In my first year as a medical student I thought I had a pretty good notion of what medicine was all about. I saw it as a branch of mechanical engineering, like building bridges, say, but inside the human body. If you want to build a bridge across a river, you’d have to take measurements and make calculations, choose building materials and then construct your bridge. Doesn’t matter whether you are working in Timbuktu, in Marseille, or on the moon.
Medicine is not like that at all. In Timbuktu it’s a completely different enterprise than in Marseille and on the moon there is no medicine. This multifariousness of medicine was brought home to me when Professor B., after describing a very complicated surgical procedure, concluded the demonstration by adding, “Of course I would never do this type of operation in a patient who is above eighty.”
I was shocked. What’s wrong with patients older than eighty? Aren’t they worth the trouble? It took me quite some time before I realized that that was not the point. Humans form a biological population, which means that every individual is a little different from all the others. Without this variety there would be nothing to select within the evolutionary process. Every face is different. Every fingerprint, every nose, every tone of voicethey are all different. The same goes for all the potatoes and roses of one kind. They are all different from each other.
In physics this is most emphatically not the case. A hydrogen atom on Mars is precisely the same as such an atom in the Andromeda nebula or in Tutankhamun’s mummy. That’s the difference between a biological population and a physical class. In a biological population each member is different, in a physical “population” all members are exactly the same. There’s another difference between these two collections. Atoms are immune to wear and tear. They do not age. They are not caught in biological time, in which individuals grow old and die. Atoms are deathless. Nor can it be said that they live: they are lifeless as well. This is not to say that they are tougher than potatoes, better put togetherno, the point is that potatoes are conceptually different from atoms.
It is notoriously difficult to delineate the precise nature of medicine because it harbors so many irreducible concepts. It is impossible to put “noses” and “atoms” into one conceptual framework. Replacing an aortic valve is a feasible undertaking in a sixty-year-old, but in a patient above ninety it’s a reckless feat of daring. Which is strange when you realize that the molecules in a sixty-year-old are exactly the same as those in a ninety-year-old. Yes, but in the ninety-year-old they’re scattered about in a different fashion.
You’ll never succeed in translating “scattered about in a different fashion” into “too old for this operation.” “Too old” means that the risk of complications (infection, hemorrhage, cardiac damage, and so on) is unacceptably high. You will end exclaiming, “But she’s not going to survive this!”an exclamation which cannot be put into biochemical terms, because molecules are beyond exclamations. They do not survive, nor do they die.
The strange fact is that we are partly analyzable in molecular terms. Take diabetes: biochemically neatly explicable. But the main problem, a too-high concentration of glucose in the blood, is a perfect example of the mismatch between biology and biochemistry. Biochemically a blood-glucose level of 36 mmol/l is just as interesting as a level of 8 mmol/l. But biologically 36 is too high, because ultimately life-threatening. It appears that in such a simple statement it all seems to fit together seamlessly, while in fact there is an unbridgeable gap between “too high” and “blood-glucose level.” In biochemical terms no concentration of glucose can be said to be too high, because among molecules nothing can be life threatening.
It is often said that in the end biology will turn out to be biochemistry, but this reduction is unthinkable. The biochemist would not know what to investigate if the biologist didn’t direct him there. What I am trying to say is that the stuff to which we apply medicine is not very straightforward. It is at the same time physical and biological, and there’s a third even more confusing dimension.
Within medicine there’s always an ongoing debate about the misleadingly simple question “Which therapy works?” Estimates vary, but experienced clinicians easily state that thirty to fifty percent of the treatments we supply are of little or even no use at all. You may think this is an excessively negative assessment, so let us say that only twenty percent of what we do is of no use. The awkward fact is that the debate about this percentage is one of the most salient aspects of medicine. Imagine a civil engineer saying that about twenty percent of the bridges he constructs are useless, meaning that not even a small dog could get safely across them. What is going on here?
Medicine is a rather inscrutable amalgam of biochemistry, biology, physics, engineering, electronics, fear of death, empathy, lust for power, faith, cynicism, religion, superstition, financial profit, and hope. On the one hand, science, and on the other side, the rest of the gang.
An example. Mister B. is seventy-two and has lung cancer with many secondariesa dying man, really, but not so in the eyes of his oncologist. She has another course of chemotherapy in store for him, euphemistically described as “palliative chemotherapy.” Two days before he is to undergo this treatment, the oncologist dispatches a special courier to our hospital to deliver medication which is going to protect his white blood cells against the coming onslaught. I dutifully inject the stuff, though I know this is useless. Next day he is moved to the oncological center to undergo his treatment, which is precisely as destructive as the oncologist feared. Yes, she knows very well what havoc chemotherapy can create, and yet she goads her patient into that minefield instead of sitting down with him and saying: Mister B., if you want to visit your grandson in Italy or would like to see your favorite French cathedral one more time, do it now. When the chemotherapy was started, his white blood cells succumbed almost immediately and two days later he died. The injection cost 1750 euros.
Medicine does not merely consist of this type of senseless initiative, but it’s a lot less rare than we are willing to admit. How do we explain my skeptical attitude (“this stuff is not going to work”) and the contrasting seriousness with which the oncologist sends a special courier across town in order to ensure that Mister B. gets this medication?
You might say good medicine, “proper” medicine, ideally would only be motivated by considerations based on biochemistry, physics, engineering, etc. And if only the oncologist would think “properly,” she wouldn’t throw 1750 euros down the drain by ordering a useless injection. This untainted approach is entirely workable when one is building bridges, but here the trouble starts. Bridges do not fear death, they are not surrounded by pity, and they are impervious to hope. The oncologist is afraid the patient’s death will in some way be her fault. And she finds the suggestion that her scientific training is completely useless in this clinical situation deeply unsettling. Mister B. is afraid of death and he fears his wife may blame him for passing up a chance to lengthen his life. All these fears and anxieties result in that futile injection. As to my skepticism: having practiced medicine for more than thirty years, I have no illusions about the efficacy of chemotherapy in the final stages of lung cancer.
In view of all this, we might come to understand why it is so difficult to draw up a list of effective medical treatments. Insurance companies would jump on such an inventory, but it will never come about. The proposal to apply only those medical treatments which are effective reminds me of the fruitless suggestion that all the money that is spent on arms should be spent on food and durable sources of energy.
Saint Paul wrote of faith, hope, and charity as the most wonderful mental tools available in order to make life bearable for ourselves and others. In medicine faith and hope (and possibly, in homeopathic dosage, love) tend to get inextricably mixed up with knowing and doubting in order to lighten the burden of traveling towards the grave. On our planet there’s an interminable parade of creatures heading towards death, among them humans, and to medicine falls the task of making this one species believe they’re heading elsewhere.
Believing can be described as a not entirely kosher form of knowing. On your way to the station in a town you don’t know very well, you might say: “I believe this is the way.” And when you end up at the station you will say with some relief: “I knew it!” The believer and the knower cover the same route and, face to face with the station, they mingle together. (As they are torn asunder when, after aimlessly wandering around for a whole hour, they end up in the cemetery at the other end of town: “Shit!”)
Every doctor guides a patient through a city he thinks he knows reasonably well, the way to the station being no problem. Having delivered the patient there, she will be loaded with embraces, flowers, and gratitude, and that evening at home she will say to her husband: I knew it!
This is no unusual course of events. Neither is it unusual for doctor and patient to spend days, months even, frantically running around and ending up nowhere near the station, but at the wrong end of town, in the cemetery. Shit!
Patients believe that all roads lead to the station. Doctors know better, but even they believe this of many more roads than they can justify on the basis of previous efforts. We encounter two forms of faith here, which are both incomprehensible if we don’t pay attention to La Rochefoucauld’s hope, of which he says: She may be a lying jade, but she does at any rate lead us to the end of our lives along a pleasant path.
Complementary or alternative medicine is not very interesting in this context, because their discipline, if you’ll pardon the expression, is so obviously and unmysteriously wrapped up in superstition, faith, money, hope, etc. without sprouting any redeeming feelers towards the domain of ascertainable fact, which we call science. Conceptually they reside in the historical region where the mental and the physical had not as yet been sent on their separate ways. They feel uncomfortable about this and therefore try to cover themselves with a very odd array of pseudo-garments, borrowed, or filched rather, from the scientific wardrobe. This accounts for their fondness for “rays,” “waves,” “molecules,” “electrons,” “currents,” and particularly “energies,” all of which concepts parade in their circus in a guise that is completely incomprehensible scientifically. Their faith is pure faith, and as such not very puzzling. The puzzling variety of faith is that which you find in doctors who reckon that all of their doings are science-based.
I spoke of faith in medicine as driven by the fear of death, empathy, lust for power, etc., but there is also a faith in the very business of medicine itselfa faith which doesn’t only come to the fore under the threat of death, but which leads to the most common daily practices for which there is no foundation. It is faith in a social phenomenon that is (mistakenly) believed to have been beneficial on a stupendous scale during many centuries. It is this type of faith that makes doctors perform, and patients endure, all kinds of procedures and regimes which are silly at best but often plainly harmful. And all this because other doctors told them, as those other doctors were told in their turn. You would like medical students to realize that medicine is not just a scientific discipline but also a very intricate social phenomenon, yet there is hardly any time for students to go into this. Young doctors are altogether too busy filling their minds with enzymes, operations, medications, scans, anatomy, and so forth. They never find the time to take a distant view of the whole enterprise as one of the oddest puppet-shows on earth. One of the funniest apparitions in this spectacle is quackery disguised as science.
William Osler, by far the most superior mind issuing from late nineteenth-century medicine, said jokingly, “The difference between men and animals is the desire to take pills.” He might have added that the difference between doctors and laymen is the desire to prescribe them. I will here only mention two classes of medication which are prescribed effusively in Western medicine, antibiotics and antidepressants. There is ample scientific evidence that these two medications are abused on a grand scalethat is to say, administered when there is no scientific basis for doing so, and not merely in the face of death, but as an everyday aspect of medicine. The basis for this is not proven fact but an unquestioning belief in Medicine as a hallowed discipline.
Afinal word on the amalgam. It will have occurred to you that biochemistry, biology, physics, engineering, and electronics are aspects of the physical world, while fear of death, empathy, lust for power, faith, cynicism, religion, superstition, financial profit, and hope all refer to mental states. Where are we? We are in the midst of Cartesian dualism. That’s not a philosophical stance, it’s a philosophical problem. Cartesian dualism, the riddle of consciousness arising out of physical events (I say “arising” but I don’t know the proper verb, nobody does) may sound like an old problem that we have left behind as we traveled into the brain. But since the Greeks sent Matter and Mind on their separate ways, nobody has been able to bring them together again. Everything we hear from the fields of neurophysiology, neurobiology, psychophysics, neuropsychology, and their ilk is wholly and hopelessly dualistic.
The mindless adulation of MRI scans as “pictures of mental life” has created an atmosphere in which drawing attention to the body/mind problem sounds as if you want to return to horse-drawn means of transport. But medicine is in some aspects incomprehensible precisely because we do not know how to attach mind to body. So far no one has been able to make sense of the fact that we are both mortal and molecular.
Author Note, as in: Bert Keizer is a doctor and philosopher who works with geriatric patients in Amsterdam. The author of Dancing with Mister D, he has also written an opera about Alzheimer's and has translated Emily Dickinson's letters into Dutch.