Scope and limitations of therapies: A neomillennial epistemological evaluation for helping medical practicesM Kothari, L Mehta
Formerly Professors of Anatomy, Seth GS Medical College, Parel, Mumbai, India
Medical practice is in crisis - the sophistications are enormous and expensive, and the outcomes leave much to be desired. An epistemologic evaluation that weighs the scope and limitations of any -pathy or any procedure seems to be the need of the day. As an example, described herein is the logic of such an exercise; and a sample of the exercise itself, taking cancer as an example.
Keywords: Cancer, cause, course, curable, epistemology, medicine, trans-research, trans-science, trans-technique
The unimaginable "gadgetic" sophistication of modern medicine (MM) is inevitably pregnant with heightened expectations by doctors and patients. The survival, nay dominance, of maverick works such as Illich's Medical Nemesis  and Malleson's Need Your Doctor Be So Useless?  in the teeth of the technological triumphs calls for an epistemological assessment of the global medical scene, all -pathies included.
"As we move into the new millennium, medical practice is going through an uneasy time. None of the richer Western societies have come to grief with how to cope with the increasing expectations of medical care and its spiraling costs." This fin de millennium despair of Sir David Weatherall  is symptomatic of an illness called medical science,  rich in medicolegal wrangles and a tarnished image of hitherto noble profession. All medical -pathies together have enough data to arrive at a state of Patient/Public Rationally Informed; Doctors/Donors Enlightened (PRIDE). The evidence-based PRIDE principle promises to repair and reinforce the bridge of faith, friendship and fraternity that connects the patient to the doctor. Enough goodwill, which can be based on evidence, is in store to inspire us to strive for a litigation-free, love-laden medical practice.
Epistemology, also called gnoseology or gnanology, is the science of evaluating the SCOPE and LIMITATIONS of any idea or action. Eminent anthropologist Ardrey  sums up epistemology in 4 words: Apples still fall down. The apocryphal fall of an apple on Newton's pate spawned the universalizing principle of gravitation, working on which for the past 300 years, we know about it to 40 places beyond the decimal point. And yet, gravitation refuses to get dictated by us, and an apple refuses to fall up. So do a gene, a cell, a cancer cell, a collagen fiber or coronary. None of the foregoing takes orders from any -pathy. The compelling logic behind the epistemologic clarity hopes to serve medical science. We had debated the issue in the British Medical Journal (BMJ).  What follows is an evidence-based elaboration of the same.
Cure, care, chirurgie, surgery are traceable to Skt. kar, Gk. cheiros and L. curatio - all implying hand, and through that, the act of caring. This etymologic elegance makes the EPIC (Every Problem Is Curable) concept applicable to issues ranging from development to death; and common cold to cancer, all of which can be taken care of. The "cure-ative" SCOPE of all -pathies - Heaven be blessed - is limitless.
From Skt. matra comes L. modus, implying measure, and spawning modern and medicine. Modern is that which is done in measured steps, i.e., carefully; and medicine is that which is administered in a precise measure. Modern medicine never connotes latest/ costly/ imported/ sophisticated acts, but such connotations have suited the 5-star culture admirably.
Skt. digga, disha, dakshata and L. decree gift us with the twin words doctor and doctrine, each connoting to teach/ guide/ direct. Skt. patit = fallen/in distress; and adding the suffix -ent to it creates the word patient, i.e., someone ill- at- ease. Treatment is derived from tractus = path, and involves showing to the patient the right direction. Ear after ear (pun intended), it has been universally realized, but, alas, not recognized that the physician's unhurried presence, the patient's words (= history), and the measured (= modern or medical) verbal response of the doctor are the best diagnostic, therapeutic and prognostic agents capable of inexpensive relief and of aborting iatrogeny and litigation.
What I like about WHO
Is no one knows what they do.
We still wait to be told
The cure for a cold.
- A clerihew by Sir W. M. James
There is a tremendous literature on cancer, but what we know for sure about it can be printed on a calling (visiting) card.
- August Bier (1861-1949), a leading surgeon of his time in Germany, medical historian and a philosopher of great erudition
In terms of cause/ course/ cure, medical systems "fighting" common cold to cancer find themselves unhelped by science, gadgetry, research, genetics or molecular biology. Whatsoever is offered by whichever -pathy is palliation of some sort. "The New Genetics begins to appear like a relentless catalogue of failed aspirations." (Le Fanu J.)  Nobelist Burnet  makes 2 evidence-loaded generalizations: (a) that "the contribution of laboratory science to medicine has virtually come to an end" and (b) "there has been no human benefit whatever from all that has been learnt of molecular biology." The poly-trans nature of medical science reduces it to more a matter of heart than head, more of compassion than conferences, more of tact than technique - the shift fully justifiable on the basis of evidence.
The human body is a binary unit - the cell representing the zero, and the fiber representing 1. Cytology is tottering on a precipice, for the nucleus has been dethroned and the nebulous cytoplasm rules the roost. Collagen, too complex a molecule, beyond all theories of wear and tear, exhibits a pan-mammalian plan whereby collagens of all mammals are strictly comparable, given the life-span adjustments. Albert Szent-Gyorgii,  a Nobelist, when asked "What is a cancer cell" regretted that he even did not know "what a normal cell is." And cancer cell is now deemed to be an irreversibly differentiated normal cell. 
Bertrand Russell  wrote way back in 1918 that causalism has disappeared from all advanced sciences. The survival of causalism in medicine indicates that medicine is neither science nor advanced. The allopathic - "genocentricism" (cancerogen, diabetogen, atherogen, schizophrenogen); the avurvedic lofty tridosha of vatta, pitta and cuffa: the homeopathic miasma; the naturopathic toxins have failed to help elucidate the cause of human maladies, for they, truly, are not causal in origin but coursal in nature. And all that the allopathic causalism has spawned is kill-joy preventionism, which has made no dent on the course of all human illnesses. The tenets of causalism ordain that the cause must precede the effect, which must follow the cause without loss of time. The dual facts, viz., cancers occurring despite absence of alleged causes and their not occurring despite the presence of the same, rule out medical causalism.
Globally respected medical thinkers have provided compact concepts on the limitations of MM. Cooke,  contributing to The Oxford Companion to Medicine, commenting under the heading doctors, sums up: "It needs to be more generally recognized that most of medicine is about relief of, and comfort in, suffering, and in the main very little to do with saving life." Bradshaw  of Ireland, drawing on BMJ, Lancet, JAMA and NEJM, has staged a mock trial, viz., Doctors on Trial, wherein, at the end of a lot of deliberations, the judge concludes: "In view of all this, not to speak of many minor faults, I find western doctors today are certainly more productive, directly or indirectly, of ill-health, in every sense, than of health; and therefore in the terms of the brief of this court I have no hesitation at all in finding doctors 'Guilty.'" The iconoclastic Illich  submits: "The pain, dysfunction, disability and anguish resulting from technical medicine make medicine one of the most rapidly growing epidemics of our time." Iatrogeny, in America (and elsewhere), competes with car accidents in terms of morbidity and mortality. Bloomfield,  a US physician, on the basis of a personal iatrogenic tragedy, has poignantly presented the therapeutic double edge: "Every hospital should have a plaque in the physicians' and students' entrances: 'There are some patients whom we cannot help; there are none whom we cannot harm'."
Erich Segal,  a doctor writing on Doctors, recalls the 1958 address by the Harvard dean to neophytes: "Gentleman, I urge you to engrave this on the template of your memories; there are thousands of diseases in this world, but Medical Science only has empirical cure for twenty-six of them. The rest is … guesswork." A Stanford dean has reportedly elaborated on the foregoing: "It is generally known that 50% of what we teach in medical schools is correct. The trouble is no one knows which 50%."
The GOLDEN-LETTERED TRIUMPHS OF MM reside in palliation - easing of whatever the "dis-ease"; repair of structural defects, including trauma; implants - dental, valvular, vascular, lentine, cochlear, articular; and managing emergencies. And these are the abiding victories that have earned for doctors, over the millennia, the status of GOD; and in R. L. Stevenson's words, "the honor of being the flower of our civilization". Wildavksy,  a US physician, while admitting that "most of the bad things that happen to people are at present beyond the reach of medicine," generalizes that MM is clearly helpful/ successful in 1 out of 10 problems. MM has progressively refined the diagnostic/ therapeutic wherewithal to tilt, in acute emergencies, the disturbed physiologies in favor of survival. However, global survey and experiences confirm, in the best of Medical Intensive Care Unit (MICU) and Intensive Cardiac Care Unit (ICCU), the Chinese proverb: The doctor's medicine works on a patient destined to survive. The PLATINUM-LETTERED TRIUMPH OF MM STUDDED WITH DIAMONDS AND RUBIES lies in its ability to relieve the worst kinds of pain expeditiously and effectively. Needless to emphasize, that the whole discipline of anesthesiology is an example of pain-relief, and has paved ways for the extant and expected surgical miracles.
A huge tome on Controversies in Psychiatry has its first section on the "future of psychiatry," wherein the following three are the launching words: "BLEAK AT BEST."  Koestler  addressed the World Psychiatric Association in 1969 under the title "Can psychiatrists be trusted?" to conclude, after adequate details, in the negative. The 26 th edition of Martindale's Pharmacopoeia, in its section on tranquillizers and psychotropic drugs, sounds bluntly candid  : "The term tranquillizer is not altogether an appropriate one because many of the compounds to which it has been applied do not differ markedly in their effects from barbiturates given in appropriate dose. Other terms which have been used such as ataractic drugs, psychotropic drugs, and neuroleptic drugs are no more specific in their connotation and offer no advantages over the established, if abused, term tranquillizer."
A definition encases definitiveness that gives direction. But MM is poor on defining normal, abnormal, blood pressure (BP), coronary artery disease (CAD), cancer, diabetes mellitus, hyperlipidemia, infection, fever and what have you. Medical texts - all disciplines - and dictionaries, not excluding the Encyclopedia Britannica, use the words normal and abnormal pan-textually without bothering to define them. The latest, 2007, edition of the Dorland's Dictionary,  now, goes as far as defining the word normal (from L. norma = rule) as "agreeing with the regular and established type;" which raises the question of what really is the regular and established type. The great Virchow declared that a man even under the threat of death cannot define what cancer is. And the high-BP guru, Pickering,  lamented that neither he nor his colleagues know where normality ends and abnormality begins. Ardrey  clarified that normality is a range, not an average, and is inapplicable at an individual level. So MM, like the stocks and "Sensex," keeps on lowering the levels at which you call it hypertension or hyperlipidemia - a free-for-all with lot of iatrogeny with botched-up bedroom and breakfast.
It is popularly acknowledged that the diseased do not necessarily die nor the healthy necessarily survive. The Roman emperor Marcus Aurelius,  1 st century AD, aphorized: "Many a physician forecasting doom for the patient has had his own funeral attended by the same patient." Hardin Jones,  of the National Cancer Institute, concluded from a global survey that not cancer but "some physiologic mechanism" causes death. Such shows repeat in coronaryology, neurology and so on. Thomas McKeown,  a prominent public health man in UK, summarized that MM and its physicians cannot be credited with having added to the human life expectancy. Alex Scott-Samuel,  community physician, Liverpool, generalized that "the sacrifice encouraged by the radical critics of Western health care in moving away from a tradition of professional dominance may be nothing like as great as hitherto been feared."
The viruses and bacteria, barely visible through the microscope, aggregately create a microuniverse , that outweighs the total animal biomass - worm to whale - by 100 times. They are the host; and we, humans, the pampered guests. We survive and thrive through their grace. Each human carries  on the body 10 bacteria for every single human cell, the bacterial biomass weighing  over 2 kg. The facts that the human population has been, recordably, climbing up  and up 1450 AD onwards; that after the arrival of antibiotics the survival/ mortality rates of humans have shown no deflection; and that despite crass pollution of air and water, the poorest countries keep on piling up their population, can only mean that the axiom Friendship between microbes and man is a rule; enmity, an exception can be accepted as valid. Koprowski  in his address "The future of infectious diseases" in a Ciba symposium on Man and His Future, 1963, issued a stern warning: "If a universal antibiotic is found, immediately organize societies to prevent its use. It should be dealt with as we should have treated, and did not treat, the atomic bomb. Use any feasible national and international deterrents to prevent it falling into the hands of stupid people who probably will still be in the majority in your time as they were in mine." Professor Raeburn  writing in The Lancet, 1972, on "antibiotics and immunodeficiency", delivered a grave prophesy: "In years to come, the story of antibiotics may rank as Nature's most malicious trick" against mankind. Sanderson,  also of UK, generalized that "bacteria have successfully survived the antibiotic era." Antibiotics, at best, are microfluctuators for better or worse.
The above is the title  of a multispecialty/ multi-authored tome from the Rockefeller Foundation, USA. Whereas the mighty USA spent a mere 8 to 10 billion dollars per year on health in the 60s and 70s, close to the fin de millennium and thereafter, it has been spending 5 billion dollars a day, which means the manufacturers, hospitals, doctors are doing better, but the patients are feeling worse. We are mentioning this in passing to emphasize that no amount of money can lessen MM's limitations or widen its scope, in USA and in India. Money is not the solution to MM's realistic incompetence.
The above denunciation (10 points) may seem a hyperbole in pessimism. We need to underscore a Russian proverb: A pessimist is a well-informed optimist. Our thoughts and treatise on cancer  are 35 years young, in quite a few languages overseas and in India, and have stood the test of time in needing no change even of a punctuation mark. The 10 th chapter in the smaller version Cancer: Myths and Realities of Cause and Cure  of the above-mentioned tome The Nature of Cancer  is terse: "Cancer is unresearchable," and has remained unassailable. The book on death  has two chapters "Trans-science" and "Trans-technique Aspects of Disease and Death", both of which have survived unchallenged. This entire presentation may be taken as a personalized hyper-view, but our work has been upheld on par  with such "major antidevelopment thinkers as Masunobu Fukuoka and Gustavo Esteva."  We plead in the lines of Michael O'Donnell,  that skepticism is a necessary stimulant that MM desperately needs today.
Set below are 10 compact generalizations  made by us on cancer over 35 years ago. We plead that other disciplines may follow suit.
The overweening regard that MM posits in whatever is peer-reviewed is understandable, but the same has failed to fulfill its presumed function. A recent editorial  in The Times of India, Mumbai, October 23, 2008, is titled "Peer-reviewed Rubbish", with an epigraphic note: "Even the respected science journals often publish spurious research." Nobelist Burnet  holds no punch in declaring that telling a white lie, for the avowed purpose of getting grants, has turned into a norm in medical research. An anthology  of medical frauds by Broad and Wade, significantly titled Betrayers of the Truth - Fraud and Deceit in the Halls of Science, is a significant pointer. The foregoing empowers an average medical student or teacher or researcher to have a healthy disrespect for whatever that passes on as standard MM. John Horgan's profound tome exposes The End of Science and urges Facing the Limits of Knowledge in Twilight of the Scientific Age.  Bertrand Russell  bemoaned, circa 1930, that modern education teaches more to do and less to reflect. A paradigm shift in medical thought, teaching and doing is warranted.
Medical practice, all -pathies included, is turning into a genureflexopathy - a knee-jerk treatment for every visit, every complaint. Harvard's Jerome Groopman's How Doctors Think  reveals that, we, doctors, have stopped thinking. Burnet's  1971 prophesy - "The great pharmaceutical houses … may come to feature in history as examples both of the productivity of science applied to industry and the evil inherent in the technological momentum of a competitive industrial society" - is turning into a hard third-millennial reality. The 7-star medical conferences, full of banquets and cruises, portray an unholy alliance , between marketing and medicine. Either we medicos wake up or we may never.