Abstract
Medicine is increasingly subject to various forms of criticism. This paper focuses on dominant forms of criticism and offers a better account of their normative character. It is argued that together, these forms of criticism are comprehensive, raising questions about both medical science and medical practice. Furthermore, it is shown that these forms of criticism mainly rely on standards of evaluation that are assumed to be internal to medicine and converge on a broader question about the aim of medicine. Further work making medicine’s internal norms explicit and determining the aim of medicine would not only help to clarify to what extent the criticism is justified, but also assist an informed deliberation about the future of medicine. To illustrate some of the general difficulties associated with such a task, the paper concludes by critically engaging Edmund Pellegrino’s account of the aim of medicine as well as the Hastings Center’s consensus report.
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Notes
The exact temporal boundaries of the “golden age” are not drawn consistently in the literature. Some maintain that the golden age comprises the first half of the twentieth century; others hold that it characterizes a period after World War II (see [3]); and still others associate it with the “conquest” of epidemic infectious disease [5].
Some of McKeown’s most forceful claims were based on studying mortality decline in England and Wales. Since then, researchers have pointed to similar examples during the mid-twentieth century (China 1949–1979, Cuba 1959–1979) where medicine has played only a minor role in mortality decline compared to improvements in housing, sanitation, and education [6].
Indeed, EBM—stressing that clinical decisions ought to be made on the basis of the best available evidence of effectiveness—is in part motivated by recognizing that the history of medicine is dominated by harmful or ineffective interventions.
The equation states that the probability of H given the evidence is equal to the prior probability of H, multiplied by the probability of E given the hypothesis, divided by the prior probability of E. The probability of H given E, P(H|E), depends on: (i) the prior probability of H being true, irrespective of the evidence (i.e., P(H)); (ii) the probability of the evidence given the hypothesis (i.e., P(E|H)); and (iii) the prior probability of E, irrespective of the hypothesis (i.e., P(E)).
Some distinguish between criticism and critique, taking the former to refer to something less elaborated and directed toward persons and the latter to refer to a more developed consideration of a subject. However, this distinction is ambiguous and not used systematically in the literature. For example, in his discussion of criticism in science and philosophy, Karl Popper consistently speaks of “criticism,” even though the way he uses the terms fits the definition of critique [35]. For this reason, I will use “criticism” in a broad sense, which includes instances of critique.
It is not clear, however, that practices can be said to be governed by rules. Drawing on Wittgenstein’s work on rule-following, some have argued that rules as more or less adequate representations of aspects of practices that are primary to the rules. Rules cannot keep participants in practices “on the rails” of the practice. Being able to comprehend what it is to follow a rule might require a prior conception of practice.
An institution is not itself structured by the aim and norms of the practice it organizes, but in terms of practice-external goods (e.g., status, money, power) [34, p. 194]. Because institutions have a tendency to separate from the practice they sustain, the pursuit of two kinds of goods constitutes a source of potential conflict. For Alasdair MacIntyre, without virtues (e.g., justice, truthfulness) practices would not be able to withstand the corrupting power that institutions exert. This is problematic not only because the aims of practices are not achieved. There is much more at stake, because practices are the vehicles through which the common good and the potential of human beings is actualized.
This is often referred to as “immanent criticism” in the literature, particularly in the tradition of critical theory (see [37]). I will not observe this additional distinction for the sake of simplicity.
While Pellegrino’s account is particularly helpful when it comes to illustrating some general difficulties, there are of course other accounts available, such as the one proposed by Alex Broadbent [13]. Moreover, there are also other “list approaches”—or “consensual” approaches (see Schramme [39])—that proceed by cataloguing several aims, put forward by Howard Brody and Franklin G. Miller, Bengt Brülde, and Christopher Boorse.
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This work was supported by a research Grant from the Carlsberg Foundation (CF19-0350).
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Varga, S. The criticism of medicine at the end of its “golden age”. Theor Med Bioeth 43, 401–419 (2022). https://doi.org/10.1007/s11017-022-09598-9
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DOI: https://doi.org/10.1007/s11017-022-09598-9