by James Willis
Keynote address on ‘Science’ given to the 50th Anniversary Spring Symposium of the Royal College of General Practitioners, Birmingham International Conference Centre, 13 April 2002
It is a great privilege and honour to be asked to give this talk on this occasion. Indeed I believe the fact that I am here is scientific evidence that there must be hundreds, if not thousands, of parallel universes in which people much better qualified than I am to speak on Science, are at this moment clearing their throats to start the same address.
But seriously, I think that being (until recently) an ordinary GP gives me the best qualification of all – to speak as a representative of my peers, if that is not too presumptuous, as a kind of Everyman, or at least an EveryDoc. And if you will bear with me, I certainly have something to say…
Introduction: My upbringing in science
My father was a scientist. A ‘proper doctor’. A PhD. He was one of the team who set up the Atomic Energy Research Establishment at Harwell after the Second World War. He went on to become Atomic Energy attaché at the British Embassy in Washington and later secretary of the British Association for the Advancement of Science. The “British Ass”, as it is affectionately called.
Throughout my childhood I had countless conversations with him about science. While he was servicing his car, while I was helping him make chicken houses in our garden out of off-cuts from Bagley Wood sawmills, on car journeys, and especially, I remember, while washing up after Sunday lunches.
I grew up thinking that everyone had fathers who understood, with crystal clarity, the principles of science. At that time Britain was developing no less than three separate technologies for the generation of nuclear power, as well as being heavily involved in the exploration of the sub-atomic structure of matter. And my father was at the centre of it all, and loved sharing his excitement at the rapidly unfolding mystery.
Here we are, on this great occasion, the fiftieth anniversary meeting of this great college, talking about something as serious and grand as science, and what am I doing talking about my childhood, and washing up?
And that is my first point: Science is just as true over the washing up as it is at a great meeting. Correctly applied, science is objective, democratic, and empowering of every single one of us who is willing to learn its ways. What you say is what is important in science, not who you are or where you are saying it.
You may scoff at this naiveté, but I am talking about real science here, not one of its many perversions.
The challenge – and my subject
My message today starts with the premise that medicine must adhere to scientific principles and that doctors must remain scientists.
I will argue that the greatest challenge facing contemporary medicine is for it to retain its humanity, it’s caritas – or perhaps to regain its humanity – without losing this essential foundation in science. …To find a middle way. And more particularly, to justify that middle way in scientific terms.
I will argue, using the metaphor of my title, that medicine must steer a course between a sea monster and a whirlpool. In other words between Scylla and Charybdis.
My ‘Scylla’, hard on our port bow, has two heads (not unusual in a sea monster) – Antiscience and Pseudoscience.
And, to starboard , we have my ‘Charybdis’ – Scientific Fundamentalism.
I will argue that professions such as medicine require something which goes beyond rigid, classical science; and that for at least the foreseeable future they will continue to require the mysterious qualities of individual human minds. And that in order to do the job that is required of them, these minds must be freed from rigid constraints, and from illusory goals.
Finally, if we are going to marry the mechanism of medical practice with its mystery, which we must if we do not want to be forced to choose between the two, I will suggest that general practice may have a role to play in the search for a new scientific theory. One which finds some accommodation between the Classical and Romantic philosophies which diverged in Ancient Greece.
This is the sort of grand discussion which would have served well as a background to washing up the lunch.
Definition of science
There are many definitions of science, which of course comes from the Latin, scientia, meaning ‘knowledge’.
Louis Pasteur said:
‘Science advances through tentative answers to a series of more and more subtle questions which reach deeper and deeper into the essence of natural phenomena’
Konrad Lorentz said something slightly shorter:
‘Truth in science can be defined as the working hypothesis best suited to open the way to the next better one’
And the most elegant definition I have ever come across is by George Eliot, describing the new scientific ideas of Lydgate, the idealistic young general practitioner in her novel Middlemarch:
‘He was enamoured of that arduous invention which is the very eye of research, provisionally framing its object and correcting it to more and more exactness of relation…’
Science is the never-ending search for a better understanding of the laws that determine the form and functioning of the universe we live in. The point being that the whole edifice of science is based on the premise that there are such laws. And that they apply everywhere in the universe. And that we can understand them.
As Albert Einstein said,
‘…the eternal mystery of the world is its comprehensibility.’
But we can understand the world. And the continuous discovery of unexpected and beautiful laws underlying nature is compelling evidence that those laws exist as realities, not merely as a products of our imagination. This is because time and again they have proved more complex, internally-consistent and beautiful than mortal imagination could possibly have anticipated.
In other words this is compelling evidence that the laws must have been ‘out there’ already. Quod Erat Demonstrandum
This is the crucial point I want to make at this stage: However elegant the scientific model, there is always a reality out there, beyond, which the model represents.
So science is the study of the world as it is, not as we think it is. It has always surprised us in the past and for it not to go on surprising us would be not so much surprising, as inconceivable.
Antiscience is the first of the hazards on our journey – the first ravenous head reaching to snatch our medically-qualified crew as we navigate, Odysseus-like, through the straits of Messina.
The principal error of antiscience is the belief that many of the ills of the modern world arise from science per se, and not from the misapplication of science.
There is a strong vein of antiscience in all of us. We feel threatened by science, demeaned by its apparently-unchallengeable authority, by its aura of certainty. While we are fascinated by its power we fear the abuse of that power. Hiroshima, the Cuban missile crisis, Chernobyl, Thalidomide. We wonder where science is leading us now and what disasters may lie ahead. Mobile ‘phones suffusing our brains with microwaves. The world’s crops being genetically modified to produce insecticides in their sap. Cloning presenting the nightmare prospect of arbitrary numbers of identical copies of rich celebrities. Churchill’s words still resonate, about a ‘new dark age, made more sinister, and perhaps more prolonged, by the lights of a perverted science‘ This fear of science is deep-seated and instinctive. In its extreme form it manifests as a fashionable vilification of science and sometimes of individual scientists
Science in its coldest, most dogmatic form seems to leave no room for art, for humanity, for those things that make life worth living. It creates the illusion that everything is buttoned-down and that progress has become so technical that there is nothing of importance left for individual people, unsupported by elaborate apparatus or academic status, to do. It deprives them of their crucially-important opportunity (their birthright, some would say) to make a difference in the world. And it seems to paint a bleak picture of humanity, casting us as mere automata in a purposeless universe.
In medicine we see patients rejecting standard advice, impeccably science-based though it may be, because they have assessed the pros and cons presented to them and they have applied their own values. And we can sympathise with this ‘non-compliance’. Indeed ‘compliance’, a quaintly patronising term to modern ears, invites reaction and scepticism. Individual people, doctors and patients alike, often place a higher value on the quality of their lives than on their length. Many sympathise, if no more, with the South American adventurer who, attacked by piranha fish in a particular way while swimming in the Amazon, is said to have walked straight to his revolver on the riverside and shot himself. And many would choose to forgo treatment of their marginally-raised blood pressure, labelled ‘hypertension’, if they understood not just that it was its treatment that was making them impotent (an understanding for which, of course, they would have science to thank) but that the protection offered is marginal, not absolute as they are inclined to hope, or as medicine, in spite of its claims to science, is inclined to imply. They would certainly be justified in reacting against any implication that the need for the treatment was absolute, or that failure to accept the advice was irresponsible.
Antiscience is fundamentally different from this justified reserve. It is irrational. In our science-dependent world, we seem to be faced just now by a worldwide resurgence of irrationality. We see patients rejecting treatments, vaccines, and ‘DRUGS’, through nothing more than an irrational rejection of all things scientific. How often do we hear people saying things like ‘of course they pumped him full of STEROIDS’ when the story sounds to us like a life being saved. There is an extraordinary faith in things that are ‘natural’. That all you have to do to remain well is to eat whole food, avoid E numbers, drink a great deal of water, dangle a Feng shui crystal, ‘detox’ (whatever that means) regularly, avoid power lines and make your bed on ley lines.
Not that a lot of our patients don’t still do what we doctors say, often more literally than we ever intended. But a lot of the ones who wouldn’t do what we say are invisible to us because they simply avoid us. And when these individuals are forced to confront scientific medicine, for example when society expects them to allow their children to be immunised with MMR vaccine, we are surprised by the strength of their reaction. This problem was greatly exacerbated by the fiasco of false reassurance and unscientific assertion which was the BSE catastrophe.
Let us examine this rejection, it may help us to clarify the meaning of science.
‘Just another theory’
More than half the American Nation, including its President before last, declares. ‘We are not going to believe (Darwinian) evolution – it’s just another theory’. I remember my daughters saying exactly the same thing to me when they were at that stage, (long since past, I’m happy to say) and I remember how impossible it was to argue with them. They simply didn’t accept the terms of my discussion. I couldn’t get any purchase. ‘It’s just another theory, Dad.’
But Darwinian evolution ISN’T ‘just another theory’. It is incomparably the most plausible explanation advanced so far for a complex series of observations. My ‘O’ level biology teacher, Joe Talbot, taught us the principle of natural selection in one sentence, ‘If you drop everyone in the sea a mile from Dover you get an incredibly rapid selection for people who can swim one mile’. That is not ‘just a theory’, it is quite obviously something which happens. And here is Fritjof Capra, author of The TAO of Physics, which was an early attempt to bridge the science/humanities divide, on the subject of evolution:
‘Pure chance, absolutely free but blind, at the very root of the stupendous edifice of evolution. This central concept of modern biology is no longer one among other conceivable hypotheses, it is today the sole conceivable hypothesis – the only one which squares with observed and tested fact and nothing warrants the supposition or the hope that on this score our position is ever likely to be revised.’
It is essential to make clear that science does not claim that this hypothesis is certain. On the contrary, science insists that Darwinian Evolution, like every other scientific theory, is incomplete.
Newtonian physics was a scientific theory which explained all the phenomena of nature which can be observed over scales extending from a fraction of a millimetre to roughly the distance between stars. The predictions of this theory were the basis of the industrial revolution and Newton is rightly regarded as one of the greatest scientists who has ever lived. But Einstein overturned Newton’s ideas about the absolute nature of space and time with his Theory of Relativity, and the subsequent remarkable prediction, later confirmed by observation, that massive objects can actually bend starlight.
Newton’s ‘classical physics’ and its claim to predict exactly the motion of all matter, also started to fail once we were capable of making observations of the unusual random behaviour of very fundamental particles of nature, like the electron and the photon (particle of light). And so the profoundly mysterious and fascinating theory of Quantum Physics and its Uncertainty Principle came to be put forward.
So, we have to choose our words carefully when we describe the progression of science. Newton was not ‘wrong’; rather his theory was brilliant in interpreting, and ‘modelling’ in mathematical terms, the natural phenomena observable in his day. Many elements of his theory are still valid and are in daily use. But his theory was incomplete.
So, undoubtedly, is Darwinian Evolution incomplete. It will certainly undergo progressive refinement. But while major revision is possible, it is, as Capra states, exceedingly unlikely.
But so-called creation science is utterly different. It does not have the remotest claim to be consistent with currently observable natural phenomena. On the contrary, it makes a virtue of rejecting the attempt to construct any such chain of logical deductions from observations, and claims pre-eminence for blind faith in the literal truth of the Bible. Furthermore its proponents insist that it is certain, and they insist that it cannot change. This, ladies and gentlemen, is the antithesis of science.
The truth is that we are utterly dependent on science in the modern world, whether we like it or not. We are doomed to ride the tiger of science, or suffer the usual fate of those who get off tigers. We need to understand how to use it better. Rejecting it is not, as they say, an option.
The second head of our sea-monster is even more deadly than antiscience, it has been snatching passing sailors for thousands of years. This is pseudoscience – the dressing up of non-science (or non-sense if you like) in scientific clothing.
The Romans employed a class of Etruscan diviners, Haruspices, who deduced the will of the gods by observing the entrails of sacrificial animals, (which, it has been pointed out, is not unlike obstetricians interpreting intrapartum cardiotocographic traces). These entrail observers also interpreted unusual phenomena of nature, especially thunder and lightning, and prescribed appropriate expiatory ceremonies after such events (which again has been likened to prolonged bed rest in hospitals and sanatoria!). The Encyclopaedia Britannica describes entrail divining as ‘a most complicated pseudoscience’ and tells us that the Roman Empire maintained a collegium of 60 haruspices; forming not so much a state priesthood, as a body of salaried expert advisers. I leave you to speculate on where today’s parallel with that may be.
Here is a copy of Ronald Reagan’s natal Chart.
Ronald Reagan probably consulted an astrologer. And his wife, Nancy, certainly used astrology in helping him to choose auspicious dates for his programme of events.
Even closer to the present time, here is the current internet advertisement for aerobic oxygen, warning against ineffective imitations, and with a remarkably up-to-date section as follows.
We have been asked about Aerobic Oxygen’s ability to kill Anthrax. We do not have the ability to obtain Anthrax for a test, however, Aerobic Oxygen does kill harmful bacteria and we feel it would probably kill Anthrax too
Now, please, don’t go home and give this advice to your patients.
And what of homoeopathy? I once had a patient who came to me for a treatment for her migraine. She said she’d got different homoeopathic ‘stuff’ for right and left migraine, but this time her migraine was at the back. She thought she’d come and see if some of my ‘stuff’ would do for that.
I tell patients I am delighted if homoeopathy helps them, but if it is doing anything physical to their body it is doing so through mechanisms which are unknown to science. Needless to say, they know the answer to that one!
The ‘Barefoot Doctor’ in the Observer newspaper, with his attribution of every ailment under the sun to ‘kidney meridians’ is a national disgrace. Not because he is free to say what he likes, that is a national pride. The national disgrace lies in the fact that a responsible newspaper gives its authority to this pseudoscience without distinguishing it from articles, much less sensational no doubt and much less conducive to sales – on real, empirical science. As though the two were on equal terms – as though each was, ‘just another theory’.
And that is another important point. While at the level of surface appearances such newspaper articles appear to be just different examples of the same kind of thing, what lies behind those articles is utterly different. One relates to our progressive groping towards understanding of a reality beyond, the other is pure hokum.
Popper’s principle of falsifiability
We cannot discuss the meaning of science without mentioning Sir Karl Popper’s principle of falsifiability. This man, who was our contemporary in England between moving here in the war until he died 7 years ago, was described by the Nobel Laureate Sir Peter Medawer as, ‘incomparably the greatest philosopher of science the world has ever known’
Steven Hawking, in his recent book, The Universe in a Nutshell, summarised Popper’s approach thus:
‘According to Popper’s way of thinking, a scientific theory is a mathematical model that describes and codifies the observations we make. A good theory will describe a large range of phenomena on the basis of a few simple postulates and will make definite predictions that can be tested. If the predictions agree with the observations, the theory survives that test, though it can never be proved to be correct. On the other hand, if the observations disagree with the predictions, one has to discard or modify the theory.’
Hawking, with his disarming, dry humour, adds in parentheses,
‘At least that is what is supposed to happen. In practice, people often question the accuracy of the observations and the reliability and moral character of those making the observations.’
Anyway, Popper rejected as ‘pseudoscience’ any system of beliefs that could not pass this ‘falsifiability criterion’. That covers entrail-observing, astrology and quack remedy peddling. It also includes politicians putting on scientific raiment when it suits them and casting it off when it doesn’t. Today it is politicians who have adopted the tricks of the old quacks, which were laughed at in the sixteenth century by the French renaissance philosopher Montaigne: their unintelligible language, their pretence of being masters of the mysterious, their contradictory doctrines, their incredible promises.
So we see politicians instructing doctors to practice according to ‘evidence’ when it suits them, and then telling them they must embrace ‘alternative medicine’ when they think that will win them votes. Even the British Medical Journal was misled into theming its 20 January 2001 issue on ‘Integrated medicine : orthodox meets alternative‘ as though colluding with the nonsense that this rag-bag of unproven remedies, charlatanism, self-deception and downright fraud could somehow meet scientific medicine on equal terms.
If anybody can show evidence that a particular remedy is effective, or has more than a ( not-to-be-despised ) placebo effect, then scientific medicine will embrace it.
But science has high standards for acceptance. Professor Stanley Prusiner, having received the 1997 Nobel Prize for Medicine after enduring decades of ridicule for suggesting that there might be a class of non-nucleic acid containing infectious agents – prions – said that scientists had been right to doubt him: ‘I think that scientists should be very reticent to accept new ideas’ he said, ‘99% of new ideas are wrong. We have to be very tough on our colleagues.’
On the other hand, John Kenneth Galbraith once remarked, ‘Faced with the choice between changing one’s mind and proving there is no need to do so, almost everyone gets busy on the proof.’ And I quoted Stephen Hawking a moment or two ago saying something very similar. So there is a resistance to new ideas that has nothing to do with science, but is merely a common feature of human behaviour. Science should constantly examine new ideas, the more bizarre the better.
Once supported by scientific evidence, not just of effectiveness but of safety, the absorption of a novel therapy into the mainstream will happen whether or not the change is welcome to the originators of the therapy, and even though it may result in the loss of some of its original ‘alternative’ magic. This magic can be very powerful – witness our patients’ reports of the uniform effectiveness and freedom from side-effects of the tablets they borrow from friends on holiday!
But real scientific knowledge is nobody’s territory, it is ‘out there’ to be discovered, and once a new hypothesis has become established it will be there for all to use until such time as it has been superseded by a better one. That process can’t be changed to suit the political convenience of governments any more than the preferences of individuals, and real doctors cannot be ‘told’ to adopt unscientific ideas, by governors or by Princes, any more than real science teachers can be ‘told’ to teach anti-science.
Having said all that trenchant stuff, which I sincerely believe, I have a confession to make. I practice many unscientific therapies myself. In particular, I manipulate joints. I also invent my own new and sometimes better ways of doing things, and I use them before they have had anything approaching the dignity of a randomised controlled trial. I can’t list them all now, in fact it would take longer than I have just to tell you my techniques for removing peas from children’s noses, let alone my technique for stopping pin-hole leaks from oedematous legs, which almost never fails. Or my original idea (as it was at the time) of using tiny doses of beta-blockers for driving-test nerves, it was a long time before I had a failure with that as well.
So how do I justify all this? Am I being inconsistent, or am I a hypocrite?
Well, this comes very close to the heart of what I am trying to say. I think there is a middle way, which we can justify in scientific terms, and I think it has a lot to do with something called scientific humility. We GPs know our limitations, we know that we don’t know all of the answers in medicine. And we have our laboriously-acquired, and still-more laboriously maintained, body of scientific understanding. That differentiates us from the quacks. But we also know, and I think I can speak for almost all of us here, that ‘There are more things in heaven and earth, Horatio, than are dreamt of in our philosophy’. I’ll come back to that at the end.
So, as we strive to steer our course clear of the ravening jaws of Scylla the two-headed sea monster, we are drawn perilously towards the whirlpool on our other side – the Charybdis of Scientific Fundamentalism.
It is another curious feature of the modern world that the retreat from rationality and authority that I have referred to is mirrored by a world-wide resurgence of fundamentalism, notably in religious faith. (Or perhaps this is not so much a mirroring as an intertwining, because there are undoubtedly fundamentalist aspects to the antiscience I have described.)
When we talk of religious fundamentalism we tend to think of Islam, but the rebirth of something similar in Christianity is closer to home for most of us. After a long period of free thinking and liberality, during which the Church of England at least was moving towards a sensitive and multi-faceted accommodation between faith and the picture of reality revealed by science, there has recently been a reaction against the insecurity and uncertainty that was the inevitable result. A new kind of evangelistic religion has arisen which has comforted some, and recruited many, but which has also disturbed and alienated those who had thought the church had moved into more enlightened times. It is hard not to see in this phenomenon a wholesale closing of minds and a retreat into blind faith. As the proverb says, ‘Men have greater faith in those things which they do not understand’. It is also hard not to see a link with changes that have been happening recently in medicine.
By Scientific Fundamentalism I mean the belief that science provides us with a complete explanation. This reminds me of one of Edward de Bono’s aphorisms, ‘The left front wheel of a motor car may be excellent, but it is not sufficient.’
This idea that science is sufficient and the assumption that its object is to get the world ‘finally, sorted out’, was brilliantly parodied by the late Douglas Adams in his BBC radio play The Hitch-hikers Guide to the Galaxy. With great perception, he attacked the idea that ‘THE ANSWER’ (…to the World, the Universe, and Everything…), once it was revealed, would be some sort of number. He famously made it the number 42 in his play. The scientific fundamentalist in each of us knows that it will really be a much bigger and more complicated number than that, but a number, sure enough, is what it is going to be. In other words, to a very large extent, the whole of our present culture assumes that the world is digital.
But, to return to evolution for a moment, our minds have evolved to deal with the world as it is, not as we think it is. And if our minds are digital machines, with one hundred thousand million neurones to apply to the job, it is hard to see why we have to do simple sums by counting on our fingers (our ‘digits’!) or on increasingly sophisticated substitutes (written numbers, abacus, computer, etc.).
Therefore, rather than being extraordinarily inefficient digital machines, it seems obvious to me that our brains have evolved (just as the functioning of an Olympic gymnast has evolved) to model the reality around us in an exquisitely efficient but fundamentally different way – by analogy. And that means modelling reality as it is, not as we think it is. In fact they are incredibly efficient, analogue machines, whose power to model reality our generation has enormously undervalued, because we can’t count that sort of thing…
In this digital age more and more aspects of life are being controlled by hard rules instead of by soft judgement. Indeed, the creation and refinement of rules is very close to being what we have come to mean by Progress. And rules, like numbers – digits – are absolutes. They are meant to be applied literally. Rules are not ‘made to be broken’ – not any more. Information technology and management technology have taken care of that. That’s what is meant by that word ‘modernisation’, which terrifies me when I see it used by newspaper leader-writers.
Yet sometimes it becomes clear that a particular rule does not work in practice. Usually this becomes apparent to the people who are trying to implement the rule at the same time as they are trying to implement all the other rules — long before it becomes clear to the people who drafted that particular rule, because the latter, understandably, think this is the one which is really important. (This is another human characteristic which has nothing to do with science or rationality.)
Now, the question of scientific fundamentalism comes in as we consider what we should do next, when everybody agrees that a particular rule is impractical. Do we go on refining the rule, in the belief that eventually it will be made perfect, and all the problems will be ‘sorted out’? Or do we decide that there are some aspects of life which cannot be decided by rules, and leave human minds the maximum possible freedom to sort them out in the way that human minds are uniquely evolved to do. In other words, to use the method which has served mankind pretty well from the dawn of civilisation until about 1990.
Here again, we are close to my central message.
The AI debate
The ongoing debate about whether electronic computers can reproduce all the functions of a human mind, the Artificial Intelligence debate, is crucial here and must be gone into, if only briefly. There are some advocates of ‘hard’ artificial intelligence who qualify as scientific fundamentalists. Marvin Minsky of the Massachusetts Institute of Technology is perhaps the best known. The ‘hard AI’ proposition is that computers, operating strictly in accordance with mathematical logic, can reproduce every aspect of the functioning of the human mind. That means feelings, morality, creativity – the lot. That in fact they will be minds. Estimates of when this will happen keep being revised forwards, but in principle the idea that our functioning as individual human beings, in its entirety, is computable, is accepted as self-evident by these theorists. You only have to listen to the confidence with which they speak to wonder whether they have already made the transition.
On the other hand there are other theorists, notably Professor Sir Roger Penrose, of Oxford University, some of whose lectures I have been privileged to attend, who insist that they have demonstrated through a variety of mathematical and other proofs that the functions of the human mind go beyond what is computable. Especially through Gödel’s incompleteness theorem. The latter is the accepted mathematical proof that all systems of formal logic, however elaborate and beautifully constructed (that includes, of course, the algorithms which control the workings of computers) will invariably contain internal inconsistencies. In other words, things that can’t be proved. So there is an alternative body of proper scientific opinion that argues that the world is not digital, that it is more like an analogy; more, to allude to Iona Heath’s William Pickles lecture Uncertain Clarity, more like waves than particles.
Medicine sucked into the whirlpool
‘We are witnessing the culmination of a process which has been going on for many years – the gradual replacement of individual human judgement by a structure of external rules’ Bruce Charlton. The double-blind, randomised controlled trial and its place in medicine. British Journal of General Practice, 1991;41:355-6
The idea that we have moved beyond individual judgement, based on personal understanding and experience, and that almost everything in medicine should now be done according to agreed and scientifically-evaluated models is the Charybdis I am referring to as my third danger. The metaphor is apt because the danger is so seductive, and it is a whirlpool because it spirals round and round and has no bottom.
The ambivalence that is so commonly felt towards that current ‘big idea’, Evidence Based Medicine (EBM), is an instructive microcosm.
Iain Chalmers, director of the UK Cochrane Centre, the pioneering assembler and repository of amalgamated medical research evidence, has been a friend since medical school, and I went to see him as part of my preparation for this talk because I was sure he was not a scientific fundamentalist, as some perhaps thought, any more than I was anti-science, again as some perhaps thought.
I was therefore delighted to hear him say, right at the start of our discussion, ‘I regard uncertainty as one of the most important characteristics of a scientific theory’.
I was an immediate enthusiast for the book Iain co-authored in 1998, A Guide to Effective Care in Pregnancy and Childbirth. It was a shortened version of his massive review of the evidence-base which underlay current obstetric practice – or rather, which ought to have underlain it but didn’t. The book was a revelation to me and I bought a copy for my midwife and together we put it into immediate effect to modify the antenatal care we gave in our clinic. We were able to do this because in those days we were still permitted to work as a professional team.
Interestingly, Iain has never used the phrase, ‘evidence based medicine’, himself, feeling that as a non-practising clinician he has no right to do so. But when it was a new idea, the systematic review and authoritative presentation of amalgamated research evidence was an unprecedented weapon with which young Turks like Iain attacked the entrenched ideas and the vested interests of the medical establishment of the day. In spite of meeting with opposition which was as unjustified as it was often vitriolic, the major public service they performed has been recognised by Iain’s subsequent knighthood.
But I have to say that I and many others continue to have deep reservations, not so much about Evidence Based Medicine per se, but as to the way it has been misunderstood and misapplied.
Principally, I am dismayed by the extent to which, in the new management culture which has been imposed on British medicine, the people who now control medicine have seized on the deeply-mistaken notion that scientific evidence delivers certainty. And instead of using such evidence to inform independent professional judgement – its correct and hugely-important role – they have accepted the idea (in my view also a mistaken idea) that clinical freedom is dead, and have started to apply ‘evidence’ to ‘govern’ the clinical decision-making of individual doctors from the centre. They have even adopted the word ‘governance’ for one of the many new mechanisms by means of which they intend to achieve this end. What is more, such is their certainty that this radical innovation in medical practice constitutes Progress, and such is their confidence that this new way of doing things is free of unexpected and unwanted effects, that, in a supreme paradox, the new way of doing things has itself never be the subject of scientific evaluation. The rigid imposition of Evidence Based Medicine is not, itself, evidence based.
Bruce Charlton wrote a seminal leading article, Medical practice and the double-blind, randomised clinical trial, in the BMJ in 1991, and we have been friends ever since I wrote to him to congratulate him on it. This was the paragraph I highlighted at the time:
“…there is a price to pay for the objectivity of the double-blind, randomised, controlled trial. Gain in objectivity is achieved by simplification and at the cost of completeness. General results are only achieved by a process of reductionism. The whole philosophy of the double-blind randomised clinical trial is to exclude individual differences and concentrate on group similarities. Indeed, the exclusion should ideally apply to every aspect of the therapeutic encounter except for the specific intervention under assessment. All of this has unintended results; the patient is depersonalised, the doctor is deskilled, and the treatment is rationalised. Management tends to become the routine application of simple algorithms and could just as easily be carried out by an appropriately trained technician with a computer. The double-blind randomised controlled trial, therefore, aspires to a world where effective medicine is so simple that the vagaries of doctor expertise and patient peculiarity are rendered unimportant compared with the objective probabilities established by rigorous evaluation.”
It is in front-line general practice, perhaps only in front-line general practice, that the truth of this analysis is overwhelmingly apparent.
In the last few years a plethora of official guidelines, regulations and regulatory bodies have grid-locked general practice. Attempts to list or even count these initiatives, for example the list of bodies established to regulate us – many of them explicitly to ensure that we are not Harold Shipmans (Shipmen?) – which I have included in my recent book Friends in Low Places, are met with incredulity, hilarity, resignation or mere boredom. Long lists are boring, and nobody bothers to take the whole lot on board – except the people who are compelled to include all of the items simultaneously in their daily work.
Even as the people who have to do the work of the health service, as indeed the work of schools, the police forces and the social services departments, wilt under this burden, and many of the best leave in despair, there is not the slightest sign that those in authority are able to see that there is any problem. Further regulation, or more refined regulation, is seen as the answer to every new problem that arises. ‘We will make sure it can never happen again’ is the reflex response. Montaigne’s ‘incredible promises’ again. And so the spiral intensifies. The futile quest for perfection and the final elimination of error and risk from life twists round and round.
The enormous progress in the effectiveness and safety of medical care that scientific medicine has brought has had a paradoxical effect. Instead of making people feel more secure, it has intensified their anxiety about the problems that remain. This is a trend which nobody anticipated: The safer medicine gets : the more people worry about it. The more trustworthy doctors become : the less people trust them. While society invariably reacts to each new problem by elaborating its rules, all the evidence is that this only makes such problems worse. And this phenomenon looks like going on for ever. If medicine advances to the point when only one mistake is made in a thousand years, think of the size of the headlines there will be when that mistake is actually made…
The same problem applies to the endless pursuit of safety and the establishment of more and more elaborate precautions against more and more remote threats. There is no logical point at which this process can end – no point at which you can safely – and above all justifiably – say ‘stop’. No formula will ever provide such an answer.
And this problem gets still worse when you stand back and view the world on the population scale. In fact, if you stand far enough back from life, nothing is safe and nobody can be trusted. But although this seems to be a rather elementary inference, our society still appears to operate on the assumption that we ought to be pursuing absolute safety and, as Onora O’Neil said so eloquently in the first of her current Reith lectures, the paradoxical result of the vogue for accountability and transparency in public life is an exacerbation of the problem and further diminution of trust.
‘Everything is done by accountants these days’ is a common complaint which provides another view of the same phenomenon. And yes, the honest observations of people in their daily lives are a kind of scientific evidence. Science should take note of all honestly reported experience – that is the point of the story of the Emperor’s New Clothes. Accountants are nice enough people and their work is extremely important. But they deal, exclusively, with things which can be counted. So the complaint is not that accountants are, personally, ‘taking over’, but that figures, digits, things that can be counted, are taking over. And that the world has begun to operate on the assumption that everything of importance can be measured and reduced to a formula.
Alan Ryan put it neatly in the Education section of The Independent newspaper last April – ‘Counting counts only when we know how to count what counts’. There is a widespread feeling amongst doctors and other people dealing with individual human problems that we do not know how to count what counts. Hard-core managerialism, which I distinguish from the sensitive management which undoubtedly also exists, is a kind of fundamentalism. By thinking that only the measurable counts this approach is blinding itself to feelings, wisdom, experience, human judgement, love. With devastating consequences for human motivation and performance.
Like the gap apparent this week between the views of those who have been called the ‘chattering classes’, who saw and disparaged a 101 year old lady with a lot of money and a very big diamond, and that of the public, who saw a Queen, and a Mum. Strangely, this supposedly-obsolete figurehead was the very antithesis of the aridity and amorality which exists in the official levels of our society today. An aridity which has taken us well on the way towards a Health Service which only does the things which managers can see. Current health service management has taken to speaking of ‘packages’ of care. But the truth is that care doesn’t come in ‘packages’.
The truth is that the world is analogue, not digital. The mistake is utterly fundamental. The better the models become and the more like the real thing they become, the greater is the danger. This is another paradox. Because the more accurately they come to model the real world, the more likely it is that we will mistake the (digital) model for the (analogue) reality. Yet the hidden difference is, and always will be, absolute.
The most dangerous thing of all
A friend of mine who is an Anglican priest visited Thailand recently and spent some time in a Buddhist monastery. He was told there of an instruction once given by a Buddhist teacher to a pupil,
“When you meet the Buddha, Kill Him!”
Now, Buddhists don’t kill anything; they don’t tread on an insect if they can avoid it. So the implication of this teaching (in as far as anyone is supposed to understand, still less explain, any Buddhist teaching) is that when you think you have found the answer – the truth, the final solution – you are not merely wrong; you are confronting the most dangerous thing you can possibly encounter.
Science-based medicine may sometimes be wrong because it’s models are mistaken – the research-base may be flawed, or because models which are valid are misinterpreted or misapplied, and perhaps in a simplistic manner inappropriate to the complexity of the circumstances. This is especially true when in vitro research is applied to the in vivo complexity of general practice. These things we can try to put right by refining the models. But the thing which defines what is wrong with Scientific Fundamentalism is Certainty. Certainty in science, contrary to our fondest wishes, is always wrong.
The thing that is wrong with Antiscience, as we have seen it exemplified by creationism, is the same thing, certainty.
And the thing that is wrong with Pseudoscience, as we have seen it exemplified by Etruscan entrail-diviners and by the Observer’s barefoot doctor, is the aura of certainty which it too adopts.
One of the characteristics of a modern, scientific general practitioner is that he or she hardly ever feels certain about anything. Increasingly we share this uncertainty with our patients, certainly I did, and one of the greatest questions of our age, brilliantly tackled by David Misselbrook in his recent book Thinking about patients is whether this is entirely a good thing, and the extent to which doctors may be abdicating a vital part of their healing role by sticking to this line. I have already referred to my uncomfortable recognition of inconsistencies in my own approach to practice.
Simultaneously with the move towards the kind of fundamentalism that I have been describing in medicine we have seen an apparently-contradictory move by committed scientific doctors, including myself, towards the humanities. Books like Iona Heath’s, The Mystery of General Practice, and David Greaves’ unjustly neglected, Mystery in Western Medicine, have charted a growing unease that science is giving us only part of the story, and perhaps not the most important part. A tension is building up and there is a growing danger that medicine will fly apart – into two different realms – science and non-science. The flirtation I have described at the political/managerial level of British medicine between science and pseudoscience whilst at the same time the same people apply fundamentalist science with unprecedented rigidity elsewhere, may even be the beginning of this split.
We must not let this split occur. Science is big enough to encompass such a dichotomy; we could learn to incorporate within science elements of both Evidence and Mystery, if that turns out to be the next step in representing truth. Our current theory of how the world works is bound to be incomplete, and if, as I suggest, we are now observing reality in new ways which are revealing new inadequacies, we may have to adapt our current hypothesis, in other words refine our model.
The General Practitioner and Science
Our culture currently assumes that the view from on high, the detached, analytical, objective view, provides a higher wisdom than the view from on low. It is time we considered the possibility that things are the other way round. It is time, in particular, to give credence to the general practitioner’s uniquely privileged view of reality. The extraordinary fact is that we GPs have a ringside seat at one the radical revolutions of history: the application of information technology and computer-modelling to individual human interactions on a population scale. Nobody knows better than we GPs do how this experiment is working out. And I mean quite literally nobody.
In the past rulers have always wanted to control their subjects, for good reasons more often (I want to believe) than bad. And now, for the first time in history, they can actually begin to do it in previously impossible detail : The arrival of the computer – from nowhere (the microchip had not been invented when Neil Armstrong landed on the moon) has given them the necessary tool. That is what is really behind all the new talk of ‘audit’, ‘accountability’ and ‘transparency’, which we so confidently assume to be Progress when we stand back from life, but which seems so threatening, and more importantly, so misguided, when we are in the thick of the consequences.
This attempt, this uncontrolled experiment, to apply theory, rigidly, to everyday practice, is well under way, and I for one see it producing unexpected and unwanted side-effects. Those side-effects include the collapse of morale, the falling of recruitment, the destruction of trust we have mentioned, and the exodus of people like me (and as it happens my wife, a teacher) from the front-line professions. I see this ‘madness’ of the modern world as the most important disease that I as a doctor ought to be trying to treat. That is why I do my writing, and that is the reason why I am so pleased to be giving this talk. But I should like to record that I also left practice without once having conceded my professional independence, a stance which I judged would no longer be possible to sustain in the new climate. So don’t try to tell me that nothing has changed.
Revolutions in scientific understanding are always mysterious, otherwise they would not be new. ‘I am going to tell you what nature behaves like.’ said Richard Feynman, describing Quantum Mechanics, ‘If you will simply admit that maybe she does behave like this, you will find her a delightful, entrancing thing. Do not keep saying to yourself, if you can possibly avoid it, “But how can it be like that?” …Nobody knows how it can be like that.’
We general practitioners have a particular view of ‘what nature behaves like’. And it seems to me that our experience of the population-scale attempt to apply mathematical rules and classical logic to intimate human interactions may actually be demonstrating a fundamental nonsense that throughout the whole of history has never previously shown up, still less mattered. We made the assumption that the human world in all its complexity was ultimately a simultaneous equation, and this assumption worked perfectly well until we had the means to work out the sum accurately and on the necessary scale. Now that we have those means, in the form of electronic computers, we can see, for the first time in history, that the sum doesn’t add up – that world does not have one right answer. Perhaps it has many right answers, perhaps an infinity of right answers, and all of them different ones. Perhaps the attempt to control individual behaviour from the centre is also a mathematical nonsense. I suggest that that would fit with our common, daily experience as generalist practitioners.
If we believe the evidence of our eyes, and accept the implications of that evidence, we may be forced to postulate a more sophisticated model than can ever be described in classical, digital, form. We may be compelled to find some accommodation between the Classical and Romantic philosophies which has not been necessary since they diverged in Ancient Greece. This idea, radical though it is, has already been expressed by serious philosophers of science, if we include, as I believe we should, Robert Pirsig and his wonderful book, Zen and the Art of Motorcycle Maintenance.
Look at that title: Zen (i.e. Reality) – And the Art of Motorcycle Maintenance. Surely, Pirsig is telling us, if there is an art in something as archetypically technical as motorcycle maintenance, and his book makes it abundantly clear that there is, then there is an art in anything.
So there is an analogy here with the Art – of scientific medicine and another with the relationship between Care and Knowledge (Science) which are the two parts of the college motto –
…which is itself the theme of this 50th Anniversary meeting.
So we need a better model which combines these two – the science and the art. But if and when we do find such a model, even if it is as utterly mysterious and surprising as, for example, quantum mechanics, it will still be science. That is the all-important point.
This is my conclusion:
Not only must doctors remain scientists in order to serve their patients, steering between the Scylla and the Charybdis of my metaphor. I also believe they have a unique contribution to make to science itself. General practice, through its academic wing, through its Royal College, but especially through its individual practitioners, doing the best, the most rewarding, and perhaps one of the most important jobs in the world, can make a contribution to the next step forward in our understanding. Provided they have confidence in the validity of their view of life, and provided society gives them the freedom and the respect they need to do their job.
I should like to thank, Iona Heath, Bruce Charlton, Iain Chalmers and Trevor Hill for unstinting advice at various stages in preparing this talk, and I should like to thank you for doing me the honour of inviting me, and for listening to me. Most of all I thank my wife Lesley, another scientist and teacher, whose contribution is inextricably entwined in everything I have said this morning.
Authors note: when for one reason of another I return to this text, I sometimes feel compelled to make small alterations to its wording and punctuation to try to make my intended meaning as clear as I possibly can (because I want readers to understand it!) This is particularly so towards the end, which I expanded and clarified freely as I delivered the lecture on the day. This is the sort of thing that this technology makes it easy to do, especially for those of us who maintain their own websites, but I hope it is acceptable. The last such amendment was on 24 February 2016