JRSM >
Volume 97, Number 8 >
Pp. 403-405
BOOK OF THE MONTH |
Weatherall Institute of Molecular Medicine, University of Oxford, UK
'We have our philosophical persons, to make modern and familiar, things supernatural and causeless'— William Shakespeare'When I study philosophical works I feel I am swallowing something which I do not have in my mouth'— Albert Einstein
In 1981, two American philosophers, Edmund Pellegrino and David Thomasma, in A Philosophical Basis of Medical Practice,1 suggested that the crisis of modern medicine lies in the lack of a suitable philosophy of medical practice whereby 'non-measurable clinical factors and values can be treated with the same attention as clinical indicators of disease'. In short, they held that the only solution is the search for a philosophy of medicine developed from the practice of medicine itself and not from the external imposition of philosophies which already exist; in particular, they did not believe that the philosophies of science which had evolved over many years were germane to the increasingly complex issues of medical practice in the 20th century.
It is only necessary to read Peter Medawar's delightful essay 'Is the scientific paper a fraud?'2 to appreciate that, although philosophers like Russell and Popper had a considerable influence in defining the nature of the scientific endeavour in the 20th century, their conclusions often appeared to be at variance with the day-to-day practice of research. The published papers based on the Herbert Spencer lectures given at the University of Oxford in 1979, entitled Scientific Explanation,3 suggest that the philosophy and practice of science are not entirely happy bedfellows. In summarizing the lectures the editor, A F Heath, pointed out that those by the scientists displayed an absence of doubt and suspension of disbelief, while the philosophers expressed considerable uncertainty about the validity of the accounts which the scientists had given of their activities. And he went even further, suggesting that the two most influential philosophies of science of the 20th century are self-refuting—not the most encouraging of messages for proponents of a new philosophy of medicine!
Although it could be argued that there has been little movement towards evolving an all-embracing philosophical basis of medical practice since the appearance of Pellegrino and Thomasma's stimulating book, at least as evidenced by the undoubted progress that has been made in bioethics over recent years, a more focused application of the disciplined thinking of philosophers has had much to offer the current medical scene. Onora O'Neill, for example, has provided an invaluable contemporary background to defining some of the problems of medical ethics in the light of duty or rights-based approaches and utilitarianism.4 Although these principles have had to be applied with considerable flexibility, they have formed a broad framework for discussions on a variety of topics including confidentiality, conflicting rights, rationing and prioritizing of healthcare, inequalities of care, and many other related issues. Also, by combining clarity of thought with good common sense about public expectations, the work of philosophers such as Mary Warnock5 has been one of the major reasons for the relative success of the UK in handling such delicate issues as embryo research, cloning and stem-cell therapy. Indeed, on bodies like the Nuffield Bioethics Council and some of the government regulatory committees, the philosophers who joined the scientists and lay people who were grappling with the difficult decisions raised by modern biotechnology were of inestimable value in better defining the questions involved, not to mention generating a more sensible basis for their solution. And, on the broader issues of bioethics, the writings of philosophers and historians of science—Dan Brock,6 Jonathan Glover7 and Daniel Kevles,8 for example—have provided a valuable platform on which to debate the extent to which society may wish to see the power of human genetics harnessed in the future.
But although there has been wide discussion about the shortcomings of the medical profession it seems unlikely, given the extraordinary rate of change and diversity of problems in the fields of biomedical research and patient care, that an all-embracing philosophical basis for medical practice, as outlined by Pellegrino and Thomasma, will become a reality in the foreseeable future. Steven Pinker's book The Blank Slate,9 which, incidentally, gained its name from a passage in John Locke's An Essay Concerning Human Understanding, emphasizes the rapidly changing concepts of human nature as they are becoming more clearly defined by the neurosciences, genetics, evolutionary psychology and developmental biology. This new and rapidly changing field alone offers enormous challenges for the philosophical analysis of the human state. The exploration of the human genome and the increasing evidence that we are what we are as a result of our genetic make-up, our current environment and the long history of the cultural milieu that has been handed down to us, offers a further example of the remarkable complexity of human beings. When the added stress of illness is thrown in for good measure, the concept of a unifying philosophical basis for the many facets of illness and its management appears increasingly unreal.
There is no doubt, however, that we will have to prepare our students much more effectively for the increasing problems of biological complexity that will dog them throughout their careers. The clinician's Occam's razor—'plurality of causes and diseases is not to be assumed without necessity'1—will no longer do. This issue was summed up recently: 'the principal problem for those who educate our doctors in the future is how on the one hand, to encourage a lifelong attitude of critical, scientific thinking to the management of illness and, on the other, to recognise that moment when the scientific approach, because of ignorance, has reached its limits and must be replaced by sympathetic empiricism'.10 This aim will only be achieved by developing an increased facility for communication and listening, by sustained discussion of the ethical, social and pastoral aspects of medical practice, and by training aimed at maintaining a functional level of scientific literacy in a discipline of ever-growing complexity. It is vital that our young doctors develop a frame of mind in which they continue to tussle with these issues throughout their careers.
A new work, Philosophy for Medicine,11 presumably directed towards some of these goals, consists of a series of lectures given at a seminar in Wales in 2001. As an act of reader-friendliness, the theme of each chapter is illustrated by short inserts which describe episodes in the life of a surgical registrar who appears to have had his thumb almost amputated by an assistant in the operating theatre. After an introduction to what is meant by the 'philosophy of medicine', subsequent chapters cover the clinical encounter, questions of knowledge and certainty, guilt, aesthetics, the changing philosophies of medicine over the centuries, and some aspects of medical ethics. In addition, there is an interesting excursion into the healing arts in different cultures. Many of the topics that are discussed cover well-trodden ground—for example, the uniqueness of the patient/doctor relationship; communication skills; reductive and mechanistic approaches to sick people. While many more questions are raised than answers offered and at first glance doctors may not find much here that is new, the way the issues are presented in clinical settings should make this useful background material for courses in bioethics and communication skills.
However, the central question raised by Philosophy for Medicine is to what extent this field should assume a separate new discipline to be added to the rapidly expanding curriculum for medical students, directed at making them into more rounded and caring individuals. They will certainly not want yet another burden added to their work as doctors. In this context, they may feel that there is little new and even less that is helpful to them in at least some sections of Philosophy for Medicine. But this is not to say that there is no place for philosophy in the evolving field of medical practice.
There are undoubtedly some aspects of medicine, at least as presented in Philosophy for Medicine, for which it is difficult to perceive an immediate practical role for the approaches of philosophy—examples being the complexities of the doctor/patient relationship and the ability to listen and to evolve a holistic view of the prevention and management of disease. Similarly, unless the current trend in medical education further undermines the teaching of the science on which medicine is based, students should be adequately prepared to cope with the doubts and uncertainties of their work, even to the extent of understanding the clinical limitations of evidence-based medicine. On the other hand, the biological sciences and the very scope of modern practice are raising complex new ethical and political issues that change almost day by day. And, as we have seen, philosophers are playing an increasingly important role in helping to define and address these problems. It is during the training of students and doctors about how to recognize and grapple with them that the approaches of philosophers could well be introduced; these approaches, if well presented, will then be perceived as valuable assets towards the clarification of the day-to-day problems of a doctor's life as well as broader political issues such as the prioritization of healthcare. At the same time, philosophers will continue their important work in training bioethicists and in aiding decision-making at national and international levels. Wider philosophical inquiry into the process of healthcare, as with science, can be left in the safer hands of philosophers.
It could be argued that this narrow, highly selective and rather pragmatic view of the relationship between philosophy and medicine ignores the broader value of a knowledge of philosophy as part of the general education of a physician. Undoubtedly, many students of previous generations had their lives enriched by reading Bertrand Russell's Wisdom of the West,12 and young people of today may find similar satisfaction in acquainting themselves with popular works on philosophy such as Simon Blackburn's Think.13 But medicine is of necessity a pragmatic profession; unless the principles of philosophy are introduced to its students linked to questions of immediate relevance to their patients or communities, and even more importantly, in a language and context in which they can perceive the possibility of solutions to the protean problems of sick people, the value of this disciplined way of approaching the complexities of medical practice may well be lost on them.
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