De filosofische basis van de geneeskunde

As scholars we recognize the debt we owe our colleagues who take our work seriously enough to offer carefully developed criticism. We are therefore delighted that Dutch physicians and philosophers would offer their criticism of our work in the philosophy of medicine (1985;2512-7). Their comments will help us to clarify our position, to consider new questions and to tighten the lines of our arguments. Even more, we are encouraged about the still-budding discipline itself to see that all of our critics agree that there is some basis for a philosophy of medicine that deserves exploration. Nevertheless, some points require comment from us. We wish to respond first by making some general points, and second by addressing specific topics.

Our critics appreciate that we have undertaken a serious, important, but very difficult task. We were under no illusion, however, as Dr. Verbrugh suggests we might have been, that our book might heal the rift between philosophy and medicine on its own, or that we have exhaustively covered all possible topics in the philosophy of medicine, or that our work would please those scholars who do not share the same philosophical suppositions and methodology. Further we thought we had made clear that ours was not the first systematic American effort to address a philosophy of medicine (we think that honour belongs to F.Scott Buchanan).1 Note, too, that Dr.Endtz thought we presumed uniqueness by placing the clinical event at the center of medicine. Our references during the discussion leading to that placement should disabuse anyone from that notion.

We can't refute the objections to our philosophical method at this time, nor try to resolve difference in our presuppositions between ourselves and our critics. They obviously approach philosophy differently than we do. Nonetheless much of the criticism stems from our clear intention to find the roots of a philosophy of medicine in the actual phenomena of medicine itself, and from those roots, to explore health and illness, and indeed, ethical axioms and consequences of these axioms. Prof.Broekman seems sympathetic with this enterprise, but quite concerned that axioms leave no room for discussion. Here a problem with language occurs. We regard axioms not as ultimate principles to which one must always adhere, but rather, as context-derived guidelines for action. We argue that such axioms are dependent upon the healing aims of medicine and are required to reach that aim. They do not rule out discussion between doctor and patient at all. Rather dialogue about the healing aim, specifically what counts as healing for the patient, is necessary to accomplish the moral task of medicine.

In this effort, we do not deny the importance of other dimensions of medicine, especially such dimensions as prevention, public health, the issue of resource allocation, and the role of social values in the practice of medicine. Indeed, each of us, in several places, has discussed both the ethics and the philosophy of many of these other dimensions of medicine. As we said in the beginning of the book, our intention was to initiate the discussion needed to develop a new philosophy of medicine for our day. In particular, this development would be a ‘systematic’ study of medicine. That is to say, philosophy of medicine includes its logic, epistemology, ontology, aesthetics, axiology, sociology and anthropology, to name just a few of the components needed.

First it puzzles us that the same book would provoke such widely divergent response, from finding much merit (Prof. Van der Meer and Dr. Endtz) to little merit for Dutch readers (Dr.Verbrugh). The reason seems to lie in expectations more than anything else. We did not set out to write a philosophy of epidemiology or prevention, but rather a philosophy of medical practice. Given our approach toward clinical practice (recall that our title emphasized practice), we took great pains in the book to demonstrate that the clinical event (the doctor-patient relationship) was the distinguishing feature of the discipline of medicine, and not just the result of a personal bias of ours due to training, experience, and proclivities. One could write a philosophy of epidemiology or prevention, but such a philosophy could not be extrapolated to the clinical event. However, a philosophy of the clinical event makes possible other extrapolations, for example the social nature of medicine as a profession.

Second, Prof.Broekman fears that the philosophy of medicine as we have developed it is in danger of being skewed toward intervention and the medical model. We tried to avoid such skewing by emphasizing decisions made for and with the patient (a point missed by Prof.Broekman). We realize that much more needs to be written about the exchange of values in the relationship, and beyond it, in society itself. This concern prompted by criticism that our views lacked a social perspective, has led us to adumbrate these features in detail in our second work to be titled, ‘For the good of the patient: the restoration of beneficence in medicine’, which will soon appear from Oxford University Press.

Third, a fundamental disagreement about a starting point is present. Should the discipline start with the social reality of medicine or the individal and his diseases? Which has metaphysical priority: the individual or society? We are undeniably social beings, but also individuals. The question is like asking which came first, the chicken or the egg? Hence, we sought a compromise between the study of the individual and the study of medicine as a social reality – a tertium quid, if you will, the relationship of the doctor and patient. From this vantage point, one may address individual, social, professional, economic, scientific, and institutional concerns.

Fourth, Dr.Verbrugh takes us to task for equating theory and philosophy throughout our book. In his words: ‘Filosofie is niet hetzelfde als theorie’. He is right, of course. Philosophy is not equivalent to theory. But the obverse is true. Theory in medicine is equivalent to a philosophy. As our historical development in the book demonstrated, thinking in medicine about the craft, disease entities, and all other concerns, always betrays a philosophical basis. This point is very well articulated by Prof. Broekman at the end of his critique. Medicine rests on a philosophical and ethical base prior to any particular philosophical analysis. While Dr.Verbrugh is correct, then, in tracing the divergence between philosophy and medicine since 1840, we should not uncritically accept his implication that no philosophical thinking occurred in the development of the theory of medicine over the past century. We liked his analogy between a chronically i11 patient and the often troubled relation of philosophy and medicine – many efforts will be necessary to rejoin the two in dialogue. Further, he is correct to argue that rejoining the two disciplines on the basis of ethical and economic concerns is not sufficient. That is why we set a modest goal of taking a ‘first step’ toward developing a philosophy of medicine.

Finally, a word about methodology. We perceive some exasperation with our realistic, empirical, analytic, phenomenologic, and eclectic method. Further, Dr.Verbrugh and Dr.Endtz seem puzzled by a personal, ‘first person’ approach in a scholarly work. We are not the first, nor the last, to note a fundamental rift between Anglo-Saxon and continental approaches in philosophy. Points made in the latter method appear to English-speaking analysts as hopelessly vague and obtuse. Further, the modes of ‘detached’ analysis in continental philosophy do not properly portray the personal engagement of the thinker thinking that our first-person plural style does portray. Further still, practical conclusions and implications are essential in any philosophy of medicine, which is perforce, a practical discipline. As H.Tristram Engelhardt notes: ‘Medicine approaches the world not simply to understand and explain it but to master it’.2

A more intensive cross-cultural dialogue is needed to correct cultural bias if a truly authentic philosophy of medicine is to emerge. We are grateful to our Dutch colleagues, then, for contributing to this effort despite their disagreements with us.

We thank Prof.Thomasma and Prof.Pellegrino for their serious attempt to bridge cultural and linguistic rifts. I have asked the writers of the bookreview to comment on the remarks of our American colleagues.

Prof.Broekman is of the opinion that a decision made by a doctor for and with the patient is already characterized by the medical model. He upholds his objection against the equalization of that decision with other decisions pertaining to life events. He objects to the individualistic starting point of the authors in their discussion of the doctor-patient relationship, again an expression of the medical model. It is wrong to make a choice between ‘metaphysical priority’ of individual and society; this would suggest that an individual might exist prior to a society.

Dr.Endtz and Dr.Verbrugh wrote long replies, from which I select the following remarks.

Dr. Endtz: my cry for definitions remains unanswered. Since medicine is universal and medical practice ideally is tending to be so, the first thing to do is to define the words for use. As for me, I am not against a personal approach and I do not object to changing our axioms, but if we want to be understood, we have to know what we are talking about. I am still puzzled by the easiness shown by Prof.Thomasma and Prof. Pellegrino in their use of the terms ‘medicine’ and ‘medical practice’. I eagerly try to follow their discourse but they do not make my trying easier in this way.

Much remains to be said about the supposed identity between ‘medical practice’ and the ‘healing aims of medicine’. Times have changed since Hippocrates stressed the importance of prognosis and we are better armed to intervene in prognosis; but is not this intervention, and thus the healing aim, only part of medical practice?

One word on psychiatry. I am aware that American psychiatrists today are ready to bridge the rift between psychiatry and the rest of medicine.

Dr. Verbrugh: I still have great misgivings about a venture in ‘a philosophy and ethic of the healing professions’ presented under the title of ‘A philosophical basis of medical practice’. One can describe how people go about setting medical matters, particularly how they deal with situations in which there are conflicts of interests and other ‘ethical’ issues. This is not a ‘philosophical’ ethics, however, it is sociology or journalism, not philosophical reasoning. This is my main objection to the book.

The authors see ‘the actual phenomena of medicine primarily in the clinical event’ (page 4), and although this is historically certainly a valid procedure, I would argue that many, perhaps even most issues which are medically-philosophically controversial and relevant have their roots outside the phenomena of the clinical event. The roots of the reasons why people think and feel and act in the way that they do about such issues as euthanasia, abortion, artificial procreation, psychiatri-psychosomatic treatment, the coping ability in the case of cancer and other serious diseases, etc., are not to be found in the phenomena. It can be fruitful to start the discussion on the basis of the phenomena, but I would also want many more examples taken from practice than Thomasma and Pellegrino provide in their book. Indeed, having a second (or, rather a third or fourth) look at their book while writing this reply to their comment, I am again impressed by the paucity of actual medical cases and phenomena. It is from such case-studies that the reader is incited to discover for himself the actual phenomena of philosophy.

This brings me to another point. I ‘seem puzzled by a personal, “first person” approach in a scholarly work’. On the contrary, I dearly miss the ‘first person’ where it would be appropriate, that is to say, in the narration of personal experiences and in the explicit taking of sides in issues. What I consider to be a defect in the book, is the lack of equilibrium between (subjective) personal experience and engagement on the part of the authors, and the absence of any objective philosophy, in the sense that the great lines of philosophical thought as it has developed in the last 25 centuries are not summarized with reference to medicine today.

I like to close this reply by quoting the last section of Dr.Endtz's letter: ‘Finally I want to thank Prof.Thomasma and Prof.Pellegrino for having formulated their ideas first in their book, now in their reply. They have been of great help for me in clarifying my own ideas and, I am sure those of many others. The last word will never be said but I hope that the dialogue will continue’.

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