Is Medicine really a Science?

“If your physician does not think it good for you to sleep, to drink wine, or to eat such and such meats, never trouble yourself; I will find you another that shall not be of his opinion; the diversity of medical arguments and opinions embraces all sorts and forms.”

So wrote Michel de Montaigne over four centuries ago.

Well, things have changed. Today, a growing body of information is attracting a consensus within the medical profession. However, the information is by no means stable. A journal of the Mayo Clinic in the US (its Proceedings) published a study in August 2013 of all the original research articles from the prestigious New England Journal of Medicine over a decade. It found that:

• 1344 articles examined a new or existing medical practice
• Over half of them (56.3%) suggested a new practice superior to an existing practice. This is known as ‘replacement’, where a new treatment is to be preferred to an old one
• Far more worrying, nearly one in nine (10.9%) found that a treatment in common use was inferior to what had preceded it and should be stopped. This is known as a ‘reversal’, where a new treatment is found to be inadequate and practice reverts to an older approach

That’s just one decade and just one journal, even if it is one of the publications with the most impact in medicine.

Maybe that means that Montaigne, if he were living today, would have to change his advice slightly: if you don’t like the advice your doctor’s giving you, you don’t so much have to find another doctor, just wait a bit – before long there’ll be some new advice coming along.

Of course, you do have to survive for as long as it takes to get that new advice.

Bloodletting: once one of the most common of medical practices
Now regarded as not generally beneficial...

What prompted me to think about all this? Why, the new advice from the Lancet, another of the most prestigious medical journals, that salt, against which we’ve been warned for so long and so loudly, for the harm it does to the heart, might actually be beneficial for cardiovascular disease if consumed in moderation.

Doesn’t this remind you of attitudes towards, say, aspirin? It was perceived as a panacea, a cure for practically any disease, when it was first discovered. Then the profession turned sharply against it, above all for its effect on the digestive system. But now the pendulum has swung back and aspirin, in moderation, is recommended for many conditions, and in particular as a preventative for certain heart problems.

As for red wine, I’ve lost track of where we stand now. Is it good for you? Is it bad for you? Maybe I should just take a leaf out of Montaigne’s book and just do what I like and, since I like red wine, keep drinking it.

In moderation, of course.

Naturally, all this progress is based on scientific work. Highly effective, intelligent research is slowly moving us forward. It’s causing us to question old remedies, and sometimes – maybe as often as one time in nine – even new remedies. Which means that medicine is becoming more scientific.

Gone are the days of bleeding patients, as in the eighteenth century, just because that’s what a physician does. After all a scientist might well come along and question the practice. But it seems that could also happen for many of the practices we still use, unlike bleeding. With so much of medicine subject to questioning, I’m not convinced that it’s reasonable to call it a science.

Perhaps it’s just a practice on the way to becoming more scientific…

There’s a great quote attributed to Mahatma Gandhi, though he probably never said it. Asked by a journalist what he thought of Western Civilisation, the story says Gandhi replied that he thought ‘it would be a good idea’.

Medical science? I don’t know what Gandhi would have thought. But to me it seems like it would be another good idea.

Shocking internet searches, hagiographic biographies and inspiring teachers. All linked

Beware the internet search: it can sometimes shock and sadden.

And another fundamental truth: out and out partisanship for the subject can make for the most exciting teaching.

Ralph Waldo Emerson claimed “there is properly no history, only biography.” I’ve always been interested in history, so I’ve very properly turned my attention to biographies in recent years – reading them or listening to them, a great way to enhance such experiences as walking a dog, or even more fulfilling, washing floors.

My interest in American history (it’s good, because there isn’t too much of it) inevitably led me to consume biographies of such extraordinary figures as George Washington, Thomas Jefferson or James Madison. My sympathies have tended to be with the Jeffersonians, with their passionate commitment to democracy and human rights. My son Michael, on the other hand, has a soft spot for the man who became and remained their nemesis during his lifetime: Alexander Hamilton.

Eventually I felt that I really had to turn my attention a biography of Hamilton too, and chose one by Ron Chernow, who wrote so masterfully about Hamilton’s mentor, George Washington. I’m enjoying the imaginatively titled Alexander Hamilton.

How massively have I had to change my viewpoint. I knew, of course, that Jefferson and Madison (Washington too, as it happens) were slaveowners, but I was unaware that Hamilton, on the other hand, was a passionate abolitionist throughout his life. Who then, as Chernow asks, was truly committed to human rights?

It’s always good to have your presumptions challenged. On the other hand, there were times when I began to despair of Chernow’s tone. Jefferson and Madison, as well as being denounced as hypocrites, also come across as conniving, cowardly and backstabbing. This began to feel over the top, so I dug out my copy of Lynne Cheney’s James Madison, a life reconsidered, if only so I could contrast accounts of the same events from the two points of view. Cheney, of course, is as hagiographic towards her subject as Chernow is to his. In fact, I had to smile when I came across her description of Jefferson and Madison as “the two greatest minds of the eighteenth century.”

So we’re setting aside men such as Hamilton, are we? To say nothing of Newton, Locke, Leibniz or Voltaire among so many others?

It’s interesting how biographers tend to become partisans of their subjects. You don’t have to. My PhD thesis turned into Pierre-Louis Moreau de Maupertuis: an intellectual biography and I have to say, the more I found out about Maupertuis, the less I liked the man – prickly, self-aggrandising, paranoid and not above being a bully – so I felt no need to canonise him. Equally, I recently enjoyed A Country of Vast Designs: James K. Polk, the Mexican War and the Conquest of the American Continent by Robert Merry, who doesn’t pull his punches concerning the faults of the eleventh US President (he was prickly, paranoid and not above being a bully, though perhaps less inclined to self-aggrandisement.)

Still, one has to admire teachers who become so enthusiastic about their subject that they identify personally with it. A man I greatly admired did just that in lectures about the French Renaissance writers, at what was then called Bedford College, University of London, which he allowed me to attend although I was a student at another college.

He gave a series of classes about Michel de Montaigne during which he gave marks of extreme humility. Most striking was his comment that he only felt qualified to teach the course by his profound sense of inadequacy to the task. Now, Montaigne wrote a series of pieces he called “Essays”, the first time the word was used for such writing – so he’s responsible for that bane of schoolchildren’s lives from his days to ours. But at his time, an “essay” was a trial, in the sense of a trying out – “these are the trials of my natural faculties” he says of his book. So everything he wrote was tentative. Indeed, I know of no author who used expressions equivalent to “on the other hand” more than he did.

Montaigne: the inventor of the essay
Ushering in centuries of pain for schoolkids everywhere

When the lecturer finished the classes on Montaigne, he switched his attention to the poetry of Pierre de Ronsard and introduced the subject by informing us that we should immediately forget everything we had ever read or heard about Ronsard, because everyone else had got him entirely wrong. Ronsard, as it happens, believed that no one had written anything that could be properly called French poetry before him. He saw himself as the greatest poet since Classical Antiquity, and probably superior to the Greeks and Romans too.

It was a privilege to be taught by a man who was so entirely adopted the personalities of his subjects.

It occurred to me that I ought to look him up to see what had become of him. I could only remember his first name, Malcolm. But google is unbeatable. “Malcolm Bedford Ronsard” immediately gave me a series of hits. Sadly, the first of these was a 1994 article from the Independent headlined Obituary: Professor Malcolm Smith.

Another giant of Renaissance studies, Professor Screech, had written the tribute. It ended:

His Oeuvres Complètes de La Boétie for the Editions de la Pléïade was submitted last December when he already knew that his cancer was terminal.

His edition of Du Bellay's Antiquitez de Rome with Edmund Spenser's Ruines of Rome was printed and bound in America days before he died.

He’d died at only 53. But right to the end he’d maintained his fiery enthusiasm for his subject. The enthusiasm that I’d found so inspirational when he taught me.

In all likelihood, you wouldn’t remember me, Professor Smith, if you were still around. But I remember you, with admiration undimmed. Thanks for all you did. And thanks for the passion you communicated in doing it.

The best of friends

Being made redundant is, I’ll admit, a pretty depressing experience (particularly when it happens for the third time – why, I may soon have to start wondering whether I’ve been doing something wrong in my career, a thought that had never previously occurred to me). However, there are benefits too.

First of all, there’s the time for reflection offered by what I hope will turn out to be a brief period of unemployment. Then there’s the redundancy itself which can be quite a learning experience.

In my case this has led to my giving some thought to the nature of friendship.

My reflections were helped by listening to a discussion on the theme in an old episode of In Our Time. The participants started their review way back in classical antiquity.

Now I should say that I don’t always go along with the unquestioning admiration of all things Greek. For instance, Plato’s Lysis which I learned is devoted to the subject of friendship, rules out the attraction of opposites as a possible basis. This is because it would imply the good being attracted to the bad. This strikes me as a painfully formalistic and limited view of good: two people of opposite temperament can still both be good – there are many ways to be good. My way of being good may be the best way, but I’m tolerant and broad-minded enough to admit that yours may not be entirely without merit.

What really interested me was when they got onto the subject of Aristotle. He, it seems, distinguished three categories of friendship on the basis of utility, enjoyment or excellence. The problem with the first two is that as soon as the utility or enjoyment ends, so does the friendship – only the third endures.

Now this I can go along with. Utility friendship is clearly the kind of thing that exists in general between colleagues. At the lowest end of the scale, it’s forced – you oblige yourself to get on with people you’d probably go out of your way to avoid, left to your own devices. I confess I’m not good at that kind of artificial friendliness as people read my real feelings much too easily. I like to think that I have no patience with fools, but lots of people link to think that: after all, it’s a neatly disguised boast wrapped in contempt for others. Clearly, I think numerous people around me are fools, while thinking that I’m not a fool myself. Ironically, I’m probably at my most foolish when I get impatient with others who disagree me with me (and class themselves by that token with the fools).

Then there are the colleagues with whom one can have a real friendship. These are people one admires or who do outstanding work or with whom it’s just fun to work. Sadly, however, once we part company there’s little basis for the friendship to continue. It’s a pity, but I suspect before long all I’ll have of these utility friends is some pleasant memories and a sense of pride over some of our of things we achieved together.

This is the same as what happens with friends of enjoyment. Drinking friends or friends with whom one plays football are great until one realises that hangovers really aren’t much fun and running up and down the same pitch several dozen times is no way to spend an hour or two. When you go off to do something a bit more rational – which means more or less anything – you tend to lose touch with the old friends, some of them getting very old, who are still trying to cling on to the image of their youth and its pastimes.

Then there are the friends of excellence. These are the ones to whom you’re bound by an affection that’s mutual and unconditional: they’re your friends not because they’re cleverer or more skilful or more amusing than others but because they are who they are. No-one summarised that better than Michel de Montaigne, the sixteenth-century French writer. After his friend the poet Etienne de la Boétie died, he wrote if people pressed him to say why he loved la Boétie, he could find no better of way of replying than to say ‘because he was Etienne de la Boétie and I was Michel de Montaigne’.

Now that’s the kind of friendship that’s worth having. And I’m glad that I leave my former company with a few friendships of that strength and they won’t be broken by a mere inconvenience like redundancy.