John Goldie is a retired GP and Medical Educator
In my final years in practice, I became the GP lead for our diabetic clinic. Care had become more structured since starting in practice, no longer squeezed into a patient’s five minute appointment slot. At first, I took satisfaction in completing QOF screens and tracking HbA1c, cholesterol, and blood pressure—exactly what I had been trained for at medical school and in hospital posts. But that satisfaction soon gave way to moral distress.1 Many patients lived with multiple conditions, psychological struggles, and the daily challenges of lifestyle, family, and ageing. Too often, I lacked the time or resources to offer truly holistic care, falling back on extra prescribing as a stopgap.
Too often, I lacked the time or resources to offer truly holistic care, falling back on extra prescribing as a stopgap.
This tension reflects two competing views of medicine. The biomedical model treats disease as a mechanical fault—health is the absence of illness. In contrast, another perspective sees illness as a personal experience, shaped by life and culture.2 Health is not a box to tick, but a journey. To understand why the biomedical model sometimes feels inadequate in primary care, I turned to process philosophy.
Western medicine has long been shaped by substance philosophy, from Aristotle and Descartes. Substance philosophy is the view that reality consists of fundamental, independent entities that possess properties (like colour or shape) but remain the same distinct “thing” even when these properties change. It treats diseases as discrete entities located within bodies, amenable to diagnosis and intervention. In hospitals, this underpins the biomedical model: health problems are faults in the body, like broken parts in a machine. The goal is to find the problem, fix it, and move on. This approach has delivered enormous advances in diagnosis, treatment, and public health. Yet it reduces people to illnesses, separates mind from body, and neglects lived experience.2,3
Process philosophy, developed by Alfred North Whitehead and Henri Bergson, offers another lens. Reality is not static things but ongoing events, relationships, and processes. What looks like a “thing” is just a snapshot of constant change. Whitehead called these moments “actual occasions.”4 In medicine, each consultation can be seen as such an occasion. Health and illness are emergent from dynamic interactions among biological, psychological, social, and environmental processes. Doctors and patients work together over time. Each appointment is a chance to understand the patient’s life, adapt care, and support their journey. Whether they flourish depends on the systems we build.
Healthcare is built on substance philosophy: classification, protocols, standardisation. For acute problems—like MI or meningitis—this model is essential. It also structures disease management. But for multimorbidity, mental health, and long-term illness, it struggles to capture the whole patient.2,3,5,6 Here, general practice aligns more with process philosophy, where health is relational, narrative, and contextual, and care emphasises continuity, holism, and responsiveness.
These philosophical insights are not abstract—they are borne out in research. Continuity of care, which unfolds as a story across time, reduces mortality rates.7,8 Holistic, person centred care improves satisfaction, adherence, and outcomes.5,9 Social prescribing demonstrates the value of community embeddedness.10,11 Narrative medicine shows that viewing patients as stories rather than cases fosters empathy, trust, and therapeutic effectiveness12,13. These are not add ons; they are the very fabric of general practice—and process metaphysics gives them their philosophical backbone.
Process philosophy also reframes ethics. Shared decision-making becomes a co-creative process that honours the patient’s unfolding story. Autonomy and beneficence are not static principles but situated, emergent practices. Justice is broadened: recognising patients as embedded in social networks highlights the ethical imperative to address social determinants of health and promote equity. The GP’s role is not to manage conditions as fixed entities but to steward processes of becoming.
What I felt as moral distress was not failure, but philosophy calling—reminding me that general practice is medicine’s living philosophy. It must be resourced accordingly.
This distinction matters even more as medicine faces the rise of AI, which thrives on substance logic but struggles with the relational dimensions of care. AI can identify the broken part, but it cannot do what GPs can: hold silence, co‑create meaning, and accompany patients through change. Far from replacing general practice, AI makes it more essential.
Consider a patient with type 2 diabetes, obesity, and depression. Substance philosophy sees a collection of biological errors to be corrected, focusing on static measurements and standardised protocols. Care is episodic, authority lies in the guideline. Process philosophy sees the patient as a narrative in motion, exploring how life circumstances interact and aiming for resilience and adaptation. Regular follow-ups anchor the patient through a relationship that evolves as circumstances change.
Integration—the unique skill of the GP—lies in bridging these worlds. It means maintaining biomedical rigour while holding space for ongoing conversations about the patient’s life and goals. Treatment is adjusted not just on today’s data, but on the patient’s life trajectory.
What I felt as moral distress was not failure, but philosophy calling—reminding me that general practice is medicine’s living philosophy. It must be resourced accordingly.
References
1. Perni S. Moral Distress: A Call to Action. AMAJ Ethics 2017,19(6):533-536.
2. Kleinman, A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books. 1980.
3. Foucault, M. (1973) The Birth of the Clinic: An Archaeology of Medical Perception. London: Tavistock.
4. Whitehead AN. Process and Reality. New York: Macmillan; 1929.
5. Nkhoma KB et al. Systematic review of person-centred interventions. BMJ Open, 2022 Jul 13;12(7): e054386.
6. Illich I. Medical Nemesis: The Expropriation of Health. London: Calder & Boyars. 1976.
7. Pereira Gray D et al. Continuity of care and mortality: systematic review. BMJ Open, 2018;8: e021161.
8. Goodwin JS. Continuity of Care Matters in All Health Care Settings. JAMA Netw Open. 2021;4(3): e213842.
9. Pearson-Stuttard, J et al. Multimorbidity—a defining challenge for health systems. The Lancet Public Health, 2019:4(12); e599 – e600.
10. Spanos S et al. Systematic review of social prescribing referral pathways. International Journal of Integrated Care, 2025 Aug 19;25(3):21
11. Cooper M, Avery L, Scott J, et al. Effectiveness and active ingredients of social prescribing interventions targeting mental health: a systematic review BMJ Open, 2022 Jul 25;12(7): e060214.
12. Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA, 2001 Oct 17;286(15):1897-902.
13. DiFrances Remein C et al. Systematic review of narrative medicine programmes. BMJ Open, 2020 Jan 26;10(1): e031568.
Featured photo by Tim Marshall on Unsplash.
