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Abstract

The epistemological revolution of basic sciences which irrefutably documented the interaction subjectivity-biology-environment,determined a shift from the dominant intrinsic deterministic mechanic bio-technological paradigm toward a person centered indeterministic one. Its introduction in clinics and research is necessary to prevent epistemological biases leading to unreliable and invalid results. The Person Centered Health paradigm is the epistemological basis of Person Centered Medicine.
The Person Centered Health Paradigm and its impact on health sciences
Giuseppe R.Brera
Abstract
Physiology , epigenetics, affects science, psychoneuroimmunology, quantum biology and
epidemiology documented the action of the person’s qualitative variables on health and life, determining the
sunset of the bio-technology deterministic , paradigm, reducing the person to be an abstract “tool” or a “case”
of statistics. An only quantitative paradigm in health sciences is an epistemological bias leading to unreliable
and invalid results in research and clinics. A Person Centered Health Paradigm, coherent with basic sciences
and structured on the interaction of variables belonging to subjectivity, biology and environment, is presented.
It allows to build an anthropic conception of human nature, founded on the concept of a relativity of biological
reactions to the possibilities offered to or built by persons at the moment of an adaptive quest for change. The
new paradigm, epistemological basis of Person centered Medicine, needs the introduction in research and
clinics the “ resilience “ and “vulnerability” concepts.
*****
WHO in 1948 defined “Health” as “A complete state of physical, mental and social well-being, and
not merely the absence of disease or infirmity. (1) . Claude Bernard’s) epistemological theory (1865)
introduced the necessity of measurable laboratory results produced by empirical experiments for building a
theory of disease pathogenesis. (2) To date standard statistical analytical methods play a primary role for
significant confirmations of biological experimental hypothesis or reliability and validity of epidemiological
data but individual existential choices and human behaviours or socio-political and environmental factors,
account for millions of deaths. Genomic, the battle horse of contemporary investigations, accounts only for less
than 5% of the major cancers and coronary heart disease (3), and it has been recognized that epidemiology and
clinics must introduce variables belonging to lifestyle (4,5) related to the persons’ values and choices. Herbert
Marcuse (6) underlined an epistemological bias in modern science based on the prevalence of “Function” and
methods : “How it is” , and “ What is” , reducing reality to mental operations expressed by numbers and in
such a way determining the lost of dialectic values as person centered variables . This functionalist approach
in health sciences has lead to the person’s reduction to be a knowledge or a clinical application “object” , a
“case” of statistical analysis of clinical trials and therapeutic application or prevention strategies, where the
person becomes perceived as an abstract tool , a probable event, not a subject, a value himself, as if his
qualitative world made by values, beliefs, affects, emotions, familiar and social relations, behaviours,
constituting his existence, should be independent from his health. In health sciences there is a discrepancy
between quantitative standardized statistical methods and their knowledge objects, in health sciences “what”
and “how” are “who”.
During the last thirty years, we assisted in Medical Science to an epistemological revolution in basic
sciences . The Cannon’s theory of “Homeostasis” (7) “ Stability trough Constancy” has been overcome by the
Sterling’s concept of “Allostasis” (8-9) “Stability through Change” ; the genetic determinism has been
overcome by epigenetics, (10,11) which explained the existence of a direct relation between culture,
environment, behaviour and biology; psycho-neuro-endocrine-immunology (PNEI) already to an
experimental level, destroyed the Selye stress deterministic theory (12,13) and documented the relation
between motherhood quality and the endocrine brain (14) ; at the clinical level, it appears a robust association
between religiosity and lower death rate (15) ; a role of emotions on pathways to positive health has been
extensively documented by many investigations exhibiting the deep relation between postive and negative
affects , emotions, neurophysiology, allostatic load and survival. (16 ) Investigations identifying a new
discipline that could be named “Quantum biology” documented the existence of a direct relation between
conscience intentions , emotions affects and DNA. (17-18). With the Kandel’s discovery of the cell nucleus
basis of the synaptic plasticity, (19) caused by the long term potentiation, a great contribution to a scientific
basis of body-mind interaction , already theorized by John Eccles(20), was defined giving an explanation to
the mankind evolution.
These theories support the existence of a qualitative anthropic time made by the relativity of biological
variables to the possibilities and qualities of the person’s choices and his coping quality with environmental
and subjective, individual stimuli. There is an indeterministic shift in health construction differentiating
“Biological constants” necessary for life, from “ Biological variables”, whose variabilitiy at the time of
adaptational requests, appears associated with the person’s intentions and purposes that determine the
interpretation of possibilities , change and building an inner and outer reality through thoughts, affects,
emotions, behavior, correspondent to genetic transcriptions for new adaptations to the environmental and inner
quests. (21). An irreducible and unpredictable anthropic time characterizes the person’s symbolic and
biological work which interpretes and creates the experience unpredictable possibilities-like a scientific
hypothesis or an important love- that are interconnected with biological reactions in a bidirectional way
finalized to warrant the realization of intentions , what we could call Quality of choices”. Science and the
constant of the existence mystery irrefutably appear interconnected.
In investigation, clinical method and programs in public health there is the necessity to consider the
person’s affective-emotional and cognitive symbolic work for studying the adaptive changes communicated
to cells via neuromediators, hormones, cytokines determining the genetic transcription supported by the cell’s
mitocondrial energy production (ATP) and inducing the metabolic changes necessary for life. To date
interactionism in research and in clinics at the same time introducing biological, subjective and
environmemental variables in the hypothesis formulation, is the epistemological necessary condition for
reliable and valid results
An epistemological and epochal shift of biology , health sciences and clinics toward an indeterministic
paradigm is irrefutable with the bio-technological mechanistic determinism sunset.
The person’s quality and his life style expressed in affects, emotions, behavior, directly interacts with
biological and environmental variables , drawing a scientific basis of a new person centered health and
medicine paradigm presented in 2011 at WHO, and called “ The best possibilities for being a human person”.
(fig 1) (22), giving a real indeterministic scientific fundament to the health concept.
To date health appears like a music which a person plays on a piano, interpreting a score (DNA) and
pushing the piano keys (receptors), generating emotions , affects (symbolic level) and proteins ( biological
level), through the genetic transcription.
To date the key words of this new health concept are possibilities and resources , factors determining
protection or if absent or reduced, risk for life and health. This approach determines the necessary introduction
in health sciences and in clinical method the concepts of “ resilience “ , like a ratio between protective
factors/risk factors and “vulnerability”, like a ratio risk factors/protective factors, changing also the
epidemiological theory toward the necessity of computing resilience odds and rates for building resilience
models and in clinics the empathic analysis of individual strength points and resources, menaces and problems
and the person’s way to cope with these. Education in Person Centered Medicine and person centered clinical
method (23) lead to amazing results in saving human suffering and health costs, giving new perspectives also to
health governance. (24-25)
References and notes
.
1. WHO. Preamble to the Constitution of the World Health Organization as adopted by the International
Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.
2. Bernard C, An Introduction to the study of experimental Medicine (Dover Pub. Inc 1957).
3. B.R. Winkelmann et al., Am.Hearth J. 140, 511 (2000).
4. Willet C.W, Science, 296,695-697 (2002).
5. Rees.J, Science, 296,698-700 (2002).
6. Marcuse H, One-Dimensional Man: Studies in the Ideology of Advanced Industrial Society
( Beacon Press 1991).
7. Cannon WB, Am. J.Med. Sc. 189, 1-10 (1935).
8. Sterling P, in Allostasis, Homestasis and the Costs of Adaptation , J.Schukin Ed. (Cambridge
Univ.Press 2004) pp 1-36.
9. Seeman T.E ,B.H, Singer J, W.Rowe, R.I.Horwitz, B.S. McEwen, Arch.Int.Med. 157, 2259-
2268.(1997).
10. Robinson E.G, Fernald R , Clayton D, Science 322, 896-900 (2008).
11. Zhang T. Y., Meaney M, Annu Rev Psychol, 61(4), 439-66, (2010).
12. Selye H, The stress of life (Mac Graw-Hill New York 1956).
13. Laundeslangers M.L.,Ryan S.M.,Drugan S.F.F et al., Science 221, 568-570 (1983).
14. Liu D., Dorio J, Tannembaum J, Science 277, 1659-1662(1997).
15. Mccullough M, Oyt W, Larson d.B, Koenig H, Thoresen C, Health Psychology, 19(3), 211-22(2000).
16. Ryff C.D and Burton H., Singer J. The role of emotions on pathways to positive health in Handbook of
affective sciences , R.J.Davidson, K.R.Scherer & H.H. Goldsmith Eds.. ( Oxford Univ. Press 2003 New
York) pp. 1083-1897;
17. Rein G. Effect of conscious intention on human DNA, in Proceedings of the Int. Forum of New Sciences
Denver.CO. USA pp 1-12 (1996).
18. Rein G,Atkinson M,Mc Craty R, J.Advanc. Med. 8 - 2, 87-103 (1995).
19. Kandel E. J Neurosci, 29, 12748-12756 (2009).
20. Friedrich Beck, John C. Eccles , Proc. Natl. Acad. Sci. U.S.A. 89 (23): 1135711361 (1992).
21. Brera G. R, A Revolution for the Clinical Method and the Bio-Medical Research: the Determinate and
the Quality Indeterminate Relativity of Biological Ractions (Università Ambrosiana ed. 1996).
22. Brera G.R, The medical education change toward Person Centered Medicine Paradigm paper presented
in the WHO Symposium on Education in Person Centered Medicine , Geneva , 4 May 2011.
23. Brera G.R, Person Centered Medicine and Medical Education in the third millennium in it. La Medicina
centrata sulla persona e la formazione del medico nel terzo millennio, ( IEPI Pisa 2001) .
24. A first investigation made on the effects of Person Centered Medicine on clinical application showed
amazing results available on :
http://www.unambro.it/html/pdf/Person_Centred_Clinical_Method_Teaching.pdf
25. 144 clinical reports of 72 physicians’ prepared to apply the Person Centered Medicine Clinical method,
showed a method reliability of 0,81and validity of 0,80. It (in “Reliability and validity of Person Centered
Medicine Clinical Method for a Person and People Centered Care: a survey on 144 clinical reports of 72
physicians trained to apply Person Centered Clinical Method to adolescents from the Academic Year
1997 to 2002 at the Milan School of Medicine of the University Ambrosiana” Paper presented in the 5th
Geneva Conference on Person Centered Medicine April 30 May 2, 2012.
FIG 1
THE PERSON CENTERED HEALTH MODEL
BS T1…Tx BR T1…Tx
SjS T1…Tx P SjR T1…Tx
ES T1…Tx ER T1…Tx
P : the Person ; BS : Biological Stimuli; BR : Biological reactions (e.g. genetic expression);
SjS :Subjective Stimuli (e.g.: emotions, affects, behaviors, communications, values); SjR : Subjective reactions;
(emotions, affects, questions on the meaning, behaviors, beliefs, knowledge, quality of coping)
ES: Environmental Stimuli ( e.g. quality of motherhood and parental care , interpersonal and familiar relationships quality
, education level and quality, culture, religion, natural, socio-political events ,accidents, group dynamics and pressures);
ER : Environmental Reactions; ( e.g. fight and flight behaviours, work, social attitudes and conflicts, dependency from
group ) T1…Tx = time 1…time x (x is the unpredictability constant) means the variables assessment during the person
different life times . The arrows direction means the variables actions on person and the person actions on variables.
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Book
Summary of the book A Revolution for the Clinical Method and Biomedical Research : the Determinate and the Quality Indeterminate Relativity of Biological Reaction Giuseppe R.Brera ©Copyright Università Ambrosiana 1996 The book introduces the concept of "Relativity of Biological Reactions" separating these from "Biological constants" necessary for survival., leading Medicine to an indeterministic paradigm against determinism and mechanism and limiting for clinics results of experimental investigations on animals. The book is the epistemological basis of Person Centered Medicine and introduces in Medicine the interactionist paradigm, causing the end of the Stimulus-Answer model, mechanistic and deterministic one of the Selye’s stress theory centered only on animals’ biological variables change determined by bio-chemical stimula . Humans differently through subjective symbolic affective ,cognitive resources related to emotions elaborate and interpret internal and external stimula, that are influent on the gene expression. The theory has been based on experimental studies on the interactions between central nervous, immunitary and endocrinological systems, mind and behavior. The core of this theory is expressed in 4 equations, A-B-C-D. The base of the theory has been the experimental evidence about the variability of immunitary reactions in relation to the experimental possibility offered to animals to escape - or otherwise - conditions of stress determining the obsolescence of Selye’s concept of stress and permitted the formulation of a theory on «The determinate relativity of animal coping» called “Equation C” . Equation C (Rb = Bc x Pt (a)) draws the relativity of animal biological reactions to coping possibilities determined by the probability of positive or negative social and/or environmental conditions in relation to drives, Individual genotype and biological homeostasis. Equation D differently draws for humans a different relativity. Equation D Pt x Qc HmRb = -------------------- Bc HmRB = Human biological Reactions PT= Possibilities of coping AC = Quality of coping The equation introduces the concept of the “Quality” of coping related to the indeterminate subjective possibilities of humans ( values, emotions, affects, relations, behaviors) which determine a “ Coping quality” (Qc) related to choices in experience. This unforeseeable possibility (Pt) of choice but like animals related to genotype, biological homeostasis, social and environmental conditions but in a only human way to cognitive and psycho-sexual structural stage of development, is the indetermination constant of the Equation D. Biological constants (Bc) appear inversely related to possibilities of choices. Less possibilities of coping there are more biological reactions are determined by a direct actions of biological constants on life, how physicians and surgeons know when they work in emergency. Different epistemological models for human and animals are dependent from the presence in humans of self-determined, cognitive and psychosexual levels, and indeterministic factors ( eg. : moral and religious thinking, hypothetic-deductive reasoning, meaning awareness and will, creativity, parents’ education ). which determine a ” quality” in cognitive and affective symbolic processes, emotions, behaviors, coping and consequently different biological reactions. These qualitative and subjective factors are strictly related to neuromodulators, hormones and immunitary system actions in a bidirectional way through a new gene expression and receptors synthesis. Quality of coping is caused by the only human quality to choose among perceived and interpreted possibilities according the cognitive and psychosexual level, like Piaget and Freud showed., but possibility of an experience is unforeseeable like a dream or an encounter. Persons give a meaning to these showing a transcendent not empirical teleology existent in human nature well described by kairological theory. Mechanistic theory of human nature is obsolete and wrong and introduces necessarily new variables in medical research, clinics and medical education if wants arrive to true results. A new concept of health related to protective factors played by human possibilities, quality of the interpretation of reality, existential choices corresponding to affective and cognitive processes and neuromodulations, hormones transduced messages to cell membranes, that is a new indeterministic universe to be explored and related to person is born. Health to date can be interpreted and defined in a new way : “ Possibilities and qualities for being an human person based on a balance between protective and risk factors, that is resilience vs/ vulnerability” The theory of the relativity of biological reactions to possibilities and quality of coping (RBR theory) appears to introduce a new epistemological chapter in human biology and medical science allowing a reformulation of the scientific method applied to human nature and a new clinical method based on a. the necessity of introducing into human biology and clinical research variables belonging to the subjective world of humans determining quality of life : values,beliefs,emotions, affects, coping, behaviour and level of cognitive and psychosexual development. b. the existence of a teleology in human nature and the importance of affective and cognitive symbolic world in a culture determining possibilities and qualities in reality interpretation, choices and behaviours. c. the impossibility to directly transfer and apply to humans experimental inferences, based only on results of experimental studies because of the difference between Equation C and Equation D d the change of the health concept and the introduction in Medicine and Medical education the concepts of Resilience and Vulnerability. e the necessity to change clinical method according RBR equations B and D f the necessity of introducing in the experimental method new RBR variables according equation A and C d. the existence in humans of a mysterious indetermination constant The RBR (Relativity of Biological Reaction) theory opens new perspectives in Medical Science and Medicine and at clinical level constitutes the basis of the Person Centered Medicine Clinical Method.
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In an introduction L. J. Henderson reminds us that the discoverer of natural knowledge by the abstract character of his researches has his individuality obliterated and by the rational form of his conclusions his methods concealed, so that the young student has great obstacles which really keep him from gaining a true understanding of the art of research and of the inevitable conditions and limitations of scientific discovery. This book is therefore considered one of the most important of documents for the young worker, particularly of the biological sciences; for it makes it possible not only to see Claude Bernard at work, but even "to discover his purposes and his feelings." A short account of Claude Bernard's life by Paul Bert, dated Paris, February 12th, 1878, prefaces the main work. This is divided into three parts. The first is entitled Experimental Reasoning. The opening chapter is on Observation and Experiment, and concerns the distinction between sciences called "sciences of observation" and sciences called "experimental." Chapter 2 bears the heading The A Priori Idea and Doubt in Experimental Reasoning. Part II of the volume is on experimentation with living beings, while Part III deals with the applications of the experimental methods to the study of vital phenomena. The book is a mixture of profound logic, scientific methodology, and the psychology of observation, and thinking. For illustrative content it makes use of physiological and pathological material. "I believe in a word, that the true scientific method confines the mind without suffocating it, leaves it as far as possible face to face with itself, and guides it, while respecting the creative originality and the spontaneity which are its most precious qualities." (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference
WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.
  • T E Seeman
  • B H Singer
  • W Rowe
  • R I Horwitz
  • B S Mcewen
Seeman T.E,B.H, Singer J, W.Rowe, R.I.Horwitz, B.S. McEwen, Arch.Int.Med. 157, 2259-2268.(1997).
  • T Y Zhang
  • M Meaney
Zhang T. Y., Meaney M, Annu Rev Psychol, 61(4), 439-66, (2010).
  • D Liu
  • J Dorio
  • J Tannembaum
Liu D., Dorio J, Tannembaum J, Science 277, 1659-1662(1997).