15.03.2013

Medicine and Science*

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)

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