Medical Hypotheses Mdialtiypdu8s (1992) 39,63-66 oL4mgmmormpuKLld1992
Beyond Positivism: A Metaphysical Basis for Clinical Practice? J. HERMAN Department of Family Medicine, University Center for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Address for correspondence: Joseph Herman M.D., 42 Harav Uzziel Street, Bayit V’gan 96424, Jerusalem, Israel)
Abstract-Medicine does not have its own unified body of scientific knowledge. Instead, physicians who are oriented to research make sporadic incursions into the basic sciences such as genetics, biochemistry, immunology, epidemiology, physiology, pharmacology and so on. These latter, taken together, comprise biomedicine which is said to have adopted the positivist epistemology or the Cartesian/Newtonian one that regards the scientist as an uninvolved observer of nature. In effect, medical science has come to rest on a theory of knowledge which links meaning to probability and considers prediction as the scientists chief task. Like its predecessor, the probability theory of meaning rejects metaphysical speculation and remains connected to observations made, directly or indirectly, by means of the five senses. Despite some brilliant successes touching on relatively uncommon disorders, biomedicine cannot explain most day-to-day clinical acitivity. An understanding of what transpires between patient and doctor, of its diagnostic potential and therapeutic weight requires hermeneutic, or phenomenological, inquiry which brings about changes in both parties to it. Such a science, as ontological speculation has been called, cannot be deciphered by an epistemology couched in the imagery of physics and chemistry.
Introduction
areas where mensuration is possible and human individuality may be neglected. Thus, what we refer to as medical science is a composite of biochemistry, biophysics, epidemiology, immunology, genetics, pharmacology, physiology and the like. These disciplines, taken together, comprise biomedicine which has been accused, in recent years, of submission to the positivist theory of knowledge (3) or to the Cartesian/Newtonian view of the scientist as non-participant observer dating to the 17th century (4). I suggest
Medicine, charged with concern over ‘...a11the various aspects of man’s humanness’ (l), has no unified body of scientific knowledge. Stephens states categorically that ‘...there is no orthodox Flexnerian science of the mind, much less of the self, the family or the community...’ (2). Rather, the investigative activities of physicians, prestigious and academically rewarding as they are, really constitue incursions into Date received 16 February 1992 Date accepted 1 April 1992
63
64
that medical science is more up to date than either of these accusations implies and that it has come to rest, unwittingly, on a philosophical infrastructure that superseded positivism just over two generations ago. I shall call this newer epistemology the probability theory of meaning, a name used by Hans Reichenbath, one of its foremost proponents. He regarded it as maintaining ‘...the anti-metaphysical position of positivism and pragmatism without taking over the too narrow conception of meaning from which these theories suffer’ (5). Can medical science, on the threshold of the 21st century and a bare decade and a half after the promulgation of an expanded paradigm (6), allow itself to eschew metaphysical speculation? Can it live by a theory of knowledge that is couched in the imagery of the exact sciences? Should it continue to work on the assumption that human beings act rationally? Seeking answers to these questions will be the task of the ensuing inquiry. Philosophic disagreements
With respect to metaphysics, the situation is confused even among philosophers. Kant is credited with demonstrating that metaphysical speculation cannot be scientific (7) whereas Butler defines ontology, one of its main branches, as the science that ‘...comprehends the investigation of every real existence...incapable of being the direct object of consciousness, which can be deduced immediately from the possession of certain feelings of principles and faculties of the human soul’ (8). Is a subatomic particle a direct or indirect object in this sense? Is it a theoretical construct that, in the absence of a better approximation, enables us to understand why a light switch can illuminate a room? Is it real by dint of the applied consequences of theorizing about it? Is its existence ultimately confirmed by an electric shock or tracks in a cloud chamber? Furthermore, positivism and its probabilistic outgrowth differ strongly over certain basic issues despite their common attitude towards metaphysics. The former holds with meaning as absolute verifiability, thus relegating questions concerning the existence of a Deity or an afterlife to the realm of the meaningless where one may refuse to consider them. The latter believes that the truest aim of science is prediction, not the assigning of a truth-value to propositions (5). Predicting the future gives us the only rational basis possible for taking action, a process initiated in the pursuit of a purpose and presupposing a volitional decision. The statement (proposition) ‘It is raining’ is absolutely verifiable but neither its verification nor its negation is of much help in deciding whether or
MEDK!ALHYFT2THEsEs
not to cancel a picnic scheduled for the morrow. For this, according to Reichenbach, we need a probability formulation based on knowledge of meteorological trends obtaining in the region under consideration. He calls such a formulation ‘weight’ and one might express it as ‘There is a 70% likelihood that it will rain tomorrow morning’. This should have a familiar ring to physicians engaged in research! Reichenbach believed that the connection of meaning and action, an apparently natural outcome of his probability theory, was ‘...the best guaranty of its correspondence to empirical science and the intention of language in actual life’ (5). The question of what kind of science remains to be asked. What choice has medical science made?
Despite McWhinney’s charge that positivism dominates biomedical thinking today, medicine has actually opted for the probability theory of meaning. It rejects the cross-sectional and the retrospective (absolutely verifiable) in favor of the prospective (weight), thus fitting in well with Reichenbach’s contention that the former cannot serve as a basis for predicting outcome. Furthermore, its research results are formulated in terms of odds ratios, predictive values and confidence intervals, all of which indicate a healthy distaste for the absolute. Medical decision making is grounded in probability calculations as are attempts to determine cost-effectiveness and the policies they engender. The fractionation of medical science mentioned earlier and the submission of the discipline to an epistemology of the exact sciences have gained it respectability. Some of its intellectual achievements are on a plane with the greatest advances of physics and chemistry and have been equally rewarded. Unfortunately, they often seem irrelevant to the nitty-gritty of everyday clinical life and, on occasion, an elegantly defined entity displays a kind of cussedness that suggests meaning beyond a molecular derangement. The number of patients with pernicious anemia or hypothyroidism who ‘refuse’ to feel better or who find something else of which to complain after their deficiencies are corrected by flawless medical logic is quite surprising. Regarding them, if we inquire ‘...where is the defect, the dissatisfaction, the avidity, we must recognize that it may be anywhere, in the plenum of being: that it may be in their molecules, their motives or their relations with the world’ (9). Super-empirical meaning
Reichenbach concedes that language, in addition to its communicative function, has a suggestive one that
65
BEYOND F’OSITIVISM
can produce powerful emotions and lead to action not based on predictive knowledge. Propositions dealing with the existence of a Supreme Being or life beyond the grave cannot be verified or refuted scientifically but have proponents willing to sacrifice their own lives and those of others when the occasion demands. He refers to such sentences as having super-empirical meaning for their adherents who deny that the usual methods of science are the only means of determining a truth-value. He states that these propositions can always be reduced to others that are logically verifiable and serve as the basis for the same actions. To a cat worshipper’s belief that the object of his adoration is divine, Reichenbach opposes the statement: ‘The cat is an emotion-producing animal’. Both propositions, he maintains, will lead equally to our refraining from killing cats and, as a result, any surplus meaning contained in the word ‘divine’ is denied. This peculiar contention suggests someone who has spent his life observing how nuclear physicists reconstruct their inductions and has mistaken such reasoning for the totality of human behavior! Konrad Lorenz, the Nobel Prize-winning ethologist, understood that men live by surplus meaning, although his view of the Jewish dietary laws was somewhat simplistic. However, even as a parable, his assumption that Moses knew the dangers of trichinosis but chose to camouflage the injunction against eating pig as God’s will shows the difference, for action, between super-empirical meaning and its ‘equivalent’ logical reduction (10). Spengler went still further when he stated that religion, art and science are the three supreme expressions of all cultures which themselves are subject to inexorable laws of rise and decline (11). Thus, science is relative and belongs only to a certain time and we should not allow our staggering technological successes to blind us to these daunting facts.
since ’ ...there is no groove of abstraction which is adequate for the comprehension of human life’ (12). The matter is further complicated by the shading of the abstract into the concrete. Many people have a strong belief in angels; painting, sculpture and the Bible are all replete with vivid physical descriptions of them. In the mind’s eye they have all the attributes of being despite an absence of scientific proof that they exist. It is not impossible that, in the next decade or so, an enterprising biochemist will decode the molecular sequence imprinting ‘angel’ in human memory. Will the seqeunce, then, be abstract or concrete? The uniqueness and one-timeness of higher forms has been remarked (13) so that our patients are quintessentially concrete, although their life-worlds are furnished with abstracts we are bound to try and understand. Blois has posited a hierarchy of scientific activity with that at the lowest level being given entirely to mathematical formulation (14). Further up, say where family therapy is practiced, lengthy descriptions are required for reporting outcomes that cannot be quantified. McWhinney emphasizes the impossibility of vertical induction: ‘The higher cannot be derived from the lower. Biology cannot be fully explained in terms of physics, nor psychology in terms of biology. Each higher level includes the lower levels but transcends them (3).
The abstract and the concrete
more or less complex stimuli. The motions of Uranus are highly predictable, whereas those of men are not.
The probabilistic variant of positivism under discussion here also denies existence to the abstract (5). Using an isomorphism similar to the one that ‘reduced’ the super-empirical to the merely logical, Reichenbach equates The State with a series, not necessarily finite, of realities: its citizens, geographical boundaries, natural resources and so on. He admits that, in the minds of certain people, often depending on their profession, abstracta have particular reality. For physicians, diseases have a noumenal or textbook existence, no less immediate for being far removed from what a sick person experiences. We should beware of our penchant for abstracting people upward to a common denominator of disease manifestations
‘It is hard to believe that a man will refrain from a certain action which natural inclination urges him to perform only because he has realized that it involves a logical contradiction’ (10). Could one imagine a more succinct refutation of the claim that the probability theory of meaning is suitable to a unified science of medicine? According to Lorenz, the three major determinants of behavior in human society are instinct, norms developed by cultural ritualization and responsible morality (10). The former two are subject to natural selection while the latter may be regarded as a compensatory mechanism of very limited power to curb the dangers man has brought on himself with the gift of conceptual thought.
Has medicine chosen well? When a comprehensive medical science arises, consonant with the biopsychosocial model proposed by Engel (6), a new epistemology will be required. Despite the definition of action given by Reichenbach-a ptocess initiated by men in the pursuit of a purpose that pre-supposes a volitional decision and a kind of knowledge concerning future events-most human behavior is unplanned and constitutes reaction to
66 In other wordr, man> whole system of innate activities and reactions is phylogenetically so constructed, so ‘calculated’ by evolution, as to need to be complemented by cultural tradition. For instance, all the tremendous neuro-sensory apparatus of human speech is phylogenetically evolved, but so constructed that its function presupposes the existence of a culturally developed language which the it$ti has to learn (10).
The fertile concept of homeostasis, intellectual father to cybernetics and systems theory, suggests the following definition of life: A temporary suspension of the Second Law of Thermodynamics. Thus, the very act of living implies a negation of certain basic tenets of physical science and so cannot be comprehended by a theory of meaning that pretends to consonance with the language of physics and chemistry. Reichenbach’s epistemology, eminently suited to the fragmented experimentation in immunology, pharmacology and other basic sciences that is typical of today’s biomedicine, is not applicable to the bulk of clinical activity. Given our renewed awareness of the centrality of the interview to medical practice, not just as part of the diagnostic process (15) but as basic to outcome (16), we are faced with the task of ‘scientizing’ qualitative research (17). The probability theory of meaning, with its ‘reductions’ of the superempirical to the logical and of the abstract to the concrete, is not sufficient to the challenge any more than biomedicine’s reductionism was to Engel’s summons (6). Medicine is still dominated by the belief that the only valid knowledge is what may be obtained by the empirical method, the verification of hypotheses by recourse to data accessible to the five senses (3). ‘In the English-speaking tradition, empiricism is indissolubly associated with the scientific method. In the Continental tradition, other rigorous routes to scientific knowledge are recognized...’ (3). The data arrived at from these additional avenues of inquiry are about meaning and they are equally applicable to patients experiencing illness with a defined anatomic basis and to those for whom there is none. They may be subsumed under the classification of henneneutic or phenomenological investigation wherein an understanding of a person’s thoughts, feelings and sensations is achieved by progressive clarification of words and other symbols. Surely the superiempirical meaning of the probabilists comes under this heading and a physician, when talking to his patient, ignores it to both their cost. ‘When the level of the knower is not adequate to the level of the object of knowledge, the result is not a factual error, but something much more serious: an inadequate and impoverished view
MEDICAL HYpoTwEsEs
of reality’ (18). These words might have been written by Arthur Kleinman who pointed out that there is no metric in biomedical and behavioral research for the existential qualities of suffering. The thinned-out image of patients and families arising from symptom scales and survey questionnaires may be scientifically replicable but ontologically invalid (19)! This, in turn, recalls Butler’s definition of ontological study as comprehending real existences that can be ‘...deduced immediately from the possession of certain feelings...’ (8). Clinical activity, therefore, has a metaphysical base and medicine is bound to choose a relevant epistemology. The significance of hermeneutics was recognized by Plato over two millennia ago and it is still part of every artist’s trust: ‘And for the soul, if it is to know itself, it is into a soul that it must look’ (20). References 1. Dubos R. Hippocrates in modem dress. Proc Inst Med 25: 242. 1965. 2. Stephens G G. Reflections of a post-Flexnerian physician. ~172 in The Task of Medicine (K L White, ed) The Henry J. Kaiser Family Foundation, Menlo Park, 1988. 3. McWhinney I R. A Textbook of Family Medicine. Oxford University Press, New York, 1989. 4. Engel G L. How much longer must medicine’s science be bound by a seventeenth century world view? ~113 in The Task of Medicine (K L White, ed). The Henry J. Kaiser Family Foundation, Menlo Park, 1988. 5. Reichenbach H. Experience and Prediction. The University of Chicago Press, Chicago, 1961. 6. Engel G L. The need for a new medical model: A challenge for biomedicine. Science 196: 129, 1977. 7. The New Columbia Encyclopedia. Columbia University Press, New York, 1975. 8. Webster’s Twentieth Century Dictionary, 2nd ed. Collins World, USA, 1978. 9. Sacks 0. Awakenings. E P Dutton. New York, 1983. 10. Lorenz K. On Aggression. Methuen & Co Ltd. London, 1968. 11. Spengler 0. The Decline of the West. Alfred A. Knopf, New York, 1947. 12. Whitehead A N. Science and the Modem World. Cambridge University Press, Cambridge, 1926. 13. Bettelheim B. Reflections: Freud and the soul. The New Yorker 1 Mar: 53, 1982. 14. Blois M S. Medicine and the nature of vertical reasoning. N Engl J Med 318: 847, 1988. 15. Metcalfe D H H. The. Edinburgh Declaration. Fam Pratt 6: 165, 1989. 16. The Headache Study Group of the University of Western Ontario. Predictors of outcome in headache patients presenting to family physicians-a one year prospective study. Headache 26: 285, 1986. 17. Malterud K. On promises and premises in qualitative general practice research. Stand J Prim Health Care 8: 67, 1990. 18. Schumacher E E A Guide for the Perplexed. Harper and Row, New York, 1977. 19. Kleinman A. The Illness Narratives. Basic Books, New York, 1988. 20. Plato. Quoted in Seferis G. Poems. The Bodley Head, London. 1960.
Beyond Positivism: A Metaphysical Basis for Clinical Practice? J. HERMAN Department of Family Medicine, University Center for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Address for correspondence: Joseph Herman M.D., 42 Harav Uzziel Street, Bayit V’gan 96424, Jerusalem, Israel)
Abstract-Medicine does not have its own unified body of scientific knowledge. Instead, physicians who are oriented to research make sporadic incursions into the basic sciences such as genetics, biochemistry, immunology, epidemiology, physiology, pharmacology and so on. These latter, taken together, comprise biomedicine which is said to have adopted the positivist epistemology or the Cartesian/Newtonian one that regards the scientist as an uninvolved observer of nature. In effect, medical science has come to rest on a theory of knowledge which links meaning to probability and considers prediction as the scientists chief task. Like its predecessor, the probability theory of meaning rejects metaphysical speculation and remains connected to observations made, directly or indirectly, by means of the five senses. Despite some brilliant successes touching on relatively uncommon disorders, biomedicine cannot explain most day-to-day clinical acitivity. An understanding of what transpires between patient and doctor, of its diagnostic potential and therapeutic weight requires hermeneutic, or phenomenological, inquiry which brings about changes in both parties to it. Such a science, as ontological speculation has been called, cannot be deciphered by an epistemology couched in the imagery of physics and chemistry.
Introduction
areas where mensuration is possible and human individuality may be neglected. Thus, what we refer to as medical science is a composite of biochemistry, biophysics, epidemiology, immunology, genetics, pharmacology, physiology and the like. These disciplines, taken together, comprise biomedicine which has been accused, in recent years, of submission to the positivist theory of knowledge (3) or to the Cartesian/Newtonian view of the scientist as non-participant observer dating to the 17th century (4). I suggest
Medicine, charged with concern over ‘...a11the various aspects of man’s humanness’ (l), has no unified body of scientific knowledge. Stephens states categorically that ‘...there is no orthodox Flexnerian science of the mind, much less of the self, the family or the community...’ (2). Rather, the investigative activities of physicians, prestigious and academically rewarding as they are, really constitue incursions into Date received 16 February 1992 Date accepted 1 April 1992
63
64
that medical science is more up to date than either of these accusations implies and that it has come to rest, unwittingly, on a philosophical infrastructure that superseded positivism just over two generations ago. I shall call this newer epistemology the probability theory of meaning, a name used by Hans Reichenbath, one of its foremost proponents. He regarded it as maintaining ‘...the anti-metaphysical position of positivism and pragmatism without taking over the too narrow conception of meaning from which these theories suffer’ (5). Can medical science, on the threshold of the 21st century and a bare decade and a half after the promulgation of an expanded paradigm (6), allow itself to eschew metaphysical speculation? Can it live by a theory of knowledge that is couched in the imagery of the exact sciences? Should it continue to work on the assumption that human beings act rationally? Seeking answers to these questions will be the task of the ensuing inquiry. Philosophic disagreements
With respect to metaphysics, the situation is confused even among philosophers. Kant is credited with demonstrating that metaphysical speculation cannot be scientific (7) whereas Butler defines ontology, one of its main branches, as the science that ‘...comprehends the investigation of every real existence...incapable of being the direct object of consciousness, which can be deduced immediately from the possession of certain feelings of principles and faculties of the human soul’ (8). Is a subatomic particle a direct or indirect object in this sense? Is it a theoretical construct that, in the absence of a better approximation, enables us to understand why a light switch can illuminate a room? Is it real by dint of the applied consequences of theorizing about it? Is its existence ultimately confirmed by an electric shock or tracks in a cloud chamber? Furthermore, positivism and its probabilistic outgrowth differ strongly over certain basic issues despite their common attitude towards metaphysics. The former holds with meaning as absolute verifiability, thus relegating questions concerning the existence of a Deity or an afterlife to the realm of the meaningless where one may refuse to consider them. The latter believes that the truest aim of science is prediction, not the assigning of a truth-value to propositions (5). Predicting the future gives us the only rational basis possible for taking action, a process initiated in the pursuit of a purpose and presupposing a volitional decision. The statement (proposition) ‘It is raining’ is absolutely verifiable but neither its verification nor its negation is of much help in deciding whether or
MEDK!ALHYFT2THEsEs
not to cancel a picnic scheduled for the morrow. For this, according to Reichenbach, we need a probability formulation based on knowledge of meteorological trends obtaining in the region under consideration. He calls such a formulation ‘weight’ and one might express it as ‘There is a 70% likelihood that it will rain tomorrow morning’. This should have a familiar ring to physicians engaged in research! Reichenbach believed that the connection of meaning and action, an apparently natural outcome of his probability theory, was ‘...the best guaranty of its correspondence to empirical science and the intention of language in actual life’ (5). The question of what kind of science remains to be asked. What choice has medical science made?
Despite McWhinney’s charge that positivism dominates biomedical thinking today, medicine has actually opted for the probability theory of meaning. It rejects the cross-sectional and the retrospective (absolutely verifiable) in favor of the prospective (weight), thus fitting in well with Reichenbach’s contention that the former cannot serve as a basis for predicting outcome. Furthermore, its research results are formulated in terms of odds ratios, predictive values and confidence intervals, all of which indicate a healthy distaste for the absolute. Medical decision making is grounded in probability calculations as are attempts to determine cost-effectiveness and the policies they engender. The fractionation of medical science mentioned earlier and the submission of the discipline to an epistemology of the exact sciences have gained it respectability. Some of its intellectual achievements are on a plane with the greatest advances of physics and chemistry and have been equally rewarded. Unfortunately, they often seem irrelevant to the nitty-gritty of everyday clinical life and, on occasion, an elegantly defined entity displays a kind of cussedness that suggests meaning beyond a molecular derangement. The number of patients with pernicious anemia or hypothyroidism who ‘refuse’ to feel better or who find something else of which to complain after their deficiencies are corrected by flawless medical logic is quite surprising. Regarding them, if we inquire ‘...where is the defect, the dissatisfaction, the avidity, we must recognize that it may be anywhere, in the plenum of being: that it may be in their molecules, their motives or their relations with the world’ (9). Super-empirical meaning
Reichenbach concedes that language, in addition to its communicative function, has a suggestive one that
65
BEYOND F’OSITIVISM
can produce powerful emotions and lead to action not based on predictive knowledge. Propositions dealing with the existence of a Supreme Being or life beyond the grave cannot be verified or refuted scientifically but have proponents willing to sacrifice their own lives and those of others when the occasion demands. He refers to such sentences as having super-empirical meaning for their adherents who deny that the usual methods of science are the only means of determining a truth-value. He states that these propositions can always be reduced to others that are logically verifiable and serve as the basis for the same actions. To a cat worshipper’s belief that the object of his adoration is divine, Reichenbach opposes the statement: ‘The cat is an emotion-producing animal’. Both propositions, he maintains, will lead equally to our refraining from killing cats and, as a result, any surplus meaning contained in the word ‘divine’ is denied. This peculiar contention suggests someone who has spent his life observing how nuclear physicists reconstruct their inductions and has mistaken such reasoning for the totality of human behavior! Konrad Lorenz, the Nobel Prize-winning ethologist, understood that men live by surplus meaning, although his view of the Jewish dietary laws was somewhat simplistic. However, even as a parable, his assumption that Moses knew the dangers of trichinosis but chose to camouflage the injunction against eating pig as God’s will shows the difference, for action, between super-empirical meaning and its ‘equivalent’ logical reduction (10). Spengler went still further when he stated that religion, art and science are the three supreme expressions of all cultures which themselves are subject to inexorable laws of rise and decline (11). Thus, science is relative and belongs only to a certain time and we should not allow our staggering technological successes to blind us to these daunting facts.
since ’ ...there is no groove of abstraction which is adequate for the comprehension of human life’ (12). The matter is further complicated by the shading of the abstract into the concrete. Many people have a strong belief in angels; painting, sculpture and the Bible are all replete with vivid physical descriptions of them. In the mind’s eye they have all the attributes of being despite an absence of scientific proof that they exist. It is not impossible that, in the next decade or so, an enterprising biochemist will decode the molecular sequence imprinting ‘angel’ in human memory. Will the seqeunce, then, be abstract or concrete? The uniqueness and one-timeness of higher forms has been remarked (13) so that our patients are quintessentially concrete, although their life-worlds are furnished with abstracts we are bound to try and understand. Blois has posited a hierarchy of scientific activity with that at the lowest level being given entirely to mathematical formulation (14). Further up, say where family therapy is practiced, lengthy descriptions are required for reporting outcomes that cannot be quantified. McWhinney emphasizes the impossibility of vertical induction: ‘The higher cannot be derived from the lower. Biology cannot be fully explained in terms of physics, nor psychology in terms of biology. Each higher level includes the lower levels but transcends them (3).
The abstract and the concrete
more or less complex stimuli. The motions of Uranus are highly predictable, whereas those of men are not.
The probabilistic variant of positivism under discussion here also denies existence to the abstract (5). Using an isomorphism similar to the one that ‘reduced’ the super-empirical to the merely logical, Reichenbach equates The State with a series, not necessarily finite, of realities: its citizens, geographical boundaries, natural resources and so on. He admits that, in the minds of certain people, often depending on their profession, abstracta have particular reality. For physicians, diseases have a noumenal or textbook existence, no less immediate for being far removed from what a sick person experiences. We should beware of our penchant for abstracting people upward to a common denominator of disease manifestations
‘It is hard to believe that a man will refrain from a certain action which natural inclination urges him to perform only because he has realized that it involves a logical contradiction’ (10). Could one imagine a more succinct refutation of the claim that the probability theory of meaning is suitable to a unified science of medicine? According to Lorenz, the three major determinants of behavior in human society are instinct, norms developed by cultural ritualization and responsible morality (10). The former two are subject to natural selection while the latter may be regarded as a compensatory mechanism of very limited power to curb the dangers man has brought on himself with the gift of conceptual thought.
Has medicine chosen well? When a comprehensive medical science arises, consonant with the biopsychosocial model proposed by Engel (6), a new epistemology will be required. Despite the definition of action given by Reichenbach-a ptocess initiated by men in the pursuit of a purpose that pre-supposes a volitional decision and a kind of knowledge concerning future events-most human behavior is unplanned and constitutes reaction to
66 In other wordr, man> whole system of innate activities and reactions is phylogenetically so constructed, so ‘calculated’ by evolution, as to need to be complemented by cultural tradition. For instance, all the tremendous neuro-sensory apparatus of human speech is phylogenetically evolved, but so constructed that its function presupposes the existence of a culturally developed language which the it$ti has to learn (10).
The fertile concept of homeostasis, intellectual father to cybernetics and systems theory, suggests the following definition of life: A temporary suspension of the Second Law of Thermodynamics. Thus, the very act of living implies a negation of certain basic tenets of physical science and so cannot be comprehended by a theory of meaning that pretends to consonance with the language of physics and chemistry. Reichenbach’s epistemology, eminently suited to the fragmented experimentation in immunology, pharmacology and other basic sciences that is typical of today’s biomedicine, is not applicable to the bulk of clinical activity. Given our renewed awareness of the centrality of the interview to medical practice, not just as part of the diagnostic process (15) but as basic to outcome (16), we are faced with the task of ‘scientizing’ qualitative research (17). The probability theory of meaning, with its ‘reductions’ of the superempirical to the logical and of the abstract to the concrete, is not sufficient to the challenge any more than biomedicine’s reductionism was to Engel’s summons (6). Medicine is still dominated by the belief that the only valid knowledge is what may be obtained by the empirical method, the verification of hypotheses by recourse to data accessible to the five senses (3). ‘In the English-speaking tradition, empiricism is indissolubly associated with the scientific method. In the Continental tradition, other rigorous routes to scientific knowledge are recognized...’ (3). The data arrived at from these additional avenues of inquiry are about meaning and they are equally applicable to patients experiencing illness with a defined anatomic basis and to those for whom there is none. They may be subsumed under the classification of henneneutic or phenomenological investigation wherein an understanding of a person’s thoughts, feelings and sensations is achieved by progressive clarification of words and other symbols. Surely the superiempirical meaning of the probabilists comes under this heading and a physician, when talking to his patient, ignores it to both their cost. ‘When the level of the knower is not adequate to the level of the object of knowledge, the result is not a factual error, but something much more serious: an inadequate and impoverished view
MEDICAL HYpoTwEsEs
of reality’ (18). These words might have been written by Arthur Kleinman who pointed out that there is no metric in biomedical and behavioral research for the existential qualities of suffering. The thinned-out image of patients and families arising from symptom scales and survey questionnaires may be scientifically replicable but ontologically invalid (19)! This, in turn, recalls Butler’s definition of ontological study as comprehending real existences that can be ‘...deduced immediately from the possession of certain feelings...’ (8). Clinical activity, therefore, has a metaphysical base and medicine is bound to choose a relevant epistemology. The significance of hermeneutics was recognized by Plato over two millennia ago and it is still part of every artist’s trust: ‘And for the soul, if it is to know itself, it is into a soul that it must look’ (20). References 1. Dubos R. Hippocrates in modem dress. Proc Inst Med 25: 242. 1965. 2. Stephens G G. Reflections of a post-Flexnerian physician. ~172 in The Task of Medicine (K L White, ed) The Henry J. Kaiser Family Foundation, Menlo Park, 1988. 3. McWhinney I R. A Textbook of Family Medicine. Oxford University Press, New York, 1989. 4. Engel G L. How much longer must medicine’s science be bound by a seventeenth century world view? ~113 in The Task of Medicine (K L White, ed). The Henry J. Kaiser Family Foundation, Menlo Park, 1988. 5. Reichenbach H. Experience and Prediction. The University of Chicago Press, Chicago, 1961. 6. Engel G L. The need for a new medical model: A challenge for biomedicine. Science 196: 129, 1977. 7. The New Columbia Encyclopedia. Columbia University Press, New York, 1975. 8. Webster’s Twentieth Century Dictionary, 2nd ed. Collins World, USA, 1978. 9. Sacks 0. Awakenings. E P Dutton. New York, 1983. 10. Lorenz K. On Aggression. Methuen & Co Ltd. London, 1968. 11. Spengler 0. The Decline of the West. Alfred A. Knopf, New York, 1947. 12. Whitehead A N. Science and the Modem World. Cambridge University Press, Cambridge, 1926. 13. Bettelheim B. Reflections: Freud and the soul. The New Yorker 1 Mar: 53, 1982. 14. Blois M S. Medicine and the nature of vertical reasoning. N Engl J Med 318: 847, 1988. 15. Metcalfe D H H. The. Edinburgh Declaration. Fam Pratt 6: 165, 1989. 16. The Headache Study Group of the University of Western Ontario. Predictors of outcome in headache patients presenting to family physicians-a one year prospective study. Headache 26: 285, 1986. 17. Malterud K. On promises and premises in qualitative general practice research. Stand J Prim Health Care 8: 67, 1990. 18. Schumacher E E A Guide for the Perplexed. Harper and Row, New York, 1977. 19. Kleinman A. The Illness Narratives. Basic Books, New York, 1988. 20. Plato. Quoted in Seferis G. Poems. The Bodley Head, London. 1960.
