Imperial College School of Medicine, Dovehouse Street, London SW3 6LY
The labourers' strength has failed, and there is too much rubble;
shall never be able to rebuild the wall by ourselves. Nehemiah 4:10.
Everything is possible for God. Mark 10:27.
Address at the London Medical Society May 1999
In 1993, an international congress was held in London with the thought-provoking title Tuberculosis - Back to the Future1. At that congress, speaker after speaker came out with horrifying accounts of the devastating effects that tuberculosis was having on the health of the human race. One third of the world's population was infected with the tubercle bacillus: each year eight million developed the disease and three million died of it. So alarming were these accounts that, at that congress, the World Health Organization took the unprecedented step of declaring tuberculosis a Global Emergency. Yet, since that declaration six years ago, the incidence of this killer disease has continued to rise relentlessly throughout the world.
This might be understandable if there was no cure, or only a very ineffective one, or if the cost of the cure put it out of reach of all but a privileged few. But none of these apply: the cure for tuberculosis is not only one of the most effective of all cures for a life-threatening disease but it is among the most cost-effective. Investment in tuberculosis control costs a mere 60 pence for each year of healthy human life saved.2 This therapy, which in a past age would have been hailed as miraculous, evolved as a result of numerous extensive laboratory studies and field trials and it a glowing example of what is nowadays termed 'evidence-based medicine'; namely medical practice based on evidence of efficacy obtained from carefully controlled clinical trials. Yet the dreadful paradox is that, despite the well-proven efficacy of the available therapy, there will be more new cases of tuberculosis in 1999 than in any previous year of human history and the disease will be responsible for a quarter of preventable adult deaths.
The first edition of the British Journal of Tuberculosis carried a paper entitled Civilisation and Tuberculosis which opened with the statement "The tubercle bacillus is an index by inversion of the real progress of the human race. By it the claim of civilisation to dominate human life may fairly be judged".3 The paper goes on to state that tuberculosis claims every seventh life and stresses the close link between this disease and poverty. "Society's 'submerged strata', which cannot free themselves from the grip of pestilent environment - the darkness, wretchedness, and starvation upon which the saprophytic bacillus propagates its teeming millions - yield victims far in excess of those claimed by all other infections put together." This is, perhaps understandable as this paper was published in 1907 - 92 years ago. Yet have things changed? Today, tuberculosis likewise claims 1 in 7 adult lives and it causes more morbidity and mortality than any other infectious disease.
Why has the situation not changed dramatically? In a recent article in the British Medical Journal, entitled Tuberculosis: story of medical failure,4 Chris Holme, a journalist, referred to the strange paradox that although we have the wonder drugs we have miserably failed to control this disease. His diagnosis is that modern medicine is in an ivory tower, divorced from reality. He raises that prevailing theme of 'evidence-based medicine' which, as already mentioned, is medical practice based on the results of carefully controlled clinical trials conducted according to a set of rules known as 'good clinical practice' (but is really no more than good form-filling) and analysed by established statistical methods. Holme voices concern that one reason for the current obsession with evidence-based medicine is the need to conduct controlled clinical trials for the purpose of furthering research careers and filling the estimated 22,000 biomedical journals. He then adds the challenging statement "Something has got lost along the way in the quest for the holy grail of therapeutic paradigm: a wider sense of purpose and reality."
This is not the first time in history that a claim has been made that medicine is locked in an ivory tower and divorced from reality. During the late 15th century, at the beginning of the Renaissance, there was great enthusiasm for 'ancient truths'. In medicine, Galen and Avicenna, who held that disease arose internally as a result of imbalances in the 'humours', were accorded almost infallible status. The same reliance on ancient wisdom was evident in the natural sciences and in theology but, fortunately, three great original thinkers arose early in the 16th century - Luther, Copernicus and Paracelsus.
Paracelsus, whose real name was Theoprastus Bombastus von Hohenheim, is regarded by many as the father of rational medicine based on observation and experiment rather than reference to 'authority'. An aggressive and forthright man - the word 'bombastic' is derived from his middle name - his definitive act of rebellion against establishment was to cast the University of Basle's precious copy of Avicenna's Canon on to the bonfire on the Feast of St. John on Midsummer's Day, 1527. Not a good career move - he was driven out of Basle and ended his days as a wanderer - but this defiant act heralded the era of modern medicine. One wonders whether Paracelsus drew inspiration for his defiant stance from Martin Luther who, in Wittenberg, just seven years previously (in 1520), had publicly burned the papal bull that denounced the Reformation. Indeed, Paracelsus has been called 'the Luther of medicine'.
What would Paracelsus say to us today? Would I be too far off the mark if I were to suggest that the great ill of modern medical science is that we have returned to the pre-Paracelsian days of rigidity and authority? With certain glorious exceptions, we appear to be living in an age of increasing fundamentalism, not just within religion but within the biosciences, medicine, philosophy, economics and, with the notable exception of cosmology, almost anywhere one chooses to look. Am I alone in noticing a covert but widespread tendency to encapsulate perceived truth and wisdom into rigid, unshakeable and unquestionable dogmas?
There has, as most serious scientists would admit, been no just cause for a conflict between religion and science since the vindication of Galileo delineated the boundaries between these two human activities. What now superficially appears to be a conflict between religion and science is usually a rather artless clash between different forms of fundamentalism.
The principal types of conflict that we are currently witnessing are actually between rationalism and irrationalism, although these terms are not easily defined. Sir Karl Popper, in The Open Society and its Enemies, suggests that rationalism is an attitude of readiness to listen to critical arguments and to learn from experience and is thus an attitude of admitting that 'I may be wrong and you may be right, and by an effort, we may get nearer to the truth'.5 Importantly, Popper does not equate rationality with intellectual gifts and states that "Clever men (and, presumably, also women) may be very unreasonable; they may cling to their prejudices and not expect to hear anything worth while from others". Don't we all know academics (and clergy!) just like that? Intriguingly, Popper is careful to distinguish between cleverness and creativity, adding that "Creativeness is an entirely irrational, a mystical faculty ...'.
One reason why 'clever' people may be more unreasonable than the average person on the Clapham omnibus is that they are more capable of developing elaborate mental constructs and devising arguments and experiments to reinforce them. Edward de Bono, of lateral thinking fame, has applied the phrase 'logic bubbles' to internally consistent and often very convincing systems of thought but which differ fundamentally from equally internally consistent systems developed by other people. Goethe arrived at the same conclusion: " When the progress of a science comes to a standstill despite the best efforts of many active researchers, the fault usually lies in a certain habitual way of looking at things, to which the majority will acquiesce without further ado, and from which even thinking people tend to extricate themselves only with great difficulty".
In order to sustain a logic bubble, one must have belief that its truth can be upheld by what is within that system. Common sense shows that this is an illogical circular argument but it required the German philosopher Kurt Gödel to demonstrate mathematically that the credibility of any logical system of thought must be determined in relation to something outside. This, of course, makes any system self-transcending because the 'outside' something used to verify the system then becomes part of the system, and so on possibly ad infinitum.
I would suggest that the pressures of modern academic life are putting us in serious danger of losing the ability to look outside our various spheres of reference. Albert Einstein wrote that "Everything that is really great and inspiring is created by the individual who can work in freedom". But how free are scientists today? The very real pressures on them to emerge as authorities or 'experts', not to mention their career prospects, must inevitably restrict their breadth of interest and their willingness to challenge the cherished axioms of their seniors. In addition, the incredible success of scientists, especially over the last few decades, may well have contributed to mental inflexibility. In the face of such stunning advances in so many disciplines, it seems almost sacrilegious to raise doubts concerning major issues.
Thus, for example, the philosopher Mary Midgley recently stated that "Science has such prestige that other truths are not accepted", a sentiment echoed by Simone Crawley: "The success of scientists has made them as arrogant and inflexible as religious fundamentalists", and by Jon Turney's tongue-in-cheek remark that "Some already have their theories of everything. Evolution by natural selection is the grand unified theory of biology, and is unchallengeable."
An extreme example of the arrogance generated by such scientific fundamentalism comes from Richard Dawkins' book, The Selfish Gene: "We no longer have to resort to superstition when faced with deep problems: Is there a meaning to life? What are we for? What is man? When you are actually challenged to think of pre-Darwinian answers to the questions, can you, as a matter of fact, think of any that are not now worthless except for their (considerable) historical interest? There is such a thing as being just plain wrong, and that is what, before 1859, all answers to these questions were".
Infallibility is, in fact, contrary to the whole fabric of real science. The scientific method, eloquently portrayed by Karl Popper, whom I have already mentioned, consists of looking at the available information, formulating hypotheses on the basis of that information and devising experiments to attempt to refute those hypotheses. To be 'scientific', any statement must therefore be open to falsification. Thus, according to Popper, scientists can never formulate any infallible and final statement concerning a natural phenomenon and we may therefore often be much further from the truth than we believe we are. Though agreeing with Popper's analysis of the scientific method, Sir Peter Medawar, another great philosopher of science, noted that, in practice, scientists work in a much more ragged and undisciplined manner. Medawar even claimed that many scientific publications are fraudulent because the hypotheses set out in the introductions are derived retrospectively from the results obtained and are thus really the hypotheses for the next series of studies. Certainly, scientists often seem more concerned with the defence and reinforcement of their hypotheses than with attempting to test them to destruction.
Despite the writings of thinkers such as Popper and Medawar, the philosophical trend known as 'Modernism' has led to the widely held belief, and it is only a belief, that scientific descriptions of reality are the only credible ones, implying that truth is not to be found in other disciplines. This fundamentalist belief system has been termed 'scientism'. Medicine is certainly not above such beliefs and in a thought-provoking paper in the Journal of the Royal Society of Medicine entitled Medical scientism: good practice or fatal error, Martyn Leggett warned of the growth of 'medical scientism' which he defined as 'an approach to medical practice that regards the scientific understanding of the disease as the only relevant issue, whilst ignoring any other factors'.6 In this context, Leggett notes that scientism implies that there is no reality beyond the material world but adds that the reality of the scientist can be deceptive. He cites a comment made by Lord Cherwell in 1936 that scientists create models to explain experimental results but their fatal error is to believe that the model is the reality.
The question that we now need to address is whether the anti-intellectual trend of scientism belongs purely to the ivory tower of academia or whether it has widespread and practical consequences. I would suggest that it has had, and is having, profound detrimental effects on both medical science and medical practice.
The first detrimental effect of scientism is its increasing influence on what science is done and how it is published. This effect stems from the belief that the performance of scientists can be numerically quantified. Clearly, universities cannot afford to retain people whose work is just plain bad or outmoded, but ways of assessing performance can aspire to ludicrous levels, such as the discipline of 'scientometry' in which academic performance is measured by the number of published papers and the number of times these papers are subsequently cited. The academics' response to this has been the so-called 'salami syndrome'; namely, the publishing of a set of data in many small papers with extensive cross-citing, rather than in a single definitive paper - and the inclusion of numerous friends and colleagues in the list of authors, even if their input had been minimal.
Such 'scientometry' forms the basis of the Research Assessment Exercise, held every four years, on which funding for universities is based. Understandably, there is an enormous amount of effort to get as high a score as possible but this may not lead to good science. On the contrary, there is great pressure on academics to do the type of research that will attract funding and generate the type of work that will be accepted by key journals with high citation indices. Thus the scientific agenda is increasingly set by university administrators, funding bodies and journal editors.
Closely linked to this is a disincentive to do imaginative and innovative work as this may be too original and challenging to attract funding and to generate a steady stream of papers that are readily accepted for publication. In addition, those who challenge the axiom and pursue their researches into novel and controversial territories may - and I speak from personal experience - come up against a very real hostility, born of fear that their 'maverick' ideas may well have adverse effects on the name and reputation of their College. One of the Pro-Rectors of Imperial College has lamented that preservation of the status quo is high in the agenda of universities.7
The second detrimental effect of scientism is the uncritical devotion to the golden calf of evidence-based medicine. Now we need to tread very carefully here. No one in their senses would doubt that it is in everyone's interest that therapeutic interventions are safe, effective and cost-effective and that the very real power of scientific investigation should address these interests. Unfortunately, the principles of the controlled clinical trial that underpin the entire edifice of evidence-based medicine have, metaphorically speaking, been carved on tablets of stone and anyone criticising the axioms and dogmas are in danger of being accused of denigrating the very foundations of scientific medicine. In a paper entitled The limitations of evidence, Sir Douglas Black was clearly aware of this danger and thus wrote "My intention in this paper is not to disparage evidence-based medicine, but to deprecate any attempt to equate it with the whole of medicine".8 He adds that the original advocates of controlled trials were fully aware of their limitations but that prophets are not in control of their disciples "who may deny the value of medical thought and experience in situations where a categorical evidence base is still lacking".
Even the concept of a 'categorical evidence base' is open to serious question as the underlying statistical methods are poorly understood, if understood at all, by most medical researchers and are therefore unquestionably and uncritically applied. In fact, the statistical foundations of evidence-based medicine have been seriously criticised in, for example, a Guardian article entitled Silly science and, more recently and more formally, in an article by Nick Lane in the Journal of the Royal Society of Medicine entitled Common sense, nonsense and statistics.9 In addition to the fundamental questions surrounding the validity of the statistical methods themselves, by their very nature their application reduces the exceedingly complex and highly variable individual human patient to a mere statistic. The wielding of Occam's razor may well generate data suitable for publication but may also slice off the disease process from the whole human being.
Thus, in his paper on medical scientism, Leggett warns of the increasing dissociation between patient and disease brought about by the methods of modern medicine. As clinical trials aim to rule out variation, the results implicitly contain the rider 'other factors being equal', but human beings are not equal! The ugly daughters of evidence-based medicine are 'managed care' and 'clinical governance' which, in their extreme but not improbable forms, will set out a series of diagnostic and therapeutic algorithms to be followed exactly in respect to a given clinical situation. Any doctor deviating from the protocol out of a genuine desire to address a patient's individual needs will risk disciplinary action and even litigation. In a thought-provoking book entitled Do we still need doctors?, John Lantos, an American paediatrician, tells of a young girl with a range of physical, psychological and social problems.10 He follows the managed care protocol to the letter - nobody could fault him if she died - but he confesses that the system ensured that he had totally failed to address her profound underlying needs which were major contributing factors to her illness. He adds that there were features in this girl's case that nobody wanted to see or understand or acknowledge. Elsewhere in this profound book, Lantos remarks that there is a "philosophic position from within medicine that doctors ought to be scientific and that medicine ought to be rational. The irony is that the rationality of medical science is largely superficial or illusory, cloaking a series of value choices that are apparent to philosophers, sociologists, and novelists (among others) but that are ignored or simply not noticed within the insular and isolated world of medical education and policy".
This leads to one of the dilemmas of modern medicine. Despite the undeniably wonderful advances achieved by the application of science to medicine there is, paradoxically, an ever increasing public call for poorly validated complementary therapies. As one anonymous doctor recently expressed it "People are turning away from modern medicine not because it is ineffective but because it is inhuman." This is a grave indictment of current medical practice and should cause us ask very serious questions concerning the foundations of medicine and the life sciences and the limitations of the scientific method to address many health issues.
Wittgenstein realised the limitations of the scientific method and asserted that "we feel that even when all scientific questions have been answered, the questions of life remain unanswered." An anonymous author wrote "The catastrophic and progressive sundering of questions of science from questions of spirituality and religion in the 17th and 18th centuries has left the West exposed not only to the scurrilous recrudescence of superstitious mania and manipulation, but to the even more damaging phenomenon of a fragmentation of reality.
In fact, although most medical researchers and practitioners are probably barely aware of it, the bastions of modernism have been breached by post-modernism, which rejects absolute truth and holds that everything is relative. But post-modernism itself is crumbling because it simply doesn't work - it is contrary to all that we feel. Look at the post-modern 'Sea of Faith' movement which denied the reality of God and reduced Him to a mere linguistic construct. That movement really went out with the tide or, more likely, drowned in the returning tide. Post-modernism has not just led to a welcome collapse of secular modernism but, through its intrinsic inadequacy, to a move to what has been called the post-secular society; namely, one which has stopped pretending that spirituality is an epiphenomenon. In an article by Nicholas Beale on the Starcourse website, the key ingredients of post-secular society are listed as the collapse of secular societies (notably communism), the bankruptcy of materialism, the increasing observer-awareness in physics and the increasingly spiritual awareness in art, literature, music and philosophy. Deepak Chopra has written that "We are in the midst of the climacteric overthrow of the superstition of materialism".
May I suggest, however, that we await another key ingredient - post-Millennialism. The Millennium, with its ill-conceived dome and other trappings, is what could be called an 'event horizon'. We have all experienced event horizons, like preparing for a long visit overseas, in which that event occupies all our consciousness and planning and in which the future beyond that event just seems a blur. Once the Millennium celebrations are over, the Western world may well experience what Philip Blond has termed "the dreadful vacuity and despair that this age has fallen into", and which only "an utter dependence upon God can overcome". This challenging statement brings us to a consideration of whether concepts of God and spirituality have been victims of the same limiting and claustrophobic trends as the biosciences.
If scientism is a parody of science, is 'religionism' a parody of religion? A friend of mine, a distinguished scientist not exactly noted for his humility, often makes disparaging remarks about 'religious' people and I had assumed that he was an atheist. Recently, though, he confided to me that this was not the case, quite the contrary, but that he found the narrowness and smallness of the concept of God held by many 'religious' people to be quite insufferable. I mentioned that he is not the most humble of mortals but, notwithstanding, this criticism deserves attention by theologians and other religious thinkers and, indeed, a theologian, J.B. Phillips, has written a book entitled "Your God is too small"!
In this respect, may I quote from a talk given by Richard Chartres, Bishop of London, to the Star Course.11 "You can be related to the true and living God .... but you can't possess God, even as an idea. You can be IN God, but you can't have anything but an Idol as a possession. You can't have a God. If you possess a God, if you talk about My God, my own little possession that helps me, my asset, then what you have is not the True and Living God ..... but an Idol, a God made in our own image. And .... much of the history of religion, even in the Christian Religion, is an attempt to make Gods of ourselves, by launching ego-projections into the middle distance - plop - and then having an affair with that ego-projection. That's what religion has been, so very often."
Is this why, in addition to the major world religions, we have thousands of divisions, creeds, sects, cults and so on - perhaps as many as 20,000 Christian sects? Why, throughout the centuries, has division been the hallmark of religion? Is the problem once again that of the logic bubble? The trouble is that a passionate devotion to the contents of one bubble can all too readily induce a contempt or even outright hatred of those who do not share these views. In fact, some religious people resort to all sorts of activities, sometimes quite offensive ones, in order to reinforce their logic bubbles containing their Gods.
The absolutism of the fundamentalist is, however, in marked contrast to the way of the mystics, who have always been aware that ultimate reality can never be entirely encapsulated by our intellectual endeavours. The mystic therefore speaks of the cloud of unknowing and regards dogma as a barrier to insight and enlightenment. The 14th century mystic Julian of Norwich wrote a really wonderful book called 'The Revelations of Divine Love', the title of which aptly sums up the contents.12 It is evident from her writings that, despite her efforts to accommodate it, Julian experienced conflict between the all compassionate and all merciful God that she actually experienced in her visions and the teachings of the Church. She had, for example, been taught by the Church that multitudes would be damned by the wrath of God, including all Jews because they had crucified Jesus. But her visions present her with a radically different view: that God's love will eventually conquer all and that, to quote her famous phrase, "All shall be well, and all shall be well, and all manner of things shall be well".
One of the most profound chapters in Julian's truly remarkable book is the final one in which she describes how she meditated upon the meaning of her visions for fifteen years before she had a further vision in which it was revealed that Love is God's entire meaning. If only all those who claim to practice religion could grasp this simple fact! Jesus, who more than anyone else broke free from the bonds of religious dogma, stated that the two great commandments were to love God and to love each other, and that this is the key to salvation. In his first letter, St. John states simply that 'God is Love' - perhaps the three most important words in the Bible - and it is reported by St. Jerome that when St. John was a very old man his simple message was "Just love one another, that is all you need."
But how are love and truth related? Sheila Upjohn, a leading authority on Julian of Norwich, wrote "The pursuit of truth must consider love. There is no way to prove, or test, or measure love. Yet the working of love is far more important than, say, the scientifically proven first law of dynamics". In a recent television programme, Archbishop Robin Eames of Ireland stated that knowledge is obtained by both proof and experience, and it is unfortunate that in this age so much dominance is given to the former. The importance of the working of love was the simple and sublime message of Jesus, vividly demonstrated through his words and actions. Yet, over the ensuing two millennia, countless people have suffered and died because others, acting in the name of Jesus, have replaced his lucid message with their own projections and dogmas.
So how should we address the problem of the fragmentation of knowledge, and the fundamentalism it induces, as we enter the new Millennium? The antidote to fragmentation and reductionism is wholeness, a word which has the same root as holiness and health. Far from being the mere absence of disease or infirmity, health has been defined by the World Health Organization as 'a state of complete physical, mental and social well-being'. In a declaration made in 1978 and subsequently known as the Alma-Ata declaration, the World Health Organization affirmed that 'health is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector'.13 The Christian would call this state of complete physical, mental and social well-being the Kingdom of God on Earth.
In order to make this world a truly healthy place, people involved in a wide range of activities, including science and theology, will need to come together in a spirit of reconciliation. Many painful sacrifices will have to be made: cherished dogmas and logic bubbles, on which reputations and authority have been built, must be shed. It will be no easy task. One of the most loved and respected spiritual leaders on the continent of Europe, Brother Roger of Taizé, recently wrote "It is so clear that each of us is faced with the most audacious adventure of reconciliation". He tells of the time that he met some Muslims in a slum in Bangladesh and one of them said to him "All human beings have the same Master. This is a secret that has not yet been revealed. But later on people will find out".14
In the Alma-Ata Declaration of 1978, the World Health Organization set the challenge of achieving 'Health for All by the Year 2000'. Clearly, this aim has not been achieved but this does not call for despair. Health for all could still become a reality but only if there is a radical shift in our underlying philosophy of health and health care provision, and from fragmented materialism to a post secular holistic viewpoint. The only barriers that need to be dismantled are those of our own making and we need the humility to ask where we are going wrong. The author and playwright Robert Ross surprised his doctors by surviving apparently incurable cancer - a survival that he attributed to help from the Bristol Cancer Help Centre. In an account of his experiences in the BMA News Review,15 he stressed the importance of 'patient centeredness' in treatment but stated that "... a holistic view seems hard for many doctors to embrace. At their worst, doctors seem to be obsessed with cancer by body part, mesmerised by global statistics and enslaved by a reductionist view of human biology. .... But will the next generation of doctors be suitably trained in the practical applications of patient centeredness?" This is a very serious question that the medical profession needs to address very thoroughly and very soon; not least because the public finds that modern medical practice increasing fails to address their needs as human beings and because there is a continuing exodus of some of the most sensitive and talented members of the profession who likewise find the system dehumanising.
Is a holistic view any easier for the Church to embrace? Jesus' own 'Mission statement' was "Preach the Good News and heal the sick", yet so often the last four words are omitted from the agenda of the Church. In this respect, I will merely, without comment, cite two challenging remarks made at the World Council of Churches' Congress in Harare last year: "The New Age movement has taken over 'wholistic' health - the church has failed", and "Jesus came and did not leave health out. He took it as a priority to heal the sick. May be we as priests should stop preaching and focus on healing".16
In conclusion, I return to the terrible pandemic of tuberculosis that
I described at the outset. In this case, we need to ask how and why the
deployment of one of the most effective evidence based remedies for any
life-threatening disease has failed so catastrophically. We need to look
at the biomedical model from the outside and this means relating to, and
embracing the work of, those within other disciplines such as ethics, anthropology,
psychology, education and the social sciences. The Owl of basic research
and the Pussycat of holism need to sail off in the same boat to their wedding.17
In the words of John Sbabaro, a greatly respected tuberculosis physician
"We must have the courage to challenge the future with new ideas rather
than to repeat the failures of the past by clinging to the old".
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