Medicine, modernism and after: a new role model for the doctor?

"Everyone has something to contribute to the truth . . ." Aristotle ¹

MJA 1997; 167: 570-571

Mainstream philosophy, which is characterised by the philosophical ideas of the Enlightenment, has been strongly criticised in the past 30 years or so for being too "rational" and too "empirical". Its critics have insisted that the basis for knowledge is much less secure than these schools of philosophy, which include logical positivism and scientific realism, would have us believe.2 Side by side with this critique, there has developed a critique of the North-West European (specifically, Scandinavian) Welfare State, which has been called a modernist attempt to achieve the "good life" or a "good society" by rational, empirical means, such as equal distribution of goods meeting "basic human needs". The Welfare State has been characterised as the welfare expression of one kind of economic rationalism. The most radical of "postmodern" critics, however, claim that the rationalist project has failed. We cannot even define things like "truth", let alone legislate to achieve "the good", says this line of argument: everything has to be determined by discourse among local communities; it is up to the individual citizen to decide how to live his or her life; one claim is as good as another -- relativism rules. This negative critique has been directed at the State in general, under the ideological motto "Less State, more community". Combatants in politics and political philosophy should learn, however, from combatants in branches of philosophy, particularly the philosophy of science. They have had to learn the dangers of throwing out the baby with the bath water. Thus, it has not been possible to jettison concepts of truth and rationality, but it has been necessary to repolish them and repair the damage done by the critiques.3 It is true that the institutions of the Welfare State have become paternalistic, have suppressed the autonomy of citizens and neglected the diversity of perspectives and values within pluralistic societies. There is no doubt that all this should be opposed. But there is little reason to think that nations will benefit from dismantling State institutions, and replacing them with entrepreneurial services operating within the marketplace. What is needed instead is a radical understanding and disclosure of the mechanisms which have sometimes made the State a controller rather than a system promoting human well-being.4-6 Instead, critics have claimed that a dangerous symbiosis has developed between paternalistic welfare systems and irresponsible citizens, who perceive opportunities to accumulate wealth by exploiting the system. There is, however, absolutely no reason to believe that a politics which defends the rights of citizens and which provides necessary services should in any way undermine human autonomy. Equally, there is no reason to believe that people living in local communities without State interference would be any more responsible than citizens in a State devoted to providing security and opportunities. The "Less State, more community" catchcry assumes that the Welfare State has systematically corrupted its citizens. There is little evidence to support this claim. The German philosopher Hegel argued that there were strong reasons to believe that the activities of the State were perfectly compatible with the development of autonomy, 7 and there is no reason to doubt that he was right. Hegel claimed that the modern idea of the self-conscious individual, with ideas of freedom and autonomy, is based on the presupposition of a social structure, with institutions that included social and public services. To put this in a European context: what makes a Danish citizen a Dane is his or her being part of a society where institutions of social justice have been created, in which it would not in principle be accepted that any individual in that society should fall by the wayside, and that everything possible should be done to allow individuals and groups to flourish. It is not the citizenry that is in decline. The decline is in politics and politicians. It is the gradual destruction of the political institutions built over the past century or so that undermines individual autonomy and social cohesion, and diminishes the notion of social justice. Has medicine a part to play in reconstructing the performance of the body politic and a respect for politicians? To begin, it might need to broaden its view of its knowledge base, taking a more generous view of the truths that come to it from outside its very reductionist science. Its concern with human welfare would then start to look rather like the avowed concerns of the Welfare State. However, there may be a more direct role for medicine. From at least the time of Aristotle, Western medicine has inherited the idea of an analogy between medicine and politics. Both have practical goals: medicine, the health of the patient; politics, the conditions for human security and well- being. They are both (or should be) responsive to the individual. In medicine, there is a perceived inequality of power between the doctor as expert and the patient as supplicant. The person of practical wisdom (the ideal politician), on the other hand, "engages you actively in the 'treatment', taking your view of things as seriously as his own; he leads you on through the interchange of calm and clarifying argument to what he hopes will be an articulated picture of the good".8 In an age when politicians and planners often do not live up to this model, medicine might try to realise an even closer analogy between the doctor and the person of practical wisdom than Aristotle thought possible. Medicine might play a role in redeveloping the Welfare State as a system realising the Aristotelian ideal that "everyone has something to contribute to the truth . . .".1 We are left with two final questions, which are also challenges. Do doctors in general have the capabilities needed to act according to this ideal of practical wisdom? And, if not, how should medical education be changed to legitimate and encourage these capabilities? Uffe Juul Jensen Professor, Department of Philosophy University of Århus, Århus, Denmark Aristotle. The ethics of Aristotle: the Nichomachean ethics. London: Penguin, 1976. Rorty R. Philosophy and the mirror of nature. Princeton, NJ: Princeton University Press, 1979. Putnam H. Reason, truth and history. Cambridge: Cambridge University Press, 1980. Jensen UJ. Practice and progress -- a theory for the modern healthcare system. London: Blackwell Scientific Publications, 1987. Jensen UJ, Mooney G. Changing values: autonomy and paternalism in medicine and health care. In: Jensen UJ, Mooney G, editors. Changing values in medical and health care decision making. New York: John Wiley and Sons, 1991: 1-15. Jensen UJ. The year 2017: a revolution for democracy? The future of general practice in Europe. Copenhagen: European Union of General Practitioners, 1992: 18-24. Hegel G. The philosophy of right. Oxford: Oxford University Press, 1952. Nussbaum MC. The therapy of desire -- theory and practice in the Hellenistic era. Princeton, NJ: Princeton University Press, 1996.

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