The Journal of Continuing Education in the Health Professions, Volume 21, pp. 170181. Printed in the U.S.A.

Copyright 2001 The Alliance

for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for
Hospital Medical Education. All rights reserved.

Innovations in Continuing Education

Existential Medicine:
Martin Buber and Physician-Patient Relationships
Felicia Cohn, PhD
Abstract
Martin Bubers (18781965) social existentialist thought offers a unique lens through which
physician-patient relationships may be interpreted. Buber develops concepts of relationships
and dialogue that provide insight into physician-patient relationships. His notions of I-Thou
and I-It relationships have relevance for contemporary medical education and practice. Current
medical practice is situated in the It-realm of order, objectivity, detachment, abstraction, and
experience. This perspective is necessary for medical education and practice but can result
in the progressive decline of the interhuman relationships that define medicine. I-Thou rela-
tionships, characterized by spontaneity, subjectivity, reciprocity, and recognition and acceptance
of the unique other, are essential for humanhood. However, physicians and patients may be
constrained from achieving I-Thou relationships by the very nature of their interactions, which
are planned and purposive. Buber describes the possibility of a therapeutic relationship that
approaches the I-Thou realm. Bubers thought suggests three conceptual shifts that facilitate
the development of therapeutic relationships in medical practice and have implications for
medical education: (1) from disease-centered to person-centered care, (2) from crisis to every-
day management, and (3) from principles and contracts to relationships.
Key Words: Communication, continuing medical education (CME), dialogue, existential
medicine, Martin Buber, medical education, physician-patient relationships

There are many different ways to look at the prac-
tice of medicine, with each perspective both high-
lighting and hiding various aspects. Existentialism
provides one more lens through which to view
medicine, and Martin Bubers (18781965)
thought lends a unique focus. This article explores
Bubers thought in the context of physician-
patient relationships and describes distinctive
images of interactions and communication within
the medical setting that Bubers unique brand of
Reprint requests: Felicia Cohn, PhD, Director of Ethics
Education, University of CaliforniaIrvine, College of
Medicine, Medical Education Building 802, Irvine, CA
92697-4089.
existential thought suggests. For Buber, rela-
tionship and dialogue are not issues for medi-
cine; rather, medicine is a matter of relationship
and dialogue. Analysis from this perspective will
challenge more traditional views of medicine and
will offer new insights for medical education and
practice.
Martin Bubers Social Existentialist Vision
According to Buber, an individuals basic con-
nection to the world is an expression of his or her
own existence. Human beings have a dual char-
acter, formed by the relations in which they are
involved. The I alone is merely an abstraction
that can be actualized only with another form.
That is, the I exists in connection with a Thou
or an It. Both types of relationships are necessary

170
 Cohn
for existence.* The major difference lies in how
another is recognized, either in concrete unique-
ness (I-Thou) or as the content of ones experience
(I-It).
I-Thou relationshipscharacterized by reci-
procity or mutuality, spontaneity, acceptance and
confirmation of otherness or uniqueness, imme-
diacy, wholeness, exclusiveness, inclusion, and
alternation of actuality and latency1,2are integral
to humanhood, defining individuals. An individ-
ual is fully realized in a relationship with another
unique being, a Thou. Bubers thought, then, sug-
gests that a physicians very being, like other indi-
viduals, depends on a relationship with others,
patients.
Physician-patient interactions, however, appear
to occur primarily in what Buber calls the It-
world, one of abstraction, causality, detachment,
and utility. He notes, In our time there predom-
inates an analytical, reductive, and deriving look
between man and man,3 indicating what he per-
ceived to be a significant problem of our time. Our
need to understand is, to a certain extent, over-
whelming what we are trying to understand, scru-
tinizing the subjects of our inquiry to the point of
objectification. This reflects a particular view of
medicine based on certain assumptions, stereo-
types, and generalizations. Briefly stated, this
view of medicine involves concern about an
overemphasis on technology in the clinical prac-
tice of medicine to the detriment of human rela-
tionships, limited recognition of the significance
*The literal German translations of Beziehung and
Verhltnis are pulling, tugging and being held in
place, respectively. Beziehung (relationship) occurs
between an Ich and a Du (I and Thou/You), whereas
Verhltnis (relation) describes a meeting of an Ich and an
Es (I and It). Ich-Du has been translated as both I-Thou
and I-You in English, but neither seems to capture the
full meaning Buber intended. Thou suggests an inappro-
priate air of formality in present-day English, whereas
You fails to indicate the unique character of this rela-
tionship. Thou is generally used throughout this article,
but the use of I-Thou or I-You is maintained in
quotations.
171
of the physician-patient relationship for healing,
the appropriate role of detachment in a therapeu-
tic relationship, and beliefs that the practice of med-
icine needs to be and can be improved. The con-
ventional wisdom regarding inadequacy with
physician-patient relationships stems primarily
from tertiary care medicine, where, it is important
to note, most medical education occurs. Certainly,
the stereotypes do not fully describe the practice
of medicine or how particular clinicians practice
medicine but are rooted in reality and indicate
perceptions regarding problems in the practice of
medicine.
Buber recognizes that the analytical method
of the human sciences is indispensable.3 The I-
It relation is, for Buber, a necessary anthropo-
logic category, offering familiar order, reliable
experience, and continuity in space and time.
Thus, as it is a necessity for human existence, it
is not inherently evil.
A problem with boundaries, however, exists.
Analysis is necessary wherever it furthers knowl-
edge of a phenomenon without impairing the
essentially different knowledge of its uniqueness
that transcends the valid circle of the method.3 In
allowing the It-world to represent the totality of
human existence, knowledge of uniqueness is
impaired, and individuals are reduced to abstrac-
tions or categories. According to Buber, When
man lets it have its way, the relentlessly growing
It-world grows over him like weeds, his own I loses
its actuality, until the incubus over him and the
phantom inside him exchange the whispered con-
fession of their need for redemption.4 The It-
world becomes evil if people presume that it pos-
sesses the actualitythe concrete, immediate,
inclusive, relational qualitiesof the Thou-world.
Buber suggests that loss of relationship is a
danger of modern times. The history of the
Although no evidence is provided for this concept of
medicine, here it is supported in the writings of several
physicians and bioethicists, including Francis Peabody,
Eric Cassell, Jay Katz, Melvin Konner, Howard Brody,
and Stanley Joel Reiser, several of whom are cited in this
article.
 Existential Medicine
individual and the history of society both signify
a progressive increase in the It-world.4 This
growth decreases the capacity for relationship and
so, according to Buber, is a sickness of our age.4
As people become more able to use and experi-
ence, the possibility of I-Thou encounters becomes
more remote, and individuals are less able to cre-
ate and maintain a balanced dialectic between the
Thou- and It-spheres. Buber explains:
When a culture is no longer centered in a
living and continually renewed relational
process, it freezes into the It-world which
is broken only intermittently by the erup-
tive, glowing deeds of solitary spirits. From
that point on, common causality, which
hitherto was never able to disturb the spir-
itual conception of the cosmos, grows into
an oppressive and crushing doom.4
The practice of medicine exemplifies a pro-
gressive augmentation of the It-world. Physician-
patient relationships reflect a variety of changes:
increased research and technology, growth in the
health care enterprise, shifts in medical practice
models, a more regulatory and litigious society, and
development of the health insurance industry. His-
torian David Rothman notes this growth of the It-
World: Practically every development in medi-
cine in the post-World War II period distanced the
physician and the hospital from the patient and the
community, disrupting personal connections and
severing bonds of trust.5 The introduction of cer-
tain medical tools and techniques, such as the
stethoscope and chest percussion, have reoriented
the practice of medicine, with physician bias shift-
ing from a scholarly disdain for touching patients
to an emphasis on manual examination. How-
ever, physicians
. . .became so enraptured by the evidence
produced by applying their own senses to
the evaluation of illness that they increas-
ingly disregarded the sensations experienced
and described by the patient as unreliable,
172
unconfirmable, and inferior by compari-
son. . . From the beginning of their
introduction in the mid-nineteenth century,
automated machines that generated results
in objective formats such as graphs and
numbers were thought capable of purging
from health care the distortions of subjec-
tive human opinion. They were supposed
to produce facts free of personal bias, and
thus to reduce the uncertainty associated
with human choice. This view, held by prac-
titioners and patients, stimulated the intense
use of these devices, sometimes to excess.
This excess has been characterized by over-
reliance on technologically depicted
features of illness, inadequate understand-
ing of the capabilities and limits of
machines and the information they gener-
ate, and relative inattention to those aspects
of medicine learned by inquiry into the
patients experiences and views. . .
[Machines] can make us forget the hands
and minds behind their creation, they can
make us forget ourselves.6
Increased physical contact with patients has
not resulted in the development of interhuman
relationships; in fact, it appears to interfere with
expression of the Thou-world. With technology,
human interaction may be sacrificed in the name
of expediency, subordinated to another goal, or
neglected entirely. Physician and patient may
meet, but not encounter, speak but not reveal, and
hear but not listen. Two concurrent monologues
masquerade as dialogue.
These are broad generalizations, and certainly
a number of solitary spirits remain. The med-
ical profession does not appear to have yet expe-
rienced a crushing doom, but it does seem prone
to the dogma of the gradual running down that
Buber claims represents mans abdication in the
face of the proliferating It-world. 4 Medical
progress has made treating disease more effective
and successful, at least on a physiologic level,
but in the quest for better medicine, other aspects
 Cohn
of patient care may have been overlooked or
deemed unimportant. Physicians now often do
not know their patients, usually work in institu-
tional or office settings instead of attending patients
in their homes, and rely on a barrage of tests for
examinations. Patients, anxious for treatment,
may tolerate a lack of personal interaction, sub-
mitting to a more mechanical and impersonal
medical domain. Whether the image of the caring
doctor who visits individuals in their homes
throughout their lives is a myth or not, stories of
such personal care often underlie the cries for
reform to practice and education now heard.
A lack of dialogue, in Bubers sense, appears
central to the problems in medicine. What has
been true for the evolution of mankind has been
equally true for the progress of medicine: We have
spared no effort to make better tools but we have
paid little attention to learning how to commu-
nicate better with one another.7 For example, the
SUPPORT study documented limited physician-
patient communication, even after measures were
taken to improve communication.8,9 If dialogue
serves as the basis of relationships, as Buber
argues, limited communication in the medical set-
ting may be the key to the predominance of It-
relations in that context.
Therapeutic Relationships
The implications of Bubers thought, however,
suggest that the relationships of physicians and
patients need not be limited to the I-It realm. The
conditions of clinical practice are challenges to
legitimate the Buberian encounter: the physician-
patient relationship is kept from full mutuality by
the very factors that occasion it, the meeting of doc-
tor and patient is purposive, and the relationship
is not one of equals in a fully mutual partnership.
Some I-You relationships by their very nature may
never unfold into complete mutuality if they are
to remain faithful to their nature.4 The patient
seeks assistance from a professional who is trained
to do what the patient cannot. This imposes what
Buber has described as a normative limit on
173
mutuality.4 But because Buber believes that reci-
procity can be achieved in degrees, it may be pos-
sible to strive toward a relationship in the clinical
setting.
Buber depicts his notion of normative limits
in the context of a teacher-student relationship,
which he describes as a kind of dialogical rela-
tionship. He asserts:
. . .however intense the mutuality of giving
and taking with which he [the teacher] is
bound to his pupil, inclusion cannot be
mutual in this case. He experiences the
pupil being educated, but the pupil cannot
experience the educating of the educator.
The educator stands at both ends of the
common situation, the pupil only at one
end. In the moment when the pupil is able
to throw himself across and experience
from over there, the educative relation
would be burst asunder, or change into
friendship.10
The physician, like the educator, sees the sit-
uation from both sides, experiencing the treat-
ment of the patient. So the physician may gain
inclusive understanding of the patient, imagining
the patients situation while maintaining his or
her own perspective. The patient, like the pupil,
experiences the treatment but not what it is to
treat. If a patient is able to understand from the
physicians perspective, either the relationship
would end or change forms. Mutuality must remain
one sided or incomplete. Hence, a doctor-patient
interaction is constrained by what it is or, in
Bubers language, is normatively limited.
Such normative limits do not entirely pre-
clude the clinical meeting from the I-Thou realm.
To care for a patient, and not just a symptom, a
person-to-person encounter is important. As a
This is one of three types of dialogical relationships. The
other two are an instant connection between strangers and
a friendship.
 Existential Medicine
person is comprised of more than his or her illness,
a physician should recognize more than just the
disease within the patient to care for the whole per-
son. According to the normative limits, an element
of detachment in the meeting of physician and
patient remains necessary for the practical goal of
healing. However, the physician and patient should
work as partners, discussing and negotiating a
treatment plan, instead of issuing and adhering (or
not) to orders, respectively. With such efforts, the
interaction may approach, although not reach, the
I-Thou pole (Fig. 1).
Facilitating Therapeutic Relationships
Progress along the continuum from the It-pole to
the Thou-pole requires a paradigm shift in which
the relationship between physician and patient dis-
places technical skills and knowledge of disease as
central to practice and education. Although the
therapeutic relationship, in accordance with its
nature, may be destined to fall short of the Thou-
pole, a certain degree of mutuality would enhance
the practice of medicine. A consideration of patients,
physicians, and the institution of medicine in light
of some Buberian premises provides insight into
how to promote therapeutic relationships.
According to Bubers thought, a patient must
be seen foremost as a person, not a disease. Physi-
cians, caught up in their obligation and desire to
cure, may neglect the person in whom the illness
resides.11 While attention to symptoms is critical
for medical practice, the patient is more than a
medium for disease. By recognizing the whole per-
son, treatment becomes more than efforts to cure
the present symptoms:
We need to develop a more critical aware-
ness of sickness, poverty, and lifes bad
deals. Many of our patients today are
Konner shares a poem entitled Please See My Need,
which some nurses had taped to a wall in a surgical unit of
the hospital where he did his medical training. The poem
emphasizes a patients need to be recognized as a person.
174
indeed afflicted with disease, but they are
also afflicted by other circumstances
beyond their control. Who knows their
despair, their loneliness, their over-
whelming frustrations? To send them away
cured of bodily maladies but still mired in
their stress and misery is to abdicate our
responsibility as healers.12
Healing entails attending to each patient, both
symptoms and circumstances. In Buberian terms,
the physician acknowledges the concrete other
before him or her and attempts to experience the
situation from the patients side.
A physician who has personally experienced
being a patient says of his colleagues,
We are often oblivious to our environment
and treat patients as though they were fur-
niture. Careless and unfeeling talk has a
pervasive influence on the atmosphere of
our institution. . . The practice of medi-
cine is concerned with people not
molecules. There is no incompatibility
between the two, but it seems that only
one is intensively taught.13
Attention to medical needs overwhelms atten-
tion to human needs so that physicians may see
people, even those they are not treating, as patients
first.11
Sharing his experience as a physician who
became a patient, Oliver Sacks recounted his
thoughts prior to meeting the surgeon who would
operate on his leg:
I knew he was a good surgeon, but it was
not the surgeon but the person I would
stand in relation to, or rather, the man in
whom, I hoped, the surgeon and the person
would be wholly fused. . . If he were a sen-
sitive man he would be instantly aware of
the distress and dispel it, with the quiet
voice of authority. . . I required only the
voice, the simplicity, the conviction, of
 Cohn
Figure 1 Buberian continuum of human relationships.
authority: Yes, I understand.. . .If he
could not, in truth, reassure me with such
words, I would want an honest acknowl-
edgment of the fact. . .I should respect
whatever he said so long as it was frank
and showed respect for me, for my dig-
nity as a man.14
Sacks wanted more than truth telling and
disclosure from his surgeon. He wanted the sur-
geon to see him as more than a patient, to under-
stand what he was experiencing, and to demon-
strate respect. Or, as Buber might say, Sacks
wanted the surgeon to encounter him, imagine
the experience from his side, and confirm him
as a person. Sacks, as both physician and patient,
was able to see the surgeon as more than a sur-
geon and hoped that this would be mutual; he
desired a relationship.
Similarly, Ed Rosenbaum wrote of an insen-
sitive neurosurgeon who learned about relation-
ships through a personal experience with illness
and friendship.15 These events in his life became
teaching moments, from which he was ready to
teach. Buber explained:
. . .the I that steps out of the event of the
relation into detachment and the self-
consciousness accompanying that, does
not lose its actuality. Participation remains
in it as a living potentiality. . .the seed
remains in him. This is the realm of
175
subjectivity in which the I apprehends simul-
taneously its association and its detachment.4
Based on his experiences, the doctor endeavors to nor-
matively limited I-Thou relationships with his patients.
In doing so, the doctor creates opportunities for
physicians-in-training to understand the distinction
between an It-relation and a Thou-relationship.
During rounds with a senior physician, a med-
ical student recognizes a similar teaching moment,
recognizing the meaning and importance of car-
ing about patients:
We visited the bedsides of four of Dr.
Nathans patients. . . He didnt miss a trick
medically, and his visits were in that sense
equivalent to those of any other doctor on
the ward. But there was a warmth in his
voice, in his smile, in his hands. His
patients believed he cared about them, and
for the best possible reason: he did. He
was real, that was all. Real. I figured that
if I could get mastery of half of what he
knew about how to be with patients, it
would be worth more than all I could learn
from the famous physicians at Galen and
their minions.11
Using Bubers language, this sense of being
real is authenticity or actuality and is both a basis
for and a product of a relationship. Thus, not every
physician needs to have the experience of being a
 Existential Medicine
patient to learn how to treat his or her own patients.
Some efforts at recognizing the actualitythe con-
crete, distinct reality and potentialof each patient
and imagining his or her situation through role
modeling and emulation may be sufficient.
Medical training generally appears either to
create a dichotomy between healing and curing,
so that they appear to be mutually exclusive, or to
suggest that curing is all there is.11ll# Bubers Thou-
and It-worlds help explain that dichotomy but
also reveal how the opposite poles are connected.
The It-world need not efface the Thou-world, just
as curing need not overcome caring. Movement
between the poles is possible.
According to Bubers thought, the physicians
humanity also requires recognition; personal iden-
tity is not lost under a white coat, although it may
be hidden. Recognizing both the physicians and
patients human identities offers common ground
on which to base interaction as partners. The
physician
. . .in any relation is not an abstract, or the-
oretical ideal type, but a human being, with
all the achievement, skill, awkwardness,
and error that characterizes even the most
competent professional. Such a recogni-
tion of the human dimension actually is
quite consistent with the critical element
of dialogue. . . In all the situations defined
by the working out of a purpose, the helper
also needs help, or at least should be under-
stood as potentially needing help. Living
out a purposive relationship in the light of
that recognition can empower the imple-
mentation of the defining task without the
ll
Konner recalls the advice of a neurologist-clinical precep-
tor from his first year of medical school: If you want to
be a fixer, dont go into neurology, but if you want to be a
healer, it may be the field for you.
# ceptions of human beings and interhuman relationships.
Eric Cassell distinguishes between humanistic healing
and scientific curing based on the distinction between ill-
ness and disease. Cassell E. The healers art. Cambridge,
MA: MIT Press, 1976.
176
rigid sense of hierarchy which is the enemy
of mutuality.1
Physicians may end up needing the same kind
of help they offer. Even if this is not the case, physi-
cians need help from their patients in determining
the diagnosis and working out treatment plans.
Recognition of the other, even if not fully mutual,
allows each to help the other in ways appropriate
to the normative limits of the relationship.
A similar theme is apparent in the use of the
metaphor of covenant to describe medical rela-
tionships.16** With this image of mutual fidelity,
**See May W. The physicians covenant. Philadelphia:
Westminster Press, 1983. Other metaphors or models may
also capture the meaning of Bubers concept of relation-
ship. James Childress and Mark Siegler note that there are
several possible and appropriate types of physician-patient
relationships. They favor a metaphor of negotiations,
although they recognize its limits. They suggest that this
metaphor captures two important characteristics of med-
ical relationships: (1) it accents the autonomy of both
patient and physician and (2) it suggests a process that
occurs over time rather than an event that occurs at a par-
ticular moment. This metaphor reflects elements of
Bubers I-Thou relationship. Although the language of
autonomy is foreign to Bubers conception of relationship,
the term suggests an acceptance and confirmation of the
concrete otherness of each, including a recognition of dis-
tinct perspectives and capacity to direct the course of ones
life. In making the negotiations an ongoing process, each
negotiator may be able to experience the position of the
other, making the relationship inclusive. The relationship
is exclusive in that the negotiations are limited to the
physician and patient and is immediate as it occurs without
mediation in the ongoing present. Mutual participation in
the negotiations may contribute to the possibility of
achieving a therapeutic relationship. Buberian dialogue,
however, would be rooted in a connection between inde-
pendent persons, whereas for Childress and Siegler,
negotiations stem from autonomous choices made by the
parties to a negotiation. For Buber, a relationship is more
than a matter of autonomous choices made over time.
Although the results of a negotiation or a Buberian dia-
logue may be similar (e.g., comfortable agreement
between the physician and the patient on a treatment plan),
there are significant conceptual differences rooted in per-
Childress JF, Siegler M. Metaphors and models of doctor-
patient relationships: their implications for autonomy.
Theor Med 1984;5:1730.
 Cohn
interaction, respect for individual dignity, and
acceptance as a gift, more is required of a physi-
cian than merely fulfilling the terms of a contract
or meeting certain medical standards; it estab-
lishes professional responsibility within a broader
human context. Depiction as a covenant enriches
the meaning of physician-patient interactions in
much the same way as the concept of a Buberian
relationship.
In addition to the human context, institu-
tional context influences interactions between
the physician and the patient. The organized
realm of the It-world provides the continuity
needed for medical education, medical research,
and the general practice of medicine and offers
an environment in which relationships may spon-
taneously occur. Systematic order is an anthro-
pologic necessity that only becomes problematic
when it precludes the possibility of encounter.
Encounters in institutional settings need not be
inhibited by the organization and order of the
domain around them but instead can humanize
the purposive associations between two people,
permitting mutuality within working relation-
ships.1 The health care delivery system can model
social support, cohesion, and interdependency
rather than only disinterest or detachment. Allow-
ing for the Thou does not mean sacrificing the It-
world elements necessary for the institution, such
as the depersonalization indispensable for physi-
cians to do their work (e.g., dissect human cadav-
ers, avoid fainting at the sight of blood, cut into
a living human body, and maintain white coat sex-
ual purity). But an overemphasis on the It-world,
too much detachment, could result in a harmful
progression of the It-attitude against which Buber
warns.
Dialogue is vital in this environment to occa-
sion and nurture therapeutic relationships, espe-
cially when a physician and a patient are strangers.
The doctor cannot heal, in the broad sense of the
term, and the patient cannot be healed, without dia-
logue. In addition to verbal exchange, dialogue
entails really listening to one another and even
seeking the opportunity to listen.
177
Lessons for Medical Education
As the practice of medicine evolves, so does med-
ical education, although the causal association
therein is unclear. An emphasis on relationships
is fundamental to the current phase of evolution:
In our era, what is new in medicine is not
merely a new understanding of disease
or new drugs or technologies. . . What is
new is a fundamental shift in the focus
of doctors away from a primary interest
in disease toward a basic concern for the
sick person. . . In this way of seeing the
world of the sick, medical science and
scientific knowledge of disease have not
become unimportant; rather they have
taken their place in a larger, richer under-
standing of the sick and the human
conditiononly one of the many kinds
of knowledge that doctors must have to
do their job well.
I believe that the changes occurring
in medicine today are part of a larger social
transformation. . . In view of this social
transformation, it is not surprising that
Americans are changing their relationship
to medicine and to their doctors, wanting
to be treated as the persons they are, not
primarily as containers of disease; they see
themselves as partners in, rather than
merely objects of, medical care. . .17
Bubers thought offers a framework for that
larger, richer understanding of the human condi-
tion within which medicine is considered. This
enhanced understanding of human relationships
offers a context that can facilitate physician
progress toward I-Thou relationships with the
persons for whom they provide medical care.
To enable physicians to practice a more exis-
tential medicine requires three conceptual shifts
in practice and education. First, medicine would
be centered on persons rather than preoccupied pri-
marily with disease; medicine would be person
 Existential Medicine
centered, in contrast even with the current empha-
sis on patient-centered care. The application
of Bubers thought to medicine constitutes just such
an effort, moving medicine from the It-pole to a
location on the continuum nearer to the Thou-
pole or shifting focus from diseased persons to per-
sons with disease. This has practical implications
for education and practice:
Ideally, physicians should define their diag-
nostic and therapeutic goals in terms of
the everyday life and function of individ-
ual patients. Unfortunately, that ideal is
seldom met because of the difficulty of
holding impersonal technical imperatives
in check, and because doctors seem to be
trained to focus on diseases almost to the
exclusion of how sick persons actually live
their lives in families and communities. In
part the problem arises because physicians
are trained from the first days of medical
school to disregard the knowledge they
bring with them of everyday life and
human function as irrelevant to medicine.
Another obstacle is that doctors are not
trained to include in their decision making
the kind of soft and often subjective
information that is relevant to the every-
day life and function of sick persons.
Correction of these educational errors
would do much to help change physicians
priorities in patient care.18
For example, in treating a ballet dancer with
asthma, a Buberian physician would understand
the ballerinas priority of continued career over
exemplary airways. Recognizing both the dancers
Although patient-centered care does seem a recognition
of the importance of the individual patient in the process
and decisions of medical care, it only begins to approach
the Buberian notion of the I-Thou relationship. Focusing
on the patient still recognizes the person as a patient, a dis-
eased entity, first. Buberian thought would suggest
recognizing the person first.
178
personal and medical goals, knowing that she
didnt live just to breathe, but breathed so that she
could dance, the physician would not impose a
medical goal, such as total control of the disease,
that did not account for her personal identity.19
Existential medical education would incor-
porate the lessons life teaches and use cases like
that of the ballet dancer, enabling students to learn
to see the meaning of illness for an individual. An
existential ethic would not abstract from the indi-
vidual patient; instead, it would consider the patient
in his or her individual context. Existentialism
removes the either/or proposition, allowing med-
icine to be both art and science and physicians to
care and cure.
Second, the mundane everyday matters of
patient care would garner as much attention as cri-
sis situations. Bubers thought requires attention
to specific context and particular persons. So, a
Buberian approach would entail greater attention
to the everyday events of life and the particular-
ity of the involved persons. Additionally, a rela-
tionship implies ongoing interaction rather than
intervention under emergency circumstances.
Human existence is a complex of many events, all
of which form individual identity. It is that iden-
tity that is presented in a relationship. Human life
cannot be reduced to particular incidents or the
moment of decision making. Bubers existential-
ism recognizes the commonplace and the pivotal
and would embrace both in medical practice and
ethical discussion. For medical education, attend-
ing to the everyday involves teaching students
how to engage in ongoing interaction with patients,
in addition to parading students in to witness acute
situations or to identify an unusual diagnosis.
Third, medical practice would be framed in
terms of relationships and codes. Bubers anthro-
pologic and ontologic thought does not translate
into a systematic code of ethics for medical prac-
tice but instead offers an alternative or supple-
mentary worldview. Existentialism would either
help to establish a conceptual shift or join an
already existing movement away from an empha-
sis on governing principles, specifically benefi-
 Cohn
cence and autonomy, or contractual models toward
a focus on the persons involved, how they inter-
act, and the impact of those interactions on med-
icine. This movement is a deviation away from the
mainstream of orthodox Western medicine of
the twentieth century, [which] has its roots in the
Hippocratic emphasis on astute empirical obser-
vation, rationality, the demystification of disease,
and what can be referred to as the scientific men-
tality toward a recognition and incorporation of
patients values into medical care.20
Buberian existential values arise from recog-
nition of the actual relations that currently inhere
in medical practice and of the possible relation-
ships that might exist. In this way, the ethics of
medical practice would reflect living, dynamic,
human experience rather than metaphysical
abstractions, to some extent bridging the distinc-
tions between theory and practice:
Bubers philosophy of dialogue not only
finds the narrow ridge between the sub-
jectivist identification and the objectivist
sundering of the is and the ought, but
it also radically shifts the whole ground of
ethical discussion by moving from the uni-
versal to the concrete and from the past to
the presentin other words, from I-It to
I-Thou. Buber does not start from some
external, absolutely valid ethical code
which man is bound to apply as best as
possible to each new situation. Instead he
starts with the situation.21
Although Veatch so characterizes Western medicine, his
alternative also does not seem compatible with Bubers
thought. Veatch offers a contractual model in which a
physician and a patient construct a contract based on a par-
ticular list of principles. This contract is framed by a larger
societal contract that is based on the same list of princi-
ples. Such artificial structures appear antithetical to a
Buberian approach. A contract would seem to interfere
with the development of a Buberian relationship as it
would situate the association between a physician and a
patient in the It-world.
179
This does not mean that all traditional ethi-
cal values are to be rejected. They symbolize
how relationships are understood in the abstract
and can be useful in decision making. However,
they should not precede the personal interaction
in the concrete situation. The suggestion here is
not that medical ethics should rely on situation-
ism in the spirit of Joseph Fletcher. 22 Buber
explains:
No responsible person remains a stranger
to norms. But the command inherent in a
genuine norm never becomes a maxim and
the fulfillment of it never a habit. Any com-
mand that a great character takes to himself
in the course of his development does not
act in him as part of his consciousness or
as material for building up his exercises,
but remains latent in a basic layer of his
substance until it reveals itself to him in a
concrete way. What it has to tell him is
revealed whenever a situation arises which
demands of him a solution of which till
then he had perhaps no idea. Even the most
universal norm will at times be recognized
only in a very special situation. . . There
is a direction, a yes, a command, hidden
even in a prohibition, which is revealed to
us in moments like these. In moments like
these the command addresses us really in
the second person, and the Thou in it is no
one else but ones own self. Maxims com-
mand only the third person, the each and
the none.10
It is the context of a concrete relationship,
not the particular circumstances of the situation,
that is primary in determining the good.
What existentialism helps avoid is disregard
for persons in the name of rule following, an atti-
tude that Konner displays:
I have developed the impatience with the
ethical discussions characteristic of most
house officers. It isnt that I dont consider
 Existential Medicine
them important, its just that I dont con-
sider them my job. I follow the rules laid
down by the hospitalmeaning, the rules
laid down by society. Tell me in plain
English what the Do Not Resuscitate order
means and exactly whom it applies to, and
I will carry it out. . . Tell me the rules
define them as strictly as you canfor
taking the heart out of patient A and putting
it into patient B, and I will go on with that
dazzling technical miracle; I wont have
pangs of conscience, which I really dont
need and which only make my work
harder.11
Medicine is an inherently moral profession
[because it] has directly to do with the welfare
and the good of others.17 The pangs of con-
science that Melvin Konner hopes to avoid are
integral to the work, work that is not necessar-
ily supposed to be easy. An existential approach
to medicine is based on the good of a specific
other, avoids blind recourse to any given set of
rules, and serves as a reminder of the complex-
ity of life.
One cannot come to an understanding of
the norms of medical ethics in the abstract.
Stanley Hauerwas enjoins people to under-
stand what it is physicians and patients do when
they make themselves available to one another
in times of illness and crisis.23 Medicine is not
about having stock answers that may be applied
to increasingly difficult situations. It is funda-
mentally about caring for patients; ethical prac-
tice and education should reflect this. The norms
must be taught as practical action guides, but
medical education must also involve exercising
judgment so that abstract norms become mean-
For Hauerwas, religious premises underlie the ethic of
care. Another question, outside the scope of this article, is
the role of religion in improving the physician-patient rela-
tionship. The theological implications of Bubers work
might also be helpful in examining the role of religion in
medicine.
180
Lessons for Practice
A conceptual shift is needed in medi-
cine from disease-centered and
patient-centered medicine to person-
centered care.
Person-centered care involves defin-
ing diagnostic and therapeutic goals in
terms of the everyday life and function
of each individual patient.
The mundane everyday matters of
patient care should garner as much
attention as crisis situations so that
physician-patient interaction is ongo-
ing rather than emergency focused.
Medical practice and education should
be framed in terms of relationships
and codes so that they focus on the
persons involved and personal interac-
tions rather than the governing princi-
ples of professional conduct and ethics
codes or contractual models.
ingful in real situations. There is no complete
rule book for human interactions, and that may
be the most difficult lesson for medical educa-
tion and humanity. Perhaps through dialogue and
openness to relationships, the physician and
patient can meet on the narrow ridge of the
I-Thou.10 ll ll
ll ll
Buber used the narrow ridge metaphor frequently in his
writings. It first appeared in The Legend of the Baal-Shem
(1908) (Buber M. The legend of the Baal-Shem. Friedman
M, trans. New York: Harper, 1955.) and was usually used
to describe the constant tension in human existence
between concreteness and abstraction. Human beings walk
this ridge with faltering steps, trying to avoid the abyss on
either side. Later, the narrow ridge came to represent the
dialogical relationship. According to Buber, even at the
highest peak of a relationship, an essential difference
between the partners persists unweakened, while even in
such nearness the independence of man continues to be
preserved.
 Cohn
References
1. Berry D. The vision of Martin Buber. Albany,
NY: State University of New York Press,
1985.
2. Mundackal J. Man in dialogue. India: Little
Flower Study House, 1977.
3. Buber M. The knowledge of man. Friedman
M, Gregor Smith R, trans. Atlantic Highlands,
NJ: Humanities Press International, 1988.
4. Buber M. I and Thou. Kaufman W, trans. New
York: Charles Scribners Sons, 1970.
5. Rothman D. Strangers at the bedside. New
York: Basic Books, 1991.
6. Reiser SJ. The machine at the bedside:
technological transformations of practices and
values. In: Reiser SJ, Anbar M, eds. The
machine at the bedside: strategies for using
technology in patient care. Cambridge, NY:
Cambridge University Press, 1984:7.
7. Katz J. Silent world of doctor and patient.
New York: The Free Press, 1984.
8. The SUPPORT Principle Investigators. A
controlled trial to improve care for seriously
ill hospitalized patients: the study to under-
stand prognoses and preferences for outcomes
and risks of treatments (SUPPORT). JAMA
1994;274:15911598.
9. Dying well in the hospital: the lessons of sup-
port. Hastings Cent Rep 1995;
25(Suppl):S1S36.
10. Buber M. Between man and man. Gregor
Smith R, trans. New York: Macmillan, 1965.
181
11. Konner M. Becoming a doctor: a journey of
initiation in medical school. New York:
Penguin, 1987.
12. Brennan CH. Restoring intimacy to the physi-
cian-patient relationship. Health Progr 1979; 79.
13. Byck R. Patienthood. Yale J Biol Med 1992;
65:161162.
14. Sacks O. A leg to stand on. New York:
HarperCollins, 1984.
15. Rosenbaum E. The doctor: when the doctor is
patient. New York: Ballantine, 1988.
16. May W. Code, covenant, contract, or philan-
thropy. Hastings Cent Rep 1975.
17. Cassell E. The healers art. Cambridge, MA:
MIT Press, 1976.
18. Cassell E. The place of humanities in medi-
cine. New York: Institute of Society, Ethics,
and the Life Sciences, 1984.
19. Childress J, Siegler M. Metaphors and models
of doctor-patient relationships: their implica-
tions for autonomy. Theor Med 1984; 5:1730.
20. Veatch R. The patient-physician relationship:
the patient as partner, part 2. Bloomington,
IN: Indiana University Press, 1991.
21. Friedman M. Martin Buber: the life of dia-
logue. Chicago: University of Chicago Press,
1976.
22. Fletcher J. Situation ethics: the new morality.
Philadelphia: The Westminster Press, 1966.
23. Hauerwas S. Suffering presence: theological
reflections on medicine, the mentally handi-
capped, and the church. Notre Dame, IN:
University of Notre Dame Press, 1986.