Book Review

Science, Technology, and the Art of Medicine

N Engl J Med 1993; 329:1747-1748December 2, 1993

Article

Science, Technology, and the Art of Medicine
(Philosophy and Medicine. Vol. 44.) Edited by Corinna Delkeskamp-Hayes and Mary Ann Gardell Cutter. 335 pp. Boston, Kluwer Academic, 1993. $99. ISBN: 0-7923-1869-2

This book is the 44th volume in the series “Philosophy and Medicine” begun by Tristram Engelhardt and Stuart Spicker in 1975, a comprehensive collection of contemporary thought on philosophical issues pertinent to medicine. To name a series “Philosophy and Medicine” is to acknowledge the difficulty of articulating what a philosophy of medicine might be. In any case, almost two thirds of the books in the series are devoted to medical ethics, a few to assessing medical knowledge or the clinical encounter, and the remainder to miscellaneous topics. The predominant problem in Science, Technology, and the Art of Medicine is defining the extent to which medicine is a science, a form of technology, or an art. Not surprisingly, each school of thought is represented, and the thoughtful concluding essay by Delkeskamp-Hayes fairly integrates the tripartite character of medicine.

The intellectual level of these 17 essays is uniformly high, and for each of the four topics addressed in the book -- theory formation, explanation of disease, medical decision making, and the doctor-patient-public relationship -- there are thoughtful explorations of the highly eclectic nature of medicine. This rich library of historical, philosophical, and sociologic analyses attempts to explain what it means to be a physician, as well as the intellectual sources of the craft of medicine.

For the most part, physicians take only a passing interest in medical philosophy. Nevertheless, medical ethics have commanded an increasingly attentive audience, and clinical decision making is an emerging discipline of some rigor. But medical ethics remains dominated by judicial rather than philosophical thinking, and the application of logic and cognitive science to medical practice remains just that, an application. Neither medical ethics nor medicine's logic allows sufficient scope for a philosophy of medicine, and they do not in any way address the fundamental issues of such a discipline. Both ethics and logic must rest on a much broader philosophical base. This collection attempts to meet that challenge. Certain essays are indeed philosophically sophisticated, but the uninitiated need not be wary of esoterica, opaque scholarly vocabulary, and the like. (Readers might be put off only by the cost of the book, and the publisher should be urged to issue it in paperback).

Ultimately, this anthology is successful because it clearly articulates the essential philosophical tension in modern medical practice and presents it to the general medical community. The task undertaken is to analyze how medicine goes beyond science. Subsuming medicine under science or technology is intended to prove that medicine is like any other scientific theory or technological practice; but to call medicine an art is to bring to the foreground its more essential character, its traditional vocation of caring, rather than its aspirations as a program of progress. It is with deciphering medicine's underlying ethos as “art,” its humane concerns, that a philosophy of medicine should begin, and several of the articles penetrate the technological and scientific veneer of Western medicine to make that bold assertion.

All the important issues may be traced to the 17th century, when the study of the human body began to demand the objectification of ourselves as subjects of scientific inquiry. The predominance of a mechanistic philosophy for understanding bodily functions also strengthened the Cartesian division of mind from body. When the somatic entity was divided from our core sense of selfhood, the stage was set for an “objective” science, whose underlying logic would remain divorced from, and inadequate to account for, an integrated, holistic medicine. Health may be defined as the state in which we are unaware of a duality of mind and body. To be ill is to declare that one does not feel “oneself.” What is voiced as a complaint is therefore essentially an estrangement, and when we plumb to the very source of how we express our sickness, we discover the foundations of this somatic and psychic division. Aside from philosophical speculation, when we are ill dualism looms before us -- “My hand is cut,” “My chest hurts,” “I am not myself.” The manner in which we experience sickness is a cardinal and primordial expression of such dualistic thinking.

Medicine, perhaps surprisingly, finds itself committed to the broadest post-Cartesian tradition of philosophy -- namely, to fuse our bodily and mental selves by restoring health. While invoking science and technology, the physician should place these resources in their appropriate context, guided by the underlying philosophical structure of “art.” According to this view, the physician must recognize that somatic complaints are in fact part of a more comprehensive psychosomatic complex, and that medicine most effectively ministers at this fundamental stratum. The ethical implications are self-evident: positivist science would objectify disease so that the patient is reduced to a “case” and treated as an object of research. A humanistic science would make the patient, in toto, the dominant subject of attention. Thus, a separate epistemology, beyond that governing science, must be developed for medicine. Science and technology are preoccupied with different concerns, and these may indeed come into play but must be subordinated to medicine's own agendas. In short, medicine must again find and assert its own philosophy.

Several papers in this collection touch on this issue, but Toulmin addresses it most directly. He emphasizes medicine's humane concerns and puts science and technology in the service of the patient, through what he identifies as the principal function of the physician, history taking. In this activity the doctor establishes a relationship with the patient at all levels -- scientific, technological, and ethical. In the construction of the clinical history, the panoply of medicine's roles is expressed, and the physician is urged to function beyond the role of scientist or technician. In Toulmin's words, “It is not just a case, of the physician treating the patient as a `whole man,' but rather one of the physician himself, as a `whole man,' dealing with the patient as a `whole man.' . . .”

I believe that a comprehensive philosophy of medicine will be articulated on the foundations of this humane orientation. Moreover, such a philosophy must be firmly connected with the overarching philosophical tradition from which it originated. I suspect that in large measure, the impediment to establishing a philosophy of medicine lies in the broader crisis that plagues current philosophy. There is no readily available “solution” to issues concerning selfhood and the mind-body duality. As long as the self remains in “doubt,” we will be thwarted in our attempts to find a firm foundation for medical philosophy. But medicine can have an interesting role in these philosophical discussions, especially in view of its special place in defining the relation between mind and body. As medicine gropes to define its underlying philosophy, fundamental problems are exposed and beckon to be addressed, for this is undoubtedly a challenging period for medical science, technology, and philosophy.

Alfred I. Tauber, M.D.
Boston University, Boston, MA 02118