Clinical Practice and Medical Science: The Doctors’ Dilemma
T standing
he spectacular advances in our molecular underof health and disease began at the turn of the century when Jacques Loeb [l] gave an unambiguous rebuttal of contemporary vitalism. “We [shall] attempt to put science beyond the possibility of mysticism. . , , Biology will be scientific only to the extent that it succeeds in reducing life phenomena to quantitative laws.” The mystery of life was to become the chemistry of life. The impetus for this revolution in 26th century medicine was Loeb’s catalytic belief that the direction of scientific research should be reductionist. This quest, this burrowing for the essential elements of scientific reality, had not been man’s original approach to the study of nature. Homer, for instance, did not think of man as possessing an essence. In the “Iliad,” Achilles cannot transcend his reputation and possessions; he is synonymous with them. Nevertheless, the roots of the reductionist approach are Greek; they originate in the thought of a sixth century Ionian philosopher, Thales. According to Aristotle, Thales was the earliest to search out the first principle (arch&) of all things, and he opted for water. “All is water” is the one eerie fragment that remains of his writings. Today, particle physicists no longer shape their theories in Thales’ paradigm, As the number of “elementary” particles of the universe increased logarithmically, their elementarity was called into question. The simple notion that there is some elementary particle from which all complex systems are derived has been replaced by a less atomistic and more dynamic metaphysic: “all particles are considered similar in being possible states in which energy can ‘condense’ ” [z]. In sharp distinction from particle physicists, medical scientists have not abandoned the ancient paradigm of Thales. Indeed, there has been such rapid and farreaching success in the biochemical analysis and treatment of disease that the reductionist approach has never been more strongly espoused. It is with good reason that Sir Peter Medawar [3] argued: “Reductive analysis is the most successful explanatory technique that has ever been used in science.” Certainly Jacques Monod [4] accepted and magnificently exploited the
10
January 1979 The American Journal of Medicine
power of reductionism, and we must agree that: “To the extent that all the structures and performances of organisms result from the structures and activities of the proteins composing them, one must regard the total organism as the ultimate epigenetic expression of the genetic message itself.” Nevertheless, one might be excused for wondering if biologists have really uncovered the arche of life. Can the behavior of living creatures and their complex societal interactions be replaced, at least in principle, by complicated talk about nucleic acids? Has Thales’ aphorism “All is water” now become “All is DNA?” It is clearly foolish to deny the vital importance of the reductionist approach for understanding health and disease; indeed, the growth of 20th century medicine has been a reflection of the growth of physiology and biochemistry. Paracelsus [5] was wrong to proclaim that “the true ground of medicine is love,” but we might be equally mistaken to base it solely on chemistry. People, not chemicals, get sick, and people as well as chemicals are needed to restore health. Admittedly, there is a certain sense in which people are chemicals; there is no ghost in the machine. But a chemical analysis of Homo sapiens does not depict a human being, and a chemist is not a physician. We can generalize about nature at different levels; we can investigate the human organism with, as it were, different powers of magnification. At each level of analysis different features appear prominent. The reductionist approach restricts the scientific description of nature to a few fundamental levels; unfortunately, its success may have blinded some to its narrowness. There is no compelling reason for restricting scientific analysis to any level or group of levels. Whitehead [6], a mathematician and physicist who continued generalizing until he reached the stage of speculative philosophy, wrote: “Each phase of generalization exhibits its own peculiar simplicities which stand out at Just that stage and at no other stage. There are simplicities about a bar of steel that are obscured if we refuse to abstract from the individual molecules; and there are simplicities concerning the behavior of men that are obscured if we refuse to abstract from the in-
Volume 66
MEDICINE.
dividual peculiarities of particular specimens.” Investigation of man at the chemical level may disclose biochemical correlates of human behavior, yet these biochemical events could never be correlated without observation of the behavioral events themselves, Some of the first to appreciate the limits of the reductionist approach were the romantic poets. As is the poet’s wont, they overstated their case-science is surely not, as Poe [7] thought, a “vulture whose wings are dull realities.” Nevertheless, the reaction of these poets to the absolute claims of reductionist science is justified. For example, if the beauty of a rainbow is not captured in a quantitative report of the relations between water molecules and electromagnetic radiation, then the rainbow has not been adequately described. My point is not that the report is false, but that it is incomplete; as Emerson [8] put it, “The reality is more excellent than the report.” The reports of reductionist science are manageable abstractions removed from the textured fabric of experience: the world is not what we report, but what we live through. There is more to being human than is captured in the nets of reductionist science: man is more than a jumble of chemical compounds. Human health and disease are features of the world which are not fully revealed at the level of chemistry; their nature can only be completely understood at more complex levels of organization. Just as the rainbow transcends its physical description, so health encompasses a never-ending range of chemical states and performances of the body. Health is difficult, perhaps impossible, to define with rigor. This difficulty has encouraged some medical scientists to withdraw into areas in which rigorous definition is more easily articulated and experimentally evaluated: they remain content with a purely chemical account of health. The genetically determined limits of man’s homeostatic mechanisms impose necessary constraints, but they do not produce health itself. Health, in this expanded sense, is essentially beyond the calculus of certainty. It is more difficult to make a positive description; such descriptions will inevitably be personal and reflect one’s concept of individual contentment. The use of psychoanalysis to achieve contentment in this expanded definition of health has recently, and properly, come under sharp attack for not being falsifinble. Its theoretic framework can generate facile explanations for the whole spectrum of human behavior, including rejection of the theory itself. Freud’s theories are indeed unfalsifiable, but interestingly this alone does not prove them wrong, it only proves them unscientific if we accept that all those statements which we commonly accept as scientific are falsifiable. To falsify the statement (which we believe to be scientific) “Some deformed children are the offspring of mothers who took thalidomide while pregnant,” we would have to prove the truth of its negation, namely, “No deformed children are the offspring . . .” But this is a universal
January
SCIENCE
AND
SOCIETY
statement, and no Popperian antiinductivist would think it possible to prove the truth of a universal statement. Therefore, if falsifiability is the criterion of demarcation of science from metaphysics then the statement “Some deformed children are the offspring. . .” is metaphysical. Medawar [9] was surely pointing us in the right direction when he tempered the Popperian belief that falsifiability is the sole criterion of science: “Theories are repaired more often than they are refuted.” Thus, the unreliability of Freud’s theories is not quite as damning as has been thought; he was, however, unwise to shape them in a reductionist mold. Anachronistically, we could say that he was wrong to search out the DNA correlate of the total person. Under the spell of the reductionist approach which puts an essence behind every event, and a doer behind every deed, Freud created his id, ego and superego as the essential agents behind the flux of human behavior. But Freud’s essences are not, like DNA, quantifiable; they are merely convenient fictions for the expression of his comprehensive theory of the total person. The Theory of Evolution is another example of a descriptive theory which depicts reality at a very general level; consequently, it is difficult to imagine an event that would falsify the theory. Our acceptance of the Theory of Evolution does not mean we have also to accept Freud’s psychoanalytic theories, for there are criteria other than falsifiability for judging the merits of these very general theories. Such theories are judged both by their logical coherence and their compatibility with the metaphysic embedded in contemporary science. We cannot say whether the reductionist or holistic approach is more important to medical practice. Indeed, this is the wrong question. We can only say with respect to a particular disease, and, perhaps more crucially, to a particular person, that one approach or the other is relatively more important. The recent success in the treatment of many people with manic depression with lithium shows that the illness which we label “manic depression” can be treated successfully by approaching the disease at the chemical level alone. However, we should be wary of thinking that theories of the total person will always be replaced by biochemical reductionism: [when one asteroid became Uranus all asteroids did not cease to exist]. Nevertheless, the success of lithium treatment in manic depression provides additional evidence of the power of the biochemical and reductionist approach to demythologize mental illness The evident and continuing success of reductionism must not foreclose a holistic approach to our patients. Fear that medicine will be “dehumanized” or that sympathetic doctors will be replaced by the calculus of computers and chemistry is wholly unjustified. A better understanding of health and disease requires that we attend to individual persons, to families and to society
1979
The American Journal of Medicine
Volume
66
11
MEDICINE,
SCIENCE
AND
SOCIETY
itself, as well as to the complex biology of mankind about which we are still so woefully ignorant. For this ignorance there is at present no better cure than a vigorous reductionist science which remains humanely sensitive to the evolving synergistic relations of man and society. ALEXANDER
G. BEARN, M.D. Editor-in-Chief
ACKNOWLEDGMENT
I am grateful to G.C.F.B. for drawing my attention to the Pre-Socratic roots of reductionism and for much valuable discussion during the development of this essay.
12
January 1979
The American Journal of Medicine
REFERENCES 1. Loch J: The Organism as a Whole from a Physiochemical Viewpoint, New York, G. P. Putnam, 1916. p 11. 2. Livingston MS: Particle Physics, New York, McGraw-Hill. 1968, p 84. 3. Medawar PB, Medawar JS: The Life Science. New York, Harper & Row, 1977, p 166. 4. Monod J: Chance and Necessity. New York, Vintage Books, 1972, p 109. 5. Rachtcr HM: Paracelsus: Magic into Science. New York, Collier Books, 1961, p 152. 6. Whitehead AN: Process and Reality. New York, Harper Torchbooks, 1960, p 25. 7. Pot EA: “Sonnet-To Science.” A Book of Science Verse, (Eastwood W. cd] London, Macmillan & Co. Ltd., 1961, p 130. 8. Emerson RW: The Complete Essays and other Writings of Ralph Waldo Emerson, New York, Random House. 1950, p 4il. 9. Medawar PB: Induction and Intuition in Scientific Thought. Philadelphia. American Philosophical Society, 1969. p 30.
Volume 66
T standing
he spectacular advances in our molecular underof health and disease began at the turn of the century when Jacques Loeb [l] gave an unambiguous rebuttal of contemporary vitalism. “We [shall] attempt to put science beyond the possibility of mysticism. . , , Biology will be scientific only to the extent that it succeeds in reducing life phenomena to quantitative laws.” The mystery of life was to become the chemistry of life. The impetus for this revolution in 26th century medicine was Loeb’s catalytic belief that the direction of scientific research should be reductionist. This quest, this burrowing for the essential elements of scientific reality, had not been man’s original approach to the study of nature. Homer, for instance, did not think of man as possessing an essence. In the “Iliad,” Achilles cannot transcend his reputation and possessions; he is synonymous with them. Nevertheless, the roots of the reductionist approach are Greek; they originate in the thought of a sixth century Ionian philosopher, Thales. According to Aristotle, Thales was the earliest to search out the first principle (arch&) of all things, and he opted for water. “All is water” is the one eerie fragment that remains of his writings. Today, particle physicists no longer shape their theories in Thales’ paradigm, As the number of “elementary” particles of the universe increased logarithmically, their elementarity was called into question. The simple notion that there is some elementary particle from which all complex systems are derived has been replaced by a less atomistic and more dynamic metaphysic: “all particles are considered similar in being possible states in which energy can ‘condense’ ” [z]. In sharp distinction from particle physicists, medical scientists have not abandoned the ancient paradigm of Thales. Indeed, there has been such rapid and farreaching success in the biochemical analysis and treatment of disease that the reductionist approach has never been more strongly espoused. It is with good reason that Sir Peter Medawar [3] argued: “Reductive analysis is the most successful explanatory technique that has ever been used in science.” Certainly Jacques Monod [4] accepted and magnificently exploited the
10
January 1979 The American Journal of Medicine
power of reductionism, and we must agree that: “To the extent that all the structures and performances of organisms result from the structures and activities of the proteins composing them, one must regard the total organism as the ultimate epigenetic expression of the genetic message itself.” Nevertheless, one might be excused for wondering if biologists have really uncovered the arche of life. Can the behavior of living creatures and their complex societal interactions be replaced, at least in principle, by complicated talk about nucleic acids? Has Thales’ aphorism “All is water” now become “All is DNA?” It is clearly foolish to deny the vital importance of the reductionist approach for understanding health and disease; indeed, the growth of 20th century medicine has been a reflection of the growth of physiology and biochemistry. Paracelsus [5] was wrong to proclaim that “the true ground of medicine is love,” but we might be equally mistaken to base it solely on chemistry. People, not chemicals, get sick, and people as well as chemicals are needed to restore health. Admittedly, there is a certain sense in which people are chemicals; there is no ghost in the machine. But a chemical analysis of Homo sapiens does not depict a human being, and a chemist is not a physician. We can generalize about nature at different levels; we can investigate the human organism with, as it were, different powers of magnification. At each level of analysis different features appear prominent. The reductionist approach restricts the scientific description of nature to a few fundamental levels; unfortunately, its success may have blinded some to its narrowness. There is no compelling reason for restricting scientific analysis to any level or group of levels. Whitehead [6], a mathematician and physicist who continued generalizing until he reached the stage of speculative philosophy, wrote: “Each phase of generalization exhibits its own peculiar simplicities which stand out at Just that stage and at no other stage. There are simplicities about a bar of steel that are obscured if we refuse to abstract from the individual molecules; and there are simplicities concerning the behavior of men that are obscured if we refuse to abstract from the in-
Volume 66
MEDICINE.
dividual peculiarities of particular specimens.” Investigation of man at the chemical level may disclose biochemical correlates of human behavior, yet these biochemical events could never be correlated without observation of the behavioral events themselves, Some of the first to appreciate the limits of the reductionist approach were the romantic poets. As is the poet’s wont, they overstated their case-science is surely not, as Poe [7] thought, a “vulture whose wings are dull realities.” Nevertheless, the reaction of these poets to the absolute claims of reductionist science is justified. For example, if the beauty of a rainbow is not captured in a quantitative report of the relations between water molecules and electromagnetic radiation, then the rainbow has not been adequately described. My point is not that the report is false, but that it is incomplete; as Emerson [8] put it, “The reality is more excellent than the report.” The reports of reductionist science are manageable abstractions removed from the textured fabric of experience: the world is not what we report, but what we live through. There is more to being human than is captured in the nets of reductionist science: man is more than a jumble of chemical compounds. Human health and disease are features of the world which are not fully revealed at the level of chemistry; their nature can only be completely understood at more complex levels of organization. Just as the rainbow transcends its physical description, so health encompasses a never-ending range of chemical states and performances of the body. Health is difficult, perhaps impossible, to define with rigor. This difficulty has encouraged some medical scientists to withdraw into areas in which rigorous definition is more easily articulated and experimentally evaluated: they remain content with a purely chemical account of health. The genetically determined limits of man’s homeostatic mechanisms impose necessary constraints, but they do not produce health itself. Health, in this expanded sense, is essentially beyond the calculus of certainty. It is more difficult to make a positive description; such descriptions will inevitably be personal and reflect one’s concept of individual contentment. The use of psychoanalysis to achieve contentment in this expanded definition of health has recently, and properly, come under sharp attack for not being falsifinble. Its theoretic framework can generate facile explanations for the whole spectrum of human behavior, including rejection of the theory itself. Freud’s theories are indeed unfalsifiable, but interestingly this alone does not prove them wrong, it only proves them unscientific if we accept that all those statements which we commonly accept as scientific are falsifiable. To falsify the statement (which we believe to be scientific) “Some deformed children are the offspring of mothers who took thalidomide while pregnant,” we would have to prove the truth of its negation, namely, “No deformed children are the offspring . . .” But this is a universal
January
SCIENCE
AND
SOCIETY
statement, and no Popperian antiinductivist would think it possible to prove the truth of a universal statement. Therefore, if falsifiability is the criterion of demarcation of science from metaphysics then the statement “Some deformed children are the offspring. . .” is metaphysical. Medawar [9] was surely pointing us in the right direction when he tempered the Popperian belief that falsifiability is the sole criterion of science: “Theories are repaired more often than they are refuted.” Thus, the unreliability of Freud’s theories is not quite as damning as has been thought; he was, however, unwise to shape them in a reductionist mold. Anachronistically, we could say that he was wrong to search out the DNA correlate of the total person. Under the spell of the reductionist approach which puts an essence behind every event, and a doer behind every deed, Freud created his id, ego and superego as the essential agents behind the flux of human behavior. But Freud’s essences are not, like DNA, quantifiable; they are merely convenient fictions for the expression of his comprehensive theory of the total person. The Theory of Evolution is another example of a descriptive theory which depicts reality at a very general level; consequently, it is difficult to imagine an event that would falsify the theory. Our acceptance of the Theory of Evolution does not mean we have also to accept Freud’s psychoanalytic theories, for there are criteria other than falsifiability for judging the merits of these very general theories. Such theories are judged both by their logical coherence and their compatibility with the metaphysic embedded in contemporary science. We cannot say whether the reductionist or holistic approach is more important to medical practice. Indeed, this is the wrong question. We can only say with respect to a particular disease, and, perhaps more crucially, to a particular person, that one approach or the other is relatively more important. The recent success in the treatment of many people with manic depression with lithium shows that the illness which we label “manic depression” can be treated successfully by approaching the disease at the chemical level alone. However, we should be wary of thinking that theories of the total person will always be replaced by biochemical reductionism: [when one asteroid became Uranus all asteroids did not cease to exist]. Nevertheless, the success of lithium treatment in manic depression provides additional evidence of the power of the biochemical and reductionist approach to demythologize mental illness The evident and continuing success of reductionism must not foreclose a holistic approach to our patients. Fear that medicine will be “dehumanized” or that sympathetic doctors will be replaced by the calculus of computers and chemistry is wholly unjustified. A better understanding of health and disease requires that we attend to individual persons, to families and to society
1979
The American Journal of Medicine
Volume
66
11
MEDICINE,
SCIENCE
AND
SOCIETY
itself, as well as to the complex biology of mankind about which we are still so woefully ignorant. For this ignorance there is at present no better cure than a vigorous reductionist science which remains humanely sensitive to the evolving synergistic relations of man and society. ALEXANDER
G. BEARN, M.D. Editor-in-Chief
ACKNOWLEDGMENT
I am grateful to G.C.F.B. for drawing my attention to the Pre-Socratic roots of reductionism and for much valuable discussion during the development of this essay.
12
January 1979
The American Journal of Medicine
REFERENCES 1. Loch J: The Organism as a Whole from a Physiochemical Viewpoint, New York, G. P. Putnam, 1916. p 11. 2. Livingston MS: Particle Physics, New York, McGraw-Hill. 1968, p 84. 3. Medawar PB, Medawar JS: The Life Science. New York, Harper & Row, 1977, p 166. 4. Monod J: Chance and Necessity. New York, Vintage Books, 1972, p 109. 5. Rachtcr HM: Paracelsus: Magic into Science. New York, Collier Books, 1961, p 152. 6. Whitehead AN: Process and Reality. New York, Harper Torchbooks, 1960, p 25. 7. Pot EA: “Sonnet-To Science.” A Book of Science Verse, (Eastwood W. cd] London, Macmillan & Co. Ltd., 1961, p 130. 8. Emerson RW: The Complete Essays and other Writings of Ralph Waldo Emerson, New York, Random House. 1950, p 4il. 9. Medawar PB: Induction and Intuition in Scientific Thought. Philadelphia. American Philosophical Society, 1969. p 30.
Volume 66
