Is medicine a scientific enterprise?

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I was recently involved in a Twitter tiff triggered by the following Mayo clinic announcement:

Readers were promptly outraged:

I intervened with what I thought was a mild rhetorical question:

The response was swift:

A tweeting quarrel ensued, in which I briefly took a guilty pleasure.

The outrage, of course, reflects the belief held by some that medical care should be “scientific” and purged of all “nonsense.”  This idea is particularly popular among enthusiastic champions of a peculiar view of science as the sole and omnipotent purveyor of all real knowledge.  Some of those involved in the tiff were undoubtedly of that persuasion.

But apart from holding sway in the minds of Richard Dawkins devotees, the notion that medicine should be a scientific undertaking pervades, to varying degrees, the entire health care community.  After all, it is on the basis of this idea that Abraham Flexner boldly constructed the report which gave birth to our health care system a little over a century ago.

Now, the idea that medicine should be a scientific enterprise–even to the slightest degree–is an erroneous idea.  Medicine itself cannot be viewed as scientific for the simple reason that the aim of science is to acquire knowledge, whereas the aim of medicine is to heal.  These are two distinct ends.  Furthermore, a scientific enterprise is best carried out with dispassion: observation and experimentation.  Healing, on the other hand, is best accomplished through personal involvement: caring.

Of course, this is not to say that scientific inquiry cannot inform doctors on the proper course of action.  It certainly can, should, and does.  But scientific inquiry can only be subordinate to medical care.  It is because one cares for the patient that one seeks the best material ways to cure or treat the body, and scientific knowledge provides valuable information in that regard.  But scientific knowledge and scientific methods cannot be the prime or deciding factors in clinical decision-making for at least two reasons.

First, we should recognize that biomedical science is only scientific in a limited way.  When, at the dawn of the modern era, science separated itself from philosophy to take on a decidedly empirical cloak, the human observer could no longer properly be the subject of scientific inquiry, except in an indirect manner.  And where physics and chemistry have been able to uncover “laws” of nature, biomedical science generally limits itself to making tentative, statistical predictions on human data aggregates—populations.

Causality in physics (notwithstanding its Humean objections) is not the same as causality in biology, and is even less related to causality in human affairs.  Medical care is a pursuit of health for the good of the another human being, an individual person.  That person exists in and expresses a contextualized reality: Mrs. Jones is not a 76-year old woman with cancer, except as a shorthand identification.  Mrs. Jones is a being of a rational, self-determining nature and, strictly-speaking, incomparable to any other 76-year-old woman with the same cancer.  The scientifically “proven” benefit or ineffectiveness of treatment X is never proven (or disproved) in the case of Mrs. Jones.

Secondly, to circumscribe medical care inside the realm of science limits the autonomy of the patient.  Perforce, “scientific medicine” in the Flexnerian sense separates the physician from the patient, because the latter becomes an object in (or a subject of) the scientific enterprise, and therefore, at some level, must be deemed incapable of judging the value of the care received: no one asks the falling apple if it would prefer to be considered under the law of universal gravitation or under the general theory of relativity.

The Flexnerian notion of scientific medicine, then, brings to the fore the “information asymmetry” in the doctor-patient relationship and justifies State intervention by way of licensing laws.  In turn, licensing laws give credence to and materialize this asymmetry.  Patients, as object of scientific medicine, can no longer freely choose their care as the State intervenes to ensure safety and efficacy according to objective, scientific norms.

The entire regulatory apparatus of the last 100 years emanates from the Flexnerian error of scientific medicine.  The apparatus either perpetuates the error (quality and safety movement) or attempts to counter it (patient autonomy movement).  A more effective solution is to get rid of the error altogether.  Scientific medicine is truly nonsense.


You can find a related post on the topic of the Mayo Clinic and information asymmetry in the Pre-Flexner era here.


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13 thoughts on “Is medicine a scientific enterprise?

  1. Nuance and intelligent discussion don’t mix very well with Twitter. You’re brave to have even attempted to raise an alternative opinion…

  2. Several years ago I wrote a blog commentary semi-facetiously about teaching an anti-hubris course for medical students. In it I quoted Dr. Nortin Hadler who made a distinction between scientific truth and clinical truth and legal truth. Legal truth, he said, was based on settling a dispute, and clinical truth may utilize some scientific truth but clinical truth was basically something worked out between the physician and the patient.

  3. What as amazing piece of tripe. “Patients, as object of scientific medicine, can no longer freely choose their care as the State intervenes to ensure safety and efficacy according to objective, scientific norms.” Sorry, in the US (isn’t that where you practice?) doctors CAN’T impose therapy without permission. That is what they call a massive straw man argument.

    “to circumscribe medical care inside the realm of science limits the autonomy of the patient.”.. an utterly meaningless string of word salad. Funny, last time I got a flu shot, I had to agree by signing an informed consent.

    If I want caring, I’ll go to my mother. If I want curing, I’ll go to a doctor practice science-BASED medicine…not the magic-based medicine of which you are apparently enamored.

    https://www.sciencebasedmedicine.org/in-which-i-steal-a-title-is-medicine-a-scientific-enterprise/

    • James, I’ll assume by your comment and your use of the word “tripe” in reference to something you disagree with that you are a physician of some sort. “Tripe” seems to be a favorite adjective of educated medical professionals, so, well done on your word choice.

      You may not see things from a patient’s perspective very often but if you stop and talk to a patient with the intention of learning something about allopathic medicine you’d be surprised at what they have to say. Many patients have no idea of the risks, benefits and alternatives to what their doctors are proposing as treatment because allopathic doctors don’t bother discussing this with their patients; nor do patients have a lot of health care options because of a thing called “standard of care”. Thus, if I go see my doctor who wants to give X treatment for Y disease but I don’t like option X and I go see another doctor it will 9/10 just be a slight variation of treatment X. There is little patient autonomy in allopathic medicine, it was designed that way. Physicians are the gatekeepers to health and “if you want to be healthy you need to come see us so we can give you the right pills.”

      Many (not all) physicians count on their patients being uninformed and unable to understand medicine and when a patient does start to question treatment options the physician gives the ultimatum of “do as I say or find another doctor”. Not very conducive to autonomy, in most cases.

      I particularly enjoyed your last statement but especially the part where you say “If I want curing, I’ll go to a doctor practice science-BASED medicine…” as if conventional medicine can “cure” anything outside of infectious diseases – even that is getting sketchy these days. I believe your statement would have been more accurate if it were reworded to say “If I want my disease to be ‘managed’ by ever increasing doses of medication for the rest of my life…”

      Now that the “tripe” has been addressed, I wanted to comment directly on the article because I found it quite good. It is sad to see how many physicians are so prejudiced and narrow -minded. It would be one thing if they were the sole victim of their animosity toward different ways of thinking, but their patients will pay a price for it as well.

  4. Dr. – this is a really insightful post. I do think there is something wrong with all these Internet skeptics.

    Some time ago, my husband was having recurring back pains and was referred to a chiropractor. 2 weeks in, his months of back pain went away.

    He mentioned this on Facebook and was accused of being a “science denier”, a follower of “WOO” and was slammed with a series of links back to the “Evidence based” sites.

    Neither he or I know how to read scientific studies, but something about their attitude and demeanor makes me think they are not at all objective.

    • Russ,

      As you can see from other comments on this post and elsewhere, I have been duly informed of that rebuttal. Since it is a rather long article, I would appreciate it if you could tell me which specific criticism (from Dr. Gorski or anyone) you would like me to address. Bear in mind that many who tout the value of science as an objective good fail to recognize the metaphysical presuppositions of that position and, moreover, fail to even acknowledge that there are metaphysical presuppositions at play. That may be the reason why it is difficult to engage with them in a civil discourse. They feel their point of view is “obvious.”

      Michel

  5. Agree with much of this. “Biomedicine” has always had an uneasy tension baked into it. Examples of this tension can be found in, e.g., the Tuskegee syphilis study, the ABCC study of atomic bomb survivors (Susan Lindee), or my own little paper on the Stateville Prison malaria study (“The prisoner as model organism”).

    I would add a couple of complications. First, I disagree with your hierarchy in which science is always the handmaiden of medicine. That’s a clinician’s POV. Those on the basic science side tend to see it the other way. I’d say both are right (or can be); it’s a reversible reaction, and which direction predominates depends on local conditions. The information asymmetry is real but relative, depending on the observer’s POV.

    Second, there are attempts currently to develop a “science of the individual” or “n of 1” studies. Recent developments in science are beginning to allow researchers to take idiosyncrasy into account. I’m not talking about the hyped versions of “personalized medicine”. Rather, it’s more of a systems approach. Still too early to tell where it’s going or how successful it will be. My point is simply that some people are trying to bridge the gap.

    Finally, I’d just point out that others, such as Eric Smith of the Santa Fe Inst. and Sara Walker at ASU, are exploring the possibility that biology indeed does hold some distinctive laws. They lie in the specialty of statistical physics. In other words, a few serious people today are arguing that Schrödinger may have been right!

    • Thank you so much for your comments. I didn’t mean to establish a competition between science and medicine, only to highlight their distinct ends (but perhaps I came off a bit too strongly).

      I am very interested in the “N=1” trials and wrote about those a few years ago, but I suspect that powerful economic forces will continue to glorify N = 10,000 (http://alertandoriented.com/why-n-of-1-is-enough).

      And thanks for the pointer toward Smith and Walker. I just submitted a paper where I claim to have found coherence between Aristotle’s theory of “mixed bodies” and elements and the cell theory. If that’s correct, then that could support an argument in favor of biological law. Certainly not having biological laws (or denying they exist) is twisting the entire field into a knot! Thanks again! Michel

  6. This piece is excellently written. Another issue is the distinction between quantitative, reductionist science based on deduction and qualitative, holistic science, based on inductive synthesis IE- Traditional East Asian Medicine (TEAM). The later is not guilty of objectifying, isolating, or undermining the autonomy of the patient in the way this article describes. TEAM is highly rigorous as a qualitative science and promotes the participation and free agency of the patient.

  7. thank you for this; a colleague and friend of mine in a related health field (she’s an RN supervisor, i’m an acupuncturist) have been discussing the problems associated with “scientism” for years. Larry Dossey, MD pointed out the same issue about biomedical science itself with regard to quantum physics in “Space, Time & Medicine” published in the 1980s. A must read for everyone.

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