Medicine and the Transcendental Values
Medicine and the Transcendental Values
Drawing on a tradition notably begun by Parmenides and later elaborated by Socrates and Plato,
Aristotle speculated that among all of the traits a thing may have are certain traits it must possess in order to be at all, that is to be fully and non-defectively real: unity, truth, goodness, and beauty. He called these traits the transcendentals because they are coextensive with being itself, in such a manner that anything that is or exists is or exists exactly in so far as it exemplifies these traits.
Accordingly, one may do well to define or refine the conception of a subject matter by using the transcendentals collectively as a principle of organization and definition. I propose that exercising this reflection on the topic of Medicine, or the Health Care profession, will go far in clarifying what it really is or needs to be, and how its mission ought to be defined.
First, we need to become more acquainted with the transcendentals themselves.
Unity is a transcendental value in that nothing can be judged clearly to exist or be real except in so far as it has integral constitution, that is, a recognizable pattern, organization, or criterion allowing us to distinguish it from all other things, and especially from its close neighbors, with which it is most likely to be confused.
Truth is a transcendental value in the sense that nothing can be clearly recognized as existing or being real except in so far as a consistent and coherent set of claims about it can be judged to be the case. If unity is the value that allows us to lock on to the thing, truth is the value that allows us to process and enrich our awareness of it ad infinitum once we are locked onto it: its fullness of depth, richness, consistency, and cohesiveness of intrinsic (related to itself) and extrinsic (related to other things) detail.
Goodness is a transcendental value in that anything that exists or is real has its own unique raison d’êtreor purpose, which Aristotle called its final cause. Two things may be quite similar in all other respects, and yet their purpose still suffices to distinguish them. There are letter openers that look very much like small swords and even potentially might be confused for being such. Yet, they are letter openers. Someone who judges such a thing to be a sword is making a mistake. Sikhs from India often travel wearing a sacred ceremonial sword, similar to the Knights of Columbus in full regalia, which is clearly not intended to be an actual weapon. Those who judge it to be such are in error. Every natural kind has a purpose, even if we can’t exactly put our finger on what it is. We can say “reproduction”, but it’s more than that. We know they have purpose because they are driven, and driven to do certain things and not others. There clearly are certain things they are “up to”, and certain things they are not up to. It is a challenge to figure out what the purpose of something is even when we see it has a purpose.
Of course, as humans, we can invent additional purposes for things. In fact, that is part of our purpose. But we have to be careful that our invented purposes are consistent and compatible with our uninvented purposes. If I learn to walk on my hands, I have invented a purpose for my hands which is clearly not intrinsic to them. Yet it seems a bit silly to say that walking on one’s hands is “against nature”, as if I were going against the purpose of human life when I did it, such as cutting my hands off, or refusing altogether to be social. Provided I take due safety precautions,walking on my hands embellishes human life without contradicting its other purposes, whatever they are.
Finally, beauty is a transcendental value in the sense that to the extent that we can clearly recognize the unity, goodness and truth of something real or existent, we experience an aesthetic appreciation of that thing’s reality. This makes beauty in a sense a composite of the other three transcendentals. In fact, our experience of beauty will typically be marred by any of the following three things: our recognition of the falseness of it, our recognition of the privation of good (e.g. moral corruption, failure to meet its purpose) in it, or our recognition of a lack of unity in it. The beauty of a rainbow, for example, gradually dissipates as, coming closer and closer to it, we have a harder and harder time seeing it as one thing. On the other hand, sometimes the beauty of something particularly complex is mistaken for ugliness simply because we are not up to the task of appreciating how all its many elements somehow do form a sensible unity.
Applying these four values to medicine, we are challenging ourselves to arrive at a vision of the unity, truth, goodness and beauty of the health care profession, which would be the health care profession as it really ought to be. This is not an easy thing to do, but it is an important exercise nonetheless, as not attempting to do it is tantamount to giving up on medicine being anything more than a rainbow, something whose being is only apparent when seen as a distance, and which, upon closer and closer examination, is less and less of a “thing”.
The dangers of getting this reflection wrong are also to be warned against. But this danger is readily avoided as long as we maintain reflective cognizance of the fact that human knowing is an infinite task. Therefore, any apparent arrival at absolute judgments in a finite amount of time must be dismissed as illusory. The only honest manner of proceeding in this reflection, therefore, is an epistemically pluralist approach, in which no perspectives are to be ignored or summarily dismissed, but at the same time all are to be submitted to rigorous scrutiny as well.
Here we will sketch the most general aspects of the reflection, and then proceed to cases.
Appreciating the unity of medicine consists in our maintaining and building upon a coherent, consistent and critical narrative of what it is, what it has been, and what it is or may be becoming. This reflection must be open to the fact that human institutions do evolve, and the fact they do is not to be taken as proof of their corruption. It is, in other words, up to us to maintain an ongoing scrutiny of the quality and integrity of the health care profession as it evolves and develops.
In this regard, the social sciences have a role to play in allowing us to envision medicine not as something invented in one culture alone, but a transcultural human phenomenon. A closer look at what we now accept as modern medicine reveals that it has its roots in many cultures, with more coming on board as the world gets smaller and the world economy develops. Of course, all things must be subjected to scrutiny; even accepted aspects of modern medicine should be subject to ongoing scrutiny.
Appreciating the truth of medicine consists in maintaining an ongoing working definition of it which allows us to see it as an institution distinct from other possible institutions using the same tools and involving the same expertise. As Plato noted, those expert in medicine, i.e. in healing and promoting the health of the organism, are also incidentally expert in killing and harming. But few would allow that the use of medical tools and expertise to kill and harm rather than heal counts as medicine. To be sure, the borderline between the two is a bit fuzzy, since we may in extreme cases wonder whetherwe may in a sense heal by killing or harming. Still, killing and harming are objective actions which medicine by and large seeks to avoid, regardless of subjective wishes. Medicine is not merely about “giving the customer what s/he wants”, such that, if killing or harm is asked for, it is given. Harm does not magically become non-harm just because someone asks for it.
Appreciating the goodness of medicine consists in maintaining a clear sense of its mission: what is medicine for? What counts as a genuine calling to be a health care professional and what does not? How can it be the case that I can be a bad doctor, nurse, etc., even in spite of the fact that I have mastered all the tools of medicine and am quite adept at using them? To be sure, the mission of medicine may be evolving, but, as Aristotle well noted, the change of a thing necessarily implies an unchanging core. Clarity of vision as to the mission of medicine ultimately depends on developing a good sense of what the unchanging core of medicine’s purpose is.
Finally, appreciating the beauty of medicine consists in maintaining and even cultivating an increased aesthetic and moral sense of how wonderful the health care profession is when it is functioning well in our society. This appreciation of its beauty is so important for keeping each of us locked in from minute to minute and day to day, both as health care professionals and as clients, to the genuine reality - the unity, truth, and goodness - of what medicine really is and needs to be for human society and for the world. At any point in time, the results of our transcendental reflection on medicine yields tentative results; so an ongoing appreciation of its beauty is vital to keeping us well-oriented to continue building up medicine to better and better fulfill its mission.
I have chosen the following items as cases in point for how a transcendental-values based reflection on medicine can be relevant to our getting a better grasp of what medicine is how its sense of mission is to develop. In all of these cases, failure to maintain a transcendental “big-picture” reflection of medicine has led to trouble, and having such reflection has led or will lead us out of trouble.
-The use of prescription drugs to mimic, stimulate the release of, inhibit the release of, or inhibit the reuptake of certain excitatory and inhibitory neurotransmitters, the body’s so-called “reward drugs”;
-The gradual, eclectic incorporation of acupuncture into mainstream medicine;
-The now defunct Pain-As-Fifth-Vial-Sign movement;
-The once routine U.S. medical practice of episiotomies on delivering women; and
-Fine-tuning the definition of the purpose of palliative care.
The original stated and accepted premise for the advocacy and promotion of certain, usually excitatory neurotransmitters such as serotonin, dopamine, epinephrine, etc., often called the “indoleamine hypothesis” based on the appearance of this term in the title of a single research paper advancing the claim in 1977*, is that certain individuals have a chronic deficiency in their body’s ability to supply a certain neurotransmitter, such as serotonin (the transmitter cited in the research paper) or dopamine, and that therefore it might be appropriate for such individuals to be on prescriptions to alleviate this deficiency. Once there neuro-transmitter manipulating drugs were passed, no further research was done to scrutinize the hypothesis. Along the way, as we began to understand better exactly what these drugs do, it became more and more clear to chemists and others that the hypothesis was unfounded. Specifically with respect to the serotonin reuptake inhibiting drugs the original article dealt with, the logic seems off. Why should we be administering a drug like Prozac to someone who by hypothesis has a serotonin deficiency? Prozac does not replace or mimic serotonin. All it does is prevent the reuptake of the serotonin the organism has already been stimulated by its own processes to release into the blood. The longer the serotonin remains in the blood, the faster it gets used up. The faster it gets used up, the greater the danger of actually producing a serotonin shortage, which often results in emotional crisis. If some people really have a deficiency in something the shortage of which often results in organismic crisis and which we have no known reliable synthetic substitute for, then should not our policy be to help these individuals by means of strategies aimed at conserving their supply?
The reason we never hear this kind of conversation, I fear, is that no one in the know really believes in the indoleamine hypothesis. It was merely the ticket into the park.
The same goes for the dopamine-reuptake inhibiting drugs accepted for the treatment of attention-deficit disorders. There is no evidence that some people don’t have enough dopamine in their bodies. All the evidence points to the fact that attention-deficit disorders are based on the absence of established habitual dopamine-releasing triggers for certain activities as opposed to others. A young man who just can’t get his dopamine flowing for mathematics may have no trouble getting it flowing for hockey or piano. The likely prescription such a person may end up with for his academic problems, methylphenidate (Ritalin) or its ilk, works by preventing the body from re-uptaking the dopamine already in the blood, which will enhance performance while using up the body’s supply of dopamine more rapidly. Once the dopamine is gone, one has to wait for the body to synthesize more. At this point, the Ritalin can’t help and the individual will suffer from a drained dopamine supply.
These drugs aren’t bad, but we must come to grips with what they really do, and not have false premises for taking them. If we take them, we must develop strategies and schedules for taking them safely, such as in lower doses and with plenty of “holidays” scheduled in.
And by the way, what about the prospects of doing what we can to get more people excited about math, or physics, or Shakespeare? When people get excited about something, their dopamine gets flowing. Naturally. Why have we lost patience with psychotherapy.
*Zarcone VP Jr,Berger PA,Brodie KH,Sack R,Barchas JD. “The indoleamine hypothesis of depression: an overview and pilot study.” Dis Nerv Syst.1977 Aug;38(8):646-53.
Let’s face it: acupuncture theory does not interface well with modern medicine and what we have learned about the human organism in physiology. Yet certain kinds of acupuncture treatment seem quite effective, perhaps as well as or better than western approaches which often carry more dangers with them. We are now seeing a gradual integration of acupuncture, or at least greater acceptance of it, with modern medicine for relief of dysfunctional pain and for restoring certain kinds of limitation on range of motion. Moreover, acupuncture supplies these benefits with very low costs in terms of side-effects. Besides harms derived from acupuncture malpractice, such as misplacement of and breaking of needles, etc., there isn’t much harm that acupuncture will do even if it doesn’t work. The same often cannot be said for its pharmacological alternatives. In the meantime, modern science has the opportunity to come to understand why the acupuncture that works for us works, and thus gradually integrate acupuncture theoretically into modern medicine.
The current opioid addiction crisis we are now experiencing did not begin on the streets, but in hospitals and clinics. The American Medical Association admitted as much when in June of 2016, it officially discontinued the almost exclusively American (US) movement to include pain as the fifth vital sign. This movement is known to have been spurred by the pharmaceutical industry as a marketing strategy. Some research was drummed up, now disowned by its author, to suggest that opioid medications of certain kinds and manufactured in certain ways were not addictive if taken as prescribed and if previous opioid addicts were screened out. This turned out to be false, as many people became addicted to their opioid painkillers on their first round. In the meantime, articles were appearing accusing American health care professionals of undertreating pain, and thus violating patients’ rights. This led to a movement to include pain across the country as a fifth vital sign. Now, health care professionals were required , along with taking pulse, temperature, heartbeat, and respiration rate, to ask patients what level of pain they were at from 1 to 10. In addition, penalties were often instituted to punish health care professionals who, in peer review, were determined to have undertreated patient pain, e.g. perhaps by not prescribing an opioid. All this led to a great upsurge in opioid prescriptions across the country. It was not atypical that the protocol of a particular institution would be to prescribe opioids to any patient reporting a pain level of 5 or higher.
The more thoughtful, experienced health care professionals, I am told, never went along with the Pain-As-Fifth-Vital-Sign movement. They saw it as a passing fad. Nonetheless, it was taught in medical academia for years as fact, and young professionals came into the clinics and hospitals having drunk the Kool-Aid of the new Pain cult. The damage was done. Even though there may have been enough collective wisdom in the field to have prevented it, nothing was done, because it was no one’s job in particular to make sure that medicine makes sense when reflected on as a whole.
In the United States and practically nowhere else, it used to be routine practice to give an episiotomy (perineotomy)to a woman at a key moment in the delivery process, to open up the birth canal more and prevent tearing, which was then assumed to be worse than cutting. (The perineum is the area between the anus and the vulva.) In the meantime, health care professionals in other developed countries, also solicitous of preventing a tear to the perineum, usually found it sufficient to massage the perineum at certain key times, rendering it more flexible. While this was known in our country, that another, much less invasive intervention was in use in modern medicine and with effective results, it was decades before we finally switched gears definitively to end the practice of routine episiotomies, spurred on finally by new studies that were showing that it is actually better to suffer a tear of the perineum that to have it cut, since tears heal better than straight cuts.