//Medicine, Philosophy and Ideology

Medicine, Philosophy and Ideology

To me the so-called ‘debate’ about the acceptability of the presence of CAM (Complementary and Alternative Medicine) in society and its availability on the NHS belongs much more in the paradigm of political philosophy than it does in science.

It is also clear to me that many of those who deplore CAM are much more concerned with the affront it makes to their ideologies – namely scientism and statism – than they are with the health of the nation or what sort of medicine the people want for themselves.

CAM’s detractors are fond of criticizing the Government for upholding the public’s right to choose CAM and to receive it on the NHS and are often bitterly disappointed when successive Governments repeatedly favour personal choice  for patients and doctors’ discretion about treatments, capsule over their draconian recommendations to ban any medical interventions with which they (the detractors) do not agree.

The Enlightenment is often cited as the point at which humanity finally learned to use reason to trump ignorance, unhealthy superstition and other errors. Somewhat ironically its heyday was in the mid 18th Century, the time of birth of the founder of homeopathy, Samuel Hahnemann.

I have mentioned the name of my late mentor Eric Karl Ledermann on these pages before.  After qualifying as a doctor in Berlin, Ledermann fled the Nazis in 1933, requalified as a doctor in Edinburgh and went on to become a holistic doctor, a psychiatrist and medical philosopher who espoused a whole person philosophy in physical medicine and an ethos in existential psychiatry which stated that ‘the goal of psychotherapy is to make the unconscious conscience of the patient conscious.’

His classic text, Philosophy and Medicine, begins with his appreciation of the great Enlightenment philosopher Immanuel Kant. His views are rooted in logic and philosophic precedent and he could not have been further removed  from the crackpot profile of a practitioner of CAM so often cited by the opponents of whole person orienated methodologies in medicine.

It is a pity in these modern  days of very limited attention span, that few people have either the patience or the time for philosophy of medicine but retain the mouth for voicing highly opinionated and biased political ideology on healthcare in medicine. More can be read about the remarkable Dr Ledermann on his website, in a transcription of an interview I conducted with him here and in his obituary in  The Times in 2005.

By | 2012-10-14T13:47:30+01:00 October 14th, 2012|Current Affairs|4 Comments

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4 Comments

  1. Ruth October 18, 2012 at 11:47 pm

    Doc,

    The whole medical industry has morphed into something akin to The Tower Of Babel. Unfortunately, the patient ends up suffering the most.
    In my experience, doctors frequently find it difficult to perceive an immediate practical role for the various approaches of philosophy, e.g.,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.
    Each patient is authentic. Care pathways/protocols and associated reductionist and mechanistic approaches to care are still too basic to acknowledge the ‘intangibles’. I rarely see an evidence-based care pathway that can incorporate the complexities of co-morbidities and the much-neglected authenticity of each patient.
    ‘Personalized Medicine’ is the new term being bandied about, primarily in relation to achieving more granularity in diagnosis and choice of treatment. We are perhaps slowly moving away from the ‘widget’, towards a re-awakened recognition of true holistic individuality.
    I like Lederman’s story (and thanks for the links). For an orthodox practitioner like me, his admonition to be holistic in approach should not be taken lightly. EBM has significant limits. The certainty of the scientist must sometimes genuflect to brutal reality. Science rapidly becomes art, yet denial of this often appears to be increasing, again to the patient’s detriment. We are lost in care pathways and billing codes (in the USA, at least). Adherence to these fledgling pathways and outcome metrics are a basis for reimbursement. Some of us scream that no 2 patients are alike, e.g., a person who develops a myocardial infarction may also be a diabetic with kidney compromise. This mandates the incorporation of several ‘pathways’ and pretty soon we end up using much more judgement than evidence-based fact or guidance. The payers then find ways to punish us for not adhering to many simple guidelines. Moreover, as some folks like Goldacre point out, the body of evidence is frequently compromised, at the very least by cohort constraints on prospective trials.

    Medical philosophy belongs back in the core curriculum and the people who are ultimately best qualified to evolve the skill are doctors themselves. It should be a grassroots function. We do indeed have a form of attention deficit while caught up in the dizzying array of inputs and outputs in today’s relatively modern and dysfunctional medical environment.

    My philosophy of medicine begins with the patient and the absolute realization that true wealth is health of body, mind and spirit. While we can often work wonders with the physical carriage, woe to the caregiver who neglects the other two essential elements of the most priceless asset of all.

    I sure hope that a dialectic can evolve, versus counterproductive food fights. Big Game investigation, when fully understood, presents a unique opportunity to see how bereft of philosophy this profession really is, unless one simply focuses on patients as a substrate for business success. This latter ‘philosophy’ has trashed patient interest and it is no joke that USA medicine is ranked 37th in the world (NEJM, Jan 2010). This is perhaps only fully realized when we become patients with serious diseases, and the ‘joke’ is then on us. Trust me…I am a doctor *and* a patient.

    Ruth

    • Dr. Kaplan October 19, 2012 at 9:05 am

      Thanks Ruth,
      I could not agree more with you. esp: We are perhaps slowly moving away from the ‘widget’, towards a re-awakened recognition of true holistic individuality. We can only hope this happens. Let us hope that what you say about the incorporation ‘ the complexities of co-morbidities and the much-neglected authenticity of each patient’ actually happens in medicine. There is certainly nothing unscientific about perceiving a patient as a ‘whole’ person.

  2. David Eyles October 23, 2012 at 8:27 pm

    Brian,

    A copy of Ledermann’s book is on its way to me via Amazon (its still available second hand)so I will read it with pleasure.

    But in advance of that, I have to say that I find Kant and his Hegelian dialectics a little too close to its modern incarnation in the hands of Marx to be entirely comfortable. It seems to me that dialectics always winds up being too black-and-white, too digital (on or off), too right or wrong. It is this kind of thesis/antithesis which leads to polarity in argument and there is always a risk that wrong can win the argument simply by finding some form of fault with the opposition. And, for Heaven’s sake, look where Marx got us to: 80 years of bloody revolution, millions of people killed in its name, lives and families destroyed, peoples torn apart; and misery, suspicion and destruction embedded for perhaps generations because of it. And then look at the arguments we get into on these very pages, with the opposition taking statist, absolutist positions and then expecting to dictate their own theories upon others; and then tell us all what we shall and shall not receive in the way of medical treatment. Theirs is the triumph of theory over evidence. And by evidence I mean whether the patient in front of you or Ruth (or the sheep in front of me), actually gets better or not. I do not mean evidence derived from a mythical “average patient” with no concommitant problems or symptoms, but the one that we actually come into contact with, right before our very eyes.

    So I suggest that biological sciences (including medicine)need to look at things much more in terms of gradations of colour and tone, like the continuous spectrum of visible light. Or perhaps in terms of continuous distributions (Gaussian is one, but there are others, skewed and not so skewed). Within these shades of grey resides our patient, whose case we take as an individual – in a sample size of precisely one – and whose treatment we give and will review and vary according to the response of that individual. And their recovery, or otherwise, is also an individual response. The only part of this process which sometimes requires an “evidence base” is the intervention itself.

    And, unfortunately, the tools that we use to determine that evidence base are statistical. They depend upon probabilities which are derived from large populations or samples, and where the individuals who took part in that study or trial, have their entire experiences of that intervention summarised as a single data point. And that in turn is amalgamated with many other data points and from these, the chimera of the “average patient” is manufactured and his repsonse to the intervention is thus described. Furthermore, the individual we are actually treating is now expected to respond in the same way as the “average patient”.

    Having criticised our statistical colleagues in the way that I have, I admit that at present I cannot think of a better way of doing things. For the time being, we are stuck with things as they are. But there is no doubt at all in my mind that we need to change things to get us away from the situation which Ruth and you and many others complain about, on both sides of the Pond, even though the systems which administer clinical medicine are still quite different.

    At least part of the problem that Ruth describes so eloquently is that medical knowledge has exploded exponentially, whilst medical care has struggled to keep up. Furthermore, the bureaucrats have got hold of the idea of ‘evidence based medicine’ and have started to use the tools for their own ends. Suddenly, everything in medical management is ‘evidence based’. And so now the bureaucrats have placed their power into the realms of ‘science’ and on an equal footing with the clinicians. And that’s why Ruth has difficulty with insurance companies, and clinicians over here have to fight to keep a patient in a hospital bed because that patient needs a day or two extra care. Medical care and judgement has been hijacked by the bureaucrats.

    But you may be right. Maybe things are changing for the better. There is a sense that, whether we pay for our medical treatment via taxes or insurance, that things are just not good enough. Whether it is the incidence of hospital borne infections, iatrogenic illness, medical negligence or just the plain sense of anticlimax that patients feel when they are not able to get some miracle cure because the medical scientists themselves have elevated our expectations too high with the trumpeting and spin of their successes, somehow the patient is now better informed than they ever have been and are prepared to vote with their feet and struggle because they are determined to get better.

    And that is the point at which they will only stop when they find a clinician who will actually take them as individuals seriously; and who will listen and put their problems into a context which they can understand and deal with in their own ways.

    David.

    • Dr. Kaplan October 23, 2012 at 8:39 pm

      Fine words David. Ledermann only began with Kant. Jaspers was a far bigger influence on how he eventually practised medicine. Philosophy and Medicine is a masterpiece. Enjoy.

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