Note: This was written as a book review for Skeptical Inquirer magazine and will be published in its Jan/Feb 2014 issue.
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Medicine is chock-full of philosophy and doesn’t know it. Mario Bunge, a philosopher, physicist, and CSI (Center for Skeptical Inquiry) fellow, wants to bring philosophy and medicine together for mutual benefit. He has written a book full of insight and wisdom, Medical Philosophy: Conceptual Issues in Medicine.
Whether doctors recognize it or not, medicine is firmly based on the philosophical principles of materialism, systemism, realism, scientism, and humanism. Bunge explains that:
Without materialism, both diseases and therapies would be taken to be purely spiritual.
Without systemism, every disease would be attributed to an independent module.
Without realism, diseases would be viewed as either imaginary or as social flaws.
Without scientism, either nihilism or dogmatism would prevail, and all the achievements of biomedical research of the last 500 years would be consigned to oblivion.
Without humanism, all medical practice would be mercenary, and there would be no public health care.
He points out that all these scenarios are alive and well elsewhere. Under the guise of “alternative medicine,” ancient prescientific medical systems are still being practiced nearly everywhere “to the detriment of people, the flora, and the fauna.” CAMs (complementary and alternative medicines) are isolated bodies of belief that are not based on science and do not examine their own philosophical presuppositions. Like religion, alternative medicine relies on the gullibility of its clients, who have been educated to believe without evidence and without explanation. Bunge says that acupuncture is useless except as an analgesic placebo, that the Ayurvedic pharmacopeia is fantastic, that only a few of the 11,000 Chinese herbal medicines have ever been subjected to controlled clinical trials, that fully 1/5 of the most commonly prescribed Japanese medicinal herbs are toxic, that homeopathy ignores the whole of science, and that naturopathy is only marginally better in that it combines an ignorance of the scientific method with remedies in amounts that might have actual effects on the body. The CAMs have contributed nothing true or useful to health care. He discourages any further research on CAM hypotheses that are incompatible with the bulk of scientific knowledge.
The concept of vitalism is now obsolete. Reductionists postulated some kind of supernatural vital spark because they couldn’t imagine how the whole could have properties not present in the parts; today we understand that new properties are emergent and develop by purely natural processes. A remnant of reductionism is seen in DNAism, the simplistic idea that everything is reducible to DNA. Understanding complex facts in biology requires both a top-down and a bottom-up approach. We exist on several levels, and conditions like obesity and addiction are affected by social factors, inadaptations, and wrong decisions. Social and environmental factors can affect the action of genes through epigenetics and alterations of gene expression.
In medicine, “it is systems all the way.” Holism sees a forest but not the trees. Individualism sees a single tree. Systemism recognizes that there is no whole without its parts and that some wholes have global properties that their parts lack.
Bunge throws another wrench into intelligent design: if our body were wise, it wouldn’t get sick except through accident. The body produces antibodies for protection against infections, but it also produces endotoxins and maintains cancer cells.
He covers the history of medicine and the emergence of science, defined by Richard Feynman as “the belief in the ignorance of experts.” He laments the way so many people confuse frequencies with probabilities: there isn’t a 30% probability that you have a disease, you either have it or you don’t.
He covers the scientific method, why randomized controlled trials (RCTs) are necessary but insufficient, and why most published research findings are false. He explains that the placebo effect is not evidence of the power of an immaterial mind over the material body, but just the opposite: the effect of a material cerebral cortex on material subcortical organs.
Like those of us on the Science-Based Medicine blog, he is a critic of evidence-based medicine (EBM). He complains that evidence-based medicine is not as novel as its champions claim it to be and that it exaggerates the weight of evidence at the expense of that of hypothesis. EBM “has only strengthened the empiricist tendency to accumulate undigested data and mistrust all theory.” Science only advances when experiments are guided by hypotheses. Those who hold that passing a randomized controlled trial is all we need for proof are stuck in empiricism. RCTs are the gold standard, but there is a platinum standard (RCTs plus mechanisms of action) that is better. And even studies that fit the platinum standard should not be idolized.
Preventive medicine is arguably the most important medicine of all, and it is a social issue. Secular humanism is the only ethical system that defines “justice” as the balance of rights with duties. Everyone has the moral right to medical assistance. This implies a moral obligation to providing sanitation, vaccination, and access to health care for those who can’t afford it. Today, modern pharmacology only reaches 2 out of every 7 human beings. Libertarians would let individuals make their own decisions about vaccination, but in health matters, individualism just doesn’t fly. Sanitary systems, compulsory vaccination, and epidemic management require action by society as a whole.
Bunge calls for a systemic approach to solve problems at the intersection between medicine and politics; he proposes a whole package of social policies with a multifaceted program to address access to health care, planned parenthood, more effective preventive measures including better education about diet and hygiene, income inequality, housing, environmental protection, price control of pharmaceutical drugs, reinforcing NGOs, and more participation of the citizenry in politics. Even if you don’t agree with his solutions, you will probably agree with his identification of the problems.
This is not a “fun” read or an easy one, but it is packed with information and with food for thought about serious issues that affect every one of us. It is a challenging book that will make readers re-consider their unconscious assumptions, confront new ideas about things they haven’t thought about, and think more deeply about things they may have taken for granted. Oliver Wendell Holmes, Sr. said, “A mind that is stretched by a new experience can never go back to its old dimensions.” This is a mind-stretching book.
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Followup note: This book gave me a new perspective on the term “holistic.” I had interpreted it as being similar to the conventional medical approach of looking at all aspects of a patient, treating the whole patient rather than just one body part; but according to Bunge it means seeing the forest only as a whole, without paying any attention to individual trees. What conventional medicine does is what he calls systemism, recognizing global aspects as well as individual parts. CAM “holism” can mean seeing only the global aspects and ignoring basic details like anatomy, physiology, and biochemistry. Good medicine has always encompassed both the details and the emergent global properties, seeing the whole forest along with the details of every tree. It is holistic while simultaneously being individualistic; in a sense, it is more “holistic” than so-called holistic CAM: there can be no whole without its parts.