A review of A philosopher goes to the doctor: A critical look at philosophical assumptions in medicine by Dien Ho, published by Routledge in 2019.
The common paradigm of narrative medicine, the most widespread one, is that physicians and healthcare providers are competent on technical skills, scientific knowledge but they lack narrative competence that can help them build more empathetic relationships with the patients [1].
In addition to creating a more empathetic care relationship, there is another reason for using narrative medicine. When health care professionals don’t understand the contexts in which patients live, their beliefs, expectations, and values, providers cannot care for their patients properly. The commitment to maintain a shared decision-making clinical process means that clinicians ought to respect others’ values and attitudes [2].
Physicians, scientists, psychologists and anthropologists clearly are invested in research and clinical applications of narrative medicine. Can philosophers provide reasons to establish the importance of narratives in modern medicine (especially not merely in terms of improving health outcomes)?
A philosopher goes to the doctor: A critical look at philosophical assumptions in medicine is an eye-opener. It introduces readers to how scientific knowledge is gained, how medical and scientific theories are tested (or not), and above all, the limits of our Western scientific method, especially our focus on finding solutions with biostatistics as urged on by Evidence-Based Medicine.
The problem with how evidence supports hypotheses, Dien Ho argues, has been around for centuries. The 18thcentury empiricist David Hume, for example, questions the foundation of probabilistic reasoning; he states we will never be certain that tomorrow that the sun will rise. The rising of the sun will be always a chance, with a high likelihood to happen but it is not a certainty. Hume’s concern is not merely how we should live in an uncertain world but what epistemically justifies how we reason with probability. Ho’s historic journey then takes us to the work of Karl Popper who was arguably the most influential scientific philosopher of the past century. Popper attempts to address Hume’s worries about probability with this idea: something is likely to be true until is not falsified. This is the pillar of clinical trials; that is, the null hypothesis—unless evidence shows otherwise, the default is that there is no difference between placebo and the active drug. Defeating the null hypothesis becomes the basis of experimental design.
Ho recounts the classic example in astronomy of the discovery of Neptune by Le Verrier and Adams. Scientists had long noticed that Newtonian celestial mechanics had repeatedly failed to predict the precise location of Uranus. According to Popper’s falsifiability approach, Newtonian physics should have been deductively rejected because it made false predictions with regards to Uranus. Yet, Le Verrier and Adams (and most astronomers of their time) did not reject Newton’s physics; instead, they sought to identify possible hidden assumptions within the orthodox celestial view that might explain the incorrect predictions. Le Verrier and Adams posited independently that an eighth planet might exist and that its gravitational field was disturbing the orbit of Uranus. Using the perturbation of Uranus’ orbits, Le Verrier and Adams calculated the mass and the orbit of the mysterious eighth planet which was later identified and named Neptune. This particular episode in the history of science, Ho argues, shows that the “logic of science” is hardly as clear cut as Popper had envisioned. Another example in physics comes from the work of Kuhn. If we consider Newtonian physics, mass is always conserved, but according to Einstein, mass is relativistic and is not conserved. If the meaning of scientific terms depends on the theory within which they are couched, then Newtonian “mass” has a different meaning than relativistic “mass.” Kuhn’s lesson is that comparing “mass” across different theories is akin to comparing syntactically identical words from two different languages. The incommensurability of theories should give us pause when we assess medicine; different people with diverse world views might understand medicine radically differently. In reality, conducting clinical trial is far more complex than Popper suggests—it is almost impossible to avoid all biases. Furthermore, it is rather short-sighted to continue to view science in such simplistic ways. Ho suggests that we should view medicine as a part of our overall cultural practice.
Should we stop conducting clinical trials? No, not at all, Ho urges. But, we should be mindful of the limits and uncertainty inherent in our scientific method. Scientific interferences often involve a vast number of considerations that include what we observe and interpret. To ensure that our inferences are warranted, researchers try to minimize the numbers of possible confounding factors (which are there in nature and culture) with the goal of hitting a 0.05 p-value (that is, 5% chance of false positive). This limit is arbitrary, however. We can demand a higher threshold of certainty but constraints such as funding limitations require that we trade certainty for some non-epistemic benefits. Moreover, given the diversity of real life settings, it is not clear how we can universally translate bench-side discoveries to bed-side applications. This is one reason why the application of EBM is so fundamentally challenging in clinical practice.
A wonderful insight by Ho is presented in the investigation of our reliance on causality to explain why things happen which is a key research goal in epidemiology and medicine. Consider a concrete example: if I smoke and drink alcohol, I have a higher relative risk of developing lung or colon cancer respectively. The causal link is well established by science and it is one of the clearest biological causal relationships in epidemiology. This causal chain, however, does not include the origins of my addictions: Why do I smoking? Why do I drink? How is my happiness/wellbeing in life? Almost no one has invested money in a clinical trial exploring the causal connection between happiness and lung cancer or colon cancer. For starter, the depression scale is stuck in the hands of psychiatrist and psychologists and does not reach oncologists. The questionnaire of quality of life of oncological patients are asking only superficial questions of mood: it relates how the disease impacts the patient’s current life; it does not explore how life was before illness. Understanding the limitations of of etiological and pathological causality provides a wonderful place for narrative medicine to enter and contribute to the conversation.
Ho emphasizes how science often oversimplifies the acceptance or rejection of causal relationships: in locating the therapeutic effectiveness of a treatment or the causal power of risk factors, researchers make numerous assumptions of what qualifies as plausible causal agents. For instance, we do not draw causal connection between my wonderful red coat and my wellbeing on the ground that I believe it will protect me against evil and the red colour will give me energy? Modern medicine generally eschews investment in research that does not square with the dominate medical paradigm. In a liberal democracy, however, we pay taxes or insurances to have health care; should we have a say in the direction of research? Should we ask scientists to explore the therapeutic effectiveness of old anthropologic superstitions? Ho criticizes, and I agree totally with him (as I have written in my book [3]), the way decisions are made and the manner money is allocated in health care. Some drugs are covered by insurance and National Health Service but other “alternative” or “complementary” medical practices, such as Yoga, are excluded. In the case of Yoga, it is even worse because there are trials that provides evidence for the health benefits of Yoga that can help save a lot of money on hypertension pills. Understanding the limits and biases of the scientific method makes us become better scientists—it broadens what constitutes “plausible” in our quest of finding out what is “true.”
Ho’s chapter on explanations in medicine is very interesting: when we infer a hypothesis on the basis of our observations, we are engaging in inference to the best explanation. These explanations are storytelling. Hilary Putnam, an influential philosopher of last century, reinforces the need to have explanations: “if we have no explanation our success in sciences are reduced to miracles.” The case of Ignaz Semmelweis and how he invented a story based on the observation of women’s increased risks of dying in his hospital after baby delivery as opposed to those who gave birth at home is a paradigmatic case of the importance of using intuition, observation, and logical thinking. Semmelweis, without any technological support, was right in his hypothesizing. Unlike other scientists whose contributions were heralded and accepted (for instance identifying the cause of pellagra by Goldberger), Semmelweis was banished by the scientific community. Another contemporary example I can bring is Neuroplasticity—a term which was practically forbidden to use in most of the 20th century. The orthodox theory of brain cells was that we possess finite amounts of neurons. These neurons are fixed and they can only deteriorate in our lifetime. Numerous imaging studies have shown that this static view is wrong [4]. Although brain cell deterioration exists, we now know that there is also the possibility to activate silent neurons and build new synapses. Neuroplasticity is slowly entering into the neurological and rehabilitation debate as an accepted view.
Ho in the end of the book calls for a science more open to criticism, a humbler medical system, and the closing of the gap between science and the humanities.
The subtitle of my book Narrative Medicine is “Bridging the gap between evidence-based care and medical humanities.” When I wrote this subtitle I was taking for granted the fact that the scientific competence is somehow indisputable. My book focused on empowering the relational competence through the classic tools of narrative medicine.
Now, through this book A philosopher goes to the doctor, we take one step beyond: we are not only using narrative method since we want to be more empathetic; instead the limits, biases, and personal interpretations question whether science is as objective, “pure,” and value-free as we have assumed. Narrative does not differ in “social status” from quantitative research and it can certainly contribute in research, clinical practice, and education.
With a metaphor, I would conclude that Numbers are Sons and Narratives are Daughters of Science and Care: the masculine and the feminine according to the Jungian theory, or the Yin and the Yang. A philosopher goes to the doctor ought to be read by current and future doctors and researchers. More than this, it is also a must read by current and future health humanists because we all have to learn about the power and boundaries of our current scientific and medical method.
[1] Charon R, The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 2001 Oct 17;286(15):1897-902.
[2] Greenhalgh T, Russell J, Swinglehurst D. Narrative methods in quality improvement research. Qual Safe Health Care. 2005;14(6):443–9.
[3] Marini MG (2016). Narrative Medicine: Bridging the Gap between Evidence-Based Care and Medical Humanities. Springer.
[4] Ramachandran, VS (2011). The tell-tale brain: A neuroscientist’s quest for what makes us human. New York, NY, US: W W Norton & Co.
