Kuhn’s Science and Does Medicine Really Care About Patients?
Interview by Richard Marshall.
‘Probably the most important criticism of The Structure of Scientific Revolutions with respect to its revision, occurred during a 1965 colloquium held in London. The critics were Karl Popper and his followers. Popper espoused a falsificationist approach to science, in which falsifying evidence suffices to reject a theory. Kuhn criticized Popper’s approach in Structure as being naïve in the sense that the scientific community often does not reject a theory vis-à-vis falsifying evidence. Rather, as Kuhn had shown through historical research on scientific revolutions, a scientific community is often loathed to abandon a paradigm simply based on falsifying evidence and would strenuously endeavor to maintain it until another paradigm could resolve the problems.‘
‘Kuhn would not go as far to say that scientific progress (a scientific discovery and its justification) is simply about construction, especially as the strong programme of the Sociology of Scientific Knowledge (SSK) espouses it. Briefly, according to strong SSK, scientific discoveries are not about dis-covering or un-covering (I must point out that feminist philosophers of science such as Carolyn Merchant and others charge that this terminology is at best sexist) of facts about the world but about their social manufacture or production that depends upon the negotiations among members of a scientific community. Kuhn still held to a discovery process that was not only independent of theories but also dependent on them, at that same time.‘
‘Only when clinicians genuinely ‘care about’ people, especially as persons, can they ‘care for’ patients effectively. And this includes appropriating the scientific dimension of medicine. Francis Peabody gives an example of a patient who presented with a general abdominal complaint and was dismissed because the diagnostic tests did reveal a specific pathology. He chides the attending clinicians as being too scientific because they relied only on technology but also as not being scientific enough because they did not keep pursuing the etiology of the patient’s illness. For a rigorous scientific approach to medicine, according to Peabody, is to keep asking questions until the cause of the patient’s illness is discovered.‘
James Marcum is professor of philosophy and Faculty-in-Residence at Earle Hall—the Science and Prehealth Living and Learning Residence Hall at Baylor University. He earned doctorates in philosophy from Boston College and in physiology from the University of Cincinnati Medical College. He also earned a Masters of Arts in Theological Studies from Gordon-Conwell Theological Seminary. He was a postdoctoral fellow at Harvard Medical School and Massachusetts Institute of Technology and a faculty member at Harvard Medical School for over a decade before coming to Baylor University. He received grants from several funding agencies, including the National Institutes of Health, the National Science Foundation, and the American Heart Association. He delivers invited lectures frequently at both national and international conferences. His current research interests include the philosophy and history of science and medicine. Here he discusses two elements of his work: Thomas Kuhn and the Philosophy of medicine. He talks about philosophy of science before Thomas Kuhn, why Kuhn revised his book, incommensurability, whether science is just a construction, whether Kuhn saw scientific progress interns of revolution and evolution, Kuhn’s influence, philosophy of medicine, its two crises, why we need virtuous physicians, caring and competence as key virtues for medicine and why binary oppositions need not be oppositional. If anyone wonders why we need philosophy, read this …
3:AM: What made you become a philosopher?
James Marcum: While a postdoctoral fellow in the biomedical sciences at MIT in the early 1980s, a friend of mine lent me a copy of Thomas Kuhn’s The Structure of Scientific Revolutions (Structure). Although I found the book interesting, I was not quite sure how Kuhn’s description of science related to the world of everyday research in which I was engaged at the time. During the 1982 spring semester, Kuhn taught a course on philosophy of science and I took it. I found the course very informative and inspiriting, and through Kuhn’s encouragement I completed a second doctorate in philosophy (my first is in physiology). Since the early 2000s, I’ve been fortunate enough to earn a living as a philosopher of science and medicine.
3:AM: You’ve written about the philosophy of science, and Thomas Kuhn is a figure who has played a big part in this area of philosophy. What was the historical background to philosophy of science before Kuhn?
JM: Prior to Kuhn, the dominant philosophical approach to science was analytic, linguistic, and logical—especially as formulated by logical positivists and empiricists. Kuhn, along with many others such as Willard Quine, N.R. Hanson, and Paul Feyerabend—to name but a few, challenged this approach. Specifically, Kuhn’s challenge was in terms of what others have branded the ‘historical turn’ in the philosophy of science. In other words, Kuhn used the historical record of science to address perennial problems in the philosophy of science such as progress, reality, and truth.
3:AM: So can you sketch for us what his thesis of the structure of scientific revolutions is?
JM: Briefly, Kuhn’s philosophy of science as articulated in Structure can be represented accordingly: Pre-Paradigmatic Science → Normal or Paradigmatic Science → Extraordinary Science → Scientific Revolution → New Normal Science. For Kuhn, most scientists are engaged in Normal Science that is guided by a specific paradigm. For example, today Darwinism is the paradigm that guides the activities of most evolutionary biologists. Prior to Darwinism, there were other paradigms, such as Lamarckism and Creationism, which competed with one another in terms of explaining speciation. This stage Kuhn calls Pre-Paradigmatic Science. However, according to Kuhn, once one paradigm solves a critical puzzle or problem facing the scientific community, it is adopted by the community and Normal Science ensues. Unfortunately, no paradigm solves all the puzzles or problems facing a scientific community, and when further anomalies (i.e. incongruities between paradigm and a natural phenomenon under investigation) arise then competing paradigms are proposed and what Kuhn calls Extraordinary Science ensues, until either the reigning paradigm or a competitor solves the anomalies. If a competitor wins, then the scientific community undergoes a Scientific Revolution with the instantiation of a new paradigm and the practice of New Normal Science.
3:AM: He revised his book didn’t he? Why and how?
JM: At first, book reviews of Kuhn’s Structure were sympathetic; however, these reviews were generally by historians. Philosophers were less sympathetic, especially Dudley Shapere who severely criticized it in a Science review—claiming the paradigm concept was too permissive and basically vacuous conceptually. Probably the most important criticism of Structure with respect to its revision, occurred during a 1965 colloquium held in London. The critics were Karl Popper and his followers. Popper espoused a falsificationist approach to science, in which falsifying evidence suffices to reject a theory. Kuhn criticized Popper’s approach in Structure as being naïve in the sense that the scientific community often does not reject a theory vis-à-vis falsifying evidence. Rather, as Kuhn had shown through historical research on scientific revolutions, a scientific community is often loathed to abandon a paradigm simply based on falsifying evidence and would strenuously endeavor to maintain it until another paradigm could resolve the problems. As for the colloquium, one critic, Margaret Masterman, was particularly instrumental in helping Kuhn to see the ambiguity associated with his paradigm concept. She identified over twenty different uses of it in Structure. In response to critics, Kuhn published a second edition of Structure that included a ‘Postscript—1969’ in which he articulated the paradigm concept in terms of disciplinary matrix and exemplar. The former includes models, symbolic generalizations, metaphysical positions, and values, while the latter represents the solved puzzles or problems that are used for pedagogical and research purposes.
3:AM: What is Kuhn’s incommensurability thesis and how has it evolved?
JM: Kuhn, along with Paul Feyerabend, introduced the incommensurability thesis (IT) to make sense of statements from antiquity that seem meaningless or even silly to our contemporary ears. Kuhn gives the example of Aristotle’s concept of motion, i.e. objects seeking the center of the earth, which he found baffling given the traditional Newtonian paradigm. Basically, IT states that there is no ‘common measure’ or overlap among the terms and concepts of competing paradigms. In other words, incommensurable paradigms use terms and concepts in such different ways with respect to what they mean that members of the competing paradigmatic communities can talk past one another. Kuhn’s IT certainly evolved throughout his career, especially in response to the criticism that it made science both irrational and relative. Initially, he distinguished between local and global incommensurability, in which the former was concerned only with piecemeal changes between incommensurable paradigms in contrast to the latter’s wholesale changes. Later in his career, Kuhn shifted from a historical to an evolutionary philosophy of science and with the shift came a new function for IT. Now the thesis functioned to isolate the lexicon (a substitute for paradigm) or set of terms and concepts of one community from those of others so that is can develop fully, generally as a new specialty—much like a new species evolves when isolated from its parent group.
3:AM: Does all this switching of paradigms and incommensurability imply that science isn’t about discovery but about construction?
JM: Kuhn would not go as far to say that scientific progress (a scientific discovery and its justification) is simply about construction, especially as the strong programme of the Sociology of Scientific Knowledge (SSK) espouses it. Briefly, according to strong SSK, scientific discoveries are not about dis-covering or un-covering (I must point out that feminist philosophers of science such as Carolyn Merchant and others charge that this terminology is at best sexist) of facts about the world but about their social manufacture or production that depends upon the negotiations among members of a scientific community. Kuhn still held to a discovery process that was not only independent of theories but also dependent on them, at that same time. In other words, empirical data are important in the discovery process, especially in terms of anomalies, but the process is to some extent theory-laden. In some sense, his position was more of a Mertonian sociology of scientists and scientific practice rather than a sociology of scientific knowledge in terms of either weak or strong SSK. Moreover, contra the logical empiricist’s discovery-justification distinction, Kuhn held that the two contexts went hand-in-hand. Thus, Kuhn was not a naïve realist who believed that scientific progress is simply pulling away the cover of ignorance; but, on the other hand, he was not a social constructionist who believed that scientific facts are the end products of social construction.
3:AM: Did Kuhn see philosophy of science in evolutionary terms?
JM: Towards the end of Kuhn’s career, as mentioned above, he switched from a historical to an evolutionary philosophy of science, with also a shift from the paradigm concept to the notion of lexicon. Briefly, scientific advance for Kuhn was evolutionary in the sense that just as there is proliferation of species in the biological world so there is proliferation of specialties in the scientific world. Thus, just as biological evolution involves the appearance of new species in response to environmental changes, so scientific evolution involves the appearance of new specialties—each with their unique lexicon of terms and concepts—as the cognitive environment changes. For example, as virologists came to understand more about the various types of virus, especially those having an RNA genome, retroviruses were discovered and retrovirology evolved as a specialty with its own lexicon containing terms such as DNA provirus and reverse transcriptase.
3:AM: Is Kuhn still important in the philosophy of science and the natural sciences?
JM: Yes, in that he was a significant contributor to contemporary philosophy of science’s history. One illustration of his impact on philosophy of science is the discipline’s response to his retirement from MIT in the early 1990s, in what Carl Hempel called the ‘Kuhnfest.’ Besides Hempel, other leaders in the field participated and discussed the significance of Kuhn’s scholarly work. The papers can be found in an edited volume called World Changes: Thomas Kuhn and the Nature of Science (MIT Press, 1993). Another ‘Kuhnfest’ was held in 2012 at the Minnesota Center for the Philosophy of Science in honor of the 50th anniversary of Structure’s publication. Indeed, there were numerous celebrations of its anniversary. I myself participated in several of them. These testify to the continued relevance and impact of Kuhn on contemporary philosophy of science.
But what Kuhn’s impact on and relevance for the field in the future is hard to presage. Part of the reason is that he did not have many graduate students, especially in the philosophy of science. I personally wanted to do a doctorate with him. To that end, I met with the then chair of the philosophy department at MIT and was informed that there was Kuhn, on the one hand, and then the rest of the department, on the other. The message was palpably clear that doing doctoral studies with Kuhn would not be an easy task politically. Personally, I do think that Kuhn will continue to be relevant and important for contemporary philosophy of science’s immediate future. However, given the pluralistic approach to philosophy of science in terms of different philosophical positions such as analytic or phenomenological, or with respect to different physical, biological, or behavioral sciences, a single methodological approach like Kuhn’s or even others is unlikely to dominate the field in the future.
3:AM: Has he had an impact beyond natural science, in the behavioral, social and political sciences too?
JM: There is probably not a discipline or area of human endeavor that Kuhn, especially his paradigm concept, has not had an impact on—and this is not an exaggeration! Besides the natural sciences and the history and philosophy of science, the disciplines range from the fine arts and humanities to the behavioral, social, and political sciences. As one commentator observed, Kuhn’s paradigm concept was like a ‘virus’ that infected not only the academic community but also the public at large. For example, in the current debate over global warming many have called for a Kuhnian paradigm shift from a consumptive to a sustainable approach to the earth’s resources. On the other hand, Kuhn has been blamed for impeding science’s progress. For example, the physicist Steven Weinberg in a 1998 issue of The New York Review blamed Kuhn for the demise of the supercollider.
3:AM: You’re also interested in the philosophy of medicine. You argue that medicine is fundamentally moral, and that contrary to perhaps what is the established way of looking at it, the moral or ethical dimension eclipses the scientific dimension. What’s the argument here – you say that your approach stems from acknowledging two crises for medicine. So what are these two crises? Do they link with the ‘scandal’ identified by Hillel D. Braude that Socrates’s mortality is entailed in an Aristotelian syllogism?
JM: Historically, the moral nature of medicine extends back to Hippocrates. According to the Hippocratic tradition, the physician is charged not to harm but rather to benefit the patient. If anything was eclipsed it was this tradition, with the ‘basing’ of medicine and its practice on the natural sciences—especially today as Evidence-Based Medicine. Certainly, the scientific dimension of medicine is good and necessary but if it adds to the patient’s suffering, as Eric Cassell argues, then it’s morally bankrupted. Medicine’s reliance on science to the exclusion of its humanistic dimension has resulted in two crises.
The first is professionalism. Who is the physician? The answer to this question has changed dramatically through the centuries. For the Greek and Roman traditions, for example, the nature of the physician shifted from priest to philosopher. Today another shift has occurred, from philosopher to scientist—especially technician. The human factor has been eliminated or greatly marginalized, and so professionalism is often reduced to technical competence. Little if any human competence, if you will, is required of a medical professional today, and this can result in patient harm and compromise the morality of modern medicine. Unfortunately, modern medicine too often resembles an industrial factory in which patients are placed on a conveyer belt, and then anatomized, tested, and treated.
The other crisis, which is related to the first, is the quality of healthcare. Many patients want their physicians to act as human beings and to treat them as human beings as well. Their chief complaint against them is the impersonal delivery of healthcare. Finally, these two crises are linked to the ‘scandal’ identified by Hillel Braude that our mortality is often severed from morality and as such death is trivialized—with patients generally separated from family and friends and dying in an inhospitable hospital room. Braude points to the Aristotelian syllogism about Socrates human mortality and argues that the patient has slipped through the cracks in medicine’s reliance on strictly the analytical and technical approach to healthcare delivery. The task of humanizing modern medicine is to resolve these crises by reintroducing its human dimension and thereby to rescue the patient who has slipped through the cracks and to revive medicine’s moral and fiduciary duty to the patient to do no harm but rather to do good.
3:AM: You introduce the notion of the virtuous physician as a response. So what is the virtuous physician? What are these basic virtues you say are so important? Are you arguing from a virtue ethics position?
JM: Philosophers of medicine—such as Fred Tauber, Eric Cassell, and the late Edmund Pellegrino, to name a few—have proposed a variety of means to humanize modern medicine. For example, Braude introduces intuition in terms of phronesis to resolve the ‘scandal’ of dehumanized medicine mentioned above. Phronesis is a practical kind of wisdom that incorporates the everyday or common sense into clinical judging and knowing. Edmund Pellegrino and David Thomasma were best known for appropriating both the cardinal (wisdom, courage, justice, and temperance) and theological (faith, hope, and charity) virtues into clinical practice. For them, virtues like prudence, compassion, integrity, and justice are critical for the delivery of quality and moral clinical care. These virtues and others, which I discuss in my book, The Virtuous Physician (Springer, 2012), are certainly important. But for me, the two most important virtues are caring and competence, which I discuss below. Finally, the argument for the role of virtues in clinical medicine relies on more than simply virtue ethics and even virtue epistemology but it also incorporates the values that animate these virtues. In the end, it is ‘who’ the physician is as a person and not so much ‘what’ in terms of characteristics or even professional guidelines and practices encoded in deontological or rule-based ethics.
3:AM: And virtue epistemology also comes into play, doesn’t it? Can you sketch for us what you mean by this term, and how it applies?
JM: As mentioned above, virtue epistemology is a critical dimension of the virtuous physician. Basically, it pertains to the role intellectual or epistemic virtues play in cognitive activity and it incorporates the other cardinal virtues besides wisdom. In other words, courage—generally considered a moral virtue—is also an intellectual virtue in the sense that the courageous epistemic agent is not afraid to pursue the truth even though it may mean harm or discomfort for the agent. For the clinician, these epistemic virtues are vital for making sound clinical judgments and for deciding—in consultation with the patient—the most efficacious therapy.
Richard Weinberg, a gastroenterologist, provides a powerful example of intellectual courage in an essay called ‘Communion,’ which he contributed to a 1995 issue of Annals of Internal Medicine. He was treating a patient with ‘chronic abdominal pain.’ During one consultation, the patient described a nightmare that obviously stemmed from sexual assault. Rather than ignore the dream’s implications, Weinberg asked the patient whether she had been sexually assaulted. The patient then went on to tell him about the assault. Weinberg was intellectually courageous in stepping outside his professional comfort zone to treat a patient in which he was not board certified. I must also add that he exhibited intellectual humility in consulting with colleagues who were psychiatrists to ensure he was helping and not harming the patient.
3:AM: Caring is the key virtue for you, isn’t it? And carelessness and incompetence the chief vices in medicine—is that right? And, does this link up with your argument for holistic approaches rather than fragmentation?
JM: Caring is certainly a key virtue for practicing medicine. Francis Peabody, a well know Harvard clinician in the early part of the twentieth century, expounded on this virtue for delivering the best quality healthcare—even scientific healthcare. ‘One of the essential qualities of the clinician is interest in humanity,’ asserted Peabody and then argued, ‘for the secret of the care of the patient is in caring for the patient.’ In other words, what motivates clinicians should be a general concern for the health and welfare of fellow human beings. Only when clinicians genuinely ‘care about’ people, especially as persons, can they ‘care for’ patients effectively. And this includes appropriating the scientific dimension of medicine. He gives an example of a patient who presented with a general abdominal complaint and was dismissed because the diagnostic tests did not reveal a specific pathology. Peabody chides the attending clinicians as being too scientific because they relied only on technology but also as not being scientific enough because they did not keep pursuing the etiology of the patient’s illness. For a rigorous scientific approach to medicine, according to Peabody, is to keep asking questions until the cause of the patient’s illness is discovered. Along with caring goes competence, whether technical or ethical. Both go hand-in-hand, for if clinicians are simply caring and not competent then they risk violating the moral demand of medicine to benefit and not to harm the patient. Thus, carelessness and incompetence are the two chief vices at the heart of the professionalism and quality of care crises, as well as the fragmentation of medical care.
One of the main reasons for my interest in the role of caring and competence in delivering quality care involves my mother’s experience with breast cancer. In her late thirties, she underwent a radical mastectomy—during the late 1960s—to remove her right breast along with axillary lymph nodes. The breast cancer was stage four and the prognosis was, unfortunately, not good—at most, six years to live. My mother then endured radiation therapy, which left her physically weak, nauseated, and caused her hair to fall out. A few years later, the cancer appeared in her lungs, which was inoperable; and she underwent a hysterectomy to slow the cancer’s growth. My mother then began to complain of vertigo or dizziness and diplopia or double vision. Her primary-care physician prescribed aspirin for the vertigo and referred her to an optometrist who prescribed reading glasses for the diplopia. At the time, I was a first year student at the University of Cincinnati’s College of Medicine. During the course of my studies, I took an introductory neurology course. One day, as part of the course’s practicum, I learned how to administer a neurological exam. I shall never forget that day. After learning how to administer the exam, I suddenly realized—given my mother’s medical history—that her vertigo and diplopia were more serious and required treatment other than aspirin and reading glasses.
I went to my parents’ house later that day and gave my mother a neurological exam. I was certain that she had lesions within both the cerebellar and occipital regions, and I encouraged her to make an appointment with her primary-care physician. She did and I accompanied her to the consultation. After the primary-care physician examined my mother, I told him my concerns about possible brain lesions. He assured me that my concerns were unfounded—even though he was well aware of her history with cancer—and that no further action was possible or necessary. I refused to accept his clinical judgment and requested that he refer my mother to a neurologist for further examination. At first he refused, but I insisted and he eventually consented. My mother left the office with a referral to the Mayfield Neurological Clinic in Cincinnati. The consultation with the neurologist at the Mayfield was brief. My mother had at least two lesions, one within the cerebellum and the other in the occipital region. The neurologist admitted her into a local hospital for further tests, which confirmed the diagnosis. Unfortunately, the lesions were simply inoperable and chemotherapy too questionable. She died shortly thereafter.
3:AM: Does your position then break down the usual division between the sciences and the arts in a field that has been a paradigm for science over arts in that you’re saying that medical practitioners need to be both competent in medicine as evidence AND in patient-centred art? This seems to be something that might be generalized beyond medicine – teaching seems an obvious extension candidate, engineering, law another perhaps. Do you agree that your arguments ask that culturally we stop the two-cultures approach to everything i.e. science vs humanities/arts and that we’d get a firmer grip on the issues facing the world at the moment i.e. climate change, inequality if we were educating people along the lines you suggest in medicine everywhere else too?
JM: Binary opposition runs deep in our Western culture, and it is the basis of our epistemic and moral foundation. For example, the pre-Socratic philosopher, Parmenides, claimed that something cannot be and not be at the same time. And, it forms one of the basic logical laws of Western thinking—the law of non-contradiction—along with the laws of identity and the excluded middle. Such oppositional thinking is also the foundation for our reductionist approach to the world, in which a phenomenon is divided into its contradictory (binary) parts. Such a reductionist approach has resulted in our fragmented healthcare, since we reduce the body and its parts into either the physiologically normal or the pathologically abnormal and then treat only the diseased part. But binaries need not be just oppositional, they can also be complementary—as in the Chinese yin-yang. This complementary approach is at the heart of holistic medicine today.
As you mention, this approach to medical education and practice is also applicable to other professions and even to wider social issues—especially in terms of virtues. For example, I have been collaborating with Martin Stuebs in the accounting department to utilize virtue theory to address various scandals in business, such as Enron, WorldCom, and Tyco—to mention a few. Moreover, the ‘two cultures’ approach particularly with respect to the sciences and the humanities—as C.P. Snow so famously referred to it in his 1959 Rede Lecture—is simply unable to sustain an equitable world. What is occurring in our society is a greater polarization along oppositional poles, e.g. the rich get richer and the poor poorer. Somehow we must find the means or a third culture to unite or overcome the differences that exist rather than to aggravate them. Again, virtues are vital for resolving our problems in that who we are is important for what type of society we want to build. In the end, we must have a flourishing society for all and not just for some.
3:AM: And finally, are there five books you could recommend that will take the readers here at 3:AM further into your philosophical world?
Obviously, Thomas Kuhn’s Structure is a must read,
along with R.G. Collingwood’s An Essay on Metaphysics, which provides a rather critical and insightful analysis of Logical Positivism/Empiricism.
Thomas Mann’s The Magic Mountain for me is still one of the most powerful critiques of the banal life and a challenge to live an authentic life.
Fyodor Dostoyevsky’s The Brothers Karamazov is at best disturbing in the sense of how dark human nature can be—especially chapter 4 ‘Rebellion,’ right before the more famous chapter, ‘The Grand Inquisitor.’
And finally, there is Nikos Kazantzakis’ Report to Greco—
although his best book for me is Saint Francis—which opens with these three prayers:
1) I am a bow in your hands, Lord. Draw me, lest I rot.
2) Do not overdraw me, Lord. I shall break.
3) Overdraw me, Lord, and who cares if I break.
ABOUT THE INTERVIEWER
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First published in 3:AM Magazine: Friday, December 23rd, 2016.