Philosophy of Medicine
1. Introduction to Philosophy of Medicine
The philosophy of medicine is a field given little attention and is dwarfed by the philosophy of natural sciences. The past thirty years has seen the philosophy of biology and philosophy of physics develop rapidly, and it is recognized that work concerning biology and physics has direct relevance to medical science, clinical practice, and health care. Biology and physics are medical school prerequisites in the UK and similar countries. Medical professionals understand that health and pathology are ultimately biological processes that occur within the laws of chemistry and physics. A knowledge of biology can directly enhance medical practice. An example is the pharmaceutical industry where the understanding of chemicals and biological processes is used to develop drugs to cure diseases. Thus, the philosophical study of biology and physics often has medicine in mind. Despite this, the philosophy of biology and philosophy of physics are not to be treated as one entity, and they can be divided into theoretical and general philosophy of biology/physics and philosophy of human biology. The former discusses biological theory and general issues, the latter is no different from the philosophy of medicine, and we would expect that a philosopher engaging in the philosophy of human biology would consider the work of philosophers of medicine.
Philosophy is a discipline that approaches subject matter in a different way to science or the empirical method that is common today. Contrary to empirical examination, philosophy poses questions which may not have straight answers. There is no way to ‘test’ the hypothesis to determine which answer is the right one. These questions include value judgments or conceptual problems about the subject matter. The act of philosophy provides an alternative approach to understanding that is both complementary to the empirical techniques and a critique of them. This introduction examines the approaches available to the philosophy of medicine and their relevance to medical science and practice.
2. The Nature of Health and Disease
Given that correcting or preventing disease is the main goal of medicine, then most of what goes on in medicine can be seen as trying to move people from one state of health to a ‘better’ state (though not necessarily to a state of perfect health).
In contrast, health is not simply the lack of disease. At one end of the scale, there are athletes and fitness fanatics who would consider themselves unhealthy if they caught a simple cold. At the other end are elderly people or those with chronic illness who would consider themselves healthy if they were simply able to get out of bed each day.
There is a tendency for philosophers of medicine to focus their attention on the nature of disease rather than on the nature of health. Although both concepts are complex, it is easier to decide what does and does not constitute a state of disease. This is usually thought to involve demonstrating some form of deviation from the normal (however that is defined).
A. Methodological Considerations B. The Explication of ‘Health’ and ‘Disease’ C. In Search of the Nature of Medicine D. Health as a Normative Concept
3. Ethics in Medicine
There is some degree of relation between deontology and the standard ethical considerations enshrined within the Hippocratic Oath. Altruism and lack of self-interest on the part of the physician are going to be suggestive of researching whether an act is of benefit to a patient, and comparison of different personal or professional interests might raise issues of justice in the allocation of different sorts of medical care, essentially between plans of treatment for different people. The issue of informed consent to patients before attempting treatment or research upon them has been a large topic of debate, and this is very much an offspring of the consideration of patient autonomy, from a time when it was thought permissible to withhold information from patients if it was felt that the physician knew better. A patient now has the right to know and make decisions based on his own benefit from medical information available to the physician. This is essentially a process where medicine has been forcing itself to be more and more accountable to patients.
In more recent years, the issue of ethics within the field of medicine has become a more prominent concern. This has been largely due to a wealth of understanding of the history of how patients have been treated and the knowledge of past research upon humans. There are now various mechanisms to ensure that physicians take ethical considerations into account when getting involved in patient care, instead of just their own self-interest. Many countries now have national or local ethics committees which issue opinions on the ethical appropriateness of actions or decisions relevant to patient care or the allocation of resources within health care.
4. The Role of Science in Medicine
Now medical technology in all its aspects has generally developed not through the application of the theory of the time to which it pertained, but through the often empirical pursuit of quick results by men who were not always concerned with the nature of the theory that they were seeking to apply. Because of this, many aspects of technology have at various times been judged to be unscientific. But it is a bad philosopher who judges an action to be not in accord with a given theory and then proceeds to follow that judgment with a blanket rejection of the theory concerned. Now the judgment of the scientist or philosopher has no therapeutic qualifications and viewing a theory from the standpoint of its relevance to medicine is nothing more or less than a special case of trying to assess a scientific theory from the standpoint of its truth value. This sort of assessment has never been made in medical technology with regard to a theory of the time and has often been made with regard to theories that have succeeded it. But because change in medical technology was often a change from a therapy guided by one theory to a therapy guided by a totally different theory, practice has often been a forlorn hope, evidence has often been sought with a view to establishing a theory or changing a previous theory rather than with a view to better understanding the etiology of the disease.
Scientific theories grow through a process of critical discussion and controlled observation. Controlled experiment only provides a method of exposing error which if the hypothesis is sound has come to light in some other way and cannot be expected to provide any shortcuts. The classical instance is provided by the discovery of sunstroke. The theory that it was a heating effect on the brain was advanced by John Cooke in 1769 on the grounds that it concorded with the known effects of high environmental temperature. This theory was confirmed 150 years later by the controlled experiments of Leonard Hill on soldiers (Shrine 1951). The hypothesis of Cooke had guided the treatment of heatstroke during all this period. Controlled experiment is not the only type of scientifically valid observation, for every accurate and relevant clinical observation is an uncontrolled experiment, but it is the only type of observation which is not open to more than one interpretation.
Science is related to medicine in two ways. On the one hand, the value of a scientific theory to medicine cannot be assessed independently of the value of medicine as an art, since a theory which has no therapeutic implications is irrelevant to medicine. On the other hand, the development of medical technology must be assessed in terms of the extent to which it has fulfilled the promise of the science on which it is based. In this chapter, I shall be concerned with the second of these two relationships, i.e. the extent to which the developments of medical technology can be said to have fulfilled the promise of the science on which it is based. This is of more than intrinsic interest, since a study of the more or less tragic, depending on one’s point of view, history of e.g. chemical therapy, surgery, and nutrition can help towards an understanding of the determinants of the health of populations and of the influence of social policy on the etiology of disease.
5. Philosophical Perspectives on Medical Practice
An alternative view to this is the Popperian philosophy of medicine. It holds the assumption that medical knowledge can never attain a state of finality. This stems from the fact that patients and diseases are constantly evolving, which means that what we know about treating a specific disease today might change in the future. Any change in the knowledge will be the implementation of a solution to a problem, i.e. the problem was and still is to cure the disease or alleviate symptoms pertaining to it. This philosophy can lead to some criticism as the effectiveness of treatment no longer applies to the past knowledge, and knowing whether a problem has been solved often requires resorting to the previous knowledge. This means that a Popperian view can sometimes become indistinguishable from a positivistic view.
Positivism and its assessment of medicine is the first philosophy we will look at. According to the positivistic view, medicine is a science, and medical knowledge is the sum of what we know about health and disease. This view holds the closest affinity to medical practitioners who seek to produce the best possible health outcomes. The central tenet of this view is that the value of knowledge is in its application. Thus, the criteria for the truth of medical knowledge is the effectiveness with which it can be used to solve specific problems in medicine. This effectiveness is usually best demonstrated in research seeking to diagnose and treat disease pertaining to a specific population. Another aspect of the positivistic view is that diseases have an underlying reality that can be detected, and that treatment for specific diseases is more effective than treatment for patients with a disease. This leads into the educative academies of medicine teaching students to apply specific knowledge to specific cases.
