Science vs. Medicine

Dr. Marsden Wagner says, “[T]here is a fundamental difference between the practice of science and the practice of medicine. To generate hypotheses, scientists must believe they don’t know while practicing doctors, to have the confidence to make life and death decisions, must believe they do know.” (Click here for the full article, so you can see the context.)

I’ve thought about this statement, in conjunction with a statement I’ve heard many doctors say about their medical training — something along the lines of, “Half of everything you learn in med school will be proven false in twenty years.” Is that more disheartening to the eager-beaver med students, or more scary to us, their patients, on whom they will practice? I believe the statement is designed to encourage them to be life-long learners, always reading and learning about the latest advancements in science and medicine, to be able to provide the best care, and always willing (unlike the old dog) to learn some new tricks.

If you look back in history, you’ll find several notable examples of famous people killed by their doctors who were just doing the best they could at the time. They believed they knew. (The following is based on my memory of reading some of the Uncle John’s Bathroom Readers many years ago, so forgive me if I misremember any of the particulars; the general idea still stands.) One case was Pres. William McKinley who was assassinated in 1901. He was shot and probably would have lived, except the doctors tried to take the bullet out, and made several mistakes while so doing. Another case was King Charles II of England, who had had a stroke, and his doctors followed the practice of the day believing they knew, and over-treated him to death. They bled him on several successive days, probably removing almost enough blood to kill him just with blood-letting, because they knew that his condition was due to “bad blood” and if they could just get rid of the bad blood, he’d get better. They also prescribed powerful emetics and purgatives (substances to make him throw up and “cleanse his colon”), because they knew that if his system was rid of the bad substances in his body, he would get better. They bled him and “cleansed” him to death. He was rendered too weak from the loss of blood and lack of food to get better. There are probably countless other similar deaths, only they happened to the poor and un-famous, so we never hear of them.

Another example is malaria. It got its name because people thought it was caused by breathing “bad air” (“mal” is French for bad, and similar in other Latin languages). That’s a logical assumption, since people who went into the “bad air” of swamps often contracted malaria; but we know it’s wrong. I remember in one of the Little House on the Prairie books, the entire Ingalls family came down with malaria one time. Pa had found some watermelons growing nearby, and brought them home to eat; but Ma steadfastly refused to eat any, because she thought (along with a great many people in her day) that eating watermelon gave a person malaria. Also a logical assumption since watermelons grow in wet places where mosquitoes breed; but also wrong. (Ma found out she was wrong, because she ended up with malaria, even though she didn’t eat any watermelon.) Now we know that malaria is caused by being bitten by a malaria-carrying mosquito.

Scientists or medical doctors of the day missed a step. It’s a common logical fallacy — that because A comes after B, that A causes B. Instead, many times A & B are related, or there is a correlation between the two, but one does not necessarily cause the other. The relation of “bad air” or watermelons to malaria was not causative — and such an idea is almost funny to us nowadays, that people used to think that; but it makes me wonder what we’re currently attributing to bad air or watermelons, while the real cause is unknown.

Here’s the problem with things that are correlated but not necessarily causative — removing one factor may prevent the disease from happening, but it doesn’t necessarily mean it’s the real cause of the disease. Just as not breathing the bad air of swamps would keep you from getting malaria, not because of the supposed cause — the fetid air — but because it also keeps you from the actual cause — the mosquitoes that also love the swamps and breed there.

But back to doctors believing they know… Doctors hold the power of life and death in their hands — which is why Hippocrates, the ancient doctor, emphasized in the oath named for him that doctors must first do no harm. He recognized that the patient wouldn’t know whether this powder or pill or potion would kill him or cure him, so he dictated that it was unethical for a doctor to harm a patient, intentionally or unintentionally. Doctors have to believe that they know that the medicine they prescribe or the procedure they undertake will not harm the patient but instead will help him. They must believe that, otherwise it would be unethical for them to prescribe or operate.

Scientists, though, have to believe that they don’t know, so that they can figure out for sure whether this powder, potion, pill, or procedure is actually beneficial (or more beneficial than harmful, because all drugs have side effects). This is why there are clinical trials before any new medication is released, because scientists don’t know for sure of the benefit and efficacy of the drug. After its effectiveness is proven, and the main side effects noted, and it is determined that the benefits do indeed outweigh the risks, then the medicine is released and doctors are told that the medicine works. They then know (or at least think they know — sometimes drug reps use loaded language to make the drug they’re selling sound much better than it really is, or to make the side effects as much milder or rarer than they really are).

So, when your doctor suggests a course of action, he believes he knows that it is right. He has to, or else it would be unethical for him to suggest it — can you imagine a doctor who suggests you get your leg amputated when he knows that an antibiotic would cure the infection in your leg? But he might be wrong. His understanding might be limited. I just recently heard a story in which illustrates this point.

A preacher’s elderly mother was on a blood-thinner and had severe rectal bleeding; at the hospital, her doctor said the only course of action was immediate surgery to remove part of the colon, but it was unlikely that she would survive the surgery (at least partially due to her being on the anti-coagulant — when surgeries are scheduled in such patients, they are many times weaned off the pills a few days before, so they don’t bleed to death on the operating table). He called a preacher friend of his and had just started telling him when they were disconnected. He tried the friend’s cell phone, and when the man answered, he picked up the story where he left off, telling him his mother’s situation and what the doctor said and the hopelessness of it all. But the man who answered the second call was not his friend (the friend hadn’t had that number for years, but the first man hadn’t updated his address book), instead he had inadvertently called a man who happened to be a doctor who specialized in just this problem — it was the friend’s old cell number, but this doctor had happened to have gotten it for his cell phone. (Anybody have chills yet? I do!) So, the doctor suggested a different course of treatment, one which was likely to work without killing the elderly woman. The physician either hadn’t heard of the procedure, or just never thought of it, but when the son told him, he agreed that it would likely work, so did that instead of the operation.

The doctor in the above story was acting completely ethically when he suggested a surgery which would likely kill the elderly lady, because her situation was so bad without surgery that she would more likely die without the surgery than with the surgery. It was the only option he knew, but it was not the only option. But he believed that he knew. He had to, otherwise he couldn’t have acted — he would have been paralyzed with doubt over whether what he was suggesting was right or wrong. The problem is, he would have been ethical yet still ultimately wrong. Had the woman’s son not accidentally called a doctor who specialized in just this type of problem, the doctor would have never known that his decided course of action was not the best course of action — just as King Charles’s doctors probably died in the belief that they had done the best thing for him, when they actually were responsible for his death. They did the best they knew to do, but they would have done better had they done nothing!

One Response

  1. Cue the segue to back to birth and maternity care…

    It is quite a conundrum that doctors must find themselves in these days. We’ve all heard the expression, “Doctors will get off of their pedestals when women get off of their knees.” How stressful and morally challenging it must be to bear the role of the ultimate expert yet live in fear that every move will be scrutinized and possibly punished in a court of law.

    To believe that one is the expert on *every* birth, not just ones at the end of a complicated pregnancy, is presumptuous. And how offensive and obnoxious it must seem for a woman to claim to be an expert on her own body, when everyone knows that YOU are the expert on her body, even if the first time you meet her is when she’s crowning.

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