Abstract
That the tendency to think of medicine as resting upon a scientific biological foundation is not strictly accurate is often put down to medicine really being an art rather than a science. But, where centred on the human being, biology itself only appears to be dealing in the same terms as medicine. In practice, medicine seeks to cure whereas biology seeks to understand. Significantly, while various aspects of biological science have supplied technical support and innovations aimed at providing objective information about the human body, there has been less conceptual transfer from biology to medicine than might have been expected. Now potential exists for this to change.
Changes in the British Higher Education system, for example, have meant that a non-clinically orientated academic interest in disease and health is now evident, catered for by departments of biological science and social studies. Whereas previously in the biological sciences, many of our notions about disease and health have been adopted somewhat uncritically from medicine's long and often unscientific tradition, now a uniquely biological understanding of such concepts is becoming necessary as a philosophy of 'health science' emerges.
One such application of biological ideas has been through Darwinian medicine which seeks to apply evolutionary theory to understanding our vulnerabilities to disease. This, and the extent to which evolutionary theory is now being applied more broadly, suggests that, in certain respects, biology might, given the way in which it provides a basis for influencing our worldview, be used as a more liberal discipline than it is at present. In this respect, biology has the potential to serve as a conceptual bridge or conduit between philosophy and medicine. New biological philosophies – providing comprehensive understandings of the human organism – rather than mere materialistic descriptions are possible.
In this respect, certain terms used by both medicine and health science are in need of revision from a fundamentally biological philosophical perspective. As an example, it will be suggested that the clinical term 'illness' has greater biological significance than is usually realised, especially in terms of individual survival; that the term 'pathology' needs to be more clearly distinguished from 'disease'. It will also be suggested that 'disease' and 'health' are better understood as labels that represent sets of experientially subjective and physiologically objective phenomena that contribute to alterations in the overall biological state of an individual as an organism.
Introduction
In an editorial in the Journal of Medicine and Philosophy some thirty years ago, Edmund Pellegrino wrote that,
'Central to the enterprises of both philosophy and medicine are the images and ideas held about what man is and what his existence signifies for himself and the world …'
He went on
'… medicine and biology are two powerful instruments of scrutiny of the image of man. Together with philosophy, they can help contemporary man to understand a little more about what he is …'
(Edmund Pellegrino – Editorial – Journal of Medicine and Philosophy, 1976, p101)
Implicit in what Pellegrino suggests is the fact that medicine and biology look at Man in different ways – they are two powerful but, in practice, different instruments of scrutiny.
Medicine is often described as an 'art' and its primary intention is the comfort and treatment of individuals suffering from a variety of physical (as well as mental) ailments, whereas biology is a 'science' and its primary intention is to understand. Biology – as applied to Man – does this, without focusing on individuals as such but by determining what is generally the case. As a result of these different approaches, certain phenomena may be given different emphases and differently nuanced images of Man, even as a physical entity, may be offered.
But in this quotation, Pellegrino adds a third discipline. He mentions that 'medicine and biology … [t]ogether with philosophy … can help contemporary man to understand a little more about what he is …'
My interest, as a human biologist with philosophical training, is that of trying to understand something of Man's physical existence. In particular, I am interested in the biological significance and meaning of those clinical phenomena to which terms such as illness, disease and health are applied – as well as the definition of these terms themselves. As such, I would like to consider the question of the possibility of a new juxtaposition of medicine, biology and philosophy and what this may entail for these terms.
Connections
I have already mentioned a couple of differences between biology and medicine but the way in which they interact with each other is also important. In particular, one finds that biology has supplied various forms of technical support and innovation for medicine, in that it has developed numerous laboratory techniques and procedures that medicine has been able to co–opt for its own use. However, fewer of biology's theoretical insights seem to have made the same journey.
Perhaps the clearest example of this relates to evolutionary theory. While it forms what is, in effect, the 'grand unifying theory' of biology, its influence is essentially absent from medical explanations of clinical phenomena. This continues to be the case despite the efforts of a number of workers engaged in Darwinian – or Evolutionary – Medicine.
For those not acquainted with Evolutionary Medicine, it has been described as …
'the enterprise of trying to find evolutionary explanations for vulnerabilities to disease'.
(Randolph Nesse)
Evolutionary Medicine emerged in the early 1990s as a discipline intended to contribute to medicine. However, so far it appears to have enjoyed more success academically amongst human biologists and biological anthropologists.
One feature of Evolutionary Medicine that has particularly interested me has been the way in which it has prompted a re–appraisal of our ideas about certain clinical phenomena. Evolutionary Medicine has suggested, for example, that phenomena such as vomiting and diarrhoea are defence mechanisms that expel harmful toxins from the gut and that while these may be associated with a feeling of illness – which we tend to disvalue – the net effect is to confer a benefit on the individual. Similarly, a fever during an infection, it has been suggested, is a mechanism whereby body temperature is raised so as to impede the activity of the infectious agent. Thus, although the febrile patient feels ill, the fever is of benefit to them.
As a result, our notion of illness may be in need of reinterpretation and may even need to be considered as an aspect of being healthy. That is, a healthy individual may be one that is able to mount a response that is experienced as 'illness' but which ultimately contributes to that individual's recovery and/or survival. What we disvalue experientially may be beneficial biologically.
But while it has been difficult for certain biological concepts to enter medicine, a biological interest in medical matters appears to be growing. As noted, Evolutionary Medicine has been more successful with human biologists and biological anthropologists than with the medical profession. But there is another area where medical ideas have entered the biological sphere.
Developments in the British Higher Education system in the last decade or so have meant that a non–clinically orientated academic interest in clinical phenomena and in health, in general, has been developing. Students who do not intend to enter careers related to healthcare but who are simply interested in the subject are now following courses in what is generally being called Health Science.
This interest is largely being catered for by departments of biological science – sometimes with secondary input from departments of social studies – but, noticeably, not by departments of medicine. As a result, the objects of medicine can no longer be said to be the sole intellectual preserve of the medical or allied professions and the study of clinical phenomena is no longer confined to the purely clinical context.
'Middle Ground'
Both Health Science and Evolutionary Medicine mix the subject matter of biology with that of medicine in such a way that they may be seen as occupying an academic 'middle ground' between the two.
Consequently, where there was once a 'philosophy of medicine' and a 'philosophy of biology', now a philosophy of this 'middle ground' may be set to emerge. How this actually develops one can only wait to see but it is likely that what emerges will also be of interest to both those engaged in the philosophy of biology and the philosophy of medicine. However, in presenting this paper, I would like to propose how I would like to see this 'middle ground' developing.
A 'Liberal Biology'
By the very nature of this 'middle ground', Health Science and Evolutionary Medicine deal, not only with the biological, but also the conceptual when it comes to dealing with what constitutes illness, disease and health. In so doing, they cross, and possibly blur, boundaries by dealing with both the scientific subject matter of biology and the art of medical interpretation and the classification of disease states.
However, in order to make this blend of biology and medicine intellectually most productive, I believe that the fundamental ethos of this 'middle ground' should be a deliberately more liberal one than is usually associated with biology or, for that matter, medicine.
I take my cue for the use of the term 'liberal' from Lynn Margulis who, in her book The Symbiotic Planet, refers to a course entitled 'Natural Science Two' that she took as a student at the University of Chicago.
She states that,
'As taught in Nat Sci 2, science was a liberal art, a way of knowing. We were taught how, through science, we could go about answering important philosophical questions ...
There science facilitated the query of profound questions where philosophy and science merge ...'
(Margulis, L. (1998) The Symbiotic Planet, London: Phoenix. p30)
She does not go into detail about how that course achieved this – in practice, there may be many ways in which this may be done – but she does leave the reader with the belief that finding a way of exploring conceptual issues as part of a course in science is possible. I certainly believe that there is scope for the biology within Health Science and Evolutionary Medicine to be used to facilitate enquiry about philosophical questions as thrown up by medicine and as thrown up by the phenomenon of life in general. Questions, that is, of a sort that modern biology rarely allows itself to ask.
In the context of the 'middle ground' between biology and medicine, one alternative to a 'liberal biology' would be, what might be called, a 'pathological biology' focused, in a reductive way, primarily on changes that occur at cellular and tissue level and missing the issue of the organism as a whole being.
Instead, questions that need to be addressed here include those associated with the definition and biological significance of terms such as illness, disease and health. Now that Health Science and Evolutionary Medicine are using terms such as these in a scientific context, a more precise understanding and use of these terms is essential. For example, one not uncommonly finds the terms pathology and disease being used interchangeably. Now, while the former can be related to discernable physical lesions, the latter – in keeping with the etymological origin of the word 'dis–ease' (meaning a 'lack of ease') – seems to imply something about the individual as an entity, not just a part thereof. At least, that is how I currently see it. A 'liberal biology' is one that could also allow scope for individuals to be addressed as entities.
I noted earlier that, Evolutionary Medicine is …
'the enterprise of trying to find evolutionary explanations for vulnerabilities to disease'
(Randolph Nesse)
As such, Evolutionary Medicine must rely upon a notion of disease so as to offer evolutionary explanations for vulnerabilities to them. Should that notion be flawed, then so too would the explanations offered. Significantly, Evolutionary Medicine does not appear to have asked whether a medical ascription of disease is sufficient, or even appropriate, when trying to offer what are fundamentally biological explanations.
To put this in exaggerated terms. If the prevailing medical notion was still that disease is a product of an imbalance in the four bodily humours, then, should Evolutionary Medicine offer explanations couched in much the same terms, it would be offering erroneous explanations due, not to its own internal logic, but to relying upon concepts adopted uncritically from elsewhere.
One of the ways in which the notion of disease works, in the clinical setting, is as a medical construct or a convenient label that allows clinicians a framework within which to practise. Significantly, it is not the accuracy of this label that is of prime importance but the efficacy of the treatment which that label prompts. (Indeed, the accuracy of an original diagnosis may sometimes be queried after the patient has got well again.)
If Evolutionary Medicine is to offer what are essentially biological explanations for vulnerabilities to disease then it must have a biological concept of disease with which to work rather than just a clinically convenient label. After all, Evolutionary Medicine is NOT 'the enterprise of trying to find evolutionary explanations for vulnerabilities to medical constructs'. These are certainly not the product of biological evolution.
Biologically, a disease may also be considered as a label. However, rather than being a clinically convenient label that helps guide treatment, this label may be one used to describe the overall state of the individual as an entity engaged in a struggle to survive. This overall state may, in turn, be said to consist of two fundamental sets of phenomena: the individual's objective anatomical and physiological state and that individual's subjective state of self–awareness – be this at a conscious or sub-conscious level.
I would suggest that a biological notion of disease – and of health – must take account of both of these objective and subjective elements. Each, in their different ways, has a bearing on how well an individual is able to survive and also how successfully they are able to reproduce. In short, both these objective and subjective elements are open to evolutionary pressures and would, therefore, be amenable to evolutionary explanations.
However, as yet, it cannot be said that combining the objective and the subjective is a common feature of modern biology – which typically takes a strongly reductive approach. Again, a more liberal approach, I suggest, may avoid this.
Conclusion
To Pellegrino's three disciplines, I have suggested that an academic 'middle ground' between biology and medicine now exists in the form of disciplines such as Health Science and Evolutionary Medicine. Since these combine aspects of biology and medicine, I have suggested that this is an area that is best served by a 'liberal biological' approach which allows itself to deal with issues of a more conceptual nature, as well as with typically tangible biological phenomena. In so doing, this 'liberal biology' forms a link not only between medicine and biology – with which it shares many objects of interest – but also philosophy – in that it must ask questions which are not only philosophically pertinent to itself but also to the philosophies of medicine and biology.
Ideally, this liberal approach will also be able to contribute to helping us understand a little more about what we are – at least, as biological entities.