As a primary care physician, I’m grateful for Dr. James’s remarks. I share his desire to help others, including our fellow Christians, live healthy lives. I also agree with some of his concerns about contemporary mainstream medicine. As Wendell Berry claims in his wonderful essay “Health is Membership,” the medical “world of efficiency” often does a kind of violence to patients. It detaches them from their homes and communities and then separates them further into body parts and systems in order to isolate the problem. As Dr. James argues, physicians often strive to make the right diagnosis and initiate the proper treatment as quickly as possible, perhaps neglecting the contextual features that contribute to this patient’s illness or even ignoring the patient’s unique story altogether. The paradigm of “value-based care,” by which payers reimburse physicians whose patients comply with “population health” measures such as screening tests, has perhaps exacerbated the problem despite its good intentions, for as Dr. James says, this system encourages attention to “biomarkers” at the expense of the patient’s holistic “sense of well-being” in his or her daily life. Such “health care” belies the etymology of the word health, which as Berry points out derives from the same roots as wholeness and indeed holiness.
Faced with this crisis, I agree with Dr. James that we physicians need an alternative approach and that Christianity has much to offer. However, I have two concerns about his proposal for “Biblical Functional Medicine” (BFM). First, although it clearly differs from the approach of some specialist physicians who perhaps focus on one system or biomarker instead of the patient as a whole, I question how different his model is from my own standard primary care practice. Much of his practical advice – eat well (“input”), stay active (“output”), get sleep and rest (“recovery”) – comports with the advice I give my own patients in my general internal medicine practice. Much like Dr. James, I too am a pragmatist when it comes to diet and exercise. I talk with my patients about finding a plan that they enjoy and can sustain over a long life, not necessarily what is optimal or popular. I also emphasize the importance of good sleep and rest. Indeed, I discuss sleep so often that I have developed a handout for patients entitled “The 12 Commandments of Healthy Sleep.” Even when I do not ask directly about leisure, my patients frequently tell me what they enjoy doing in time off work, including going to church and spending time with family. I think I speak for most of my colleagues in saying that I consider all of these healthy practices important, as does Dr. James.
Some of Dr. James’s recommendations differ from what primary care physicians in mainstream medicine tend to discuss. A general internist will rarely address “inputs” such as others’ voices or pornography, much less the patient’s relationship with God. On this latter point, physicians should perhaps heed the extensive literature showing that patients want physicians to address their religious and spiritual lives. Dr. James also correctly points out that structural factors in American medicine, many of which derive from federal policy decisions, make it difficult for physicians to offer holistic patient care, as he himself experienced in attempting to open his own practice. Yet some of these policies can be changed in beneficial ways. For example, payers such as Medicare have begun to reimburse primary care physicians for time spent with patients, not just for how many diagnoses they address and tests they order, creating an incentive for me to spend time simply talking to my patients about their goals for their health care rather than focusing narrowly on one or two conditions. This incremental change, and others like it, can perhaps encourage reforms in American health care that obviate the need for an entirely new model.
My second and larger concern with Dr. James’s BFM model is that it may not be biblical enough. Although his advice about eating and sleeping well is excellent, it does not seem uniquely Christian. Surprisingly, Dr. James does not mention Jesus, even though Jesus in becoming fully human took on the bodily vulnerability that has always led patients to seek out physicians. A truly biblical medicine should be Christo-centric, following from Christ’s own example in the Gospels. Indeed, the many healing miracles recorded in the Gospels reveal Jesus as the true source of healing and wellness. At times, Dr. James seems perhaps unintentionally to give the impression that Christians can achieve optimal health entirely through their own efforts, by following the steps he describes to “captain their own metabolism.” Although physicians should empower their patients, such an approach runs the risk of encouraging a prideful and judgmental attitude in those who are healthy, as when Jesus’ disciples assume in John 9 that the blind man’s ailment must have resulted from his parents’ or his own sinful misbehavior. Jesus says rather that his condition is so that “the works of God might be made manifest in him” (John 9:3), creating an opening for God’s glory, not for human effort. For his part, the healed man admits his ignorance of the means of his healing (John 9:25) and can therefore thank Jesus for the gift of health. A Christian model of medicine should take care not to overestimate the degree of control that humans have over their health and thus disrupt this fundamental stance of gratitude to God.
Another theme emerging from the healing miracles is Jesus’ solicitude for human sickness and frailty. In these narratives, the sick individual often makes a request regarding a specific bodily concern in the hope that Christ can provide help. Instead of redirecting the person’s attention, Jesus focuses intently on his or her complaint. This healing often serves as a prelude to a more holistic change in the person’s life, as after the healing at Bethesda Jesus behooves the former paralytic to “sin no more” (John 5:14), but Jesus first addresses what the person finds most intolerable. This pattern suggests that mainstream medicine’s focus on diagnosis and treatment may not always be misguided. Although I share Dr. James’s desire to promote my patients’ overall health, many of them first present to me with specific concerns, and in those instances I may need temporarily to narrow the scope of the visit, making use of “biomarkers” and other indicators to provide the healing of which contemporary medicine is capable. Insofar as Christ is the ultimate source of all good gifts, including health, the healing I offer as a physician prefigures and participates in God’s final healing, which is to come (Revelation 21:4).
Although these miracles demonstrate Christ’s healing intent toward the sick, the Gospels also seem to make clear that physical health is not of absolute concern. Dr. James indicates that Christians ought to achieve 80-90 years of “full, active, working life.” Yet not only did Jesus Himself suffer immense pain and death in His early thirties, but He also maintained the wounds inflicted by the Cross on His resurrected body. He makes clear that, although health is good, God also invites even those who cannot achieve it, such as “the crippled, the lame, and the blind,” to come as they are to the heavenly banquet (Luke 14:13). The Gospels offer hope to all humans, whose flesh makes them ever vulnerable to injury and disease, but as many theologians concerned with disability have argued, they appeal in a special way to the disabled, whose bodies may preclude “full, active, working life” in their youth, let alone in their eighties. Christian medicine thus needs paradoxically to avoid absolutizing the goodness of health even as we encourage our patients to pursue it. Even those who cannot achieve or maintain their health can have higher goods, such as fellowship with others and union with God. Indeed, in the divine economy of grace, those such as the disabled, who are more reliant on others and less capable of “captaining” their bodies, may become open to spiritual gifts that others find it difficult to receive humbly. I also cannot help but think of Christians such as St. Perpetua, who died a martyr at the hands of the Romans, or Damien of Molokai, who died ministering to lepers. As these and countless other examples demonstrate, following Jesus may in fact be hazardous to one’s health. Jesus does not promise wealth, fame, or even health, but the Cross (Matthew 16:24-26). Yet the Bible makes clear that we Christians are nevertheless to love God and serve our neighbors.
Above all, a Christo-centric medicine should reveal the love of God for the world, the love by which He shared our humanity and made Himself vulnerable to suffering and death. Dr. James correctly points to relationship as the “chief cornerstone” of biblical medicine, and indeed the “Relationship” section of his article is the most theological, beginning as it does with the Trinity and the Fall. Not only should Christian physicians promote health in such a way that it advances their relationships with others and with God, but they should also manifest God’s loving concern in their own relationships with their patients.
As Berry argues in his critique of medicine’s “world of efficiency,” too often we physicians think of ourselves as mere technicians, even cultivating detachment from our patients as an ostensibly more “scientific” and “objective” posture. Yet this approach leaves us unsure what to do in those moments when contemporary medicine has little or nothing to offer, such as when our patients receive a diagnosis of an incurable illness or are nearing death. In “Health as Membership,” Berry tells the story of his brother’s hospitalization for coronary artery bypass graft surgery, during which a nurse came to inform his brother’s wife that he had suffered a small setback after the operation. When she became upset at the news, the nurse attempted to reassure her by repeating the medical facts, but the nurse eventually fell silent, realizing that mere scientific information was insufficient. At that moment, she simply gave the patient’s wife a hug, “which brings us to a starting place,” according to Berry. This embrace represents the world of love, which Berry as a Christian considers the real world, breaking into medicine’s world of efficiency, offering a foretaste of God’s own love for us. Christian physicians can aim to show such love in their relationships with patients. We can structure our practices so that “the poor, the crippled, the lame” (Luke 14:13), not just the wealthy and well-educated, can be served. We might also seek not only to provide efficient diagnosis and treatment but also to accompany our patients, whether healthy or ill, offering compassion as a response to the vulnerability to disease and death that we humans share and that Christ accepted for Himself.
Dr. James and I agree that contemporary health care fails patients in many ways and that Christianity has something to offer physicians and patients alike. Yet rather than simply changing the emphasis from disease to function and aiming for a longer lifespan, I would suggest that Christians might look instead to the model of the ancient Basiliad, the world’s first hospital and a uniquely Christian institution. Here, Christians offered the sick not only treatment aimed at cure or improved function but also, in Berry’s words, membership in a community of care and prayer. Undoubtedly many of the caregivers died of communicable diseases acquired in this service. Yet they served anyway because of their faith and hope that Christ had already conquered death, freeing them to love God and their neighbors without fear. Theirs was a medicine worthy of being called “biblical,” and indeed “Christo-centric.” Perhaps ours may yet be.
Kyle E. Karches, MD, PhD is Associate Professor, Albert Gnaegi Center for Health Care Ethics, St Louis University.
As a primary care physician, I’m grateful for Dr. James’s remarks. I share his desire to help others, including our fellow Christians, live healthy lives. I also agree with some of his concerns about contemporary mainstream medicine. As Wendell Berry claims in his wonderful essay “Health is Membership,” the medical “world of efficiency” often does a kind of violence to patients. It detaches them from their homes and communities and then separates them further into body parts and systems in order to isolate the problem. As Dr. James argues, physicians often strive to make the right diagnosis and initiate the proper treatment as quickly as possible, perhaps neglecting the contextual features that contribute to this patient’s illness or even ignoring the patient’s unique story altogether. The paradigm of “value-based care,” by which payers reimburse physicians whose patients comply with “population health” measures such as screening tests, has perhaps exacerbated the problem despite its good intentions, for as Dr. James says, this system encourages attention to “biomarkers” at the expense of the patient’s holistic “sense of well-being” in his or her daily life. Such “health care” belies the etymology of the word health, which as Berry points out derives from the same roots as wholeness and indeed holiness.
Faced with this crisis, I agree with Dr. James that we physicians need an alternative approach and that Christianity has much to offer. However, I have two concerns about his proposal for “Biblical Functional Medicine” (BFM). First, although it clearly differs from the approach of some specialist physicians who perhaps focus on one system or biomarker instead of the patient as a whole, I question how different his model is from my own standard primary care practice. Much of his practical advice – eat well (“input”), stay active (“output”), get sleep and rest (“recovery”) – comports with the advice I give my own patients in my general internal medicine practice. Much like Dr. James, I too am a pragmatist when it comes to diet and exercise. I talk with my patients about finding a plan that they enjoy and can sustain over a long life, not necessarily what is optimal or popular. I also emphasize the importance of good sleep and rest. Indeed, I discuss sleep so often that I have developed a handout for patients entitled “The 12 Commandments of Healthy Sleep.” Even when I do not ask directly about leisure, my patients frequently tell me what they enjoy doing in time off work, including going to church and spending time with family. I think I speak for most of my colleagues in saying that I consider all of these healthy practices important, as does Dr. James.
Some of Dr. James’s recommendations differ from what primary care physicians in mainstream medicine tend to discuss. A general internist will rarely address “inputs” such as others’ voices or pornography, much less the patient’s relationship with God. On this latter point, physicians should perhaps heed the extensive literature showing that patients want physicians to address their religious and spiritual lives. Dr. James also correctly points out that structural factors in American medicine, many of which derive from federal policy decisions, make it difficult for physicians to offer holistic patient care, as he himself experienced in attempting to open his own practice. Yet some of these policies can be changed in beneficial ways. For example, payers such as Medicare have begun to reimburse primary care physicians for time spent with patients, not just for how many diagnoses they address and tests they order, creating an incentive for me to spend time simply talking to my patients about their goals for their health care rather than focusing narrowly on one or two conditions. This incremental change, and others like it, can perhaps encourage reforms in American health care that obviate the need for an entirely new model.
My second and larger concern with Dr. James’s BFM model is that it may not be biblical enough. Although his advice about eating and sleeping well is excellent, it does not seem uniquely Christian. Surprisingly, Dr. James does not mention Jesus, even though Jesus in becoming fully human took on the bodily vulnerability that has always led patients to seek out physicians. A truly biblical medicine should be Christo-centric, following from Christ’s own example in the Gospels. Indeed, the many healing miracles recorded in the Gospels reveal Jesus as the true source of healing and wellness. At times, Dr. James seems perhaps unintentionally to give the impression that Christians can achieve optimal health entirely through their own efforts, by following the steps he describes to “captain their own metabolism.” Although physicians should empower their patients, such an approach runs the risk of encouraging a prideful and judgmental attitude in those who are healthy, as when Jesus’ disciples assume in John 9 that the blind man’s ailment must have resulted from his parents’ or his own sinful misbehavior. Jesus says rather that his condition is so that “the works of God might be made manifest in him” (John 9:3), creating an opening for God’s glory, not for human effort. For his part, the healed man admits his ignorance of the means of his healing (John 9:25) and can therefore thank Jesus for the gift of health. A Christian model of medicine should take care not to overestimate the degree of control that humans have over their health and thus disrupt this fundamental stance of gratitude to God.
Another theme emerging from the healing miracles is Jesus’ solicitude for human sickness and frailty. In these narratives, the sick individual often makes a request regarding a specific bodily concern in the hope that Christ can provide help. Instead of redirecting the person’s attention, Jesus focuses intently on his or her complaint. This healing often serves as a prelude to a more holistic change in the person’s life, as after the healing at Bethesda Jesus behooves the former paralytic to “sin no more” (John 5:14), but Jesus first addresses what the person finds most intolerable. This pattern suggests that mainstream medicine’s focus on diagnosis and treatment may not always be misguided. Although I share Dr. James’s desire to promote my patients’ overall health, many of them first present to me with specific concerns, and in those instances I may need temporarily to narrow the scope of the visit, making use of “biomarkers” and other indicators to provide the healing of which contemporary medicine is capable. Insofar as Christ is the ultimate source of all good gifts, including health, the healing I offer as a physician prefigures and participates in God’s final healing, which is to come (Revelation 21:4).
Although these miracles demonstrate Christ’s healing intent toward the sick, the Gospels also seem to make clear that physical health is not of absolute concern. Dr. James indicates that Christians ought to achieve 80-90 years of “full, active, working life.” Yet not only did Jesus Himself suffer immense pain and death in His early thirties, but He also maintained the wounds inflicted by the Cross on His resurrected body. He makes clear that, although health is good, God also invites even those who cannot achieve it, such as “the crippled, the lame, and the blind,” to come as they are to the heavenly banquet (Luke 14:13). The Gospels offer hope to all humans, whose flesh makes them ever vulnerable to injury and disease, but as many theologians concerned with disability have argued, they appeal in a special way to the disabled, whose bodies may preclude “full, active, working life” in their youth, let alone in their eighties. Christian medicine thus needs paradoxically to avoid absolutizing the goodness of health even as we encourage our patients to pursue it. Even those who cannot achieve or maintain their health can have higher goods, such as fellowship with others and union with God. Indeed, in the divine economy of grace, those such as the disabled, who are more reliant on others and less capable of “captaining” their bodies, may become open to spiritual gifts that others find it difficult to receive humbly. I also cannot help but think of Christians such as St. Perpetua, who died a martyr at the hands of the Romans, or Damien of Molokai, who died ministering to lepers. As these and countless other examples demonstrate, following Jesus may in fact be hazardous to one’s health. Jesus does not promise wealth, fame, or even health, but the Cross (Matthew 16:24-26). Yet the Bible makes clear that we Christians are nevertheless to love God and serve our neighbors.
Above all, a Christo-centric medicine should reveal the love of God for the world, the love by which He shared our humanity and made Himself vulnerable to suffering and death. Dr. James correctly points to relationship as the “chief cornerstone” of biblical medicine, and indeed the “Relationship” section of his article is the most theological, beginning as it does with the Trinity and the Fall. Not only should Christian physicians promote health in such a way that it advances their relationships with others and with God, but they should also manifest God’s loving concern in their own relationships with their patients.
As Berry argues in his critique of medicine’s “world of efficiency,” too often we physicians think of ourselves as mere technicians, even cultivating detachment from our patients as an ostensibly more “scientific” and “objective” posture. Yet this approach leaves us unsure what to do in those moments when contemporary medicine has little or nothing to offer, such as when our patients receive a diagnosis of an incurable illness or are nearing death. In “Health as Membership,” Berry tells the story of his brother’s hospitalization for coronary artery bypass graft surgery, during which a nurse came to inform his brother’s wife that he had suffered a small setback after the operation. When she became upset at the news, the nurse attempted to reassure her by repeating the medical facts, but the nurse eventually fell silent, realizing that mere scientific information was insufficient. At that moment, she simply gave the patient’s wife a hug, “which brings us to a starting place,” according to Berry. This embrace represents the world of love, which Berry as a Christian considers the real world, breaking into medicine’s world of efficiency, offering a foretaste of God’s own love for us. Christian physicians can aim to show such love in their relationships with patients. We can structure our practices so that “the poor, the crippled, the lame” (Luke 14:13), not just the wealthy and well-educated, can be served. We might also seek not only to provide efficient diagnosis and treatment but also to accompany our patients, whether healthy or ill, offering compassion as a response to the vulnerability to disease and death that we humans share and that Christ accepted for Himself.
Dr. James and I agree that contemporary health care fails patients in many ways and that Christianity has something to offer physicians and patients alike. Yet rather than simply changing the emphasis from disease to function and aiming for a longer lifespan, I would suggest that Christians might look instead to the model of the ancient Basiliad, the world’s first hospital and a uniquely Christian institution. Here, Christians offered the sick not only treatment aimed at cure or improved function but also, in Berry’s words, membership in a community of care and prayer. Undoubtedly many of the caregivers died of communicable diseases acquired in this service. Yet they served anyway because of their faith and hope that Christ had already conquered death, freeing them to love God and their neighbors without fear. Theirs was a medicine worthy of being called “biblical,” and indeed “Christo-centric.” Perhaps ours may yet be.
Kyle E. Karches, MD, PhD is Associate Professor, Albert Gnaegi Center for Health Care Ethics, St Louis University.
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