The fuzzy concept of ‘holistic care’: a critical examination

We are concerned by the fact that the concept of ‘holistic care’ is used in a variety of contexts without any clear definition of what is meant by the term. Generally, one finds the term used in the caring scientific literature, as a way of being attentive to individual, emotional, social, psychological, existential (and sometimes spiritual) dimensions of the human being. There is often a reference to notions of ‘balance’, ‘harmony’ and ‘wholeness’, but these terms are not defined either. There is nothing inherently wrong with a holistic perspective. On the contrary, it is laudable. However, the texts that use the term ‘holistic’ are often riddled by a vagueness and lack of philosophical rigour which gives the entire approach an air of the New Age movement which does not further the cause. We need a sound, scientific concept that can contribute in a meaningful way to the study of health and illness in order to have credibility in the evidence-based paradigm of today. Unfortunately, such a concept is lacking. In the following editorial, we would like to problematise the way the term ‘holistic’ is used in caring science literature and present a way to remedy some of the vagaries that surround this terminology Finally, we have noted that the same type of conceptual vagueness found in ‘holistic care’ seems to be emerging in relation to the recent concept of ‘person-centred care’. We believe that it is important to ground all scientific concepts in appropriate philosophical and epistemological frames of reference and be clear about the definitions and boundaries of the concepts one is using. For that reason, it is our hope that our criticism of ‘holistic care’ can give rise to a critical reflection on the use of this kind of terminology in general. References to ‘holistic care’ found in Swedish healthcare documents and healthcare rhetoric have to do with regarding the patient as a ‘whole person’, that is, with biological, psychological and social needs. A search on the Internet for scientific articles on ‘holistic care’, ‘holistic medicine’ and ‘holistic treatment’ yields thousands of hits. We found several attempts in the literature to define what ‘holistic care’ means 1-3 as well as a variety of empirical studies purporting to use a ‘holistic’ framework in clinical practice 4-7. The term ‘holistic’ functions most often in these texts as a negative category, that is, as a name for that which is not reductionist medicine. For example, holistic care is characterised as nontechnical, nontask oriented (relation-oriented), nonfragmented, nonutilitarian, nonstatistical and so on. The term is introduced as an alternative to the strictly medical approach, although what it actually entails is not clearly defined. The ‘whole’ in holism seems to be the idea that the whole (the human being) is more than the sum of the parts, an implicit (sometimes explicit) criticism of the biomedical tradition that only tends to the somatic ‘part’ of the human being. There are good intentions behind challenging the one-sided reductionist approach of the traditional biomedical approach, and focusing on patients’ experiences is not wrong, but in order to fill the term ‘holistic care’ with meaning, we will need more than declamations that one is interested in the ‘life-world’ of the patient. The concept of holistic care needs to be grounded in a sound philosophical perspective in order to contribute to a nonreductionist conceptualisation of the human being. We believe that the phenomenology of Maurice Merleau-Ponty 8 can offer such a philosophical grounding, as his work on the body provides us with the fruitful concept of the ‘lived body’, which is not to be confused with the objective body that is characterised by medical science. Merleau-Ponty's work is especially relevant in this context since his notion of the lived body is an attempt to philosophically define and characterise the ‘whole’ human being through a radically new conceptualisation of mind/body and world. The concept of the lived body is the term used by Merleau-Ponty to designate the lived unity of the mind–body–world system. The lived body is necessarily ambiguous, since it is both material and self-consciousness, both physiological and psychological. But these realms of existence (mind, body and experience of the world) are not as dichotomous as one would imagine. The self, the body and the world of things and others are neither separated from each other nor to be confused with each other, but can rather be seen as three sectors or levels of a unique field. Where there is a body, there is a personal world, an opening upon the world which is unique. This uniqueness has to do with our life as mind, as persons, with the fact that we have language, history and culture and can ask questions about our own existence. Likewise, there is no personal life or mind without a body, nor any bodies without a person. Finally, this intertwined mind–body unity is always embedded in and present to a concrete situation. There is no world (as perceived) without a human to experience it, and there is no human experience that is not of the world. Thus, we cannot discuss the body as if it were something cut off from both mind and world. In order to do justice to this profound given of human experience, we need to reformulate our conceptualisations of personhood, bodies and lived situations. This conceptual work would clearly benefit all discussions concerning holistic care. The lack of a genuine conceptualisation of the human being as a whole, grounded in philosophically appropriate terminology, results in the ironic situation that ‘holistic care’ is actually just as reductionist as biomedicine, in that the divisions between the human being as a biological, psychological social being are reinforced, maintaining a duality we need to overcome. Due to the vagueness and open-ended usage of terms like ‘holistic care’ in official documents, combined with researchers who use such terms without a sound philosophical grounding, the concepts of ‘lived experience’, ‘lived body’ and ‘holistic care’ are nothing more than labels without content. They become empty phrases harbouring a variety of idiosyncratic meanings, none of which are properly explicated. Healthcare science would benefit from a theoretical grounding of care in a philosophical explication of holism that overcomes both dualism and reductionism. On a final note, the concept ‘person-centred care’ has become very popular these days. This is an important notion, as is the notion of holistic care. However, we fear that this term is on the way to becoming the same kind of buzz word as holistic care. Our intention with this editorial is to raise the issue of how these terms are understood, both in policy documents as well as in healthcare research and practice. We encourage a critical examination of these terms in order to raise the credibility of the much needed concepts which attempt to address the unique needs of human beings in need of health care.