by Pierre Mallia MD MPhil PhD MRCP FRCGP
Associate Professor of Family Medicine and Patients’ Rights
Department of Family Medicine, Medical School
University of Malta

The first thing we need to ask is whether philosophy of science matters at all for medicine; and indeed what do we mean by philosophy of science anyway? Perhaps the best way is to answer the question whether medicine, as a science, depends on tradition, and secondly, if there is a tradition, what are the goals of this tradition. Prima facie most doctors would agree that there is a tradition of medicine, which is to heal patients and to do good. Yet this tradition is being challenged when some doctors fell it their duty of assist in ending the life of a suffering individual. When one asks whether this is or should be the goal of medicine, one is making an inquiry about the philosophy of one’s practice. Even if it is not the aim, the ethos, of medicine, it may still be within the grasp of the general aim of scientific method. To illustrate this better, we can use reproductive technology or stem cell research as an example. Scientific advances in this area by no means held back the medical profession from using them; at least the former. Yet some may still challenge them on moral grounds outside medicine and then ask whether it should be within the scope of medical practice to host these technologies which some (or many) may question on moral grounds.

There are two principal movements in the philosophy of science, which can be applied to medicine, which have made their voice heard even in circles not inherent to the field. These are those of Karl Popper and Thomas Kuhn. Both did not concern themselves with medicine, but with philosophy of science per se. Popper is portrayed as the more objectivist and traditional, putting science on a level of challenges. We uphold a theory until it is challenged by a better one. The good scientist thus allows his theory as a working tool but is open to challenges and indeed may challenge it himself. Kuhn, on the other hand can be thought of more as coming from the American Pragmatic school and is considered more liberal and indeed relativist, saying that science moves forward by the practice or though of the day, which he called paradigms. These paradigms create small revolutions in themselves and scientists work around them. It is therefore more authoritarian and based on historical research as well. This historicism is a learning experience, if you may, on which one builds. Yet when a paradigm changes, all the material of the previous thoughts are put aside. Kuhn was a physicist and limited his discussion to this field. A clear example was theoretical physics which at the time was passing through a revolution of thought because of general relativity, quantum physics. Cosmology, with the ‘Big Bang’ created this new paradigm of thought, for example, and cosmologists work around this theory even though some still challenge the Big Bang concept.

Do we do the same in medicine? In many ways, we do. We speak of current thoughts in medical practice and historical development do take their toll. If one asks whether medicine is liberal or indeed relativist, there are indeed those who would go to all means in order to cure patients, or indeed to gain external advantages, given the necessity of industry to push forward medical research and development. Thus some would little question the embryo once this is for the gain of benefits obtained by stem cell research. Yet medicine has it long tradition and we take joy in speaking about the Hippocratic Oath and such. When it comes therefore to the teaching of bio- and medical ethics, one often appeals to tradition; but this tradition does change with the times. The principle of respecting autonomy has, for example, challenged paternalism – the notion that the doctor knows all and the patient must obey.

Does this matter at all? Indeed if medicine is to maintain its repute as doing good, it does. Doctors who are paternalistic are not only challenged but may face trouble. Whereas in the past it was relatively fine to take organs from dead bodies for research and study purposes; today medicine has fallen in line with obtaining consent and indeed has pioneer the concept of ‘informed’ consent – something which the business world, for example, including those giving out medical insurance, must still master. Moreover medicine has become socialized  Today people are more and more aware of their cholesterol, weight, exercise. Far from what certain authors say, that medicine has manipulated the world, this is the result of society. The very fact that many other social factors come into play in medicine – politics, insurances, pharmaceutical industry etc, implies that there are more that doctors and paramedics involved in health care. This breeds the question – should these not all have the same ethics? Should they be obliged to follow the rules of medicine?

If we can speak of a philosophy of medicine, then we can answer in the affirmative. This would oblige insurance, politicians, and even brands promoting a certain butter to follow the same rules – that of respecting the principles which we as doctors uphold – respecting autonomy, beneficence, nonmaleficence and justice. Whilst the latter would apply mostly to politicians, we would not tolerate advertising which works upon scare mongering techniques – if you do not choose this butter you may be at a disadvantage; or manipulation – such as facial creams ‘approved’ by dermatological foundations sponsored by the same company producing the cream. As conflicts of interest apply to doctors, they should apply to anyone who is in any way making a profit on patients.

If medicine had no philosophy, no ethos, then there is nothing to stop us from making profit the main principle and motive factor as morally correct. This would be relativism at its best. Even if paradigms may be the rule of the day, it does not mean they are always correct (and many, including myself, do not believe in Big Bang, a term which after all was coined by its great opponent Fred Hoyle. Many are blind however and continue to work notwithstanding many unanswered questions). What results is that we try to build an ethics which suits our needs, as scientist would try to work around experiments which prove rather than disprove a theory.

This is perhaps the challenge of modern medicine today. We must not lose sight of what MacIntyre calls the ‘practice’, which as a ‘tradition’ defines the goals and goods internal to the practice, even if the practice itself can have the benefits of goods ‘external’, such as profits and prestige. The fact that we have to a certain extent omitted this has meant that defining and teaching of ethics within the medical community has been lost to external forces such as theology, philosophy and sociology – all inputting, defining, dictating what doctors should or should not be doing. When the same people come on the hospital bed they will realise that they have been shouting in vain as they may indeed realise that the science of medicine is not, after all, the enemy. Then maybe, these much important fields will help medicine by becoming facilitative rather than didactive – that is, by helping the profession maintain its identity by their important contributions. Doctors will indeed appreciate the value of philosophy because they feel the need to define the philosophy of medicine. Medicine can only work within the cultural, social, and psychological spheres and does not concern itself, even if the rest of science does, with solely the scientific and biological. Perhaps that is why it continues to procure the title of an ‘art’ as well as a science. Yet it has to maintain a sense of what it stands for; even if assisted suicide may become acceptable to society, does this mean that doctors should do it?

Thus whereas Popper may have been wrong by strongly being opposed to what he called ‘historicism’, that is, the notion that historical instances made us into what we are today (one cannot argue that the second world war did not teach us lessons. One can forgive Popper for his ideas as he was an exiled Jew during the war, but he took too much to heart the ‘historicist’ philosophers such as Hegel, who really meant that both good and bad work towards forming humanity, and not, that we are not free to choose our paths. He seemed to interpret Hegel as too deterministic on humanity and that thus the attempt at the extermination of the Jews was an inevitable process); Kuhn, on the other hand, with his notion of paradigms, puts us in dangerous grounds of having to define our ethos by the socio-psycho-cultural ‘paradigm’ of the day. This sets us back to having medicine defined by the regimes and thoughts of the day – as indeed was reflected in the Nuremberg trials.

If you have to be within a tradition to understand it and formulate your ethos with the changing times, then perhaps, Popper, with his limitations, gives us a better working formula, for at the end of the day medicine does move forward in research by ‘challenges’ to current thought, and when it comes to moral values and the goals of medicine, as MacIntyre said in his more analytical book Whose Justice, Which morality?, a tradition is upheld when is withstands the challenges of the times. This is why he upholds Aristotelian and Thomistic morality over the geneologists like Neitchze and Foucault who resent conservatism. Yet with its limits, conservative values have withstood challenges in time and indeed it is because of what was built on conservative values that the so-called post-modernist thought can build its nest. Yet at the same time conservatism has responded to changing times as well. If Christian values have withstood many tests in time, then one cannot blame medicine for upholding those values before it ventures too deep into research such as the New Genetics – for that would be the philosophy of this ‘tradition’. To do this properly one has to give due importance to teaching young doctors the philosophy of their practice and tradition, which otherwise would simply be subject to relativist thoughts. One cannot then speak of a unifying tradition any longer.