Georg Ivanovas From Autism to Humanism - systems theory in medicine
When I started this thesis in the year 2000 it was a pioneering work. Systemic ideas in medicine were practically non-existent. This was slowly changing when the work was first finished in 2005. From that time on articles on systemic biology and medicine mushroom. It seems that the time has come that these principles enter the medical discourse.
As this work has never been published, due to certain delays, much has been expressed more detailed and better in the meantime. Thus, parts of this thesis may be somehow ‘outdated’ in terms of novelty. It became even apparent that recursive logic is necessary to understand biological processes (Isalan/Morrison 2009). Or ideas like that of a ‘viral flora’ (Ivanovas 2006) are now discussed occasionally (Holmes 2007) although not as a generally accepted fact.
Anyhow, this work might still have some value, as it discusses the epistemological foundations of a systemic medicine more detailed than specialised articles and reviews. Moreover, it has been written from the practitioner’s point of view. That is, it includes a lot of empirical observations, rarely found in normal scientific papers.
A good example is the field of epigenetics, as it is called today. Until recently everybody who claimed that there is a transmission of inherited characteristics would have been regarded as heretic and would have been burned on the pyre of the scientific opinion. Nevertheless, such formerly heretic and now modern opinions exist. Homeopathy always had a rather elaborate model of how acquired infections might contribute to the development of chronic diseases in the offspring. Such an empirical knowledge might contribute more to the understanding of epigenetics than laboratory testing with rats.
We see here a typical example of the area of conflict between observational medicine relying on empirical evidence and a ‘scientific’ medicine relying on laboratory experiments and randomised trials. This conflict is essential for medicine (Vandenbroucke 2008) and will be discussed in many different regards.
Until now, empirical knowledge had been mostly neglected. One reason is prejudice. Simple observation is often discredited as unscientific. However, in order to understand such complex and nonlinear issues like robustness and the self-organization new strategies of observation are necessary. The reductionist setting just does not do it anymore. That is, an emphasis on observational medicine is a natural consequence of the new direction medicine has to take in order to solve the forthcoming problems.
This thesis is absolutely biased towards the observational arm of medical science. Of course, this is a controversial attitude, difficult to get used to. But it is somehow a natural response to the one-sidedness of the last 50 years.
Another obstacle for the usage of empirical knowledge is language. Most clinical observations are made outside of the scientific frame of the universiterian medicine. They are mostly made by people not or insufficiently trained in the scientific method, more often than not using a kind of obscure theoretical framework. This becomes especially true when observations of former centuries based on archaic theories are taken into account. To discard such a knowledge is as will be demonstrated later not appropriate.
In order to use such empirical knowledge it has to be translated into the scientific language. This is somehow difficult, as the current theory of medical science does not provide an adequate terminology and/or epistemology to evaluate empirical knowledge. That is, the current scientific approach is defective when it comes to the assessment of individual human reactions.
The appropriate epistemological tool for this purpose is systems theory. Nobody earnestly concerned with biological and medical research today doubts that systems theory is the key for future research. A search in the database of the European Science Foundation with the key word ‘systems biology’ might be proof enough.
However, it requires a close acquaintance with the underlying principles to apply systemic concepts. No article on systemic biology and medicine should be published without a detailed knowledge of recursive processes. Unfortunately, this is mostly not the case. More often than not a systemic vocabulary is just used to promote old linear concepts.
The main concern of this work is not about the issues discussed. The main concern is how it is possible to think about such issues. Of course, it is a rather serious question whether current medicine creates a rigidity in the humans leading to a reduced adaptability. But not the question as such is important in this context. Important is how we become able to model, conceptualise and discuss these kinds of subjects. It is my strong conviction that it is less important what we think, in order to solve the impending problems. Important is how we think.
It is often heard that medicine is in a crisis. Of course, there is an ethical crisis concerning stem cell research, cloning or the question whether a single, unemployed woman living in a three room flat having already six children should really deliver octuplets through fertilization treatment requiring 46 physicians and helpers only for the delivery (Harris 2009). This might be a medical success. But should really everything be done that could be done? There is an economic crisis, as well, as it becomes ever harder to afford current medical treatments. Moreover, there is a medicalisation of medicine (McLellan 2007) as nearly everybody is treated with drugs from before birth until death. 40% of the German population are continually treated with drugs. Among elders above 65 years the percentage is 80%, not included the over the counter drugs (ABDA 2008). Addiction to medical drugs became a major problem (chap. 4.6.b) and fatal side effects of drug therapy sum up to 3% of all deaths in the general population (Wester et al. 2008). But even deeper is the crisis concerning the whole orientation of medicine. Medical thinking became very restricted. “Medical schools had become schools of molecular biology and biochemistry, rather than schools of medicine” (Herbert Simon cited in Rees 2002). As a result, clinical research is neglected or even “dying” (Clark/Smith 2003), as some judge. And primary care tends to leave everything to specialists (Bodenheimer 2006).
The very reason for this crisis is to a large extend that the logical and epistemological developments of the last hundred years have never been incorporated into the medical discourse and thinking. On the contrary, as it will be demonstrated, scientific medical thinking made a step backwards since its programmatic formulation through Bernard 150 years ago (Bernard 1865). When Bleuler 80 years ago described the medical thinking of his time as autistic and undisciplined (Bleuler 1962) there still was a lack of suitable tools to cope with complexity. But although the logical tools are now available, they are not applied in medical research and practice (1). Therefore, the statements of Bleuler are still up to date.
A minute analysis will show that the overemphasis of the so called ‘scientific approach’ is not more scientific than a lot of ‘unscientific approaches’ that have been discarded the last decades.
Some time it seemed that evidence based medicine (EBM) would be a key to solve the current crisis, but this is not the case. EBM is subjugated to the same epistemological inconsistencies and fallacies that characterize the whole experimental approach (chap 2.5).
General medicine is in a sort of dilemma which I have call the practitioner’s paradox (chap. 2.1.g). A physician has knowledge of the function of parts (provided by anatomy, physiology, biochemistry and pharmacology) and of populations (provided by trials). But it is an insular, uncorrelated knowledge, not able to represent the complexity of medical practice. For example, “a lot of data exist about treatment of chronic obstructive pulmonary disease or management of type 2 diabetes for patients younger than 75 years. There is, however, little evidence about how to treat an 82-year-old patient who has both disorders” (Maesemeer et al 2003). In fact, when we see it strictly, there is no evidence.
Patients have to be understood as a whole and not only in their parts. It has to be understood what really constitutes their illness, something that exceeds the simple diagnosing process. “Without the ability to do this, textbook knowledge is singularly futile” (Swales 2002). Medical education does not provide an according knowledge. The best proof is the experience of every physician opening his/her office (Lancet editorial 2004). Patients have a lot of unclear symptoms leading to “extensive somatic investigation and treatment, which is largely ineffective and sometimes iatrogenic” (Ring et al. 2004). This problem is not due to a lack of scientific knowledge. It is due to the false or non-existent complexity management in medicine and “throwing more money at such problems is unlikely to produce meaningful or sustained change” (Clark/Tugwell 2004). In order to treat a particular patient in a specific situation a kind of contextual evidence is necessary (Maesemeer et al, 2003).
There have been attempts to solve this problem. British undergraduate teaching has totally changed recently promoting a problem based learning. As this dismisses the usual way of understanding medicine, it has been harshly criticized (Williams/Lau 2004).
In the US the Initiative to transform medical education aims to improve the learning situation with many different measures. One are courses of the narrative medicine movement where students have, for example, to read and write literary texts. The aim is to improve the ability to communicate with patients (Smith D 2003), to understand better their individuality (Chen 2008).
Both attempts have something in common. They tend to change not so much what students think, but how students think. This can exemplified by an analysis of the scientific and the artistic approach to medicine: “Physicians are taught to shun conclusions based on single experiences and to look for evidence based on a substantial number of cases. Consequently, their approach has to be statistical. Writers, however, seek out anecdotes as a way of making larger statements, a way not just of capturing attention but of highlighting a point. The anecdote or individual story is the natural language of the writer. Similarly, writers tend to shun statistics. In the writer's world, statistics obscure souls. Whole lives get gobbled up by whole numbers. If nothing is real to medical researchers except as it happens to a significant number of people, nothing is real to a writer save as it happens to a single person.
The medical scientist is trained to avoid conclusions except on the basis of repeated experiences. He reasons from the general to the particular. The writer is readily attracted to individual experiences. He reasons from the particular to the general and searches through the crowd for the few faces that can become the biography of their times. In novels, the experience of a vast aggregation of human beings becomes real only as it is portrayed through the lives of a few individuals. The evils or ordeals lodged in sectors of society are best understood in terms of their impact on individual lives and have meaning precisely because readers see themselves in the story. Reality rides on direct connections from one life to another.” (Cousins 1990: 12-13).
What we see here is a good description of the practitioner’s paradox. That is, medicine is much more artistic than the scientific picture suggests. The former editor of the British Medical Journal (BMJ) even compares doctors with jazz musicians, not with scientists (Smith 2004c). This is a good metaphor, even used in economics (Jazzonomics), meaning that jazz and economics are played in a collective context. There is a rhythm. You pick it up. You go into the tune. And then you improvise. There are no clear cut plans. They are not possible, neither in jazz, nor in economics. You have to follow what comes up. (Ostrowski 2009). The same has to be presumed for medicine. If plans are followed too strictly, the patients may have to pay for it.
The Lancet has its column about the ‘art of medicine’ and, of course, medicine has been called an art from ancient times on. Consequently, the advices of BMJ’s editorial board to young doctors are centred around other issues than scientific truth. They have much more to do with the attitude and with human values. The 12th advice even says “Don't believe what you read in medical journals and newspapers” (Smith 2003f, appendix I).
However, there is a certain fallacy in this discussion about the dichotomy between art and science. This dichotomy does not really exist. It is a characteristic of the map (chap. 3.8), of how we understand science, not of the territory the practice of medicine. The impression of some medical textbooks that it is possible to treat a disease in the absence of a physician and of a patient is wrong. As long as there is a difference between a (scientific) medicine in theory and an (artistic) medicine in practice the used epistemology must be defective.
It really would be poor reasoning to maintain that it is simply impossible to say something scientifically about a single patient. It also would be poor reasoning to regard the relation between the physician and the patient as being no part of the ‘real’ science. And it is still poor reasoning to neglect the wider frame of the social context and/or to define it as ‘non-medical’ (chap. 3.6). A simple example is the cholesterol discussion: An intense media campaign has convinced people that it is most important to lower cholesterol levels. Thus Liptor® (Atorvastation) became the best selling drug ever with sales over 8 billion $ (McKinnell 2003) and many patients believe that cholesterol is a kind of unavoidable poison. After the ENHANCE study failed to prove that Vytorin® (a combination of two cholesterol lowerers) performs better than a placebo (Greenland/Lloyd-Jones D 2008, Kastelein et al. 2008) leading cardiologists explained publicly that “the idea that you’re just going to lower LDL and people are going to get better, is too simplistic, much too simplistic” (Berenson 2008b). Others even declared that the whole cholesterol issue is but an unproven hypothesis (Taubes 2008). Such events remind us that medicine is also big theatre and in order not to forget the artistic part of medicine that we are all protagonists in a comédie humaine.
Nevertheless, a science of medicine has to provide the epistemological tools to investigate even these events. How shall we conceptualise the current paradigm of ‘medicine = giving a drug’ in a scientific frame? Of course there is an ongoing tendency to make medicine more ‘scientifical’. But if the human nature of medicine is not understood, any ‘solution’ is more a part of the problem than a part of the solution.
A first attempt to overcome some of these difficulties was the psychosomatic movement of the last decades. But it was not able to fulfil the expectations as it was also conjugated to the same epistemological restrictions as the normal scientific medicine. That is, it had no tool to deal with complexity and remained within a two valued logic (chap 2.3).
Modern epistemology, especially systems theory provides the necessary logical tools to solve the problems posed above. It enables to conceptualise a lot of current open issues and gives insight into deeper structures leading to a better understanding of health and therapy.
The aim of this thesis is to apply the concepts of general systems theory onto medical thinking, to formulate old and new medical insights and to provide sound categories for a discourse on medical complexity.
In the first section of this work I will make an attempt to define the current medical paradigm and try to show its limitations on following levels:
In the second section relevant epistemological fundamentals of the last century are presented and connected to medical issues, in order to show their impact.
The third section comprises cybernetic and systemic concepts. These tools are important to understand and to conceptualise organisation. There is a growing use of such tools now, but mainly in basic research as in biology, less in medicine.
The most important attempt to use systemic models was undertaken by systemic psychotherapy providing a solid ground for the investigation of medical structures. But also other methods of the so called empirical or observational medicine have used similar models since ancient times. That is, physicians always had a systemic approach. The discussion of such methods like the systemic psychotherapy, Hippocratic medicine and some parts of the so called complementary and alternative medicine (CAM) is done in the fourth section, demonstrating that old observations are in line with current concepts of health and disease and often exceed them in their understanding of organisation.
In the fifth section I will try to combine different findings and to pave a way towards a systemic medicine, that is, a medicine which is based on the understanding of complexity and self-organization.
(1) Bateson, a major forerunner in complex thinking, resumed after having taught all kind of medical professionals from college students to experienced psychiatrists: “I have encountered a very strange gap in their thinking that springs from lack of certain tools of thought” (Bateson, 1980: 27).