Medicine, Philosophy of
MEDICINE, PHILOSOPHY OF•••
Over the last two and a half millennia—since the beginnings of Greek philosophy and medicine—there have been rich conceptual reflections regarding medical findings, reasoning in medicine, the status of knowledge claims in medicine, and the special concepts that structure the science and art of medicine. The philosophy of medicine is a corpus of considerations and writings uniting these reflections by contributors as diverse as Plato, Aristotle, and Galen; René Descartes, Immanuel Kant, and Georg W. F. Hegel; and contemporary thinkers. Because these examinations of medicine are philosophical in different senses, the term philosophy of medicine is ambiguous, covering a heterogeneous field of intellectual concerns. For the purpose of this overview, they have been collected under four categories.
The first category, speculative philosophy of medicine, has existed from the beginning of medicine. Speculative medicine may be characterized as the attempt to discover the basic philosophical principles that lie behind the practice of medicine. Here philosophy attempts to discover theoretical frameworks or foundations that give shape or content to clinical data. In this sense, philosophy of medicine provides a priori points of departure for medical knowledge and practice. The second category, the logic of medicine, brings together attempts to clarify the character of scientific reasoning in medicine. It identifies the basic principles that make medicine a coherent science. This category of philosophy of medicine studies, for example, the way in which diagnoses are made and judged to be accurate in medical practice and research. A third area of the philosophy of medicine may be understood as a subspecialty of philosophy of science. This area is concerned with what is accepted as knowledge in medicine and the healthcare professions. Much of the recent exploration of the status of concepts of health and disease or the status of the unconscious and explanation in psychoanalysis falls into this third category. Finally, a fourth category describes the explorations of other philosophical issues that have special salience in healthcare, for example, the nature of persons and its implications for the morality of abortion. Philosophy of medicine in this fourth sense would include bioethics.
Just as there is ambiguity concerning the meaning of "philosophy" in "philosophy of medicine," so there is ambiguity about the compass of medicine. Medicine can be construed as a body of knowledge, skills, and social practices concerned with the health and pathology of humans. In its modern sense, medicine encompasses theory and practice, science and art. Traditionally medicine is the origin of all systematic concerns with healing, including nursing and the allied health sciences. The focus of the philosophy of medicine, as a consequence, can have a broad or narrow scope.
The Philosophy of Medicine as Speculative Medicine
The ancient Greek philosophers sought to understand the world on a rational rather than a supernatural basis. Early Greek medicine was influenced by philosophers who held that the primary goal of a scientist was to find one basic principle or set of principles that would explain the natural world known by the senses. These physicians developed theories as to how the body worked and how diseases might be understood and controlled. At first, there was little concern to justify these theories in experience or observation. One finds, then, a tension in early Greek medicine between those physicians who grounded medicine in rational speculation—the rationalists—and those who grounded medicine in experience—the empiricists.
This tension is evident in the Hippocratic corpus. In the corpus there is approval for theorizing that "lays its foundation in incident, and deduces its conclusions in accordance with phenomena" (Jones, p. 313). Nevertheless, the Hippocratic author rejects the systematic sweep of more speculative thought:
Certain physicians and philosophers assert that nobody can know medicine who is ignorant what a man is; he who would treat patients properly must, they say, learn this. But the question they raise is one for philosophy; it is the province of those who, like Empedocles, have written on natural science, what man is from the beginning, how he came into being at the first, and from what elements he was originally constructed. (Jones, p. 53)
The author is rejecting what might be termed speculative or metaphysical medicine—namely, the attempt to construct a theory of medicine on the basis of self-evident, or basic, principles or concepts. The author also writes that medicine has no need of "an empty postulate," a concept that is not based in experience, because it has at hand the means for verifiable knowledge.
René Descartes (1596–1650) held that he could determine the fundamental laws of metaphysics, physics, and medicine (Descartes) by reason alone, without appeal to experience. On the basis of his work in speculative, metaphysical medicine, Descartes predicted that he would live an additional century or so, achieving a life span of one and a half centuries. He believed his own theories would issue in simple revisions of daily routine leading to such extensions of life expectancy (Descartes). Descartes's Treatise of Man (1662) attempts a mechanistic anatomy and physiology expressed in terms of matter and motion. Descartes explains how the human body works by comparing it to a machine. He found that this mechanistic approach could explain the physical functioning of the human body but not rational behavior. Still, Descartes's philosophical reflections concerning the body provided a framework for later explanations of human functioning that also relied on mechanical metaphors.
The success of Isaac Newton (1642–1727) in offering systematic explanations in physics inspired attempts to do this in medicine. The eighteenth-century Scottish physician John Brown (1735–1788), for example, suggested that the concept of excitability could serve medicine as the concept of gravity had served Newtonian physics: as the single concept upon which all explanations of health and disease could ultimately rest. Stimulation or excitation and response to it, he argued, resulted in an equilibrium or disequilibrium that defined health and disease, respectively. If an imbalance became too extreme, death would result. Brown's work attracted the attention of philosophers, including Hegel (1770–1831). This philosophy of medicine—as the gray area between scientific, empirical medicine and the philosophy of nature—led to the modern understanding of medicine that brings together empirical observation and theoretical construction (Tsouyopoulos).
Twentieth-century historians of medicine have appreciated this interplay between empirical and speculative medicine under the title "philosophy of medicine." William Szumowski in 1949 and Owsei Temkin in 1956 spoke of the importance of the philosophy of medicine. It is to Szumowski that much of the rebirth of the interest in this term, perhaps first coined by Elisha Bartlett in 1844, can be attributed. Lester King (1978) has used the term to identify the theoretical reflections undertaken by both physicians and philosophers engaged in speculative as well as other conceptual explorations of medicine.
The Philosophy of Medicine as the Logic of Medicine
The relationship between medical reasoning and medical practice has been an area of perennial philosophical controversy and investigation. In ancient Greek and Roman medicine, the disputes between the rationalists and empiricists were, in part, disputes about how knowledge claims in medicine ought to be justified. By the Renaissance, medicine had failed to achieve the success in healing that is often attributed to it today. This failure to achieve therapeutic success led to attempts to make medicine more scientific, in the hope of duplicating the success of fields like astronomy and physics. Thomas Sydenham (1624–1689), whose Observationes medicae appeared in a third edition in 1676, proposed a disciplined methodology of observation and treatment. Sydenham brought to medicine the scientific method of Francis Bacon (1561–1626), which sought to ground reasoning in experience, observation, and data.
This method, however, raised questions about observer bias of which Syndenham was aware. The principal difficulty is that an investigator's findings may be influenced by his or her presuppositions. These concerns about observer bias were taken up in the eighteenth century by such theoreticians of medicine as Françlois Boissier de Sauvages de la Croix (1706–1767) in his Nosologia methodica sistens morborum classes juxta sydenhami mentem et botanicorum ordinem (1768). Influenced by the writings of Thomas Sydenham and Carolus Linnaeus, Sauvages organized diseases into a structure of class, order, genus, and species. In his Nosologia there is an appreciation of medical observation as well as a concern for a logical rigor that sought to coherently relate observations to predicted outcomes. Sauvages's principal undertaking included a classification of diseases primarily based on their signs and symptoms rather than on their causes. He also sought to tie observed signs of illness to relationships that had been noted between past, present, and predicted future states of patients. The logical rigor of disciplined observation and the collection of facts is also evident in the work of William Cullen (1710–1790) and Thomas Percival (1740–1804).
The major revolutions in medical understanding born of advances in anatomy and physiology in the late eighteenth and nineteenth centuries, along with the recognition that many established treatments did not work, required a fundamental reassessment of medicine. Philosophical reflections concerning medical reasoning gave way to major treatises concerning the character of reasoning in medicine. Works such as Sir Gilbert Blane's Elements of Medical Logick (1819), Elisha Bartlett's Philosophy of Medical Science (1844), and F. R. Oesterlen's Medizinische Logik (1852) range from listing the elementary principles of life to concern with material fallacies in medicine, including excessive deference to authority, fashion, or speculative reasoning without sufficient empirical observation. Oesterlen's work, which advanced criteria for inductive reasoning in medicine based on the work of John Stuart Mill, included an analysis of the methods and means of medical investigation, the character of the inductive method in medicine, and the status of experiments, hypotheses, analogies, terminologies, definitions, and classifications. He viewed medical logic as the application of general logical principles to the field of medicine for the purpose of securing a coherent inductive and empirical science that would be free from a priori speculation. His work was followed by other studies, including Władysław Bieganski's Logika medycyny (1894) and Richard Koch's Die ärztliche Diagnose (1920).
Growing philosophical sophistication characterizes twentieth-century assessments of medical knowledge and medical reasoning. Types of medical knowledge may correspond to the different functions of medicine. Medicine can be understood in a threefold manner: biological medicine, clinical research, and clinical practice. Biological medicine is concerned mainly with scientific research in biology, whereas clinical research is focused on the development of the knowledge and technology used in clinical medicine. Finally, the area of clinical practice involves the realities of patients and disease. A philosophical concern of those writing on the logic of medicine has been to clarify the nature of each type of medical knowledge and the relationship of these different areas of medical knowledge and reasoning to one another (Wulff et al., 1986).
Since the middle of the twentieth century, a renewed interest in the logic of medical reasoning and the character of medical decision making has been expressed in the computer reconstruction of differential diagnosis. This literature has examined the logic and principles of medical reasoning—for example, the applicability of Bayes's Theorem to medical decision making (Lusted; Wulff, 1976); the logic of the taxonomy of disease and classification, including the application of set theory to the analysis of clinical judgments (Feinstein); and the role played by morbidity, mortality, and other costs in determining when and how diagnoses are framed. For example, because of the human and financial costs, one will be much more concerned about false positive diagnoses of AIDS than of athlete's foot. Recent works have given special attention to the process of making diagnoses, including the principles of differential diagnosis (Caplan, 1986; Engelhardt et al.; Wulff, 1976), as well as the elaboration of nosologies as instruments for gathering clinical information. Many of these reflections have stressed the hidden role of values and conceptual assumptions in the process and logic of medical diagnosis (Schaffner; Peset and Gracia; King, 1982).
The Philosophy of Medicine as the Philosophy of the Science of Medicine
Philosophy of medicine may also be understood as a self-conscious reflection on the status of special concepts, such as health and disease, deployed in medicine. Rudolf Virchow (1821–1902), for example, argued that designating a state of affairs as an illness has a stipulative character; that is, such concepts are defined by agreement and there are no clear natural types or divisions of nature corresponding to nosological categories. This sense of the philosophy of medicine places the accent on issues in the theory of knowledge and the examination of what should count as a medical theory or explanation. In this, it is distinguished from speculative philosophy of medicine and from the more narrow concerns with the rules of evidence and inference proper to medicine that are the focus of medical logic and medical decision theory.
Since the 1950s a considerable literature has developed that is directed to the status of concepts such as health, disease, illness, disability, and disorder. Whether such concerns constitute a subspecialty of the philosophy of science is disputed (Caplan, 1992; Wulff, 1992). There has also been interest in the character of medical explanation (Canguilhem). This literature has also explored the application of such terms to nonhuman animals. In addition, there has been attention to the extent to which these concepts are normative and the extent to which nonnormative, value-free concepts can be elaborated. Those who have argued in favor of weak or strong normative understandings of concepts such as health, disease, and illness have also addressed the character and kind of values that structure such concepts. Investigations have included the extent to which concepts of disease are instrumental to medical practice, or instead identify natural divisions in reality. In addition, there have been attempts to place medicine within the general compass of philosophical explorations of scientific theory (Kliemt). Finally, the significant changes about the relationship of theories, facts, and values in the understanding of the history and philosophy of science that occurred in the 1960s and 1970s were anticipated in Ludwik Fleck's 1935 study of changes in the meaning of syphilis and venereal disease from the fifteenth to the early twentieth century (Fleck).
The Philosophy of Medicine as the Collection of Philosophical Interests in Medicine
Even if one were to hold that medicine offers no conceptual or philosophical problems not already present in the subject matter of the philosophy of science or the philosophy of biology (Caplan, 1992), there would still be merit in exploring the ways in which philosophical study and analysis can be directed to the understanding of medicine, as well as to the healthcare sciences and arts in general. In this sense, the philosophy of medicine encompasses the ways in which the philosophy of science, the philosophy of biology, the philosophy of mind, moral philosophy, and so on are engaged in order better to understand medicine. Perhaps one would wish to characterize such explorations as philosophy about medicine rather than of medicine, in the sense that the tools, analyses, and insights of philosophy in general are brought to the particular subject matter of medicine. Calling this endeavor the philosophy of medicine underscores the heuristic advantage of treating the domain as a whole, as a single focus of attention. There is also the advantage of recognizing that general issues of justice, fairness, rights, and duties confront the special challenge of taking account of the development of humans from conception to death.
In medicine, special questions of intergenerational justice become salient, distinctions between human biological and human personal life are raised, the irremediable character of loss must be confronted, and comparisons must be made between claims for the alleviation of suffering versus the postponement of death. Though the definitions of futility, of ordinary versus extraordinary treatment, and of the beginning of life and the beginning of death may arise outside the compass of medicine, such definitions take on a special philosophical cast and character in the context of medicine. The recognition that there is this special concatenation of conceptual issues is appreciated in employing the term philosophy of medicine. This use of the term approximates the one employed by the European Society for the Philosophy of Medicine and Health Care (founded 1987), which encompasses bioethics within a constellation of philosophical concerns and undertakings. The philosophy of medicine as speculative medicine, as the logic of medicine, and as the philosophy of the science of medicine all spring from the acknowledgment that medicine constitutes one of the cardinal areas of intellectual and moral attention, central to human life, and is worthy of sustained conceptual analysis and philosophical regard.
h. tristram engelhardt, jr.
kevin wm. wildes (1995)
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