Why Science: A Rejoinder DANIEL L. CRESON, M.D.,
PH.D.*
I Forstrom's opening sentence suggests that his argument is directed at the "status" of clinical medicine as an occupation. His reference to Braithwaite lists generally recognized scientific disciplines, and Forstrom argues that medicine belongs here. He also offers criticism of Kuhn for including medicine along with calendar making and metallurgy as examples of "established crafts" (p. 8). Yet, Forstrom's comparisons of medicine with recognized scientific disciplines and his criticisms of Kuhn are insufficient for his purpose. A revision of occupational taxonomy such as he proposes must address the * Associate professor and associate chairman for academic affairs, University of Texas Medical Branch, Department of Psychiatry and Behavioral Sciences, Galveston, Texas. The Journal of Medicine and Philosophy, 1978, vol. 3, no. 3 © 1978 by The Society for Health and Human Values. 0360-5310/78/0303-0024$00.75
256
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
In his paper, "The Scientific Autonomy of Clinical Medicine" (1977), L. A. Forstrom asserts that clinical medicine "should be regarded as a relatively autonomous science" (p. 18). He seems to believe that the profession of clinical medicine is not just scientific in the way bridge building is but is rather a science in the same way that physics as practiced by physicists is a science. In this paper, I argue that Forstrom does not secure this claim, and then I suggest some causes for his failure. Forstrom appeals to two criteria for an activity being a science, which he extracts from the first page of Braithwaite's Scientific Explanation (1964, p. 1). These are (1) being concerned with an "empirical subject matter" and (2) having the function of establishing "general laws" to explain "events or objects" that are a part of that subject matter. Forstrom argues that clinical medicine meets both criteria; it is a science because it has its own domain, "the human organism, in its manifold environmental contexts, in health and disease," and because it is actively concerned with developing general laws that explain events within that domain (p. 9).
Daniel L. Creson
1
It may be that Forstrom's position is essentially correct despite the omissions in his argument. If clinical medicine is becoming a science and leaving behind or relegating to unimportance its service functions, then the subject requires much more attention than Forstrom has given it. The consequences of 257
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
nature of a nonscience occupation as well. For example, Forstrom should point out the differences that bestow "scientific status" on clinical medicine while denying that same "status" to calendar making and metallurgy. Moreover, to accept Forstrom's construal of Braithwaite's criteria as they relate to clinical medicine is to accept all occupations and technologies which have a domain of empirical interest and which aim (in part) to establish general explanatory laws as separate and distinct sciences. Such an argument opens the door to a myriad of new sciences including, but not limited to, just those endeavors Forstrom rules against: calendar making and metallurgy. Indeed, given Forstrom's adopted criteria, a strong case may be made to include such service occupations as the practice of law and investment counseling since both have a clear domain of empirical interest and an abiding concern with establishing explanatory paradigms. The service functions of many occupations set them apart from sciences, yet Forstrom dismisses these "social functions" of clinical medicine as "applications of medical science" (p. 10) and therefore as of no consequence to his revision of the taxonomy of occupations. In short, Forstrom fails to distinguish between a secondary or facilitating function of an endeavor and its principal function. The principal function of medicine is to serve the ill and troubled, while a secondary function of it is to add to its cognitive store. The principal function of physics is to establish explanatory paradigms about the relationship of objects in the physical universe. Even granting that its secondary functions turn out to be service oriented, this suggests an asymmetry between medicine and pure science. It would be simplistic to assume that any occupational group has only one function in a given social-cultural system, so it is important to distinguish primary from secondary functions. The primary function serves as an identifying marker of an occupational group. The principal identifying function of clinical medicine, both for the general populace and among medical practitioners, is that of provider of its specific service. In that respect, clinical medicine differs from generally recognized sciences. As service providers, medical practitioners accept and practice (to some degree) human values in the exercise of their roles. If clinical medicine were to adopt the function of science, semantic consistency would turn "patient" into "subject" and "treatment" into "experiment," sequelae not considered in Forstrom's paper.1
The Journal of Medicine and Philosophy
II The possibility that Forstrom is more interested in rewarding clinical medicine with scientific status than he is in analyzing the social taxonomy of occupations raises two questions. First, why would Forstrom or other apologists seek a change in the status of clinical medicine? Second, why would the rarefied air of philosophical dialogue lend itself to such an effort? One set of answers to these questions is suggested in the work of other scholars interested in occupational taxonomy. The medical sociologist, Rodney Coe, suggests that professions provide a channel for upward mobility—for both individuals and occupational groups" (1970, p. 187). He contends that " . . . occupational groups such an evolution would be far reaching in their import. If, in Braithwaite's words, "the function" of medicine (as opposed to a function of medicine) becomes the establishing of explanatory paradigms, then popular criticism of organized medicine may be based on something more fundamental than abuse of prerogatives and inadequate service (1964, p. 10). 258
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
Yet, Forstrom's manipulation of social taxonomies as they relate to occupations may have heuristic value. Many social scientists have achieved, through similar thought experiments, a better understanding of the functional interrelationship of components within the social-cultural system. For example, sociologist Erving Goffman analyzed the practice of medicine utilizing a modified occupational taxonomy and was able to demonstrate social differences between psychiatric care and other medical care. He predicates a grouping of occupations characterized by a service function "where the server has a complex physical system to repair, construct, or tinker with—the system here being the client's personal object or possession." The client brings to the relationship postulated by Goffman a respect for the server's competence, and the server is characterized by "an unservile civility." As a result of his taxonomic manipulation, Goffman was able to demonstrate that psychiatry, unlike other aspects of medical practice, serves a policing function within the social order (1959, p. 326). Unlike Goffman, Forstrom fails to demonstrate that his revised taxonomy has any advantages. He seems motivated to argue that clinical medicine is science simply because it deserves the social honor. He writes: "The practical justification of its approach, and of clinical medicine itself, rests in its accomplishments" (p. 18). Such a statement suggests that Forstrom's argument has more to do with deserved reward than with heuristic insight. If this interpretation of Forstrom's intent is correct, then the second purpose of this paper takes on added significance—an attempt to explain the paper itself.
Daniel L. Creson
2
White's term, "vectors," should be understood as identifiable components of culture that can be observed interacting and described. Vectors have magnitude and thus can be measured. For example, clinical medicine has a measurable number of practitioners and a finite amount of collectable fees. Vectors also have objectives or direction. Such objectives are more or less the same as the generally recognized "interests" of a particular grouping. For example, in the case of clinical medicine, the defeat of national health insurance legislation is entirely congruent with the lobbying activities of organized medicine. 259
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
can and do collectively strive for public recognition of their work as a professional activity" (p. 188). In recent decades, with the expanded technological base of the social-cultural system, the number of popularly recognized professions has proliferated. Many other occupational groups not generally accorded professional status have become self-proclaimed professions and are actively working to gain popular recognition as such. Current occupational competition for higher social status is an example of the competitive "vectors" described by the social anthropologist and systems theorist, Leslie White (1975, p. 59). White uses the term "vectors" to denote organizations or groups (not just professional groups) which have both a "magnitude" and an "objective." It is his contention that these vectors compete with one another in the social arena (p. 80).2 While medicine and other professions provide examples of vectors as described by White, the concept of vectors is much broader in its intended application. If Coe and White are correct in what they assert, then Forstrom's article, looked at from the sociological perspective, can be understood as a specific incidence of a strategic maneuver for higher status. As a science, clinical medicine would belong to a more prestigious and less crowded social grouping. If such is Forstrom's intent, some of the most troublesome aspects of his paper can more easily be explained. Looked at in this way, Forstrom's failure to show the heuristic advantages of his taxonomic revision can be understood as unfortunate but necessary. The paper would have been strengthened if he had been able to show such an advantage, but the fact that he did not can be readily understood by evoking a motivation that has to do with advantage rather than understanding. If I am right about Forstrom's motivation, heuristic or logical considerations are of little import except as they provide support for the argument for elevated status. Where no such support can be found, they are best ignored. It would be gratifying for any professional to find himself in the company of "sages" rather than as just another skilled craftsman or jealously competitive professional, and this must be considered in evaluating Forstrom's position. Forstrom's failure to deal with what constitutes a nonscience occupation and his failure to address the issue of how his arguments apply to
The Journal of Medicine and Philosophy
260
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
other occupations that have both service and investigative functions can also be understood in strategic terms. Viewed this way, one could say that Forstrom must think it would be counterproductive to promote the cause of competitive social vectors. Although the competitive intent of his paper cannot be demonstrated beyond question, such an interpretation helps to explain some of the most glaring omissions in his argument. Similarities between occupations would be best ignored when to address them would strengthen the position of medicine's rivals. What remains unexplained is the choice of philosophical discourse as an arena for competition. In recent decades, medicine in particular, and service professions in general, have come under attack from many quarters. During the same period, science has attained an unparalleled status in complex civilizations throughout the world. In the United States, the majority of the populace still looks to science for ultimate solutions to increasingly complex problems, while both governmental concerns and demands of consumer groups have tarnished the image of organized medicine. During this same period, organized medicine, and in particular medical education, has established liaisons with other occupational groups at least partially in response to charges leveled against it. These liaisons have been mutually advantageous (Freeman, Levine, and Reader 1963, pp. 475-79). The most recent of them has been with philosophy, as marked by the sharp increase in the number of philosophers invited to join medical school faculties (Zaner 1976) and by the increase in philosophical literature which relates directly to contemporary medicine. Medicine's problems and the recent reciprocal interest of medicine and philosophy suggest one of several possible explanations for the recourse of medical apologists to philosophical discourse in an effort to secure or advance the social status of medicine. Philosophy deals with meaning, and meaning is the concern of those who wish to redefine occupational taxonomy in order to gain advantage. Further, for some, perhaps many, philosophy has an elevated status of its own. It is not a science and does not purport to be, nor is it a service profession in the usual sense of that word. However, despite its status, philosophy has little access to social resources. It traditionally has been restricted to and dependent on institutions of higher learning for support. An implicit alliance between philosophy (as the arbiter of meaning) and medicine (with its ready access to social resources) could be of immense advantage to each in the occupational competition for social recognition. Whether or not such an alliance exists, it forms a plausible, if unproven, explanation of the argument offered by Forstrom. As with medical education, close liaison with representatives of other human endeavors are not new to clinical medicine. The current liaison between medicine and philosophy is only the latest example of
Daniel L. Creson many such liaisons. It will not result in medicine becoming philosophy any more than medicine's long-standing relationship with the various sciences has resulted in medicine becoming science. It may well result in medicine becoming more philosophical in the same way that medicine, as a result of its relationship with science, has become more scientific. Thus, to argue that medicine is science as Forstrom does is only a more plausible case of mistaken identification than is arguing that medicine is philosophy. Medicine is neither science nor philosophy, but the best kind of medicine may well depend on both.
Braithwaite, R. B. Scientific Explanation. Cambridge: Cambridge University Press, 1964. Coe, R. M. Sociology of Medicine. New York: McGraw-Hill Book Co., 1970. Forstrom, L. A. "The Scientific Autonomy of Clinical Medicine." Journal of Medicine and Philosophy 2 (1977): 8-19. Freeman, H. E.; Levine, S.; and Reader, L. G. "Present Status of Medical Sociology." In Handbook of Medical Sociology, edited by H. E. Freeman, S. Levine, and L. G. Reader. Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1963. Goffman, E. Asylums. Chicago: Aldine Publishing Co., 1959. Merton, R. K. Social Theory and Social Structure. New York: Free Press, 1957. White, L. The Concept of Cultural Systems. New York: Columbia University Press, 1975. Zaner, R. M. Toward a Philosophy of Medicine: Editorial. Journal of Medicine and Philosophy 1 (1976): 3-4.
261
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
REFERENCES
PH.D.*
I Forstrom's opening sentence suggests that his argument is directed at the "status" of clinical medicine as an occupation. His reference to Braithwaite lists generally recognized scientific disciplines, and Forstrom argues that medicine belongs here. He also offers criticism of Kuhn for including medicine along with calendar making and metallurgy as examples of "established crafts" (p. 8). Yet, Forstrom's comparisons of medicine with recognized scientific disciplines and his criticisms of Kuhn are insufficient for his purpose. A revision of occupational taxonomy such as he proposes must address the * Associate professor and associate chairman for academic affairs, University of Texas Medical Branch, Department of Psychiatry and Behavioral Sciences, Galveston, Texas. The Journal of Medicine and Philosophy, 1978, vol. 3, no. 3 © 1978 by The Society for Health and Human Values. 0360-5310/78/0303-0024$00.75
256
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
In his paper, "The Scientific Autonomy of Clinical Medicine" (1977), L. A. Forstrom asserts that clinical medicine "should be regarded as a relatively autonomous science" (p. 18). He seems to believe that the profession of clinical medicine is not just scientific in the way bridge building is but is rather a science in the same way that physics as practiced by physicists is a science. In this paper, I argue that Forstrom does not secure this claim, and then I suggest some causes for his failure. Forstrom appeals to two criteria for an activity being a science, which he extracts from the first page of Braithwaite's Scientific Explanation (1964, p. 1). These are (1) being concerned with an "empirical subject matter" and (2) having the function of establishing "general laws" to explain "events or objects" that are a part of that subject matter. Forstrom argues that clinical medicine meets both criteria; it is a science because it has its own domain, "the human organism, in its manifold environmental contexts, in health and disease," and because it is actively concerned with developing general laws that explain events within that domain (p. 9).
Daniel L. Creson
1
It may be that Forstrom's position is essentially correct despite the omissions in his argument. If clinical medicine is becoming a science and leaving behind or relegating to unimportance its service functions, then the subject requires much more attention than Forstrom has given it. The consequences of 257
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
nature of a nonscience occupation as well. For example, Forstrom should point out the differences that bestow "scientific status" on clinical medicine while denying that same "status" to calendar making and metallurgy. Moreover, to accept Forstrom's construal of Braithwaite's criteria as they relate to clinical medicine is to accept all occupations and technologies which have a domain of empirical interest and which aim (in part) to establish general explanatory laws as separate and distinct sciences. Such an argument opens the door to a myriad of new sciences including, but not limited to, just those endeavors Forstrom rules against: calendar making and metallurgy. Indeed, given Forstrom's adopted criteria, a strong case may be made to include such service occupations as the practice of law and investment counseling since both have a clear domain of empirical interest and an abiding concern with establishing explanatory paradigms. The service functions of many occupations set them apart from sciences, yet Forstrom dismisses these "social functions" of clinical medicine as "applications of medical science" (p. 10) and therefore as of no consequence to his revision of the taxonomy of occupations. In short, Forstrom fails to distinguish between a secondary or facilitating function of an endeavor and its principal function. The principal function of medicine is to serve the ill and troubled, while a secondary function of it is to add to its cognitive store. The principal function of physics is to establish explanatory paradigms about the relationship of objects in the physical universe. Even granting that its secondary functions turn out to be service oriented, this suggests an asymmetry between medicine and pure science. It would be simplistic to assume that any occupational group has only one function in a given social-cultural system, so it is important to distinguish primary from secondary functions. The primary function serves as an identifying marker of an occupational group. The principal identifying function of clinical medicine, both for the general populace and among medical practitioners, is that of provider of its specific service. In that respect, clinical medicine differs from generally recognized sciences. As service providers, medical practitioners accept and practice (to some degree) human values in the exercise of their roles. If clinical medicine were to adopt the function of science, semantic consistency would turn "patient" into "subject" and "treatment" into "experiment," sequelae not considered in Forstrom's paper.1
The Journal of Medicine and Philosophy
II The possibility that Forstrom is more interested in rewarding clinical medicine with scientific status than he is in analyzing the social taxonomy of occupations raises two questions. First, why would Forstrom or other apologists seek a change in the status of clinical medicine? Second, why would the rarefied air of philosophical dialogue lend itself to such an effort? One set of answers to these questions is suggested in the work of other scholars interested in occupational taxonomy. The medical sociologist, Rodney Coe, suggests that professions provide a channel for upward mobility—for both individuals and occupational groups" (1970, p. 187). He contends that " . . . occupational groups such an evolution would be far reaching in their import. If, in Braithwaite's words, "the function" of medicine (as opposed to a function of medicine) becomes the establishing of explanatory paradigms, then popular criticism of organized medicine may be based on something more fundamental than abuse of prerogatives and inadequate service (1964, p. 10). 258
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
Yet, Forstrom's manipulation of social taxonomies as they relate to occupations may have heuristic value. Many social scientists have achieved, through similar thought experiments, a better understanding of the functional interrelationship of components within the social-cultural system. For example, sociologist Erving Goffman analyzed the practice of medicine utilizing a modified occupational taxonomy and was able to demonstrate social differences between psychiatric care and other medical care. He predicates a grouping of occupations characterized by a service function "where the server has a complex physical system to repair, construct, or tinker with—the system here being the client's personal object or possession." The client brings to the relationship postulated by Goffman a respect for the server's competence, and the server is characterized by "an unservile civility." As a result of his taxonomic manipulation, Goffman was able to demonstrate that psychiatry, unlike other aspects of medical practice, serves a policing function within the social order (1959, p. 326). Unlike Goffman, Forstrom fails to demonstrate that his revised taxonomy has any advantages. He seems motivated to argue that clinical medicine is science simply because it deserves the social honor. He writes: "The practical justification of its approach, and of clinical medicine itself, rests in its accomplishments" (p. 18). Such a statement suggests that Forstrom's argument has more to do with deserved reward than with heuristic insight. If this interpretation of Forstrom's intent is correct, then the second purpose of this paper takes on added significance—an attempt to explain the paper itself.
Daniel L. Creson
2
White's term, "vectors," should be understood as identifiable components of culture that can be observed interacting and described. Vectors have magnitude and thus can be measured. For example, clinical medicine has a measurable number of practitioners and a finite amount of collectable fees. Vectors also have objectives or direction. Such objectives are more or less the same as the generally recognized "interests" of a particular grouping. For example, in the case of clinical medicine, the defeat of national health insurance legislation is entirely congruent with the lobbying activities of organized medicine. 259
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
can and do collectively strive for public recognition of their work as a professional activity" (p. 188). In recent decades, with the expanded technological base of the social-cultural system, the number of popularly recognized professions has proliferated. Many other occupational groups not generally accorded professional status have become self-proclaimed professions and are actively working to gain popular recognition as such. Current occupational competition for higher social status is an example of the competitive "vectors" described by the social anthropologist and systems theorist, Leslie White (1975, p. 59). White uses the term "vectors" to denote organizations or groups (not just professional groups) which have both a "magnitude" and an "objective." It is his contention that these vectors compete with one another in the social arena (p. 80).2 While medicine and other professions provide examples of vectors as described by White, the concept of vectors is much broader in its intended application. If Coe and White are correct in what they assert, then Forstrom's article, looked at from the sociological perspective, can be understood as a specific incidence of a strategic maneuver for higher status. As a science, clinical medicine would belong to a more prestigious and less crowded social grouping. If such is Forstrom's intent, some of the most troublesome aspects of his paper can more easily be explained. Looked at in this way, Forstrom's failure to show the heuristic advantages of his taxonomic revision can be understood as unfortunate but necessary. The paper would have been strengthened if he had been able to show such an advantage, but the fact that he did not can be readily understood by evoking a motivation that has to do with advantage rather than understanding. If I am right about Forstrom's motivation, heuristic or logical considerations are of little import except as they provide support for the argument for elevated status. Where no such support can be found, they are best ignored. It would be gratifying for any professional to find himself in the company of "sages" rather than as just another skilled craftsman or jealously competitive professional, and this must be considered in evaluating Forstrom's position. Forstrom's failure to deal with what constitutes a nonscience occupation and his failure to address the issue of how his arguments apply to
The Journal of Medicine and Philosophy
260
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
other occupations that have both service and investigative functions can also be understood in strategic terms. Viewed this way, one could say that Forstrom must think it would be counterproductive to promote the cause of competitive social vectors. Although the competitive intent of his paper cannot be demonstrated beyond question, such an interpretation helps to explain some of the most glaring omissions in his argument. Similarities between occupations would be best ignored when to address them would strengthen the position of medicine's rivals. What remains unexplained is the choice of philosophical discourse as an arena for competition. In recent decades, medicine in particular, and service professions in general, have come under attack from many quarters. During the same period, science has attained an unparalleled status in complex civilizations throughout the world. In the United States, the majority of the populace still looks to science for ultimate solutions to increasingly complex problems, while both governmental concerns and demands of consumer groups have tarnished the image of organized medicine. During this same period, organized medicine, and in particular medical education, has established liaisons with other occupational groups at least partially in response to charges leveled against it. These liaisons have been mutually advantageous (Freeman, Levine, and Reader 1963, pp. 475-79). The most recent of them has been with philosophy, as marked by the sharp increase in the number of philosophers invited to join medical school faculties (Zaner 1976) and by the increase in philosophical literature which relates directly to contemporary medicine. Medicine's problems and the recent reciprocal interest of medicine and philosophy suggest one of several possible explanations for the recourse of medical apologists to philosophical discourse in an effort to secure or advance the social status of medicine. Philosophy deals with meaning, and meaning is the concern of those who wish to redefine occupational taxonomy in order to gain advantage. Further, for some, perhaps many, philosophy has an elevated status of its own. It is not a science and does not purport to be, nor is it a service profession in the usual sense of that word. However, despite its status, philosophy has little access to social resources. It traditionally has been restricted to and dependent on institutions of higher learning for support. An implicit alliance between philosophy (as the arbiter of meaning) and medicine (with its ready access to social resources) could be of immense advantage to each in the occupational competition for social recognition. Whether or not such an alliance exists, it forms a plausible, if unproven, explanation of the argument offered by Forstrom. As with medical education, close liaison with representatives of other human endeavors are not new to clinical medicine. The current liaison between medicine and philosophy is only the latest example of
Daniel L. Creson many such liaisons. It will not result in medicine becoming philosophy any more than medicine's long-standing relationship with the various sciences has resulted in medicine becoming science. It may well result in medicine becoming more philosophical in the same way that medicine, as a result of its relationship with science, has become more scientific. Thus, to argue that medicine is science as Forstrom does is only a more plausible case of mistaken identification than is arguing that medicine is philosophy. Medicine is neither science nor philosophy, but the best kind of medicine may well depend on both.
Braithwaite, R. B. Scientific Explanation. Cambridge: Cambridge University Press, 1964. Coe, R. M. Sociology of Medicine. New York: McGraw-Hill Book Co., 1970. Forstrom, L. A. "The Scientific Autonomy of Clinical Medicine." Journal of Medicine and Philosophy 2 (1977): 8-19. Freeman, H. E.; Levine, S.; and Reader, L. G. "Present Status of Medical Sociology." In Handbook of Medical Sociology, edited by H. E. Freeman, S. Levine, and L. G. Reader. Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1963. Goffman, E. Asylums. Chicago: Aldine Publishing Co., 1959. Merton, R. K. Social Theory and Social Structure. New York: Free Press, 1957. White, L. The Concept of Cultural Systems. New York: Columbia University Press, 1975. Zaner, R. M. Toward a Philosophy of Medicine: Editorial. Journal of Medicine and Philosophy 1 (1976): 3-4.
261
Downloaded from http://jmp.oxfordjournals.org/ at Oakland University on May 3, 2015
REFERENCES
