Hippocratic Oaths: Medicine and its Discontents

By Raymond Tallis

In this book, the physician and philosopher Raymond Tallis yokes together his diverse intellectual interests to address important questions about our well-being. In a series of stimulating and impassioned arguments, he establishes the truth about, among many other things, recent health scares, explains why patients compete for our doctors' and nurses' time; why the exploding popularity of alternative therapies is actually bad for our health; and how one man's view of the MMR vaccine influenced a nation. This is the summation of a lifetime's thought and medical practice, by one of Britain's most original thinkers. It will, quite simply, change for ever the way we think about ourselves and our health.

• Language: English
• Publisher: Atlantic Books
• Release date: Jan 1, 2015
• ISBN: 9781782396512

Raymond Tallis

Raymond Tallis trained in medicine at Oxford University and at St Thomas’ Hospital London before becoming Professor of Geriatric Medicine at the University of Manchester. He was elected a Fellow of the Academy of Medical Sciences for his research in clinical neuroscience and he has played a key role in developing guidelines for the care of stroke patients in the UK. From 2011–14 he was Chair of Healthcare Professionals for Assisted Dying. He retired from medicine in 2006 to become a full-time writer. His books have ranged across many subjects – from philosophical anthropology to literary and cultural criticism – but all are characterised by a fascination for the infinite complexity of human lives and the human condition. The Economist’s Intelligent Life magazine lists him as one of the world’s leading polymaths.

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Hippocratic Oaths

First published in trade paperback in Great Britain in 2004 by Atlantic Books, an imprint of Grove Atlantic Ltd.

This edition published in Great Britain in 2014 by Atlantic Books Ltd.

Copyright © Raymond Tallis, 2004

The moral right of Raymond Tallis to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act of 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission both of the copyright owner and the above publisher of this book.

Every effort has been made to contact copyright holders.

The publishers will be pleased to make good any omissions or rectify any mistakes brought to their attention at the earliest opportunity.

ISBN 9781782396512

A CIP catalogue record for this book is available from the British Library.

Atlantic Books Ltd.

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26–27 Boswell Street

London WC1N 3JZ

www.atlantic-books.co.uk

For Mahendra Gonsalkorale and Bill Sang

in friendship, gratitude and admiration.

Contents

Acknowledgements

A (Very) Personal Introduction

PART ONE

Origins

1  The Medicine-taking Animal: a Philosophical Overture

2  The Miracle of Scientific Medicine

3  The Coming of Age of the Youngest Science

PART TWO

Contemporary Discontents

4  Communication, Time, Waiting

5  Power and Trust

6  Enemies of Progress

7  Representations and Reality

PART THREE

Destinations

8  ‘Meagre Increments’: the Supposed Failure of Success

9  The End of Medicine as a Profession?

10  ‘Everyone Has To Die Sometime’

Envoi

Notes

Index

Acknowledgements

This book owes its existence to the enthusiasm and encouragement of Jacqueline Korn of David Higham Associates, my agent, and of Toby Mundy of Atlantic Books. Toby it was who suggested the title of the book. Many thanks to both of you.

I am even more indebted to Louisa Joyner for her brilliant editorial work. Her eye for detail, combined with her clear understanding of the big picture, has resulted in countless suggestions that have dramatically improved Hippocratic Oaths from the original manuscript. Louisa, I can’t thank you enough. Louisa’s work has been complemented by the superb copy-editing of Jane Robertson, to whom I am enormously grateful for much judicious textual liposuction, vital structural changes, an intelligent scepticism that has tempered some of my more passionate outbursts, and an unremitting attention to important minutiae.

Finally, thanks are due to my secretary, Penny Essex a) for putting up with me not only during the period of gestation of Hippocratic Oaths but also for wonderful support over the preceding decade and a half and b) for chasing up many elusive references often on the basis of vague and/or misleading information.

1

A (Very) Personal Introduction

Nothing could be more serious than the care of ill people, nor more deserving of intelligent discussion. Few topics attract such media coverage; the National Health Service is never far from the top of the political agenda; and most people regard good health – and access to first-class care when they fall ill – as supremely important. It is, therefore, regrettable that discussion of medicine – of medical science, of clinical practice, of the profession itself – is frequently ill-informed. Comment is often shallow, even when it is not riddled with errors of fact, interpretation or emphasis. Reactive, piecemeal and disconnected from the big picture, much analysis lacks historical perspective and ignores the complex reality of medical care.

Notwithstanding all the books, column inches, air-time and screentime devoted to it, therefore, the practice of medicine remains virtually invisible. Hippocratic Oaths, which contemplates the art of medicine from a broad perspective while not losing sight of the details, aims at making medicine more visible. This is worthwhile not only because scientific medicine is one of the greatest triumphs of humankind; but also because illness is potentially a mirror, albeit a dark one, in which we may see something of what we are, at the deepest level. Making medicine truly visible may cast some light on the greater mystery of what it is to be a human being. That mystery is the starting point of this book.

Medicine, objectively, has never been in better shape. Its scientific basis, the application of this science in clinical practice, the processes by which health care is delivered; the outcomes for patients, the accountability of professionals, and the way doctors and their patients interact with each other – all have improved enormously even during my thirty years as a practitioner. Yet the talk is all of doom and gloom: short memories have hidden the extraordinary advances of the last century. The danger is that endless predictions of crisis may become self-fulfilling by making the key roles of doctor and nurse deeply unattractive. This would be a disaster, given that further progress will require more, not less, medical and nursing time.

The curious dissociation between what medicine has achieved and the way in which it is perceived originates outside of medicine itself. While medical practice is continuously improving, it has not kept up with patients’ rising expectations. Many things are much better than they were, but few things are as good as people have been led to expect. Changes in patients’ expectations reflect changes in the world at large. What is more, there is a tension between the consumerist values of society and the values that have hitherto informed medicine at its best; values that have driven its gradual transformation from a system beleaguered by fraud, venality and abuse of power¹ to a genuinely caring profession whose practices are informed by biological science and underpinned by clinical evidence.

Hippocratic Oaths does not pretend be a comprehensive account of medicine or even of its current troubles. I have aimed at depth rather than breadth. I examine the institutions of medicine and their present discontents in a series of essays – in some cases prompted by particular events or personal experiences. The book is a triptych: the large middle section deals with present discontents. It is flanked by panels that deal, respectively, with the origins and the destination of the art of medicine.

Though many of its reflections are cast in an impersonal form and address matters of public interest, Hippocratic Oaths is deeply personal. I believe that medicine is in danger of being irreversibly corrupted. This threat comes not from within (where its values are struggling to survive) but from society at large. The most serious dangers emanate from those for whom the moral high ground is a platform for self-advancement, many of whom have never borne, or have been willing to bear, the responsibilities that weigh on the daily life of practitioners. The unthinking voices of those who have a shallow understanding of the real challenges of medicine (and an even shallower appreciation of its achievements) will make patient care worse not better. Their influence already threatens to bring about a disastrous revolution in the values and attitudes of health-care professionals: if we are not careful, the patientas-client will receive service-with-a-smile from a ‘customer-aware’ self-protecting doctor delivering strictly on contract. If the current debased public perception is not challenged, medicine may become the first blue-collar profession, delivered by supine, sessional functionaries. This will not serve the longer term interests of people who fall ill.

Everyone agrees that we need to rethink medicine; in particular its relationship to society at large. This book offers an introduction to that rethink. We need to take a long view and to unpeel the layers of second-order discussion that takes so much for granted and has hidden the reality of a deeply human, and humane, profession. Only on the basis of an appreciation of what has been achieved, and a better understanding of the ends, aims and ultimate limitations of medical care, shall we be able to begin an intelligent examination of the present discontents and the future path; and arrive at a clearer understanding of what might be expected of medicine and of those who deliver medical care.

This book is dedicated to two of the many admirable people I have worked with in my thirty-two years in the NHS. Mohendra Gonsalkorale has been a consultant colleague for sixteen years. His many patients and colleagues, including myself, have benefited from his energy, cheerfulness, clinical expertise and wisdom, moral support and conscientiousness. Bill Sang is a manager whose ability to keep the larger vision in view while attending to the small details has been an inspiration. It is such people who keep the NHS afloat despite the misguided interventions of those many ill-informed individuals who wish to ‘save it’. However, neither Mohendra nor Bill would agree with everything in the pages that follow: both would be more philosophical about many of the things that cause me to bite the carpet. But they share my passion for public service and for the supremely serious calling of medicine – a passion which, over the years, has prompted them to work all the hours God made and some He has not thought of yet.

Perhaps this book should have another dedicatee: the students of Manchester Medical School, which still attracts the best and brightest. It is upon such people that the future of medicine will rest. If their sense of medicine as a calling is not destroyed, they will be doing their best for sick people in the dark hours when the hostile critics of the profession are chattering away at their dinner parties or safely tucked up in bed.

PART ONE

Origins

Nor dread nor hope attend

A dying animal;

A man awaits his end

Dreading and hoping all;

Man has created death¹

From ‘Death’ by W.B. Yeats

A crushed beetle pedals the air for a while before expiring. A wounded snake slithers to a dark place and dies. A sick dog mopes, eats grass, vomits, and waits. A cat with a damaged paw licks it incessantly. Chimps are a little more sophisticated: they sometimes dab leaves on a bloody wound. This is as far as ‘animal medicine’ goes. If medicine is ‘the provision of special care to a sick individual by others’,² there are no examples in the animal kingdom. The closest that non-human creatures get to physicianly attention is picking ticks off each other’s backs.

William Osler’s ironical definition of man as ‘the medicine-taking animal’ is therefore justified inasmuch as it captures something distinctive about humans. It is, however, inaccurate for interesting reasons. First, taking medicine is only a recent characteristic of the species. While hominids started parting company from the beasts several million years ago, taking medicine might not have begun until 10,000 years ago. We cannot be sure of this, of course. The behaviour and institutions of our ancestors prior to the invention of writing can only be guessed at. Evidence about the beginning of medical care is bound to be tenuously inferential. For the taking of medicines is not just a matter of ingesting material of therapeutic benefit as when a dog eats grass. And this is the second reason for qualifying Osler’s assertion: there is a vast cultural hinterland to the popping of the most ordinary pill.

1

The Medicine-taking Animal: a Philosophical Overture

Medicine-taking has roots in many different quarters of individual and collective human consciousness. Swallowing a safe pill makes sense only in the context of a recognized system of knowledge and belief, which encompasses many things: the significance of the suffering that prompts the search for relief; the structure and function of the human body and the means by which they may be changed; and numerous sciences, such as organic chemistry, pharmacology and industrial chemistry. What is more, it is part of a tapestry of social arrangements ensuring the dissemination of expertise in the prescription and administration of medicines, involving the division and sub-division of labour, the development of institutions, the creation of numerous forms of material infrastructure, and networks of agreements based on trust or contracts. The least-considered therapeutic action draws on fathomless aquifers of implicit knowledge, understanding, custom and practice.

In the next chapter, I will sketch the long journey that led us to this point where humanity began to pop its pills. For the present, I want to focus on the beginning of the journey. While whatever it was that made us takers of medicine sits at the heart of the difference between ourselves and animals, the science which gives scientific medicine its efficacy comes from seeing sick persons as if they were stricken animals. There is therefore a paradox: as medicine-takers we are not organisms but complex selves; but the effectiveness of the medicine we take is owed to a view of ourselves as organisms.¹ If we are to place medicine and its present discontents in perspective, and understand both its achievements and its limitations, we must bear this paradox in mind: medicine’s triumphs are rooted in a biological understanding of sickness while the science, the art, the humanity of medical care is a supreme expression of the distance of humans from their biology.

Humane, scientific medicine is a (very) recent manifestation of the special nature of a creature who, uniquely among sentient beings, has knowledge. Knowledge – articulated or propositional awareness formulated into factual information and abstract general principles – is utterly different from the sentience that all conscious animals (including human beings) possess. Medical expertise is a peculiar development of knowledge: it is directed upon the body of the knower, who is in the grip of the least mediated form of awareness, namely bodily suffering. It is hardly surprising, then, that truly scientific medicine is less than a hundred years old. It has taken a long time for ‘the knowing animal’ to look dispassionately at his own body, the place where knowledge first awoke.

No one, I expect, will count it a revelation that the practice of medicine is a manifestation of the special consciousness of human beings; that the reason sick ducks don’t go to quacks is that they have a fundamentally different relationship to the world in which they live. This special consciousness, however, is worth examining because it contains not only the seeds of medicine but also the origin of the tensions that have always beset medical practice.²

At the root of the innumerable differences between animals that merely live (and suffer illness) and human beings who lead their lives (and, for example, seek help from doctors) is a difference in their relationship to their own bodies. The animal lives its body; the human being not only lives its body but also explicitly and deliberately utilizes it, possesses it and exists it. (The awkward transitive is intended to reflect the active expropriation of the human body by its ‘owner’.) This difference originates in the emergence, several million years ago, of the full-blown hand which acquired the status of a tool. This proto-tool has a wider instrumentalizing effect: it makes both the hominid’s body and the surrounding world into a potential tool kit. Several other consequences follow. The hand tool, which instrumentalizes the body and its world, awakens not only a sense of agency but also suffuses the organism with a sense of ‘am’. The consciousness of the organism is transformed into a subject: the subject is ‘within’ the body, not entirely merged with it (as in the case of a sentient animal) but, in a sense, ‘owning’, ‘having’, ‘possessing’, ‘utilizing’ it. As subjects, we experience our bodies as objects as well as suffering them as more or less invisible destiny. This is not to imply that we are separate from our bodies as Descartes imagined. Human consciousness can never be entirely liberated from the flesh; on the contrary, humans assume their bodies, or parts of them, as themselves and use other parts of their bodies to serve their purposes as tools, as means to action.

Within the human body there are many layers of subjects and objects, of agents and tools. These primordial corporeal tools are, of course, supplemented by extra-corporeal tools of ever greater complexity, requisitioned for a variety of purposes. The proto-tool that is the hand instrumentalizes not only the body but the world outside of it. As the philosopher Martin Heidegger said, the world with which the human subject engages in busy everyday life is, to a greater or lesser degree, a nexus of tools or of potential tools – what he called ‘the ready-to-hand’.³

The sense that those tools are ‘objects’, that they have properties in themselves that are not entirely dissolved into their relationships with the user, lies at the root of science. The fundamental intuition of science is that the things that lie around us are only partially open to direct scrutiny: they have something ‘in themselves’ that is beyond the direct deliverances of our senses; and there is, therefore, more sense to be made, more to be known. What John Dewey called the ‘active uncertainty’ of human enquiry – systematized in the multifarious enterprises of science – owes its origin to this feeling that objects have a reality beyond their immediate appearance.

The world experienced by the merely sentient animal has no objects (objects in themselves) because the creature is not fully developed as a subject. Consciousness of self – which is not present, except perhaps fleetingly, in other animals⁴ – makes apparent to the human creature the incomplete transparency of its own body. A human being’s encounter with its own body as an object lies at the origin of object knowledge: the intuition of one’s own body as being only partially available to oneself, intensified by an increasing awareness of oneself as a subject, awakens the uniquely human sense of living in a world comprised of objects of incomplete scrutability. Incomplete identification with one’s own body lies at the basis of the intuition that eventually gives rise to objective or factual knowledge.

As knowledge grows, its relationship to sense experience becomes less direct. This is in part because knowledge is a collective or collectivized form of awareness: whereas sentience is solitary, knowledge is always actually or potentially shared. The collectivization of awareness is most obviously underpinned by language. Language, however, is a relative newcomer: the socialization of awareness, and the transformation of the spatial cohabitation of beasts into the more complex modes of togetherness of human societies, was originally mediated by the tools that were suggested by, or extensions of, the proto-tool that is the hand.

There are obvious ways in which tools might facilitate socialization, indeed collectivization, of human consciousness; for example, they are held in common and they are publicly visible. More fundamentally, they symbolize the needs they serve, making problems and solutions visible in shared space. More fundamentally still, they embody and signify those needs in a generalized way. Tools are consequently proto-linguistic; forerunners (by several million years) of the signs of language. It is no coincidence that the demands made on the brain by tool use are similar to those that are required for language.

This philosophical excursus is meant to underline the wide, deep gap between man, the medicine-taking non-animal and non-medicine-taking animals, between leaf-dabbing chimps and pill-popping humans. While medicine has much in common with many other complex human practices, it is rather special. Although the body apprehended by the human subject may have been the primordial object, or the primordial bearer of object-sense, treating the body itself as an object among objects, an object like any other – the necessary precursor of systematic medicine – was a late development. The collectivization and intellectualization of human consciousness was well advanced before there arose the fully developed notion of the human body as an object – and subsequently as an object of care to which abstract knowledge might be applied.

The transition from sentience to self-awareness, from sense experience to object knowledge, is the ultimate source of the medical gaze in which our bodies are objects of knowledgeable care. It seems doubtful that any animal ‘worries’ about falling ill or interprets abnormal sensations or bodily failings, with or without an evident external cause, as ‘symptoms’. Animal suffering is present experience and not a sign of possible future experiences, or future bodily states. Conceiving of her body as a vulnerable organism, with an endangered future as well as an uncomfortable present, requires an individual human being to be at once outside of her body and identified with it; to be its subject and at the same time see it objectively; to suffer it as her being and know it as an object.

This is what lies at the bottom of Yeats’ seemingly paradoxical assertion that ‘Man created death’. The animal who created death also invented disease, labelling decay, or the heightened possibility of it, with the names of sicknesses, and invented medicine to postpone the one and ward off and treat the other.

The cognitive pre-history of medicine is, of course, unwritten. The written record shows how long and difficult was the subsequent journey to scientific medicine. We shall examine this journey very briefly in the next chapter, with the primary purpose of demonstrating that it was by no means inevitable that it should have reached its present remarkable destination. If the phenomenon of human knowledge is ‘the greatest miracle in the universe’,⁵ medical knowledge – pre-scientific and scientific – is one of the most extraordinary manifestations of that great miracle. It required much cognitive ‘self-overcoming’ on the part of humanity.

2

The Miracle of Scientific Medicine

These conquests have been made possible only by a never-ending struggle against entrenched error, and by an unflagging recognition that the accepted methods and philosophical principles underlying basic research must be constantly revised… Disease is as old as life, but the science of medicine is still young.

Jean Starobinski¹

The long journey to biomedical science

I have described some conditions necessary for the emergence of Homo therapeuticus. They are not, of course, sufficient in themselves nor are they specific to medicine. Indeed, the process of placing medicine on an objective basis is not complete even today.² While we do not know how recent medicine-taking is, we do know that scientific therapeutics is little more than a century old.

It is hardly surprising that the objective inquiries of Homo scientificus should have been directed rather late to the human body – to the body of the inquirer. Since it is out of our special relationship to our bodies that knowledge has grown, the pursuit of objective knowledge about the body and its illnesses requires a return to the very place where knowledge first awoke. Somewhat less esoterically, we may anticipate that the body ‘we look out of ’ should be the kind of object we are most likely to ‘look past’. It is something that we are as well as something we know or use; mired in subjectivity, it was a late focus for systematic objective inquiry. Humans found it easier to assume an objective attitude towards the stars than towards their own inner organs: scientific astronomy antedated scientific cardiology by thousands of years.

Scientific medicine required the assumption of an attitude to the human body similar to that which physical scientists had adopted towards other objects in the world: a ‘depersonalization’ and ultimately ‘dehumanization’ of the human body. (None of these terms is meant pejoratively: they are all necessary conditions of effective – humane and non-fraudulent – medical care.) Progress was neither smooth nor swift. Even less was it inevitable. ‘Physic’ had to extricate itself from a multitude of pre-scientific world-views. Other sciences had had to negotiate such obstacles: the heliocentric theory and the notion of the elliptical orbits of the planets, for example, faced opposition from theologically based ideas about the proper order of things, and how, consequently, God would order them. They had to displace more intuitively attractive notions of the principles governing the movement of objects. In the case of knowledge of the body and its illnesses, resistance to objective understanding was particularly intimate and adherent. The brief observations that follow are not intended even to outline all the steps leading to the forms of medicine we know today. Their purpose is solely to emphasize what had to be overcome during the passage from the first therapeutic intuitions to scientific practice.

In the earliest recorded phase of medicine, sickness was attributed to ill will, malevolent spirits, sorcery, witchcraft and diabolical and divine interventions. Illness and recovery were interpreted in providential and supernatural terms.³ Illness was about persons rather than bodies and was often seen as punishment.

The secular world-views postulated in early Greek science opened up the possibility of a naturalistic understanding of illness. ‘Natural causation theories which view illness as a result of ordinary activities that have gone wrong – for example the effects of climate, hunger, fatigue, accidents, wounds, or parasites’⁴ began to displace ‘personal or supernatural causation beliefs, which regarded illness as harm wreaked by a human or superhuman agency’. The so-called ‘sacred disease’ – epilepsy – was nothing of the kind. It was caused by phlegm blocking the airways and the convulsions were the body’s attempt to clear the blockage.⁵ Crucially, the body was seen to be subject to the same laws as the world around it: it was a piece of nature. The theory of the four humours (blood, phlegm, choler and black bile), which corresponded directly with the four elements of nature (fire, water, air and earth), and dominated thinking from Hippocrates in the fifth century BCE to Galen in the second century CE, expressed this naturalistic approach. The aim of the doctor was to restore the balance of humours when it was disturbed. Analogous ideas held sway in Indian and traditional Chinese medicine.

The replacement of transcendental by naturalistic (though still intuitive) ideas of illness was an enormous step. It did not, however, bring real progress, except in so far as it removed a justification for inhumane attitudes to sick people. The step from intuitive theories of illness to science-based ones was as great as that from transcendental to naturalistic accounts of disease. It built on the Hippocratic denial of the ‘sacred’ nature of disease – and of the body that suffered from it – and allowed a new conception of illness, upon which European medicine was founded. In the sixteenth century we see this new conception active in the pursuit of the anatomical, physiological and pathological knowledge which eventually led to European medicine becoming, on account of its singular efficacy, world medicine.

Two events are crucial: the publication of Vesalius’ great anatomical textbook, De Humani Corporis Fabrica (1543) and William Harvey’s De Motu Cordis (1628). Both authors described how the body looked when exposed to the unprejudiced, undazzled gaze, what its structure was and how it, or part of it, might function. Cartesian dualism, which separated the spiritual from the natural in the human person, endorsed the mechanistic view of the body that was implicit in the work of proto-biomedical scientists such as Vesalius and Harvey. The idea of the body as a carnal machine emerged as an intellectual framework for a systematic investigation of its component mechanisms. The development of physics and chemistry from the seventeenth century onwards furnished the concepts, insights and facts necessary to translate general ideas about bodily mechanisms into specific accounts of how various parts – organs, systems, cellular components – worked. (The verb is itself illuminating.) Metaphors from the technology of the time – mechanical, hydrodynamic, and later electrical – fed into the modelling process.

This desacralization, which permitted the body to be examined as a set of mechanisms and understood illness in terms of disorders of those mechanisms, was supported by another, not entirely distinct, intellectual trend: that of de-animation. Underpinning de-animation was the discrediting of vitalism – the assumption that living tissues and nonliving matter belonged to irreducibly different orders of being. The demonstration that organic substances, such as urea (the end-product of protein metabolism in many species), which was derived from living creatures, could also be synthesized out of inorganic substances was a crucial step in the development of organic chemistry (a revealing hybrid) and eventually its mighty offshoot, biochemistry. The examination of non-living components of living tissues (isolated organs, cells, individual chemical substances) emerged as the high road to understanding health and disease.

While it was accepted long before Darwin that human health and disease could be illuminated by studies and experiments performed on animals, The Origin of Species provided blanket justification, if it was needed, of extrapolation from animals to humans. Since Homo sapiens was the product of the same processes as other species, there could be no principled limit to the applicability of animal research to human beings. While there were differences between species, similarities were more important. Biomedical sciences, which could progress faster on the basis of animal experiments, envisaged human beings as organisms like any other. The physiological or biochemical parameters that signified sickness or health were similar in monkeys and monarchs.

The sick body, a damaged carnal machine operating in accordance with the laws of physics and chemistry, is a far cry from the man or woman punished by the gods for some private peccadillo or ancestral wrong. Scientific medicine minimized the personal element in illness: disease was a manifestation of general biological processes. Illness, which could ultimately be understood in biochemical, chemical or even physical terms, was not only impersonal but in a sense inanimate. The component mechanisms were remote from the living, breathing, animate whole organism, and even more remote from the suffering endured by the whole person.

Each of these steps – desacralization, de-animation, dehumanization, and depersonalization of illness – which of course overlapped both conceptually and temporally, represents a huge collective leap of understanding. The consequences have been entirely benign: not only treatments that are effective to a degree unimaginable by our predecessors but also humanization of medical care. Priestly authorities, supposed representatives of vast invisible forces, and bearers of terror, were banished from the sickbed. Gratuitous cruelty inflicted by those pretending to intercede on behalf of the sick, often justified by the ill person’s supposed responsibility for her illness, had no place in scientific medicine. Healing (notwithstanding the complaints that will be discussed in later chapters) was separated from amorphous or pervasive power – the power of priests and shamans and of the social order they support. The obverse of this was the increasing accountability of healers – a trend which led to the establishment of regulatory authorities which policed the behaviour of healers and monitored their procedures and outcomes against collectively agreed professional and ethical standards.

One of the healthiest features of scientific medicine was the separation in time between the acquisition of knowledge (of the body and its ailments) and the ability to use such knowledge to effect cures. Biomedical science did not at once translate into science-based medical practice. It was recognized that true science was full of disappointments while only charlatans hit the jackpot every time. The disappointments were salutary: they undermined the intuitive certainties that had arrested progress. Uncertainty as to whether even robust knowledge would lead to effective treatments dissolved the priestly ‘knowledge-healer-authority’ complex. There was also disciplinary separation: the rise of the non-clinical biomedical scientist meant that those who generated the knowledge were not necessarily those who applied it.

Medicine, as Jean Starobinski pointed out, is still a young science. The dissolution of the ‘knowledge-healer-authority’ complex is not yet complete. Even now, effective practitioners have something of the charismatic healer mixed with the scientific doctor. A doctor brings personality as well as knowledge to the bedside. The rise of scientific medicine, however, put the instilling of confidence on the basis of personal authority in its proper place. Decreasing personal authority is healthy, and unique to modern Western medicine.

Another, equally profound, consequence of the rise of scientific medicine was the increasing distance between knowledge of the body and of sickness and intuitive or common-sense understanding of disease. Science, as Lewis Wolpert has pointed out, is deeply counterintuitive, to the point of being unnatural.⁶ To import that ‘unnatural’ standpoint into the body, where knowledge and understanding began, was an extraordinary achievement. A striking example is the understanding of the circulation of the blood. The beating of the heart is something we all experience; whereas the surprising fact that the blood circulates around the arteries and veins and through the capillaries had to be realized by an individual of genius. For less than a ten-thousandth part of the millions of years that hominids have been aware of the beating of their hearts have they known that the blood that is set in motion by these pulsations is circulating around their bodies.

From modest counter-intuitive beginnings such as this, a vast continent of knowledge about the body and its blood has grown. The dependence of my well-being upon, for example, my blood pressure or the level of potassium in my serum will not be something I can perceive by means of introspection. Biomedical science knows things about me in general that I could not directly intuit. ‘The heart’, Pascal said, ‘has reasons that reason knows not.’ Scientific medicine has taught us that the body has mechanisms that the embodied know not. It undermines both personal and socially mediated preconceptions.

The discrediting of common sense as a guide to understanding ill-health has profound connections with one of the most impressive and powerful engines of knowledge acquisition: scepticism and a willingness to live with, indeed to prolong, uncertainty. The sceptical physician is no less passionate about bringing the quest for cures to a successful conclusion than the traditional healer, but he is able to separate his passion from his procedures and his conclusions. This preparedness to expose ideas and claims to objective testing gradually permeated clinical medicine. (Though, as we shall see, only recently has it become ubiquitous.) Nietzsche’s aphorism that ‘convictions are greater enemies of truth than lies’ identifies by default the drivers of true progress. At its edges, scientific medicine is in constant quarrel with itself. Unlike traditional medicine, it does not take the antiquity of its ideas as independent evidence of their truth and efficacy; on the contrary, every assumption and assertion is to be tested and re-tested using ever more ingenious methodologies. Its cumulative body of reliable knowledge is the product of permanent civil war.

While scientific medicine had to advance in the teeth of prior (theological and other) convictions, it had also to overturn immediate (‘common sense’) and mediated (‘cultural’) intuitions about the nature of health and disease. What is more, these intuitions were often supported by systems of thought, themselves backed up by institutions with authority, power and menaces, and by the less organized forces of deception and self-deception. On top of all this, it had to insert longer and longer chains of argument, knowledge, and expertise between the body and its care for itself. Medical science has transformed the self-consciousness of the hominid body into a vast corpus of mediated understanding. Let me illustrate this with a personal example.

A little while back, I came to believe that I had dyspepsia due either to a stomach ulcer or to a reflux of acid into my oesophagus. I arrived at this seemingly straightforward conclusion as a result of accessing a body of knowledge and understanding that had taken many centuries to assemble. The first intimation that this might be my problem was noticing that my recurrent discomfort had a certain pattern. I was able to match this pattern against a variety of conditions whose naming has been the outcome of a vast effort of conceptualization and empirical research. My interrupted interior monologue as to what the pain might mean drew on facts and concepts emerging out of the cooperative effort of many thousands of people scattered over widely disparate times and places.

In order to test my diagnosis, I undertook a therapeutic trial of lansoprazole, a drug for dyspepsia. This seemingly simple act was not, of course, at all simple. Inserting the pill into my mouth was an act whose rationale drew on many disparate realms of intellectual achievement and human endeavour and indirectly involved many institutions, professions and trades. The manufacture, packaging and transport of the pills (which, I see, have been imported from Italy) engage many kinds of expertise, each of which incorporates and presupposes other forms of expertise. Some of these lie outside of strictly medical knowledge: the technologies of invoicing, lorry manufacture, the synthesis of plastic capsules, automated packaging, quality control in mass production, all meet in this tablet. James Buchan reflects that a banknote is ‘an outcrop of some vast mountain of social arrangements, rather as the little peaks called nunataks that I later marvelled at in Antarctica, are the tips of Everest buried under miles of ice’.⁷ This applies a thousand times over to the capsule that I swallowed in the hope of curing my discomfort. While it is true of any manufactured item, as Adam Smith pointed out,⁸ the distinctive miracle of this example of science-based technology deserves more attention.

Lansoprazole belongs to a class of drugs called ‘proton pump inhibitors’. They prevent the active transport of hydrogen ions (that is to say, atoms of hydrogen minus their electrons) across the semi-permeable membrane that constitutes the lining of some of the cells that coat the stomach wall. The point of proton pump inhibition is to switch off the secretion of hydrochloric acid. While hydrochloric acid has a role in creating an environment favourable to the first stage of digestion of food, it may also attack the lining of the very organ from which it is secreted, causing peptic ulcers, or alternatively wash up into the oesophagus, causing reflux oesophagitis. Each of these terms – proton, active transport, semi-permeable membrane, hydrochloric acid, digestion, reflux oesophagitis – is a node in a web of countless concepts, and the product of discussion spread over vast numbers of papers and presented in numerous scientific meetings and letters and corridor conversations. The pill is a meeting point of many hundreds of nunataks, the tips of Everests of discovery and their technological application.

In order to appreciate the complexity of the scientific discourse I have glanced at, consider some of the terms I have employed. For example, the notion of ‘a proton’ comes from fundamental physics; the concept of a semi-permeable membrane from physical chemistry; that of active transport comes from biochemistry; of acid secretion from physiology (and some famous experiments); and the esoteric idea of proton pump inhibition from the pharmacological application of biochemistry. I have not even considered the many layers of the drug delivery system which ensure that it arrives in the right quantity and in good condition at the places in my body where it does its work. Nor have I examined the dovetailing of the different components of the system – the capsule, the blister pack, the cardboard box, the pharmacist, the prescription, the educational institutions that enabled me to prescribe the right tablet – necessary to present the drug to my acid-scorched mucosa.

Scientific medicine delivers – life expectancy

While it is entirely proper to be impressed by the science, technology and sociology of