Chapter 1.B.3--Illness, Healing, and Alternative Medicine
"Medicine's role is to entertain us while Nature takes its course." - Voltaire
literature on the placebo effect and arguing for law taking account of it much
more actively, for instance in pharmaceutical regulation and in defenses to
breach of informed consent, see Anup Malani, Regulation with Placebo Effects,
58 Duke L. J. 411 (2008). The AMA issued an ethics opinion in 2006 that
it is unprofessional to use placebos deceptively. Taking issue with this
position, see Adam J. Kolber, A limited defense of clinical placebo deception,
26 Yale L. & Pol'y Rev. 75-134 (2007). Many physicians disagree.
See Rachel Sherman & John Hickner, Academic Physicians Use Placebos in
Clinical Prctice and Believe in the Mind-Body Connection, 23 J. Gen. Intern.
Med. 7 (2007); Olivia Judson, Enhancing the Placebo, N.Y. Times, May 3, 2010.
On alternative medicine, see Anne Harrington, The Cure Within: A History of Mind-Body Medicine (2007).
Further exploring issues relating to trust, see Richard Sherlock, Reasonable Men and Sick Human Beings, 80 Am. J. Med. 2 (1986).
information on therapeutic jurisprudence
is available on this web site:
As Buckman & Sabbagh explain in Magic or Medicine? An Investigation of Healing and Healers (1995), the healing processes that underlie the methods used by conventional versus alternative healers may not be as different as they first appear:
The placebo effect is one of the explanations of the . . . unprecedented and increasing numbers [of] patients [who] are consulting practitioners of every type of alternative or complementary medicine. Between 1986 and 1992, the proportion of people in one sample who had used complementary medicine rose from one in seven to one in four. . . . Perhaps, then, a homeopath's belief in homeopathic remedies and a crystal-therapist's belief in the energy of crystals and an aromatherapist's belief in the value of essential oils are all necessary to bring the healer close to the patient. Once close to the patient, the healer can use her or his intuitive abilities, such as counseling and empathizing, to their maximum effect. Perhaps the therapist even needs to believe in the remedy in order to be able to be a therapist or counselor -- and if so, that's fine. If it needs a few white pills or a group of crystals or a sweet-smelling oil to act as a catalyst for a therapeutic counseling and support session, then what could be wrong with that?
At its most basic level, it may be that the placebo effect is a reflection of man's fundamental desire for a magic therapy -- we are so hopeful of a remedy that we imbue even an inactive remedy with magical powers. But the placebo effect also shows us something very plainly -- if the patient believes in the magic, the magic works. If that does illustrate a fundamental feature of mankind's reactions to illness, then that's all right -- but let's use it for the benefit of the patient and not ignore it. Of all the things that we can learn from the public's migration to complementary medicine, the placebo effect and the healer-as-drug effect are the most important lessons. To ignore them totally would be a terrible waste.
There are several additional readings on this page. The first three provide more insight into the phenomenology of illness:
The other three readings focus on the contrasts and similarities between conventional and alternative medicine:
How unique is the state of illness? Is it not a common condition in many other human situations? After all, the prisoner is deprived of his freedom and civic rights; the poor and the socially outcast are constrained even in the most mundane matters of life; none of us is totally free; we must all conform to some set of social conventions. But in none of these situations is our capacity to deal with our vulnerability so impaired as in illness. We feel, usually, that we can cope with almost all of the other states of vulnerability if we have our health. After all, we perceive health as a means toward freedom and other primary values. We ask only to be released form prison, given a job or money, and if we are healthy, we can rebuild our humanity and the integrity of our person. In illness none of these things will help. Our essential existential mechanisms for coping with all other exigencies have been compromised, and more essential than that, we face the threat of loss of life itself, or we are suddenly asked to live a life not worth living.
There is a special dimension of anguish in illness. That is why healing cannot be classified as a commodity, or as a service on a par with going to a mechanic to have one's car fixed, to a lawyer for repair of one's legal fences, or even to a teacher for repair of one's defects in knowledge. The teacher-student, lawyer-client, and serviceman-customer relationships have some of the elements of the physician-patient relationship in that there is also an inequality of knowledge and skill, and one person seeks assistance from another who professes to provide it. What is different is the unique ontological assault of illness on the body-self unity, and the primacy of the freedom to deal with all other life situations which illness removes. Without denying the possible analogy with, let us say, the lawyer-client relationship, it would be difficult to argue that the degree of injury to our humanity and the kind of injury we suffer in litigation are identical in their existential consequences to being ill.
[I]llness is lived; it is a life of illness.369 For the ill person, chronic illness is only partially or not at all the disembodied disease states formulated by the nascent biomedicine of the late nineteenth and early twentieth centuries. It is not even the more robust impairment of physiologic function described by the more recently developed pathophysiology. Instead, [illness] is lived as the disruption of the activities of daily living.... It is the inability to tie one's shoes, to negotiate a curb, to attend a meeting, to read a book to one's child, and to spend time with a spouse.
Most fundamentally [illness] is the loss of bodily or mental integrity. In ordinary life our bodies are our taken-for-granted friends. In many if not most tasks we are barely even aware of their existence. We just go about our business, doing things with our bodies, which perform as if they were on autopilot. In illness, however, this taken-for-grantedness, this integrity, is lost. The body "mal-functions," it fails to perform, and this occurrence of the unexpected makes us painfully aware of bodily presence. The body is no longer the taken-for-granted friend but an object of concern and, perhaps, scientific study and attention.
As Kay Toombs describes so well, this objectification of the body is accompanied by a loss of wholeness, by a loss of the bodily assurance lived by the well. We ordinarily live our lives under the presupposition that certain things are assured. One goes to bed assured that the tree outside the window will still be there in the morning. One also goes to bed assured that in the morning one's legs will continue to work....
With chronic illness, however, this sense of assurance is lost.... [The body] is a capricious, often malevolent enemy that threatens to disrupt such plans and pursuits at any time:
Like a mother who can never be depended on, the body fails the sick person when needed most. Persons with active arthritis never know when the pain will destroy an event, a day, a week. They go to bed feeling fine, perhaps looking forward to some celebration the next day, and awaken impaired. They look for reasons in their diet, emotional state, or the weather, but no consistent explanations present themselves. The body is so untrustworthy that it does not even misbehave consistently. As with arthritis, so it is with severe asthma, ulcerative colitis, multiple sclerosis, and other chronic illnesses. [Cassell, supra note 369, at 57.]
The body becomes an it -- an alien and uncontrollable thing -- a prison from which there is no escape and an object of rage and frustration, something to be hated, even punished, and most of all, an enemy to be monitored at all times....
Perhaps the most salient result of this existential shock is the effacement of self or the reconstitution of self in illness. For our purposes, self can be defined as an individual's articulated and dramatized lifestory, a narrative and a dramaturgical presentation that has temporal dimensions -- a self has a self-constituted past, present, and future -- and multiple substantive ones. The latter include matters of private identity--an individual's conceptions of her values, interests, sentiments, and aspirations--as well as the presentation of this self to a public world--a private face and a public one, as it were....
[I]llness has the potential to, and often does, shake this self to its very core. We define ourselves at the most mundane level with reference to a field of possible engagement with the world and with others. Illness seriously limits this field spatially -- I may be confined to my bed or unable to climb stairs, cross streets, eat food I have not prepared, and so on.... Analogously, illness can be confining temporally. I may be totally immersed in the present because the struggle to maintain a life is all consuming. Further, I may be so dis-abled that I cannot even conceive of a future worth living, and I thus believe my self to be condemned to live in a painful, tortured and torturing present. Finally, but not least by any means, illness is often socially confining as the ill individual can no longer engage in his prior social life....
The result, then, is that often the [ill] person no longer has a sense of self. The prior self was constituted around the assurance -- perhaps conceit -- of eternal health. This sense of bodily integrity is lost, as are the many activities and lifeplan through which the self constituted its self-identity. Deprived of this internal anchor and cut adrift from the mirror of social interaction, which enables us to see and to express ourselves, the ill person's self is gone. Social stigma is internalized, and the ill individual has become so foreign that she no longer recognizes herself. She is then often stuck in her past life, real or imagined, unwilling to surrender it. She has no future because that prior self has been lost, because she remains in a constant state of mourning, and possibly because the future is too uncertain -- or horrible -- to imagine.
369 My account of chronic illness is drawn from my own experience and from the secondary literature. The following sources have been particularly important: Eric J. Cassell, the Nature of Suffering and the Goals of Medicine (1991); Kathy Charmaz, Good Days, Bad Days: The Self in Chronic Illness and Time (1991); The Humanity of the Ill: Phenomenological Perspectives (Victor Kestenbaum ed., 1982) [hereinafter Humanity of the Ill]; Arthur Kleinman, The Illness Narratives: Suffering, Healing and the Human Condition (1988); Marianne A. Paget, A Complex Sorrow: Reflections on Cancer and an Abbreviated Life (Marjorie L. DeVault ed., 1993); and S. Kay Toombs, The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient (1992).
375 One could write endlessly about the self, as Charles Taylor has done magnificently in Charles Taylor, Sources of the Self: The Making of the Modern Identity (1989). For present purposes it suffices to say that my definition has been heavily influenced by symbolic interactionism and existential phenomenology, albeit in my definition all aspects of self are linguified.
I wouldn't demand a lot of my doctor's time. I just wish he would brood upon my situation for perhaps five minutes, that he would give me his whole mind at least once, be bonded with me for a brief space, survey my soul as well as my flesh to get at my illness, for each man is ill in his own way.... Just as he orders blood tests and bone scans of my body, I'd like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness.
These readings provide more spotlight on the contrasts between conventional and alternative medicine.
The existing paradigm of modern scientific medicine may be called the Western biomedical model. It relies on an essentially mechanical understanding of causation, one derived from science. Repairing a body, in this view, is analogous to fixing a machine. Furthermore, this view of causation leads to a remarkably optimistic expectation that each disease has a specific cause that is awaiting discovery by medical research. Finally, because the body is the appropriate subject of medical science and practice, it is also the appropriate subject of regimen and control. Although we may not consciously think of medicine in these terms, these are, nonetheless, the doctrines of the biomedical model and thus form the subconscious cultural context out of which our thinking, professional conduct, and medical education arise.
Because it has been so successful in dealing with the deadly infectious diseases that have decimated human populations for centuries, medicine has worked itself out of much of its original job (the cure of diseases and relief of patients' sufferings) and now faces a large population of patients and potential patients that expect the same successes and advances in dealing with chronic conditions and the accumulated debilitations of advanced age. Unfortunately for physicians and their patients, scientific medicine cannot cure these conditions, and medicine will have to change its essential self-understanding if it is to be successful in the future. . . .
During earlier periods of Western history - from the early Greeks to the end of the medieval period - any complaint was considered to be the result of a combination of factors, both natural (biological) and spiritual. Health (often understood as "wholeness") included the whole person: body, mind, and spirit. Gradually, the theoretical bases of medicine moved away from religion and toward science. This change did not occur all at once, of course, and the admixture of spirit and nature continued as a dominant part of medicine. The ideas of René Descartes, however, introduced an important change. In the early, 1600's, he developed a philosophical argument that allowed nature to be "rationalized" - nature, in other words, could be materialized and transformed into an inert object. The thrust of Descartes' position is that the mind (res cogito) could be severed from the body (res extensa). Matter is thus freed from subjectivity, and pristine matter is available for inspection. Like nature, the body becomes a material object to be observed, and factors such as mind, soul, consciousness, and spirit are unimportant and dismissed because they are intangible. Disease occurs in the body, which is envisioned to be nothing more than physiologic organism.
In keeping with Descartes' ideas, other changes began to take place that were vital to modern medicine. The belief that facts could be separated categorically from values took hold in a wide range of disciplines. This meant that facts were considered external, separate from the mind, or were thought to be associated with empirical indicators. Physicians could, thus, safely become empiricists and attend solely to physiologic markers. The effects of non-empirical factors (related to culture or biography, for example) on illness became irrelevant. The experience of the person in the body was denigrated and treated as epiphenomenal, that is, the person's experience was considered a byproduct of the illness and therefore not relevant to understanding the illness itself. Only "objective" factors were considered real.
Consistent with this transformation in our understanding of nature - including the human body - was the change in how physicians reformulated their thinking about the role of causality in illness and health. Discussions revolved around "causal chains" and "webs of causation." This imagery enabled physicians to view events as structurally linked: accordingly, a sound rationale could be assigned to the advent of illness. Physicians could formulate propitious strategies because solitary causes are predictable and manipulable. Because the source of any health problem could be pinpointed through rigorous research, diagnostic activity became a scientific investigative process. . . .
A final element of the rational worldview that grew from Descartes' ideas pertains to how knowledge should be acquired. We would all acknowledge that subjectivity or interpretation is a liability in the pursuit of valid data. In order to curtail the corrosive influence of bias and subjectivity, the use of quantitative measures is encouraged. Quantification is believed to be value-free and to give unimpeded (direct, clear, "true") access to reality. Quantitative methods are assumed to be divorced from interpretation, and truth and objective reality are seen as one.
The cornerstone of the biomedical model, then, is the "materialization" of life - specifically, humans are approached as if they are simply physiologic organisms. But this view does not make sense unless we accept several proposals: dualism (that mind and body can be separated), empiricism (that reality is limited to what can be experienced by the senses and their aids), mechanical causality (that all causal relationships are linear), the equilibrium thesis (that normativeness is the goal, and stability is possible), and the neutrality of technique (scientific method removes interpretation and bias) . . . .
This doctrine is a barrier to understanding the psychosocial component of medicine, including the placebo effect, the connection between stress and illness, the importance of support groups, and the more general relationships between social support and health. Although the doctrine is no longer strictly adhered to, psychosomatic phenomena (i.e., the interactions between the mind and the body) are still often considered to be peripheral to scientific medicine. . . .
It is possible to point to some of the features of an emerging paradigm . . . . In some circles, this new philosophy is referred to as post-quantum theory, while in others, the term is postmodernism. At the core of either viewpoint, however, is the rejection of Cartesian dualism.
Broadening the biomedical model into a biopsychosocial model of medicine is to consider the patient as a social and emotional body interacting with physical and social environments in ways that affect the patient's health. This model moves away from the limiting focus of the biomedical model without losing its benefits. However, it significantly broadens the earlier model.
The Biomedical Paradigm
from, Complementary and Alternative Medicine:
Legal Boundaries and Regulatory Perspectives
Michael H. Cohen (1998)
Reprinted with Permission, Johns Hopkins University Press
The biomedical paradigm generally views disease as a biochemical phenomenon that can be classified into diagnostic categories through technological methods and treated, where possible, according to standardized, objectively validated mechanisms. The biomedical model gained ascendancy in the late nineteenth and early twentieth centuries, when Newtonian physics and Cartesian dualism dominated the intellectual world.
Newtonian physics views the universe as consisting of fundamental, irreducible building blocks made of matter. According to Newtonian theory, the motions and interactions of all material bodies obey a few simple laws. The universe is an immense, sophisticated clock, whose whirring objects follow predetermined courses. The interrelationship of parts is rational and follows basic laws. Cartesian dualism asserts that bodies exist in space, subject to mechanical laws, while minds exist elsewhere, in an isolated, independent realm. It splits the "outer" world (objective and amenable to rigorous research) and the "inner" world (subjective, marginally accessible, and scientifically unreliable).
In keeping with Newtonian physics and Cartesian dualism, the biomedical model views the body as a physical system, objectively analyzable in terms of its mechanical parts. Mechanism (the "body as machine" metaphor) and reductionism (the reduction of illness to a set of physical symptoms) dominate biomedical thinking. Disease is an outside invader that preys on a particular part of the body; treatment attacks the invader. Thus, some cancers are known as "malignant" tumors; chemotherapy aims to "attack," "fight," or "beat" the cancer.
The biomedical model provides a clearly articulated scientific framework for understanding the disease process and mechanisms of remedy, and it excels at treating infectious diseases and acute or traumatic injuries. Biomedicine excels in emergency care: a patient who suddenly experiences heart failure needs a cardiac specialist, not an acupuncturist. The model also cures many conditions that have single, specific causes.
The model is less successful with chronic, multifaceted, and terminal illnesses, such as chronic fatigue, AIDS, and cancer. Biomedicine rarely cures chronic, debilitating conditions such as arthritis, allergies, pain, hypertension, depression, and cardiovascular and digestive problems, which account for 70 percent of the health care budget in the United States and affect almost 33 million Americans. The conditions exhaust current scientific knowledge, challenge the biomedical model's approach to diagnosis and treatment, or require treatments accompanied by toxic side effects.
The biomedical model's orientation is frequently distant, detached, and deficient in empathy and warmth. The model alienates patients from their own being when their mental, emotional, and spiritual realities are seen as having little bearing on disease or healing. Feelings of depression, rage, social isolation, and bewilderment, and other subjective, but significant, experiences often are discounted, invalidated, or denied as hallucinatory. Biomedicine creates feelings of dependence and personal estrangement as individuals "exchange the status of person for that of patient." . . .
The Holistic Healing Paradigm
The critique of biomedicine's medical and psychosocial limitations has led some caregivers to examine multifaceted approaches to health care, in an attempt to restore a broader role and meaning to the notion of healing. Holistic modalities of healing adopt a wholeness or social paradigm of health care, which aims at a nonmechanistic, nonreductionistic understanding of the disease process. The holistic healing paradigm views diseases as having multiple causes amenable to multiple therapeutic interventions through a variety of systems of care, including biochemical, environmental, social, psychological, behavioral, and spiritual systems. It views conditions such as arthritis and chronic pain as having multiple, nonspecific causes (biological, environmental, psychological, social), and thus as amenable to intervention on multiple levels (pharmaceutical, individual or family counseling, support groups, nutrition, exercise, relaxation techniques). In holistic practice, the goal is balance, not only control of symptoms; subjective relief, not merely a favorable and scientifically measurable clinical outcome. . . .
Holism and Mechanism
The philosophy underlying holistic practice was articulated earlier this century by Jan Smuts. In his 1926 book Holism and Evolution, Smuts described holism as the notion that "every organism, every plant or animal, is a whole, with a certain internal organization and a measure of self-direction, and an individual specific character of its own." In wholes, "all the parts appear in a subtle indefinable way to subserve and carry out the main purpose or idea." According to Smuts, nature expresses itself in wholes, ranging from atoms, molecules, and chemical compounds to "the creations of the human spirit in all its greatest and most significant activities." Smuts expressed this "whole-making, holistic tendency, of Holism" as an organic, creative evolutionary force in the natural world and human affairs.
Smuts argued that a whole is more than the sum of its parts because the whole is not purely mechanical but has inner tendencies and interrelationships between the parts which give rise to something "more." . . .
To understand the human organism as a whole, Smuts considered not only the physical body but also the "field," the organism's presence as "a historic event, a focus of happening, a gateway through which the infinite stream of change flows ceaselessly." The organism in its field "contains its past and much of its future in its present."
Smuts contrasted holism with mechanism, the view that wholes are merely and unalterably the sum of their parts. According to Smuts, mechanism views a physical reality as a closed and complete system; holism values volition and consciousness and views life as "an active creative process [which] means the movement . . . towards ever more and deeper wholeness." The organism, as a whole, is a "synthesis or unity of parts," and thus possesses unity of action and a "balanced correlation of functions." Whereas a mechanical system reacts to disturbance by adjusting to maintain equilibrium, a holistic system creates a new unity or synthesis, "the making of a new arrangement of old elements." In this way, "wholeness, healing, holiness [are] all expressions and ideas springing from the same root in language as in experience."
. . . Holistic providers tend to . . . emphasize the inner healing process, as well as relationship, over external results and professional authority. In other words, the provider-patient relationship aims as healing as well as curing. Curing involves the eradication of disease at the physiological level. Healing involves a movement toward wholeness, growth, or greater balance on physical, mental, emotional, and social levels, "rather than just [a focus] on curing a given disease or disorder." A patient may be healed without the disease being cured. A treatment that "cures" the patient often leaves room for healing - as occurs when a breast cancer patient leaves the operating room without cancer, but without a breast. By pointing patients toward creative resolution of their disease processes, holistic therapies aim to express the centrality of personal wholeness in health.
This excerpt discusses how physicians function as
healers, and the pervasiveness of the placebo effect, suggesting how the
biomedical and holistic paradigms might merge.
The average physician would cringe at being called a "faith healer." Yet physicians are faith healers in the sense that they invite expectant trust on the part of those who come for treatment. The white coat, the stethoscope, the prescription pad, the elaborate equipment in clinic and hospital, and the supreme self-confidence on the part of the physician all contribute to the faith people have in their doctors and in the health care system the doctors administer. The greater the threat that sick people feel, the more they need powerful symbols of authority to reinforce a belief that medicine can work wonders in reversing the course of illness.
This applies to all forms of healing, of course, whether it be Christian Science, Pentecostal healing, shamanism, or prayer. Called the "placebo effect" in medicine, the faith that people have in the treatment they are receiving is an important factor in healing, wherever it occurs. . . . As noted frequently in the literature, the history of medical treatment before the Enlightenment is the history of the placebo effect. Most medications prescribed by physicians were either pharmacologically inert or downright harmful. That physicians were prescribing placebos without knowing it only escalated their effectiveness....
There are at least three dimensions of belief that are operative in the placebo effect of medical treatment: (1) the patient's belief in the method, (2) the physician's belief in the method, and (3) the patient's and physician's belief in each other. If all those factors are working optimally, even bizarre treatment procedures can produce real cures. If the opposite is true, even the most scientific and rational treatments may fail to cure. . . .
Because of its checkered past, there are a number of misconceptions surrounding the placebo and its effects. The most pervasive among them is that the placebo effect is "all in a person's head." The fact is that physiological processes that can be objectively measured are affected in both organic and functional diseases. A second misconception is that only neurotic and suggestible people respond to placebos. The truth is that the placebo effect is a factor in all healing where a person is responding under conditions that evoke expectant trust. A third misconception is that the placebo effect is a nuisance factor that needs to be eliminated from clinical practice. The fact is that placebos are, on the average, 35 percent effective. This may be a nuisance factor for a researcher who wants to determine the effectiveness of an active pharmacological agent in the treatment of a disease, but anything that facilitates healing ought to be studied and promoted. Finally, it is a misconception to limit the placebo effect to occasions when patients think they are receiving medical treatment but are not. The fact is that any intervention that enhances positive expectations elicits the placebo response. . . .
Among thecmedical treatments likely to be enhanced by the placebo effect, surgery is at the top of the list, probably because there is so much drama and ritual associated with it (hospitalization, operating "theater," masked and green-robed surgical team, induction by anesthesia). In the mid-1950s, for example, a new surgical procedure was introduced to provide relief from symptoms of chest pain due to coronary heart disease. The procedure was called "internal mammary ligation" and involved tying off an artery in the chest. One out of three patients reported complete relief of pain while three out of four reported some improvement. Since this procedure was considered successful, ten thousand operations followed.
Some surgeons were skeptical about the procedure because there seemed to be no sound physiological basis for the treatment, especially since the relief from pain was almost immediate, long before new vessels could have provided a fresh supply of blood to the heart. In a study that would be considered unethical by today's standards, seventeen patients severely limited by angina were recruited to do an evaluation of the procedure. They did not know they were participating in a double-blind study in which they were randomly assigned to receive either that operation or a sham operation. In both cases an incision was made in the chest. Patients in one group had their arteries tied while the others were simply closed up with no surgery performed -- a placebo operation. The benefits from the placebo surgery were as great as the artery-typing operation. After these results were confirmed by a replicated study, the operation was abandoned. . . .
Given the limits of the conceptual framework within which biomedical analysis takes place, it is no wonder that the placebo effect is judged as having nothing to do with the "real" business of medicine, which is to intervene in a disease process that operates in a quite mindless way. We need to look elsewhere for more convincing alternative explanations.
The most common explanation of the placebo effect is suggestion, the patient's expectation of change being causally connected to the subsequent change. Some form of body-mind communication, operating in the deep structures of the brain, underlies this change. . . .
Conditioning is another possible explanation for how placebos work. Have you ever had the experience of no longer feeling ill while you were waiting to see your doctor and wondering why you made an appointment in the first place? You associate this medical setting with the relief of symptoms that came with previous treatments received there. Later, the setting itself is sufficient stimulus to initiate the healing response.
of the above explanations, though persuasive, are limited in scope. Howard
Brody, both a physician and a philosopher, offers a much more comprehensive and
penetrating interpretation of how the placebo effect works by placing it within
the framework of the meaning of life. According to Brody, all healing practices
have two invariant features related to meaning: (1) a belief system that
explains illness in terms (natural or supernatural) readily understandable to
those who share the same way of looking at the world, and (2) a relationship
with a socially sanctioned healer occupying a role with parental-like power and
influence, which in turn stimulates caring responses from family and community.
. . .
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