Manfred's Column, November 2004: To have an idea versus to justify it - Why medicine is more than science
To Have an Idea Versus to Justify It: Why Medicine is More than Science
Ideas from philosophy of science rarely generate much enthusiasm in medical students. The subject appears to be dry, detached from reality and clinical medical practice. A look behind the scenes of philosophy of science which admittedly consist of a rather opaque mixture of methods, jargon, schools of thought and logic, however, teaches some important lessons and brings about vistas on useful concepts for the understanding of medical practice. In what follows let us discuss the example of the difference between having an idea and justifying it which has been a subject of discussions about the growth of knowledge by philosophies of science.
The distinction between having an idea and justifying it is a simple one: the question of how you arrived at the certain idea is different from the question of how you can show that this idea is actually correct.
People rarely investigate how new ideas come about and little research is being conducted within psychology on creativity and fantasy. When compared to the significance of new ideas for economics and society, the number of scientific publications about how to arrive at new ideas is in fact ridiculously low. It can only be hoped that this may change in the near future with the advent of new methods in psychology and cognitive neuroscience.
Philosophy of science in a strict sense is only about the justification of ideas. It does not deal with the question of how somebody arrived at a new idea because this question is irrelevant when it comes to the truth of its content. Both processes - to have an idea and to show that it is true - are not only different from a systematic point of view but also from how they are subjectively experienced. We know for example from scientists like Albert Einstein, that it is easy to have a new idea about the nature of light, space, time, matter and energy, but it is very hard to do the mathematics correctly and show that these ideas are actually correct.
It is obvious that a good scientist not only comes up with new ideas but is also disciplined enough to justify them correctly. Scientists however are not all equal in these respects. There are creative individuals who come up with many new ideas and need help from others to transform these ideas into projects, that is into controlled experiences subserving the justification of the ideas. On the other hand there are specialists in methodologies who are mainly engaged in the testing of well know hypotheses and who rarely (sometimes possibly never) have a new idea themselves. Science as practical enterprise is in need of both of these types of scientists and science cannot do without good new ideas and their justification. In economics this is not different. He, who has new ideas during a brain storming session may not be the same person who selects the good ones from a number of new ideas, and yet another person may have the power and persistence to transform the ideas into reality. Historians of science sometime like to dig deeply into the psychological context of the genesis of new ideas: how much wine did Riemann have, when he had his new insights about integral calculus? Why did the discoverer of the benzene ring, Kekulé, dream during that night of six dancing monkeys grabbing one another by the tail? With whom did Einstein sleep when it dawned upon him, that not time, but rather the speed of light is constant? - Questions like these may be of interest if we wonder why some people think the unthinkable and imagine the unimaginable, suddenly, out of the blue. However, the answers to these questions - if there are any - do not tell us anything, to repeat: absolutely nothing, about the truth of the ideas.
Whenever we deal with the truth of a statement we need to deal with reasons. Since the time of Aristotle, logicians try to clarify the structure of arguments that are needed to justify new ideas. Philosophers of science and logic have done a lot of detailed work that is ongoing and not yet completed. For example, when we ask the very basic question of how to ultimately justify a certain statement (just like children, scientists always continue to ask why) we have a choice to just stop asking, ask indefinitely, or argue in a circle. Notwithstanding this unresolved question, there is a highly developed culture of testing and justification of hypotheses in every branch of science, and this culture has to be appropriate to the subject matter and the methods used. It ranges from the strategies and general methods of measurement to scientific organizations, organs of publication, peer-review-systems and meetings. This scientific culture is a culture of justification.
Within science there is no culture of the genesis of new ideas. There is the story of scientists from Great Britain who during the second world war did not have funds or laboratories. Among themselves they said they still had their three "B" for research - the bar, the bathroom, and the bedroom. This satyrical story demonstrates very strikingly the absence of a culture of how to arrive at new ideas. General consent among scientists says that the generation of new ideas is always private.
Insofar as medicine deals with diseases that have to be explored like any other subject matter in science, medicine is a science and its aim for general true statements about diseases. Insofar as medicine also deals with patients, it is more than science. One reason for this is the specifically defined interaction between patient and doctor that dates back to Hippocrates and the second reason is that medicine deals with suffering and with actions to diminish suffering i.e. it is applied knowledge. These two aspects, the interactive aspect and the applied knowledge aspect have been written about extensively, especially since the rise of so many papers on medical ethics.
A third distinction concerning medicine as a science is just as basic as the two mentioned above but has not been thought through as much as the others. It is a logical one and can be clearly stated within the framework of having versus justifying an idea as outlined above. In medicine it is often highly important to come up with an idea. Once a huge pile of data has been reduced to a small set of statements and once the diagnosis has been made on the basis of such statements, the rest follows according to general rules of science. However, whether a patient is a case of disorder X or a case of disorder Y and which possibilities might be considered for X and Y is not a question of justifying an idea but rather of having one.
Little has been written about this process and a few more well know ideas are discussed under such diverse topics as "clinical wisdom", "counter transference" and "praecox-feeling". If we say that some doctors have more clinical wisdom than others we are saying that there are individual differences in the ways people come up with a new idea. The praecox-feeling has confused many psychiatrists in that it has been taken as a means to justify a diagnosis (which it is not) and not as a principle that evokes the idea that some person may be schizophrenic. To make this clear, if the psychiatrist has this strange feeling toward a patient, this feeling may actually guide him to ask the right questions and to become prescient about some answers of the patient. The feeling may guide further interview techniques and may enable the psychiatrist to find out about various symptoms of schizophrenia. These symptoms then are the diagnostic criteria for the disorder, not the strange feeling of the psychiatrist.
The same is the case for counter transference: it is wrong to say "because I am aggressive this Patient is depressed", although feelings of aggression may frequently occur when dealing with depressed patients and these feelings of aggression within the psychiatrist may be used to guide the interview and ask the right questions regarding depressive symptomatology. The idea of making counter transference reactions conscious to the psychiatrist may be the furthest medicine ever came toward dealing with guiding principles for coming up with diagnostic ideas. In fact notwithstanding all the many criticisms that are currently stated in respect to psychoanalysis one should not throw out the baby of useful clinical wisdom with the bathwater of out-dated and out-moded theoretical thinking. Doctors cannot start anywhere else but with their feelings towards the patient, when they make a diagnosis. Their clinically informed observations and their free associations bring up all the knowledge they have gathered over the years from textbooks and other patients. Lists of criteria, decision making algorithms, and high tech medicine are not the things with which to start because all these procedures belong the realm of justification which presupposes that an idea is already there. The process of having ideas cannot be eliminated from practical medicine and it cannot be replaced by a purely data - driven (brute force) approach because there are not only practical problems with limited resources but also principle problems with human finiteness, in particular when it comes to ill patients.
It may be hoped that scarce resources, quality control, economic limitations and equal distributions, i.e. ideas that guide current medical political discussions, may also lead to more thoughts about medical practice. A culture of how to generate new ideas that can be taught to students might help to render the diagnostic process more rational (because getting ideas and justifying them are clearly distinguished) more efficient (by means of establishing a climate that is brain storming friendly) and is last but not least, more human (by having a clearer concept of what medical doctors can actually do on a daily basis).
Original title: Spitzer M (2000) Draufkommen versus Rechtfertigen: Warum Medizin mehr ist als Wissenschaft. (Editorial). Nervenheilkunde 19(5):217-219