We are all concerned about our health and our health care. As doctors and nurses, or as patients (and one becomes the other too), we may also be interested in the assumptions underlying health and healthcare: its funding and impact reflects the value society puts on it, the treatment of disease and pain is shaped by the state of clinical knowledge and those methodologies by means of which such knowledge is obtained, and definitions of the self and of moral agency inform ways in which physicians and patients often come together in making decisions. These ideas take us in the direction of the philosophy of medicine, and this is the concern of this new companion from Bloomsbury. Others in their developing reference series include philosophy of science and of mind, as well (relevant here) one on Heidegger.
The overall framework of the companion is simple enough – medicine as a science (e.g. it is rationalistic, empirical, evidence-based, uses randomized trials, is praxis) and as an art (e.g. patient- and person-centredness is important, personhood and the experience of illness and suffering should be factored into care, there can be over-medicalization). These tease through into evidence-based, person-centred and value-based forms of medical practice and research, and part one (made up of two chapters on contemporary trends and on research problems and methods) identifies these. The focus is on “Western” medicine, and the contributing editor James Marcum (of Baylor University in the USA) flags exclusions like narrative, integrative and systems medicine which are omitted for reasons of space. After that come 12 chapters on Current Research and Future Directions. Contributors are international and some of their individual publications are noted in the references at the end of this review. Every essay, apart from one, is new to this work.
In a nutshell, medical and clinical practice and research throws up ontological, epistemological, and methodological challenges. This trio underlies much of the discussion, above all the overarching discussion of the paradigm shift from traditional evidence-based approaches to a wider repertoire of person-centred, phenomenological and narrative-based and values-based approaches. This has not meant that randomized trials with experimental and control groups, placebo testing, evidential evaluation of risk and causation (of illnesses for individuals and communities) have been sidelined: far from it, such things flourish – and must flourish – in modern medical care. However, a broad case is made for medical pluralism, and for an inclusive understanding of what the authors call “a causal mosaic”. Typically, then, we need to explain both the aetiology of a disease, in pathophysiology and psychiatry, and the narratological meanings patients have about conditions such as depression and in response to severe medical prognoses.
With this in mind, an essay on disease in the era of genomic and molecular medicine assesses how disease and non-disease have themselves been redefined by genetic research, how the patient as subject and as a member of society has been seen in new ways, and what the moral implications of knowing future possible risk might be. Similarly, in epidemiology, there has been a shift from monocausal to multifactorial explanation, and wider societal debate about medical issues such as lung cancer and obesity. Another essay reviews and recaps evidence-based medicine itself, again suggesting that at times reasoning can be mechanistic, and that ideas about risk, causation, validity, and benefit can be too narrow. Thought-provoking essays follow on the ways in which values-based approaches lead to improved healthcare in gender medicine (e.g. in de-medicalizing child-birth), help unpack crudely normative meanings to “disease” and get us to ask whether every disease is treatable and what we can and should be able to trust with observational studies in medicine. A case, broadly, is made for “medical pluralism”.
Another pervasive theme in the companion is that of phenomenology and what light it sheds on the practice of medicine and our experience – as patients, medics and community – of illness and of medical interventions. A strong and persuasive essay by Fredrik Svenaeus on Phenomenology and Medicine highlights how concepts like “the lived body” and how Gadamer’s hermeneutic of the self (e.g. how we articulate our understandings of what it is to practice or to suffer) illuminate and improve medical reasoning and decision-making and mitigate the deterministic use of medical technology. So good is this essay, and that of James Marcum on Patient and Person Centered Medicine (with debate about personhood and dignity in personalized healthcare), that some of the other essays dealing with the place of phenomenology in medicine are redundant. Two or three provide a historical backdrop to medical humanism and evolutional medicine which take up space that might have been devoted to some of those declared omissions cited earlier.
Readers and users of this companion – most likely to be medical students interested in ethics and philosophy, philosophy students interested in medicine and healthcare, tutors and lecturers in the field, members of ethics committees and anyone interested in the values and aims underpinning primary and secondary healthcare – will find a wealth of bibliographical material, much of it usefully current and available, such as Eric Cassell’s Nature of Clinical Medicine. There is a generous annotated bibliography and a Research Guide to reference sources, print and online. There is also a helpful Glossary, of particular use probably to new researchers and people on research methods courses.
All good reference works – if they claim to be contemporary – should act as reliable signposts to future things. The present one does in a concluding chapter on New Directions in Philosophy of Medicine, and notices these trends: an opening up of the evidence base in randomized trials, inclusion of ethical and moral and cultural discourses in medical reasoning and explanation, differentiation of methodology used in assessing outcomes for specific patient groups and wider use of genetics and neuroscience in psychiatry. All these, and more, are tantalisingly accurate forecasts and leave the reader gasping for more (and of course less backward-looking phenomenology and over-description of the history of evidence-based medicine). Given that only some of these essays really soar, and that not all of them are really needed, the shelf-life of this companion is, I believe, limited to not more than two years. The trends it identifies and explains, however, are correctly identified and this grounds the work in current practice and thinking.
