Is Clinical Medicine a Science? – A/Prof Alan Gijsbers

7 MINUTE READ

from Luke’s Journal CMDFA 2019 Vol 24 No 2

I have encountered two sociologists recently who argue that clinical medicine is a science.  They then argue that, as a science, clinical medicine is hostile to religion.

The Balbonis (1), a minister/sociologist husband and a palliative radiation oncologist wife, argue that medicine has increasingly focussed on the physical aspects of illness to the detriment of the non-physical, or transcendent aspect of the human condition.  They argue that clinical medicine, by ignoring the human soul, has become hostile to religious/spiritual inputs. They believe that clinical medicine has become dehumanized by focussing on three dimensions of hospital care – science and technology, the legal and bureaucratic, and the economic and market dimensions. Clinical medicine has neglected the fourth dimension of hospitality and caring, a dimension enhanced by spiritual and religious considerations.  The Balbonis regard religion as the physical and outward manifestation of spirituality, and claim that spirituality is expressed through religion, and that this affects hospitality and compassion. The other sociologist is Dr Paul Tyson(2), who describes modern clinicians as value-free scientists practising a utilitarian ethic and unable to develop a theistic ethic based on the intellective, qualitative and transcendent nature of Christian ethics.  The clinician as a scientist is to blame.

But what if they are mistaken in regarding clinical medicine as a science?  

But what if they are mistaken in regarding clinical medicine as a science?  What if it is not based on the quantitative measurement, immanence, and rationalistic foundations these two sociologists believe clinical medicine are placed on?  What is clinical medicine anyway?

Clinicians are primarily not scientists, although we try to base what we do on a number of very different sciences, eclectically picking up bits that are useful and dropping bits that are not.  We are primarily pragmatists, solving whatever health problems patients present to us, and doing so with the best that the profession has to offer. The aphorism: “Cure seldom, relieve often and comfort always,” summarises the messiness of what we do.  Where we can, we cure – whether it be a cut, or a fracture, or a bacterial infection – always bearing in mind the healing power of the human body to aid the healing of a cut, or the fracture, or the infection. If there is no immune system, curing infection is much more difficult, although these days we have ways of enhancing the immune response.  While the healing takes place, caring clinicians aim to relieve pain and suffering with appropriate support. Good clinicians also seek to provide the patient the comfort of an adequate understanding of their disease, their prognosis and the way in which they can best deal with the challenge of time off from work, sickness benefits and so on. In the comfort area particularly, the holistic clinician sees herself as part of a team of carers committed to the cure, relief and comfort of patients.  The Christian clinician will seek to help a patient work through the spiritual issues sickness has raised, and provide appropriate help or referral to bring help to the sufferer spiritually.

Central to this is to perceive the presenting problem as it truly is – from a mild skin lesion which can be left alone, to an urgent problem like central crushing chest pain which will require immediate and skilled attention.  We use whatever strategies work, and try to protect our patients from quackeries that do not work. We work hard, sometimes too hard, to meet the demands the public make on us. We practise humanely and ethically, conscious of the trust the public have in us, and socialising our students to develop the same professionalism that we were taught.  We have ethical boards with expectations from the profession. Those who abuse the trust that patients have in our profession are sanctioned by that board, even to the extent of deregistering the doctor. There are imperfections in the system, and those damaged by the profession believe we have not been transparent enough. Thus we now have lay representatives on our professional boards to give an external perspective on our deliberations.  For example, the Victorian Government has set up a Health Services Commission to process complaints against those in our profession who are perceived as having abused their power as professionals. The Health Services Commission in turn has set up patient advocates in each of the major hospitals to speak up on behalf of patients who feel abused by the system.

Does that mean there is no science to clinical care?  

Does that mean there is no science to clinical care?  By no means! There are many sciences – from basic anatomy, physiology, biochemistry, pathology, pharmacology and microbiology to the softer sciences of psychology, sociology, and even economics. Further, there are the public health sciences of epidemiology and ecology. These in turn are usually based on the even more fundamental sciences of physics, chemistry, biology, botany and zoology. There are even the sciences of clinical medicine: nosology, clinical epidemiology, evidence based medicine, clinical economics and health economics and we call on the help of the professions of law and business administration.  But each of these sciences, and there are others, are subsumed to the basic aim of providing competent complete patient care.

Clinicians come from all walks of life and all religious persuasions (or none), and are united in the common purpose of doing the best that we can.  That is the ideal. We recognise, however, that there are some colleagues among us who are driven by other motives – be they profit, or political power, or scientific prestige.  These days, if we desire to embark on clinical research, we are asked to submit our research to clinical ethics committees. These have been constructed following disastrous paternalistic and compassionless approaches to patients – not just of the Nazis during World War II, but also the post-war unethical behaviour in the US and other places.(3) So research ethics committees have been developed to ensure that any experiments done on patients are done ethically with fully informed consent.

Some of the best and most caring clinicians I have had the privilege of working with do not have the same faith commitment. However, they still share my commitment to excellent and compassionate clinical care.  

I believe that my being a Christian makes a considerable difference to my clinical care.  I want to model the compassion of the Master, to bring the hope and peace that he brings. His love shapes my ethics, and well as my practice.  However, some of the best and most caring clinicians I have had the privilege of working with do not have the same faith commitment. However, they still share my commitment to excellent and compassionate clinical care.  None of us have developed a coherent philosophy of what we do. In fact, we share a suspicion of those who, with the best of intentions, have tried to develop such a theoretical framework of what we do. We simply get on with it.   

Most of my non-Christian colleagues are not hostile to my faith.  Not only do they respect it, but they even admire it, even when they do not share such a faith with me.  They do not see the need for such a faith, they simply get on with what they know how to do best, to cure where we can (which is seldom), to relieve often and to comfort always.  

Is there a biblical justification for such an eclectic approach?  I believe there is. Interestingly the Wisdom literature of the First Testament describes wisdom as encapsulated, not in large, rationally-argued theses (like this article!), but in proverbs, parables, sayings and riddles of the wise (Proverbs 1:1-7). It seems that the modern ambition of one single, complete, comprehensive theory-of-everything needs to be replaced by a post-modern, far more fragmented, particular view of single issues without an overarching framework. For all its attractions, Biblical theology is not systematic, it is fragmentary, found in a selection of stories about the Master from the early church and followed by a series of ad hoc letters to churches addressing particular situations. As Christian doctors we draw on these stories for information and inspiration for what we do.  

pic-agijsbersBIO: A/Prof Alan Gijsbers MBBS FRACP FAChAM DTM&H PGDipEpi University of Melbourne, Head Addiction Medicine Royal Melbourne Hospital Medical Director Substance Withdrawal Unit, The Melbourne Clinic.  President of ISCAST.

Alan has a particular interest in a studying neuroscience and theology, the philosophy of the self, and spirituality, topics which underpin his approach to addiction care. He has won an award for clinical teaching in the Master of Psychiatry course 2017 at the University of Melbourne.

He is married to Lois, has three children and seven grandchildren.  

References:

  1. Balboni MJ, Balboni TA. Hostility to Hospitality: spirituality and professional socialization within medicine.  OUP 2019. Pp 333.
  2. Tyson P. Are “Medical Ethics” possible? Thoughts in the science/metaphysics/theology/ethics matrix.  Luke’s Journal, Dec 2018:4-6.
  3. Beecher HK.  Ethics and clinical research. NEJM 1966;274:1354-1360.

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