VIKTOR EMIL V ON GEBSATTEL ON THE

DOCTOR-PATIENT RELATIONSHIP

JOS V.M. WELIE

Department of Ethics, Philosophy and History of Medicine,

Catholic University of Nijmegen,

P.O. Box 9101,

6500 HB Nijmegen, The Netherlands

ABSTRACT. This article provides a summary overview of the ideas on

medical anthropology and anthropological medicine of the German
philosopher-psychiatrist Viktor Emil von Gebsattel (1883-1974), and
discusses in more detail his views on the doctor--patient relationship. It is
argued that Von Gebsattel's warning against a dehumanization of medicine
when the "person" of both patient and physician are not explicitly present in
their relationship remains valid notwithstanding the modem emphasis on
respect for patient (and provider) autonomy.

Key words: anthropological medicine, doctor-patient relationship, medical

anthropology, personhood, Von Gebsattel.

1. INTRODUC TION

Von Gebsattel is not very well known in the English-speaking world of

psychiatry, psychology or philosophy. Prior to the publication of this issue of
Theoretical Medicine, which contains Von Gebsattel's last article in English
translation, 1 only part of one of his articles was translated, and one
foreword.2 No major psychiatry or psychology handbook contains even one
reference to his work. Arieti 's voluminous The American Handbook of
Psychiatry is the lone exception: Von Gebsattel 's name is at least
mentioned.3 The only American author who has discussed von Gebsattel
extensively is Spiegelberg. In his Phenomenology in Psychology and
Psychiatry a full chapter is dedicated to Von Gebsattel. But Spiegelberg, too,
immediately downplays the significance of Von Gebsattel by starting this
chapter with the sentence: "Compared with Jaspers, Binswanger, Minkowski,
or Straus, Von Gebsattel hardly seems to deserve a special chapter in the
present context. "4

The fact that Spiegelberg's book is about phenomenology and not about
medical anthropology cannot be ignored. Spiegelberg correctly contends that
Von Gebsattel is not a theoretician of phenomenology.5 Why then did he
dedicate a whole chapter to Von Gebsattel? Spiegelberg gives various

Theoretical Medicine 16: 41-72, 1995.

© 1995 Kluwer Academic Publishers. Printed in the Netherlands.

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JOS V.M. WELIE

reasons which merit further consideration in the present context as well. First,
Von Gebsattel "was a senior member of the inner circle of four
phenomenological psychopathologists, which included Binswanger,
Minkowski, and Straus, and ... they considered him an equal member and
even the 'most intuitive' among themselves."6 Indeed, Von Gebsattel was
highly respected by contemporaries of various professional disciplines.

According to Minkowski, he was unattainable as an example for

psychiatrists, 7 a statement which Buytendijk seems to have confirmed. 8 On
the occasion of his 70th birthday the philosopher Heidegger and other
contemporary celebrities gave lectures at Wiirzburg University. A special
honorary volume was published, and again on his 75th, as well as his 80th
birthday. In the last volume primary advocates of medical anthropology gave
contributions, such as the psychopathologists Binswanger, Minkowski and
Straus, the psychologist-physiologist Buytendijk, the philosopher Demph,
Von Gebsattel's students Caruso and Wiesenbiitter, and younger members of
the school such as Christian, Brautigam, and Pliigge.
The problem with this first reason, therefore, is not - as Spiegelberg states - to
evidence this particular credential. Rather, the problem is that this credential
is primarily of interest to the historian of the anthropological school in
medicine, not to the critic. The same is true for the second reason Spiegelberg
provides. Von Gebsattel was indeed a skillful organizer and administrator.
For many years he led the psychology and psychotherapy section of Gorres-
Gesellschaft, the German society for the advancement of Catholic studies,
and he co-founded the Germany Jahrbuch fur Psychologie und
Psychotherapie (1952), which a few years later became the Jahrbuch far
Psychologie, Psychotherapie und medizinische Anthropologie (1959);9 he
was on the editorial board of various journals such as the German Nervenarzt,
Zeitschrift far Psychotherapie, Confinia Psychiatrica and the Zeitschrift fur
Sexualforschung;10 Von Gebsattel was one of the three editors of the five-
volume Handbuch der Neurosenlehre und Psychotherapie (1959); and with
Giese he edited a book on Psychopathologie der Sexualitat (1962).11 But
again, whether his influence went beyond organization remains to be
examined. The only reliable source in this regard are his own publications.

It is precisely in this area that Spiegelberg finds the most important reason to
downplay the importance of Von Gebsattel.12 His literary output certainly is
no match for what fellow medical anthropologists such as Buytendijk and
Von Weizsacker have accomplished. Von Gebsattel published less than 60
articles about such diverse topics as death, marriage, fetishism, and
tuberculosis, Christianity, psychotherapy, and fear. Many of these were
collected in the three compilations, Christentum und

THE DOCTOR-PATIENT RELATIONSHIP

43

Humanismus (1947),13 Prolegomena einer medizinischen Anthropologie

(1954),14 and Imago Hominis (1964).15 He published only one monograph,
Moral in Gegensatzen, but, dissatisfied with this youthful lapse, had it taken
out of print.16

Von Gebsattel may not have published that many articles and books, but as
the Latin proverb says, non multa, sed multum ("not many, but good"). With
the exception of Siebeck, perhaps, there has been no other physician of that
generation who has recognized and analyzed the problem of medical
anthropology as clearly as Von Gebsattel.17 This is why devoting an article
to Von Gebsattel in the present issue of Theoretical Medicine on
anthropological medicine is justified.

2. BIOGRAPHY

Viktor Emil von Gebsattel was born on February 4, 1883 in Miinchen,

Germany. His noble title of "Freiherr" (baron) dates back as far as the
fourteenth century when his ancestors ruled the little Frankish town of
Gebsattel. Among many knights, robber barons, generals, and bishops, his
most famous forefather probably was Lothar Anselm von Gebsattel (1761-
1846), the archbishop of Miinchen and Freising, who was much concerned
with the religious and moral re-education of the clergy and laity.

Viktor Emil's own education must have been strongly influenced by Roman
Catholicism as well, since his medical anthropology is imbued with Catholic
spirituality. Having finished the gymnasium in Wiirzburg, Viktor began
studying law, since his family expected him to become a diplomat.

But his interest in philosophy made him change studies and he took courses
with, among others, Dilthey in Berlin, Bergson in Paris, and Lipps in
Miinchen. In 1905 he earned his doctorate with a dissertation on the
irradiation of feelings, supervised by Lipps. 18 A man of adventure, Von
Gebsattel traveled to Italy, Switzerland, Greece, and France. In Paris he met
the French sculptor Rodin and the painter Matisse, as well as the German
poet Rilke with whom he became good friends. Not lacking literary qualities
himself, Von Gebsattel published "Two Letters to the Poet Chenedolle," and
translated from the French 50 of the 118 sonnets of the Cuban-born French
poet Jose Maria Heredia (1842-1905), published as Les Trophies. "19

As the title of his philosophical dissertation indicates, Von Gebsattel was

very interested in psychoanalysis. He met Freud at the first Psychoanalytical
Congress and started a psychoanalytical training with Seif. Shortly
afterwards, he applied for medical school and studied with famous physicians

44
JOS V. M. WE LIE

such as Kraepelin and Von Malaise. In 1915 he graduated and in 1919, after
an internship in Miinchen, he earned a doctorate in medicine with a
dissertation on atypical tuberculosis (nowadays called sarcoidosis or Morbus
Boeck). 20

In 1920, Von Gebsattel married Karoline von Falkenhayn. Four years later,
he joined Leibbrand in the management of the Spa in Westend, Berlin.

In 1926 he moved to the castle of Fiirstenburg in Meckelenberg where, in

1927, he started a private clinic. When in the following decade the National

Socialists took over the German government, Von Gebsattel opened the door
of his clinic for dissident artists. He also hid Jews. The German government
was not very pleased with Von Gebsattel's resistance and in 1939 his clinic
was confiscated. After the war, he taught and practiced in Berlin, then in
Austria (Vienna), and again in Germany (Uberlingen, Baden Weiler, and
Freiburg). In 1949 the University of Wiirzburg offered Von Gebsattel a
professorship in medical psychology and psychotherapy.

Three years later, aged 69, he received the chair for anthropology and genetic
biology. Viktor Emil Freiherr von Gebsattel died on March 22, 1976 in his
old house at the Jacobsplatz in Bamberg, at the respectable age of 93.

3. VON GEBSATTEL AND MEDICAL ANTHROPOLOGY

The primary purpose of anthropologic reflection on medicine is to keep

medicine from one-sidedness and impermissible practices. But anthropologic
medicine is more than positivistic medicine within the limits of
permissibility. The anthropologic reflection aims at a change of medicine
from within. This goal only makes sense given the assumption there is
something fundamentally wrong with contemporary medicine. And this is
indeed what Von Gebsattel and his fellow anthropologists have assumed.

In his last article Von Gebsattel quotes his contemporary Von Weizsacker
who is supposed to have said that standing trial in Nuremberg were not
primarily simplistic, derailed, or corrupted individual physicians, but "the
spirit of scientific medicine." According to Von Gebsattel, the cause, or at
any rate, a conditio sine qua non, of the atrocities committed by German
physicians of the Third Reich was the scientific orientation of contemporary
medicine. That is not to say that biomedical science is the ultimate evil; as we
will see later, Von Gebsattel actually stresses the importance of a scientific
approach in medicine and assigns it its own stage in the practice of medicine.
But he assigns it for one stage only in what he calls the comprehensive act of
medical practice. Von Gebsattel discerns two

THE DOCTOR-PATIENT RELATION SHIP

45

more stages, one (the immediate or elementary-sympathic stage) that

precedes, and the other (the personal stage) that follows the scientific (or
diagnostic-therapeutic) stage (see below). The fundamental mistake of
contemporary, so called scientific, medicine is that it simply overlooks,
maybe even intentionally denies, or totally disregards the existence and
importance of these other two stages. The fundamental mistake is to identify
medicine with the scientific stage.

Science owes its success to its ability to classify individual and seemingly
unique phenomena into groups that share particular characteristics, obey
certain natural laws, and react in a more or less predictable manner to
external influences. This classification, in medicine also called diagnosis,
enables the scientist to manipulate the phenomenon and the physician to treat
the disorder. The disease is abstracted from the unique environment of the
individual patient, reduced to a mere example of a common phenomenon, and
treated as such. For the scientifically-oriented physician there are no unique
patients, just carriers of diseases. Patients are cases, known only in so far as
they fit into certain scientific categories. The rest, that is, the patient's unique
individuality, is reduced to a mere number which has to match the number on
the status before the surgeon will start his appendectomy. As individuals
patients are but strange aliens to the scientificallyoriented physician.

Again, this estrangement between physician and patient is, as such, not
problematic. it becomes problematic when it is no longer recognized as an
estrangement but considered an original and genuine doctor-patient
relationship. It becomes problematic when it is no longer recognized as an
inevitable but temporary stage which must be surpassed. When the patient is
never recognized as a unique person to start with, and never will be
recognized again as such, when the patient was, is, and will always be only a
case among many other similar cases, then there is something fundamentally
wrong with medicine and in particular with the doctor-patient relationship.

4. THE THREE STAGES OF THE DOCTOR-PATIENT RELATIONSHIP

4.1. The Elementary-Sympathic or Immediate Stage

In his The Meaning of Medical Practice (1963) Von Gebsattel maintains that
the biomedical scientific relationship between doctor and patient cannot be an
original relationship. The very idea to even develop a biomedical science
presupposes the need to do so. It presupposes the apparent lack of

46

JOS V .M. WELIE

means to adequately help, which in tum presupposes somebody crying out for
help. And as trivial as it may sound, it also presupposes somebody who
sympathically experiences the urge to help, which presupposes he or she
heard this cry, which in turn presupposes this person is willing to listen.

Thus, we find two human beings, one in need of help, the other willing to
help but unable to do so adequately. It is this feeling of inability which has
led and still leads people to engage in the study of medicine and the
biomedical sciences, and to even devote their whole life to it.

Perhaps Von Gebsattel was too idealistic in assuming that people decide to
go to medical school or become biomedical scientists because of such
humanitarian sentiments. But that leaves standing - as Von Gebsattel argues

- the fact that medicine only makes sense in that light. Without such a
humanitarian foundation of the doctor-patient relationship there is no
guarantee that the relationship itself will be humanitarian. The atrocities of
the Third Reich are the most gruesome examples of inhumane acts committed
by medical professionals, but they are not the only such examples and
probably not the last.

In response to such immoral practices bioethicists nowadays try to limit the

physicians' power by assigning the right of self-determination to the patient
and a host of other derived rights such as the right to information, choice of
health care provider, confidentiality, refusal of treatment, etc. But the very
fact that these rights need to be assigned, in many an instance even by
positive law, suggests that they are not grounded in the doctor-patient
relationship itself. If agencies external to medicine, such as the law, have the
power to influence the moral standards of medical practice positively, there
are few reasons to believe some other external agency could not at any time
exert a negative influence as well. It has happened in the past, and it may
very well again do so in the future.

In his article "In seelischer Not" from 1940 Von Gebsattel cites the following
outcry of one of his patients: "Is it the physician whom I am talking to or is it
my fellow man?"21 According to Von Gebsattel in this outburst another,
complementary question is expressed: "Am I a suffering human being or just
a psychiatric patient?" 22 These two opposites can be reconciled only if the
doctor-patient relationship is not characterized by mere technical aspects,
related to the skills and power of medicine, but also by another, internal
aspect, 23 or as Von Gebsattel writes some years later:

"By an effectiveness that is grounded in reality and an attitude that is

grounded in sincerity."24 Then, the patient shall have both faith and trust in
the physician. The faith concerns the physician as a member and
representative of a profession, because the patient has no knowledge of the
real skillfulness of the individual physician. The trust, however,

THE DOCTOR-PATIENT RELATIONSHIP

47

concerns the individual physician himself. In his faith, the patient views the
physician as a skillful authority; in his trust, as a loving fellow human
being.25
A genuine relationship of care, therefore, must start with trust, which is not
the result of agreements, but precedes any future agreements. This trust must
be established immediately in the encounter between a human being calling
for help and another human being responding with an offer to help.

This stage, which Von Gebsattel calls the elementary-sympathic stage, or

stage of immediateness, must precede any scientific approach and must be
acknowledged as such. 26 Only then is the physician able to recognize that
the second stage in the encounter between him/her and the patient, the stage
of true medical thinking, planning, and acting, the so called diagnostic-
therapeutic stage, is also a stage of alienation.

4.2. The Diagnostic-Therapeutic Stage

The first stage in the doctor-patient relationship cannot be skipped, but it is

not paradigmatic of the doctor-patient relationship. Von Gebsattel
characterizes this first stage as elementary-sympathic because the patient's
cry for help is audible to every fellow human being willing to listen. One
does not need the mediation of scientific knowledge and diagnostic skills to
hear the cry for help of a fellow human being. Hence, the relationship is
immediate.

Although the first stage in theory is not paradigmatic of medical practice, it is

factually. One does not need to be a physician to hear the cry for help of a
sick fellow human being, but as a matter of fact patients go to physicians and
ask them for help. 27 Only those who can swim can save a drowning man.
Physicians are the only fellow human beings having the technical skills to
help.

Hence the relationship between doctor and patient is characterized by

inequality. However, the technical power which the physician has and the
patient does not have is neither the only nor the most important cause of the
inequality between doctor and patient. The traditional status difference
between doctor and patient is not the primary cause either, nor is any kind of
patient incompetence due to sickness or pain. On the contrary, the patient at
this stage is the only competent participant in the relationship. The patient is
suffering, not the physician; (s)he is diseased, anxious, nauseated, in pain,
frightened, handicapped, old, and not the physician. Von Gebsattel stresses
that despite the deepest sympathy, compassion and support of the health care
provider towards the patient, the fact remains that the latter is suffering
whereas the former is not. 28

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JOS V.M. WELIE

The only way to bridge this distance is biomedical science. Via skillful
scientific diagnosis the physician can learn a little bit more about the
suffering of the patient, enough to open some possibilities for effective help.
Hence, the elementary-sympathetic stage must be followed by the stage of
true medical thinking, planning, acting, that is, the diagnostictherapeutic
stage.

As explained in the previous stage, indispensable as the second stage may be

in order to become acquainted with the objective needs of the patient, it
implies an alienation from the patient as the subject of these needs. For at the
second stage the patient is reduced to a mere example, a case, stripped from
all of his individuality that makes him a unique person.

This second stage, therefore, must be succeeded by a third stage which can
annul the alienation induced by the second mode of the encounter between
patient and physician. 29 This third stage Von Gebsattel calls the personal or
partnership stage.

4.3. The Personal Stage

If suffering is a private experience causing existential distance between the

health care provider and the patient, and if a scientific approach alienates the
physician from the patient, thereby in some way increasing this distance even
further, the question arises what possibly can constitute the basis of this
personal partnership. What, other than being human, do physician and patient
share? Nothing, it seems, yet nothing other than being human is needed to
complete the medical act and turn the doctor-patient relationship into a
personal relationship. What, then, is the difference between this third stage
and the first, which, after all, was based on sympathy, a basic human act as
well?

Prior to analyzing this question it should be remarked that the three stages are
not, at least not essentially, chronological stages that succeed one another in
time. Literally, Von Gebsattel calls them Sinnstufen, meaningful stages,
stages at which the encounter between doctor and patient has a distinct
significance, stages at each of which their relationship should be interpreted
differently. In a footnote Von Gebsattel characterizes these three Sinnstufen
as dialectical stages. 30 The "thesis" of immediate sympathy, and the
"antithesis" of scientific alienation, must be encompassed by a new

"synthesis" of personal partnership. Thus, the personal stage must contain

elements of both other stages.

This answer may sound like an escape from the question at hand by the
present author, and indeed he cannot deny that it is partially. For it is at the
personal stage that we run up against considerable unclarity in Von

THE DOCTOR-PATIENT RELATIONSHIP

49

Gebsattel's writings. What exactly is this synthesis all about, and even more,
how it can be realized? Von Gebsattel has not explained it very clearly.

The first issue in need of clarification is whether the new synthesis, or as Von
Gebsattel calls it elsewhere, the personal factor in the healing process,31 is
essentially an ethical verity or a therapeutical tool? Obviously, the two cannot
be separated totally, but there is a fundamental difference.

If the whole notion is primarily a matter of concern about the moral status of
medical practice, then every encounter between doctor and patient, whether it
involves minor surgery or the treatment of a dying patient, should be staged
in three levels, and not merely those encounters that are in need of a special
healing method when standard medicine has little more to offer.

This interpretation of the concept is supported by Von Gebsattel's warning

that personal psychotherapy - we probably may generalize - personal
medicine and health care, is not a new method of healing, to be discussed in
medical handbooks as one method among many. That, Von Gebsattel argues,
would be equally incorrect as devoting a separate chapter to moral medicine
among many other forms of, apparently, immoral methods of healing. 32

However, elsewhere Von Gebsattel maintains that there are situations in

which the patient's disease is not the result of some objectifiable somatic or
mental disorder that can be treated with second-stage medical interventions,
but the expression of his/her personal, secret nihilism (to be explained in a
later paragraph), the healing of which requires a personal response from the
physician. How exactly this healing is to be realized, and whether the care
given must be a physician, remains unclear.

In 1928, Von Gebsattel admitted that the healing power of the personal
relationship has not yet been carefully examined. 33 In his publications from
the early 1940s, he provided some insight in this difficult and controversial
matter. 34 But more than ever, Christian moral theology turns out to be a
necessary precondition for understanding and acceptance of Von Gebsattel's
insights. A decade later, Von Gebsattel still cannot answer the question as to
what exactly constitutes the healing power of third-stage personal-medical
interventions. He actually concludes that this answer cannot be given as a
theoretical answer, but only as an existential effort.35

Furthermore, he admits that the personal element can never be the sole
therapeutic tool, as it seems to have become in Freudian transference. 36 It
actually should never be employed as a therapeutic tool, but at the most as an
appeal to the patient to turn away from nihilism. The physician may not take
away the patient's personal responsibility, nor is it his or her task to convert
the patient. 37 The care-giver who tries to turn the personal

50
JOS V.M. WELIE
element in a therapeutic method has become a religious minister instead of a
physician or a psychotherapist. 38

The recognition of the limits of medical practice is a crucial element of the

personal stage of the doctor-patient relationship, and this is one of them: not
to medicalize the nihilistic tendencies in man's existence. Another limit is not
to forcefully establish the third stage. The first stage does not need any
activity to be realized, but mere passive suffering and passive sympathy.

The second stage requires activity, but only from anonymous,

"exchangeable" representatives of two classes of human beings, doctors and
patients.

The third stage, however, requires active communication between unique,

individual persons, between partners. But as with any relationship between
partners, it cannot be enforced. As Von Gebsattel 's last published sentence
reads: "Whoever tries to establish it arbitrarily and violently is in danger of
violating the law of freedom in the other, thereby calling into question the
very partnership which he is trying to establish." 39 Hence, the physician
must first examine his own position in this relationship. He must examine the
status of his "ethos."

In his 1953 article on "The Structure of Medical Practice," Von Gebsattel

concludes with the statement that recognition and observance of the structure
of medical practice in its three dialectical stages constitutes the "ethos"

of the physician.40 But this interpretation, obviously, is insufficient, for in

that case there is really no third stage but only two - two that must be lived
through consciously, but two only.

Von Gebsattel provides a more detailed answer, in his earlier publications of

1948 on "Christian Professional Medical Ethics" and "The Ethos of the
Physician."41 However, in both articles, Von Gebsattel relies heavily on
Christian moral theology. In the latter, he actually maintains that if the
physician's love for his fellow human is not shaped and secured by Christian
anthropology, his or her ethos is in danger of succumbing. 42 Since the
present article intends to discuss the doctor-patient relationship from a
religiously neutral perspective - in so far as that is at all possible - only those
ideas in these publications will be singled out and discussed that do not
require a Christian framework of thought as necessary background.

The ethos of the physician is not identical with the aggregate of ethical
guidelines, moral principles, and written and unwritten rules of conduct
which make up so called "professional ethics." 43 It is, on the contrary, the
very foundation of any professional ethics, Von Gebsattel maintains.

Without it, professional ethical standards are floating in the air, to be blown
away by the slightest turbulence. Professional ethical standards are influenced
too much by political tendencies, legal codes, social circumstances, public
opinion, briefly, the empirical-historical context, to be a dependable

THE DOCTOR-PATIENT RELATIONSHIP

51

guideline for medical practice.44 If the physician's ethos cannot be the

outcome of a socially established code of behavior, it must be developed out
of an understanding of individual existence, out of an analysis of the
possibility of the personal being which the encounter with the patient
provides. 45 The third stage is characterized by communication that "includes
the person of the fellow man in its logos."46 But what is the "person" of a
human being? To answer this question, a brief detour into Von Gebsattel's
rather "personal" philosophical anthropology must be made.

5. VON GEBSATTEL'S CONCEPT OF THE PERSON

A careful examination of Von Gebsattel's philosophical anthropology would

require a review or at least a summary discussion of the history of the
concept of the person. But since this would be long, diverse, and
complicated, such a review falls outside the scope of this article. However,
Theunissen's broad distinction of two main schools in this history may help to
place Von Gebsattel. Theunissen first remarks that, since Kant, there has been
a consensus about the idea that a "person" and a

"thing" are contradictory concepts. 47 Whether only human beings can be

persons is a question that cannot be answered here; but the very question
implies that personhood is not the same as humanness. What, then, is a
person? Theunissen concludes that traditionally two different answers are
given: The person is interpreted being either relationality or absoluteness.

The first answer is given, among others, by Buber, Hartmann, and

Binswanger. In opposition to being a thing, to exist as a person means to be
able to exceed one's own boundaries, to "ex-sist," to relate to something else
and, in particular, to someone else. Without a Thou, I cannot be; /

exists in the relationship to a Thou.

Disagreeing with this interpretation of the concept of a person is a second

group of anthropologists, represented by Scheler and Guardini, who
acknowledge the fundamental ability of humans to enter into a relationship
but do not consider this relationship to constitute the person. Being a person
does not depend on a Thou; it is absolute, equally absolute as traditionally
man's God-given soul is understood to be.

Von Gebsattel, being inspired by both Scheler and Guardini, must be

classified under the second group. Yet he stresses that the person achieves
actual existence in the I-Thou relationship.48 By means of the relationship to
the other, the absolute being of the original person is "transferred into its real,
worldly form of existence."49 The person, therefore, is not the result

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JOS V.M. WELIE

of a series of acts, a life history, a process of self-determination, all in relation

to the other, but the necessary precondition, the fundament, and the final goal
of such a process of self-realization. The result of this process is what Von
Gebsattel calls the "personality."50

Religiously neutral as this may sound - it has been written intentionally so by

the present author - Von Gebsattel makes no attempt whatsoever to hide the
Christian connotations of his personalist anthropology. The person constitutes
not merely the ability to develop, for plants and animals have that capacity as
well. The person essentially is "ought-to-be" (Sein

Sollen). Realizing one's personhood into a particular personality is a human's

most fundamental task in life, but at the same time is a matter of free choice,
a God-given choice which can be accepted or renounced. Every human being
desires to accept, to determine, realize, and complete his or her own being.

But deep in every human's interior also hides a secret nihilism, a tendency not
to be what one already is, Von Gebsattel maintains. He argues that this secret
nihilism actually is the source of a number of severe psychological diseases,
such as neuroses and some psychoses. This being the case, psychiatry in Von
Gebsattel's eyes obviously cannot be a religiously neutral enterprise. Again,
the present article does not allow further elaboration of this intriguing, yet
rather unusual theory. In the article translated and published elsewhere in this
issue of Theoretical Medicine, Von Gebsattel makes brief reference to this
theory. The interested reader is referred particularly to Von Gebsattel's
publications "About the Question of Depersonalization: A Contribution to the
Theory of Melancholy" from 1937, "The Disorders of Existence and the
Experience of Time Related to Psychiatric Diseases" from 1939, and "The
Person and the Limits of Depth Psychotherapeutical Procedures" from
1950.51

Of importance to the present article is the much less surprising idea that
mental as well as somatic diseases influence the existence of humans.

Humans suffer from their disease, but they are not blindly caught in their
disease as are animals. A human being, in as much as (s)he suffers, is always
able to put distance between his/her disease, to view the disease as the other
and to relate him/herself to his/her own disease. Consequently, disease
influences the personal self-realization of humans. They always incorporate
the experience of disease in a unique, personal way. The reality of suffering
essentially is not a symptom of a damaged or threatened organism, but a
unique expression of human existence.

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53

6. THE THIRD STAGE RECAPITULATED

For our understanding of the third stage in the doctor-patient relationship, the
personal stage, one element out of the preceding short overview of Von
Gebsattel's anthropology must be singled out: Existence on earth as a unique
human being is a matter of relating oneself to the other, the Other with a
capital, that is, God, or the other as the world in which one lives
(Daseinswelt); the other as one's fellow human beings with whom one shares
existence, among them respectively the patient and the health care provider;
but also the other as one's own self, whether healthy and directable to
perform medical practices, or painfully acting up and estranged through
mental disorders or somatic diseases.

Remaining at the second stage, at which the patient is but a case among many
others and the physician likewise but a health care provider among many
others, would imply disregard, even denial of the meaningfulness of the
situation.52 Any occurrence, unimportant as it may seem, in which human
beings play a role, is significant, that is, it bears some meaning in the unique
life-history, in the personal self-realization of those human beings.
Remaining at the second stage, therefore, entails the danger of losing sight of
the respect for the uniqueness of individual human beings, the respect which
doctor and patient owe one another as partners in personal existence.

Respect is the essence of the third stage of the doctor-patient relationship. But
the respect Von Gebsattel has in mind certainly is not the libertarian kind,
"leaving your fellow man alone," or in the words of the contemporary
bioethicist Engelhardt: "Acquiescing in the policy that persons may do with
themselves and consenting others whatever they wish, despite what others
may think or feel in the matter."53 Von Gebsattel thinks more in terms of
Ehrfurcht, awe, an attitude of devotion and reverence at the same time.
Devotion, because the patient is the physician's neighbor who, as such,
deserves to be looked after (re-spectus). Reverence, because the patient's
neighborship is vested in God. "When the patient is no longer a neighbor, that
is, when the secret of his existence disappears, the secret that makes him a
representative of the suffering Christ, the last spark of awe in the physician
will extinguish, the personal rapport to the patient will be Iost.54
Again, Christian theology emerges as the decisive and unescapable
background of Von Gebsattel's thinking. As mentioned in the earlier
biographical section, Von Gebsattel was born and raised in a thoroughly
Catholic environment. And unlike his friend Scheler, who felt forced by the
outcome of his philosophical reflections to leave the Catholic Church, Von
Gebsattel

54
JOS V.M. WELIE
never seem to have felt even the slightest inclination to develop a religiously
neutral medical anthropology and anthropologic medicine. As the many
valuable ideas Von Gebsattel's articles may present for the religiously neutral
reader who is concerned about the ethical quality of contemporary health
care, for Von Gebsattel there was no doubt that only a medical practice
drenched in Christianity has a chance of resisting the ever-increasing
temptation of the biosciences with their compulsory reductivism and
disregard of the personal individuality of the patient.
7. ASSESSMENT
In the homage volume in celebration of Von Gebsattel's 70th birthday Von
Gebsattel's pupil Caruso wrote: "The appraisal of von Gebsattel's existential
anthropology ... will not be easy, diverse as his publications are, concisely
formulated, and excitingly literary in their presentation."55 But neither
meticulous, nor comprehensive, we must add. Von Gebsattel never published
a comprehensive theoretical work. Wiesenhiitter has explained that writing
voluminous books simply was not his teacher's cup of tea.56

But this does not explain why writing such volumes was not Von Gebsattel's
cup of tea. Certainly, the problem cannot have been his inability to put down
on paper the comprehensive theory he had in his mind. Von Gebsattel did not
lack literary talents; on the contrary. Hence, the question arises whether Von
Gebsattel had such a comprehensive theory in mind at all.

In 1954, when forerunners of the medical anthropological school such as the

philosopher Scheler and the physician Krehl had already died, Viktor von
Weizsacker had retired, and the latter's student Christian had just finished his
thorough overview study of the medical anthropological movement (1952),57
Von Gebsattel remained remarkably cautious as to the achievements of this
movement: "Speculations focussed on an anthropological program proceed
with most certainty towards their goal if they, while never losing sight of that
very goal, are nonetheless satisfied with provisional indicative insights. The
time has not yet come, neither for a philosophical, nor for a medical
anthropology in the true sense of the word."58 In the next five years, Von
Gebsattel published some of his most important articles, such as "About the
Application of Anthropological Perspectives in the Area of Psychotherapy "
(1955) and the six chapters in the Handbook of the Theory of Neuroses and
Psychotherapy (1959), including the chapter on anthropological
psychotherapy, which is his most extensive theoretical treatise. But to the title
of an article that was published at the end of that year, "Medical
Anthropology," Von Gebsattel added

THE DOCTOR-PATIENT RELATIONSHIP

55

the subtitle: "Introductory Thoughts."59 In the next four years, he published

four more articles, the last of which is reprinted in the present issue of
Theoretical Medicine. But this article on medical practice does not provide
any radically new insights either. And unlike his colleague Buytendijk who
published some 70 articles and books during the last 14 years of his life, Von
Gebsattel did not put pen to paper any more until his death in 1976, two years
after Buytendijk's death.

There may never have been a comprehensive theory of medical anthropology

in Von Gebsattel's mind, but there undoubtedly was an anthropologically-
oriented medical practice. Ten Have has already explained,

"medical anthropology .. . is the draft for an anthropologically-oriented

medical practice, but at the same time the result of this practice, as the
practice always precedes the theory."60 The introductory paragraph to the
present article has shown there is little doubt Von Gebsattel was a living
example for his contemporary colleagues of a practice that precedes theory.

But we do have to ask the final question: was this impact lasting? In The
Psychology of the 20th century, published in the year of Von Gebsattel's
death, Wyss contends Von Gebsattel's "statements," though temporary, are as
relevant to our times as they were in those days.61 Why, then, has hardly any
of Von Gebsattel's work been translated into other languages? Why is he
referenced only sporadically by other authors?62

It would not be fair towards Von Gebsattel to suggest that among all
anthropologically-oriented physicians he is the only one whose work has
remained unquoted and untranslated. The whole anthropological movement
seems to have disappeared in the archives, to be studied only by a few
historians of medicine and philosophers interested in such esoteric issues as
"the essence of man" and "the purpose of being." Contemporary medical
students are told by their teachers such issues are merely a matter of
"unrealistic abstractions." The physician should not take any such patient
questions seriously; on the contrary, the patient must learn

"to view the world with different, sober eyes."63 Philosophical insights are
no longer considered of much importance for medical practice. The German
Yearbook for Psychology and Psychotherapy, which was renamed Yearbook
for Psychology, Psychotherapy and Medical Anthropology in 1959 - probably
at the instigation of Von Gebsattel who also wrote the explanatory preface to
the first renamed issue - has again changed names in 1972 and is now the
Journal for Clinical Psychology and Psychotherapy. 64

Few health care providers and patients will deny that there is something
fundamentally wrong with the modern provider-patient relationship.

The trust between provider and patient, a necessary precondition of any

56
JOS V.M. WELIE
respectful relationship between human beings, seems to have turned into
doubt, even suspicion. Written contracts, informed consent forms,
disclaimers, codified laws, and last but not least lawsuits, are but a few signs
of the distrust ruling the provider-patient relationship. Von Gebsattel's
alternative may sound outdated to the modem reader, too idealistic to ever
become reality, to ever have been reality. But the very historical fact that
these ideas once had reality, namely in the person of Von Gebsattel, should
make us realize that we too wear blinders that keep us from looking beyond
the attraction of a scientific attitude and the monopoly of legal solutions.

Von Gebsattel never claimed to have found the final answer. All too well did
he realize that his writings were only "prolegomena" to a future medical
anthropology. The real job was still to be done. Unfortunately, nobody seems
to have done so.
REFERENCES
l. Vom Sinn des artzlichen Handelns [The meaning of medical practice] (
1963). Reprinted in: Gebsattel VE von. Imago Hominis (Veitriige zu einer
persona/en Anthropologie).

Neues Forum, Schweinfurt, pp. 58-74.

2. Gebsattel VE von. The world of the compulsive (translated and

abridged by S. Koppel).

In: May R, Angel E, Ellenberger HF, eds. Existence: A New Dimension in

Psychiatry

and Psychology. New York: Touchstone, Simon & Schuster, and Basic
Books, 1958: 170-187. Also: Tellenbach H. Melancholy: History of the
Problem, Endogeneity,

Typology, Pathogenesis, Clinical Considerations (Foreword by V. von

Gebsattel; translated by E. Eng). Pittsburg: Duquesne University Press,
1980.

3. Arieti S. The American Handbook of Psychiatry. 2nd ed. New York:

Basic Books Inc., 1974.

4. Spiegelberg H. Phenomenology in Psychology and Psychiatry: A

Historical

Introduction. Evanston: Northwestern University Press, 1986 (2nd ed.):

249-259.

5. Spiegelberg: 254. Spiegelberg does, however, give the chapter on Von

Gebsattel the subtitle Phenomenology in medical anthropology.

6. Spiegelberg: 249.

7. Minkowski E. Lettre-homage au professeur v. Gebsattel. Jahrbuch fiir

Psychologie

und Psychotherapie. 1958;6:316--318.

8. Wiesenhiitter E. Viktor Emil Freiherr von Gebsattel +. Zeitschrift fiir

klinische

Psychologie und Psychotherapie. 1976;24,3:197-199.

9. Yearbook for Psychology and Psychotherapy; Yearbook/or Psychology,

Psychotherapy

and Medical Anthropology (which, since 1972, is called: Zeitschrift fiir

klinische

Psychologie und Psychotherapie).

10. Neurologist, Journal for Psychotherapy, Confinia Psychiatrica, Journal

for Research
on Sexuality.
11. Handbook of the Theory of Neuroses and Psychotherapy;
Psychopathology of Sexuality.

12. Ibid.: 249.

13. Christianity and Humanism. Full title: Christentum und Humanismus;

Wegen des

menschlichen Selbsverstiindnisses. Stuttgart: E. Klett, 1947.

14. Prolegomena to a Medical Anthropology. Full title: Prolegomena einer

medizinischen

THE DOCTOR-PATIENT RELATIONSHIP

57

Anthropologie; Ausgewahlte Aufsatze. Berlin/Gottingen/Heidelberg: Springer

Verlag, 1954.

15. Full title: Imago Hominis; Beitrage zu einer persona/en Anthropologie.

Schweinfurt: Neues Forum, 1964.

16. Morality in Antitheses. Full title: Moral in Gegensatzen; Dialektische

Legenden.

Miinchen: G. Miiller, 1911.

17. Verwey G. Antropologische geneeskunde in discussie. Algemeen

Nederlands Tijdschrift voor Wijsbegeerte. 1984;74/4:207-227.

18. Gebsattel VE von. Bemerkungen zur Psychologie der Gefiihlsirradiation.

Archiv fur die gesamte Psychologie. 1907;10:132-192.

19. Gebsattel VE von. Zwei Briefe an der Dichter Chenedolle. Hyperion.

1908;3/1:46-60; Gebsattel VE von. Die Trophaen van Jose Maria Heredia
(Ubersetzung aus dem Franzosischen). Miinchen: Hyperion Verlag, 1909.

20. Gebsattel VE von. Beitrag zum Verstiindnis atypischer

Tuberkuloseformen. Beitrage zur Klinik der Tuberkulose. 1920;12/1:1-27.

21. Gebsattel, VE von. In seelischer Not (Brief eines Arztes). Christliche

Besinnung.

1940;26: 1-16 (p. 6).

22. Ibid.: 6.

23. Ibid.: 7-8.

24. Gebsattel VE von. Imago Hominis: 29 (This chapter entitled "Not und
Hilfe.

Prolegomena zu einer Wesenslehre der geistig-seelischen Hilfe" was first

published in 1944).

25. Gebsattel VE von. Prolegomena: 274.

26. Gebsattel VE von. Image Hominis: 58-74. This chapter entitled "Vom
Sinn des iirtzlichen Handelns" has been translated into English and included
in this issue of Theoretical Medicine.

27. Gebsattel VE von. Das Ethos des Arztes (Ein Gespriich). Wort und
Wahrheit. 1948;3/9: 652-666.

28. Gebsattel VE von: See his article in this issue of Theoretical Medicine.

29. Ibid.

30. Gebsattel VE von. Prolegomena: 377, footnote l.

31. See, for example, Gebsattel VE von. Prolegomena: 495-506.

32. Gebsattel VE von. Gedanken zu einer anthropologische Psychotherapie.

In: Frankl VE, Gebsattel VE von, Schultz JH, eds. Handbuch der
Neurosenlehre und Psychotherapie (Band Ill). Miinchen/Berlin, Urban und
Schwarzenberg, 531-562.

33. Gebsattel VE von. Prolegomena: 94-103 (This chapter entitled "Was

wirkt bei der Psychoanalyse Therapeutisch? Gedanken im Anschluss an
einem Aufsatz von Fritz Mohr" was first published in 1928).

34. See for example, Gebsattel VE von. In seelischer Not (Brief eines
Arztes). Christliche Besinnung. 1940;26:l-16; Gebsattel VE von. Von der
christlichen Gelassenheit.

Christliche Besinnung, 1940;35:l-16; Gebsattel VE von. Imago Hominis 240-

270

(This chapter entitled "Religion und Psychologie" was first published in

1941); Gebsattel VE von. Imago Hominis: 23-57 (This chapter entitled "Not
und Hilfe. Prolegomena zu einer Wesenslehre der geistig-seelischen Hilfe
(Vortrag)" was first published in 1944).

35. Gebsattel VE von. Prolegomena: 347-361.

36. Gebsattel VE von. Prolegomena: 495-506.

37. Gebsattel VE von. Das christliche Berufsethos des Arztes. In: Borgmann
K. ed. Anruj und Zeugnis der Liebe; Beitrage zur Situation der Caritasarbeit.
Regensburg, 1948: 118-135.

38. Gebsattel VE von. Prolegomena: 347-361.

39. Gebsattel VE von: See his article in this issue of Theoretical Medicine.

58

JOS V.M. WELIE

40. Gebsattel VE von. Prolegomena: 361-371 (This chapter entitled "Die

Sinnstruktur der lirztlichen Handlung" was first published in 1953).
41. Gebsattel VE von. Das christliche Berufsethos; Gebsattel VE von. Das
Ethos des Arztes.

42. Gebsattel VE von. Das christliche Berufsethos: 126.

43. Gebsattel VE von. Das Ethos des Arztes: 654.

44. Ibid.: 656.

45. Gebsattel VE von. Das christliche Berufsethos: 120.

46. Gebsattel VE von. Prolegomena: 375.

47. Theunissen M. Skeptische Betrachtungen fiber den anthropologischen

Personsbegriff.

In: Rombach H. ed. Die Frage nach dem Menschen. Freiburg/Miinchen:

Karl Alber, 1966:461-490.

48. Gebsattel VE von. Imago Hominis: 58-74.

49. Gebsattel VE von. Gedanken zu einer anthropologische Psychotherapie:

538; emphasis added -JW.

50. Ibid.: 545.

51. Gebsattel VE von. Prolegomena: 347-361 (This chapter entitled "Zur

Frage der Depersonalization: Ein Beitrag zur Theorie der Melancholie" was
first published in 1937); Gebsattel VE von. Prolegomena: 128-144 (This
chapter entitled "Die Storungen des Wesens und des Zeiterlebens im Rahmen
psychiatrischer Erkrankungen" was first published in 1937); Gebsattel VE
von. Prolegomena: 329-347 (This chapter entitled

"Die person und die Grenze des tiefenpsychologischen Verfahrens" was first
published in 1950).

52. Gebsattel VE von. Das christliche Berufsethos: 120.

53. Engelhardt HT. The Foundations of Bioethics. New York/Oxford:

Oxford University Press, 1986: 13.

54. Gebsattel VE von. Das Ethos des Arztes: 657.

55. Caruso IA. Viktor E. Freiherrn von Gebsattel: Zurn 70. Geburtstag.
Jahrbuch fiir

Psychologie und Psychotherapie. 1952/53; 1: 133-138 (p. 135).

56. Wiesenhiitter: 198.

57. Christian P. Das Personsverstiindnis in modernen medizinischen

Denken. Tiibingen: Mohr, 1952.

58. Gebsattel VE von. Prolegomena: iii.

59. Gebsattel VE von. Medizinische Anthropologie; Einfilhrende Gedanken.

Jahrbuch fiir

Psychologie, Psychotherapie und medizinische Anthropologie. 1959;7:193-

198.

60. Have H ten. Antropologische geneeskunde. Silhouet van een specifiek

menselijke geneeskunde. Metamedica, 1983;62: 10-21 (p. 15).

61. Wyss D. Die anthropologische Psychologie. In: Balmer H. et al. eds. Die
Psychologie

des 20. Jahrhunderts Zurich: Kindler, 1976:528.

62. The present author could trace only two such discussions: Schoeps HJ.
Was ist der

Mensch? Gottingen: Musterschmidt Verlag, 1960 (Translated into Dutch as:

Over de

Mens: Beschouwingen van de modernefilosofen. Utrecht/Antwerpen: Ania,

1966), which contains a discussion of Von Gebsattel's writings on addiction
and related topics. Does de Willebois AEM van der. Vervreemding en
Verslaving: Over alcohol en de psychopathologie van de zelfverbeelding
2nd ed. Nijmegen: Dekker & Van de Vegt, 1978, which contains an extensive
discussion of Von Gebsattel's medical anthropology, particularly on
addiction, sexuality, and depersonalization.

63. Smolders F. Probleemidentificatie: Van vraagstelling tot

behandelingsdoel. In:

Handleiding Sociale Vaardigheden voor 2e jaars geneeskundestudenten

[Guidebook Social Skills for 2nd-Year Medical Students]. Maastricht:
Faculteit der Geneeskunde Rijksuniversiteit Limburg, 1984/85:37-45 (p. 39).

64. See reference 9.

APPENDIX

VICTOR E . V ON GEBSATTEL:

THE MEANING OF MEDICAL PRACTICE

( TRANSLATION: JOS V.M. WELIE)

VIKTOR E. VON GEBSATTEL (1883-1974)

Late Professor of Anthropology and Genetic Biology,

Wiirzburg University, Germany

TRANSLATOR: JOS V.M. WELIE

Assistant Professor for Medical and Clinical Ethics

Department of Ethics, Philosophy and History of Medicine

Catholic University of Nijmegen

P.O. Box 9101
6500 HB Nijmegen, The Netherlands

1. TRANSLATOR'S INTRODUCTION

Von Gebsattel's three-stage model of the doctor-patient relationship was

developed as early as 1948.1 In 1953 he further explains the model in

About the Meaningful Structure of Medical Practice.2 In his last article

written in 1963, which is translated below, Von Gebsattel gives a final
account of his theory.3 (Note that the word "man" is often used to devote the
human person. This older language is preserved in this translation: J.W.)

2. THE BREAKTHROUGH OF THE NEW INSIGHT

At the beginning there is the question of the physician to the other person:
Why are you here? and: What is wrong with you? All categories of
Aristotelian logic are contained in this most fundamental question. How?

Where? When? Whence? Why are you suffering? Hence, it is with questions
that the attack on the disease starts. Is the physician pursuing the disease
itself, or are his investigations directed towards his opposite, the living
fellow-human in pain?

The physician usually does not consider this question. Disease and

60

JOS V.M. WELIE

fellow-human are the same in his eyes; now and then he does not even notice
that he cannot see the wood for the trees, the living human being for the
symptoms. Initially, for the physician the disease is nothing but an aspect of
the other being, that is, a segment of the whole and living human being. And
if he does not want to be anything more than just a manager of diseases, the
physician will not look beyond this segment. But surely the depicted
presentation of the question essentially does not differ from the one posed by
a veterinarian or a tree surgeon in the encounter with his charges. The only
difference lies in the answer, since the veterinarian will not receive an answer
expressis verbis and only has signs and signals as his guide. Yet the muteness
of animals and plants is certainly not merely a disadvantage for the
diagnostician. For all too often it is necessary in the encounter with patients
to first get rid of a host of absurd imaginations, confused thought processes,
and unreliable statements - conscious or subconscious - by the patient about
his own condition!

But despite all prejudices which the patient entertains while facing himself,
the very fact that he does face himself reveals the uniquely human factor in
being ill. Blindly is the animal caught in his disease, submerged up to its ears,
so to say, in the disease, maybe twisting in the snares of its pains, but unable
to go beyond its body which, like the pain, forms an unsurpassable limit. The
human being, however, can take distance from his painful condition, and
actually does take distance incessantly, at least tentatively. In the relationship
to himself he also relates to the disease, confronts it, takes it tragically or
easily, surrenders or defends, impatiently or resignedly; briefly, the
relationship of a human to himself (Selbstbezug) which is always a mediated
(vermittelt) relationship, accompanies him into his disease, takes from the
disease its pure immediateness and goes through the disease back to the
individual. Thus, disease turns from a mere incident into his affair, to
something that he has, something that he handles.

Since the "What" of the disease is inextricably united with the reactive self-
relationship of the patient, that is, since this relationship of the patient to the
disease is what forms the entirety of his disease, the interest in the area of the
basic concepts underlying medicine has been focussed on the issue of the
diseased human being as such. "Real in the true sense of the word are not the
diseases, but only the diseased human being." This phrase stems from Von
Weizsacker, if I am not mistaken. In any case, it can be considered the motto
of what is now called general medicine or medical anthropology. In this
perspective, disease is understood as one way of being human. Under the flag
of "the diseased human being" nowadays sails the reflection of the
metabiological and metapsychological, that is, the ethical and religious
foundations of medicine.
THE DOCTOR-PATIENT RELATIONSHIP

61

It should be realized that after the period of romantic medicine in the first half
of the nineteenth century - for example, Schelling, Schubert, Ringseits, Ritter,
Justinus Kerner - a period which was relatively fruitless for medical practice,
medicine, while binding itself closely to the natural sciences, loosened its
connection with theology and philosophy. Medicine thereby lost the
anthropological theme, which had been its primary theme once before, that is,
at the end of the eighteenth and the beginning of the nineteenth century.
Meanwhile, this loss of a fundamental notion that surpassed the various
sciences, and its cataclysmic consequences remained hidden for a long time:
too impressive were the marvelous successes of the biomedical sciences, such
as bacteriology, serology, hygiene, pathological anatomy and physiology, as
well as the successes of medicine itself, particularly surgery, but also clinical
medicine in all its specialties. And even though the increasing somatization
and technicalization of medicine threatened to confuse the average
practitioner more and more, the effects of this confusion were neutralized for
a long time by the representative and creative physicians of the scientific era.
Their elevated humanity had made them immune from the deterioration of
the medical ethos. It was only during what the sociologist usually calls the
"abnormalization of society"

that the disarray in the nature of medicine was revealed.

What took place was a very rare exposition: in a world in which the most
unusual and most terrible events had happened and in which abnormality had
forfeited its psychiatric and psychopathologic qualification, the shift in the
attitude of physicians became visible to everybody in particular examples, a
shift that was prepared over a long period of time, yet became symptomatic
only in specific extreme incidents - I am thinking of

"euthanasia" and "involuntary experiments with human subjects." It was Von

Weizsiicker who said that in Nuremberg the spirit of scientific medicine was
brought to trial. What he meant to say is that those responsible for these
outrageous deeds and misdeeds were certainly not sick people considerably
off-track, nor abnormal individuals, but very much everyday people. Hence,
it does not suffice to explain such events by pointing the finger at those
responsible on a State or Party level. Rather, these events revealed, very
much like a sociological experiment, that the average representative of
scientific-positivistic medicine had no defensive power against the dictatorial
invasion of forces foreign to medicine that arrogantly tried to determined the
medical practice from the outside.

As mentioned, this was not the result of a pathology of those physicians who
were in the power of an equally abnormalized collectivity; the collectivity
could exercise those powers only because in the territory of medicine itself
the axioms were lost which should have guided medical

62

JOS V.M. WELIE

practice normatively. "What healthy and what sick means in general, is a

question about which a physician is the last to rack his brains," Jaspers has
once remarked. The newness of the contemporary situation consists in
physicians having started to ponder such issues - something that has not
happened for a long time. The first medical anthropology was, as far as I
know, developed after the World War in Vienna by Oswalt Schwarz, a
urologist, psychoanalyst, and philosopher in one person, who analyzed the
importance of the act as the human "vital category" (Vitalkategorie) in the
area of medicine. It was always philosophically-oriented physicians who
were stirred in an anthropological direction, such as Binswanger, Von
Weizsacker, Kiitemeyer, Matusse; or sometimes theologians, if they had as
sound a scientific knowledge as did George Siegmund.

In closing itself off from philosophy and theology, science is as unable to

conceive of a concept of disease as of a concept of health. This conclusion is
verified over and over again in discussions with extremely positivistically-
oriented physicians. They claim competence in the evaluation of health and
disease, but if one urges one of them to provide more precise definitions and
conceptions of value, then he escapes into the plentitude of disorders which
he encounters everyday, and it is shown that his general concept of health and
disease does not differ from that of the layman. In this context I have to
remind the reader of Max Scheler's "natural perspective on the world"
(natiirlichen Weltanschauung). This means that in everyday life the scientist
or scholar lives in a prephilosophical world; in a world in which the sun
comes up and goes down, which is filled with qualities whose presence he
disputes as a scientist, yet that determine his everyday behavior, and which
he cannot evade. Similarly, the concepts that regard the value of health and
disease are part of the natural perspective on the world: health is simply
desirable, disease undesirable, and in everyday life this view is entertained by
the physician as well.

Yet, these original conceptions of the value of health and disease change
when they become part of the perspective which the expert holds about the
world and the human being; for conceptions of value do not exist in the
scientist's perspective of the world. Actually, a diseased human being does
not exist in the eyes of the scientist, or if he does, only as the object of
medicine and its auxiliary sciences. Undoubtedly, the subdiscipline of
medicine perceives the subsections, which it has set apart from the whole of
the real human being in accordance with its methodology, sharply and
clearly, particularly in their pathological appearance. But the disease is not
identical with the pathological. What the scientist is not at all interested in are
the existential aspects of a human's diseased state, where these aspects
actually are the essence of the disease in the eyes of the patient.

THE DOCTOR-PATIENT RELATIONSHIP

63

For the pathological is only of interest to the patient on a second plane.

The scientific objectification of the patient contrasts sharply with the latter's
very existential way of being, that is, his being a subject, an individual, a man
or a woman, a person, the totality of all those aspects; science objectifies
something that in fact cannot be objectified. Yet science objectifies the
human being, turns him into its object, which science can do only by
abstracting from the living reality altogether. The real, true human being,
whether healthy or diseased, is necessarily beyond the scope of science.

Rational, methodological analysis of its object requires science to be

reductive, even if its object is the person. What is more, science cannot be
blamed for this procedure, since it is a prerequisite for all scientific
knowledge and thus a conditio sine qua non of scientific successes and
triumphs. As long as its findings are merely the measuring rod of what has
afflicted the human being or his organs, this reductive and abstractive
approach is not problematic; but it is when these findings become the
measuring rod of what it essentially means to be a human being there are
problems. In the area of medicine, the scientific attitude threatens to turn the
living fellow-person with all his needs, into the mere object of a
technological contact and the irreplaceable unique person into a regular

"case."

It cannot be maintained, as has often happened, that it was the introduction of

psychotherapy into medicine, particularly psychoanalysis and individual
psychology (Jndividualpsychologie), which radically changed the situation.
The introduction of psychology certainly was not equally significant as the
postulated introduction of the subject or, even more, the person into
medicine. On the contrary, Freud's and Jung's ambitions went so far as to also
investigate the human soul by means of a scientific method.

They talked about the mechanisms of depth psychology, about psychic

apparatus and functions, about affective and impulsive dynamics, complex

and libido energies, and they talked proudly about energetic processes such
as the alpha and omega of the psychic reality. Not the encounter with the
diseased human being, but the analysis of the diseased mind was the theme.

The mind was turned into the object of therapy just like any other corporeal
organ of the human being. That it concerned the mind did not change the
basic scientific attitude in the least. After all, the mind was, to be precise, but
an organ that was overlooked by traditional medicine, just one organ among
many, and the analysis of its functions was the continuously debated subject
of research. When in traditional medicine corporeal organs were considered
the seat of diseases, now also the human mind was available for the
localization of other diseases. The newness of the contents, the emphasis on
the subconscious, the analysis of impulses, instincts,
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affects, the talk about psychic entities, all that seemed to be fully consistent
with a scientific position.

But despite the efforts psychotherapy undertook in this initial phase to adopt
the scientific attitude, to bring its object under this perspective, this venture
did not appear to work out very well. For essentially the human being cannot
be divided, and the radical division in material apparatus on the one hand,
which the so-called organic medicine had to take care of, and on the other
hand, the psychic mechanisms of the neurosis were carried on by the
psychotherapeutic clinic ad absurdum. Long before the name itself was
developed, psychosomatic medicine had taken a hold. Concepts surfaced
such as "psychogenic causation of organic diseases" (the so called organic
neuroses); in addition to conflict neuroses, the hysteric conversions of
psychological ideas in the language of the body were recognized - in the so-
called "organ dialectic" (Organdialektik); briefly, the functional connection
between the various layers of the personality became more and more evident,
and the slogan "mind-body-unity" emerged. At the same time it became clear
that individuals are able to escape the mental and psychological problems of
life by fleeing into seemingly organic diseases, and this forced medical
thinking to complement the purely causal approach to processes with a final
approach, already pointed towards the meaning of disease in the context of
life itself. In addition to the question concerning the cause, the question
concerning the purpose was acknowledged, which was the question about the
meaning, even if only in a provisional form.

Furthermore, the scope of medical thinking was considerably expanded when

internists and neurologists of the standing of Bergmann, Von Weizsacker,
Siebeck, and others made it their business to introduce the experiences of
psychotherapy (in the narrow sense of the word) into the internal medicine
clinic in the form of "biographical medicine." The technique of anamnesis,
traditionally the principal instrument for arriving at a diagnosis in the area of
psychiatry, upon transformation in the conversation-hour of depth
psychology, became the biographical method of the internal medicine clinic.
The patient's biographical perspective on his own existence had thus become
the very focus of history taking. For man essentially exists in history, and in
the sometimes cowardly, sometimes addicted, sometimes obstinate, but
always egocentric opposition against the developmental law of personal
being, the therapist nowadays recognizes pathologic disorders of a totally
new type. In comparison with such centrally and existentially threatening
disorders of the personality - I call them

"existential neuroses" - biographical and psychosomatic medicine has to deal

with disorders that regard the marginal zone of life; examples being: biliary
colics that occur in connection with professional degradations; an

THE DOCTOR-PATIENT RELATIONSHIP

65

angina attack which appears recurrently in connection with erotic crises; a

tuberculosis which breaks out at dramatic turning points in life; a Basedow,
such as I observed myself, following thirty hours of deathly fear after a fall in
a glacier trench.

But what exactly was so clearly revolutionary about the infusion of

psychotherapy in the medical thinking of those days? Certainly not, at any
rate not primarily, the mere introduction of the psychic reality in medicine or
in some other newly discovered psychopathological science, for example of
the unconscious, or the affect dreams of pregenital sexuality, or of the
archetypical world. Neither was it the piecing together of these new
discoveries into a depth psychology system such as the theory of the
individuation process, nor putting it into a new technique for dealing with
mental patients. Rather, its revolutionary character was due to the new
direction that was taken that the very creators of depth psychology had not
even acknowledged as such, and to the fact that medical thinking was moving
on the new road of psychotherapy towards a goal that was effective without
even being recognized. This goal was the human being.

But how could this most familiar, most self-evident being that was known to
everybody, how could the human being become a new goal of a discipline
which never had to care about anything but man's weal and woe, how could it
become the new meaning of medical practice? Obviously, there was no lack
of formulas in which the recognition was expressed of this newness that was
being approached. The new aspects of the crucial questions of life usually are
as old as the hills. Man forfeits his knowledge in a thousand dubious ways,
only to find it back again, totally surprised, as if such knowledge was never
known and experienced. Nature is denied and with that man too has become a
ghost. The spiritual is denied, and man ends up in nothingness and emptiness.
The transcendental is denied, God is renounced, Christ is declared a mere
genius, or otherwise a delusional patient, and the effect of all this is the
distorted image of man, a caricature.

In the past decades of psychotherapeutic research ample formulas emerged

intended to capture the newness. There was the slogan of the "whole human
being," intended to mold a whole out of the body of scientific information
about the human being. The theory of the mind-body unity emerged,
undoubtedly a useful theory, but only a partial redress.

Consequently, the theory of the whole human being was placed under the
personality theories and the physician turned from a "doctor of the body"

into a "doctor of the personality" (Speer); yet we know - one is reminded of

the anthropological studies of Guardini and Ernst Michel - that the

"personality" is only one aspect of the whole and integral human being

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JOS V.M. WELIE

and not the pinnacle of a philosophical or religious anthropology. The

Swedish neurologist and sculptor Paul Bjerre, while comprehending the
synthetically formative forces of creative life, placed the synthetic dream
analysis in the center of his therapy; but the very point of convergence in
which the digressing tendencies of human nature should be synthesized, in
the end were left more or less to the blind aspirations of the liberated human
nature. In Vienna, Viktor Frankl was the first to place the mind-body unity
under the spiritual; psychotherapy became logotherapy. The will, the
awareness of responsibility, and the decision, in his eyes - and correctly so -
had again the task of integrating the human into the higher unity of freedom
and truth, guided in its existence by the spiritual.

The fact that man in his pure egocentricity is a mere torso, that the
selfrealization of man requires the integration of the individual in the "us,"
that is, in a higher community, requires that the commitment of man to others
is constitutive for personal life - this insight, in surpassing the so-called
individual psychology of Adler, Kunkel and Kuhnel, was finally infused into
medical psychotherapy by Ernst Michel, the Catholic psychotherapist, and
Martin Buber, the Jewish mystic.

The Christianization of medical anthropology had been prepared along the

detour of a deepened theory of neuroses, slowly, and came as a total surprise.
It clearly had become necessary to approach newly emerging therapeutic
tasks with new conceptions of the human being, including the diseased
human being, conceptions that differed considerably from those espoused in
internal medicine, neurology, and psychiatry. What is highly astonishing, is
that it became clear that these conceptions were nothing but the secularized
basic principles of the old Christian personal theory of man and his
destination. In one of those surprising turns of which the history of ideas is
full, it became clear that even though there is a difference in the way
questions are phrased when analyzing human existence from a metabiological
and metapsychological perspective on the one hand, and a theological
perspective on the other hand, there is no longer an incongruity. Both theories
stand against one another in a relationship of mutual clarification and
supplementation.

3. THE MEANINGFUL STAGES OF MEDICAL PRACTICE

At the base of medical practice, the soil on which it matures, is the encounter
between physician and patient and the relationship which unfolds in this
encounter. The meaningful stages of medical practice, therefore, are
elaborations of a special situation with its particular meaning that

THE DOCTOR-PATIENT RELATIONSHIP

67
appears in the threefold modulation of the relationship between doctor and
patient. The three meaningful stages stand against one another in a dialectic
relationship and are not deduced from the concept of disease, but in reference
to the diseased human being. They are the following: l . The elementary-
sympathetic stage of being called by the need of an encountered human
being: this is the immediate stage in the relationship.

2. The stage of true medical thinking, planning, acting, the

diagnostictherapeutic stage: this is the alienation stage in the relationship.

3. A stage which encompasses the former two modes of encounter, the stage
of partnership between physician and patient: this is the personal stage of the
relationship.

At each of these stages the physician and patient relate to one another
differently; at each stage the physician is solicited differently. First as a
fellow human being, called upon by the need of a fellow human being and
thereby becoming a participant in that need; next as the technical executor of
this call in the sense of combatant of need: the physician in the everyday use
of the word; and finally as the personal partner of the patient, as "Thou"

of a "Thou," in light of the solidarity of mankind in its relationship to the

transcendental that encompasses guilt, suffering, death, and love.

"Mastership" in the higher and true sense of the word develops when these
three meaningful stages of medical practice are combined into a rankordered
comprehensive act.

The beginning, or original stage, is the sympathetic call stemming from the
need of another being. In the acceptance of this call, acknowledging the need
of a stranger, and through the elementary participation in this need, one
becomes the fellow of the other (like the patient, inversely, turns from a
stranger, the mere other, into a fellow as well). Strictly speaking, in this
original state one is not really standing as a physician yet. It is only, upon
being called by this need, when one feels instigated to help, that the
undetermined, sympathetic solidarity takes the configuration of a physician.
In and by itself the need has the character of a call, regardless of whether that
call is audible or whether the need in painful muteness only cries out to the
heavens. Even as a smothered call, the need searches for the listener, because
the patient is smothered when he is caught in his own suffering; yet the
patient recovers a breath through the sympathy of the other.

However, perceiving a stranger's need, the readiness to lend a favorable ear

and a compassionate heart is not yet really a response to the call stemming
from the need. The appealing presence of the need implies that it looks for a
response, and this response is a named "help.'' The need of the fellow-human
drives the one who does not suffer out of the pure

68

JOS V.M. WELIE

pathetic communication between the one who suffers and the one who does
not, into the active fight against the need, that is, into help. By its very nature,
help is a responsive act. To be constituted as such, the possibility to master
need must exist. Only the person who can swim can vigorously and
effectively respond to the cry for help of a drowning person. The need of the
human being that has the shape of disease has the character of a call as well.
Without the call of such need, whether it stems from a pain the threat of
death, troubles or insufficiency, or, on a moral level, from the intrusion of
nothingness into one's existence, nobody would ever seriously hit upon the
idea that he is destined to consider as his life-work the observation of a
physician's responsibilities. In the existential sense of the word, disease
always is not-being-able-to-be somehow coming to power.4 And the call of
this needful way of not-being-able-to-be provides the foundation of the
medical profession. The physician has to call the patient back into uncurtailed
being. Thus, at the elementary stage of the comprehensive medical act, an
immediate needful encounter between doctor and patient takes place, which
institutes an original, immediate vital unity between the two.

This bond and willingness, however, is again being lost in the medical
management of the need at the second stage of the encounter between
physician and patient, which I therefore named the "alienation stage." At first,
this explanation will give rise to amazement, for in the art of diagnosis and
therapy, the performance of the physician and his service to the patient is
generally considered as being culminated. However, what this means shall be
unfolded using the analogical example of pain.

If the need of the patient consists of physical or psychological pain, it is

immediately evident that the physician's sympathetic rapport to the sufferer
cannot undo the fact that the pain-free witness of the pain-stricken patient is
separated in his existence from the existence of the other by an abyss which
is called painlessness. Having suffered himself, he may be able to gain a
more meaningful and realistic understanding of the pain of the stranger, but
thereby the pain of the stranger will never become his own; sorrow for the
suffering of the other does not become suffering with the other, if we leave
aside the borderline case of an emotional affection which is pathological
itself and ultimately deceitful. The fact irrefutably remains, that the pain-free
person is assigned another place than the person overwhelmed by pain. The
pain isolates the sufferer fully by chaining him to his situation, but likewise
the pain separates the helper from the helpless.

Since the existential separation of the helper and helpless, which has now
suddenly appeared, cannot be abrogated at the level of the pain or

THE DOCTOR-PATIENT RELATIONSHIP

69

any other distress, as a thorn this separation urges the helper to remove the
pain of the stranger. Thus, the pain appears to be a leap into the wellbeing of
the sufferer as well as a leap into humane solidarity; and likewise, the call
stemming from the need caused by disease urges one to fight the latter. This
fight has the shape of a scientific and technically skilled act of help. The
disease, instead of the diseased, becomes the enemy; and the act of help
becomes a duel with the disease, like it is a duel for the patient; a duel with
himself. The condition of the other person, the cause of his suffering, and the
possibilities of removing them, all must be clarified in a process of
objectification. In doing so, it can easily happen that the patient is no longer
viewed as a person and has become the mere object of a technological
contact.

Consequently, at this second stage of medical practice, though it represents

the actual area of implementing medical rationality and the realm of its
highest triumphs, the ethos of the physician is endangered. For the need
which is calling for subjection is not a scientific construct, even if science
understands all of its biological preconditions entirely; rather, it concerns a
human being, and the fight against the need of the patient should be a service
to him. However, when we look at the issue carefully, then in the sphere of
diagnostic-therapeutical contact, the patient is actually not subjected as an
individual to diagnostic-therapeutical procedures; he is only a case adapting
to the general regularity and conformity laws, which make knowledge and
technology possible in the scientific sense of the word. Careful as we may
individualize and look for laws that apply in this case only, there remains the
fact that physician and patient relate to one another as subject and object at
the stage of separation. For it is not at this level that the higher meaningful
unity can be found which is appropriate in overcoming the alienation stage.
Thus, it can easily happen that this service to man, because at this stage there
is no concern for man in his personal worth, is interpreted in an inhumane
manner, as service to the state, the population, or the race; in which situation,
the physician, being degraded to a functionary of society, is tempted to
sacrifice the individual to the health of the population, the purity of the race,
or the utility of the state.

Hence, the second stage of the act of help, in so far as it considers diagnosis
and therapy the only important issues, prompts for a stronger grounding of
medical practice. After all, it is not merely two individuals that are related to
one another as physician and patient, but two persons, and at the level of
personal existence a style of communication is required other than the
sympathetic rapport of the elementary stage, but also more than the mere
diagnostic-therapeutic impact on the patient, skillful and

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exact as it may be. It is only in a practice which involves the person of the
fellow man that the spiritual-pastoral and similarly the spiritual-medical
comprehensive acts take place.

That man can be suffering terribly, despite unlimited disposition of his

somatic and vital functions, that is, despite full physical health, from an
agony which Kierkegaard (with staggering, nowadays still not fully
understood, emphasis described as "Sickness unto Death,") has opened our
eyes to the third dimension of medical practice. Now the duel of the
physician with the need of his fellow man enters a profundity formerly
unknown to medicine, into the heart of personal existence - it enters its own
metabiological center. The notion then arose that it is God's call which called
the person into existence.

The word of the Bible came alive: "I have called you by your name, you are
mine." And it was furthermore recognized that it is up to man to anchor his
life in this deepest existential foundation or to renounce it. Thus, a new form
of need appeared; the need of an existential raggedness which divides the
personality into a will to determine its final destination and an equally
vehement counter-will.

The kind of need that characterizes the "existential neurosis" advances deeper
into the interior of man than others and should be understood as the effect of
a secret nihilism of personality. Since the appearance in the burning bush, the
first time in history that the essence of the person has revealed itself in the
expression: "I am that I am," there is for man, the image of God, a two-fold
possibility: Either to realize the challenge of personal existence or to
renounce this challenge and to maintain about oneself, "I do not want to be
that I am." Of course such statements are usually not explicitly expressed.
They exercise their power in the dark background of man: Their purpose is to
dethrone God in man's own soul: Given man's actual stand, this dethronement
is realized via the enthronement of one's own person. Thus, thoroughly
hidden behind superficial disorders in man's psychological economy, deep
lacerations are brought about in the dark will of the personality. This causes
severe hinderance for the selfrealization in love, community, and creative
life-formation - the integrative process of the personality - that is, its
completion. The nihilism of the central counter-will, which is hidden, yet
present in every act of life, breaks through in the form of a multi-dimensional
obstruction of man's development. That man heads towards nothingness, even
desires it like an addict, and recklessly succumbs to it, is symptomatic of
man's personality drifting away from its own center. Personal existence can
prosper only in a Thou-relationship to the transcendental in its personal
reality.

THE DOCTOR-PATIENT RELATIONSHIP

71

This is the only genuine, original psychological disease because the socalled
psychological diseases are known to be primarily disorders with a somatic
origin (Somatosen). The existential neurosis has revealed the third stage,
which actually provides the very foundation of medical practice.

We called it the stage of partnership, and this designation indicates that at this
stage the physician is called to engage as a person in the communication with
another person. Once this stage has been reached, it becomes clear that the
technically oriented effort of the helper, to a large degree, is subordinated to
the guidance of the existential effort. This is the only possible order that
coincides with the very idea and essence of comprehensive medical practice.
The effort required by neurosis must continue to determine in the background
the essence of the doctor-patient relationship always and everywhere.

The neurosis illustrates the meaning of what has been said. For when the
existential need of his partner calls for the responsibilities of the physician,
the latter cannot abstain from first examining his own existential position.
Unwillingly, the other in his need calls the physician into the same need. In
this solidarity of need, which stems from the eternal dissatisfaction with our
personal reference to the transcendental, the sufferer changes from being the
object of skillful management to the personal partner of the physician, and
then to a longing Thou who stands in the same reference to the transcendental
as the I of the physician. The alliance between the helper and the helpless
turns into the partnership between persons who are equal in regard to being,
that is, in their attempts to find domicile in it. There thus emerges a
community of partners between irreplaceable persons.

Although partnership is the genuine relationship between physician and

patient, it cannot be initiated and achieved as diagnosis and therapy. The
source of personal being is itself not the object of action. This source cannot
be supplied by a moral institution or a new kind of therapy, such as the
impetuous type of psychotherapist tired of psychoanalysis would favor: But
Christianity can; for it is a reality beyond the applicability of practical-ethical
norms, not an aggregate of moral guidelines and imperatives.

Personal existence, from the perspective of man, is a venture of faith, and

from the perspective of God, an act of love. This applies as well to the
partnership between physician and patient. Whoever tries to establish it
arbitrarily and violently is in danger of violating the law of freedom in the
other, thereby calling into question the very partnership which he is trying to
establish.

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NOTES
1 Gebsattel VE von. Das Ethos des Arztes: Bin Gespriich. Wort und
Wahrheit 1948;3/9: 652-666; Gebsattel VE von. Das christliche
Berufsethos des Arztes. In Borgmann K, ed.

Anruf und Zeugnis der Liebe: Beitrage zur Situation der Caritasarbeit.
Regensburg, 1948:118-135.

2 Gebsattel VE von. Zur Sinnstruktur der iirztlichen Handlung. Studium

Generate 1953;6/8: 461-471. Reprinted under the title "Zur Sinnstruktur
der iirztlichen Handlung." In Gebsattel VE von. Prolegomena einer
medizinischen Anthropologie: Ausgewiihlte Aufsiitze. Berlin/

Gottingen/Heidelberg: Springer Verlag, 1954: 361-378.

3 The article first appeared in 1963 as "Yorn Sinn des iirtzlichen

Handelns." It was reprinted In Gebsattel VE von. Imago Hominis:
Betriige zu einer persona/en Anthropologie. Schweinfurt: Neues Forum,
1964:58-74.

4 "Disease emerges always from the erection of a relatively not-being

over a being."

(Krankheit entsteht irnrner aus der Erektion eines relativ Nicht-

seyenden iiber ein Seyendes.)

Schelling, Die We/alter [Footnote of Von Gebsattel].