The commonest undergraduate degree of students entering the medical school at University of California Irvine is philosophy. The medical school, traditionally the richest and most arrogant of university departments, has at UC Irvine reached out to the philosophy department for help. At a conference there last month I met a student who is simultaneously studying medicine and doing a PhD in philosophy. I was there at a meeting on social epistemology, feeling a little out of my depth, but I came away with a conviction that healthcare, which is suffering an existential crisis, badly needs the help of philosophers.
The questions science cannot answer
Philosophy, the philosopher Bertrand Russell argued, can be thought of trying to find answers to those questions that neither theology nor science can answer. There was a time when religion provided an answer to every question—How did the world begin? Why are we here? What is a good life? Is there an afterlife?—but sceptics, and philosophers, began in Ancient Greece to look for their own answers.
Initially science was a branch of natural philosophy, but with a rush in the Renaissance it developed its own experimental methods. Science cannot, however, answer some of our most important questions, and those of us educated in science have to be wary of thinking it might. Philosophy can’t answer most of them either, but it provides a means of rigorous and critical thinking and examination that can keep us from hubris, something to which medicine is prone.
What is medicine for?
Science has in the past century given medicine tremendous impetus and capacity, but it can’t answer questions like “What is medicine for?” It can’t even define health. Medicine is a discipline and most doctors within it have not stopped to ask “What is medicine for?” but have rushed ahead to do whatever it can. As doctors are interested primarily in disease in all its protean and sometimes spectacular forms the business of medicine has become “fighting disease” rather than promoting health, but what are we fighting disease for, and how far should we go? Are we trying to defeat death? Is extending life our aim? Is a longer life a better life? And what is disease anyway? Is the concept of disease still the best way for medicine to think about what it is trying to do when risk factors become “diseases” and most patients have multiple “diseases”? What can we learn from reflecting on “diseases” like drapetomania (the mental illness that led slaves to escape)? And is it right that healthcare is increasingly consuming resources that could be spent on education, housing, social care, the environment, the arts, and much else?
Beyond ethics to metaphysics and epistemology
Ethics is the branch of philosophy that has developed the closest links with medicine, but perhaps we have just as much need for metaphysics (“the branch of philosophy that deals with the first principles of things, including abstract concepts such as being, knowing, substance, cause, identity, time, and space”) and epistemology (the theory of knowledge, especially with regard to its methods, validity, and scope. Epistemology is the investigation of what distinguishes justified belief from opinion).
Social epistemology and medicine
The conference I attended at UC Irvine was concerned with “social epistemology” and medicine. I had some idea of epistemology (How do we know things?) but was unsure about social epistemology. I looked it up in Wikipedia, itself I thought a fruit of social epistemology. “Social epistemology refers to a broad set of approaches to the study of knowledge that construes human knowledge as a collective achievement. Another way of characterizing social epistemology is as the study of the social dimensions of knowledge.”
I worried that I might not have anything useful to contribute, but I read on: “More practical applications of social epistemology can be found in the areas of library science, academic publishing, guidelines for scientific authorship and collaboration, knowledge policy, and debates over the role over the Internet in knowledge transmission and creation.” So thinking about medical journals, which might be described as knowledge tools for medicine, is relevant, and evidently my book “The Trouble With Medical Journals” is used by at least one teacher of social epistemology.
Examples of how social epistemology can help doctors
- As always at conferences, what others had to contribute seemed much more interesting than what I had to contribute, and here are some things I heard that helped me to begin to understand what social epistemology can offer to healthcare and to reflect on what philosophy more broadly might offer healthcare.
- Epidemiology (science) gives us data on the trade-off between false positives and false negatives with diagnostic tests, but how do we decide on where to set the bar for a “positive” diagnosis? Science can’t answer that question. It is an epistemological question that lies at the heart of, for example, the controversy over mammography.
- For a doctor to take blood from a patient without consent is a crime, assault, but we don’t get written consent for a blood test. Nor do we often even ask for consent. The patient “knows” that the doctor approaching with a needle is going to take a blood test and assumes (perhaps wrongly quite often) that the test will benefit him or her. This is an example of “presumed consent,” but might something similar be used when, an example discussed at the conference, a procedure is going to be used on a “community” where individuals could not give actual consent at the time because they will be too sick when seen? Might consent be presumed if the “community” was notified about the procedure and when it would be used? If so, how much notification might be needed? Would everybody in the community need to understand completely? Would people have the chance to opt out?
- This example made me think of getting consent from patients for data gathered about them in a trial to be published and shared. Is it necessary for every patient to give fully informed consent? Is that even possible when data will be used by others to answer new questions? And what about the many datasets already collected where patients did not give explicit consent? We tend to think of this as an ethical question, trading off the benefit to the community from sharing data against the harm to the patient of information about the patient becoming published? But it’s also an epistemological question by asking how much information the community might need for consent to be presumed?
- The current debate in The BMJ about the value of qualitative research to the readers of The BMJ is a classic epistemological debate about the relative value of different forms of knowledge. I started my talk with the example.
- WHO has eight definitions of “infertility” and epistemologists have shown them to be full of contradictions and phrases that are insufficiently exact. Is infertility a function of individuals or couples? The WHO definitions include both. One definition talks of a year of unprotected sexual intercourse, but there is no mention of frequency or of whether ejaculation is necessary? The definitions are also value laden in assuming that couples are heterosexual and should have children? Perhaps I would be better—more epistemologically clear—not to try and define infertility but instead to restrict definitions to the phenomena leading a man or woman not to be able to bear children?
- A man undergoing gender reassignment surgery to be given “female” genitalia is caught in an epistemological bind. “He” has neither the knowledge of the surgeons of what female genitalia look like (with wide variations) nor a woman’s knowledge of the genitalia. How can “he” chose what result “he” would like or decide if the outcome is good? One surgeon in the US has tried to make progress with this problem by showing “men” about to have operations the book Femalia, which comprises 32 colour photographs of female genitalia published without comment. One of the ideas behind the book is to illustrate the diversity of female genitalia to counteract the narrower and idealised versions seen in medical textbooks. Pornography is another potential source of knowledge about the result they might expect from an operation, but a deceptive one. The surgeon shows the “men” the pictures not as a catalogue from which to choose a result, but rather to illustrate diversity. In fact we heard that surgeons all tend to have their own operations and that an informed observer can in the US accurately identify the surgeon who did the operation nine times out of 10.
- Why do we have so many “types” of medicine—scientific medicine, evidence based medicine, patient centred medicine, personalised medicine, translation medicine, precision medicine, pragmatic medicine, and so on? And can we agree on the definition and aims of these different forms? Ever since evidence based medicine appeared we have been debating what it is and how useful it is, but it does seem to have had considerable success in column inches if not necessarily in patient outcomes and in spawning other “types” of medicine. The very fact that we have all these forms shows how we in medicine need the help of epistemologists.
The epistemologists are keen to increase the number of practising doctors/physicians/clinicians at their next conference. If you are interested visit these websites:
Richard Smith was the editor of The BMJ until 2004.
Competing interests: RS had his expenses paid to attend the conference, and his wife went with him. Her expenses were not paid, but in the US hotels charge by the room not the number of guests. RS was not paid a fee.