Georg Ivanovas From Autism to Humanism - systems theory in medicine
Rarely a term was as successful as Kuhn’s paradigm introduced 1962 into the scientific discourse. Since then everybody is talking about a ‘shift of paradigm’ and nobody really knows what it means. This is not astonishing because Kuhn never defined the term accurately. He did not have the logical tools cited above, as they were only established at the time when Kuhn published his book. With these tools, it is easy to define what a paradigm is: A paradigm is the decision of an in principle undecidable question (chap. 3.4). It decides on the axioms to be taken into account. It is Bateson’s frame giving meaning to the facts (chap. 3.6).
A paradigm is, according to von Foerster, the result of a metaphysical act. Kuhn describes it that way: “The man who embraces a new paradigm at an early stage must often do so in defiance of the evidence provided by problem-solving. He must, that is, have faith that the new paradigm will succeed with various large problems that confront it, knowing only that the older paradigm has failed with a few. A decision of that kind can only be made of faith” (Kuhn: 158). However, the decision to follow the current, accepted paradigm is a decision of faith, either. It is also a metaphysical act, not a scientific decision. As it is impossible not to communicate, it is as well impossible not to decide on a paradigm.
The paradigm of a certain period is never explained. Actually, often it is impossible to explain it. Even logicians are faced with this problem within their own discipline: “When the neophyte asks ‘What is mathematics?’ or ‘What is physics?’ perhaps the best reply is: ‘You can make up your mind as to that, after you have become acquainted with what mathematicians and physicists do.’ The same general point holds true of logic” (Mattes: 3-4).
“The study of paradigms …is what mainly prepares the student for membership in the particular scientific community with which he will practice” (Kuhn: 10-11). Becoming used to the official paradigm means to enter normal science. The best way to study the paradigm is to read a textbook on the subject. “When the individual scientist can take a paradigm for granted, he need no longer, in his major works, attempt to build his field anew, starting from first principles and justifying the use of each concept introduced. That can be left to the writer of textbooks. Given a textbook, however, the creative scientist can begin his research where it leaves off and thus concentrate exclusively upon the subtlest and most esoteric aspects of the natural phenomena that concern his group” (Kuhn: 19-20). The science based on textbooks is an esoteric science, laid down in journals and discussed on congresses, only understood by those belonging to this group. That is, when a paradigm is set, it is much easier to explain all related issues, something not true, when a new approach is introduced. (1)
An esoteric science based on the decision of an undecidable question brings up only decidable questions. Kuhn calls this process puzzle-solving, the main activity of scientists. “Mopping-up are what engage most scientists throughout their careers. They constitute what I am here calling normal science. Closely examined, whether historically or in the contemporary laboratory, that enterprise seems an attempt to force nature into the preformed and relatively inflexible box that the paradigm supplies. No part of the aim of normal science is to call forth new sorts of phenomena; indeed those that will not fit the box are often not seen at all. Nor do scientists normally aim to invent new theories, and they are very often intolerant of those invented by others. Instead, normal-scientific research is directed to the articulation of those phenomena and theories that the paradigm already supplies” (Kuhn: 24).
Such a paradigm possesses it cannot be different large unseen areas. This leads to the following situation: “Normal science, the activity in which most scientists inevitably spend almost all their time, is predicated on the assumption that the scientific community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost. Normal science, for example, often suppresses fundamental novelties because they are necessarily subversive of its basic commitments. Nevertheless, so long as those commitments retain an element of the arbitrary, the very nature of normal research ensures that novelty shall not be suppressed for very long. Sometimes a normal problem, one that ought to be solved by known rules and procedures, resists the reiterated onslaught of the ablest members of the group within whose competence it falls. On the other occasion a piece of equipment designed and constructed for the purpose of normal research fails to perform in the anticipated manner, revealing an anomaly that cannot, despite repeated effort, be aligned with professional expectation. In these and other ways besides, normal science repeatedly goes astray” (Kuhn: 5-6). “Failure to achieve a solution discredits only the scientist and not the theory…... ‘It is a poor carpenter who blames his tools’” (Kuhn: 80).
In medicine there are many such anomalies: the excesses in neurology (chap. 2.2), the placebo effect (chap. 2.4), the findings of nutritionism (chap. 2.8.a), the development of chronic disease or the handling of multi-morbidity. Such examples represent the anomalies of the normal science, of the current paradigm. The current medical paradigm is not able to solve these problems. However, “though (scientists) might begin to loose faith and then to consider alternatives, they do not renounce the paradigm that has led them into crisis. They do not, that is, treat anomalies as counter-instances, though in the vocabulary of philosophy of science that is what they are” (Kuhn: 77).
Kuhn’s approach is restricted. He concentrates his research only onto scientific contents. Thus he misses the meta-level of the frame. In medicine the students do not only learn ‘knowledge’ and study the paradigm. They learn, as well, how a correct professional has to behave, the correct attitude (chap. 6.14).
This part of the studies has been called the ‘hidden curriculum’ (Lempp/Seale 2004, Chen 2009). An investigation of the current hidden curriculum showed six major learning processes that medical students have to perform: loss of idealism, adoption of a "ritualised" professional identity, emotional neutralisation, change of ethical integrity, acceptance of hierarchy, and learning less formal aspects of good doctoring (Anbbasi 2004b). The decrease of empathy in medical students is well established and it seems that the current biochemical paradigm is a main contributor to this decline (Shapiro 2008).
(1) This concerns also this thesis. It aims to support the introduction of a new paradigm into medicine. Thus many issues have to be explained at length which are evident for those acquainted with systems thinking.