Robert M. Young Online Writings
SCIENTIFIC MEDICINE AND THE SOCIAL ORDER
Wellcome Unit for the History of Medicine
University of Cambridge
I want to suggest that we begin to develop a critical perspective on medicine. In particular, I want to suggest that we scrutinize our own dream about the progress of science and medicine as they affect our images of our selves and our patients' images of medicine and its practitioners. These questions will be related on the one hand to the fundamental assumptions of modern science and on the other hand to our social and ideological beliefs. In order to gain a better perspective on ourselves, we might fruitfully turn to the writings of social scientists who are not modelling their work on the approach of the natural sciences but instead are attempting to enter sympathetically into the perceptions of patients and who are critically analyzing the institutional and social settings in which medicine is practised. I hope that the argument will lend weight to the conclusion that it is impossible to separate the scientific aspect of medicine from its conceptual, historical and social dimensions.
British medical education is currently undergoing reform in the wake of the Report of the Royal Commission on Medical Education — the 'Todd Report', which was presented to Parliament in 1968. It is a fundamental document which represents an extremely important change in the whole approach to medical education and in the long run to medicine itself. Its main lesson is that it is no longer possible to teach medicine: it's just too complicated. Instead, the proposed aim is to produce people who can think critically and evaluate new findings and procedures. This means that the whole approach must become more abstract, leaving the doctor to find the relevant applications, to sort things out for himself. The conception of medical education is-altered from a tendency to be assimilable to the model of technological training to that of a broad scientific and social education.
For example, Todd advocates a deeper approach to the subject, stressing scientific method and principles, He speaks of acquiring a proper grounding in and appreciation of the scientific basis of medicine. The approach to the patient must be made in terms of a broader perspective, one which he calls 'human biology', and includes the history and significance of family life, love, play and aggression, along with the nature, origin and development of communication between human beings. These recommendations lead us into an area which has hitherto played almost no part in medical education, the so-called 'behavioural sciences'. The Royal Commission approvingly refers back to a report by the General Medical Council of 1967: 'In the Council's view the study of human structure and function should be combined with the study of human behaviour. The Council considers that instruction should be given in those aspects of the behavioural sciences which are relevant to the study of man as an organism adapting to his social and psychological, no less than to his physical, environment. Instruction in the biological and sociological bases of human behaviour, and the principles of learning theory, should be included.'
One more quotation will help to convey the full import of the fundamental reorientation of our approach to medicine which is being called for: 'Deliberate and sustained efforts should be made to show students the relevance of social phenomena, whether treated conceptually, comparatively or historically, to the roles and functions in society of doctors and of organizations for medical care.'
In what follows, I shall suggest that we take a very ambivalent approach to these recommendations. We must surely welcome the teaching of medicine in a way which expands its scope to include conceptual, comparative and historical approaches to its setting in society. At the same time, I think we should take a very sceptical approach to the hope that we are thereby being given a new scientific tool which is merely an extension of the others in the physician's black bag. What I mean is that if we lean too heavily on the 'behavioural sciences' and if we rush too fast to bring the human and social dimensions into the domain of science, we will be attempting to use very blunt instruments to operate on the delicate tissues of human relations in a complex social and political context.
Putting the matter starkly, medicine is in danger of becoming de-moralized. By this I do not mean the onslaughts of successive governments on free prescriptions, the continuing crisis in the hospitals and other medical institutions, or even the morale of doctors. Rather, in using the term 'de-moralized', I am pointing to the conventions of moral and ethical neutrality which underlie the objective, value-free ideology of science, an objectivity which is supposed to extend to science's maximum penetration into the community — the practice of medicine. To lend credence to the claim that we are in danger of being demoralized, we must consider the philosophical and methodological context in which medical concepts lie: they are in a crucial mediating position between science on the one hand and society on the other.
We must first look down the line from the practising physician to hospital medicine and the university medical centre, on to the Medical Research Council research laboratories, to scientific biology, and finally to the physico-chemical sciences. Moving in the other direction, we can travel back up the same path and cross the boundary between medicine and the behavioural and social sciences and finally reach the non-scientific context of the rough-and-tumble of personal, social and political life — the sort of life which patients daily bring with them into the surgery and which physicians encounter every day during house calls. (It is worth adding the physician brings these contexts with him, however much they are mediated by his professional role.) If we can explore these two perspectives, we may be able to begin to see medicine in terms of both at once. If so, we will have a greater appreciation of the conceptual niche which medicine occupies in its relations with biology and the physico-chemical sciences. At the same time we can perhaps attain a healthy scepticism toward the validity and the desirability of our present conventions about scientific and medical objectivity. This second perspective could help us to see the limits and pitfalls of too much faith in science. It can do this by unmasking or demystifying its most extreme claims to accounting for man's place in nature and society.
The purpose of this approach is not to glorify self-indulgent subjectivity and irrationalism but to advocate as responsible an attitude toward the relations between science and medicine on the one hand and moral, social and political issues on the other, as doctors are trained to have in the use of stethoscopes, drugs and scalpels. The point is not merely to exhort the medical community to think more in moral and political terms — though that certainly is part of the point — but to consider the proposition that willy-nilly we already do that more or less covertly. It seems to me that it would be a real improvement if we could acknowledge that dimension in medical work, and could become self-consciously critical about the moral and political issues which penetrate deeply into the allegedly objective aspects of medical science and medical practice.
In holding out the promise of enlightenment from the behavioural and social sciences, the planners of medical education have offered us a potentially dangerous mixture of science and scientism. Scientism is the illegitimate or premature extension of the methods and assumptions of science into areas in which the relevant findings and theories are not available. Scientism cloaks many ethical and political views in a specious aura of scientific objectivity. Surely it would be better for us to discuss these issues as such, rather than get swept away by the dreams of science at the expense of our humanity.
In an important sense every general practitioner knows very well what is being argued here, but he doesn't know that he knows it, because he does not have a set of categories for talking about it. There is no technical or scientific language for talking about moral and political issues as they arise in medicine They are relegated to informal judgements — to the 'bedside manner' or to a gift for dealing with 'the troublesome ones', to 'clinical judgment' or to 'wisdom'. But the issues are not considered in a disciplined way: they are the subject of informal discussions. I am arguing that we must learn to think in a more self-conscious and disciplined way about the relation ship of medicine with science and of medicine with its social and political context. This, of course, is not a set of issues which one can get straight once and for all. The boundaries between medicine and science and with society are uncertain and shifting.
Now let us stand back and begin to take a reflective view of the role of the doctor. The Todd Report has some helpful things to say about this: 'There are certain matters of general social interest on which...to quote from evidence we have received, "the doctor is still considered to he an 'oracle, and the student should recognise the responsibility this entails." We do not think that medical education should encourage the doctor to assume an authority beyond that implied by his profession or his responsibilities as a citizen. We recognise, however, that there are many important matters of moral and social controversy in which doctors inevitably become involved: abortion, drug addiction and artificial prolongation of life are examples.' There are many more — and more-subtle ones — such as the life styles of non-conformist or 'deviant' patients, which will be discussed below. Todd goes on: 'No doctor, however remote from clinical practice, can detach himself entirely from such questions and we agree that the student needs help in preparing to deal with them.' The Report argues that medical students should not be segregated from other sorts of students and that it is essential that they work out a personal philosophy of life which will enable them to deal with such issues. The basis for this must be provided by an informed understanding tutored in psychology, sociology and social medicine. This passage, like much of the Report, raises important issues and then retreats at the last moment into an effort to find a strictly scientific way of considering them by means which are more in the domain of scientism than science. But in addition to this point, I don't think the Report gives sufficient weight to the tremendously highly-charged role which the doctor plays. Let's ponder it for a moment.
People unclothe on request before a relative stranger. They allow him (or her) to explore orifices which — in other contexts — are taboo and/or only accessible in one's most intimate relationships. They allow him to violate their integument with needles and knives. They swallow unknown substances on trust and in conformity with a schedule laid down by the doctor. They go to bed when they don't feel like it and get up when told, even if it causes pain. They reveal their innermost secrets and fears and even allow psychiatrists (as their critics put it) ’to plug them into the mains'. It is largely because of this extraordinary role that physicians work within highly-defined and emotionally-charged conventions which have evolved to protect both the patient and the doctor. At the same time, the openness and vulnerability of the patient have the effect of their placing tremendous trust in the doctor in a whole range of areas which extend far beyond his technical and professional competence. We cannot simply set those constraints aside or escape from the obligations which they imply. We can, however, attempt to become much more reflective about them.
Much of the argument of what follows has been adumbrated in the above introductory remarks. The explicit form of the argument is in four parts. First, an attempt to locate medicine in the scheme of the sciences and society by examining a set of related concepts. Second, a brief consideration of the dreams of scientific medicine will be given, to support the argument that we will never reach a medical utopia and are therefore inevitably thrown back on our own resources in facing complex moral and political questions. Third, I shall give examples of the shifting boundaries between the scientific and the scientized aspects of medicine and society. Finally, some examples from psychiatry will help to illustrate the relationship between medical institutions and social values. Throughout the discussion there is one central theme — the difficulty in ever knowing when one is being legitimately scientific and when one is being scientistic, i.e., expressing moral and political judgements cloaked in the language of science.
In turning to certain key concepts in medicine, we are engaged in an unfamiliar exercise in thinking about concepts which are so commonplace that we seldom examine them. Rather, we think in terms of them, and their fundamental role is only perceptible — and a critical attitude toward them only recoverable — if we focus sharply on some of our most commonplace terms and begin again to see the extent to which they shape our views of symptoms, of health and disease, and beyond these, how they determine our whole views of nature, man and society.
*
force
field
energy
OBJECTS ORGANISMS PATIENTS PERSONS
PHYSICAL SCIENCES BIOLOGICAL SCIENCES MEDICAL SCIENCES SOCIAL SCIENCES
matter structure health order- stability
motion (physiology) function disease disorder-instability
number (endocrin- adaptation normal norm-adjusted-deviant
ology) maladaptation pathological
(pharmacol (mental health)
ogy) (psychopathology)
(molecular
biology)
(electron
microscopy)
particles
elements
process..............................................................................................praxis
science..............................................................................................scientism
This chart requires considerably more elucidation than can be given in a relatively short essay, so only its bare bones can be laid out here. The goals of explanation of modern science which were developed in the sixteenth and seventeenth centuries led (in the so-called Scientific Revolution) to the definition of what would qualify as a scientific account. Such accounts were thenceforward to be made in terms of matter, motion and number, and all other phenomena were to be explained in terms of those three fundamental defining concepts, which, in principle, could account for all of the natural world. All scientific explanations aspire to the purity of physico-chemical explanations, and the additional concepts of force, field, energy, particle and element have been elaborated in the spirit of the physical reductionist programme which lies at the basis of science. The historical figures whose work is most prominently associated with laying down the model of explanation of modern science were Galileo, Descartes and Newton.
There is, of course; an important gap between physico-chemical explanations — ones which are concerned with objects - and all of the other levels of explanation which we will consider. There are no evaluative concepts allowed in physical explanations, but as soon as we move to the domain of organisms, we encounter concepts which are fundamental but which involve more or less explicitly evaluative concepts, the most basic being that of 'function', the rock bottom conception for discussing living systems. Indeed, the distinction between life and death itself (along with its more general biological equivalents —survival and extinction) has no place in a purely physical explanation. There is, of course, continuity between the methods of the physical sciences and those of the biological, medical and human ones, but there is, I maintain, a radical break in their philosophical status. (This depends on the fundamental distinction between 'primary' and 'secondary' qualities and the resulting fact-value distinction, but these matters cannot be considered here.) The work of Harvey, Descartes and von Haller (the father of modern physiology) provided the conceptual links between modern science and the categories of biological explanation, while that of Malthus and Darwin played the central roles in including man in the domain of biology. Men — whether simply as people or in the particular role of patient — are seen as organisms as a result of the theory of biological evolution. Similarly, a number of disciplines which antedate the awareness of a general science of biology (a term which was coined in 1802) as a related set of disciplines, have a firm conceptual niche as a result of evolutionism. These (and their modern expressions) are traditionally seen as medical, but their conceptual place is somewhere between the physical and the biological sciences: anatomy (especially microscopic anatomy and the visual study of molecules in electron microscopy), physiology, endocrinology, and molecular biology. Aspects of pharmacology and pathology also lie close to the work of physicists and chemists, but their main research is closely related with the practice of medicine, and they are less 'purely' scientific in the main.
There are direct analogies between crucial pairs of biological, medical, and social concepts, and it is on the validity of these analogies that the claim that medicine (and especially the scientific study of man in society) depends for its legitimacy in treating patients and people — in all their aspects — as part of the domain of science. Once again, these analogies depend on evolutionism, a theory which implies that man and all his works are, in principle, part of the natural order and (again in principle) subject to explanation in terms of scientific concepts and laws. Our basic dilemma is to reconcile this generalization with the incomplete state of science and the fact that actual men have conflicting values, goals, politics and ideologies. We are in grave danger of allowing the general principle of scientific naturalism to lead to premature claims which make my values or yours produce premature, specious scientistic conceptions.
Thus, when it is argued that the biological concepts of 'adaptation' and 'maladaptation' provide a secure scientific foundation for the medical concepts of 'normal' (= healthy) and 'pathological' (= diseased) and that these, in turn, provide a secure basis for scientific evaluations of individual, social and political behaviour, we are in grave danger of replacing science with scientism. Moving from the medical concept of health to the social ones of 'order' and 'stability' or from that of disease to that of 'social disorder' or 'instability', leads us to assume that the status quo in society is part of the natural order. In individual behaviour, the same analogy is made between the biological concept of 'adaptation' and the medical concept of 'normal' on the one hand and the social concept of 'adjusted' on the other. The same, of course, is true of 'maladaptation - pathological' and psychological or social 'maladjustment' or ’deviance’. The medico-social concepts of 'mental health', 'psychopathology', and 'social pathology' illustrate the conflations which I am suggesting we treat with grave reservations. Radical critics have provided us with some useful terms for identifying these dangers, and they suggest that the reduction of men's deliberate, principled actions to categories of natural science is to reduce their 'praxis' to 'process', and the resulting treatment of men as things is termed 'reification', The boundary between legitimate explanation of biological and human phenomena in scientific terms and the specious procedure of doing so in the name of science — thereby substituting scientism for science — is so frequently difficult to draw, that we should be very wary of relinquishing our moral and political categories to this new group of so-called 'social sciences', with their experts who will provide 'scientific' accounts of what is good and bad, possible and impossible, in individual, social and political life. There is, of course, an opposite danger to this one which I have called 'de-moralization': that of instant 're-moralization', Thus, in the debate on abortion — particularly in the public statements of the Professor of Obstetrics and Gynaecology at Birmingham — men appear in their roles as professional experts, complete with the power to influence appointments to hospital posts over a wide geographical area. They express their own moral and political convictions ex cathedra. This won't do either, and we must therefore find a way to engage in moral and political debates as such.
I want to turn now to a second topic: the dream of medical utopia, holding out the promise that science will eventually relieve us of these moral and political dilemmas. In doing his we must consider the patients' perception of the doctor and their shared beliefs about science and medicine. Of course, patients hope and fear more than doctors, but, on the whole, they share a very optimistic view about the progress of medicine, based on the dramatic advances in basic science and its applications. In my own lifetime the whole gamut of antibiotic drugs, of effective insecticides and of ataraxic drugs have come to the centre of medicine and public health. Each of these has turned out to be a mixed blessing, but few would argue that they are no blessing at all. Even more recently we have been blessed with dramatic improvements in controlling the immune reactions which stood — and to a large extent continue to stand — in the way of all sorts of surgical repair and replacement. And it is only a matter of months since the staggering possibilities of genetic manipulation have come onto the horizon.
Now I don't want to knock progress but only to put a biological — and then a social and psychological — perspective on these developments and the dreams which stem from them. In his excellent essay on The Dreams of Reason (Columbia paperback, 1961), Professor René Dubos has put the issues very clearly: 'Granted the lack of precise information, it is clear that there have been spontaneous ebbs and flows in the prevalence and severity of many diseases. Plague invaded the Roman world during the Justinian era; leprosy was prevalent in western Europe until the sixteenth century; plague again reached catastrophic proportions during the Renaissance; several outbreaks of the sweating sickness terrorized England during Tudor times; syphilis spread like wildfire shortly after 1500; smallpox was the scourge of the seventeenth and eighteenth centuries; tuberculosis, scarlet fever, diphtheria, measles took over when smallpox began to recede; today virus infections occupy the focus of attention in our medical communities; and long before viruses had become scientifically fashionable, pandemics of influenza at times added a note of still greater unpredictability to the pattern of infection.' (pp. 66-7) 'Coming now to our own times, who could have dreamed a generation ago that hypervitaminosis would become a common form of nutritional disease in the Western World; that the cigarette industry, air pollutants, and the use of radiations would be held responsible for the increase of certain types of cancer; that the introduction of detergents and various synthetics would increase the incidence of allergies; that advances in chemotherapy and other therapeutic procedures would create a new staphylococcus pathology; that alcoholics and patients with various forms of iatrogenic diseases would occupy such a large number of beds in the modern hospital?' (p. 69)
Dubos goes on to draw conclusions which are of fundamental importance for our evaluation of the relationship between scientific progress and moral and political issues: 'The belief that disease can be conquered through the use of drugs deserves special mention here because it is so widely held. Its fallacy is that it fails to take into account the difficulties arising from the ecological complexity of human problems. Blind faith in drugs is an attitude comparable to the naive cowboy philosophy that permeates the Wild West thriller. In the crisis-ridden frontier town the hero single-handedly blasts out the desperadoes who have been running rampant through the settlement. The story ends on a happy note because it appears that peace has been restored. But in reality the death of the villains does not solve the fundamental problem, for the rotten social conditions which opened the town to the desperadoes will soon allow others to come in unless something is done to correct the primary source of trouble. The hero moves out of town without doing anything to solve this far more complex problem; in fact, he has no weapon to deal with it and is not even aware of its existence.
'Similarly, the accounts of miraculous cures rarely make clear that arresting an acute episode does not solve the problem of disease in the social body — or even the individual concerned... To state it bluntly... my personal view is that the burden of disease is not likely to decrease in the future, whatever the progress of medical research and whatever the skill of social organizations in applying new discoveries. While methods of control can and will be found for almost any given pathological state, we can take it for granted that disease will change its manifestations according to social circumstances. Threats to health are inescapable accompaniments of life.' (pp. 83-4)
These cautionary remarks help us to see two things. The first is the importance of the biological perspective — seeing man and disease in ecological terms as ongoing evolutionary processes in which man has decisively intervened with controls which are, in the nature of the evolutionary process, unlikely ever to be complete. More generally, if we are unlikely ever to be able to replace the texture of physical disease and its moral implications, how much less is science likely to find 'magic bullets' and cure-alls for our social and political malaise, for exploitation, for injustice, and for the relations among states.
Turning now to the topic of the shifting boundaries between the scientific and the scientized aspects of science, medicine and society, I want to move from somatic medicine to its relations with psychiatry and the social sciences. Once again, the theory of evolution provides the key link between somatic medicine and man's mental and social aspects. Evolutionism provided the general framework within which psychiatry reached the general conclusion that all abnormal behaviour has a scientific explanation. In its nineteenth-century form, this thesis took the form that since the brain is the organ of the mind, all mind disease is brain disease, Psychopathology thereby becomes neuropathology. It was in this 'somaticist' atmosphere that Freud elaborated his psychoanalytic theories, theories which began with the study of brain disorders and moved on to express his new findings about people's troubles in physicalist terms. Modern psychiatry has drawn heavily on his metaphorical languages, and the following terms are commonplace: 'the anatomy of the mental personality', 'the mental apparatus', 'mental energies', 'mental forces', 'mental structures'. From biology came the concept of instinct, an idea which in its current form is providing the basis for a renewed biologization of social and political philosophies. There are innumerable conceptions which move uneasily between the somatic and the psychic realms. The concept of 'stigma' which Erving Goffman discusses so perceptively, operates in both realms at once (Stigma. Penguin paperback, 1968). The physical disabilities which stigmata originally denoted, provide a bridge between medical and social abnormalities and the conceptual shift from somatic pathology to social deviance and labelling.
Going further, psychopathic behaviour provides an example of a diagnostic category which jumps about from year to year. The majority of people in prisons have been labelled as psychopathic or sociopathic personalities. This must mean that they have been held responsible for their actions. However, for a period it was strongly argued that these people were the victims of deprivation in the crucial period when the social conscience is being formed. They were then seen as suitable cases for psychiatric treatment, not responsible for their actions. But when it turned out that they were not responsive to treatment or that they required more psychiatric resources than were available, they were placed again in prisons, this time because there was no other place to keep these deviants whom we could not afford to help sufficiently to learn to internalize obedience to society's norms. Then it was thought that they suffered from an abnormality in the chromosomes. At this point their behaviour was firmly linked with genetic inevitability — their behaviour patterns were said to be innate. This evidence turned out to be equivocal, but in the same period others argued that to identify psychopaths by genetic screening, to subject them to eugenic prohibitions from breeding or to require them to carry identity cards, or, finally, to incarcerate them for reasons of preventative detention — that these procedures would be to treat people as objects and to deny them their political rights. The case of psychopathy is an extremely complex one, but it can be argued that it neatly illustrates the dilemma of the scientific versus the moralistic and political models of our approach to persons.
Turning to the social sciences, we find that quasi-scientific terms are frequently employed. The concept of 'social pathology' appears in the titles of two well-known books in the field, thereby scientizing a debate which has traditionally been seen as a moral and political one. In one of them, Lady Wooton's Social Science and Social Pathology, the very definition which she adopts undermines the potentially scientific nature of the domain. Social pathology turns rut to include anything the state spends money to prevent. Yet when one looks in detail at the Todd Report, one finds the following in a 'Specimen Syllabus in Social Factors Related to Medicine': 'Social Pathology: Deviance and conformity in society; sociological, philosophical and legal aspects of delinquency and crime, institutional neurosis, suicide, drug addiction and alcoholism. Group behaviour and the role of the doctor and others concerned in the prevention and treatment of behaviour disorders.' (p. 279) This outline provides an intimate mixture of the scientific and the scientized, all presented in the objective language of science. If we follow the spirit of the Todd Report to the letter, we will find ourselves addressing moral, social and political problems in terms of a set of concepts and assumptions which will prematurely — and, I believe, illegitimately — draw them into the domain of biology and somatic medicine.
My last arguments are drawn from psychiatry. I do this because the points come out most clearly in that context, but every general practitioner knows that questions which are assigned to the domain of psychiatry are inextricably intermingled with all of his or her practice. Similarly, the issues which are raised sharply in psychiatric examples arise on all sorts of occasions in which people cast themselves in the role of patient to see other people in the role of doctor: abortion, venereal disease, drugs, and other less explicit aspects of non-conformist and unusual behaviour which gets labelled as 'deviant' and 'pathological', So, in turning to psychiatry, we are only illustrating in a clear light issues which arise throughout medicine.
In his essay on 'The Moral Career of the Mental Patient', (Asylums, Penguin paperback, 1968), Goffman strips away the clinical and scientistic language used in psychiatric practice and interprets the experience of the patient in terms of his self-esteem and his relations with other people. All too often his loved ones collude with the doctor, the doctors and staff patronise him, and his social relations with the other people ('inmates', 'patients') in the institution are unnecessarily restricted. The perspective which he provides is very revealing. Few of us would be proud of behaving in our ordinary social relations in the ways he describes, much less with people who were particularly vulnerable and sensitive. But — and this seems to me the most important point — these same medical people claim to be treating the patient in disinterested, morally neutral ways. When Goffman turns to case notes, the gulf between the self-image of psychiatry (and much the same can be said for other branches of medicine) and the actual morally and ethically censorious language employed, is very great: 'Armed with a neat appearance and natty little Hitlerian moustache this 45 year old man who has spent the last five or more years of his life in the hospital, is making a very successful hospital adjustment living within the role of a rather gay liver and Jim-dandy type of fellow who is not only quite superior to his fellow patients in intellectual respects but who is also quite a man with women. His speech is sprayed with many multi-syllabled words which he generally uses in good context, but if he takes long enough on any subject it soon becomes apparent that he is so completely lost in his verbal diarrhoea as to make what he says almost completely worthless.' (p. 145) Goffman dryly observes that this, far from being morally neutral, is defamatory and is characteristic of all levels of mental hospital staff. In my own experience with case notes in mental hospitals, I have not seen this extreme language, but I have often seen (and employed) language which is on the same continuum — more morally evaluative than 'clinical'.
It is difficult to gain a perspective on the role which psychiatry and psychiatric institutions play in our culture. In this respect, historical analyses can be very illuminating. In particular, Michel Foucault's Madness and Civilization (Tavistock paperback, 1971) helps us to see that the role of such institutions has always reflected certain basic issues in the development of the economic and social assumptions, the prohibitions and sequestrations of the societies in which they occurred. We find it easy to criticise the incarceration of social and political nonconformists in the Soviet Union, but we are less disposed to ask how much our own supposedly objective criteria produce analogous results in our mental hospitals.
Returning to the present, I should like to conclude by retailing some of the arguments of Professor Thomas Szasz, which I have chosen as an antidote to excessive faith in the extendibility of scientific concepts from biology and medicine to society. His strictures seem to me to apply to many forms of deviance encountered in medicine and the ancillary medical services. In his book of essays on Ideology and Insanity (Anchor paperback, 1970), he begins by commenting on the psychiatric terms 'maturity' and 'immaturity', 'independence' and 'dependence', 'mental health' and 'mental illness', 'sanity' and 'insanity': ’I believe all these psychiatric terms are inadequate and unsatisfactory, for each neglects, or deflects attention from, the essentially moral and political character of human development and social existence. The language of psychiatry thus de-ethicizes and depoliticizes human relations and personal conduct... By seeking relief from the burden of his moral responsibilities, man mystifies and technicizes his problems in living... on the other hand, the demand for "help" thus generated is now met by a behavioral technology ready and willing to free man of his moral burdens by treating him as a sick patient.' (pp. 2-3) He continues, 'In contemporary social usage, the finding of mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms... The discipline of medicine — both as pure science (for example, research) and as an applied science or technology (for example, therapy) — contains many ethical considerations and judgements. Unfortunately, these are often denied, minimalized, or obscured, for the ideal of the medical profession as well as of the people whom it serves is to have an ostensibly value-free system of medical care.' (p. 17) He argues that the concept of mental illness 'functions as a disguise: instead of calling attention to conflicting human needs, aspirations, and values, the concept of mental illness provides an amoral and impersonal "thing" — an "illness" — as an explanation for problems in living... My aim... is to suggest that the phenomena now called mental illness be looked at afresh and more simply, that they be removed from the category of illnesses, and that they be regarded as the expressions of man's struggle with the problem of how he should live.' (p. 21) 'If moral values are to be discussed and promoted, they ought to be considered for what they are — moral values, not health values. Why? Because moral values are, and must be, the legitimate concern of everyone and fall under the special competence of no particular group whereas health values (and especially their technical implementation) are, and must be, the concern mainly of experts on health, especially physicians.' (p. 41) I believe that Szasz addresses a serious and basic issue but that his argument goes too far in completely separating psychiatry from science. Conversely, his belief that somatic medicine is unproblematic and can be neatly separated from ethical and political issues seems to me to be naive and simplistic.
The problem in its general form, is that of attaining objectivity in social issues which is analogous to that in the physico-chemical sciences. The whole aim of this argument has been to show that the hopes held out by the Todd Report and other attempts to turn to science for social and political answers is at best a dangerous move and at worst a resignation from our identities as people who can strive to achieve the sort of world we choose to make. In his perceptive book on Beliefs in Society (Penguin paperback, 1971), Nigel Dennis makes the central point very clearly. 'Objectivity in social questions can mean no more than a certain open-mindedness; a willingness to acknowledge that one is oneself a party, or at least has priorities; a willingness to examine all the information available, all the arguments, and a willingness to answer them. It cannot mean presenting an answer over and above the answers of the existing parties to a dispute, adopting the posture of God who sees all things as they "really are". Of course, in practice mediation or arbitration is sometimes useful, but this is an ad hoc procedure either to split the difference or to strengthen one side; it is not revealing the true nature of reality which has been obscured by fictional prejudice, for we are all prejudiced. Thus, the question with which we began, "How can I know that I am right?" is more easily reformulated as, "What purposes shall I pursue?"' (p. 225) In applying this approach to our roles as doctors who are attempting to address ourselves to social issues, the same question arises, and no extension of concepts from more nearly objective sciences will let us off the moral and political hook. Thus the old, traditional moral, political and ideological questions are not to be escaped in medicine or by medicine. It is no haven for us or for our patients. And as we approach their reasons for coming to us, we have an equally heavy burden in giving completely serious attention to their definitions of health, as well as ours. They may feel that the doctor's job is to help them achieve their own purposes and not ours. Then we must decide whether or not we think it right to help them, and the answer does not lie in a textbook of psychology or sociology.
Reading List
The works listed below provide a 'short-list' of writings which consider the complex interrelations among concepts in the physico-chemical sciences, biology, medicine, the social sciences, as these raise issues on values, politics and ideology. All are available in inexpensive editions.
Abercrombie, M. L. J., The Anatomy of Judgment: An Investigation into the Processes of Perception and Reasoning (London: Hutchinson, 1960; also Penguin paperback) — an illuminating study of the role of assumptions and biases in the perception, definition, and evaluation of evidence drawn from discussions with medical students.
Dubos, R., Mirage of Health: Utopias, Progress and Biological Change (London: Allen & Unwin, 1960) — a very perceptive study of the relations between medical, biological and environmental conceptions by an eminent bacteriologist.
_____ The Dreams of Reason: Science and Utopias (N.Y. & London: Columbia, 1961; also Columbia paperback — an extension of the argument to include the whole domain of science; see especially ch. 4 - 'Medical Utopias'.
Fuller, W. (ed.), The Social Impact of Modern Biology (London: Routledge Kegan Paul, 1971; also RKP paperback) — twenty short papers which consider the social and ethical problems raised by biology and medicine, with particular emphasis on the implications of genetics and immunology; contributors include, in many cases, the discoverers of the relevant findings and techniques.
Goffman, E., Stigma: Notes on the Management of Spoiled Identity (New Jersey: Prentice-Hall, 1963; also Penguin-paperback) — a sociologist considers the relations between medical and other handicaps on the one hand and social identity on the other and relates these to the problem of deviance.
______ Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (N.Y.: Doubleday Anchor, 1961; also Penguin paperback) — considers the problems of manipulation and self-perception of people who find themselves in 'total institutions'; very incisive about the relations among the doctor, the patient and his family; see especially chapter on 'The Moral Career of the Mental Patient'.
Szasz, T. S., Ideology and Insanity: Essays On the Psychiatric Dehumanization of Man (N.Y.: Doubleday Anchor Original paperback, 1970) — provocative essays on the problem of relating medical and psychiatric conceptions of man with ethical and political issues; although occasionally overstating his case, Szasz provides an important corrective, helping us to see the emotional problems of patients as problems of how to live rather than as purely value-neutral medical disorders.
Foucault, M., Madness and Civilization: A History of Insanity in the Age of Reason (London Tavistock, 1967; also Tavistock Social Science paperback) a difficult but brilliant interpretation of the relations between conceptions of insanity and the changing economic and political contexts since the seventeenth century; particularly revealing about the uses which society makes of confinement in institutions.
Weiss, P., The Persecution and Assassination of Marat as Performed by the Inmates of the Asylum of Charenton under the Direction of the Marquis de Sade (London: Calder paperback, 1965) — a highly successful play which relates Foucault's argument to current social and political issues by means of a play within a play set in a not-so-different time.
Whitehead, A. N., Science and the Modern World (Cambridge, 1925; also Cambridge paperback) — an interpretation of the fundamental assumptions of modern science and the problems which they raise for man's place in nature.
Douglas, M., Purity and Danger: An Analysis of Concepts of Pollution and Taboo
(London: Routledge and Kegan Paul, 1966; also Penguin paperback) — an anthropological interpretation of the ways in which concepts of health and disease, clean and dirty, etc. play a central role in ordering society, regardless of their utilitarian value; provides an important perspective on biological and medical conceptions of man and nature.
Titmuss, R. M., The Gift Relationship: From Human Blood to Social Policy (London: Allen & Unwin, 1970; also Allen & Unwin paperback* — beginning with the medical problem of obtaining supplies of blood for medical use, sociologist of social policy relates it to a series of wider issues of economics, altruism and the economics of health services and of technological societies, especially Britain and America.
Harris, N., Beliefs in Society: The Problem of Ideology (London: Watts, 1968; also Penguin paperback) — a politically committed sociologist relates the social context of men's beliefs to the different ideological perspectives on man and society held in Britain, Russia, China and the Third World; his argument shows how the most mundane and apparently apolitical beliefs are related to complex assumptions about the order of society.
Recent works on medical history and medical sociology (not available in cheap editions):
McLachlan, Gordon and Thomas McKeown (eds.), Medical History and Medical Care: A Symposium of Perspectives (London: Oxford, 1971).
Mechanic, David, Medical Sociology- A Selective View (London: Collier-Macmillan,
Friedson, Eliot, Profession of Medicine: A Study of the Sociology of Applied Knowledge (N.Y.: Dodd, Mead, 1970).
______ Professional Dominance: The Social Structure of Medical Care (N.Y.: Atherton, 1970).
Eckstein, Harry, The English Health Service: Its Origins. Structure and Achievements (Cambridge, Mass: Harvard, 1964).
Contrasting interpretations of the deviant behaviour of students and other young people:
Bettleheim, B., 'Obsolete Youth: Towards a Psychology of Adolescent Rebellion', Encounter 33 (1969), 29-42 (Sept.)
Erikson, E. H., 'Reflections on the Dissent of Contemporary Youth', International Journal of Psycho-analysis 51 (1970), 11-22.
Primary sources on the history of relations among natural science, biology, medicine, and society:
Harvey, W., An Anatomical Disquisition on the Motion of the Heart and Blood in Animals (1628; London, Everyman's Library cheap edition).
Descartes, R., Discourse on Method (1637; Penguin paperback) — see especially Part V, in which Descartes relates his philosophy of biology to Harvey's discovery and, by deducing the motion from first principles, gets the relationship between systole and diastole backwards; compare Harvey's answer to Descartes in his 'Second Disquisition to John Riolan, Jun.', reprinted in Everyman edition (above). Important issues about the relationship between biology and the physical sciences are reflected in this debate.
von Haller, A., Dissertation on the Sensible and Irritable Parts of Animals (1752), with an introduction by 0. Temkin, Bulletin of the History of Medicine 4 (1936), 651-699. Von Haller's Dissertation is an important explicit statement of the ways in which biological concepts deviate from the insistence on physico-chemical reductionism.
Malthus, T. R., An Essay on the Principle of Population (1798; Penguin paperback, with an introduction by A. Flew — a central document in the history of attempts to apply the methods and categories of science to the study of man, Malthus' Essay provided the rationalization of most subsequent social and political and economic views on man's relationship to society and to nature. At the same time, he provided the key analogy for Darwin's theory of evolution by natural selection.
Darwin, C., On the Origin of Species by Means of Natural Selection, or the Preservation of Favoured Races in the Struggle for Life (1859; Penguin paperback, with an introduction by J. W. Burrow) — the fundamental argument relating man and society to the laws of biological nature. Although man is only mentioned in one cautious sentence at the end, Darwin's theory provided the basis for biological theories of man and society, theories which underlie the uncertain position of medicine and medical practice at the intersection of scientific, moral, legal, social and political pressures.
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This is a modified version of a lecture given in a General Practitioners' Refresher Course at the Postgraduate Medical School, University of Cambridge in July 1971. An abbreviated version was published in Science or Society? 'Special Issue on Medicine and Society' No. 4 (Nov. 1971), pp. 7-12.
Copyright: The Author
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