Keekok Lee explores the philosophical foundation of modern medicine, a link often ignored if not denied in the literature. Lee argues that this relationship explains why modern medicine possesses the characteristics it does. Nathan Emmerich finds the work to somewhat confused and more of a study of the philosophical foundations of biomedical science.
The Philosophical Foundations of Modern Medicine. Keekok Lee. Palgrave Macmillan. 2011.
Contemporary philosophy of medicine is a diverse and sometimes fractured subject. It ranges across phenomenological explorations of the patient, illness, and medical practice, and philosophies of human biology in both continental and analytic traditions. It can be informed by historical, social and cultural factors or it can be entirely ahistorical, asocial and acultural.
The conflicts of the field can be clearly perceived in practice. Philosophical debates about the nature of medicine reflect the competing worldviews of science and humanism, and an understanding of the patient as a biological organism and as a socially and culturally located individual. Robert M. Veatch has suggested that the advent of the modern professional medicine was marked by a disruption in the dialogue between humanist philosophy and a nascent scientific medicine. In his view, this disruption ended with the advent of bioethics. However, it remains an open question whether bioethics opened the door to broader philosophical perspectives or if our understanding of medicine maintains a narrow focused on all things ‘scientific’.
Such is my concern with Keekok Lee’s claim to lay bare the philosophical foundation of modern medicine. The book has a somewhat more limited scope and what is in fact on offer is an exegesis of the philosophical foundations of biomedical science, an account that is presented in three movements. In the first movement we are offered a brief account of the affinity between ‘philosophy’ and ‘science’, coupled with the claim that an ontological volte-face made scientific biology historically possible. This volte-face is the Cartesian reconception of the organism as machine. In the second movement this ontological volte-face is, literally, writ large. The result is, we are told, that medicine is not simply ‘medicine’ but, rather, ‘MEDICINE’ something which is also ‘ENGINEERING.’ This thinking is then applied to ‘some sciences’ and ‘some technologies’ of biomedicine and thus the non-metaphorical truth of the propositions that medicine is engineering and organisms are machines have been established. The final movement presents an account of (monogenic) causality that purports to explain the inner workings of the machine or, perhaps, MACHINE. This final movement is closed by an account of epidemiology which contradicts much of what Lee has philoscientifically established. The point of this last chapter appears to be that different sciences are underpinned by different philosophical commitments.
Whilst this is a relatively unobjectionable conclusion because there is little critical engagement with philoscientific account of biosciences, one reaches it with some surprise. When reading this book I was under the impression that Lee had been seeking to establish the ontological, or philoscientific, truth of the organism-as-machine ‘episteme.’ The never fully discussed conclusion is that whilst this is true from within the epistemic perspective of the biosciences there are other equally scientific (and philosophical) but different perspectives within which it is not true, such as epidemiology. Nevertheless this seems to run counter to the path one has been invited to tread.
This book is not really a philosophy of medicine but, rather, a philosophy of the bioscientific worldview. This limitation does not appear to be fully recognised by Lee and thus when medical education is briefly mentioned, the author speaks of ‘biomedicine’ and the way it is constituted by the clinical and pre-clinical curricula (p.65). However Lee’s understanding is only really applicable to the pre-clinical aspect of medical education. Lee consistently talks of ‘medicine’ but does not make clear that clinical practice is beyond the scope of her comments. Furthermore there seems little justification for reducing the relevance of the patient’s phenomenological experience to medicine to the reporting of symptoms (p.115-116) and there is certainly no reason for doing so without referring the reader to the distinction between illness and disease and to work such as Carel’s celebrated book ‘Illness’ (2008). One could say that in making this point I am criticising this book for not being something else, for not being a philosophy of clinical medicine, a claim that has also been levelled at Evidenced Based Medicine. However Lee, and EBM for that matter, invites this charge precisely because they do not adequately recognise the limitations of the philoscientific paradigm.
This flaw can also be perceived in Lee’s lack of engagement with the troublesome nature of the placebo. Certainly at the end of chapter 8 she provides a reasonable discussion of the placebo and notes the implications “may well entail calling into question … the axiom of body-is-matter-is-machine.” (p.112) Nevertheless whilst this may well be entailed it is not carried through. Most subsequent references to the placebo are in footnotes and the axiom remains unquestioned. Indeed Lee adopts the ontology of Scientific Naturalism in such a manner as to deny the metaphorical nature of the organism-as-machine view considering it ontological or categorical (by which I assume she means true). One of her examples is that it does not make literal sense to say that “Tuesday is red or Sunday is Green.” Such statements can only be metaphorical. However in the phenomenological experience of some synesthesiasts is can make literal sense to say such things, nevertheless such individuals can recognise the truth of such statements. What this shows is that our ontological understanding of days of the week as not being amenable to having colour properties is not pre-theoretical but theory laden. Our ontological grasp of the world is not, as Lee suggests (p.25), beyond language. Rather it is intimately and inescapably bound up with it. Thus whilst some people have indeed ‘noticed’ “rivers and mountains are lifeless things [but] birds, fishes and plants are living things” (p.26) doing so embodies a theoretical perspective. Others have considered rivers, mountains and, indeed, entire planets to be living things.
This being the case we might consider how philosophical foundations of the biosciences distinguish between life and lifelessness. Lee embraces reductionism and rejects vitalism or any sense that, as a whole, the organism is greater-than-the-sum-of-is-parts. The organism is a ‘naturally occurring mode of being’ but to say such a thing offers little help in determining precisely when, for example, twinning turns one foetus into two or if an aspect of ‘my naturally occurring mode of being’ – the flora in my gut – is itself a naturally occurring mode of being distinct from my own and vice versa. Indeed it is not clear that how Lee, or the biosciences, distinguish between life and death. Hans Jonas suggested that vitalistic monism was “replaced by mechanistic monism, in whose rules of evidence the standard of life is exchanged for that of death” and reading Lee it is difficult to disagree. Mechanistic organisms such as birds, fishes, plants, and human beings are ‘linearly causal’ and ‘monogenic.’ In contrast, rivers, mountains, planets, and populations – the object of epidemiological study – are causally multi-factorial, non-linear and, therefore, not ‘mechanistic.’ In the biosciences, life has come to be defined as the mechanical body, which is to say the functional dead body. If this is correct then, ethically, modern medicine cannot be considered a bioscience. Nor can its philosophical, or philoscientific, foundations lie within the biosciences. To paraphrase Sartre, medicine is a humanism, and there is little humanistic about this book.
Nathan Emmerich is Visiting Research Fellow in the School of Politics, International Studies and Philosophy, Queen’s University Belfast. He took his PhD in the School of Sociology, Social Work and Social Policy at QUB and his subsequent book ‘Medical Ethics Education: Interdisciplinary and Social Theoretical Perspectives’ is in press with Springer. He is currently working on conceptions of Bioethical Expertise. He tweets @bioethicsuk and he has an academia.edu profile. Read more reviews by Nathan.