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Book of the Month: Philosophy for Medicine

In 1981, two American philosophers, Edmund Pellegrino and David Thomasma, in A Philosophical Basis of Medical Practice,1 suggested that the crisis of modern medicine lies in the lack of a suitable philosophy of medical practice whereby ‘non-measurable clinical factors and values can be treated with the same attention as clinical indicators of disease’. In short, they held that the only solution is the search for a philosophy of medicine developed from the practice of medicine itself and not from the external imposition of philosophies which already exist; in particular, they did not believe that the philosophies of science which had evolved over many years were germane to the increasingly complex issues of medical practice in the 20th century. It is only necessary to read Peter Medawar’s delightful essay ‘Is the scientific paper a fraud?’2 to appreciate that, although philosophers like Russell and Popper had a considerable influence in defining the nature of the scientific endeavour in the 20th century, their conclusions often appeared to be at variance with the day-to-day practice of research. The published papers based on the Herbert Spencer lectures given at the University of Oxford in 1979, entitled Scientific Explanation,3 suggest that the philosophy and practice of science are not entirely happy bedfellows. In summarizing the lectures the editor, A F Heath, pointed out that those by the scientists displayed an absence of doubt and suspension of disbelief, while the philosophers expressed considerable uncertainty about the validity of the accounts which the scientists had given of their activities. And he went even further, suggesting that the two most influential philosophies of science of the 20th century are self-refuting—not the most encouraging of messages for proponents of a new philosophy of medicine! Although it could be argued that there has been little movement towards evolving an all-embracing philosophical basis of medical practice since the appearance of Pellegrino and Thomasma’s stimulating book, at least as evidenced by the undoubted progress that has been made in bioethics over recent years, a more focused application of the disciplined thinking of philosophers has had much to offer the current medical scene. Onora O’Neill, for example, has provided an invaluable contemporary background to defining some of the problems of medical ethics in the light of duty or rights-based approaches and utilitarianism.4 Although these principles have had to be applied with considerable flexibility, they have formed a broad framework for discussions on a variety of topics including confidentiality, conflicting rights, rationing and prioritizing of healthcare, inequalities of care, and many other related issues. Also, by combining clarity of thought with good common sense about public expectations, the work of philosophers such as Mary Warnock5 has been one of the major reasons for the relative success of the UK in handling such delicate issues as embryo research, cloning and stemcell therapy. Indeed, on bodies like the Nuffield Bioethics Council and some of the government regulatory committees, the philosophers who joined the scientists and lay people who were grappling with the difficult decisions raised by modern biotechnology were of inestimable value in better defining the questions involved, not to mention generating a more sensible basis for their solution. And, on the broader issues of bioethics, the writings of philosophers and historians of science—Dan Brock,6 Jonathan Glover7 and Daniel Kevles,8 for example—have provided a valuable platform on which to debate the extent to which society may wish to see the power of human genetics harnessed in the future. But although there has been wide discussion about the shortcomings of the medical profession it seems unlikely, given the extraordinary rate of change and diversity of problems in the fields of biomedical research and patient care, that an all-embracing philosophical basis for medical practice, as outlined by Pellegrino and Thomasma, will become a reality in the foreseeable future. Steven Pinker’s book The Blank Slate,9 which, incidentally, gained its name from a passage in John Locke’s An Essay Concerning Human Understanding, emphasizes the rapidly changing concepts of human nature as they are becoming more clearly defined by the neurosciences, genetics, evolutionary psychology and developmental biology. This new and rapidly changing field alone offers enormous challenges for the philosophical analysis of the human state. The exploration of the human genome and the increasing evidence that we are what we are as a result of our genetic make-up, our current environment and the long history of the cultural milieu that has been handed down to us, offers a further example of the remarkable complexity of human beings. When the added stress of illness is thrown in for good measure, the concept of a unifying philosophical basis for the many facets of illness and its management appears increasingly unreal. There is no doubt, however, that we will have to prepare our students much more effectively for the B O O K S