality while others employ an eclectic approach, often of their own design. Holism often calls on individuals to be active, asking them to make major modifica- tions in their lifestyles. It may also ask them to be passive, to simply receive prayer or a transfer of healing energy.

The term holism was adopted by some of the pioneers of this movement to express their inclu- sion of the mind, body, emotions, spirit, and envi- ronment of the patient in the healing process. The principles of connection and integration that underlie the holistic paradigm arise from the fluid, multi-modal, right-brained thinking that, after centuries of devaluation in the West, is finally

� �beginning to regain lost ground 31 . While the whole brain is involved in all brain functions, it is possible to say that the right hemisphere is pre- dominantly involved in perceiving the gestalt, the whole. In contrast to the classifying and segment- ing unimodal approach of left-brained, linear sys- tems of thought, fluid thinkers use multimodal means of perception to apprehend the whole and to intuit the ever-shifting relationships of its parts. It is thinking of, with, and through the body and the spirit � holistic thinking, fluid thinking that transcends logical reasoning and rigid classifica-

� �tions in favor of what Starhawk 32 , one of its principal spokespersons, calls the ‘spiral dance.’ She means the spiral of the vortex, the tornado, the creative matrix in which all things are tossed around and mixed up beyond any making sense. From the deep integrative chaos of this energy vortex arises the surprise � the unpredictable relationship, the unexpected connection, the re- vealing intuition � that so often constitutes a prime element of holistic healing.

3.1. The 12 tenets of the holistic model

( )3.1.1. 1 Oneness of body-mind-spirit Mind and body, wrought asunder by Cartesian

rationalism, and reconnected in medical human- ism, are re united in holistic medical care. The worst problem here is language: we are so used to speaking in terms of mind�body separation that even holistic healers find themselves still using the words ‘mind’ and ‘body’; when they are care- ful, they will refer to the ‘bodymind’ to indicate that it is all one thing. A large part of the initial impetus for the reuniting of mind and body in holistic healing was the dawning realization that the brain, the physical seat of the mind, is not located only in the head but in fact extends throughout the central nervous system. Under- standing that the brain is distributed throughout the body makes it much harder to talk or think about body and mind as separate entities.

If the mind is the body, and the body is the mind, then how one responds to the treatment of even so mechanical a thing as a broken arm will have as much to do with how one thinks and feels about that broken arm as about what kind of cast is put on it. In the holistic approach, addressing the psychological states and emotions of the preg- nant or laboring woman is not just helpful, it is the essential aspect of care. Like humanists, holis- tic physicians are finding that they need much more engagement with the patient to get at those intangibles of mind and emotion now seen to be as much a part of the illness as its physical manifestation.

The holistic paradigm also insists on the partic- ipation of the spirit in the human whole. In incorporating soul it into the healing process, holistic healers bring medicine back into the world of the spiritual and the metaphysical from which it was separated during the Industrial Revolution. The spirituality of holistic healers tends to be fluid, and to take the form of a loose identifica- tion with eastern or New Age philosophies more often than with Judaism, Christianity, or Islam. Where the technomedical model is rigid and sep- aratist, the holistic model recognizes no sharp divisions or distinct boundaries. This is another reason why holism is so threatening: in many

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S17

people’s minds, to trifle with boundaries is to invoke chaos. And indeed, chaos theory and sys- tems theory both inform and underpin the holistic paradigm and its insistence on the oneness of body, mind, and spirit.

( )3.1.2. 2 The body as an energy system interlinked with other energy systems

The holistic paradigm moves far beyond the narrow view of the body-as-machine, past the humanistic view of the body as an organism, all the way to a limitless view of the body as energy. Defining the body as an energy system provides a powerful charter for the development and use of forms of medicine and treatment that work ener- getically such as acupuncture, homeopathy, intu- itive diagnosis, Reiki, hands-on healing, magnetic field therapy, and therapeutic touch. ‘Energy medicine’ acknowledges the possibilities that an individual’s health can be influenced by such sub- tleties as the vibrations of anger or hostility or the electromagnetic fields created by power plants and microwaves, of these presuppose non-physi- cal reality. Today’s physicists relish documenting the vanishing frontier between matter and energy. Medical research would require complete restruc- turing if it accepted such conclusions from other disciplines. For example, while medicine hotly refutes the impact of the investigator on research, physics recognizes the Heisenberg Principle, which acknowledges the influence of the observer on the observed. Even the intentionality of the experimenter can profoundly affect the outcome

� �of an experiment 33 . How can an observer sepa- rate from the observed phenomenon affect its behavior? Acceptance of this second tenet an- swers this question: the observer and the observed are not separate, but are energy fields in constant interaction with each other.

Many midwives Davis-Floyd has studied in the US define themselves as holistic and consciously seek to work with what they call ‘birth energy.’ Indeed, they believe that the primary intervention a midwife can make is at the energetic level. Intervening to ‘redirect the energies’ can ensure that no other type of intervention will be needed. If a labor stalls and a cesarean seems imminent, a

midwife who has a feel for the power of energy may throw open the window, put on some music, and get the mother up to dance. Or she might leave the room to allow the birthing couple some privacy, so that the loving energy of their rela- tionship can infuse the birth experience. The im- portant point is that for the practitioner who works at the level of energy, these sorts of inter- ventions will not be afterthoughts or overlays, but will be basic and primary � the first line of care.

( )3.1.3. 3 Healing the whole person in whole life context

This tenet of the holistic model of medicine, a logical corollary of the first two, acknowledges that no single explanation of a diagnosis, no sin- gle drug or therapeutic approach, will sufficiently address an individual’s health problems; rather, such problems must be addressed in terms of the whole persons and the whole environments in which they live. It is no accident that the most commonly asked question in holistic health is ‘What’s going on in your life?’ This question expresses the holistic view that illness is a mani- festation of imbalance in the bodymindspirit whole. Here holism accepts to the fullest findings from psychoneuroimmunology and other fields that the immune system, or the process of preg- nancy and birth, can be impeded by exhaustion, depression, emotional stress, the loss of a loved one, toxins in the air and the water, the stresses of technocratic life. The corollary of this view, of course, is that a healthy immune system, as well as a healthy pregnancy and birth, can be facili- tated by multiple means, from dialogue to dream analysis to dance, from massage to exercise to organic food.

( )3.1.4. 4 Essential unity of practitioner and client Many holistic practitioners try to drop the word

‘patient’ in favor of ‘client,’ as this term implies a mutually cooperative, egalitarian relationship. Where the humanistic model emphasizes the value of a mutually respectful connection between practitioner and client, still essentially separate and distinct beings, the holistic model offers the possibility that they are not separate but are fundamentally one. If the body is an energy field,

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S18

then as they interact the energy fields of client and practitioner can merge.

( )3.1.5. 5 Diagnosis and healing from the inside out While they may, if appropriate, order ‘outside-

in’ diagnostic tests, holistic practitioners will pri- marily diagnose and treat from the inside out--in other words, they will rely to a significant extent on the knowledge that arises from their own intuition, just as they will trust the inner knowing of their clients. Intuition is defined by the third edition of the American Heritage Dictionary as ‘the act or faculty of knowing or sensing without the use of rational processes; immediate cogni- tion.’ The knowledge on the basis of which deci- sions are made is defined as ‘authoritative

� �knowledge’ 3 . Technomedical practitioners tend to regard textbooks, diagnostic tests, and the ad- vice of experts as authoritative, and to dismiss the still, small voice of intuition. But holistic practi-

Ž .tioners like some humanists tend to regard intu- ition as a primary source of authoritative knowledge, along with the books and the ma- chines. Thus, in holistic practice, ‘diagnosis and healing from the inside out’ can refer to the information that arises from deep inside both patient and physician � a phenomenon ex- plained at its core by their essential unity.

Midwives often consider intuition to be a pri- mary source of knowledge about pregnancy and birth, as do all the holistic obstetricians Davis-

� �Floyd has interviewed 34,35 . Their willingness to rely on intuition comes from their deep under- standing of the body as energy and their trust in right-brained, gestaltic kinds of thinking that do not rely on logic but on that sudden flash of insight from which unity and healing can arise.

( )3.1.6. 6 Indi�idualization of care Holistic physicians are trained in tech-

nomedicine and have seen the damage standard- ized hospital policies and hierarchies can do to individuals. In general, they do their best to re- spond to the individuality and unique needs of each patient within the constraints imposed on them by hospital and legal regulations. For the laboring woman, individualization of care means that standardization does not apply. Her labor is

uniquely her own. She eats and drinks and moves about at will. She gives birth in the place of her choice attended by the people and practitioners of her choice. And the practitioner does not re- spond to the variations in her labor in standard- ized ways. A midwife dealing with a stalled labor might invite one woman to dance, might ask another if she is afraid to give birth, and might suggest a long walk with a third. Her intuition will guide her to respond to individual circumstances in individual ways. But the focus stays on the birthing woman. It is her unique needs and rhythms that will be paramount in the unfolding of her birth.

The unexpected twists that can result from holism’s high value on both individualization and interconnectedness are suggested in the theory of

� �self-organizing systems 36 , which states that even the smallest event, if it happens in just the right place at just the right time, can dramatically alter the whole system. Holistic healers try not to make assumptions about cause and effect. They tend to expect the unexpected and to be prepared for healing to arise in strange places and mysterious ways. A chance remark can instantly transform a woman’s perception of her condition and become the foundation of a cure. Holistic healers know better than to assume that they are the ones who heal the patient. They know that any one of a myriad of interactions over which they have no control can spark a healing process. Their genius lies in their ability to recognize that tiny flame when it is lit and help it to grow instead of extinguishing it.

( )3.1.7. 7 Authority and responsibility inherent in the indi�idual

A basic tenet of holistic healing is that ulti- mately, individuals must take responsibility for their own health and wellbeing.1 No one can really heal anyone else; individuals must decide for themselves if they want to be healed, and if so, they must take action to achieve that goal � give up smoking, exercise, eat right, maybe even give up a lucrative job that makes them unhappy or a relationship that is harmful to their health. Holistic practitioners in general tend to see them- selves as part of a healing team, of which the

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S19

patient is a full-fledged, indeed the most signifi- cant member. Many of our interviewees repeat- edly expressed their frustration with patients who refuse to take responsibility for their own health. They may greet the new client prepared to offer her empowerment, full participation in decision- making, informed choices, and so on, yet the patient may want only to be handed a prescrip- tion and told how many pills to take, or to sched-

� �ule her cesarean between conference calls 37 . Although some of our interviewees refuse to re- vert to the hierarchical mode and may refer such patients to another MD, most accept and work with the patient’s desire to place the physician in charge, or try to re-educate patients to take back the authority and responsibility they have surren- dered.

( )3.1.8. 8 Science and technology placed at the ser�ice of the indi�idual

If the technocratic model of medicine can be snappily characterized as ‘high tech�low touch,’ and the humanistic model as ‘high tech�high touch,’ then it would seem to follow logically that the holistic model of medicine would be ‘low tech�high touch.’ Sometimes this is true, as in the case of hands-on energy, nutritional medicine, herbal therapies � healing modalities for which no technological artifacts are used. But holistic healing can and often does incorporate high tech- nology, from biofeedback machines to lab tests and diagnostic computers. Holistic healers in gen-

1 Please note: The notion that authority and responsibility for health inhere in the individual is useful for thinking about the health care of the middle and upper classes. But the poor usually do not have the luxury of choosing their diet, their job, or their lifestyle. Nor can they afford the many options pre- sented by holistic healers, as these are usually not covered by private or government insurance systems. A huge limitation of holistic healing has been its confinement to the wealthier segments of society and its almost total unavailability to the poor. Perhaps the greatest challenge confronting proponents of holism is to make their services available to the poor: it will take a global paradigm shift of epic proportions in order for insurance systems in all countries to reimburse multiple forms of care. But this is the ultimate holistic vision: that allopathic hegemony would be replaced with systems in which all modali- ties would be equally accessible to all people.

eral do not reject technology; rather, they place it at the service of their clients, instead of allowing the technologies of health care to dominate, in- timidate, and lay the ground rules for treatment. Usually these technologies are not invasive, nor do they produce the toxic effects of many of the technologies of conventional medicine. In child- birth, they range from administering oxygen to a laboring woman in need of extra energy, to birth balls that facilitate changes in position, to Jacuzzis with overhead ropes to pull on as the woman bears down. Such technologies do not dominate and control; rather, they work with physiology to empower the woman to give birth.

And what of science? As we have seen, physi- cians are reluctant to change many commonly used procedures even when evidence reveals them to be inappropriate. French physician Michel Odent, a world leader in holistic childbirth, often notes that ‘science will save us.’ He is referring to the emerging trend in western obstetrics toward evidence-based care. If obstetrical care in most hospitals were to become truly evidence-based, then most standard interventions, including rou- tine IVs, routine use of pitocin, and the lithotomy Ž .flat-on-the-back position would have to be eliminated; women would eat, drink, and move about freely during labor; and they would give

� �birth in upright sitting or squatting positions 4�7 .

( )3.1.9. 9 A long-term focus on creating and maintaining health and well-being

Technocratic physicians often express extreme frustration over the patient’s failure to follow doctor’s orders. In contrast, holistic physicians most frequently voice frustration over patients who make no long-term commitment to improv- ing their health but want the doctor to provide them with a quick fix and let them get on with their lives as before. Quick fixes are poor substi- tutes for long-term lifestyle changes that can maintain good health. Holistic practitioners want their clients to make long-term changes in their diets and lifestyles that will not simply prevent illness but will actively generate good health. Giv- ing up sugar, caffeine, and highly processed foods, taking vitamin supplements, eating nutrient-rich organic vegetables, exercising regularly, and deal-

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S20

ing with stress through meditation are examples of the kinds of long-term changes that are often necessary to the creation of wellness. Holistic obstetrical practitioners know that pregnancy is an important time to be making such changes, not only for the health of the baby but also to ensure the long term health of the mother. The problem is of course that many people are resistant to such long-term lifestyle alterations. Holistic prac- titioners must engage in a great deal of client education, and must maintain a great deal of patience, in order to support people in making this kind of change.

( )3.1.10. 10 Death as a step in a process Beyond the humanistic view of death as ‘the

final stage of growth’ lies the holistic paradigm’s redefinition of death not as any kind of final end but as an essential step in the process of living. This view stems from holists’ definition of the body as an energy field, and from their deep- seated understanding of the transmutable nature of energy. Because of their integrated views on the essential oneness of body, mind, and spirit, it is only at the moment of death that holists grant these a conceptual separation. At death, in this view, the energy of the body decays and returns to earth, while the energy of the spirit or the individ- ual consciousness continues on. Most holists seem to accept some version of eastern philosophies of reincarnation, a processual view that allows the interpretation of death as an opportunity for con- tinued growth into a new kind of life in spirit and then again in flesh. While this positive view of death does not lead holists to rush to embrace death, it does tend to give them a strong sense of trust in the essential safety of the universe and in the wisdom and worth of its ways.

( )3.1.11. 11 Healing as the focus To say that the holistic model focuses on heal-

ing instead of on profit is not to dismiss the role of money and the practitioner’s need to make a livelihood within the system. Holistic practitioners have strong views about money � both for them- selves and as part of their professional identity. While they are conscious of the need to earn a living, it follows their personal commitment to

work rather than drives it. Few of the holistic physicians I have interviewed practiced within the framework of managed care, for example, where medicine and money are strongly affiliated. Only a few were on staffs of hospitals, where major health expenses are incurred, and virtually none

Žwere members of organized medicine as exempli- fied by the American Medical Association and its

.regional counterparts . Recognizing that healing occurs not in re-

sponse to their actions but in the support and stimulation of the vital force, in the exchange of energy between individuals, or in the long slow progress toward health that often rewards serious lifestyle changes, holistic doctors are keenly aware of their partnership with patients. Money is part of this exchange. Unlike doctors who practice technomedicine and are apt to live stressful and harried lives wherein they are unable to care for themselves adequately, holistic doctors are tend to find that their own healing often accompanies that of their patients, as it is practically impossi- ble to espouse a holistic philosophy without ap- plying it to oneself. In the mutual appreciation that often arises between holistic doctor and patient, a deep experience of �alue replaces the focus on money.

( )3.1.12. 12 Embrace of multiple healing modalities As we have seen, the holistic paradigm’s defi-

nition of the body as an energy field in constant interaction with other energy fields makes possi- ble its embrace of multiple modalities that remain unacceptable to proponents of the technomedical paradigm. The ultimate holistic vision entails a profound revolution in health care. Were this paradigm to gain cultural ascendance, the domi- nance of the technomedical model would be re- placed with the cultural valuation of a multiplicity of approaches. Midwifery, homeopathy, naturopa- thy, acupuncture, et al. would take their places as respected and legitimate disciplines. Practitioners of each modality would know enough about the others for appropriate referral. Above all, the public would be educated in the techniques of self-care, healthy lifestyle and the appropriate use of a variety of approaches to healing.

Holistic medicine’s embrace of multiple healing

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23 S21

modalities is gaining increasing public attention and acceptance. The clearest evidence for this statement comes from a study which determined that one third of Americans sought the services of a non-MD practitioner in a 1-year time period � and paid out of pocket for three-quarters of the

� �cost of these services 38 . Another finding of this survey was that 72% of the maverick patients did not tell their doctors about their use of alterna- tive medicine. Perhaps the center stage given to this study reflects the financial impact on medicine it uncovers, as well as the finding that the users of non-conventional therapies were well-educated, middle-income whites, from 25 to 49 years of age � one of the very best markets for orthodox medicine.

As a society’s medical system mirrors its core values in microcosm, so the evolution of medicine can influence the evolution of the wider culture. We must ask, Who do we want to make ourselves become through the kinds of health care we cre- ate? Contemporary obstetrical practitioners have a unique opportunity to weave together elements of each paradigm to create the most effective system of care ever designed on this planet. Infor- mation is available about indigenous childbirth

Žpractices from many cultures, some of which such .as massage and upright positions for birth are

highly beneficial and should be incorporated. More information than ever is available from scientific studies that tell us much of what we need to know about the physiology of birth and

Table 1

Ž .Technocratic model Humanistic biopychosocial model Holistic model

1. Mind�body separation 1. Mind�body connection 1. Oneness of body-mind-spirit 2. The body as machine 2. The body as an organism 2. The body as an energy

system interlinked with other energy systems

3. The patient as object 3. The patient as relational subject 3. Healing the whole person in whole-life context

4. Alienation of practitioner from 4. Connection and caring between 4. Essential unity of practitioner patient practitioner and patient and client

5. Diagnosis and treatment from 5. Diagnosis and healing from the 5. Diagnosis and healing from Žthe outside in curing disease, outside in and from the inside out the inside out

.repairing dysfunction 6. Hierarchical organization and 6. Balance between the needs of the 6. Networking organizational

standardization of care institution and the individual structure that facilitates individualization of care

7. Authority and responsibility 7. Information, decision-making, and 7. Authority and responsibility inherent in practitioner, not responsibility shared between patient inherent in each individual patient and practitioner

8. Supervaluation of science and 8. Science and technology 8. Science and technology technology counterbalanced with humanism placed at the service of the

individual 9. Aggressive intervention with 9. Focus on disease prevention 9. A long-term focus on creating

emphasis on short-term results and maintaining health and well-being

10. Death as defeat 10. Death as an acceptable outcome 10. Death as a step in a process 11. A profit-driven system 11. Compassion-driven care 11 Healing as the focus 12. Intolerance of other 12. Open-mindedness toward other 12. Embrace of multiple healing

modalities modalities modalities Basic underlying principle: Basic underlying principles: Basic underlying principles:

separation balance and connection connection and integration Type of thinking: Type of thinking: Type of thinking:

unimodal, left-brained, linear bimodal fluid, multimodal, right-brained

The three paradigms: the technocratic, humanistic, and holistic models of medicine

( )R. Da�is-Floyd � International Journal of Gynecology & Obstetrics 75 2001 S5�S23S22

the kinds of care that truly support women to give birth. And technologies exist to support every kind of labor choice. If we could apply appropri- ate technologies, in combination with the values of humanism and the spontaneous openness to individuality and energy chartered by holism, we could in fact create the best obstetrical system the world has ever known. This is the challenge we offer to those who attended the Fortaleza conference and to those who wish to continue their work.

Acknowledgements

I wish to express deep appreciation to Dr Ani- bal Faundes for his careful, thorough, and sensi-´ tive editorial work on this article, and to Gloria St. John, co-author of From Doctor to Healer, for allowing me to adapt some of our mutual work for this article.

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