Wednesday, 20 August 2008

PHILOSOPHY AND MEDICINE

PHILOSOPHY AND MEDICINE

I mentioned in the introduction that one of my aims is to attempt to exhibit medicine as ‘an integral part of scientific, philosophical, social and political life’, and to highlight the ‘philosophical’ aspects of various diseases.

It is very fortunate that there are philosophy books like the fantastic one by Bertrand Russell, ‘History of Western Philosophy’, whose full title (which is rarely put on new editions) is ‘A History of Western Philosophy and Its Connection with Political and Social Circumstances from the Earliest Times to the Present Day’, where he very successfully shows philosophy as “an integral part of social and political life: not as the isolated speculations of remarkable individuals, but as both an effect and a cause of the character of the various communities in which different systems flourished”. He also states in the first few lines of his introduction:

“The conceptions of life and the world which we call "philosophical" are a product of two factors: one, inherited religious and ethical conceptions; the other, the sort of investigation which may be called "scientific," using this word in its broadest sense”.

In the presence of his book, my aim will be a lot easier to achieve. Russell has done all the hard work; all that I can do is quote and slightly expand on what he says!

In any case, Russell’s works are what introduced me to this wonderful world of philosophy. As I learn more and more about it, the more I realize how ignorant we are of many of the deeper questions of life, and how rarely, in the hustle and bustle of everyday life, we think about them. Philosophy does not give answers; it is merely about those questions, as I explained above.

There are many definitions of philosophy; to say it is ‘the love of wisdom’ is not a definition but a translation. In addition, defining it like so ignores a very important aspect to it - that it is an active pursuit, rather than a passive sentiment. It is an intense training on how to think clearly, reason and put together sound arguments, and indeed, some philosophers have described themselves as, “specialists in thinking and thoughts”. Thinking and thoughts about everything in life, especially those that deal with “with ultimate reality, or with the most general causes or principles of things and ideas and human perception and knowledge of them, physical phenomena (natural philosophy) and ethics (moral philosophy)”.

Needless to say therefore, medical professionals, who deal with matters of life and death everyday of their careers, would benefit from learning what the great philosophers have to say about these matters. And it is indeed excellent news, for those who wish for the survival of philosophy in our rather unreflective age, that medical professionals are obliged, in most countries (including England) to learn a bit about the ideas of some philosophers. They learn about the moral philosophers, such as Immanuel Kant, Jeremy Bentham and John Stuart Mill in the course of medical ethics lectures. All medical students know, or should know, Kant who came up with the ‘deontological ethics’ sometimes named after him (‘Kantian ethics’) ((duty-based ethics, based on an inherent sense of right and wrong)), whose ideas were extended by Tom L. Beauchamp and James F. Childress, two American philosophers, who consequently laid down several fundamental duties, based primarily on the ideas of Kant, which include fidelity, reparation, gratitude, justice, beneficience, self-improvement, non-maleficence, autonomy and veracity, which are the basis for much that the medical professional stands for. They also ought to be familiar with Jeremy Bentham and John Stuart Mill, who came up with the teleological (consequence based) ethics (where right actions are determined by the results produced without regard to the nature of the action), the most important of which is ‘utilitarianism’ (greatest happiness for the greatest number.

NHS directors, and those interested in such things ought to be familiar with the ideas of political philosophers, such as John Rawls, about whom a recent article was published in a major psychiatry journal, with the following abstract:

“Scarcity of resources compared with need results in resource-allocation decisions that will have a beneficent effect on some clinical populations and will be detrimental to others. Political philosophy, through theories of social justice, aims to establish generally applicable principles to guide such decision-making. We introduce here the work of the foremost liberal political philosopher of the second half of the 20th century, John Rawls. As well as having implications for resource allocation, John Rawls’s work is of relevance to law and ethics in clinical practice, especially for psychiatrists, who often work with vulnerable, disadvantaged and stigmatised people”

Anyone sitting the ‘MRCPsych’ (the membership exam for the Royal College of Psychiatrists) is obliged to have a solid background in philosophy, a welcome move instigated by K.W.M, Fulford and G. Adshead over 14 years ago, in a wonderful little paper, ‘The attitudes of psychiatrists to philosophy,’ published in ‘Psychiatric Bulletin’ ((1994), 18, 343-345).

It is a really big shame that most medical professionals, except those involved in psychiatry, do not pay much attention to philosophical questions, except in times of crisis, when confronted with a difficult ethical clinical dilemma for instance. This is because I feel medicine is one of the few fields that can benefit from, and be of benefit to philosophy, and medical professionals and philosophers can greatly benefit from one another.

The most important contribution medicine can make to philosophy is to ground it in deep everyday questions of life, the questions that intrigued the great philosophers of the past. For me, philosophy began with the Ancient Greeks and has been in a long coma since the beginning of the existentialist movement. It will never die, so long as thinking human beings exist[1]. But if it remains in its current state of ‘disciplinary narcissism’, as Peter Suber put it, in its obsession with questions far removed from everyday life, in the almost sterile discussions which pervade it (which are too dry and technical for any ones liking, converting philosophy, which was always meant to be for everyone, into a discipline for few ivory tower intellectuals), it will also remain in its coma, and the fears of Julie Von Camp, another American philosopher, would be realized:

“My worst fear is that philosophy will go the way of classics, Latin, and Greek... The responsibility for avoiding the fate of classics lies with those of us in philosophy. We must ensure that the rest of the academy understands the importance of what we do as much as we do”.

Medicine, being the most down to earth specialty, and probably the oldest specialty known to man (as the great William Osler put it, “The desire to take medicine is perhaps the greatest feature which distinguishes man from animals”) can provide philosophy with a great deal of solid substance, probably only second to quantum physics and cosmology. It is for this reason that Patrick Bracken (a psychiatrist and professor of philosophy) and Philip Thomas (a psychiatrist) highlighted the usefulness of philosophy to the physician in an editorial in the BMJ a few years ago, and concluded that “medicine should have a deeper relation with philosophy”[2].

Von Camp was not mistaken when she said that those who wish for ‘proper’ philosophy to survive can do so by highlighting that, “Philosophy can enrich all the disciplines at the university”.

And the relationship is reciprocal. Through learning philosophy, the medical professional becomes a better thinker, since philosophy “teaches how to analyse alternatives, and how to speak and think clearly”.

He or she would also become a more fulfilled professional. No one put it better than the great Bertrand Russell:

“It is not to be supposed that young men and women who are busy acquiring valuable specialized knowledge can spare a great deal of time for the study of philosophy, but even in the time that can easily be spared without injury to the learning of technical skills, philosophy can give certain things that will greatly increase the student's value as a human being and as a citizen. It can give a habit of exact and careful thought, not only in mathematics and science, but in questions of large practical import. It can give an impersonal breadth and scope to the conception of the ends of life. It can give to the individual a just measure of himself in relation to society, of man in the present to man in the past and in the future, and of the whole history of man in relation to the astronomical cosmos. By enlarging the objects of his thoughts it supplies an antidote to the anxieties and anguish of the present, and makes possible the nearest approach to serenity that is available to a sensitive mind in our tortured and uncertain world”

The point about ‘exact and careful thought’ that Russell makes is extremely important, particularly for the Muslim physician, who in developing this habit, would see the great inconsistencies, weaknesses, and contradictions of most of our ‘Islamic heritage’. It is only through an honest analysis and critique of our thought, stripped of any emotional attachment and preconceptions that we will progress. As Russell put it in the chapter, ‘The Philosophy of Logical Analysis’ in his ‘History of Western Philosophy’:

“Morally, a philosopher who uses his professional competence for anything except a disinterested search for truth is guilty of a kind of treachery, and when he assumes, in advance of inquiry, that certain beliefs, whether true or false, are such as to promote good behaviour, he is so limiting the scope of philosophical speculation as to make philosophy trivial; the true philosopher is prepared to examine all preconceptions. When any limits are placed, consciously or unconsciously, upon the pursuit of truth, philosophy becomes paralysed by fear, and the ground is prepared for a government censorship punishing those who utter "dangerous thoughts"- in fact, the philosopher has already placed such a censorship over his own investigations”.

I could not have put it better. The almost religious reverence that Muslims have for those who wrote their works more than a thousand years ago is one of the most abhorrent features of our culture. There is a fear of thought, a fear of criticism of their ideas, that will lead us to nowhere but our current state of intellectual, moral, spiritual and scientific stagnation. As Taha Jibir Al-Alwani, a contemporary Islamic thinker said:

“There is general agreement that the Ummah is passing through an extremely difficult stage, one of disintegration and schism, loss of identity, failure of institutions, and inability to extract itself from its present state of bewilderment…After pondering the matter at length, looking at it from different perspectives, and considering objectively the attempts of the Ummah in the past to extract itself, we are convinced that the process of change must begin in the thought of the Ummah. This is because thought naturally precedes deeds, whether they prove to be correct or faulty. Only sound thinking will result in sound reconstruction, and only sound thinking will deliver the Ummah from the crisis which threatens to strangle the life from it.”

Another thinker put it thus:

“The Muslim mind, therefore, has remained a prisoner of those concepts and basic approaches that doom it to remain bound by past mistakes and digressions and bereft of the ability to penetrate, distinguish, and amend its own course, or to plumb the depths of the issues confronting it. Thus it is unable to boldly chart a course for the future, for it sits bound and blindfolded in a dusty corner of the distant past.

If the methodology of thought does not undergo change, and if its approaches are not rectified, the Muslim mind will remain unable to take a critical or penetrating look at anything. Instead, it will continue to gravitate from one failed solution to the next. There can be little doubt that continuing along this path can only lead to further disintegration and collapse.

To add to the burdens of the wretched Muslim mind, the Ummah's intellectual and political leaders, whether by design or otherwise, despaired of ever having a complete monopoly on leadership. What each group sought, then, was to force its own kind of terrorism on the Ummah. Regardless of what its Intentions might have been, the political leadership practiced a sort of material terrorism, whereas the intellectual leadership perpetrated a sort of psychological terrorism. These two groups engaged in this type of activity in order to ensure the continued pacification, weakness, and subjugation of the Muslims vis-à-vis the leadership in their private and public lives. What is so laughably regrettable, however, Is that this terrorism reached a point where even the intellectual and political leadership themselves were negatively affected. The final result was that the infirmity of the Ummah caused the collapse of the leadership's power base and left it unable to defend itself in the face of the onslaught of foreign colonial powers.

Owing to the fogginess of the Muslim vision and the way that it has been hampered, we find that Muslims either accept their past with all its deviations and peculiarities of thought, society, and organization, or they reject it, along with all its inherent values, entirely. Over the centuries, this vision has grown increasingly weaker as the Ummah's personality has been beset by a series of devastating illnesses that have left it unable to distinguish between truth and dogma, ends and means, religion and folklore, values and commonplace events, and concepts and imitation.

In essence, the Muslim mind was divided between groups that called upon it either to reject or to accept everything, without differentiating between historical fact and fiction or distinguishing between the means and the end. Some groups within the Ummah even claimed that peoples and societies whose material resources have suffered are actually the victims of Immaterial or abstract crises.

In order to progress, we must understand that many past mistakes were made with the best of intentions. It therefore behooves us to study the past in order to extract from it only that which is positive and beneficial.”

In learning about Aristotle and other epistemologists, the medical professional will understand how much he or she is indebted to those great philosophers who devised what is knows as the ‘classificatory approach’ to knowledge. Edward de Bono, one of the few great thinkers of our times says (who is also a qualified physician) explains:

“The benefits of medicine as a practical art have depended almost entirely on the classificatory approach. The scientific basis of medicine has been very slow to catch up with the operative needs of medicine because the human body is so very complex a system. Meanwhile, patients cannot wait. They are treated on the classification basis. Diseases are recognized and labeled on the basis of a sort of classification of manifestations. Experience and observation attached to one classification is fed back as treatment. Now and then further understanding breaks down and resorts the classifications”

In learning philosophy, the medical professional involved in psychiatry can help ‘elevate the threshold’ for the likelihood of mental illness. This is done by teaching new coping strategies and ways of dealing with life, based on the thought and experience of some of the greatest minds to embrace the Western world.

As one professor of psychology remarks:

“Without it (philosophy), human beings are at risk of psychological damage. A psychologically damaged human being unquestionably requires medical treatment that focuses on the illness. This is why many health insurance policies cover psychological services. Philosophy, on the other hand, is a condition that makes psychological health possible, but it is not itself a kind of medical or psychological treatment”

The same writer makes the following analogy:

“Philosophy is analogous to proper shelter and clothing… Proper shelter and clothing is essential to sound physical health. If someone is left exposed, in shorts and a t-shirt, in the snow, it will be extremely difficult to maintain physical health. Exposure to cold puts a human being at risk of hypothermia, infection, and pneumonia. Illness is not guaranteed; natural physical strength, prior exposure to microorganisms, poor diet, lack of exercise, etc, vary from person to person. But exposure to cold makes illness more likely. Once a person has developed illnesses as a result of improper shelter and clothing, it isn't enough to simply supply sweaters and an insulated building. Medical treatment will be required. But treatment alone is not enough, either: even if antibiotics and fluids are provided, clothing and shelter must also be supplied, and the person will be in danger of ill-health returning if clothing and shelter are not constantly available in the future. Thus, it's obvious that clothing and shelter are required for good health, but neither the clothing industry nor the building industry are medical professions, and medical insurance has never covered sweaters and cold-weather insulation. Clothing and medicine are entirely separate specialties”

The renowned American psychologist, Dr. Abraham Maslow, even remarked that, “the great case of much psychological illness is the fear of oneself – of one’s emotions, impulses, memories, capacities, and potentialities”. And what was the first instruction in philosophy? ‘Know thyself!’ (This command was even engraved at the entrance to the Temple of Apollo at Delphi).

It is for this reason that many great physicians and philosophers recommended philosophy – it is because they realized its therapeutic value. Plato remarked somewhere that, “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated”. Cicero, the greatest of the Roman philosophers famously told his students:

“There is, I assure you, a medical art for the soul. It is philosophy, whose aid need not be sought, as in bodily diseases, from outside our selves. We must endeavor with all our resources and all our strength to become capable of doctoring ourselves”

The renowned Roman physician Galen even wrote a short book he entitled ‘The Best Doctor Is Also a Philosopher’. This book had a tremendous influence on many physicians, especially those of the Islamic civilization. In his book, ‘Physical and Psychological Health in Islam’, Professor Muhammad Abu Radieh of the University of Kuwait argued that, “All Muslim physicians - owing to the historical location of Muslim civilisation - are philosophers in both the Greek and Islamic senses”. In particular, Galen’s famous work had a deep impact on the medical approach and practice of Abu Bakr Al-Razi, the most famous of all the Muslim physicians (“the father of paediatrics, the author of the first medical book printed in Europe, and the world's greatest physician in the middle ages”).
And indeed, there is a current discipline called philosophical counseling, which aims to use philosophy as guidance in order to ameliorate everyday life situations. When Gerd Achenbach opened up the first practice in Cologne in Germany, it was the first clear sign that philosophy may be able to lessen the burden on psychiatrists. Dr. Schlomit Schuster summed up the essence of the approach of the philosophical counselor as follows:

“This new approach to so-called psychological problems (consists) of various forms of open-ended dialogue and reflection on life, (and) may prevent or resolve many of the "illnesses" for which people would seek psychiatric or psychological treatment. If successful, philosophical counseling would mark not only a radical shift in the direction of psychological care, but a radical return to the original, practical purposes of philosophy”.

A knowledge of the works of the great Austrian philosophers of the 20th century, Ludwig Wittgenstein and Karl Popper will help immensely in psychiatric medical work, for they provided some of the most powerful arguments against Freud’s psychodynamic psychotherapy, which dominated the psychiatry scene for many years, and remains with us to this day, despite the fact that it is expensive, lengthy, demanding, unscientific, and most of all, rather ineffective. This is something we will turn to in more detail in the introduction to psychiatry chapter. But in short, it is Popper’s principle of falsification which provided some of the biggest blows to Freud’s ideas.

Furthermore Popper was one of the fathers of ‘evidence-based medicine’, which can legitimately be claimed to be the greatest reason for some of the successes of modern medicine. As Gareth Owen, a London-based doctor said in a not unrecent BMJ publication, “Evidence-based medicine is a philosophical movement par excellence. Would it have been possible without dozens of ponderous doctors reading the works of Karl Popper?” His influence of ‘philosophical surgeons’, like Michael Baum, Emeritus Professor of Surgery at the University College Hospital in London (who recently presented the ‘Karl Popper Memorial Lecture’ in Popper’s last base, the London School of Economics, in November 2007, entitled ‘The Philosophical Surgeon: in Defence of Evidence-Based Medicine’) has been immense, as evidence by the conclusion of that lecture:

“Karl Popper inspired me, taught me to think critically and changed my life from that of a technocrat to that of a scientist. Science fed my curiosity and my original observations provided an open ticket to travel the world. I shall therefore leave the last word to him; “It is not truisms that science unveils. Rather, it is part of the greatness and the beauty of science that we can learn, through our own critical investigations, that the world is utterly different from what we ever imagined”

Karl Popper also spent a lot of his time in debunking all sorts of philosophical authorities and ideas, and in trying to spread a scientific, rational frame of thought. He famously attacked Plato, Hegel and Marx in his work, ‘The Open Society and Its Enemies’, whose ideas, he thought, provided great fuel to some of the most dictatorial movements of our time. This is relevant to clinical practice, as an epidemiology journal put it a year after his death:

“Karl Raimund Popper, who died on September 17, 1994 at age 92, was not an epidemiologist,but he solved the most basic problem in epidemiology: how to anchor our conclusions to our data using rigorous logic. In so doing he has contributed immeasurably to the public health by equipping us with a formidable weapon against the scourge of authoritarianism, which in this century, has been one of the main causes of death and suffering.

Widely accepted by practising scientists as the foremost contemporary philosopher of science, Popper's approach to his work was much like that of the epidemiologists I admire : slow, with painstaking logic, in pursuit of the public good, with deference to evidence and skepticism of popular opinions. In my view, the 'chronic disease' he studies and attempted to cure is authoritarianism, a contributing cause of which is dogmatism.

A recent manifestation of dogmatism is the infectious and pathogenic idea that science is the New Authority. In his youth, Popper saw Marxists and Freudians attract large following by pronouncing themselves scientific authorities. He was disturbed by how flexible were their theories, adaptable even to contradictory evidence. This diffuseness was in stark contrast to Einstein's General Theory of Relativity, with its precise and boldly deviant prediction that light would bend in a gravitational field. The distinction between pseudoscience and science, he discovered, lies in the testability (which for him meant falsifiability or refutability) of their statements. Hypothetical statements are more testable if they are more precise, more universal and more deviant from expectations derived from alternative theories. Authoritarians prefer less precise, less generalised and less deviant statements, because they do not like their authority to be challenged"

In this, Popper the philosopher helps everyone – in debunking the myths of alternative medicine, which have cost nations much in terms of money and health of their people, something which I will turn to in the next chapter.

Knowledge of what great philosophers like Plato, Rene Descartes and Bertrand Russell said about the value of medicine can serves as a great antidote to all those uncertainties that many of us working in the medical profession have, after having a bad day at work, whether triggered by inappropriately demanding patients or staff.

While we are taught that it was Hippocrates who first appealed to reason, rather than supernatural forces, as the cause of illness, it was Plato who first popularized this notion, in his ‘Timaeus’. As the late Roy Porter said in his classic text on the history of medicine, ‘The Greatest Benefit To Mankind’

“Thanks to Plato, Western thinking could consider medicine as having its share in understanding human nature. He emphasized the common ground between what would later become the separate disciplines of philosophy, medicine and ethics”.

In his ‘Discourse on Method’, Rene Descartes, the eminent French philosopher stated his belief that medicine is the most important tool for improving the intelligence of mankind:

“The mind so strongly depends on temperament and the disposition of bodily organs, that if it is possible to find some means which will make men generally more wise and more clever than they have been till now, I believe that it is in medicine one should seek it.”

This praise of the practice of medicine by the eminent thinker and founder of the modern scientific movement must have surely increased its respectability among the intellectual elite.

Another great French philosopher who highlighted the greatness of the medical profession was Voltaire, who remarked:

"Men who are occupied in the restoration of health to other men, by the joint exertion of skill and humanity, are above all the great of the earth. They even partake of divinity, since to preserve and renew is almost as noble as to create"

Voltaire’s insights however go beyond this. This is the same man who famously said, “The art of medicine consists in amusing the patient while nature cures the disease”. As I have mentioned before in the course of this book, medical men do not cure. They simply palliate or attempt to control the features of the disease. Diseases like diabetes, heart failure, rheumatoid arthritis – virtually every single medical disorder we know is irreversible and incurable.

He also was one of the first to highlight the importance of trying to know the social and psychological aspects of patients’ lives in helping them; he remarked:

“Doctors are men who pour drugs of which they know little, to cure diseases of which they know less, into human beings of whom they know nothing”

He made that remark in the eighteenth century, and thus helped begin a proper scientific understanding of medicine, which only really a century later. By making this remark however, he was trying to teach doctors not to be over keen on prescribing drugs, and to try to get them to focus on understanding the human being in a holistic fashion. His remarks were paraphrased by the great William Osler two centuries later, who said in his ‘Aphorisms’, “One of the first duties of the physician is to educate the masses not to take medicine”, and, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”. We will come back to Voltaire in a minute.

Such praise and speculation continues to this day; Sir Bertrand Russell (1872-1970), arguably the last of the great philosophers, argued the case for medicine in an essay written in 1932, entitled, ‘Why Are We Discontented?’ In it Russell stated his belief that the state of modern day anguish and despondency is more related to physiological causes than it is to “decay of faith and difficulty of finding some continuous purpose in life”:

“I believe the lack of zest and of fruitful purpose itself has physiological causes. A man in a really good physical condition finds something to believe in, whereas a man whose digestion or glands are out of order is prey to all the gloomy forms of doubt and despair”

And he concluded:

“If I am right, the cure for modern despair is a matter for the physician, not for the philosopher”

Thus, those great philosophers must be given a lot of credit by medical professionals for the very survival of medicine as a scientific discipline, and for its permanent role as a valuable contributor to the understanding of human life. Their words give us hope.

In learning about the works of the man, who in my view, is the most powerful of all philosophers, David Hume, the medical professional would develop a skeptical tendency which would be extremely invaluable in facing the false pretences of patients, pharmaceutical company representatives and others who wish to abuse the medical profession. Reading Hume sharpens one’s thinking more than reading any other philosopher, and that can only be of benefit to the one person who matters most to the practicing medical professional – the patient. Hume would make any consultant shake certain about his diagnosis and his or her clinical acumen, shake and shudder, and the necessity of making every statement made about a diagnosis, a mere probability. This he did by putting to doubt the very validity of inductive reasoning, the basis of all scientific (and therefore medical) thought:

“Hume concludes that no event in the world can be shown to be necessarily connected to any other event – a conclusion quite the opposite of our assumptions about daily experience, and one with implications for everything from research on the causes of cancer to the equations of physics to religious doctrines”

In a way, we ought to be thankful that oncologists and other physicians have not paid attention to Hume, for to this day philosophers have found his arguments irrefutable. As Russell says in his discussion of this great philosopher in his classic ‘History of Western Philosophy’, “I cannot but hope that something less sceptical than Hume’s system may be discoverable”. But to those who have encountered his genius, uncertainty is a very certain matter.

I have already mentioned the contributions of philosophers to the ethical theories which are used in clinical practice. It is very interesting to know that some of the fundamental posits of medical practice, such as informed consent were originated by philosophers, like Moses Maimonides. In the Ancient Egyptian, Greek and Roman civilizations, there was no such thing as informed consent; and this opinion generally continued until the Nuremberg Code was established in 1947. However, hundreds of years before, this is what Maimonides wrote:

“Medicine recommends what is beneficial and warns against what is harmful, and does not compel this . . . but leaves the matter to the sick in the form of consultation; it is they who have the choice”

Furthermore, Maimonides is believed to have been one of the first to advise the holistic approach to medicine, and was identified by George Engels as his biggest influence when he constructed his now well-established biopsychosocial model of illness. His ‘Regimen Sanitatis’, published in 1200 (750 years before Engels), embodies the essence of that model.

Finally, medical professionals can learn a lot from the ‘laughing philosophers’. Many now realize that laughter is indeed a great medicine, and indeed this is stated by some very recent medical research. For instance, Michael Miller, a director of the Center for Preventive Cardiology at the University of Maryland Medical Center and associate professor of medicine at the University Of Maryland School Of Medicine remarked in a recent article:

"The old saying that 'laughter is the best medicine,' definitely appears to be true when it comes to protecting your heart...We don't know yet why laughing protects the heart, but we know that mental stress is associated with impairment of the endothelium, the protective barrier lining our blood vessels. This can cause a series of inflammatory reactions that lead to fat and cholesterol build-up in the coronary arteries and ultimately to a heart attack."

Two philosophers have been given that title. Democritus was “known in antiquity as the ‘laughing philosopher’ because of his emphasis on the value of ‘cheerfulness,’”. Voltaire, the man in whose hands, Anatole France said, “the pen runs and laughs” is more entitled to the title however. As James Sebastian put it:

“Probably no other man in history understood better “the health restoring role of laughter in our lives.... it has been suggested that his laughter might be after all his greatest contribution to his and every age”.


So much for the philosophers’ contributions to medicine; but what of the possible medical professionals’ contributions to philosophy? Do they exist?

Indeed they do, and some of the best philosophers were originally trained partly or completely in medicine, and this provided them with a very fertile ground for their philosophical ideas.

Many believe that the idea of Aristotle (arguably the most famous of all philosophers), about the ‘unity of being’ was brought about mainly by his study of medicine:

“The fields of biology and medicine left such an indelible mark on Aristotle’s thought that he borrowed from the field of medicine the analogy needed to show how, despite the multiplicity of irreducible genera, there is a sort of unity of being”

John Locke is regarded by some as “the most worthy and undistinguished of the indisputably great philosophers. His influence has been enormous”. He was also a renowned physician, who trained in Oxford, and his medical skill and knowledge was acknowledged by Lord Shaftesbury, who appointed him as his physician from 1667 until his death in 1683.

The basic tenets of John Locke’s thought can be summarized in three words - opposition to authority. Locke always encouraged the use of reason to find the truth rather than simply accept the opinion of others or be subject to superstition. In medicine, Locke denounced the scholasticism and overt respect for past medical traditions. He and his friend Thomas Sydenham (1624-1689) (famed for the eponym ‘Sydenhams’ Chorea’) were the earliest physicians to advocate the experimental method in medicine, and collaborated in writing an influential treatise on infectious diseases, ‘Observationes Medicae’, published in 1676.

It is now clear to many scholars that a lot of John Locke’s thought was coloured by his medical outlook, to a much greater extent than has been suspected previously. In his short book, ‘John Locke and Medicine’, the late Patrick Romanell stated that, “Locke's medical thought and his background as a physician that provided the paradigm for his famed "historical, plain method" of inquiry that he applied to his philosophical analysis of human understanding.”

In his classic work, ‘An Essay Concerning Human Understanding’, Locke argued influentially that all human knowledge originates in ‘sense impressions’. He stated that direct experience is a much more reliable source of knowledge than logic and reason. This is in contrast to Descartes, who thought the exact opposite – that reason is the most important source of knowledge for man. In an article on the epistemology of John Locke, Dr. David Kerns argued that their perspectives are a logical consequence of their daily life professions – Descartes the mathematician, Locke the physician:

“Locke is, after all, a physician. Physicians rely on evidence they get from their patients, they form hypotheses as to what might be the underlying problem with their patient, and they attempt treatments. If the treatments don't work they form another hypothesis and attempt another treatment, and so on. Absolute certitude may be something mathematicians can hope for, but the physician must rely on experience and testing. Locke believes that is also how we derive our knowledge about the world”

Thus, in the life of John Locke we have a fine example of the philosopher-physician, who was perfectly at home in both fields.

In the 18th century, the age of Enlightenment, Paris became the centre of the medical revolution and a distinctive type of medicine developed, “characterized by scientific observation, and raised on pathological anatomy, the paradigm of the lesion, quantification and not least, sublime faith in its own superiority”. The finest physician in Paris for the greater part of the Enlightenment was the philosopher-physician Pierre Cabanis, who believed morality and ethics is not simply a matter of education, but that it might be affected by deficits in the nervous system. Cabanis was a very staunch materialist, and this and his study of medicine provided him with the central pillar of his thought, that the “physical determines the moral”. He believed that “medical knowledge regarding the functioning of the human body is indispensable for the understanding of the formation of ideas”.

The 19th century saw the birth of one of the greatest thinkers of American civilisation, William James (1842-1910). He is generally considered to be not only the most influential of all American philosophers, but also one of the greatest thinkers of all time. Some have regarded him as “the very representation of American thought”. The Indian scholar TK Mahadevan even remarked, “American civilisation is what it is because of William James.”

In any case this great philosopher was also a physician, having received his MD from Harvard University in 1869. The main impetuses for his study of medicine were his chronic psychosomatic complaints. To quote one of his biographers:

“James shared fully his family’s neurasthenia. He was plagued with chronic backache (he dubbed it ‘this dorsal insanity’), and suffered from digestive disorders, depressions, and acute attacks of diffuse anxiety. His eye trouble was his only truly somatic complaint”

At the same time, his medical problems are believed to have given James a “personal intimacy and intensity to the deepest problems that philosophy and religion can present to a man’s understanding”. In the life of William James we have a fine example of how medicine can help the philosopher, and how philosophy can aid the medical professional.

James was one of the cofounders of the pragmatic school of thought. The central pillar of pragmatism is that philosophy should be put to work solving the more pressing human problems instead of preoccupying itself in metaphysical speculations, as many prominent figures in philosophy had done. This, is a direct offshoot of his medical studies, there can be no doubt about it. I cannot agree more with Russell who said, “There were two sides to William James's philosophical interests, one scientific, the other religious. On the scientific side, the study of medicine had given his thoughts a tendency towards materialism, which, however, was held in check by his religious emotions”. William James is also considered as the father of modern psychology, and that too, “He was led (to) by the study of medicine”. The connections between philosophy, psychology and all medical fields (and not just psychiatry) are clear for all.

The 20th century saw the rise of many outstanding thinkers, but very few have reached the fame, wealth and fortune of Edward De Bono, the Maltese physician and philosopher (1933- ). De Bono was a genius, who entered medical school at the age of 15, and graduated as a high-flying doctor at the age of 20. He worked in several hospitals in England and elsewhere throughout his career, and eventually was given the chair of Professor of Investigative Medicine at Cambridge University.

This remarkable man attributes to his study of medicine much of his later work on philosophy and thought, which has earned him his many fortunes. It is probably no surprise that when he was asked in a BBC survey who he thought were the greatest thinkers of the last 1000 years, he put William James as his number one choice.

In an interview published in ‘the Independent’, De Bono admitted that his medical background inspired and enabled him to teach and design his now world famous thinking methods:

“Three things came together to kick off my work in the area of thinking: in medicine I was dealing with self-organizing systems such as the glands, kidneys, respiration, and circulation, and I started to ask myself what would happen if the same principles were applied to the brain. From psychology came an interest in thinking, and from computers an interest in the types of perceptual and creative thinking that computers couldn't do. The fusion of these elements led to my key book 'The Mechanism of Mind' in 1969”.

In another interview, De Bono specifically pointed out that the study of neurology as the key influence on his future work on thinking:

“My background is in medicine and in medicine I had to develop concepts of self-organising systems and by examining the behaviours of such systems as applied to neural networks designed some of the methods for thinking.”

Raymond Tallis is the latest in this long line of philosophers trained as physicians, but what is different about him is that, in contrast to Locke and De Bono, who are much more ‘thinkers’ rather than physicians, and James who never practiced what he qualified with, Raymond Tallis was equally adept, devoting equal amounts of time to both until his retirement in 2006, when he was Emeritus Professor of Geriatric Medicine at the University of Manchester. By that time, he showed he was equally adept at writing or editting books like ‘Advanced Geriatric Medicine’, ‘Brocklehurst's Textbook of Geriatrics and Gerontology’ and ‘The clinical neurology of old age’ as he was at writing books on Freud (‘Burying Freud’), existentialism (‘A conversation with Martin Heidegger’), and postmodernism, of which he is a foremost contemporary critic, highlighted in his works, ‘Not Saussure’ and ‘Theorrhoea and After’. Since his retirement he has been dedicated mostly to his philosophical pursuits, particularly in developing a solid philosophical basis for the medical profession, as outlined in his wonderful book (which I have quoted extensively before, ‘Hippocratic Oaths’) and attack on the assumptions of much artificial intelligence research (in his book, ‘Why the Mind is Not a Computer: A Pocket Dictionary on Neuromythology’). As explained by one encyclopedia article on him:

“The focus of his philosophical writings has been an attempt to supply an anthropology that acknowledges what is distinctive - and remarkable - about human beings. To this end his most recent work has been a trilogy of books entitled ‘The Hand; I Am: A Philosophical Inquiry into First-Person Being’; and ‘The Knowing Animal”.

Another example of a contemporary philosophical-physician is the aforementioned Michael Baum, who remarked:

“In defence of the thinking surgeon, I wish to propose that a modern surgeon practicing evidence-based, humane and ethical medicine must have a sound grounding in some of the fundamental principles of philosophy. I shall illustrate these principles, drawing on 40 years experience as a surgeon within the NHS and in particular my specialist practice in the diagnosis and management of breast cancer.”

Thus, I conclude, the relationship between philosophy and medicine is great, and professionals in both fields can benefit immensely from one another. To those like Dr. Philip A Sugarman, medical director at St Andrew's Hospital in Northampton who believe that ““Philosophy can be detrimental to doctors” (and contends that “human physical and social biology are far more relevant areas of study for doctors than philosophy”), I leave them with three inspiring messages.

The first is from Karl Popper, who upon being asked why he decided to refer one of his best friends to Michael Baum for breast surgery, said:

“If I wanted a surgeon to cut me open my first wish would be that he was a master of his craft, the fact that he might have an interest in philosophy would be well down on the list of personal traits I would be looking for.”

The second is from another surgeon, the contemporary Swiss paediatric surgeon Andreas M Worel, writing in the BMJ a few years ago:

“Philosophy, as the art of questioning and source of scientific evolution as well as of individual ethical responsibility, and doing the good, are both essential in medicine: science and the art of healing are the two sides of the coin. Conclusion: Banning Philosophy will result not only detrimental for doctors, but far more for patients. Philosophy, Art and individual ethical responsibility are the best active immunization against inhuman medicine.”

The final one is from an article published 42 years ago in ‘Time’, ‘What (If Anything) to Expect from Today's Philosophers’:

“There is an old saying that philosophy bakes no bread. It is perhaps equally true that no bread would ever have been baked without philosophy. For the act of baking implies a decision on the philosophical issue of whether life is worthwhile at all. Bakers may not have often asked themselves the question in so many words. But philosophy traditionally has been nothing less than the attempt to ask and answer, in a formal and disciplined way, the great questions of life that ordinary men might put to themselves in reflective moments.”

Similarly, the act of healing, of giving medicine, of surgically operating, would never have been done were it not for philosophy, for the act of ‘physik’ implies “a decision on the philosophical issue of whether life is worthwhile at all”. There can be no more fundamental question to ask in medicine. There is no doubt about that.




[1] Or as put by Peter Suber, an American philosopher, “For philosophy to leave its questions unaddressed would be a tragic abandonment of reflection and meaning. Yet it is precisely the inescapability of philosophical questions, the fact that they are not merely academic, but arise in life, which makes me doubt that we will ever suffer such a loss. A wave of barbarism and a spate of bad philosophy, yes; but never the utter end of philosophy until human beings have lost their ingenuity, curiosity, troubles, contradictions, and hopes”.
[2] Bracken & Thomas, ‘Time to move beyond the mind-body split’, (BMJ 2002;325:1433-1434)

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