JRSM >
Volume 96, Number 1 >
Pp. 40-45
Special article |
Centre for Anaesthesia, Middlesex Hospital, Mortimer Street, London W1T 3AA, UK
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 TOP INTRODUCTION PARALLELS WITH MEDICINELIFE, THE UNIVERSE AND...WISDOM AND HUMANISMTHE PHILOSOPHY OF SCIENCECONCLUSIONREFERENCES |
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In western civilization, philosophical writings date from Ancient Greece, and eastern philosophical traditions go back even further. To benefit from the fruits of so much intellectual endeavour, all one needs is an awareness of some basic philosophical arguments. In the same way, it does not really matter whether or not you can float a pulmonary artery catheter or perform a Whipple's operation, as long as you recognize their potential and know someone who can.
| PARALLELS WITH MEDICINE |
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In philosophy as in medicine, a single phenomenon can have several different explanations. Although in the former it may be impossible to prove that any one of these is definitively correct, the deductive process used to explore the possibilities could, beneficially, be applied to medical problems. Blackburn also suggests that ‘philosophy studies the structure of thought. Understanding the structure involves seeing how the parts function and how they interconnect’1. Here again there are parallels with medicine. On a direct level, to understand how the parts of the body function and interconnect requires a knowledge of their basic structure. This is not only for the more obvious physiological structure and function, but also for less tangible processes such as the interaction between body and mind. An understanding of the structure of thought can also provide a framework within which to order our knowledge and thinking. The need for such a framework increases along with the daunting growth of the medical corpus.
In my own specialty, on encountering a new anaesthetic technique I decide whether to reject it or amalgamate it into my practice. So it is with philosophies and life. But we have to bear in mind that what does not suit us may work very well for others. Furthermore, it is always possible that a rejected philosophy or technique may, one day, turn out to be the most appropriate.
The Nobel laureate Richard Feynman, in his 1974 Caltech commencement address said ‘... this long history of learning how not to fool ourselves... is, I'm sorry to say, something that we haven't specifically included in any particular course that I know of. We just hope you've caught on by osmosis’2. The trouble is that the academic discipline of ‘not fooling ourselves’ is impossible to teach per se. The teaching of philosophy may, however, provide a breadth and depth of understanding that can come as close to this purpose as is possible.
To illustrate this I will address the subject from the point of view of various philosophers in the first section of this paper, and look more at certain philosophies in the second and third parts.
| LIFE, THE UNIVERSE AND EVERYTHING |
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Montaigne (1533-1592)
Montaigne is said to have mistrusted the pretensions of systematic
philosophy: his writings are ‘richer in allusion and anecdote than in
formal argumentation, but nonetheless sparkle with philosophical
insights’3.
Education was a subject about which Montaigne had much to say. For
example:
‘I gladly come back to the theme of the absurdity of our education: its end has not been to make us good and wise, but learned. And it has succeeded. It has not taught us to seek virtue and to embrace wisdom: it has impressed upon us their derivation and their etymology... what matters most is what we put last: "Has he become better and wiser?" We ought to find out not who understands most but who understands best. We work merely to fill the memory, leaving the understanding and the sense of right and wrong empty...’4.
Although at the undergraduate level medical education is beginning to change, it still tends to place too much emphasis on the acquisition of facts. Philosophy as an attempt to understand fits in well with prevalent educational theory which values ‘deep’ more than ‘surface’ learning. To clarify these limitations in education Montaigne distinguished between learning (logic, etymology, grammar and the like) and wisdom. The latter is an elusive type of knowledge that can help a person to live well and, significantly, to apply knowledge well.
There can be little argument against the importance of wisdom in medical practice, but wisdom is not to be found in medical textbooks. The distinction is well illustrated in The Spirit Catches You and You Fall Down by Anne Fadiman5. This book tells the story of a Laotian family who moved to the USA after fleeing their own country in the 1970s. Lia, the fourteenth child in the Lee family, was born soon after their arrival in the USA. It soon became apparent that she had severe epilepsy. A lack of understanding between the American doctors and the parents led to the girl being taken away from a loving family. Not only did this cause enormous anguish, but it may also have hastened the girl's decline. In this case, the ‘learning’ was the knowledge of the pathophysiology and treatment of epilepsy, but ‘wisdom’ would have been the ability to reconcile Laotian philosophy and western medical treatment.
An awareness of one of Montaigne's own influences might have been beneficial to the doctors in this case. On the beams of his library ceiling he had fifty-seven inscriptions painted6, one of which was this line from Terence: Homo sum, humani a me nihil alienum puto [I am a man, nothing human is foreign to me]. Populations are becoming more and more fluid, and as doctors we encounter the full spectrum of cultural diversity. An understanding of the basis to both our own and other people's philosophies can help us deal with this.
In the end, such was Montaigne's lack of faith in education by rote, he was moved to write: ‘If [as a consequence of our education] our souls do not move with a better motion and if we do not have healthier judgement, then I would just as soon that a pupil spend his time playing tennis’4.
Socrates (470-399 BC)
Socratic method is a straightforward and logical process through which the
validity of opinions can be scrutinized. It is not a competitive process but a
cooperative search for both truth and understanding. The process proceeds,
approximately, along these lines:
By examining our beliefs and practice in this systematic and logical fashion we gain a deeper understanding of them. An important consequence is that, when challenged, we are able to defend our methods more effectively. Conversely, we are better able to cope with statements or practices with which we do not agree.
For doctors this can be illustrated by reference to the role of enteral nutrition in critically ill patients. Take the following statement:
‘Acquisition of enteral access and provision of a sufficient volume of enteral nutrients early in the hospital course of a critically ill patient afford an opportunity to improve the outcome of that patient through the progression of his or her disease process. Failure to use the enteral route of feeding not only squanders this opportunity, but may, in addition, promote a proinflammatory state, which exacerbates disease severity and worsens morbidity’7.
One circumstance in which this might conceivably be untrue is after major abdominal trauma, where damage to the gut may preclude successful enteral feeding. When this particular group was studied, those patients who were fed enterally were found to do better than the cohort who were fed parenterally8. Thus the statement holds true. Another study looked at patients in whom there was some doubt as to the integrity of their intestinal function. Here, those randomized to parenteral nutrition did better9. The original statement and our practice should therefore be modified and the new statement re-examined.
Hume (1711-1776)
David Hume was famous for his scepticism in metaphysics. In a typical
passage he wrote: ‘The passion of surprise and wonder, arising from
miracles, being an agreeable emotion, gives a sensible tendency towards the
belief of those events, from which it is
derived’1.
Although he was discussing the place of miracles in proving the existence of
God, the same holds true for new medical treatments. With medicine this
‘emotion’ can be all the more ‘agreeable’ being, as it
can be, mixed in with a large dose of self-interest. In his commentary on
Hume, Simon Blackburn expands the argument: ‘... miracles are the kind
of things that either never, or almost never happen. When I leave for the
office in the morning my wife might warn me against the cold, or the traffic,
or my colleagues. But she doesn't warn me against flying elephants, being
taken into sexual slavery by Martians, or conversations with the living
Elvis’10. In
medical terms the lesson is that medical novelties should always be regarded
with intelligent scepticism. It also, in a roundabout way, gives a perspective
on the information given to patients: Blackburn's vignette illustrates the
potential for absurdity in providing too much information. O'Cathain and
others11 have made
this point about detailed drug-information leaflets: these confused the
patients and lessened concordance with treatment.
Wittgenstein (1889-1951) and Nietzsche (1844-1900)
One of the philosophical ‘proofs’ of the existence of minds
other than our own is known as the argument from analogy: I have a mind
therefore all the people I encounter, and who behave in a similar fashion,
must have a mind too. Ludwig Wittgenstein points out its weakness: ‘...
how can I generalise the one case so
irresponsibly?’12
This is something doctors too should beware of, since a single case that has
gone particularly well or badly can generate an urge to alter the whole of
one's practice.
Although philosophy can highlight all these obstacles, it can also provide solace. Friedrich Nietzsche wrote: ‘Human, All too Human: in the mountains of truth you will never climb in vain: either you will get up higher today or you will exercise your strength so as to be able to get up higher tomorrow’13. In other words, the quest for a truth, philosophical or medical, may often be arduous but it will never be worthless.
Eastern philosophy
Confucius (6th-5th century BC) thought that ‘the way to great
learning is to know virtue; and self-discipline is the foundation of all
achievements’14.
He also felt that a reputation for such behaviour would enable the possessor
to bring about social changes by non-coercive means. In medical terms this
would mean the ability to influence the practice of others; and it is
certainly true that a person's perceived integrity is proportional to his or
her influence. Confucius also advocated concern for others, and put much
weight on the responsibilities that go with social position—such as
being a doctor.
Lam has lately marked the relevance of these writings by building a new ‘fantasy’ medical school around the teachings and philosophy of Confucius15.
What of Taoism? One of the general precepts might be usefully employed by doctors. It is that ‘the operation of the human world should ideally be continuous with that of the natural order’ and that one should be able to respond ‘spontaneously to situations with no preconceived goals or preconceptions of what is proper’3. This is not a call for an anarchistic return to nature, but a reminder to keep an open mind—to remember that Mr Jones' tenth ‘suspicious’ cough in as many weeks may actually be due to the cancer he always thinks it is.
| WISDOM AND HUMANISM |
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Robertson Davies, a writer without medical background, reckoned that ‘the profession of medicine... seems to be moving rapidly toward a condition where it is principally involved with science’. He felt that during his lifetime doctors had lost their status as magicians or gods and had become merely ‘middlemen between me and a large pill works’17. Just as Montaigne distinguished between learning and wisdom, Davies distinguished between knowledge and wisdom. He illustrated this concept by alluding to a staff with two entwined serpents (which he confused with the medical staff of Aesculapius, with its single serpent). In medicine, Davies saw a constant battle between the serpents of knowledge and wisdom: ‘so many of your students come to you, already such convinced worshippers of the Science snake, that they do not want to hear about anything else’17.
The practice of medicine entails a constant balancing act, not only between knowledge and wisdom but also between effect and side-effect, cost and benefit, and religious and medical beliefs. Ornstein and Sobel7 make an important distinction between health and disease. In terms of life expectancy, measures to combat disease have been far less effective than measures to improve health, nutrition and sanitation.
To broaden the intellectual horizons of medical students is difficult. In an effort to streamline the curriculum at my institution, various departments were surveyed as to what aspects of their fields they felt essential to an undergraduate education. From their replies it seemed that all students required a deep knowledge of each and every discipline. In other words the scientific demands on students' and teachers' time were entrenched. The point that seems to have been missed is that although ‘Knowledge may enable you to memorise the whole of Gray's Anatomy or Osler's Principles and Practice of Medicine... only wisdom can teach you what to do with what you have learned’17.
Whereas the Renaissance marked a shift away from the study of God to the study of man, today the trend, both in medicine and in culture, seems to be away from the study of man towards the study of science. In Medical Nemesis18, Ivan Illich described the medicalization of society and argued that medicine is replacing religion. When death, pain and sickness were entwined with religion they could be seen as part of the human condition; but the secularization and medicalization of western society has replaced this notion with an expectation of alleviation and cure. The humanistic doctor is best placed to bridge this chasm. Over three centuries ago Paré remarked ‘I dressed his wounds, and God healed him’. As doctors we can catalyse the healing process, even if we or our patient do not recognize a god, by encouraging the ‘healing brain’ to heal.
One consequence of our narrow and intense medical education, coupled with the demands of keeping up with the science, is a tendency to become over-preoccupied with medicine. Robertson Davies recalls a consultation he had with the endocrinologist Raymond Greene (1901-1982). After dealing swiftly with the medical complaint, Greene asked him what he thought to be the underlying problem, which was trouble with work. Greene then gave him this advice:
‘You know you shouldn't put so much emphasis on your work. Only second rate people do that. And then, of course, their work eats them up. Whereas they, of course, ought to eat up their work. My work would eat me up, but I keep it in its place by climbing mountains. And do you know, climbing mountains makes me a better doctor’17.
The humanistic doctor balances benefit and harm, health and disease, the physical and the metaphysical. A knowledge of philosophy can counterbalance a knowledge of science, and climbing mountains can put it all into perspective.
| THE PHILOSOPHY OF SCIENCE |
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TOPINTRODUCTIONPARALLELS WITH MEDICINELIFE, THE UNIVERSE AND...WISDOM AND HUMANISMTHE PHILOSOPHY OF SCIENCECONCLUSIONREFERENCES |
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Paradigm shifts
To begin with, it is important to understand what actually defines a
science or scientific community. Kuhn himself suggests that ‘only the
most tentative generalisations are
possible’19.
To tentatively generalize then, a science is an area of research into
fundamental questions about the behaviour of nature. Such research is only
truly understood by the scientist's peers—those with a shared
educational background and, as a consequence, a shared basis for their
beliefs. It is the generation and development of this ‘shared
basis’ that is Kuhn's particular area of interest. He argues that the
most significant scientific papers and discoveries are those which
‘attract an enduring group of adherents away from competing modes of
scientific activity. [At the same time they are] sufficiently open-ended to
leave all sorts of problems for the redefined group of practitioners....
Achievements that share these two characteristics... [are] paradigms’.
In other words a paradigm is or becomes an accepted model or
pattern19. Sciences
without paradigms remain, he suggests, immature—not really sciences at
all. A scientific topic has no real direction until there is a unifying
paradigm. Before there is, researchers in the same sphere will interpret the
same observed phenomenon in a wide variety of ways.
In the early nineteenth century chemistry was seen as holding all the answers for medicine. Even though bacteria had been seen and extensively studied in the previous century, they had not been seriously considered as possible pathogens. The subsequent development of the paradigm of pathogenic bacteria was largely due to the work of Louis Pasteur (1822-1895), who by an irony started his career as a chemist. Once this unifying paradigm had been articulated there was an explosion of knowledge as the research became highly focused and effective. The science of microbiology was born. The role of paradigms in the scientific community can be illustrated with a political analogy. Karl Marx (1818-1883) wrote: ‘The ideas of the ruling class are in every epoch the ruling ideas, i.e. the class which is the ruling material force of society is at the same time its ruling intellectual force’20. The ruling class is that which has defined the paradigm. A science without a ruling class or paradigm can be likened to a state of anarchy.
Once a paradigm has been established the concept moves into an era of what Kuhn calls normal science. It is this normal science, of fact-gathering and paradigm refinement, that takes up and defines most researchers' lives. As the volume of knowledge increases and the finer details of the paradigm are articulated, so the scientists become more and more specialized. A subspecialization occurs, a gap begins to open up between areas of what was once a single field. Such subspecialization in medicine, coupled with the explosion in knowledge, means that a medical student can do no more than scratch the surface of all these areas. There is also a justified concern that much of the knowledge gained by a medical undergraduate is irrelevant. Consequently, there is great need for a unifying framework. Philosophy, as I have outlined here, can provide such a framework. Doctors of the future will need to strike a balance between intelligent scepticism, about scientific and medical novelties, and open-mindedness. From Kuhn's philosophical perspective we see that ‘Normal science... often suppresses fundamental novelties because they are necessarily subversive of its basic commitments’19. It will always be difficult to distinguish between novelties that are simply wrong and those that expose the fallacies of the prevalent paradigm. Such judgments will be helped by an awareness of the circumstances that permit a change in the fundamental precepts of a scientific field. The catalyst for change is one or more of three basic occurrences—that problems seen to be part of ‘normal science’ resist solution; that a new instrument is not performing as expected, or producing different results from those expected; or that more and more anomalies in a theory are being unearthed. These are ‘the tradition-shattering complements to the tradition-bound activity of normal science’19. They are the scientific revolutions and the paradigm shifts. There is an analogy with Stephen Jay Gould's (1941-2002) notion of biological evolution—a ‘punctuated equilibrium’ whereby species can remain constant for millions of years until affected by an outside influence such as climate change.
Research directions
The history and philosophy of science can also provide insight into the
direction of research. I have highlighted Kuhn's assertion that most
scientific research is little more than mopping-up. That is not, however, to
belittle either the importance or the fascination of such work. The importance
of direction, or at least reasonably well-defined boundaries, has already been
outlined. But it is also instructive to look at the foci of research within
the paradigm.
The first focus is the determination of new facts in areas that the paradigm seems to facilitate most effectively. If microorganisms can be the cause of one disease then it may well be fruitful to investigate whether they cause other diseases. A second focus of investigation is in resolving any ambiguities or unsolved areas to which the new paradigm draws attention, thereby matching fact with theory. How do microbes cause disease and how do they spread? Finally, attempts can be made to apply the new paradigm in different ways to different areas. Do microbes cause cancer, or heart attacks?
Sometimes, however, our nicely directed research encounters the difficulty that the theory does not match the practice. This is the point at which, to borrow Kuhn's analogy, we realize that either the jigsaw puzzle we were putting together comes from two different boxes, or the box that we possess does not contain all the pieces.
The awareness of an anomaly—that the pieces do not fit together—is the point at which ‘discovery commences.... And it only closes when the paradigm theory has been adjusted so that the anomalous has become the expected’19. Although the miasma theory of contagion answered some of the questions of infection, the microbial theory answered all of these and more.
Just because we have all the pieces, we do not necessarily have the full picture. For example, although the complete human genome has been sequenced there is a long way to go before the function of every gene, not to mention their regulation and interaction, is determined.
Intellectual leaps
Puzzles of this sort offer a framework for research that might point the
way to other puzzles. Unfortunately, few of us have the insight to know where
the other puzzles can be found, or the wherewithal to unravel them.
Furthermore, if no solution to a problem is immediately apparent within a
framework, we may not see or even look for it. There was an example of this in
the development of anaesthesia. Sir Humphry Davy wrote as follows in the
conclusion of his Researches, Chemical and Philosophical: ‘as
nitrous oxide in its extensive operation appears capable of destroying
physical pain, it may probably be used with advantage during surgical
operations in which no great effusion of blood takes
place’21.
Many historians of anaesthesia have taken this to mean that he recognized the
potential of nitrous oxide as an anaesthetic agent. However, in the absence of
any concrete concept of ‘anaesthesia’, it is more likely that he
was putting it into a completely different, but now superseded and forgotten,
medical
paradigm22.
Even when the intellectual leap has been made and the new paradigm has been articulated, there will be resistance from those whose work and views are shown to be wrong in this new light. When, in the case of anaesthesia, Horace Wells did make the leap, his first demonstration did not go according to plan. It was indeed dismissed as a ‘humbug affair’. The concept of anaesthesia remained controversial even when Snow used chloroform to relieve the labour pains of Queen Victoria nine years later. Acceptance of the concept of anaesthesia emerges as even more protracted when we see that, two centuries earlier, Paracelsus (1493-1541) had exposed chickens to ‘sweet vitriol’ (i.e. ether) and described how it ‘quiets all suffering without any harm, and relieves all pain’23.
After our bloated, proscriptive and paradigm-rich medical education, it will be difficult to differentiate the paradigm shifter from the mistaken. My investigations into this area brought to mind an interview for medical school. The dean asked me if I thought originality was important in medicine. When I replied that originality was necessary for progress, he laughed genially and said ‘In the next five years we will knock every ounce of originality you ever had out of you’.
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TOPINTRODUCTIONPARALLELS WITH MEDICINELIFE, THE UNIVERSE AND...WISDOM AND HUMANISMTHE PHILOSOPHY OF SCIENCECONCLUSIONREFERENCES |
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