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Some thoughts on the philosophy of medical research
Early Human Development, Elsevier
9 (1984) 183-185
183
EHD 00547
Invited Editorial
Some thoughts on the philosophy of medical research There are, as the Danish savant Kierkegaard pointed out, three basically different ways of looking at our world: the religious, concerned with inter-personal relationships; the aesthetic, concerned with what delights us; and the scientific, which has to do with understanding how natural things work. The criteria by which we make judgements in each of these fields are, respectively, goodness, beauty and truth. Different cultures have tended to emphasise one or other of these aspects of living to the partial exclusion of the others: and ours could be said to be an age in which man has opted for seeking truth rather than beauty or goodness. In these times we would appear to prefer to be judged by the quality of our science rather than that of our art or politics (about neither of which we have much to boast). But, as Horace put it, “expellas naturam furca, tamen usque recurret” (fork it out and it will inevitably spring up again); and puritans and aesthetes, finding no straightforward way of imposing their values on a world which by and large does not subscribe to them, have, as I see it, been trying for some time, and with some success, to apply aesthetic and moral criteria to science, so that we now talk about “elegant” experiments and “good” or “bad” scientists. This is confusing means with ends. It is possible we could follow Keats in equating beauty with truth, perhaps as a kind of byproduct of a perfect fit between means and ends, or accept that there are certain moral qualities which a scientist brings to his work; however, in the last analysis survival of the fittest applies to theories as it does to species, and fitness in this sense has little or nothing to do with goodness or beauty but only with what is serviceable. Such a misapplication of judgemental criteria would represent a harmless enough aberration were it not that in some fields of enquiry it leads to a misapplication of resources, which in the case of medical research, for instance, are made available by the public in the hope that work so supported will improve our understanding of disease or our ability to prevent or cure it. The quality of an application as a thing in itself, or the quality of an applicant assessed in moral terms by his peers, have only an indirect bearing on whether something worthwhile will come of it if supported; and indeed the nearer to the bedside such work is conducted, the less “elegant” it is likely to be, though this is where medical research must begin. It is true that when a particular line of enquiry has reached what Kant called the “sure path of science”, subsequent work in the same field gains immensely in power and economy, and will therefore for a while, at any rate, pay high dividends both as Address for reprint requests: Dr. J.A. Davis, Paediatrics, Level 8, Addenbrooke’s Hospital,
0378-3782/84/$03.00
University of Cambridge Clinical School, Department Hills Road, Cambridge CB2 2QG, England, U.K.
0 1984 Elsevier Science Publishers
B.V.
of
184
regards understanding and its application to practical problems; but this surely should not involve a diversion of effort away from more exploratory kinds of enquiry concerned with what may for the present appear to be intractable problems, albeit of pressing importance. To think of science as only the art of the soluble might lead to a pursuit of science for science’s sake with increasing emphasis on the elegant solution of trivial questions - a kind of scientific dandyism indulged in by an elite, increasingly isolated from the pressures of ordinary life and perhaps ultimately recruited on the basis of birth and breeding rather than real ability. Scientific aristocrats are no more inclined to dirty their fingers with trade than were the aesthetic aristocrats of the nineties, the sporting aristocrats of the previous century or the religious aristocrats of ancient Tibet or present-day Iran. We must allow, of course, that money can be wasted looking for solutions to apparently important but ill-conceived questions, such as “the cause of cancer”, and that badly designed experiments may not only fail to answer questions but come up with the wrong answers. But truth is the child of error, not confusion; and the fact remains that the real world is an untidy, confusing and scientifically noisy place. Perhaps we should bear in mind Pascal’s famous distinction between “esprit de gkometrie ” and “esprit de finesse “1 the first, after the Galilean method, giving a definite answer to a definite question, but demanding that for this to be possible the observer should wrench his head into an unaccustomed position and viewpoint; the second involving an attempt to extract some kind of a pattern from the bewildering kaleidoscope of events presented directly to the senses. This, I suppose, is the most acceptable presentation of the so-called bifurcation theory, by which the methods of the arts and sciences are separated; but if it is legitimate for Medawar to speak of science as the art of the soluble, perhaps it might also be possible to speak of art as the science of the hitherto insoluble, which nevertheless we must make as much sense of as we can to get by in the real world - as physicians need to do. It is perhaps just a question of the amount of noise left in the system (entropy), represented on the one hand by an ability to pick up the scent, and on the other to follow it; and of course, to pursue the analogy, we do not want to end up chasing rabbits even if we catch them. It is perhaps the practical men, like engineers and physicians, who are in the best position to ask the important questions - just as only the scientists are adequately trained to arrive at definite answers to them; and clearly without mutual respect and comprehension, what should be a conjoint enterprise is likely to come apart at the seams, leaving the relevant questions unanswered and vice versa. Medicine is not a science but an art that uses scientific endeavour to deal with both the short and long term questions that need answering if diseases are to be adequately and economically prevented and cured. No one could deny that the pursuit of knowledge for its own sake will as often as not lead to the solution of practical problems as a kind of by-product; and equally, on the other hand, that important theoretical questions often arise when we are trying to solve practical problems. But neither approach will fructify the other if those concerned are not brought into working contact and cannot work together on a basis of mutual respect.
185
It is the general experience, with of course splendid exceptions that prove the rule, that those capable of high class scientific work are very often at sea in the clinic and at the bedside, just as those trained in clinical medicine, which often requires that life and death decisions are made on inadequate evidence, may find the hair-splitting (so necessary in the laboratory) something that does not come naturally to them; their habit of mind having been formed in a quite different context. But as Hooker put it, unto every end not every means will serve. Those now engaged in recruiting, educating and training medical students have an important responsibility in trying to ensure that the medical profession of the future is in the best position to use science in the interests of humanity. JOHN
A. DAVIS
9 (1984) 183-185
183
EHD 00547
Invited Editorial
Some thoughts on the philosophy of medical research There are, as the Danish savant Kierkegaard pointed out, three basically different ways of looking at our world: the religious, concerned with inter-personal relationships; the aesthetic, concerned with what delights us; and the scientific, which has to do with understanding how natural things work. The criteria by which we make judgements in each of these fields are, respectively, goodness, beauty and truth. Different cultures have tended to emphasise one or other of these aspects of living to the partial exclusion of the others: and ours could be said to be an age in which man has opted for seeking truth rather than beauty or goodness. In these times we would appear to prefer to be judged by the quality of our science rather than that of our art or politics (about neither of which we have much to boast). But, as Horace put it, “expellas naturam furca, tamen usque recurret” (fork it out and it will inevitably spring up again); and puritans and aesthetes, finding no straightforward way of imposing their values on a world which by and large does not subscribe to them, have, as I see it, been trying for some time, and with some success, to apply aesthetic and moral criteria to science, so that we now talk about “elegant” experiments and “good” or “bad” scientists. This is confusing means with ends. It is possible we could follow Keats in equating beauty with truth, perhaps as a kind of byproduct of a perfect fit between means and ends, or accept that there are certain moral qualities which a scientist brings to his work; however, in the last analysis survival of the fittest applies to theories as it does to species, and fitness in this sense has little or nothing to do with goodness or beauty but only with what is serviceable. Such a misapplication of judgemental criteria would represent a harmless enough aberration were it not that in some fields of enquiry it leads to a misapplication of resources, which in the case of medical research, for instance, are made available by the public in the hope that work so supported will improve our understanding of disease or our ability to prevent or cure it. The quality of an application as a thing in itself, or the quality of an applicant assessed in moral terms by his peers, have only an indirect bearing on whether something worthwhile will come of it if supported; and indeed the nearer to the bedside such work is conducted, the less “elegant” it is likely to be, though this is where medical research must begin. It is true that when a particular line of enquiry has reached what Kant called the “sure path of science”, subsequent work in the same field gains immensely in power and economy, and will therefore for a while, at any rate, pay high dividends both as Address for reprint requests: Dr. J.A. Davis, Paediatrics, Level 8, Addenbrooke’s Hospital,
0378-3782/84/$03.00
University of Cambridge Clinical School, Department Hills Road, Cambridge CB2 2QG, England, U.K.
0 1984 Elsevier Science Publishers
B.V.
of
184
regards understanding and its application to practical problems; but this surely should not involve a diversion of effort away from more exploratory kinds of enquiry concerned with what may for the present appear to be intractable problems, albeit of pressing importance. To think of science as only the art of the soluble might lead to a pursuit of science for science’s sake with increasing emphasis on the elegant solution of trivial questions - a kind of scientific dandyism indulged in by an elite, increasingly isolated from the pressures of ordinary life and perhaps ultimately recruited on the basis of birth and breeding rather than real ability. Scientific aristocrats are no more inclined to dirty their fingers with trade than were the aesthetic aristocrats of the nineties, the sporting aristocrats of the previous century or the religious aristocrats of ancient Tibet or present-day Iran. We must allow, of course, that money can be wasted looking for solutions to apparently important but ill-conceived questions, such as “the cause of cancer”, and that badly designed experiments may not only fail to answer questions but come up with the wrong answers. But truth is the child of error, not confusion; and the fact remains that the real world is an untidy, confusing and scientifically noisy place. Perhaps we should bear in mind Pascal’s famous distinction between “esprit de gkometrie ” and “esprit de finesse “1 the first, after the Galilean method, giving a definite answer to a definite question, but demanding that for this to be possible the observer should wrench his head into an unaccustomed position and viewpoint; the second involving an attempt to extract some kind of a pattern from the bewildering kaleidoscope of events presented directly to the senses. This, I suppose, is the most acceptable presentation of the so-called bifurcation theory, by which the methods of the arts and sciences are separated; but if it is legitimate for Medawar to speak of science as the art of the soluble, perhaps it might also be possible to speak of art as the science of the hitherto insoluble, which nevertheless we must make as much sense of as we can to get by in the real world - as physicians need to do. It is perhaps just a question of the amount of noise left in the system (entropy), represented on the one hand by an ability to pick up the scent, and on the other to follow it; and of course, to pursue the analogy, we do not want to end up chasing rabbits even if we catch them. It is perhaps the practical men, like engineers and physicians, who are in the best position to ask the important questions - just as only the scientists are adequately trained to arrive at definite answers to them; and clearly without mutual respect and comprehension, what should be a conjoint enterprise is likely to come apart at the seams, leaving the relevant questions unanswered and vice versa. Medicine is not a science but an art that uses scientific endeavour to deal with both the short and long term questions that need answering if diseases are to be adequately and economically prevented and cured. No one could deny that the pursuit of knowledge for its own sake will as often as not lead to the solution of practical problems as a kind of by-product; and equally, on the other hand, that important theoretical questions often arise when we are trying to solve practical problems. But neither approach will fructify the other if those concerned are not brought into working contact and cannot work together on a basis of mutual respect.
185
It is the general experience, with of course splendid exceptions that prove the rule, that those capable of high class scientific work are very often at sea in the clinic and at the bedside, just as those trained in clinical medicine, which often requires that life and death decisions are made on inadequate evidence, may find the hair-splitting (so necessary in the laboratory) something that does not come naturally to them; their habit of mind having been formed in a quite different context. But as Hooker put it, unto every end not every means will serve. Those now engaged in recruiting, educating and training medical students have an important responsibility in trying to ensure that the medical profession of the future is in the best position to use science in the interests of humanity. JOHN
A. DAVIS