Kazem Sadegh-Zadeh     Philosophy of Medicine     HAPM



Philosophy of Medicine

What is it?

Philosophizing about medicine is not new. Consider the following view on medical epistemology:

"We say that the art of medicine has taken its origin from experience, and not from indication. By 'experience', we mean the knowledge of something which is based on one's own perception, by 'indication', the knowledge which is based on rational consequence. For perception leads us to experience, whereas reason leads the dogmatics to indication".

This empiricist position was not cited from a contemporary philosophy of medicine publication, but from a book by the great Roman physician of Greek origin, Galen of Pergamon ([1], p. 24), who lived in the second century AD (129-199 or 200? 216? 217?).

Great physicians in the history of medicine have been philosophers of medicine at the same time simply because there are no sharp boundaries between thinking in medicine (object level) and thinking about medicine (meta-level). However, most physicians, especially when they are medical scientists at universities, do not like the term "philosophy". They associate it with speculation and rumination, and consequently avoid explicit philosophical inquiries into the field of medicine, even though a considerable part of their daily work in fact consists of such inquiries. For example, in conversations with her colleagues or in her publications, the chief neurologist at a university hospital may argue that her hypothesis or assertion on the genesis of multiple sclerosis is empirically better justified (supported, confirmed) than the alternative hypothesis of a competing research group. "My hypothesis is statistically significant at the 1% level", she may add. All that sounds well, but all that is medical epistemology, and thus, philosophy of medicine.

What is, and what is not, philosophy of medicine? Where would you draw the line of demarcation (i) between philosophy of medicine and medicine proper, and (ii) between philosophy of medicine and medical belles lettres? This question is meant to stimulate discussion on the nature and methodology of the philosophy of medicine. Some thoughts that come to my mind at this juncture will be sketched below.

Physician performance and physician attitude toward patients have been under increasing public criticism for many years. Apart from moral problems in dealing with patients and scientific issues, clinical practice is contaminated by misdiagnoses and wrong treatments. However, the individual physician lacks both the capability of, and interest in, reflecting about the causes and conditions of this failure. Were a physician to try to address the failure and identify its origins, she would be involved immediately in a host of problems which are not medical in nature like, for example, the questions "what is the white blood cell count of this patient?" and "what are the genuine causes of peptic ulcer disease?". They will turn out problems that transcend medicine qua medicine, and are among one or more of the following and similar categories:

  1. Semantic problems: When I make a diagnosis, what do I understand by the term "diagnosis"? Why do some of my diagnoses turn out misdiagnoses? What is a misdiagnosis? What syntax does a diagnosis have? What does it say? It is usually assumed that it ascribes to the patient a disease or multiple diseases. Is this assumption true? It doesn’t seem to be true, as I know diagnoses which deviate from that assumption, for example, when I diagnose a patient as having elevated blood cholesterol level. Increased blood cholesterol is not a disease, but a symptom. What is the difference between a symptom and a disease? What is a "disease" at all? How can I accurately differentiate between two or more different diseases, given that they are ill-defined and vague entities? Who is responsible for the vagueness of medical language: Physicians, medical scientists, or other people? Is it possible to overcome this vagueness?
  2. Methodological problems: When making a diagnosis or a therapeutic decision, do I have an explicit method, or a collection of such methods, which guide me from symptom to diagnosis, or from my knowledge about the patient to a therapeutic decision? Actually, I don’t. I must admit that I attain my diagnostic-therapeutic judgments intuitively. Why didn't my teachers teach me explicit methods of clinical judgment? Do such methods exist at all? If they do, are they algorithms and flowcharts made by some people, or are they methods of reasoning, and thus, logic?
  3. Logical problems: If a method of clinical reasoning is in fact a particular logical procedure, what does it exactly look like? To understand and use it, do I need to understand something about logic? But my academic teachers didn’t teach me logic. Why not? What type of logic would they have to teach? I have once heared that there are many different logics. I don't understand that. How can there be different logics? Logic is logic. 2 + 2 = 4, isn’t it? What are distinct logics dealing with individually? Which one of them can, or should, I use as a method of clinical reasoning? Can I trust any logic when I make clinical judgments? Is logic not man-made and may thus be fallible as well?
  4. Epistemological problems: But the fallibility of my clinical judgments may not only be due to the logic and method of reasoning I may use in my clinical decision-making. Maybe there are also additional pitfalls. For example, the piece of medical knowledge I employ in interpreting the patient’s symptoms and signs, may not be true and only mislead me. Can medical knowledge, as general scientific knowledge, be true? I have heared that it cannot be because it talks about all objects of a domain, for example, about all diabetics, whereas nobody has seen, or will ever be able to see, all of them to learn the truth about all of them that the statement asserts. So, medical knowledge will remain a mere complex of uncertain assertions, say hypotheses. But medical scientists who offer us these hypotheses could at least tell us how certain or uncertain their hypotheses are, that is, they might attach a "degree of certainty" to each of their hypotheses to enable us to guess or even calculate how certain or uncertain our diagnoses are we make using them. I have never seen a medical hypothesis that carries such a degree of certainty with itself. Is such metaknowledge not attainable? Also the patient data I use, for example, laboratory data about her blood cholesterol level and her blood sugar level, may turn out wrong because the laboratory technician has erred or the laboratory device did not function accurately. All in all, it seems I am making my clinical judgments in the dark. Is it a surprise that they are partially or mostly inaccurate?

There are of course many more problems our example physician, or physician philosopher, will encounter the more deeply she delves. Only a few simple linguistic, methodological, logical, and epistemological problems were mentioned above. All of these and related problems are not medical problems, but either metamedical ones that concern the science and practice of medicine as it is; or protomedical ones that concern the foundations of medical science and practice prior to their existence, e.g., "what is disease?", "what is illness?", etc. The entire category of such proto- and metamedical problems may be referred to as philosophical problems of medicine. Philosophy of medicine is the analysis of these problems.

[1] Galen. Three Treatises on the Nature of Science: On the Sects for Beginners, An Outline of Empiricism, On Medical Experience. Translated by Walzer R, and Frede M. Indianapolis: Hackett Publishing Company, 1985.