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Clinical medicine, despite facing criticism, grapples with the challenge of defining its theory and guiding doctrines. Over the past decades, tensions have arisen between scientific medicine and medical humanism, as well as between biomedicine and bio-psycho-social medicine, creating a debate around the art/science opposition without a conclusive resolution. Medicine’s epistemology is deemed insufficient or flawed, with various dichotomies such as body-machine versus lived body and objective knowledge versus tacit knowledge. The crisis in medicine calls for the discovery of its specific normativity to avoid planned obsolescence. The author aims to explore the latent epistemology of medicine through clinical practice rather than adhering to predetermined criteria. Two crucial points contributing to the divergence in medical practice are identified: the challenge of medical rationality and the commendable yet problematic effort to eliminate uncertainty, leading to potentially harmful remedies. These directions have metaphysical and managerial consequences. The suitable epistemology for medical clinic must consider the real object of practice, asserting that clinic is the most adequate “science” for this purpose. The text emphasizes the precarious nature of these affirmations, acknowledging the challenges of exploring familiar material philosophically. The situated perspective of the practitioner is deemed advantageous, offering insights that disinterested spectators lack. The clinic’s public nature does not negate its subjective aspects, and the engagement of the doctor’s subjectivity is acknowledged.
The coordinates of the problem
In the realm of medicine, the epistemological debate surrounding its nature has long been confined to a specialized discourse. Despite the profusion of conflicting theories, the clinic persists as an epistemological enigma, with ongoing debates centering on the dichotomy between art and science. The rise of Evidence-Based Medicine (EBM) has, however, established its dominance in training and legitimization discourses, overshadowing previous disputes. The emergence of personalized medicine and artificial intelligence further challenges traditional notions, suggesting the obsolescence of conventional practices.
The term “clinic” itself implies a practice on the brink of extinction, replaced by the precision of professionalism or the ideals of “P4 medicine.” Medicine grapples with questions about the validity of its knowledge, the identity of its recipients, and its purpose, as it navigates the shifting landscape of technological advancements. The distinction between the science of disease and the art of patient care persists, with some advocating for “personalization” based on cellular or molecular factors, while others emphasize a “person-centered” approach.
Yet, the reductionist tendencies of patient-centered medicine, relying on measurable criteria, risk overlooking crucial aspects of the human experience. As medicalization expands and conditions become increasingly complex, the demand for meaning often falls outside the realm of medicine’s power. Calls for a “new synthesis” that combines humanism and science highlight the ongoing quest for medicine to fulfill its inherent function, contingent upon responding to evolving demands.
Addressing the epistemology of medical practice requires acknowledging the real object of clinical work, aligning with the most suitable “science” for this domain. Being “differently scientific” involves recognizing medicine as the science of the limits of other disciplines’ powers. This perspective underscores the perpetual gap between available data and tailored solutions for individual patients, necessitating a blend of scientific knowledge, practical experience, and imaginative thinking. Incorporating technological advancements into diagnostics and therapy does not negate the importance of keen observation, experiential wisdom, and creative problem-solving in navigating complex medical scenarios.
The clinic as laboratory
In essence, the statement posits that the clinic serves as both the subjective and objective laboratory of medicine, embodying its essential practices and being the primary site for its development. The subjective aspect refers to the clinic as the framework where medicine’s essence, responding to patient requests, becomes most visible through experiences like research, encounters, tests, analyses, teaching, and therapy. The clinic is seen as experimental, akin to Bernard’s scientific medicine criteria, and various advancements like randomized trials and biotechnologies are considered extensions of its capacity, as long as they are integrated rather than seen as competing medicines. The objective sense emphasizes the clinic as the privileged space for medicine’s elaboration and production, where attention and assiduity are crucial. The clinic’s key features include its central role in addressing patient requests, the reciprocal experiences of doctors and patients shaping an experiment, and the inherent unpredictability of the clinical environment.
The salient features of the clinic
body,Request,Knowledge:
The medical clinic, from its inception, has focused on responding to the needs of the ailing, establishing a secular foundation resistant to fleeting trends. It intertwines three fundamental elements—body, demand, and knowledge—where bodies are examined, requests are made, and knowledge is sought. The clinic engages with the living body, encompassing illness, suffering, aging, death, pleasure, and desire, acknowledging a libidinal economy beyond physiological laws. Patient requests, often expressed through cries, create a minimal social backdrop, calling for recognition and love. Addressing these requests requires a person with the ability and willingness to fulfill them, necessitating a blend of ethical considerations and practical efficiency. While scientific goals align with therapy, biology alone falls short in capturing the complexity of bodily life, prompting physicians to integrate neglected aspects into clinical reality. Language plays a pivotal role, as bodies with language engage in medical semiology, involving semantics and hermeneutics. The clinic navigates through the entanglement of symptoms, considering the unique interplay of body, request, and knowledge, emphasizing the importance of flexible listening and understanding the multifaceted nature of communication in medical practice.
Two Fundamental operations:
The clinic undertakes two consecutive operations: diagnosis and therapy determination, focusing on essential characteristics. Diagnosis involves analyzing symptoms under time constraints, crucial for therapeutic decisions. It is a complex process, incorporating diverse epistemic practices. Materiality, indexed through bodily marks and speech fragments, aids in hypothesis development. Anamnesis, interpreting insignificant clues, guides the selection of relevant information. The doctor navigates between perceptual and conceptual realms, distinguishing organic from functional. Transforming traces into signs allows classical or probabilistic methods to come into play. The quality of this investigation influences subsequent reasoning, emphasizing persuasion over truth. Therapy determination aims at reconnecting the patient with health, prioritizing reliability over results. Therapeutics remains probabilistic, validated by individual responses, aligning with Canguilhem’s view that treatment is an experiment. The unknown nature of therapeutic action defies mathematical knowledge, requiring practical reasoning over general rules.
Concluding propositions for an epistemology of medicine:
In summary, the text explores the multifaceted nature of medical clinic practices, emphasizing their role in diverse remediations that may not always leave visible traces, especially in verbal communication. The clinic, depicted as a tekhnè, incorporates praxis, poièsis, and épistémè, grounded in aesthetics and empirical experience. It underscores the importance of examining each encountered situation thoroughly, elevating it to the level of a case for therapeutic consideration. The clinic integrates various fields like natural sciences, biotechnologies, information technologies, and social sciences to address concrete problems. Despite the diverse knowledge, medical practice faces inherent uncertainties in diagnosing and treating life’s unpredictable aspects. The individualized nature of clinical work acknowledges patients’ unique pathological experiences, with the understanding that individuation is an ongoing process. The core of medical practice lies infratechnically in aisthesis, empeiria, praxis, and phronèsis, bridging the gap between biological sciences and individual treatment. Attention to subjectivity, exemplified by psychoanalysis, is considered a technical aspect. The text challenges the scientistic desire to eliminate vagueness and fragility from medicine, highlighting the normative power of tinkering in adapting to the complexities of medical practice. Finally, it suggests that recognizing the limits of medicine is not a failure but an opportunity to understand the interweaving of multiple registers.
Source:
Weber, J. (2021). The clinic as laboratory: what epistemology for medicine?. Journal of the CIPH, 100, 8-22. https://doi.org/10.3917/rdes.100.0008