How the Biomedical Model Harms People with Chronic Illness

Written by Amy Denton-Luke

Many people in western cultures hold the view that modern medicine is an objective, unbiased, and accurate representation of health, illness, and disease. It can be difficult for us to see the ways in which our cultural lens affects the way we see the world, so it may come as a surprise to learn that our healthcare practices are not as free from cultural influence as we may expect, and actually uses a framework called the biomedical model.

The biomedical model has been the prevailing view of medicine in western culture since the mid-20th century. It has been crucial in advancing our understanding of biology, the human body, and disease processes, and at the center of many life-saving developments in medicine, vaccines, and surgery. These treatment modalities are important tools, and we should continue to use the biomedical model in the ways in which it has been successful.

However, while the biomedical model has been life-saving in some aspects, it has been harmful in others. The biomedical model is a very narrow view of disease that fails to explain all illnesses. Its limitations, combined with its influence on our society, has led to extensive consequences for the patients whose cases fall outside of its scope. People with complex, chronic illnesses are left behind by the biomedical model and subsequently, abandoned by healthcare professionals, marginalized by society, and continue to suffer in silence. In this article, I will discuss the ways in which the biomedical model causes harm to people with chronic illness.

The Biomedical Model

The easiest way to explain the biomedical model is that the body is viewed as a machine and it is the job of the physician to fix it. It is a "mechanistic view of biology, in which parts are not changed by the context, and therefore can be studied in isolation" [6]. Biomedicine focuses on the physical body, objective laboratory testing, and purely biological factors. In this model, each illness has one underlying cause, and it is always reducible to a physical, biological disease. Once this single biological cause is removed, the patient returns to health [20]. Health is defined merely as the absence of illness, so “health” in western biomedicine is primarily focused on diagnosis and treatment rather than prevention [18].  This model also supports the notion of dualism, in which mind and body are separate and do not interrelate. Biomedicine is viewed as a neutral scientific process, and healthcare is thought to be uninfluenced by social or cultural context [12].

The biomedical model is very effective in the treatment of acute illnesses and life-threatening emergencies. In these cases, there are clear biological causes, predictable outcomes, and physicians are only required to focus on one part of the patient's health. For example, bacterial infections have a specific cause that can be diagnosed with objective laboratory testing and removed following a course of treatment with antibiotics. Another example is a person who is experiencing chest pain and shortness of breath can undergo imaging to confirm a specific source of the symptoms, the physicians perform surgery to fix the problem, and the patient returns to “health”.  Physicians may also guide the management of certain chronic conditions such as hypertension and diabetes, in which there is a “gold standard” biomarker (identifiable by a single test) [9], a specific “cause” (heart, pancreas), and a particular treatment (blood thinners, insulin). The biomedical model is very “effective in acute care inpatient hospital, the setting for 95% of medical education and training” [9], and in illnesses that respond well to surgery or drugs, which are the primary treatment modalities in biomedicine. 

Despite its “success in the treatment of many disease processes, some difficult and important medical problems have proven resistant to the biomedical model” [2].  Many chronic conditions do not fit within the biomedical model.  There’s a large spectrum of illness experiences that occur between acute illness and life-threatening emergencies in which the biomedical model does not have explanatory power, diagnostic tests, or efficacious treatments.  When someone with a complex, chronic illness attempts to navigate the healthcare system, they will go from doctor to doctor, enduring test after test, until eventually one of three things happen. 1. They receive a diagnosis based on testing, but have few treatment options (e.g. EDS, POTS, Endo), 2. The tests do not identify a biological cause, so they are diagnosed based on a cluster of symptoms, and have few management options (e.g. ME/CFS, fibro, IBS), or 3.  They have medically unexplained symptoms and become ”victims of the biomedical model” because the biomedical model “fails to account for all the conditions under which a patient is in fact ill but without presenting any physical or biological sign of dysfunction” (e.g. burnout) [6].  Whatever the status of their diagnosis, all three scenarios produce the same result: biomedicine fails to effectively address their illness and the patient continues to suffer.  If the biomedical model is an accurate view of illness and disease, why does it leave so many people behind? 

Criticisms

The biomedical model has been criticized over the last 40 years for being overly simplistic, reductionist, and narrow.  Not all illnesses can be explained with a single cause. “Few morbid conditions could be interpreted as being of the nature ‘one microbe, one illness’,” says Doctors Borrell-Carrió et al, “Rather, there are usually multiple interacting causes and contributing factors” [15].  It is understood in the medical community that “even diseases caused by germs require certain conditions to thrive” [19].  For example, some people can live with an H. pylori infection without ever developing a peptic ulcer.  Psychologist Andrew Weil explains, “To say that it is the sole cause of ulcers ignores the complexity of causation and the possible influence of emotions” [14].  We know that psychological state does have an effect on the physical state. The placebo effect has long demonstrated how our thoughts and beliefs can influence outcomes, and new research in the field of epigenetics shows an evidence-based link between gene expression and lifestyle and environmental factors, including “eating habits, exercise, stress, sleep pattern, attitudes, beliefs, emotion, social relationship, neighbor, pollution, toxicity” [1].  By focusing purely on the biological factors, the biomedical model fails to consider other factors that may influence illness. It does not leave “room within its framework for the social, psychological, and behavioral dimensions of illness " [16]. 

Biological and psychological problems are treated separately in western biomedicine.  Mental phenomena is seen as “unrelated to disturbances of bodily function” [7].  This mind-body dualism is another widely criticized tenet of the biomedical model, because the concept of “mental health” and “physical health” as being distinct and separate categories is a social construction. This notion of dualism, as well as the mechanistic view of the body as a machine, are both “deeply set in the Western culture” [6]. But humans are not robots: we cannot be broken down into isolated parts free of context. Every system within the body interacts with and influences the other, and illness is a condition of the whole person. "While treatment of any of the various parts may help alleviate symptoms,” researchers Rocca and Anjum point out, “it does not actually solve the source of the problem” [6].  Root causes are not necessarily a concern of biomedicine, and neither is prevention, because under this model, illness occurs at the moment a part breaks rather than being a long-term process with many contributing factors across multiple systems that eventually lead to illness and the development of symptoms. When health is defined as the “absence of physical signs of disease” [6], we hear stories about “perfectly healthy” 50-year-olds “randomly” dropping dead of a heart attack.  Is there really such a thing? 

Furthermore, this model takes a doctor-centered approach, in which "curing a disease is exclusively a task for medical professionals and medical technology, while the patient is only a receiver of such cures” [6]. The patient submits to the authority of the expert and has no autonomy or agency.  The patient is not a subject of concern, they are merely an object of illness in which the focus is on the physical pathology.  Under this model, there is no reason for the doctor to treat the patient well and take their feelings into account, or take the time to get to know them or learn their full history.  If every illness can be traced to a single underlying biological cause identifiable with objective testing, then from this perspective it really does not matter who you are or how they treat you.  The cold, dismissive nature of many western biomedicine doctors is a function of the biomedical model rather than a flaw.  We are mere machines whose parts do not change with context, so being treated like a car at the mechanic’s shop is sufficient to diagnose the problem and treat it.  Dehumanization is standard practice in biomedicine.  And when doctors fail to identify a biomedical cause, it’s not the model that is blamed.  It’s the patient.

Consequences 

“A patient who complains of symptoms that have no obvious objective cause might also be dismissed as not being ill,” author H. Williams writes, “despite the very real affect those symptoms may have on the patient's daily life” [20].  With no identifiable biomedical cause, it's not uncommon for patients to be told it's all in their head. Of course, a diagnosis doesn't guarantee exemption from this dismissal: people with ME/CFS, POTS, fibromyalgia, EDS, Lyme, endometriosis, and others are routinely doubted and belittled, whether or not they have “physical signs” of disease. The biomedical model also negatively affects people with chronic pain when the underlying pathophysiology fails to explain the persistent pain after tissue damage is no longer present or why prescribed treatments fail [2]. Gillian Bendelow, professor of medical sociology says, “The biomedical concept of pain is unsophisticated and oversimplified, often resulting in physicians’ doubting the veracity of patients’ reports of pain and the marginalization of such patients” [4]. Medical gaslighting and medical trauma are not an uncommon experience under the biomedical model.

The failure of western biomedicine to explain, diagnose, or treat a patient’s illness or pain has consequences that extend far beyond the doctor's office. Suffering from persistent symptoms will affect every aspect of a person’s life. They no longer feel well enough to go out with friends or visit family, they no longer have energy to do their favorite activities or to pursue their passions and hobbies. Working or going to school becomes increasingly difficult and eventually, they may be forced to quit their job or drop out of school altogether. Relationships will suffer as family and friends struggle to understand what they are going through, because if you don’t get a diagnosis that is widely understood and generally accepted by biomedicine, you face societal stigma of “not really being ill, just lazy” [10].

When biomedicine doctors dismiss and abandon patients, are they to accept their fate, and resign themselves to suffer endlessly? The management of symptoms and responsibility of finding answers now falls entirely on the patient’s shoulders, putting them in an extremely vulnerable and desperate situation.  They are left with little choice but to read every piece of information they can find, trying every possible doctor and every potential remedy, in which one of two things will happen. They'll either become victims of misinformation by trying risky, expensive, or ineffective "cures", or they do find something that brings symptom relief, but because it doesn't fit under the biomedical model, it's automatically labeled as "pseudoscience" and the person is dismissed as merely experiencing the placebo effect. The biomedical model first abandons chronically ill people, then punishes them for it.

This search for answers and efficacious treatment causes a huge financial burden, because the biomedical model also determines how health care funding is allocated and what is covered by insurance. It is structured to cover the essentials of the biomedical approach [8]. Even if these essentials were relevant for the treatment of their chronic illness, without the right diagnostic code, insurance won't cover it anyway. This lack of accepted diagnosis or biomedical cause also means the person won’t qualify for economic compensation in the case of long-term sick-leave [13], or qualify to receive disability benefits.

Medical research to learn about underlying causes, diagnostic tests, and better treatments would solve many of the problems people with chronic illness face. Medical research is the reason we're learning that Multiple Sclerosis may be in part caused by the Epstein Barr Virus [5] and why we're exploring small fiber neuropathy as a potential diagnostic for fibromyalgia [21]. Medical research also determines what treatments are approved by the FDA, what illnesses are recognized by the CDC, and what is generally accepted by the medical community. But what research gets funded, what questions are asked, and what treatments are focused on are also affected by the biomedical model and our culture as a whole, and this creates yet another obstacle for people with complex chronic illnesses.

Under the biomedical model, we isolate parts of the body in order to study them, but what if an illness does not have a single biological cause or a single affected body part? Biomedicine does not like multi-symptom, multi-system illnesses. How do we study complex chronic illness in a meaningful way if we are looking at multiple systems, or multiple causal factors, or disease development over time? How do we re-evaluate our current methods of research if some disease processes are more contextual than previously thought? Additionally, research is expensive, and because of this, a lot of research will go into treatments that have the most profit potential, often in the form of a patent-able pill. This is a natural consequence of a capitalist society and a healthcare system whose primary treatment modality is drug therapy, but what does that mean for those that cannot be treated with one pill?

If we want to fund research for lesser-known illnesses it often requires not just fundraising, but awareness. Unfortunately, patients who have lesser-known illnesses are caught in a vicious cycle of not being taken seriously because of the lack of medical research, and the lack of medical research being done on these illnesses because they are not taken seriously. Take for example the difference in responses to Lyme disease and ME/CFS versus Long COVID. Some people who have been exposed to Lyme disease report having persistent and worsening symptoms after antibiotic treatment, but the extent of the response by the CDC has been to label it post-Lyme syndrome, while medical researchers dismiss it as “feeling crappy”. The response to ME/CFS has been similar. It is thought to be a post-viral syndrome, but rather than searching for the cause of these persistent symptoms, patients were told until very recently to do cognitive behavioral therapy and exercise, which is not only dismissive but can actually worsen the symptoms and the condition [7]. The response to Long COVID has been vastly different. Reports of a post-viral illness have been taken seriously from the start and widely reported on. As a result, there has been an effort to find the causes of the symptoms and learn the underlying disease processes. Biomedicine is far from being uninfluenced by culture, and rather than acknowledging that we are constantly learning more about diseases and we don't yet have all the answers, patients are often doubted, ignored, and dismissed.

While some illnesses are under-recognized, some are over-medicalized. Advocates of the sociopolitical model of disability argue that they are discriminated against because of the biomedical model [3].  The biomedical model treats “being disabled [as] a negative that can only be made better if the disability is cured and the person is made ‘normal’” [20]. Because of this, services and funding from government agencies are geared toward medical stabilization, and little attention is paid to the individual’s greatest needs [3]. When the focus is on the medical aspects, it frees society of obligations to accommodate those with disabilities, and the focus is on “fixing” the individual, rather than changing the environment. Advocates explain that disability is not an unending personal tragedy, but a neutral difference, and the barriers they face to happiness and prosperity are not medical, but societal and environmental [3,20].

So, we find ourselves in this contradiction “by which scientific advances and medical technology offer the best opportunities ever, but at the same time an increasing number of patients are over-medicalized, over-diagnosed, become chronically ill, do not find a place in the health system, or feel that they are not met as whole persons in the healthcare system” [6].   

Other Models and Approaches 

 “Biomedicine has advanced our knowledge of human biology, but the real test of a scientific model—the measure of its superiority to an alternative belief system—is whether or not it increases our ability to describe, predict, and control natural phenomena,” explains Andrew Weil, “The strict application of the biomedical model has actually made it harder for us to understand and manage common diseases” [14]. We should only use a model as long as it remains useful, and this one has not only harmed chronically ill people, it is actually associated with poorer health outcomes and greater health inequality [21]. So, what's the alternative?

The biomedical model is most often contrasted with the biopsychosocial model, proposed by psychiatrist George Engel in 1977 to “holistically assess a patient's biological, social, psychological, and behavioral background to determine his or her illness and path of treatment” [20]. Engel believed it was important to embrace all the scientific advances and advantages of modern medicine, but also found it necessary to acknowledge that not all illnesses are detectable by biological measurements [16]. Under the biopsychosocial model, the “bio” aspects still include genetics, pathogens, biochemistry, etc., and the “psychosocial” aspects would include chronic stress, trauma, lack of social support, work, social class, environment, relationships and community, thoughts and beliefs, diet and activity, etc.  The integration of all three systems, and not focusing on biological factors alone, is important in understanding a patient, their illness, and their path of treatment. He argued that “medicine needs to be informed by a more complete understanding of health and illness which better depicts the reality of human conditions” [6].  Furthermore, Engle’s model was a “fundamental ideology that tried to reverse the dehumanization of medicine and disempowerment of patients” [15]. It emphasizes the importance of a patient centered and relationship centered approach, in which the patient has autonomy, the physician has empathy, and the whole person is treated. 

The importance of recognizing the interplay of biological, psychological, and social factors, as well as environmental and occupational factors, has been demonstrated in various studies.  One study on osteoarthritis reveals “the incidence, prevalence, morbidity, and mortality of OA is considerably greater in individuals of low versus high socioeconomic status”, and the authors highlight the value of using a complementary biopsychosocial approach [9].  Another study on so-called “contemporary chronic diseases”, such as cardiovascular disease, obesity, and type 2 diabetes, discusses how psychosocial factors have an equal impact on health as physiological disruptions, and appear to be more important determinants of susceptibility and severity [1]. The authors express concern that 50% of all primary health care visits in developed countries are due to these conditions, but the current model and reductionist approach does not allow physicians to effectively address the root causes [1]. Medical students do not receive education on the importance of psychosocial factors or training on how to identify them.  

Critics of the biopsychosocial model express concern for how physicians would be trained in these psychosocial factors, and they argue there's currently no method for how to collect this information and put it into clinical practice [6]. However, these methods are already common practice for many natural and functional medicine doctors, as well as integrative medicine doctors who incorporate the use of both biomedicine and natural approaches. These doctors typically spend a lot of time with their patients, do extensive patient histories, search for root causes, and treat the whole person. As outlined in the biopsychosocial model, there's often an empathetic relationship between doctor and patient, the patient has autonomy, and there is an emphasis not only what the patient can take (i.e., drugs), but what they can do. For many people with chronic conditions, these doctors provide better long-term care and symptom management. Perhaps we can look to their practices as a framework for implementing a more holistic approach in western biomedicine.

The next concern regarding the biopsychosocial model is that the biological factors would be ignored and the focus would shift too readily to the realm of psychiatry [2]. These concerns are valid. One example of this would be reports of the “pain clinics” that take in adolescents who have medically unexplained symptoms, and proceed to brainwash and abuse them into believing that their pain is purely psychological. Indeed, too much emphasis on the psychological aspects can lead to harm as well. To ensure we are finding a balance, researchers Rocca and Anjum offer the ecological approach, which not only incorporates the biopsychosocial factors, but acknowledges the effect it has physiologically in the form of "allostatic overload". Both physical and psychosocial stress on the body can contribute over time to the development of autonomic dysfunction, changes in the immune system, chronic low-grade inflammation, and hormone disruptions [6].  By understanding human biology from an ecological perspective, we must look at how all levels of nature “are united within one single patient: physiological, biological, psychological and social. All these levels affect and are affected by health and illness.  Ecologically, we should also expect that these different influences will interact in nonlinear ways, and that what happens in one context cannot automatically be transferred to another context” [6].

Lastly, critics of the biopsychosocial model claim it is vaguely defined, subjective, and difficult to test [2].  Those in favor of the biopsychosocial model argue it is not incorrect, just incomplete.  Rocca and Anjum add that any new model is going to require a change in ontology, otherwise we will continue evaluating new models based on the ideology of the old model. They note that “any practice that falls outside of an established norm of science is likely to be considered unscientific and met with skepticism” [6]. To change the practice, there must be a radical change in the norms of science, and this requires us to openly challenge assumptions that remain widely accepted.  It is “only in times of paradigmatic changes that scientists and practitioners start to talk about ontological basic assumptions and critically discuss them” [6].  This foundational change in ontology will not only lead to a change in norms and practices, but it “should also challenge the way medicine and healthcare is organized, managed and financed” [6]. If we are going to effectively address the suffering of people with chronic illness, that is exactly what we need to do. 

Conclusions 

In 1977, George Engel said that the biomedical model has “become a cultural imperative, its limitations easily overlooked. In brief, it has now acquired the status of a dogma” [14, 16].  This statement is still true 45 years later.  These views are so deeply set in our culture that despite its limitations, it remains the prevailing view in modern medicine. We don't have to abandon the biomedical model entirely, but we are not stuck with it either.  We can look to other models and approaches to see where our current model is lacking and where we might improve. This will first require us to take a step back from our cultural lens, challenge our assumptions, and address the limitations of the biomedical model.  Andrew Weil offers this insight: “Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. But the point from which we started still exists and can be seen, although it appears smaller and forms a tiny part of our broad view gained by the mastery of the obstacles on our adventurous way up” [14].  As we climb this mountain, let us listen to people with chronic illness, acknowledge their suffering, and let their experiences be our guide toward building a better, more balanced, and complete model of health, illness, and disease. 

Sources

[1]* A Review of 21st Century Utility of a Biopsychosocial Model in United States Medical School Education by Paresh Atu Jaini and Jenny Seung-Hyun Lee (2015) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711959/

[2] Biopsychosocial Versus Biomedical Model In Clinical Practice (2018) https://nursinganswers.net/essays/biopsychosocial-versus-biomedical-model-in-clinical-practice-nursing-essay.php?vref=1

[3] Challenges to the Biomedical Model of Disability by Julie Smart, Ph.D (2007) http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.519.6586&rep=rep1&type=pdf

[4] Chronic Pain Patients and the Biomedical Model of Pain by Gina Bendelow, PhD (2013) https://journalofethics.ama-assn.org/article/chronic-pain-patients-and-biomedical-model-pain/2013-05

[5] Clonally expanded B cells in multiple sclerosis bind EBV EBNA1 and GlialCAM by Tobias V. Lanz, R. Camille Brewer and William H. Robinson (2022) https://www.nature.com/articles/s41586-022-04432-7

[6]* Complexity, Reductionism and the Biomedical Model by Elena Rocca and Rani Lill Anjum (2020) https://doi.org/10.1007/978-3-030-41239-5_5

[7] Expert reaction to updated NICE guideline on diagnosis and management of ME/CFS (2021) https://www.sciencemediacentre.org/expert-reaction-to-updated-nice-guideline-on-diagnosis-and-management-of-me-cfs/

[8] Is it possible to bridge the Biopsychosocial and Biomedical models? By Richard D Lane (2014) https://bpsmedicine.biomedcentral.com/articles/10.1186/1751-0759-8-3

[9] Low socioeconomic status and patient questionnaires in osteoarthritis: challenges to a “biomedical model” and value of a complementary “biopsychosocial model” by T. Pincus and I. Castrejon (2019) https://www.clinexprheumatol.org/abstract.asp?a=14815

[10] Naked in the eyes of the public: A phenomenological study of the lived experience of suffering from burnout while waiting for recognition to be ill by Karin Mohn Engebretsen,Wenche Schrøder Bjorbækmo (2019) https://onlinelibrary.wiley.com/doi/10.1111/jep.13244

[11] On the Body as Machine by Frank Bures (2016)  https://undark.org/2016/07/06/mind-machine-medicine-militaristic-healthcare/

[12] Society, Culture and Health: An Introduction to Sociology for Nurses by Karen Willis and Shandell Elmer (2007) Via Wikipedia page: The Biomedical Model https://en.wikipedia.org/wiki/Biomedical_model

[13] Suffering without a medical diagnosis. A critical view on the biomedical attitudes towards persons suffering from burnout and the implications for medical care by Karin Mohn Engebretsen B.Sc.,M.Sc., PhD (2018) https://onlinelibrary.wiley.com/doi/10.1111/jep.12986

[14] The Biomedical Model is Failing Us by Andrew Weil (2012) (https://www.psychotherapynetworker.org/blog/details/1055/the-biomedical-model-is-failing-us

[15]* The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry by Francesc Borrell-Carrió, MD, Anthony L. Suchman, MD, and Ronald M. Epstein, MD (2004) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466742/

[16] The Need for a New Medical Model: A Challenge for Biomedicine by George Engel (1977) https://www.science.org/doi/10.1126/science.847460

[17] The New Old (and Old New) Medical Model: Four Decades Navigating the Biomedical and Psychosocial Understandings of Health and Illness by  Albert Farre and Tim Rapley (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5746722/

[18] Understanding The Biomedical Model By Daral Chapman, SRN (2018) https://www.nursespost.com/understanding-the-biomedical-model/

[19] What are the Limitations of the Biomedical model? Joe Ford (2021) https://answerstoall.com/technology/what-are-the-limitations-of-the-biomedical-model/

[20] What is the Biomedical Model? By H. Williams (2022)  https://www.thehealthboard.com/what-is-the-biomedical-model.htm

[21] Why Small Fiber Neuropathy May Cause Fibromyalgia Pain By Adrienne Dellwo (2020) https://www.verywellhealth.com/small-fiber-neuropathy-may-cause-fibromyalgia-pain-3972935