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,
- 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
- 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
- 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
- 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
- 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
- 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
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
- 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
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
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
- 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.
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
- 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
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