Philosophy in medicine


The best physician is also a philosopher.
Galen



Medicine is intrinsically linked to philosophy in deep theoretical and methodological dialogue. Medicine tries to fight against suffering, illness and death. Philosophy proposes to medicine an epistemology devoted to concepts, theories and methodologies of medicine by physicians, and medical ethics, investigated by theologians and philosophers. Nevertheless, medicine is autonomous and philosophy does not exert any moral constraint on medicine. An enormous amount of publications has been made all over the ages and no attempt to completeness can be made.

Medicine is becoming more and more technical and scientific. An old controversy was to call medicine art or science. Medicine is a science; professional medical practice is an art based upon science. There are two ways of knowing in medical science: analytic knowledge and causal explanation, synthetic knowledge and teleological explanation. Scientific medicine prefers only the first way of knowing. A physician must know and be able to use the most recent medical technologies, but he has to take in account their finality to treat a patient, not a case or an illness. Increasing medical technology implies a scientific background of the residents and has led to a selection made upon mathematics, physics and biology as criteria. Formerly, it was possible, and even recommended, to have a cursus in humanities and philosophy to start medical studies. To-day, at least in France, a student has not the smallest chance to integrate the faculty of medicine coming from a literary path. After several years of such a policy, young doctors are technologically competent and scientifically up-to date, but unfortunately with deep insufficiencies in human communication between physician and patient. Incredible mistakes are often observed in the communication with the patients and families. Ninety per cent of the requests for mediation have as a main cause or origin a bad communication with the patient or his relatives. The problem is a lack of communication and empathy, wrong information or discussions with inappropriate words. The most serious fact is the unconsciousness of the mistake, the doctor saying that he has done the job perfectly of the technical point of view, according to standards, recommendations and the state of the art. In many countries, a teaching of medical humanities has been fortunately reintroduced in the medical cursus.

From another point of view, it would be inappropriate to oppose a philosophy of care to a medicine too technical and dehumanized, only turned toward cure. Since several years, patients have been recognized in their rights to information and consent. Many physicians have not yet fully integrated these changes in their behavior. The fundamental ethic stake of contemporary medicine is the place recognized or denied to the word. The medical conversation proceeds more from chatting or technical reflections than from the word. Chatting is a manner to use the word, without entrusting yourself, without risk in your flesh.

This lecture will try to answer two questions: what philosophy can bring to medicine? How to train physicians to more humanity ?

What philosophy can bring to medicine?

The philosophy is not a foreign discipline, but an integral part of medicine. Philosophy and medicine have a strong linkage and were born in the antic cities at the same period, about the VIst century before our era, reason why physicians were also philosophers. Hippocrates, in the Hippocratic corpus, written not by himself but by his followers, provided not only therapeutics but also precepts of life, explaining not only the human nature but also its relationship to the world. He said: “The union of the two sciences is very important for each other, and all which is suitable to the philosophy apply also to medicine”. Five centuries later, Galen of Pergamum (129-213 CE) wrote: “To practice successfully the art of curing, it is mandatory to be aware of sciences cultivated by philosophers and to practice the virtues of which they show the example, so the true physician is in the same time a philosopher”. Galen's views contribute to present-day debates on well-being and illness, concepts of humanity in bio-ethics, the societal role of medicine and the physician as well as multidisciplinarity and discipline formation. The Arabic medical physicians, Avicenna, Averroes, and Maimonides, a Jewish philosopher of the Arabic kingdom of Granada, who translated the Greek manuscripts, were also philosophers. Avicenna considers logic as the instrumental science of philosophers, but his perfect knowledge of Aristotle leads him to find the views of his logic insufficient because too far of the life. Averroes in the Colliget was also the supporter of the Aristotle's philosophy that he wants to rediscover in its purity. Pietro d'Abano, one of the pre humanists of the end of the middle age in Padua, writing the Conciliator, considered that science and philosophy are intimately linked to understand enigma of the universe, nature and human beings. “Medicine is called the second philosophy: the two disciplines are complementary, one caring the soul, the other the body…medicine and philosophy are sisters”. The tight connection between philosophy and medicine, evident in the Greek and Islamic philosophers, was not found in Latin philosophers due to different conception of the body and its functions.

The main rupture in the philosophical concept of human condition occurred between Descartes, who considered a dualism of body and soul, and Spinoza, linking body and spirit. In the Descartes' concept, philosophy was the medicine of soul, providing wisdom, when medicine aimed to health. After the death of the body, the soul was promised to and eternal life. For Spinoza, a Jewish Dutch philosopher, in rupture with his community, the monism implies a link between body and mind which leads, according to the modern neurobiology, to a complete integration of cognitive functions, such as the “neuronal man”, described by Jean Pierre Changeux. 

Ten Have recognizes three main components to the medical philosophy: epistemological, ethical and anthropological. The anthropological tradition in the philosophy of medicine lies upon three main streams: rejection of Cartesian dualism, medicine as a science of the human person and necessity of a comprehensive understanding of disease. All along history, many medical doctors were also prominent writers and philosophers. It could be boring to make a list which would be very long, but some names must be quoted at different periods, among them John Locke, Claude Bernard, Karl Jaspers and Georges Canguilhem. Many philosophers dedicated some of their publications to medicine among them René Descartes, Baruch Spinoza, Emmanuel Kant, Henri Bergson, Hans Jonas and Michel Foucault, to make an eclectic choice.

Philosophical concepts of health are different according to the ages and the locations. Extreme Oriental concepts are the oldest, back to several thousand years, in Japan, China or India. The Unique Universal principle lies upon two main laws: everything which has a beginning has an end; everything has its opposite following the Yin and Yang model. Health results of an equilibrium between opposites, and disease from a rupture of the equilibrium. Several recent publications on Eastern philosophical concepts in medicine are available, on ayurvedic medicine by Lad and Pole, on Chinese medicine, by Unschuld, but we will focus on western tradition of philosophy of medicine. In Occident, concepts of health have evolved during history between mechanical and vitalist approaches, and between a passive and an active view. The passive aspect is represented by health considered as “the life in the silence of organs” according to Leriche. The painless evolution of cancers at the initial phase makes wrong such a sentence. The dynamic concept making health a victory on illness, illustrated by the Nietzsche's sentence “That doesn't kill me, makes me stronger” is adequate for example in the frame of acquired immunity. Canguilhem proposes a unicist view, where health and illness are two appearances of the same normative power of life and death in an individual. The definition of health given by the World Health Organization, which is based upon well-being, welfare, emphasizes all the other components, especially sociological and environmental, side to clinical symptoms according to the Boorse' s theoretical concept. 

Philosophy in medicine is to-day close to other approaches, psychology, sociology, anthropology, law, political sciences, economy, and cultural history. Illnesses have generated in history various attitudes: at the middle age, the plague was considered to be a punishment sent by God, tuberculosis viewed as a social consequence of poverty issued from the industrial revolution and AIDS a result of the sexual life liberalization, accelerating a crisis of the body representation. Nowadays, despite progresses made in the knowledge of genetics, neurobiology and all the fields of medicine, new technics and technologies could be used to remodel human beings. Philosophy, and essentially ethics, will play a pivotal role in medicine, structuring the future human being, side to other human sciences. Medicine will not be only done to provide a care but will accompany the complete biological, but also ontological transformation of the human nature at this crucial moment of the human history. Philosophy must provide an ethic of responsibility Hans Jonas says.

The link between philosophy and medicine is ancient and potent. It cannot be limited to the bioethics. The questioning on philosophy in medicine must take in account the impact of the evolution of knowledge and technologies. All the three traditional parts of philosophy, logic, ethic and psychology, are of importance in medicine. Metaphysic could be added, because the doctor is faced to the death of his patients, and by the way to his own death, questioning on the sense of life, and what before and after life. The question is fundamental but the answer cannot be given by philosophy. The religions, making an apologetic of transcendence, provide explanations which need faith to be accepted.

Logic provides important tools to guide thinking and understanding the clinical processes, as well the diagnosis, the prognostic and the therapeutic. There is a medical epistemology providing a thought on the building of the medical knowledge and a medical hermeneutic, designing the processes and the rules by which experience allows symptoms interpretation. Algorithms of decision are the base but, at the difference of a computer, purely binary, a physician must be able of intuitions and communication making an art of his job. Faced to a problem, a physician, and especially an anesthesiologist, must have a logic process to reach the solution. For example, a patient having suddenly a collapse during surgery, the anesthesiologist must be able to find the cause through rigorous evidence based algorithm and firmly established in his mind. One goal of the training is to build such paths within the brain, as well to follow protocols but with the additional need to be able to abandon a protocol on a strong justification. At each step of the clinical processes, the mandatory rigor of the logical path must be criticized and modified by an intellectual reasoning but also a part of feeling, intuition. Despite the expected progresses of the artificial intelligence, the border with human brain could be, at least for a long time, this ability of intuitive thinking. Longer developments could be made on several examples but it is evident that logic is an important part of the medical reasoning and must be clarified and taught.

Claude Bernard establishing the experimental method and Austin Bradford Hill designing the features of controlled therapeutic trials put their thoughts in the frame of scientific medicine and a philosophical perspective. Claude Bernard told that “medical students must gain a philosophical and reasoned understanding of things” instead to stuff their head full of trifling details. The development of data banks on internet makes more convenient to have a critical mind and to train the faculty of reasoning more than memory.

Medical ethics are also essential and will become more and more pregnant with the progresses of the medical science even if Michel Onfray thinks that ethic must be replaced by wisdom without ethic. Some philosophers think that the bioethics is not the carrier of communication and diffusion of norms already determined but the place of discussion of these norms. Paul Ricoeur explains that this part of the philosophy is “breaking in two parts”: ethics, from the Greek ethos, and moral, from the Latin, mores. Moral refers an absolute, universal, imperative, unconditional virtue on the base of great principles. Moral overpasses morals and behavior instability, imposing in respect of the forbidden acts. Ethic is relative, particular, implying individual and his surroundings, “normative not imperative”, indicating how to behave and leading to wisdom and better life in terms of wellbeing, happiness, dignity and reason.

For Avishai Margalit, ethics is “the philosophy of the for-example”, and moral “the philosophy of that-is-to-say”. Moral is made of general principles to explicit and pass on. It is prescriptive, corrective and authoritarian to overpass the instability of behaviors. Ethics corresponds to ways of life, social habits, corresponding to the belonging to a society, limited in time and space. When the respect of an interdict is moral, you will not kill, the groping search of wellbeing submitted to the conditions of life is ethical, abortion and euthanasia. To be on the side of ethical relationships is to abandon the moral certitude for the ethical anxiety.

Ethic seems in permanent evolution following empirically the changing of the societies. The moral traditions, inherited from the past, engraved in the marble, such as the Moïse's tables of the law, cannot provide adequate replies to the new questions to which we never faced before. Ethics involve all the situations in which moral cannot settle definitively, being a practical philosophy, avoiding generalities and abstractions which prevent to understand the diversity of human behaviors. The problems of society occur when ethics is in at the opposite of moral. Within social customs, ethic is related to a society membership, limited by time and space. When the problem is “to take care”, the question is not to take in account values, rules or laws, according to a moral reasoning, but to consider the best way to provide the most appropriate reply not only to an individual but also a society. It is in an ethically justified transgression of the traditional moral that the human being give birth to his humanity. The birth-control pill, discovered by Pincus, became commercially available on August 18, 1960, changing radically the women life. Few years ago, the abortion was considered as a crime. In France, a law promoted by Simone Weil on January 17, 1975, introduced a strong debate among two parts of the society, some considering a fetus murder, other the woman life and desired birth. Nowadays it becomes in several countries, but not in all, as a right of the woman. History will retain the birth-control in 1960, the procreation medically assisted in 1978, with the Louise Brown birth on July 25, and the first success of animal cloned, with Dolly on February 27, 1997.

Euthanasia is strictly prohibited in most countries but legal in some others, as a right to die. The concept of death has changed with the progresses of intensive care, introducing the right to die, the choice of end of life against the therapeutic fierceness.  Transplantations, procreation medically assisted, ageing and dependency, severe handicap, vegetative coma, cost of health, market for human tissues… will be more and more questioned in a next future. Ethics will be permanently and deeply modified by the development of biotechnologies: determination of the human genome, opening the way to genetic therapies and genetically modified organisms but also market for human tissues and mothers of substitution.

In medicine, each country has a national committee of ethics, and many hospitals have their own committee. That means that ethics can be the result of a sentence depending upon members of a committee. In philosophy, the moral would like express universal and permanent truths. In philosophy of sciences we must accept that the ethic aspects may change with the evolution of the scientific research and the society. It is necessary to respect the freedom of searchers to avoid blocking the progress but they have an ethical responsibility to overpass a red line represented by the safety and dignity of individuals and society. Problems of  bioethics are not solved once for all. Each generation must restart their studies patiently, tirelessly. When moral brings certitude, ethics worries. The reference and its interpretation may also evolve with the time and the place. If bioethics were first designed in America with the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, in 1978, the concept went over again in Europe with the Basic ethical principles in European bioethics and biolaw published in 2000. Philosophy contains within itself a special link with the questions raised by the biomedical research and therapeutic practices: they lie upon the value and the significance of human life. 

Side to the great problems of ethic, each medical doctor must have his own ethics which can be influenced by his education and a religion. In conscience an anesthesiologist may have to take decision involving the patient's life, for example, when stop a resuscitation of a cardiac arrest. A personal ethic is made of the educational background but also thanks a brain storming, alone or collegially within a team, and a wide experience. Conflicts can arise between moral laws, religious choices and ethical acceptance of medical decisions. A conscience clause, in relation with a religious conviction, is sometimes called upon to justify an abstention, but not always accepted. Some decisions are difficult to take and a training based on clinical cases may be useful.

During the last decades, biomedical research has strongly contributed to modify the frames of reference to ethics. The ability to act on the biological profile of living organisms at their birth, development, disease and death, has questioned on the existential freedom opening on new spaces of applied ethics. The responsibility linked to the human possibility to control the evolution of the species to maintain or improve its integrity produces a clash with centuries of history of thoughts, especially religious. Bioethics birth and its fast development associated to scientific discoveries, political and social changes, made mandatory a new morale adapted to these evolutions. The Nuremberg code lies upon four principles applied to the medical research and experimentation. The principle of autonomy based upon the agreement and the freedom of the subject at the origin of the informed consent. The principle of beneficence establishing the priority of individual wellbeing and security. The principle of scientificity implying that the experience lies upon scientific methods. The principle of reversibility of side effects excluding the risk of disease, handicap or death. The Nuremberg code was at the origin of the informed consent and completed by several declarations from the United Nations and the Convention of Human Rights.

The attitude of the physician faced to pain and death has changed in part due to laws enacted by the governments but also an evolution of mentalities. Pain was considered as a fatality and accepted by the physicians and often the patients. It was the case of the labor pain until the appearance of the concept of delivery without pain and epidural analgesia. Many surgeons refused during a long period to give analgesics to treat the postoperative pain to avoid hiding complications. Around 2000, the French minister of health, Doctor Bernard Kouchner, made laws to promote analgesia and recognize the patient's rights by a charter. Despite similar laws established for the end of life, many discrepancies appear between families and medical staffs to decide the cessation of cares. Normally, therapeutic fierceness is prohibited but the understanding by the physicians and the families is sometimes at the opposite, leading possibly in court of justice. Clear explanations with empathy and psychology allow usually finding a solution satisfying for ethics. More than non-maleficence, the care must target beneficence. Michel Dupuis says that care prolongs empathy, joined to rigor, competency and engagement.

The concept of Care is a new philosophy, born in USA around 1980 in reaction against an ultra-liberalism tending to consider the patient as a case, a thing, and a problem. The Care is empathy in action. The Care is an ethic anchored simultaneously in the possibility of receptivity, relatedness and responsiveness. The theory of Care takes place in the context of a new definition of relationship between ethics and moral. Ethics may concern all the situations in which it is difficult to settle morally and definitively. Ethics is more efficient than moral when it concerns the individual and his doubts, the complexity of the reality, various fragilities. The ethical point of view on the situations never constitutes a moral based upon the application of precepts. This is a question of ethics means that rules and certitudes are missing, problems are coming. 

Alvan Feinstein said: “It is not being less scientific that we will be more humane, but been more and differently scientific”. Philosophy must keep medicine in peace, and not “bring on medical activity any normative judgment” as said Canguilhem. Philosophy must not impose to medicine neither a metaphysic nor an ethic but may learn much from medicine. Hippocrates in De la bienséance said: “Philosophy must be carried over medicine and medicine over philosophy”. Todd Meyers wonders what could be the “philosophy within medicine” instead an eventual “philosophy of medicine”. Bioethics is only a part of the philosophy of medicine even if Tristam Engelhardt wrote a book exclusively limited to such considerations. Conversely, John Harris considers that bioethics takes in account the value and the significance of human existence which constitutes a return to the core of philosophy. Toulmin said that medicine saved ethical philosophy by feeding its questioning. The philosophy of medicine integrates to-day other approaches especially sociology, anthropology, economy, psychology.

The human life is more and more in a medical frame implying a need for an ethical approach. Most people will be born and will die in a hospital. When, in the former times, fertilization and delivery were completely natural acts, to-day many techniques of artificial insemination have been promoted and most often births occur in an obstetrical service. Artificial techniques of assisted procreation are justified by the inability of a couple to have children, but more and more frequently the requests concern the satisfaction of parental wishes by unmarried women or homosexuals. On the other hand the prenatal diagnosis of diseases allows intra utero interventions or voluntary abortions. Moreover, the progresses of genetics open on genetic selection of sexes and modifications of morphotypes. External gestations development, the test-tube babies, according to science fiction novels, leads to a dissociation of sexual life and procreation.

At the other extremity of the life, the death is also more and more a medical act requesting ethical considerations. The controversy between palliative care and the medically assisted suicide, the unreasonable relentlessness and the euthanasia are pregnant questions. The laws, different among the countries, are in permanent evolution. Euthanasia and assisted suicide which are legal in Switzerland and Belgium are illegal in France. Ethics follows the evolution of the moral standards of the societies. Ageing and dependencies, severe handicaps have a cost which could become unbearable for the society. The concepts of health and illness are also changing, taking in account the social surroundings. The proportion of people cured and living with a cancer has increased considerably. The multiplication of transplantations and implementations of prosthesis, and in a near future of bionic devices, leads to a posthumanism hypothesis. Lengthening life is medically possible but the questions are with which quality of life and at which cost? With Alzheimer risk, people could live a longer time but they would not know that. The economic and social burden of aged people could become unbearable for the young generations.

Psychology is a branch of philosophy but also a quality mandatory for a medical doctor. Some people are naturally psychologist, having spontaneously a good understanding of the feeling and the behavior of their patients. Some other care providers have a complete inability to communicate with the patient and his relatives. Each physician reacts with his own personality, being more or less aggressive, optimistic or pessimistic, indifferent or empathic. When the meetings with the patient and the family are made successively with several physicians the messages, or the perceptions, may be completely different, producing a feeling of ignorance or a will to hide the truth. The confidence is the base of the patient/physician relationship. For the physician the first step is to adopt a position to be listening to the patient. The singular dialogue between the physician and his patient needs an appropriate psychology of the physician especially to announce a bad new. Some words may be extremely deleterious if the physician is fully unconscious of the understanding by the patient. The patient needs the truth but it must be said cautiously. The example given by Richard Zaner, an American philosopher, is extremely instructive, especially of the parents' resistance to hear the reality of the situation. Seldom, mediation fails due to the denial of the relatives to accept an ineluctable situation or evolution. Onora O'Neil says that the lack of confidence toward the medical team is, less than a growing autonomy, a feeling to become a foreigner for the physicians.

Clear explanations with simple words are often necessary to families without medical knowledge. In case of death, the relatives need to resign and the physician must help in their mourning. This process of resignation which may be long and difficult has been extensively studied by Freud and psychoanalysts. Care givers must be aware of the signification and the management to help the relatives and to avoid pathological mourning. To face some incomprehensible attitude, physicians must be aware of some possible explanations: for example a feeling of culpability of relatives may produce aggressiveness against the care givers. Psychology is essential to understand the patient and his family attitudes but also to provide an adequate management of the relations, adapted to their expectancies.

How to train medical doctors to more humanity? Humanities at the heart of health care: the patient-centered care.

It is not evident to train physicians to be more humane. Anne Fagot-Largeault has written: “Formerly I thought that topics such as the logic of the diagnostic reasoning or the definition of health and normality would have to be taught to medical students, but the philosophy of sciences from the theoretical point of view did not interest quite anybody”. Such a sentence is probably too pessimistic, and the Todorov's book, gathering contributions from the college of teachers in humane and social sciences for medical students, has received a very positive opinion. Courses, conferences are probably not the best way. The example given by the head of the service and his staff is certainly much more efficient. If they are not empathic, the young doctors, the residents and the nurses will not be. Students will succeed if they are able to mimic the teacher's vision and fail if they cannot. Probably, aptitude to sympathy starts earlier during youth by the education at home and at school. Preachifying is rather stupid and certainly not adapted to postgraduate and continuing medical education. The debriefing of case reports with the staff and involved people in the service may be more efficient, providing there is not individual accusation or condemnation.

Discussions on ethic may be of interest because it appears that many physicians ignore or have wrong ideas concerning the laws and their application. Similarly they are not aware of their responsibility and have false notions about litigation and judiciary consequences. In case of conflict with patients and families many heads of services are inclined to support systematically their young colleagues when they have to underline the mistake, to explain what was wrong and how to avoid similar errors in the future. Err is human but to persevere is diabolic. Mistakes of communication would have to be discussed during staff meeting of debriefing similarly to management errors of diagnosis or therapeutics, without blaming. We learn more from our errors.

A movement came from the USA, and followed in Europe, questions the evolution of the medical thought, its relationship with other disciplines, allowing throwing light medical doctors on the part, more specifically human, which means relational, of their practice. Some associations, such as the American Society for Bioethics and Humanities, have designed medical humanities as a large interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), of social sciences (anthropology, psychology, sociology) and arts (literature, theater, movies and visual arts), and their application to the medical education and practice. Humanities and arts allow understanding human being, suffering, personality, our responsibility towards each other, and bringing a historical perspective on the medical practice. The literature and arts develop the abilities of observation, analysis, empathy and personal thoughts essential in the medical care for humans. Michel Dupuis proposes a course for the training of the professionals of care and health based upon philosophy and anthropology of the body. The way in which the dehumanization has become ordinary makes mandatory to center the care on the patient. The physician cannot be only a technician, a scientist, but needs more humanity that philosophy can bring. The psychological approach of the patient is essential. A chronic pain can be understood and successfully treated only if integrated in its psychological context. Psychic states, often ancient, returning sometimes to childhood, may be at the origin of somatic symptoms, when pain deeply modify the patient behavior, explaining aggressiveness or withdrawal into oneself. A pain treatment with drugs which does not take in account the psychological, familial and social context is doomed to failure. Such approach may be situated in the psychoanalytic tradition from Freud to Lacan, or in the line of the clinical phenomenology, relating a story of life or analyzing the interior world, in the Heidegger filiation.

Literature may bring to the physician a narrative knowledge thanks to a good analysis of the psychology and many authors, among them Tolstoï, Kafka, Thomas Mann, Camus, Le Clezio, have brought excellent descriptions of the illness and the patient feeling, helping the doctor to understand the patient's expression . Simone de Beauvoir wrote a subtle story of her mother end of life and on the difficult confrontations with the physicians when she suffered during her agony. Such readings providing experiences of illness must be recommended but more generally the culture is an adjuvant to philosophy, facilitating the humanist approach of the patient and the questioning on ethics.

The anthropology helps to elucidate and formulate many questions on human brain functioning, modalities of procreation, use of devices or animals organs to replace some human body deficiencies, the possibility of cloning or to intervene on the individual genotype. The anthropological philosophy has for object the human condition that means practically to seek the meaning of illness for the suffering patient. Through anthropology and phenomenology, medicine cannot make abstraction of the human being and the body cannot be seen as physiological mechanism but, as Spicker says, a Live-Body at the interface of philosophy and medicine. Several researchers and philosophers, among them Ray Kurzweil and scientists of the Silicon Valley, think that progresses in sciences and technologies will transform the humanity in a near future with the appearance of a posthumanism or transhumanism, when robots and computers will be more intelligent than humans.

Another approach of the philosophy of medicine consists of viewing medicine from the angle of the relation of care and a social practice. Karl Jaspers and François Dagognet consider that medicine must be thought taking in account all the dimensions of the society including its culture, literature and esthetic. Following Rudolf Virchow, the German pathologist, several doctors and politicians from South America, such as Salvador Allende, Ernesto Guevara, Paulo Freire, emphasized the impact of social conditions on health and wanted to promote a social medicine. In matter of tuberculosis, where Koch saw the essential role of the bacillus, Virchow underlined the importance of poor social conditions. Considered as a component of human sciences, medicine needs a training including not only clinical sciences but also all the other disciplines, such as sociology, anthropology, philosophy, implying a new epistemology. Felice Aull in the Mission Statement of the New York University School of Medicine, presents Medical humanities as  a vigorous field of research and resistance to the biomedical normalization, providing to young doctors thoughts useful in their medical practice. Among them, literature occupies a prominent place, opening to the creative thought, exposing to the experience of illness, to existential questions, to the violence of situations, described by the authors. A practical consequence is the development of narrative medicine allowing to the patient to relate the history and his view of his illness. The literature is not introduced in the medical training as a general culture but as a practice to develop the subjectivity of the practitioner and his ability to understand vulnerable and suffering patient and what it makes sense for him.

Conclusion
Karl Jaspers reminds the Hippocrates statement: ίατρος φιλοσοφος ισοθεος, by love of wisdom, the physician becomes like gods. He was not evoking the medical doctor adding philosophical studies to his science, but the physician, adding thought to his activity, is a philosopher. As Henri Bergson said: “philosophy is simple”, because integrated to life, but philosophers make it complicated, using unusual words and obscure concepts.

Medicine is changing, being more and more dependent of the technical progresses, but, in the same time, philosophy in medicine evolves considerably. Medical epistemology is turned upside down by the massive introduction of informatics and data collection giving greater place to understanding, skills, behavior and competency instead of accumulation of knowledge.

Philosophy, as the wise conduct of life, is broken in two parts: ethics, individual and collective, relative in time and space, leading to wisdom and good life, are supplanting moral, with its values, rules, laws, absolute, imperative  and universal. The care is the concrete manifestation of the modern ethics implying empathy end attention to the other people, especially the most vulnerable. More technical and scientific, medicine needs also to become more humane: patient centered care. Doctors can work with patients rather than didactically on patients. There is not a choice between science and philosophy, both is mandatory.

Practical, more than theoretical, training to psychology is the best way to improve the doctor-patient communication and must be part of the medical education. Very simply: why a doctor must be a philosopher? For at least three main reasons: medicine is a tragic job, faced to the worse, medicine is an ethic job, because its object is a subject and medicine is a lone job, every practitioner being responsible of his acts, without transfer, abdication nor the shelter of the law.

Medical act can never be reduced to provide a technical gesture since it implies a complex medical thought, in line with history and an art of the human relationship between a patient, who requires help, and a practitioner, able to reply to his request. Medicine needs philosophy by the very fact that it concerns human being. Life and death are tightly linked physiologically as well ontologically.



Conference presented to the World Congress of Anesthesiology Hong Kong, September 2016

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