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- Herausgeber: ibidem
- Kategorie: Geisteswissenschaft
- Serie: Studies in Medical Philosophy
- Sprache: Englisch
This innovative book concentrates on the important distinction between philosophy of medicine and medical philosophy, by expanding the focus from ‘knowing that’ of the first term to the ‘knowing how’ of the latter. Thus, the idea of patient and provider self-discovery becomes integral part, method, and strategy at the basis of therapeutic treatment. Among the most important contributions of this volume, the definition of ‘Central Medicine’, overcoming the dichotomy Western–Eastern medicine and Traditional–Integrative approaches, is presented under the lenses of hermeneutics, with particular regards to neurosciences, psychiatry, and psychology. Evidence-Based and Patient-Centered Medicine are analyzed within the debate on placebo and non-specific effects. Furthermore, the clinical research presented in the appendix investigates the patient-doctor relationship, and the interactive nature of human relationships in general, including environment, personal beliefs, and perspectives on life’s meaning and purpose. Tomasi’s research covers neuroscience, psychology, philosophy, and medicine. In this book, a wide array of questions and answers pertaining to these areas is presented in a clear, readable, and detailed way, satisfying the needs of professionals, students, and anyone who enjoys the exploration of the complexity of human mind, brain, and heart.
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Seitenzahl: 754
Veröffentlichungsjahr: 2016
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ibidemPress, Stuttgart
Table of Contents
Acknowledgments
Making sure to list all the people without whom thisbookwould not have been possibleis indeed a very difficult task.It is my hope that my memory will not fail me and that all the great experiences I cherish in my heart and my mind will leave a mark, at least in part, inthewriting forthis thesis.
Firstly, I would like to acknowledge all theprofessors and academic staff at the University of Sofia"St. Kliment Ohridski"and the Bulgarian Academy of Sciencesfor all the great conversations and learning opportunities through the years: Prof. MariaDimitrova,Prof. Valeri Dinev,Prof.Julia Vaseva-Dikova,Prof.AsenDimitrov,Prof. Aneta Karageorgieva, Prof. PlamenMakariev, Prof. Nedyalka Videva,Dr. Elena Tsenkova, Ms. Deyana Andonova, Ms. Irena Cheresharova,andMs. SashaNikolova-Livsey.I also want to thank all the participants, the patients, the multidisciplinary treatment team and all the staff on the Inpatient Psychiatry Unit, Shepardson 3 and Shepardson 6, as well as all the staff at the University of Vermont Medical Center and College of Medicine. I am especially grateful to Dr. William Tobey Horn and Prof. Lou Colasanti for their assistance and supervision, and to Prof. Friedrich Luft as well as Dr. Ilaria Rubbo for their work and contributions. I also want to acknowledge the wonderful example of Dr. Dietfried Schönemann and Ms. Margarethe Wiedenhofer in helping me discover a true passion for medicine.
Furthermore, a big thank you goes to the Inpatient Psychiatry Group Therapists Carol Clawson, John Derivan, Lindsay Enman, Sheri Gates, Kevin Melo, Annie Rapaport, Emily Reyns, Joshua Shupp-Star, Adoria Tudor, and Alixandra West.I want to acknowledgethe great support ofthe University of VermontCollege of Medicine, theUniversity of Vermont College of Medicineand the University of Vermont Medical Center, especiallyDr. Robert Pierattini,Dr. Alan Rubin,Lauren Tronsgard-Scott,Katharine Monje, Stacey Ward, David Hunt,Denise Quint andGale Weld.This has been a wonderful journey and I am grateful for all the beautiful people whowere very generous in giving up some of their time totake part in our surveys and questionnaires,and the academic, research, and medical professionals who helped me with their knowledge, their insights, and their experiences.
A specialблагодаряВимногоgoes to my Professor Dr. Alexander Gungov. He has been an incredible source of academic strength, interesting and passionatedebates, and constant encouragement.Iam grateful and trulyprivileged to be receiving the attention ofsuch anoble person and wonderful teacher.
Last but not leastI would like to acknowledge the understanding, the support and the encouragement of my family both in Europe and the USA, especially my wife Livija and my son Lucas Andrej.
This study is dedicated to you.
DavidLågTomasi
Foreword
Does medicine warrant its own philosophy? In antiquity, doctors and philosophers identified the physical body as the space in which life was located and originated. They used the word psyche or soul to refer to forces organizing, inspiring, and energizing the body. Ancient physicians strived to achieve a balance, an aequinimitas in their patients; William Osler strived to achieve the same for the physicians themselves. Probably both patients and physicians need to be in balance. My pathologist friends tell me they have never encountered a soul; what a pity! Of course, by the time they arrive on the scene, the souls are gone. The soul is an octopus, multi-armed, since it organizes growth, development, and the exercise of full-ranged natural capacities.
Medical philosophy includesepistemology, ontology/metaphysics,aesthetics,and ethics of medicine.Perhaps the most notorious disciplineis medical ethics, which overlaps with bioethics. Philosophy of medicinecan be distinguished from the philosophy of healthcare, which is mostly concerned with ethical,political, and overall economicalissues arising from healthcare research and practice.Medical epistemology today includes the genome and all the"omics"disciplines. Necessarily,"evidence-based"medicine (EBM) must also be included. This"buzz"wordis an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designedclinical trialsandcarefullyconductedprospectiveresearch.Not only the economic implications are obvious, but also the Hippocratic admonition to"do no harm"arises here. Physicians conducted worthless blood letting for two millennia before the practice was discontinued.
Our author is a psychotherapist; the term"soul doctor"would do his philosophical mission too little justice. Tomasi aims to explore the relationships between medicine and philosophy particularly with regards to neurosciences, psychiatry, and psychology, since these areas of medicine particularly address connections between mind and body. René Descartes concerned himself with this same (more limited of course) issue, termedCartesian dualism.Descartesmade ontological space for modern medicine by separating body from mind–"while mind is superior to body as it constitutes the uniqueness of the human soul"(the province of theology), body is inferior tothemind as it is mere matter. Medicine simply investigatesthe body asamachine, maintain the non-philosophers.Tomasi introduces his material and the numerous chapters that divide his topic. Interestingly, he cites Aulus Cornelius Celsus, whom most physicians will not know. This Roman encyclopedist compiledDe Medicina, a compendium on diet, pharmacy, surgery, and related fields (25 BC–50 AD). During Celsus'time, medicine was clearly a part of philosophy and evolved, as did philosophy, to include development of the scientific method (Bacon and Descartes) and a steady march of ethical principles from Hippocrates, who moved towards empiricism to Kant who formalized a respect for moral law.
Tomasi briefly reviews the topic of medical philosophy historically. He touches on highlights, including Galen's treatise,The best physician is also a philosopher.Galen was very interested in the debate between the rationalist and empiricist medical sects, still a timely topic. Nevertheless, Galenwas primarily a scientist (albeit limited)and all of his claims could be supported by scientific evidencerelated to his time. Relevant to the thesis topic, Galen believed that there isno distinction between the mental and the physical. Tomasi carefully outlines his questions.
Hermeneutics (text interpretations) is a controversial topic that has particular political and economic implications. Interestingly, Tomasi considers the case of Paracelsus who named himself after Celsus and stayed true to his real name that includes Bombastus. Modesty was not one of his virtues. Paracelsus would probably not have survived EBM, even in his own time. His hermetical viewsthat sickness and health in thebody rely on the harmony of Man (microcosm) and Nature (macrocosm)come across well today.Indeed,Paracelsus is credited as providing the first clinical/scientific mention of the"subconscious". Tomasi's brief discussion of hermeneutics and suicide is very timely. The topic of"assisted suicide"where physicians act upon patient requests is currently hotly debated.Pythagoras, for example, was against the act, though more on mathematical, ratherthan moral grounds, believing that there wereonly a finite number of souls for use in the world, and that the sudden and unexpected departure of one upset a delicate balance.
Hegel would be shocked to encounter neuroscience, perhaps less so phenomenology. Tomasi emphasizes Hegel'sPhänomenologie des Geistes.Hegeldivides consciousness into sense-certainty, perception, and force through understanding. The physicist Ludwig Boltzmanncriticized the obscure complexity of Hegel's works, referring to Hegel's writing as an "unclear thoughtless flow of words."Mathematics is extremely important to philosophy, and as far as the reviewer knows, pure mathematics is ana prioriexperience. Tomasi suggests that mathematical modeling is of value. He could not be more correct! Medicine will drown in systems biology (or systems medicine). The hope here is that by gathering all information on a patient, all clinical data, her/his genomic sequence, all proteins she/he produces or can produce etc., some medical insight will be accrued. The proponents call this approach"Big Data". George Orwell would have used the term"Big Brother". Medical philosophy is desperately needed here.
Is the patient still at the center of the work? Here, Tomasi delves into Aristotle and Kant. Particularly the latter is important here and the reviewer is interested in Kant's doctrine of right and doctrine of virtue. Tomasi provides a helpful table model of physician-patient relationships. Notable is the subheading,"experimental philosophy". Can medical philosophy be subjected to EBM? We shall see!
Wither complementary, alternative, and traditional medicine? The ancients (balance wheels) taught primarily that.Alternative medicine is any practice that is put forward as having the healing effects of medicine, but does not originate from evidence gathered using the scientific method,is not part ofbiomedicine,nor is contradicted by scientificEBM.This groupingconsists of a wide range of health care practices, products and therapies, ranging from being biologically plausible but not well tested, to being directly contradicted by evidence and science, or even harmful or toxic.Despite significant expenditures on testing alternative medicine, including $2.5 billion spent by the United States government, almost none have shown any effectiveness greater than that of false treatments (placebo), and alternative medicine has been criticized by prominent figures in science and medicine as being quackery, nonsense, fraudulent, or unethical.
If we could chide the ancients, we could mention that they concerned themselves with the wealthy andthe"worried well". Hippocratesdid not serve in the Peloponnesian wars where he might have observed blood, yellow bile, black bile, and phlegm in the flesh of his dying patients. Galen served the wealthy Romans. No evidence is known that he sought out the typhus, malaria, sepsis, worm-ridden, or wounded Roman patients that must have surrounded him everywhere. Earth, Fire, Air, and Water were not the issues because his patients could afford all these attributes. Were these two icons solely"society"doctors? "According to many defenders of the scientific and therapeutic superiority of modern conventional Western biomedicine, the positive results of alternative therapies are entirely due to the placebo effect."These therapies also have rough sledding in EBM, except for influences of political correctness.
Much of philosophy through the ages has concerned God and proving that God exists. Plato believed in the afterlife. Many philosophers developed proofs (scholastics and beyond) and perhaps proofs are not necessary.Spinoza equated God with the material universe. He has thereforebeen called the "prophet" and "prince"and most eminent expounder of pantheism. More specifically, in a letter to Henry Oldenburg he states, "as to the view of certain people that I identify God with Nature (taken as a kind of mass or corporeal matter), they are quite mistaken".For Spinoza, our universe (cosmos) is a mode under two attributes of"Thought and Extension". God has infinitely many other attributes,which are not present in our world.Einstein stated that he believed in Spinoza's God. Back we move to the soul octopus; could we all meet together on that issue?
Tomasi mentions Rudolf Steiner. Steiner was a 19th-early 20thcentury phenomenon, who founded"anthroposophism", in central Europe. The movement he founded attempted to find a synthesis between science (about which he knew little) and spiritualism (where he was a self-proclaimed expert). This movement should not be underestimated. In thephilosophically oriented phase ofhis movement, Steiner attempted to find a synthesis between science and spirituality. His philosophical work of these years, which he termed spiritual science, sought to apply the clarity of thinking characteristic of Western philosophy to spiritual questions.Steiner advocated a form of ethical individualism, to which he later brought a more explicitly spiritual approach. Steinerbased his epistemology onJohann Wolfgang Goethe's worldview, in which:"Thinking…is no more and no less an organ of perception than the eye or ear.Just as the eye perceives colors and the ear sounds, so thinking perceives ideas."But then again, Goethe was a pretty good poet, but was he a philosopher (or was Steiner)?
Tomasi also discusses Camus and Sartre.Camus's first significant contribution to philosophy was his idea of the absurd. He saw it as the result of our desire for clarity and meaning within a world and condition that offers neither, which he expressed in The Myth of Sisyphus and incorporated into many of his other works, such as"The Stranger"and"The Plague".Sartre's primary idea is that people, as humans, are "condemned to be free"(lovely idea).Sartre read Martin Heidegger's,"Being and Time", an ontological investigation through the lens and method of Husserlian phenomenology (Edmund Husserl was Heidegger's teacher). ReadingBeing and Timeinitiated Sartre's own philosophical enquiry.Reviewing Sartre'sBeing and Nothingnesswe would rely on Gustav Boltzmann's interpretation of Hegel. Nonetheless, Tomasi synthesizes this material well (as well as it can be done). Perhaps in this chapter, Joseph Heller could have appeared. Catch-22 is a paradoxical situation from which an individual cannot escape because of contradictory rules.An example includes:"To apply for this job, you would have to be insane; but if you are insane, you are unacceptable for the job". A mathematical description has been worked out to solve catch-22.
What is meant byTranslational Science?This clinician is grateful for a philosopher's answer. Take for instance the first public health measures (Avicenna), and the first vaccinations (before and after Jenner). We are continuing to and already have eliminated numerous diseases (small pox,"great"pox, polio, tetanus, diphtheria, pertussis and others) from the planet.Translational research applies findings from basic science to enhance human health and well-being. In a medical research context, it aims to "translate" findings in basic research into medical and nursing practice and meaningful health outcomes. Translational research implements a"bench-to-bedside"approach, from laboratory experiments through clinical trials to point-of-care patient applications,model, harnessing knowledge from basic sciences to produce new drugs, devices, and treatment options for patients.Most clinicians/scientists operate in the opposite direction, namely from patient-to-bench. Politicians call the buzzwords here and unfortunately they are overwhelmingly economic rather than directed at curing or eliminating disease. Clinicians have been performing this mission since Celsus, to Paracelsusas best we can. We need to lean back, breathe in, and read books such as this to rediscover the ground upon which we stand. Albert Einstein is quoted:"When I study philosophical works I feel I am swallowing something which I don't have in my mouth". He managed relativity and we can too. Our author can help us in managing the field.
Friedrich C. Luft, MD
Professor of Medicine
Introduction byWilliam Tobey Horn
In an effort to understand the mechanisms causing individuals'suffering, psychiatrists often focus on neurobiological theories, neuroimaging, and lab values, sometimes obscuring the very patients they are attempting to understand. Absent intention to comprehend the nuances of the human experience, many psychiatrists succumb to materialistic biological reductionism. As a psychiatrist, I have found that to counter the temptation of reductionism it is essential to apply intention to the development of the patient-provider relationship. Establishing quality relationships enables psychiatrists to avoid treating patients as neurobiological abstractions and allows them to instead understand the entirety of a patient's unique experience. Moreover, these relationships are integral to helping a patient heal. Reading Dr. David Låg Tomasi's book, Medical Philosophy: Philosophical Analysis of Patient Self-Perception in Diagnostics and Therapy, and my great fortune of having the opportunity to be his clinical supervisor at the University of Vermont Medical Center reified and expanded this perspective.
On meeting Dr. Tomasi, I was immediately struck by his generosity of spirit, compassionate nature, impressive intellect, and diversity of interests and knowledge. These personal qualities are evident throughout his book and give life and meaning to his philosophical and empirical analysis. Philosophical analysis is critical for psychiatry—and all of medicine—in that it leads us to question and challenge our assumptions. When philosophical analysis is combined with an empirical study, as Dr. Tomasi accomplished in this book, it grounds the analysis in something more translatable to non-philosophers. As a result, the work can have a more significant impact helping those in the medical profession better understand how to help patients heal.
In his book, Dr. Tomasi defines the diverse underpinnings of Medical Philosophy and elaborates on how these underpinnings inform the field's role in academics and society. A bold and visionary thinker, his analysis of diverse topics—such as patient self-perception, the mind-brain problem, the limitations of evidence-based medicine, the role of complementary and alternative medicine, and the impact of patients'faith and/or connection to a higher purpose on healing—demonstrates how Medical Philosophy can help to shape our understanding of medicine, psychiatry, psychology, and neuroscience. Moreover, he explains how Medical Philosophy can help these fields focus on individuals and their humanity. His own work achieves this aim.
Dr. Tomasi's book highlighted what I have observed in academic psychiatry, that many psychiatrists are dismissive of interventions outside of the sphere of evidence-based pharmacological and therapeutic approaches, for example rejecting treatments from the world of complementary and alternative medicine. Yet, our patients are turning to these interventions in ever-increasing numbers. Moreover, interventions such as mindfulness and meditation that were once considered"alternative"have research to support their effectiveness. This is not to say that all"alternative"modalities of treatment are simply awaiting anointment as the next evidence-based treatment. Rather, patients might perceive benefit from treatment that conventional medicine has not yet recognized—and might never recognize—as effective. Most importantly, to best help the patient heal, the provider needs to listen openly to the patient's experience and not dismiss outright that which the provider does not understand or agree with. Working with Dr. Tomasi in person, I was influenced by his compassion and openness with patients. Reading his book reaffirmed this humanistic orientation to patient-provider relationships for me, as I expect it will for most readers.
Dr. Tomasi was beloved by patients on the Inpatient Psychiatry Unit at the University of Vermont Medical Center. Frequently, patients with whom I had a difficult time connecting opened up to Dr. Tomasi—often through discussions of spirituality. Dr. Tomasi's work highlights that many patients benefit from a spiritual orientation, one that gives their lives and their healing process meaning. Dr. Tomasi's work taught me that exploring patients'own spirituality and higher purpose in the context of the patient-provider relationship can be integral to recovery and growth.
Dr. Tomasi's book deepened my awareness of the shortcomings of medicine and of psychiatry. His work also offered and inspired potential solutions to overcome these shortcomings. Most importantly, his work enhanced my understanding of the patient experience and, in doing so, my understanding of what it means to be human. I believe that most readers will share this experience.
William Tobey Horn, MD
Assistant Professor of Psychiatry
University of Vermont Medical Center
Introduction
Philosophy is the mother of all sciences.
Exploring the relationship between medicine and philosophy is somewhat akin to exploring the connection between philosophy and science as a whole.Where do the interdisciplinary fields of theoretical medicine, medical philosophy, cognitive neuroscience,and neuropsychology intertwine?Why isthere a need to address questions such as the ones usually found in medical science within the framework of a philosophical analysis and/or debate?
This study intends to analyze the various philosophical perspectives within medical science, with a particular focus on those disciplines, such as neuroscience, psychiatry,and psychology, dealing with the direct connection between mind/brain and the rest of (human) body. More specifically,ittriesto address issues related to the above listed topics taking in consideration the perspective of the patient, in terms of perception and self-perception, within the framework of diagnosis and therapy.Furthermore, thisinvestigationfollows the specific structures and methods of the theoretical approach witha specificepistemological analysis of comparative empirical research. The ultimate purpose is to open up the discussion and generate new questions, inferring information from the data examined as well as the reasoning process.Furthermore, the aim of this research is directed at a deeper understanding of human nature, examining the links and mutual influence between perception, beliefs, sense of meaning and purpose,and the healing process.We divided this study into seven main areas of investigation, corresponding to seven chapters. The first chapter discussesgeneral aspects of Medical Philosophy, including a broad overview of its history, defined questions and applicability of results, and the relation between the epistemology of medicine and some elements of the comparison (also in causal terms) between self-image and the healing process. In chapter two we analyzethe language, the reasoning and cognitive processes, and the methods of several philosophical perspectives. We also compare them with the methodologies used in modern medicine, thus drawing important considerations as to why the analysis of psychology and psychiatry is especially important and useful in our analysis. The third chapter discussesa specific set of philosophical considerations, starting with Hegel and Merleau-Ponty but without forgetting the classics and the postmodernists (and making surenot toignore terms often associated with philosophy of mind), in search of the best way to address fundamental questions such as the mind-brain and embodied cognition problems, and suggesting a model. A further explanation of the goal of the studyis alsoincludedin this section. With chapter 4 we literally put the patient"at the center of therapy", discussing the core issues of perception and self-perception, experimentation, and therapeutic implications. The fifth chapter represents one of the possible applications of Medical Philosophy in clinical settings. The debate around Integrative Medicine is at the center of modern scientific investigation and public policy, and we attemptto examine claims, theories, and practices under the lenses of logic, culture and identity following again a multifaceted examination of what it means to be human. For chapter six and seven we present apossibleconnection on a deeper level; the first addressing transcendental elements, the second translationalelements. Chapter six discussesall those consideration that"lie between worlds"and represent the connection between the individuality ofhuman beingsand a sense of (higher) purpose and meaning. Chapter seven instead usesthe broad range of topics covered in the first part of this writing and re-morphsthem into a discussion on research method and scope, social implications, and epistemological suggestions without solution of continuity. The Appendix at the end of this volume represents part 8 of our analysis. It presents the empirical research conducted at the University of Vermont Medical Center, Inpatient psychiatry Unit, through theFocus Group Questionnaire, and theHealth Perception Survey.
The debate between an Evidence-based medicine(EBM)and a patient-centered medicine(PCM)is a logical outcome originating in these considerations, and the practical application of one perspective versus the other will certainly impact not only the theoretical premises of such science, but the very effect of clinical approaches, from the relationship between patient and health care provider, to the structuralization and scientific base of the definition of (a specific) illness or disease, its diagnosis, prognosis, and treatment, thus the whole medical-therapeutic spectrum.Medical Philosophy has been with us from a very long time; in fact we could argue that the name itself representsan alternative synonymical version of"Philosophy of medicine"or"Iatrophilosophy", thus comprising a vast spectrum of subfields such astheoretical medicine,epistemology, medical and bio- ethics, ontology and metaphysics. At the same time, Medical Philosophy represents the theoreticalbase for disciplines like metaethics, philosophy of healthcare, public health (policy)and healthcare practice.From this perspective, Medical Philosophy could possibly include, or at least be strongly interconnected with,the modern field of translational science, and even move beyond it.The interaction between medicine and philosophy was a fact since the very beginnings of our civilization, especially within the geographical and cultural apparatus of what is now considered the European (sphere of) influence, in particular in ancient Greece.
The roots of the Apollonianphilosophia divinaare translated into themedicuswho, not only observes, examines, discusses, diagnoses, treats but alsounderstands, knows, comprehends and"measures"or"expresses, talks about, gives voice to, pronounces"a"measure"[1]. In this sense, Medical Philosophy is a synthesis of this interaction, which once more connects the termsDoctorandMedicusin a broader and deeper sense, which ultimately impacts the translational aspects of such science. According to Aulus Cornelius Celsus,
"At the beginning medical science thought of itself as part of philosophy, because both the treatment (cure) of diseases and the analysis (contemplation) of natural things are known due to the work of the same authors, especially given that the ones who resorted to medicine were the ones who weakened their body in the quietness of meditations and in the night vigils. Thus, we know that we can find many learned philosophers in this science: among them the celebrated Pythagoras, Empedocles, and Democritus. Hippocrates, whom some believe to be Democritus'disciple, was in fact the first one, among all those we should mention, to separate this discipline [medicine] from philosophy."[2]
Chapter 1A brief history of Medical Philosophy
1.1General Aspects
In recent times, especially between the mid to the late twentieth century, the debate around Medical Philosophy addressed the problematic aspect of separating philosophy of medicine from either philosophy or medicine, thus creating a separate discipline. In order to better understand what Medical Philosophy is, studies, relates to, provides in terms of scientific research etc., we must be clear on the meaning and definition of the concept. AsTheoretical MedicineorScientific Medicinewe identify a specific part or branch of medicine interested in the analysis and debate of theoretical, scientific, epistemological, ontological, methodological, conceptual and linguisticaspects of the discipline and its related research and practice. In fact, from a purely academic perspective, the study of medicine presents in this modern day and age a vast array of definitions, titles and degrees, suchas MBBS, MFM, MD, ND, Dr.rer.med., Dr.med.scient., PhD, ScD/Dsc, DClinPract, DClinRes, etc. In practice, the fields of philosophy and medicine are deeply intertwined as shown through the analysis of main questions pertaining to both fields, as well as by simply examining what practitioners and researchers do in their everyday clinical and scientific work. Certainly, in the analysis of conceptual and methodological issues raised by the current scientific (especially medical) research, we understand how Medical Philosophy overlaps with fields such as bioethics or public health policy, not to mention translational science. Why is there a need to address the existence of this separate discipline?
Specifically, the ontology of general medical science and its analysis of the conceptual terms used in medical research and practice arise from the philosophical aspects of the ontological revolution. This dramatic shift in logical definitions due to a new perspective on reality, from an omnicomprehensive organismic viewpoint to a more materialistic, definitely mechanistic one, is arguably connected with the Cartesian dualism in theoretical and applied science. At the same time, important theoretical discoveries in the field of medicine contributed to this new paradigm. A giant of theoretical medicine, histology and microscopical anatomy, the Italian physician and scientist Marcello Malpighi, stated that the body was indeed a machine. Another champion of iatromechanics, William Harvey (who also studied in Italy at the University of Padua) also worked beyond the Hippocratic-Aristotelian-Galenic methodological framework, by presenting an explanation of (human and animal in general) physiological phenomena in mechanical terms. A similar worldview was the one of Giovanni Alfonso Borelli, widely considered the Father of biomechanics (as well as teacher and mentor of Malpighi). From this perspective, their scientific method could arguably be included in a radical reductionistic sphere, as opposed to a vitalistic one, and as base for the modern scientific method in medicine.Furthermore, we could argue that these premises are to be considered the necessary conditions for a further development, starting from the XIX century on, of a scientific method whose epistemological analysis is rational (and, according to some, rationalist), realist and methodologically skeptical, and whose philosophical viewpoint and ontological nature is materialist (or, again, materialistic) and systemic (which is notdiastemic, we should note).
These factors have had a direct impact in the noseological classification of illness, as defined by an evidence-observative-etiological base toward a monogenic conception of disease. But this epistemological debate is right understood only if we still want to consider the association between philosophyand medicine, from the ultra (in terms of qualitative overcoming) identification of Galen in his treatiseThat the Best Physician is also a Philosopher. To be sure, Galen also followed Hippocrates in warning medicineagainsta certain type of philosophy, namely some of the considerations of the Pythagoreans and more generally the pre-Socratics. In fact, his modality of direct observation constituted anin mediostandpoint, between rationalism and empiricism.Historically speaking, parallels between medicine and philosophy are at the center of the fundamental works by Avicenna, Averroes, Al Farabi, and Maimonides.
The beginnings of medical science and of the scientific worldview in general are deeply rooted in the continuous historic change which ultimately led to the social and cultural movements of the Renaissance, all the way to the Age of Enlightenment. We do not know precisely the specific features of the human worldview in ancient times, and from this perspective the fields of archaeology and anthropology do represent a fundamental support of any kind of knowledge on the subject of medicine, and of science in general. We postulate, based on the current comparative knowledge, that archaic sciences were based on a complex collection of magic, mystical, spiritual, divine,and perhaps obscure forces, although we cannot assert for sure that all these forces were necessarily embodied in quasi-human form, as it is often depicted with good and evil spirits, demons, gods and goddesses, tricksters, angels,and similia. We also know that some cultures used rocks, bones,and symbolic signs like divinized alphabets letters to predict a specific medical or social/personal outcome, for instance in the case of the Runes or the work of theAugures. In this sense, we understand how the process of healing was believed to happen through the help of special contacts and connections with higher (or lower) spheres of reality. What is important to notice though, is that in ancient times, and from a certain point of view this reflects also in contemporary tribal autochthonous cultures such as the aboriginal and east/west African, diseases and related therapies and possible cures present a social dimension. Thus, the healing process, although led by a superior, and in some cases mysterious, power was ultimately connected to the patient's own culture, ethnic environment or (family, tribe, village, etc.) society. We could argue that this would fit into a dualistic worldview, with a material(istic) elements such as plants, flowers, potions, amulets, rocks, etc.,and spiritual(istic) connections (as explanation) such as spirit guides and gods, all tied together by a combination of spiritual-materialistic practices and rituals. In these practices we recognize the healer's (and, in some cases, the patient's) altered state of consciousness, the meta-communication with a different realm of reality or astrological investigations. We could also argue that other practices, some still present in current times also in the Western society, especially in complementary and alternative medicine, present a layered interpretative structure of explanation, function, and purpose of medical treatments. Please note that we use the termWesternthroughout this volume in a broader, and yet translated sense. There are certainly plentiful elements within Western culture which could and should rightfully be considered the philosophical, cultural, and scientific basis for many integrative, complementary and alternative approaches, as we will see in the concept of"Central Medicine". In this sense,"Western"indicates a culture that is generally intended to be derived from a European/Indoeuropean (or related through cultural exchange, as well as precursors) substratum, specifically originating from [in alphabetical order] an Arabic, Baltic, Celtic, Germanic, Hellenic, Jewish, Latin, Slavic, Turkic, Ugro-Finnic, Basque, etc. cultural heritage). However, due to the very historical nature of the evolution of Western culture, some of the aforementioned approaches are not considered"conventional"and"standard"in modern times. This especially true from anon-continental(in the philosophical sense) perspective and especially in regard to the development of Western culture in the USA and the Commonwealth areas. We argue that part of the reason for this situation is again historically connected, and more specifically related to the cultural and philosophical"split"between a shared, traditional, folk, ethnic (etc.) background which (in the case of Europe)"naturally"(which is not to say"without struggle") evolved into modernity (e.g. in the case of rational thoughtand scientific method), and was instead"uprooted"and"separated"from its (this) origin (in the case of USA & Commonwealth), so that in the latter case, the very history of (medical) science dates to the time of European expanding (and colonizing) abroad, especially since the XIX century[3]. This is precisely why in this study we propose and defend the position according to which a more comprehensive view in medicine, especially from the patient-provider relationship standpoint, is very much needed. It is a work of reconnecting, even recollecting. We find this heritage in the case of practices such as iridology, homeopathy, chirology, (according to some) chiropractic, osteopathy etc., all the way to ayurvedic, anthroposophic and general herbal medicine which is arguably connected with the Europeandoctrine of signaturesfrom Dioscurides and Galen, to Paracelsus, William Cole, Giambattista della Porta (not to mention Giuseppe Giovanni Battista Vincenzo Pietro Antonio Matteo Balsamo, best known asConte di Cagliostro), to Samuel Hahnemann and Rudolf Steiner. A good example of this practice (using the concept of resemblance to some extent directly derived from a Neo-Platonic macrocosm and microcosm schema) is the claimed positive properties of the walnut, which, due to its physical similarity to the human brain, is used in the treatment of neurological disorders. This allegorical component is described by the following words by Michel Foucault:
"Up to the end of the sixteenth century, resemblance played a constructive role in the knowledge of Western culture. It was resemblance that largely guided exegesis and the interpretation of texts; it was resemblance that organized the play of symbols, made possible knowledge of things visible and invisible, and controlled the art of representing them."[4]
From this perspective, this doctrine is not exclusively European, being extensively used also (for example) in Traditional Chinese Medicine with a series of basic components (natural elements, human senses and body organ, plant's taste, smell and color, time of the day and of the year) used to analyze and quantify their combination within the idea of body/spirit equilibrium. Thus, similarly to what happens in Ayurvedic medicine, disease and illnesses originate in the imbalance between bodily systems.
This viewpoint is shared by the importance given to arithmetic structure across cultures. In the case of the Chinese (medical) science and philosophy we have the number 2 (YinandYangof Taoism), the 3 (Vayu, Pitta, Kapha) for the Indian tradition, the 4 humors for the (Greek) hippocratic method (Blood-air; Yellow bile-fire; Black bile-earth; Phlegm-water)[5]; the 6 (3+3 opposites) for the Jewishkabbalah, the Mesopotamian 7, etc. The very conceptual background behind this point of view needs further analysis, especially when we realize that the vast majority of the above mentioned assumptions, scientific,and more generally philosophical in nature, are deeply embedded in a substratum (which is also asuprastratum andintrastratum) of culture and history, often addressed by Medical Anthropology, which we will be discussing in Chapter 2. In particular, we need to agree on the prominent impact and influence of the historical data on the very perception of medicine as a science, thus a Medical Philosophy which would not take in consideration history of medicine and more in general history of culture, is doomed to become shallow and imprecise. The analysis of the philosophical components of medicine can benefit from the Heideggerian view on perception and circumspection from the perspective of objectivity, a necessary premise in the approach and clinical application of modern medicine. In this sense we also reenter concepts such asVorhandenheitandZuhandenheit. In the attempt to understand the patient, his singularity and individuality, both in cultural and diagnostic terms, we could argue that this circumspection is in part based on a form of pre-reflective understanding, in the hermeneutic tradition, of the patient 1) as a whole, and 2) as an individual. This alternating form of path to knowledge, from the medical perspective, is appropriately identified by Tucker:
"We all know this but over the ages this art/science ratio has undergone a dramatic change. The medical pendulum is swinging from the art to the science side. However, in my opinion, the best clinician is one who armed with this scientific knowledge, practices using excellent clinical judgment (which of course is his art). Compassion and understanding are a large part of this art."[6]
Certainly, the decision-making apparatus that every physician needsto possess in order to accurate diagnose and treat a specific illness or disease is a necessaryconditio-sine-qua-nonof advanced, empirical, rational,experimental modern medicine. In this sense there is nothing"magical"about the physician ability to link the individualquadro clinicoto the pathology of the case. The problem indeed is how to contextualize the situation within the parameters of observable data and patient's history. The physician here is required to follow the rules of the most recent, cutting-edge biomedical research, in particular the combination, appropriately addressed by philosophers such as Bluhm and Bunge, of Randomized Control Trials and theoretical approach to investigate mechanisms of action. How does Medical Philosophy address the issues related on the very approach, attitude and education in the field of medical science? Further help can come to use from the words by Mark Wrathall in discussing Hegel's position on technology:
"So, for example, education is increasingly aimed at providing students with'skills'for critical thinking, writing and study, rather than at teaching students facts or training them in disciplines. This is because skills, unlike disciplines, will let students adapt to any conceivable work situation. This is driven by the need for an economy that can flexibly reconfigure itself and shift its human resources into whatever role happens to be necessary at the moment"[7]
1.2Applicationand epistemological considerations
a)Defining the questions
In this sense we also understand the methodological component of medicine as addressed by Medical Philosophy, a discipline that is interested in addressing questions such as:
§How can we understand the specifics of scientific method within medicine from the perspectives of ontological revolution and (Cartesian) dualism[8], especially in the context of the mind-body or mind-brain problem?
§Is a disease or illness a mere list of clinical signs and/or related biomarkers?
§Are clinical data, albeit valid in terms of quantity and quality, sufficient (although here we should not forget the parameters of'necessary'or'required') to describe a disease and provide a correct diagnosis?
§Is contemporary medicine a combination of Evidence-Based Medicine and Theoretical Medicine?
§DoestheHierarchy of Evidence need re-examination in its order, content and concept?
§Are Randomized Control Trials necessary and sufficient to validate a therapeutic intervention?
§To what extent the positivistic aspects of the lack of hypothesizing and mechanism-seeking are still part of medical science and practice?
§How do we define things, in ontological and epistemological terms, which we do not perceive with the commonly accepted array of scientific methods and technologies?
§Is medicine a form of natural philosophy, a (hard) science or craft, technology, art?
§Is it possible to integrate the above form and definitions of medicine, also in relation to the steadily growing aspect of medical and scientific technology?
§What is the room for each of these aspects in medical curriculum, education and academia?
§Why is it necessary to define forms of complementary, alternative, traditional, non-traditional, school-, and scientific medicine?
§How do we define the above mentioned forms of medicine,and should these be included in medicine as a therapeutic science?
§How do we define placebos, their biological effects, and their clinical and medical efficacy?
§Are there universal biomedical truths or do we have to include and/or control for individual, culture, ethnicity, society, personal beliefs, spirituality and religion in addressing this question?
§To what extent is modern academic, pharmacological and biomedical research affected, or even controlled, by commercial interests?
§Do philosophy, philosophical debate and positions contribute to the advance of medicine as a science and therapeutic practice?
§Furthermore, is it necessary to select/exclude specific philosophies and/or philosophical methods from the paradigm of Medical Philosophy?
The last question in particular addresses a key problem in defining what Medical Philosophy is, does and ought to/should do, and if is essentially and structurally different from Philosophy of medicine. James Marcum gives us his definition:
"I opt for the philosophy of medicine relationship, which I hold to be a sub-discipline of philosophy. The relationship between the two disciplines is more than simply philosophy and medicine in that they share more than common problems and is more than philosophy in medicine in that philosophers use medicine not just to do philosophy but to understand the nature of medicine itself. I define philosophy of medicine specifically as the metaphysical and ontological, the epistemological, and the axiological and ethical analyses of different models for medical knowledge and practice. Such a definition is rooted in a standard topology for philosophical analysis. The aim of this analysis is to unpack the nature of medicine itself as articulated in the question: What is medicine? This question is at the center of the quality-of-care crisis facing modern western medicine and represents the primary issue for my philosophy of medicine"[9].
Beside what medicine is,in this study on MedicalPhilosophy we are asking ourselves what medicine does and ought to do, especially from the perspective of patient-provider relationship. In particular, the very existence of patients and disorder are questioned by some[10]in their ontological and epistemological existence and justification. This is especially true in the fields of psychiatry, psychology and mental health[11]. In fact, even from the perspective of scientific application and therapeutic effectiveness, these fields are subject to an enormous and fast paced change, although they are far from the success of other branches of medicine[12]. This lack of success is to an important extent, due to the very nature of the problems related to mental health, which are not only biological, but also philosophical, and spiritual. Certainly this is not to say that philosophy alone or biology alone will be able, in reasonable time, to completely solve all these problems. However, we argue that the most effective way to understand the complexity of human beings in relation to psychological issues is to combine all the aforementioned perspectives in a solid theoretical discussion[13]. However, there are also difficulties in achieving this goal, ultimately because of the great differences between philosophical positions, which do not all follow the same pattern, target or method. For instance, Mario Bunge is especially critical of a vast array of philosophical positions, originating in Aristotelian, Pre-Socratic, Continental and Postmodern philosophy and beyond:
"The ancient Greeks made much of the difference betweenepistemeor science anddoxaor opinion. The postmoderns deny this difference, but the rest of us have kept it because we care for truth and well-grounded action"[14].
"[…] physicalism and chemism were primitive but perhaps unavoidable phases of materialist philosophy, biology, and medicine"[15]
"In short, in medicine, as elsewhere, we must distinguish peel from pulp. This distinction, inherent in scientific realism, is denied by the anti-realist philosophies, such as objectivism, phenomenalism, fictionism, and conventionalism"[16]
"The history of anatomy confutes Karl Popper's thesis (1963) that scientific advances are not born either from observations or from experiments, but from myths and criticism of the latter"[17]
"[The] combination of rationality with materialism and with the realistic principle of the autonomous existence, lawfulness, and intelligibility of the universe was unique and it was modernavant la lettre. This may also have been the main contribution of pre-Socratic philosophy. It was indeed a new way of looking at things and exploring them, that overcame confusions, obscurities, fantasies, and irrational fears. What a contrast to the obscurantism and pessimism of the self-styled postmoderns, in particular the radical skeptics and the constructivist-relativists! These philosophers inhibit the search for truth because they deny that it is possible and desirable; they suspect that scientific research is a political conspiracy and attempt to pass off obscurity for profundity"[18]
It is interesting to note, that Bunge speaks of"Psychiatry [as] the only branch of medicine where symptomatic diagnosis still prevails – a clear sign of its backwardness"[19]. We must certainly agree that the lack of further scientific (biomedical, empirical, as well as theoretical) basisto the definitions and claims of modern psychiatry represent a lack of the discipline. At the same time,wewould argue that this scientific handicap could perhaps lead to a new way to look at psychiatry, and medicine as a whole. Does that mean that medical practice should just focus on personal impression, or even intuition? Bunge continues:
"The so-called clinical eye is a kind of intuition, or pre-analytic and fast thinking. We indulge in it when pressed for time or lacking in information. But only the intuitionist philosophers, like Henri Bergson, George E. Moore, and Edmund Husserl, have claimed that intuitions are infallible"[20]
Is it therefore absolutely no room for pre (perhaps non-) analytic thinking and/or intuition in medical practice? Trosseau argues:
"The worst man of science is he who is never an artist, and the worst artist is he who is never a man of science. In early times, medicine was an art, which took its place at the side of poetry and painting; today they try to make a science of it, placing it beside mathematics, astronomy, and physics"[21].
Perhaps we should investigate a little more not just the concept of intuition, but certainly the relationship it has with more psychological, and generally neurological models such asshort-, mid-, and long-term memory. Many have in fact argued for the imprecision of human intuitive powers, when these can be linked with memory-related phenomena such assource misattributionandconfabulation. For instance, we could refer toperceptual blindnessandinattentional blindness, as relatively recently presented inthe Invisibile Gorillaand the related"Gorilla experiment"by Chabris and Simons[22]. In fact, the authors refer to their experiment and describe some of their methods as
"[using] a wide assortment of stories and counterintuitive scientific findings to reveal an important truth: Our minds don't work the way we think they do. We think we see ourselves and the world as they really are, but we're actually missing a whole lot. […] Again and again, we think we experience and understand the world as it is, but our thoughts are beset by everyday illusions. […] The Invisible Gorilla reveals the numerous ways that our intuitions can deceive us."[23]
Without examining all the specific characteristics of such models, we have the duty to investigate what me mean here, in a scientific and clinical setting (especially when medical decision making processes are involved), by"counterintuitive","our minds","deceiving"and the very relation between"illusion"and"intuition". In fact,"many researchers have commented on the complexity and possibly elusive character of medical reasoning"[24]. To be sure, when discussing clinical decision-making, we cannot put educated and experienced physicians as well asothermedical practitioners in the same category as the general public, and for this very reason we should not apply the same discourse and expectations. However, if it is true that by"us"the authors here intend human beings in general, regardless of their titles or academic experiences, we should really ask ourselves (this time all of us, or at least the ones interested in these themes[25]) whether this lack of"intuitive infallibility"affects medical diagnosis and prognosis in important ways, in terms of quantity and quality. This is certainly another central theme addressed by Medical Philosophy. Therefore, we must at least go back to the most commonly accepted definition of intuition within the philosophical debate, or a form ofa prioriknowledge characterized by its immediacy. This can also be applied, in a more translated way, to experiential (some even argue, existential) (form of) (personal) belief. A certain confusion arises when, especially in analytic philosophy, which to some extend sees itself (and it is seen) as acorollariumto rational and empirical science, philosophers often call on intuitive perspectives when addressing methodologies used to test and verify claims. In particular, we could refer to the platonic"Justified True Belief"[26]and its further analysis, such as the"Gettier Problem", or the works by Martin Cohen, Fred Detske, Alvin Goldman, Richard Kirkham, Bertrand Russell, Alvin Plantinga, Nicla Vassallo, and others[27]. Beyond Intuitionism (in the sense proposed by Luitzen Egbertus Jan Brouwer) and conceptual intuition, proposing a particular definition of knowledge and constructing a hypothetical case and possibly rejecting it, the core problems is the definition and distinction between the connection"state of mind"and judgment, and whether this judgment is the same as belief and/or a spontaneous manifestation, or even the (therefore postulated) necessary truth.
If we need to apply the discourse on intuition within the framework of Medical Philosophy, and linking it to the requirements and characteristics of clinical practice, we certainly must understand if the methods of philosophy, analytical, continental (and/or?) beyond are indeed valid and if they are (considering the skeptical paradigm in the process), if we can separate them from the fields of natural, social, mathematical sciences or even"common sense"(if this last concept makes sense at all, given the above listed premises of human intuition). Analytic philosophers tend to identify as"rational"those intuitions which are necessary, such as mathematical truths in calculus, as a way to differentiate them from (general) beliefs. This position concentrates on the possibility of holding beliefs which are not"intuitive", or having intuitions for statements (or, in a more analytical way, prepositions) which we can (cognitively) declare false. Another positions is simply considering intuitions as a form of experiential/experienced belief, which differs according to the personality of the individual, the cultural and social (sub) structures, beliefs (often intended as the same as intuition), religion, tradition, etc.
Furthermore, we need to remember the"basic sensory information"as found by Kant in the"cognitive faculty of sensibility", a position which is somewhat linked to the neurological concept of perception and proprioception (thus in a more physical form), since our mind, in the Kantian description, produces and morphs our intuitions within (in the form of) space, versus what happen with our internal intuitions, which (our) mind casts in the form of time. The above mentioned mathematical truths are according to Kant forms of"knowledge of the pure form of intuition", thus not empirical/experimental; a position further elaborated by Brouwer, Heyting, and in part by constructivists in general, with the special characterization rejection of theprincipium tertii exclusiand the use of thereductio ad absurdumto prove the existence of something. Should we then assume that there are different levels of intuition beyond what is scientifically acceptable? And if that is the case, how do we judge different subfield in science, from a theoretical and empirical standpoint? Bunge rightfully argues that"the weight assigned to an empirical datum relevant to a given hypothesis depends on the latter's theoretical status"[28], thus reclaiming the very importance of Medical Philosophy in the scientific medical research and practice. However, the author steers the analysis of the theoretical aspects within this philosophical subfield toward a specific set of scientific levels:
"[…] in the immature sciences, it is advisable to adopt therefutationiststrategy recommended by Popper (1935), in opposition to theconfirmationismorinductivismpreached by the positivists such as Rudolf Carnap, Hans Reichenbach, and at one time Bertrand Russell as well."[29]
"Certainly, philosophers such as Anaxagoras, Democritus, Epicurus, Empedocles and many other pre-Socratic scholars presented a worldview in which the rational element of reason was taken in (high) consideration, promoting a strong scientific foundation from philosophy."[30]
Due to the very nature of psychiatry and neurosciences at this stage of scientific development, it is definitely appropriate to maintain an epistemological approach such as critical rationalism[31]. In fact, we can argue that the subjective element, both from the perspective of the patient and the one of the doctor, plays a fundamental role, especially when it comes to empirical generalizations lacking a strong theoretical background, basis, and support. In this sense, critical rationalisms holds scientific theories"accountable", in the sense that they should be rationally criticized, and even be subjected to tests (in the case of empirical science) which may falsify them, following the principle of falsifiability. To be sure, if such claims cannot be subjected to this principle, they are not necessarily"wrong", but they are not empirical, in the epistemological sense. Furthermore, we also need to be aware of the complexity of life perspectives and worldviews on the ontological and, by extension, diagnostic aspects of psychiatry. This discipline is in fact one of the closest, among medical practices, tothe connections to and betweenpatient's and clinician's perception. The reason, once more, is the level of complexity of (human) brain and being human in general. Furthermore, one of the key concepts linking Medical philosophy and psychiatry is the focus on symptomatic evidence as foundation for the mental health diagnostic apparatus, by far inferior (if here we decide to only focus on empirical, evidence-basedresearch) to the characteristics of other branches of medicine. From this perspective, psychiatry is not too far away from the unsolved problems of ancient medicine, namely the (perceived) absence of a well-structured cause-effect relation.
Throughout history, we can identify a vast array of philosophical systems upon which medicine structured its own scientific view and method. In particular, the symbolic, transcendental, spiritual,and/ormagic worldview was the basisof the connection between human life and activities, including medical practice, with the hope and expectation of a positive outcome as result of a healing process linked to the divine element. In various forms and characters, God or the Gods intervened and/or assisted human in their path toward health/salvation (Salus
