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The risk of self-referencing
Antonio del Puente

Antonella Esposito

Lorenzo Savignano

Vinicio Lombardi

Gaetano Lombardi

Raffaele Scarpa
Received: 4 October 2010 / Accepted: 28 October 2010 / Published online: 25 November 2010
Ó Springer-Verlag 2010
Abstract The medical field is becoming the sphere of a
quite peculiar confrontation, a sort of test of tension
between two different approaches: on one side self-refer-
encing, the concept that the whole set of knowledge and
capabilities generated by medical science establishes self-
sufficiency of our field; on the other, the quest to broaden
our concept of reason overcoming this self-imposed limi-
tation of reason. At stake is the need to overcome the
dissatisfaction and the crisis our field is currently going
through. This article will go over some aspects of what we
believe to be a paradigm of a much general and crucial
cultural problem.
Keywords Self-referencing Á Humanization of medicine Á
Scientific culture
One of the most debated issues today is the ‘‘humanization
of medicine’’ [1, 2], a matter that reflects the deep dissat-
isfaction of both patients and health-care workers [3, 4].
This dissatisfaction cannot be reduced to a problem of
available resources. Its origin should be sought elsewhere
and clearly identified if we really want to try to humanize
health care.
Against this background, this report aims to investigate
on what is likely the most serious—albeit poorly
acknowledged—problem faced today by the medical
community, something we may define a ‘‘cancer’’ affecting
medical professions: self-referencing.
Definition of self-referencing and its first root
What do we mean by self-referencing? It is the concept that
the whole set of knowledge and capabilities generated by
medical science establishes self-sufficiency of this field. In
other words, denying the existence of, and need for, an
objective and committing reference context for medical
professionalism: working in the medical field need not to
respond to anything other than its own internal dynamics.
In truth, this problem is common to all aspects of human
activities of current times, although in the medical field this
attitude has reached perhaps its highest expression and is
where it may have the most severe consequences, as we
will see.
The claim for self-referencing is based on two main
factors. The first is the recall to the origins of our profes-
sion and its ancient ideal reference points. The classic and
obvious reference is the Hippocratic Oath [5]. This is
considered a Magna Charta identifying on the one hand the
extent and profile of professional deeds, and on the other
expressing an exhaustive position regarding the need for
ideal support of professional devotion.
Indeed, the miracle of classic antiquities is the devel-
opment to the extreme of all human faculties. We owe
A. del Puente (&) Á A. Esposito Á R. Scarpa
Rheumatology Unit, ‘‘Federico II’’ University,
Via Pansini 5, 80131 Naples, Italy
L. Savignano
Avellino Local Health Unit, Avellino, Italy
V. Lombardi
Naples Local Health Unit No.1, Naples, Italy
G. Lombardi
Department of Endocrinology and Molecular and Clinical
Oncology, ‘‘Federico II’’ University, Naples, Italy
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J Med Pers (2010) 8:130–134
DOI 10.1007/s12682-010-0070-6
them the deep human drive that was able to discover the
value and dignity of medical care. However, this would
have remained unaccomplished had it not been grafted by
Christian civilization. This constitutive unaccomplishment
and not just technical inadequacy is well illustrated by
several considerations.
In Platonic and Aristotelian ethics, medicine was sub-
ordinated to the good of the polis; consequently, if a
physician employed part of the community’s resources to
treat someone who, destined to sure death, would never be
able to return the benefits to the community, that physician
would have failed in his professional duty. Doctors were
instructed to abandon a person affected by an incurable
condition [6]. For Hippocratic doctors—but we could
simply say for doctors in classical antiquities—the guiding
principle inspiring their actions was the ‘‘necessity of
nature’’, imposing abstention from practice in cases that
were necessarily considered incurable. Philanthropia was
subordinated to love for nature (physiophilia).
If we shed ourselves of all prejudice, therefore, classical
antiquities display a humane position—a consideration for
medical practice—that explores for the first time in the
history of humanity such a profound position. The Oath
represents the culmination of a ‘‘natural’’ attitude. And yet,
the full correspondence to human expectation remains
unaccomplished, unattainable. An expectation that within
this context can be defined by the words ‘‘charity’’, ‘‘gra-
tuitousness’’: they represent the human approach that
everyone who is ill would want to experience in his/her
relationship with the health carer.
Therefore, the referral to the origins does not justify the
claim for self-referencing of the medical field because it
does not recognize the need for the opening of the field to
other contributions, which has granted its growth. It dis-
avows, for instance, the substantial debt toward the
Christian experience. This, transplanted in a substrate
prepared by the classical culture, has generated novelty and
originality of expression for the human surge for attention
and care for those who suffer, in a way that corresponds to
the person’s expectation.
The second root of self-referencing: modern
self-limitation of reason
There is a second basis on which this claim lies: the
technical–scientific culture asserts that it has rules of its
own that do not respond to any other cultural field or
knowledge. Moreover, this culture claims to be the only
approach which can generate reasonable conclusions
(exclusive use of the ‘‘principle of reasonableness’’). It
deems rational only that which can be proven by
This attitude draws its origins on the self-limitation of
reason [7] that has gained ground in modern times: the
objective and universal knowledge can only derive from
the mathematical–scientific approach. All other forms of
knowledge remain limited to the subjective sphere and
have neither space nor saying in the debates and decisions
that concern our professional field. The medical profession,
therefore, sees itself as dependent only on evaluations that
are validated by experiments.
This reductive approach is the object of discussion
suggesting, instead, that technical–scientific culture has in
its own nature the need to open up to other realms of
knowledge: true knowledge cannot be attained by reducing
the broadness of human reason.
Consequences of self-referencing in the medical field
The severe consequences of this attitude and the applica-
tion of self-limitation of reason in medical profession can
be summarized as follows.
Mechanistic reductionism
The first consequence is that the self-limitation of reason
confines to ‘‘subjectivity’’ all the considerations on the
complex unity of the human being and its absolute value,
considerations that precede the evaluations that need to be
validated by experiments. There is in fact existential
human evidence—such as the person’s absolute value or
the respect for life from conception to its natural end—
which is absolutely reasonable, although not demonstrable
by experiments [8]. A self-limitation of reason denying
this, instead, ends up considering man as a broken machine
needing repair, and the physician as the ‘‘engineer of a
broken body’’, with an immediate negative fall-out on the
professional act, as would say anyone who was so unlucky
to experience it.
The human being is considered a product of our action, a
product that, therefore, can also be selected according to the
exigencies established by ourselves, and loses its dignity and
inviolability. In a world based on calculations, the only
‘‘reasonable’’ factor is the calculation of consequences.
The claim for a ‘‘neutral’’ technique
This purely functional rationality, this self-limitation,
engenders another distortion: it claims to confine the
medical action to a neutral technique. Such a technique
does not respond to anything other than its inner dynamics.
It only needs to be applied. No need for people capable of
judging, of relating with the patient: there is only need for
clerks applying guidelines. At this stage, the only
J Med Pers (2010) 8:130–134 131
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protagonists are the user who makes requests and the
arbitrator who verifies the proper execution of the proce-
dure. The unique dimension of the doctor–patient rela-
tionship, the need for meaning expressed by such relation,
these too are confined to the realm of the subjective. The
‘‘medicine of desire’’ and bureaucratization, which drive
the doctor towards ‘‘defensive medicine’’, become wide-
spread, and the technical goodness of the medical act is
again penalized. The claim for a neutral technique once
again turns against man, even in its professional action.
Applying this self-limitation of reason to the medical
field consequently produces results that go opposite to what
is theoretically desirable; medical profession, to be effi-
cient and effective, must consider the patient in its
wholeness, as a ‘‘person’’.
Broadening the concept of reason
Challenging the concept of self-referencing does not imply,
then, moving away from ‘‘experimental’’ evidence: rather,
it means being loyal and recognizing reality in view of all
its richness. It implies considering a person not as a
‘‘broken machine’’ needing repair, it means considering our
work as part of a wider task aiming to respect and
accomplish the global aims of the human being. It implies
facing in our work the responsibility of a confrontation
with the questions posed by what we find to be true in our
human experience. This is the work we are called to by the
quest to ‘‘broaden our concept of reason’’, overcoming this
self-imposed limitation. It means not confining to subjec-
tivity (and basically declass or neglect as ‘‘relative’’) such
relevant issues, nor denying the problems engendered by
the persisting claim for self-referencing: massification and
merchandization of patient–care giver relation; massifica-
tion and merchandization of such sensitive domains
involving human suffering, the education of young stu-
dents, scientific research; and, last but not least, the crisis
of professional roles, the dissatisfaction with one’s own
work, the dissatisfaction felt by patients [9].
Any technical action or scientific know-how, especially
if related to medical care, cannot do without the
acknowledgement of a reference context where the person
and life are considered as absolute values. The purest of all
technical and scientific actions, or the one remotest from
any applicability or apparent relation with the individual,
beyond the awareness of this reference horizon, loses its
efficacy and its technical or cultural goodness. It does not
generate civilization and turns against man. Outside this
context, it is the ‘‘technical’’ goodness of any act that falls
short. He who does not respect the other as a ‘‘person’’ and
confines such need to the subjective realm, does not work
well, cannot make products or technical actions that are
Therefore, the point is not ‘‘adding something’’ to
technical–scientific knowledge, ‘‘a bit more humanity’’, but
rather to place technical–scientific knowledge in the con-
text that makes it more effective. Going back to the
‘‘cancer’’ that self-referencing represents, it is not a matter
of adding liver cells to the lung, because the lung is
designed to carry out its own function, but rather to relate
the lung to the rest of the body ‘‘according to nature’’,
correcting and treating the cancer growth (‘‘the claim on
autonomy’’) that is taking place in that organ, which not
only is damaging the entire body, but is preventing that
organ from carrying out the role it was meant for in a
‘‘technically’’ adequate way.
Broadening the concept of reason: the delicate issue
of ‘‘common values’’
How can we achieve the opening necessary for our work?
The first step in this direction is to loyally recognize that
the various aspects of human reality are not self-referential
and that, consequently, our profession does not have in
itself the potential to make it. Which is not a drawback:
rather, it equals to acknowledging the richness of reality,
even professional reality.
This acknowledgement relates itself to the delicate issue
of trying to agree on the ‘‘values’’ or ‘‘objectives’’ of our
profession, which, if misunderstood, can become a mere
expression of the attitude of self-sufficiency previously
described, with the dire consequences we mentioned.
As a matter of fact, if the reference to professional
‘‘values’’ or ‘‘objectives’’ (as a minimum common
denominator) supports the attitude of self-sufficiency, it
falls prey of those who are stronger, i.e., those who will be
able every time to redefine the content of these values or
objectives. This is the substantiation of the self-sufficient
At times the specific reference to the professional
‘‘values’’ can also become an antiscientific attitude, as a
suggestion to move away from the experimental method,
out of nostalgia for the ‘‘artistic’’ or ‘‘poetic’’ profession
that once used to be. The experimental–biological model,
the evidence-based medicine, remains a valid instrument.
The point is placing the technical–scientific knowledge
in the reference context that would make it effective, and
that medical science alone is unable to generate. There is
need for an a priori opening. Values and objectives are
obviously necessary in our activity, but the exclusive ref-
erence to them remains ambiguous and ends up reinforcing
the attitude of self-referencing.
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Opening up to essential resources: a question
of proper laicity
In order to overcome the self-referencing attitude, a simple
fact needs to be acknowledged: what is true in our human
experience is not alien or irrelevant in our work, and vice
This is an extremely important cultural step, with
important ‘‘operative’’ consequences: in our work we need
to open wide the doors to those resources, to the educa-
tional relations that express the full extent of our human
experience. It is a call to a proper laicity, meant as
acknowledgement of full right of citizenship for positions
that openly express their motivations, recognizing their
value as resource and their social relevance [10]. This does
not limit anyone’s freedom: rather, it represents the will-
ingness to put at everyone’s disposal all the available
energy. On the opposite, laicity—meant as indifference
towards ‘‘a process of argumentation sensitive to the
truth’’ [11], laicity meant as concealing personal motiva-
tions, considered relative after all—ends up giving into
superficial reference, to ‘‘common values’’ (without sup-
port or criteria) or to ‘‘objectives’’ of a self-referencing
Opening wide the doors implies giving value to the
possibilities and resources that are before our eyes. In
particular, the Christian experience is undoubtedly an
essential resource for the world of health care, both from a
historical and a personal point of view. The contribution of
the Christian experience to professionalism in the field of
health care is not a mere idea, it is rather an educational
relationship, a fellowship that makes reasonable—and,
therefore, tends to make permanent—what everyone hopes
for in our field: considering the other (patient, colleague) in
its wholeness, as a ‘‘person’’.
Therefore, to face the problem of self-referencing and its
consequences (mechanistic reductionism and claim for a
neutral technique), it is important to promote encounters
with such experiences and the consequent development of
judgments in a spirit of proper laicity.
From ward meetings to company training courses, the
road to humanization of medicine needs to be paved by
encounters with effective professional experiences that do
not deny the relevance of motivations and their impact on
the technical action, that do not disown them as subjective
or irrelevant; otherwise, the risk is communicating only an
impression of personal ability, which does not produce
culture but cultivates self-referencing.
Consequently, if we favor these encounters, we facilitate
positive interaction among professionals, aimed at express-
ing judgments and initiatives on issues dealing with our
profession, having as starting point the broadness of reason,
without confining to subjectivity the most important aspects
of human experience (substantially declassing or excluding
them as ‘‘relative’’ in the confrontations and the decisions
that involve our professional domain).
This represents the context in which the attitudes uni-
versally claimed as indispensable for the technical
‘‘goodness’’ of our work [1]—i.e., gratuitousness, devotion,
sacrifice—can again become significant because they do
not rely on theoretical postulates or on ethical effort, but
rather on the energy that stems from liaising with other
people, from a current educational relation that one finds
humanely fascinating and professionally effective.
Some examples can suggest a path for this opening. In
the first place, it would be possible to take the opportunity
offered by the educational spaces already available as
optional courses, as it is being already done in our Medical
School for students and for health-care professionals [12].
These lessons are not primarily courses on ethics, or just
lessons, but opportunities to discuss and share experiences
with health-care professionals who are interested in an
educational path. These seminaries aim to document that a
motivated person-oriented approach of the medical pro-
fession improves medical care [13, 14].
This opening to educational relations implies being
aware, in the relationship with patients and with patient
associations, that health is part of an overall wellbeing.
Therefore, promoting health includes, together with a
passionate and sound care of the person in front of us, the
suggestion towards opportunities to open up one’s own life
to a wider perspective [15].
In addition, the opening to educational relations means
giving value to professional associations, not only in terms
of representativeness, but also as an explicit call to a proper
laicity, and as a domain where this opening can be
expressed systematically and critically.
Lastly, in our activity the confrontation that stems from
the aperture to such resources should be made methodical,
so that all our work could flourish again: it is in fact sup-
ported and modulated in every details by the way we
consider ourselves and the one before us, i.e., by our
anthropological concept.
This interaction and this opening are a conditio sine qua
non to overcome self-referencing and its consequences, and
recover our role, from mechanics of a broken body or
clerks who apply guidelines, to professionals, i.e., people
capable of bringing out in their work their complete
Acknowledgments No funding was provided from any source. The
characteristics of the manuscript did not require ethics committee
Conflict of interest None of the authors had conflicts of interest.
J Med Pers (2010) 8:130–134 133
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