The Logic of Medicine

One may regard the medical school as a professional academy for the cultivation of concerned, intelligent, responsible dispensers of the complicated art of healing. It draws on modern technics and the fruits of basic science. It is not clear why, apart from its tradition and its natural dignity, such a discipline should be in a university, any more than a conservatory of music, an academy of art or a school of ballet. Those who see a university as a seat of learning and not as a center for teaching (however sophisticated), will think that medicine as an “applied science” is out of place. It is laudable that American medical schools have fostered exchange between bedside medicine and the basic sciences. Alert practitioners of medicine maintain scientific interests. But the notions readily arise that the clinical arts are concerned with marketing the secure truths of human biology: that the creativeness of clinical medicine lies in adapting knowledge to practice and occasionally detecting intriguing problems for the scientist to solve. If the physician, dedicated fulltime to research, is not to use his medical training and must compete on an equal footing with the mathematician or the molecular biologist, one might wonder what point-apart from instilling a vague sentiment of commitment to mankind-there was in his attending medical school. The fundamental cause of this unbalanced view appears to be the lack of a strong philosophy of medicine. I used the word “philosophy” in a strict sense: not as a general attitude of purpose, but as a formal enquiry into the structure of medical thought. A distinguished medical historian has had some sense of this fundamental need [l]. I suspect, however, that history is not a discipline with the necessary abstraction and rigor of analysis to fulfill this function. We live in an age of medical reductionism, doubtless a reaction to vitalism and its mystical excesses. We uncritically hold certain views, such as, that all scientific rigor is metrical; that study of vital mechanisms can, and should, be resolved into the study of pure compounds; that multivariate processes can, without distortion, be condensed into simple quantities (like intelligence quotients or countless “diagnostic indices”]; that a medicine not intrinsically taxonomic is unthinkable: that the only alternative to determinism is chaos; that all uncertainty about outcomes is due to ignorance; that concepts are ontologic rather than heuristic: that it is better to be precisely wrong than roughly accurate; that cautious vagueness is a hallmark of mature wisdom, and much more. The peril of these views lies not so much in the fact that they may be untrue as that they are implicit: that they bespeak not so much affirmation as unreflecting assent. I could refute each of these assertions by counterexamples from human genetics, where the currently most rewarding fields are not metrical at all; where naive evolutionary theory is in decay; where ever more refined evidence of heterogeneity is sounding the death knell of comfortable taxonomies; where the formal laws of evidence are neither deterministic nor vacuous, but triumphantly probabilistic; where genetic prediction is precisely uncertain; where gratuitions vagueness in prediction is charlatanism. But such refutations skirt the main issue. Many lament that clinical medicine has become depersonalized; but if their plea is for humaneness and nothing more, there is some risk that it may degenerate into sentimentality or even discourage intellectual venturesomeness. However narrow, reductionism has at the least produced its demonstrable (and seductive) successes. The deficiencies of reductionism are more elusive than the successes. All that the study of components can tell us is what the components are like. It overlooks entirely the Aristotelian “category” of relationship.