One can
hardly argue against the necessity of a scientific basis for clinical practice.
Science for clinical practice is justifiable by being ethical or reasonable or
both: Human life is precious beyond dispute; health and well-being deserve the
maximum care and respect of the responsible and authorized professionals;
physicians possess the authority and responsibility regarding health and
well-being, therefore they must be equipped with sophisticated skills and
expertise, as well as extensive knowledge; and science is the most appropriate
means to acquire, revise, update and expand such knowledge.
Characterization of medical practice as scientific, on the other hand,
may correspond to agreement with either the first or both of the two sets of
propositions below, and this decision deserves consideration: (1) The profession must be based on scientific
knowledge, and it is possible for the profession to be based on scientific
knowledge. (2) The profession must be
based on scientific knowledge and only on scientific knowledge, and it is
possible for the profession to be based on scientific knowledge and only on
scientific knowledge.
We would agree with the first and argue against the second: It is
neither necessary nor possible for medical practice to be based only on
science. To explicate: (1) Medical profession is inseparable from value choices,
which may challenge a strictly disinterested manner with absolute obedience to
the scientific principle of neutrality. The ultimate concern of the physician
is his patient’s well-being, and this may be bound by other conditions beside
scientific facts or even be incompatible with them. (2) Medicine is exercised
in the context of human relationship, which involves emotions in every case, if
not of the same intensity. It takes special effort to remain fully neutral
towards a person whom one strives to heal. In fact, the person who aims to
maintain the proper attitude of a scientist and a physician is in a tragic
situation, in that she is constanly bound to forgo one of the two to some
extent. (3) Clinical research is almost completely limited to inductive-statistical
methods, and many clinical phenomena are too complex to lend themselves to
generalizations, i.e., the multitude of relevant variables presents a major
challenge to study power.
Although
medicine is only a profession, and not necessarily an academic one, it is
commonly mistaken as a science per se. The confusion is reflected in null
expressions like the science of medicine and
probably accentuated by the emphasis placed on the unique indispensibility of a
scientific basis for good clinical practice.
We approve the expression medical
sciences, which implies the distinction: Sciences that guide the practice
of medicine, which is a profession. Medical sciences are diverse and they are
becoming increasingly specific, from health sociology and epidemiology to high
resolution genomics and functional brain imaging. It must be emphasized here,
that despite increasing sophistication in modeling and cutting-edge technology
, conclusions are based more on generalizations than on demonstration or proof.
However, precision in methods, experimental or statistical, tends to be
attributed to conclusions, and the illusion of advanced sciences guiding
medicine tends to overshadow the robustness of fundamental and indispensible
knowledge like definite causality or structural information, established over
the years with robust, albeit less sophisticated, methods. For instance, the
affinity of haloperidol to dopamine DA2 receptors is absolute knowledge, an
established fact, whereas the degree of symptom reduction for a specific
patient on a specific dose of haloperidol can never be precisely predicted and
only inferred from the probability figures (statistics) of clinical study
reports. Similarly, increased survival rate demonstrated for a new
antineoplastic agent, an achievement of high-technology, is not a scientific
law like the cell theory or the solid information on mitotic division.
Publicity around mental illness and psychiatry has increased following
the momentum of neurosciences. Mistaking the accuracy and success of the
guiding sciences for the accuracy of information on the phenomena encountered
at practice has its repercussions not only in the popular culture but also in
the medical community: A widely and firmly held belief in the medical validity
of mental illness and an exclusively biological basis for all mental disorders,
reminiscent of the psychoanalysis era. The “brain disease” discourse around
variations of behavioral traits is not less naïve than that which adhered to
narratives pointing out repressed unconscious drives as the cause of neurosis:
Both involve knowledge that is partly factual or consistent, both admit a “need
for further studies” for the theory to be validated, both include false beliefs
reflecting incomplete understanding and oversimplification, and both have a
tendency to induce in professionals either strong advocacy, idealization and
identification or harsh criticism with disdain. As helpful as the brain disease
formulation of severe mental illnesses may have been in –arguably- diminishing
the stigma on families, it has disseminated the illusion that the symptom
constellations defining each disorder refer to a natural phenomenon, a real
disease for which cure can be expected in the near future. Moreover, credit for
the big discoveries in neuroscience has been shared by the clinical disciplines
that they apply, where, however, most of the “translation” is far from being
specific, precisely because the clinical definition is simply a construct with
questionable reliability, shaped and modified over the years by many factors,
only one of which happens to be brain dysfunction.
Credibility of the disease model in the discipline may be stemming
partly from a defensive tendency, building up with the burden of enduring
uncertainty in a field characterized by scarcity of definite knowledge,
predominance of vague clinical phenomena, blurred distinctions between
categories, difficulty establishing or
maintaining objectivity at practice stemming from the nature of the conditions
managed. Lack of an introductory course of epistemology in medical schools
might be another factor.
Medicine as a pure application of science would only have bad technique
or bad science to account for any negative outcome, which may decrease
credibility and invite unduely harsh criticism. Resolution of controversies
about professional choices by referring to scientific evidence alone would be
similarly misleading. Professional determination of method or technique in the
actual setting is shaped by many other factors, including individual differences
in value choice and reasoning style, as well as the influence of training
institutions on professional identity. Furthermore, in sciences that rely on
statistical generalization, controversial evidence is the rule rather than the
exception, and most of the time controversies simply reflect mathematical error
or methodologic flaw in one or more of the studies.
Obviously, professional training is about knowledge and skill
development, and regular professional practice rarely involves complex philosophical
justification. However, critical thinking is indispensible in order to avoid
mistaking subjective, political, ethical, and at times defensive discussions
for scientific debate grounded on absolute findings.
* Excerpt from SCIENCE PSYCHIATRY AND THE DSM (Atbaşoğlu EC & Gülöksüz S)
