Medicine+between+science+and+ethics

Read the following text and then discuss the questions

**The Practice of Clinical Medicine as an Art and as a Science (1) **

Although doctors’ medical practice is not itself science, it is based on science and on training that is supposed to teach doctors to apply scientific knowledge to people in a rational way. This distinction between understanding nature and power over nature, between pure and applied science, was first made by Francis Bacon in his //Novum Organum// of 1620. […] Science as pure science is knowledge of our natural environment for its own sake, or rather, for understanding. Science as applied science or //technology// is the exercise of a working control over it. Such is medicine. In its methodology, scientific thinking should, must, be insulated from all kinds of psychological, sociological, economic, political, moral and ideological factors which tend to influence thought in life and society. Without those proscriptions, objective knowledge of truth will degenerate into prejudice and ideology. […] **Value-neutral truth ** Although the aim of standard empiricism is value neutral truth, that does not imply that science is insulated from outside factors. It merely states that such factors are not integral to it—social context, for example.[…] Fashion is [a] powerful influence. There are treatments of fashion, investigations of fashion, diseases of fashion, operations of fashion. Hypoglycaemia comes and goes; chronic mononucleosis is probably on the way out, so is ME -even if chronic fatigue syndrome survives. Mitral leaflet prolapse syndrome caught our fancy in the 1970s when everyone who had an echocardiogram had it; then we’ve had temporomandibular joint syndrome, post traumatic stress syndromes, osteoporosis, fibromyositis, candidiasis hypersensitivity syndrome, total allergy syndrome, Gulf War syndrome, repetitive strain injury—and so they go on, a disease of fashion almost every month. One could make similar comments on treatment or investigations. The point is not simply whether they “exist”, though this is controversial in many of the examples given: it is the importance that they are accorded in a supposedly objective applied science.[..] **Rules of thumb ** At least part of the art of medicine lies in those non-scientific rules of thumb that guide decisions in practice, that enable the good doctor to affirm what he believes to be true in a particular situation. These cannot be and aren’t science. McDonald argues that these should be discussed, criticised, refined and then taught. Ockham’s razor tells us to go for the simplest unifying hypothesis in diagnosing the patient’s disease; Sutton’s law (based on the bank robber who told the judge he robbed banks because that’s where the money is), tells us to go for the commonest explanation. Perhaps we could subsume those two principles into the structures of science. Certainly simplicity or elegance have long been recognized as important features of science. But by what rules do we decide to extrapolate—for example, it works in the old or the male, so we’ll use it in the young or the female? Or it works with one particular drug, so we argue it will work with another drug that has the same effect. For example, we assume that any drug that lowers blood pressure will offer benefits to the patient. Or we assume that only a drug of the same class will have the same benefits; we extrapolate from evidence about one statin drug or one angiotensinconverting enzyme inhibitor to all others in the same class. Or we won’t extrapolate in certain other cases. Instead we use the “show me” principle. Practolol was shown to reduce deaths after acute myocardial infarction,13 but other beta blockers were not assumed to be effective until huge trials had been mounted. […] **Uncertainty ** Scientific medicine is based on evidence; but uncertainty grows when multiple technologies are combined into clinical strategies.[…] A 42-year-old mother of two small girls, despondent over job difficulties,was contemplating genetic screening for breast cancer as she approached the age at which her mother was diagnosed as having the same disease. Aside from the difficulties in taking an evidence-based approach to assigning quantitative risks and benefits to the genetic screening procedure (How much should I trust the available information?) and uncertainty about the effectiveness of medical or surgical interventions (Would knowing the results make a differ ence, and, if so, to whom?), the case raised important relationship-centred questions about values (What risks are worth taking?), the patient-doctor relationship (What approach would be most helpful to the patient?), pragmatics (Is the geneticist competent and respectful?), and capacity (To what extent is the patient’s desire for testing biased by her fears, depression, or incomplete understanding of the illness and test?). In this situation, book knowledge and clinical experience alone are insufficient. Rather there is reliance on personal knowledge of the patient (Is she responding to this situation in a way concordant with her previous actions and values?) and the doctor (What values and biases affect the way I frame this situation for myself and for the patient?) to help us arrive at a mutual decision. […] It has been said that “we don’t see things as they are, we see things as we are”. Evidence-based medicine and the doctrines of standard empiricism offer a structure for analysing medical decision making, but are not sufficient to describe the more tacit processes of expert clinical judgment. All data, regardless of their completeness or accuracy, are interpreted by the clinician to make sense of them and apply them to clinical practice.

1. What knowledge, if any, will always remain beyond the capabilities of science to investigate or verify? If there is, or can be, such knowledge, why will it always elude effective scientific treatment?

<span style="font-family: 'Tahoma','sans-serif'; font-size: 13.3333px;">2. Should research be subject to ethical principles, or is the pursuit of knowledge through research intrinsically worthwhile and, of itself, value-free?

<span class="wiki_link">(1) Excerpts from: Saunders, John. // The practice of clinical medicine as an art and as a science //**, in: **__ Med Ethics: Medical Humanities __ 2000;**26**:18–22.