A SYSTEMS APPROACH TO MEDICAL RESEARCH

A paper prepared by John Heron for the Research Council for Complementary Medicine, London, 1985

A REVISED WORLD-VIEW

We first of all need to go beyond Cartesian-Newtonian thought with a revised world-view based on some of the implications of new perspectives in physics, biology and psychology (cf. Bohm, 1980; Ferguson, 1980; de Vries, 1981; Sheldrake, 1981; Valle and von Eckartsberg, 1981; Wilber, 1981; Capra, 1982). Some features of this world-view can be conjectured as follows:

1. Reality is subjective-objective. The objective order is inseparable from subjective and intersubjective accounts of it. The constructs of the researcher are a part of what is being researched. Stated facts about the world are relative to a human context, individual and cultural, of experience, beliefs, norms and values (Kockelmans, 1975).

• Hence the outcomes of our inquiries about the world are always relative, conjectural and perspectival - constituted in part by how we choose to think about, look at, and interact with what is there, in a developing context of cultural thought.
• Hence, too, the importance in inquiry of epistemological heterogeneity, that is, the use of many and varied perspectives to overlap and thereby illuminate the chosen area of research with well-rounded and in-depth composite views (Maruyama, 1978). Subjective differences illuminate objective identities.

2. Reality is a whole made up of parts each of which is in turn a whole, subsuming further parts, and so on (Laszlo, 1972). Some features of whole-part systems are:

• A system is understood in terms of the overall pattern of organization of its parts.
• Such a pattern of organization has the interdependent aspects of process and structure: the programme and the blue-print.
• Such a pattern is an amount of information, a formula of meaning, that is of a different order or dimension of reality to that which it organizes.
• A key dynamic aspect of any overall pattern is the interdependence between the functional autonomy of each part and the functional integration of all the parts.
• A central dynamic aspect of the overall pattern of some systems (open systems) is a tendency toward self-transcendence: the capacity of the system internally to transform itself and thereby integrate with a greater whole than it had done hitherto.

3. Reality is multi-leveled in respect of being, in two basic ways:

• A system may include different orders of being, where each order is a part of the whole system. Thus a person includes physical, energetic, psychological, social, transpersonal orders. An order of being that occurs later in this list includes those that precede it; it encompasses more dimensions of reality, and requires wider categories of explanation, than those that precede it.
• A system may include different levels within the same order of being. Thus the physical body includes different levels such as cell, tissue, organ and so on.
• Within both these two sorts of system, power and influence flow in both directions, that is, both "up" and "dawn".
• And within both these sorts of system we may assume dynamic principle 2d (above) applies: interdependence between the relative autonomy of each level and functional integration of all the levels.

4. Reality is multi-leveled in terms of causation:

• There are effects of physical factors (single, multifactorial, mutual); of non-physical formative fields or patterns; of human intention; of social norms and values; of transpersonal factors.
• We may assume both the relative autonomy of each of these sorts of causation at its own level, and their relative integration into a total multi-causal system in which the different sorts of causation influence each other both "up" and "down".
• The four points of a new world view sketched in above are a conjecture about a meta-causal level of explanation, that is, a formative pattern of the scheme of things as a whole. In this conjecture so far, we have a participant subjective-objective reality in which a relative truth is found through the sharing of varied perspectives; a reality which is a set of interdependent part-whole systems within wider systems involving different levels of being and causation, with effects working within levels and between levels both "up" and "down"; and which manifests dynamic principles of autonomy, integration and transcendence.

MEDICAL RESEARCH REVISED

What kind of research in medicine stems from such a world-view? Presumably it would have the following sorts of features:

1. Medical treatment would be studied contextually as part of a total dynamic system of doctor-patient interaction. Medical research would be concerned with the pattern of such a system when it is effective, that is, when the patient emerges from it recovered. The focus is on a pattern or systems model -of explanation (Kaplan, 1964).

• Inquiry into the pattern of a treatment system would involve: (i) defining the limit or "size" of the system; (ii) defining the parts of the system in terms of its different levels of being and causation, and in terms of the salient components of each level; (iii) defining those relations between the parts that are relevant to the therapeutic effect of the system.
• The key aspects of a treatment system include: the autonomy (self-direction) of the patient, the autonomy of the doctor, and the integration or cooperation of these two; together with the capacity of the patient for self-transcendence, that is, for internal self-reorganization (getting well). In other words, the patient's intentions and the doctor's intentions in relation to each other, and the patient's intentions in relation to self, are central.
• Other features of the total pattern include: the changing relations between the different levels of being and causation within the patient during the treatment; the changing relations between the patient and his physical and social context during the treatment; relations between the different sorts of doctor-patient transaction - physical, verbal, transpersonal. And so on.
• The focus in research turns away from the effect on the patient's body of a particular physical intervention, to the outcomes in the patient's whole being and life context of participating in and contributing to the treatment system considered as a dynamic whole. Physical interventions and treatments lose their primacy of focus and become part of a complex pattern involving several levels of being and sorts of transaction at the centre of which is patient autonomy. The shift is from "it (the physical treatment) does something to my body" to "I do something to my body in the context of a multidimensional treatment system (that may include a physical treatment)".

2. Medical research would inquire into both illness and disease taken together as a system. Illness is the subjective experience of having a disease; whereas disease is the observable degeneration of function and/or structure in the body. They are complementary parts of an integrated system, and normally interact together. Nevertheless each has a certain relative functional autonomy: a person can experience illness and have no observable disease; and experience no illness and yet have observable disease. Between these extremes, the same disease condition may be associated with different degrees of illness in different persons, or in one person at different times.

• The supposition of radical inquiry is that how a person chooses to experience illness can either change a disease condition or effectively compensate for it. The functional relation between illness and disease is negotiable, open to influence by human intention. I can modify my disease by doing things with my illness. This is an aspect of the human system's capacity for internal re-organization or self-transcendence.
• The subjective-objective reality of illness-disease means that individual patient differences are fundamental in medical research. A group of patients may have the same observable disease condition yet each one have a different illness, that is, a different perspective on, experience of, that disease condition. And each may have a different capacity for internal reorganization, for altering their disease by doing things with their illness. There is a common objective warp, an idiosyncratic subjective woof. Individual differences in response to a standard treatment for the same disease condition are no doubt due, in part at least, to the fact that each patient concerned is idiosyncratically ill.
• Hence the need for a research method which does not restrict itself to the gathering of statistical averages, but depicts the varying different relationships between personal illness and a common disease condition. Facet theory (Canter, 1983) may be able to make a contribution here.
• The concept of cure, of getting better, needs to be redefined in terms of the illness-disease duality. Wellness, the experience of being well, is not to be directly equated with the absence of observable disease conditions. A treatment system is therapeutically effective when it meets some admixture of internal criteria of wellness and external criteria of physical recovery.

3. Medical research would co-opt the patient as co-inquirer, to a greater or lesser degree. This follows from the subjective-objective nature of the illness-disease to be studied.

• Only the patient can give a subjective perspective on the nature of their illness (as distinct from their disease), and on their capacity for doing things with their illness in order to modify their disease. And strictly speaking only the patient can generate the categories to be used to give an experientially valid account of these perspectives. No doubt formally trained researchers should facilitate and enable this process; but equally there is no doubt that ultimate epistemological authority lies with the patient not with the researcher.
• Each person is a special case: their subjectivity cannot be defined by generalizations drawn from other persons' accounts of their subjective perspectives and powers, although it may be encouraged and aroused by such accounts.
• How a person experiences their disease, that is, how a person is ill, is a choice, is in principle intentional. If I can learn to choose a different way of being ill, then how I was ill in the first place was already a choice. Only patients can properly inquire into this basic intentionality of their illness - by personal internal action research.
• Of course, in order to study the illness-disease system as a whole, we also need to see whether such internal action research on illness has any effects on observable disease conditions.

4. Medical research would itself constitute a co-operative system, involving patient, doctor and researcher, generating overlapping perspectives from all three points of view on the pattern of the treatment system, and making co-operative judgments of relevance from within it about what weight is to be given to what parts of the pattern in producing the treatment effect (Heron and Reason, 1984; Reason and Rowan, 1981).

• In a treatment system that includes intentional self-help on the part of the patient, varying levels of doctor-patient relationship, physical . treatments supplied by the doctor; and where the treatment effect is seen as a result of the pattern of interaction among these factors (as well as other factors); then the use of the randomized clinical trial, of matched experimental and control croups, is irrelevant since it is designed to obscure the interactive effects between physical treatments and idiosyncratic patient characteristics.
• In the last analysis it is only from within the subjective-objective reality of the treatment system that discrimination can be exercised about its pattern and the effects of that pattern. The kind of validity we are concerned with here is contextual validity (Diesing, 1972): different perspectives on a common area of inquiry illuminate it by both their similarities and their difference, and by shaving up each others shortcomings and distortions.
• This contextual validity can operate at two levels. Firstly, there is the overlap of perspectives generated within one actual treatment system. Secondly, this composite view can be overlapped with the composite views generated within further actual treatment systems.

METHODOLOGY

Finally, we can ask what research projects in the field of complementary medicine might look like if they were take account of this systems approach to medical research.

1. A study of de facto treatment systems in complementary medicine. This is a study of what actually goes on in existing treatment systems, as distinct from what is supposed to go on according to theory or tradition. The purpose is to find out what pattern of the components of the treatment system is therapeutically effective (if any).

Single practitioner study. A researcher co-operates with one practitioner, say an osteopath, to build up a composite portrait of the total treatment system of that practitioner. This could involve several stages:

• The researcher initiates the practitioner into the concept of a treatment system as outlined, for example, in this paper. Together, they work out the main parameters of a treatment system relevant to that practitioner - its "size", its component parts, the putative effective relations between the parts. They check this model with past patients of the practitioner, in order to modify it further; and with whom they also agree on some criteria for assessing initial patient state and final patient state (i.e. treatment system outcomes).
• The researcher sits in on a series of treatments with different patients from first to last treatment; the patients being selected to give a rounded view of what both practitioner and patient do in the system. Initial patient state assessments are made. Researcher, practitioner and at least some patients (who are gradually initiated into the concept of a treatment system) keep records of data on this series, on some agreed basis.
• During the series, the researcher intermittently confers with the : practitioner and the patients, using the data and direct recollection to flesh out and probably modify the model of the treatment system with which the inquiry started. After the series, final patient state assessments are made and all concerned confer to reach final decisions about the nature of the treatment system.
• At this final stage, the researcher needs to cooperate with both practitioner and patients to elicit judgments about the critical pattern or sub-pattern of the treatment system that is held to be therapeutically effective - according to the agreed criteria of "effective". This may also involve giving a weighting to differentially effective parts of the critical pattern. Of course, it may be discovered that there is no critical pattern and no therapeutic effect.

Multiple practitioner study. This is a study of the actual treatment systems of several practitioners- either within the same therapy, or across different therapies, depending on the purpose of the inquiry. One researcher can work with different practitioners (and their patients) on a serial basis, one after the other; or a team of researchers can work concurrently one-to-one with different practitioners, with intermittent meetings of all researchers and practitioners. Whatever the manpower logistics, the same basic stages given just above would be followed. The purpose of this study would be to find out more about the therapeutically effective patterning of treatment systems, either within one therapy, or across different therapies - by overlapping, comparing and contrasting the composite views of each practitioner's treatment system with the composite views of every other practitioner's treatment system.

Codifying data and presenting findings. The findings have three aspects: (i) The overall pattern of a treatment system; (ii) The critical parts and relations of the pattern that are therapeutically effective (if any); (iii) The evidence of effective outcomes. (iv) Multiples of the first three. Aspects (i) and (ii) can be represented by qualitative graphics. In the early days it is probably better not to try to use some formal quantitative system, except the simplest. Nevertheless, sophisticated formal systems in current use that may prove helpful in some respects are catastrophe theory (Postle, 1980) and facet theory (Canter, 1983).

Validity. The kind of validity involved is contextual (see page 4 above). It also depends on a range of process issues internal to the group of all those involved in the inquiry (Heron, 1982).

2. A study of the formal properties and relations of treatment systems. Once there is some representative data about actual treatment systems, it would be possible to do some theory-building about the nature and dynamics of such systems. What follow are conjectures about where such theory-building might go.

• Suppose we allow three levels (orders) of being in the patient: the physical body, the non-physical formative field of the body, human intention. Within what sorts of treatment system pattern can the third of these reorganize the first two?
• Is there a causal hierarchy in any treatment system such that beliefs, norms and values subscribed to within it empower human intention -exercised within it, which in turn empowers the formative field of the body to empower physical recovery? What is the reverse upward effect?
• What is the effective relation between the upward and downward influences among the multi-levels of a treatment system?
• How relatively autonomous is the physical intervention component (needle, pill, tincture, leverage, pressure, etc.) of a complementary therapy treatment system, and how interdependent is it with other parts of that treatment system? And so on.

3. A study of revisionary treatment systems. In this type of study new hypotheses about effective ways of patterning treatment systems derived from studies 1 and 2 above are field-tested, using the same kind of inquiry format as in studies of type 1 above.

ENDPIECE

What are the strengths and weaknesses of this systems approach to medical research?

• One strength is that it centres on patient power and intention. It attends to the potentiality of the human system as an open system, with its capacity for self-transcendence, internal re-organization.
• Another strength is that it sets physical treatment interventions in the context of human agency. It seeks to assess the effect of physical factors in treatment in the context of the effect of factors on other levels of being.
• One weakness is that to the degree that it does include in its results the effects of patient self-help, it cannot guarantee that those results will apply to patients beyond the treatment systems reported on. This follows from the idiosyncratic nature of the human will. Nevertheless its results can be a source of motivation and encouragement to others.
• Another weakness is that it cannot examine the relatively independent effect of physical treatment factors. So far as this can be done, the use of more traditional research methods is appropriate: for this see my earlier paper on the use of the randomized trial (Heron, 1984).

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