What is Medicine? Art, Science, or Both? PDF

​ What is medicine? Art? Science? Both? Neither? ○​ Art! ​ “one can perhaps ask whether good sense is calculable” - Benigno Risueño de Amador (19 c) → his answer was no ​ He thought medicine was not a science but an art...

​ What is medicine? Art? Science? Both? Neither? ○​ Art! ​ “one can perhaps ask whether good sense is calculable” - Benigno Risueño de Amador (19 c) → his answer was no ​ He thought medicine was not a science but an art ​ He resisted the growing use of statistics in medicine ​ He thought medicine is a practice of doctors and individuals ○​ You have to think about the particularities of the case of the individual, and science deals in generals ​ Doctors are more like artists and paint the particular scene in front of them ○​ Science!! ​ “Medicine is a science” - P.C.A. Louis (19 c) ​ “Medicine is a science and not an art” - Claude Bernard (19 c) ○​ Both? ​ “Medicine is a science of uncertainty and an art of probability” – William Osler (19-20 c) ​ Recognizes that medicine, if it was a science, was an inexact one that didn't have the precision that physics had ​ There was a lot of uncertainty that created room for physician judgment ○​ Both/Neither? ​ “distinct intermediate discipline”, a practice – Edmund Pellegrino (20c) ​ Medicine was neither art nor science, but something in between ○​ A practice ​ It was not involved with generals, but involved with particulars ○​ We don't go to the doctor to see a scientist, we go to the doctor to see a practitioner who will do things for us and not just learn from us ​ From medicine as science to scientific medicine ○​ Clinical medicine is becoming more integrated with independent research sciences in labs ○​ Scientists are generating the knowledge that clinicians are then supposed to use in their practice (medical science and medical practice) ​ These are brought together today. ○​ “In modern scientific medicine, clinical medicine is integrated with modern research sciences” -me (just now) ​ integrated with anatomical sciences (19 c) ​ Dissect cadaver after they succumbed to their disease in order to learn what it was that caused their death, and then you might use that knowledge for the next patient ​ Ex. Using a stethoscope and listening to the chest on a patient who has tuberculosis  ○​ Could tell that crackling sounds were an identifier of tuberculosis because previous patients who had crackling lung sounds were opened up and tubercles were found in their lungs ○​ You saw the disease after death and you learned to associate the sound with the finding on autopsy ​ integrated with laboratory sciences (19-20 c) ​ Chemical tests that could identify when people had a certain disease ​ Grow the germs that might be the cause of their infection and then apply that knowledge in order to diagnose that disease in the bedside ​ Modern scientific medicine ○​ Modern scientific medicine is a particular historical and contemporary medical tradition ○​ Scientific medicine is a historical phenomenon, things weren't always this way ○​ There are kinds of alternative medicine that are not scientific because they're not wedded to research sciences ○​ We can compare this pseudoscientific medicine with contemporary medicine to learn what makes it scientific ​ Paris clinical medicine, 1790- ○​ The French were trying new modes of physical examination, making sure we were doing autopsies to learn about the causes of death ○​ They were also counting and tabulating cases. ○​ It was only in this context (a large hospital lots of patients) that we could start to count and get statistics ​ Statistics helped, for example, to learn more about how often were certain findings with a stethoscope correlated with tuberculosis as found on autopsy ​ For instance, how long, on average, people take to recover when they're given one intervention or another. ​ We have to count groups of patients and see if there's any difference ​ 8 P.C.A. Louis, Researches on the Effects of Bloodletting, 1836 ○​ Table 1. Relationship between bloodletting and duration of illness among survivors of pneumonia at La Charité hospital seen by Louis. ○​ He's showing what happens if we extract blood from a vein of patients after a certain number of days (after 1 day, 2 days, 3 days, and so on) ​ He was comparing earlier bloodletting (intervention) to later bloodletting ○​ He counted how many days it took for patients to recover from their disease ​ You can compare, for instance, patients that were bled on days 1 to 4 to patients that were bled on days 5 or later ○​ He compared 2 groups of patients that differed in some systematic way, tried to figure out if there was a difference in their outcome ​ Classical Hahnemannian Homeopathy (1810 Organon) ○​ Principle of similars: like cures like ​ Homeopathy is a paradigm pseudoscientific medicine ​ Hahnemann decided he wanted to invent a new kind of medicine because he saw the regular traditional orthodox medicine as being too aggressive so he wanted a gentler alternative ​ You would go to the doctor for pneumonia, wind up in hospital and get cut open and pull your blood ​ He noted that one of the most effective treatments in medicine was the use of cowpox pus ​ People were infected with cowpox pus in order to vaccinate them against smallpox ​ This is principle of similars, like curing like ​ We thought this was a principle we could apply anywhere ​ Ex. If somebody had fever, you throw them in a sauna or if they were cold, you make them more cold ○​ Principle of dilution: use dilute doses ​ An antidote to this overly toxic medicine like that of bloodletting ​ Orthodox physicians would give people Mercury in large doses in order to cure diseases ​ Principle that it's fine to give people drugs but we should opt for gentler drugs and use dilute doses so that we don't harm the patient in the act of trying to cure them ​ Lecture Participation Prompt: What is scientific about the principles in fields like anatomy, physiology and clinical research? What is pseudoscientific about the principles in fields like homeopathic research? ○​ When trying to identify what kinds of medicine are scientific ​ You can point to the presence of evidence or data which is necessary for any science that tries to make claims about the natural world ○​ But you could argue the homeopaths were trying to do that too ​ They collected data and tried to learn from their own experience ○​ Something that only science has and pseudoscience doesn't ​ There are specific kinds of approaches that you might only use in science, such as the collection of statistics or the use of experiments ​ The laboratory became more of a central part of medical science ​ Experimentation was a central means by which people learned how the body works ​ Ex. In order to figure out what the pancreas does, you can remove the pancreas from some animals and see what the effects are and then use statistics. ​ This is an approach used by Louis - in order to figure out, for instance, what worked on average by comparing patients that follow different therapeutic regimens  ○​ The problem is that different varieties of scientific medicine adhere most closely to some of these methods versus others ​ Statistics, for instance, was something that the early scientific physicians in the Paris hospitals were all about ​ But later, when the laboratory became more dominant, people criticized just counting cases and thought experimentation is the only way to see what's going on ​ Claude Bernard, who agreed with Louis that medicine was a science, disagreed that we should be doing clinical statistics ​ He thought the only way to really learn about how diseases and treatments worked was to experiment in the laboratory (on animals) ○​ There seems to be something scientific about the methods that these scientific medicines use in general ​ So maybe there's a scientific method/collection of methods that are found throughout these different historical iterations of scientific medicine ​ Maybe that is the difference between scientific medicine of the time and homeopathy ○​ Pseudoscience ​ Homeopaths were just observing what would happen and use trial and error and testimonials ​ The methods that the homeopaths were using wasn't as scientific as the methods that various scientific physicians were using ​ The demarcation problem in philosophy of science ○​ What separates science from its pretender, pseudoscience? ○​ Outside the borders of the circle is science ○​ Science is separated from everything that's non-science (not science) ​ Non-sciences ​ Everything that's not science ​ Ranging from art to cooking for instance ​ Unscientific ​ Specific subgroup of those disciplines that are not science ​ It's supposed to say something about the kinds of subject matter that science tells us about, but it does so wrongly - it's contrary to science ​ Maybe it doesn't adhere to the right methods - it's unscientific ​ This might apply to scientists who are just doing their trade badly ​ Pseudoscientific ​ It is unscientific and not a science ​ It seems kind of like a science and could fool people into thinking it’s a science  ​ Homeopathy relies on data, observation, keeping records, making inferences, theory, principles, and it can at 1st glance look like a science, but arguably it's not, and therefore it's science-like ​ What separates science from pseudoscience? ○​ Karl Popper: scientific theories are falsifiable ○​ Karl Popper believes that what makes science scientific is that it has theories and those theories are falsifiable ​ In other words, they make predictions that are capable of being proven wrong ​ But some theories are not really capable of being proven wrong, perhaps because they're just too vague ​ So he was against Freudian psychoanalysis because he thought it wasn't really capable of making definite predictions ​ No matter what you observe, no matter what the patient would say, you could always kind of work it into your theory in some way ​ The theory was too flexible and it was never capable of being proven wrong. ​ Therefore it was, it was not scientific ​ That's one example of a demarcation criterion: an answer to the demarcation problem, a criterion that tries to tell us what makes something science ​ The new demarcationists: multi-criterion solutions (e.g., systematicity) ○​ There is no one ingredient because the sciences are so diverse ○​ Instead, we can come up with a checklist of criteria ​ Maybe some sciences satisfy some of those criteria, others satisfy different criteria ​ Modern medical science's demarcation problem ○​ What separates medical science from medical pseudoscience? ​ That's a specific way of framing the demarcation problem ○​ Proposal: medical science has greater systematicity (Alexander Bird, Somogy Varga) than its pretender ​ Systematicity: a cluster concept with multiple dimensions (includes the defense of knowledge claims) - the idea that it's not very well defined ○​ The defense of knowledge claims is the most important dimension/way of being systematic and involves methods that minimize error, including systematic error or 'bias' ​ In science we have hypotheses and sometimes claim that they are known ​ We need specific methods to defend certain claims ​ We can say we know this to be true because we've examined it using this specific method ​ Those methods that are systematic are ones that minimize errors/false conclusions we draw in science, including systematic error or bias  ​ For instance, a microscope that has a scratch on the lenses and every time you look you think there's this scratchy looking thing in the specimen - systematic error in your method ​ Systematicity ○​ Objection 1: arguably, homeopathy is systematic in various respects (meticulous observations and case records, accumulating experience and refining practice) ​ Homeopaths were meticulous about observing cases because in order to know that like cures like, they needed to know the effects substances ​ Ex. If you're treating somebody with fever, you need to know what herbs could cause fever ​ Meticulous observations recording of cases ​ They had people they were testing substances on keep a diary to record symptoms ​ If you gave this substance to 5 people, you would look at diaries and figure out are there any common symptoms that these treatments are producing ​ Over time you're accumulating data and experience and then modifying your practice based on what you found ​ Systematicity is too weak to distinguish pseudoscience from science ○​ Objection 2: systematicity is too abstract, needs to be specified for the case of medical science/pseudoscience ​ Science is an abstract concept and you're just substituting an equally abstract concept in order to solve it ​ Proponents think that in order to understand what it means to be systematic, we need examples - we need medicine specific examples ​ If we're talking about what methods can help medical science defend knowledge claims by reducing error, we need to be very specific about what we're talking about ​ A proper solution to this demarcation problem will tell us what specific methods allow us to say that certain kinds of medical research are scientific ​ And then what specific methods in pseudosciences are so error-prone that they are unscientific? ​ Are there any methods that are used over a long period of time of advances in science that have been retained? ○​ Then we can give a singular answer that over time it's the single kind of method that is being used in the sciences compared to the pseudosciences ​ Classical Hahnemannian Homeopathy (1810 Organon) ○​ How did Hahnemann come up with this idea that like cures like? ​ He used cases in which it seemed that somebody was given one of these substances that produced some symptom and then it seemed to cure people who received it  ​ Ex. Cowpox causes pustules in healthy people but it prevents smallpox pustules in those who would otherwise get smallpox ​ O.W. Holmes, Homeopathy and its Kindred Delusions (1842) ○​ Homeopathy belongs to the “tribe of the pseudosciences”. ​ What makes homeopathic medicine pseudoscientific is the way they argue their treatments work ○​ Hahnemann: the smell of roses causes people to faint, and “it was by these means that the [Byzantine] Princess Eudosia with rose water restored a person who had fainted!” ​ Ex. story of a Eudosia who fainted and to restore her, somebody gave her rose water ​ This is like cures like because roses cause ladies to swoon, therefore you give that rose water to somebody who'd fainted in order to restore them to consciousness ​ This the kind of way that Hahnemann is drawing conclusions and generalizing that like cures like ​ John Forbes, British and Foreign Medical Review (1846) ○​ Somebody has some symptom, you give them something, and then you observe what happens to them at some later point in time ○​ Homeopaths reason “post hoc ergo propter hoc”, ignoring the “curative powers of nature”. ​ John Forbes said the problem is that they're concluding that because something followed something else, the 1st thing must have caused the later thing ​ Homeopaths point to instances in which people used a homeopathic intervention and recovered, but they haven't ruled out the possibility that the recovery could be due to the body and not the treatment ○​ Proponents of scientific medicine thought the only way to really draw proper inferences about what works is not to observe a case, but to make a comparison between a single patient/group of people and a different group that's treated differently ​ “nothing, in short, will suffice but the experimentum crucis of a comparative trial, on the large scale, of [homeopathy’s] powers, on the one hand, and of nature’s powers, on the other” ​ Test homeopathy with people who didn't receive any treatments to compare nature's powers to homeopathy’s ​ This was the only way to draw firm conclusions about whether or not homeopathy adds anything above the healing powers of nature ​ This is exactly what Louis did in his study of bloodletting. ​ Pca. Louis wanted to test whether or not bloodletting earlier in the course of disease had any good effect on people with pneumonia ​ He examined hospital case records of patients who had been treated earlier or later with bloodletting  ​ He made sure these groups of patients aren't different in other ways. ​ He took into account the number of times they were bled over the course of their disease to make sure that there wasn't a difference in the average number of times people were bled between the 2 groups because that could explain the difference in outcome ​ He made sure the average age of these 2 groups was similar ​ P.C.A. Louis (1837), Lancet ○​ “I come now to therapeutics, and suppose that you have some doubt as to the efficacy of a particular remedy: How are you to proceed?...You would take as many cases as possible, of as similar a description as you could find, and would count how many recovered under one mode of treatment, and how many under another; in how short a time they did so; and if the cases were in all respects alike, except in the treatment, you would have some confidence in your conclusions; and if you were fortunate enough to have a sufficient number of facts from which to deduce any general law, it would lead to your employment in practice of the method which you had seen oftenest successful.” ​ The like comparison criterion (Fuller 2024) ○​ 1. Scientific therapeutic research: includes investigations that compare individuals or groups that are alike except for their treatment(s) in order to draw causal inferences about the efficacy of those treatments (comparing 'like with like') ​ Some of them are getting the treatment and others not ​ You are able to rule out that some other difference isn't responsible for their different outcomes ○​ 2. Scientific therapeutic practice: integrates the results of like comparisons (for instance, by preferring those therapies demonstrated to be most efficacious). ​ Take the results of that investigation and integrate the results into practice ​ You learn from that research in order to figure out what's most likely going to be the most effective treatment. ​ Louis relied on cross-sectional studies ○​ He wasn't taking patients and sending them off to different groups ○​ He was looking at hospital records of patients who had already been treated. ​ Homeopaths relied on case reports where you take a single case and don't compare it to anything else ​ Does the like comparison criterion still suffice? Must it be modified? Or abandoned?