Decolonizing Medicine

The phrase “traditional medicine” is commonly used to refer to medical traditions originating outside the West, and still practiced either as alternatives to or alongside Mainstream Medicine. Hard and dismissive attitudes to traditions with non-Western origins are obviously insensitive. It is clear that power and knowledge are intertwined. What counts as knowledge is partly determined by who has power. Moreover, medicine is clearly imbued with cultural influence. Yet if we reject medical relativism, we cannot accept that medicine is simply a cultural expression. We must consider which of two conflicting traditions, or two incompatible prescriptions, is correct (if either is). Medical Cosmopolitanism is a tool for negotiating the opposing temptations of excessive tolerance and dogmatism, and for understanding how one might “decolonize” medical knowledge. The chapter suggests that developments of the notion of decolonization can prevent a collapse into medical relativism, espousing “critical decolonization.”

Alternatives and Medical Dissidence

This chapter introduces the notion of medical dissidence: conscious deviation from the main current of professional opinion. Cosmopolitanism is applied as a way of getting to grips with the popularity of Alternative Medicine despite its common dismissal among the literati. Most efficacy claims are not well supported in Alternative Medicine. However, it is not necessarily irrational to give them credence, or to rely on anecdotal evidence, because testimony is so central to nearly all medical evidence, and people are very differently placed in the reasons they might have to believe or disbelieve testimony. In addition, there may be non-curative value in alternative medicine. Cosmopolitanism does not advise an attitude of “anything goes,” but does urge humility on those of whatever persuasion who dismiss other traditions or people as irrational.

Medical Cosmopolitanism

This chapter seeks an attitude to medicine that does not commit the error of EBM in committing to an unjustifiably rigid notion of evidence, nor the reaction of Medical Nihilism of adopting EBM’s standards of evidence and then raising the bar even higher. Cosmopolitanism is a position developed by Appiah in the context of ethical disagreement, designed to facilitate conversation without falling into epistemic relativism. The chapter unpacks Cosmopolitanism into four stances: metaphysical, epistemic, moral, and practical. It applies these stances to medicine to yield Medical Cosmopolitanism. On this realist view, medical facts (e.g., whether an intervention works, whether someone is sick) are not dependent on the perceiver. Nonetheless Cosmopolitanism promotes epistemic humility: the attitude that one has limited confidence in one’s medical beliefs (both of efficacy and of the inefficacy of someone else’s favored intervention). And it promotes Primacy of Practice: settle cases first, principles later.

The Goal of Medicine

In order to say what medicine is, we need to identify the goal of medicine, the business of medicine, and the nature of health and disease. This chapter introduces the Curative Thesis: both the goal and business of medicine are cure. The Curative Thesis is found to be correct that there is one ultimate goal of medicine: cure. Definitions of cure (and therapy) are discussed. The chapter considers and rejects the view that pain relief is a goal of medicine. The Puzzle of Ineffective Medicine and the Argument from the Persistence of Ineffective Medicine are introduced, concluding that the business of medicine cannot be cure. The business of medicine is the use of a competence or skill, and the persistence of ineffective medicine shows that curing is often not a competence doctors always—or even commonly—possess. But we still recognize medical skill, which must therefore be something else.

Medical Nihilism

One thread running through this book so far has been a concern that medicine is not all it is cracked up to be. This chapter considers the most dramatic version of this stance, namely Medical Nihilism. Nihilism is the view that its object is worthless, accompanied by an emotional reaction of despair. Medical Nihilism is this attitude toward medicine. It was a common stance in the 19th century because of the persistent elusiveness of cures. The chapter considers Wootton’s nihilism about historical Western medicine, but focuses on Stegenga’s recent arguments for low confidence in contemporary medicine. Stegenga’s arguments are ultimately rejected, but the larger lesson is Medical Nihilism relies heavily on the Curative Thesis. Even if Therapeutic Nihilism were warranted (which the chapter denies), this would not warrant Nihilism about the whole of medicine, if medicine is properly characterized by the Inquiry Thesis, as the earlier parts of the book contend.

Evidence-Based Medicine

This chapter marks a turn away from asking what medicine is, and toward asking what we should think of it. Evidence-Based Medicine (EBM) is the most influential development in thinking about attitudes to medicine in recent times. EBM has a prescription for medicine: make clinical decisions on the basis of “best evidence,” which is defined in a specific way. We should think more highly of interventions whose use is supported by better evidence. EBM also has a prescription for patients: hold your doctor to account, asking her to justify her proposed intervention in these terms. The chapter evaluates both prescriptions, and argues that, while both have their place, neither is a panacea.

Health and Disease

There has been considerable philosophical literature on the nature of health, which is briefly reviewed in this chapter. A distinction is drawn between two dimensions of disagreement in that literature: the objectivity dimension and the normativity dimension. With these distinctions in play, the positions traditionally considered poles of the debate, naturalism and normativism, are seen as diagonal opposites on a 2×2 matrix of possible positions, being Value-Independent Realism and Value-Dependent Anti-Realism respectively. Further support for this classification comes from a position in the bioethical literature, overlooked by philosophers of medicine, called Value-Dependent Realism (developed by Stempsey). The fourth quadrant, Value-Independent Anti-Realism, is unexplored, and the chapter proposes a theory of health in this quadrant, by arguing that health is a secondary property, akin to color, or possibly causation. This view is used to ground an evolutionary account of the health concept (quite distinct from previous evolutionary accounts of natural function).

The Business of Medicine

This chapter identifies a competence whose exercise might constitute the core business of medicine in the absence of curative competence. On the basis of an inference to the best explanation, the Inquiry Thesis is introduced: medicine is an inquiry into the nature and causes of disease, for purpose of cure. (The Inquiry and Curative Theses thus agree on the goal of medicine, but differ on its business.) The Bullshit Objection says that the core medical competence is bullshit—that is, duping patients into believing that medicine has cures when it does not. This is rejected on the basis of strong historical evidence that the ineffectiveness of medicine was widely known. The Whig’s Objection says that old medicine was just a mistake, and is rejected on the basis that it fails to acknowledge either the similarities between our epistemic position and that of our forebears, or the contribution their activities made to contemporary cures.

Varieties of Medicine

This chapter surveys the origins of medicine and introduces the concept of “Mainstream Medicine,” which is the globalized descendant of Western medicine. Based primarily on Roy Porter’s work, a broad-brush survey of the history of Mainstream Medicine is provided. The history of Alternative Medicine is also outlined, and a rough distinction drawn between Alternative and Traditional Medicine. The latter has its origins in a distinct geographical region and tradition, while the former typically involves conscious deviations from or rejections of the mainstream. Medical traditions from China, India, and Africa are briefly outlined. The chapter illustrates the geographical and temporal diversity of medical practices, in order to ground both the driving questions of the book—what is medicine, and what should we think of it? Any answer must handle the variety of medicine and be epistemically fair to the various traditions.