Doctors aren’t scientists, and medicine isn’t science

That doctors aren’t scientists is entailed by the training that doctors experience, which is appropriate for practicing medicine but not for carrying on research [“Nobel Prizes illustrate that doctors are not scientists”, 19 October 2008]. I’ve understood that for many years, so I felt quite chastened when the clearest support for that distinction occurred to me only recently: there’s a very obvious and clear-cut difference of principle between scientific knowledge and medical knowledge:

Scientific knowledge is universal, whereas medical knowledge is local.

One of the norms of science that Robert Merton identified in the late 1930s is its universality: chemists and physicists believe and teach the same facts and theories everywhere. Atoms and electrons and molecules are described everywhere under identical laws. The movements of the solar system, when accurately described, are the same for Europeans as they are for Asians or Americans. The photoelectric effect, Brownian motion, X-ray spectroscopy, etc., etc., etc., have no regional or national variations in description (facts) or in explanation (theory).

Please note that I said, re solar system, “when accurately described”. There are some dishonest scientists, and there have been some fraudulent publications in science, and at times there have been politically imposed ideologies to which scientists at times have had to bow, like Lysenkoism in the Soviet Union or “Deutsche Physik” in Nazi Germany. But no scientist with un-addled brain regarded those as constituting science. Left alone, science is universal. [Of course, I’m not saying that everything scientists believe is true. Scientific understanding changes and progresses. What I’m saying is that there are no culture-specific facts or laws of chemistry or any other science.]

Whereas science left alone is universal, medicine left alone — in the unfettered professional hands of doctors — is not universal. What doctors believe to be the best treatment for a given condition varies from country to country, because the understanding of what that condition is, the explanation of that condition, also varies from country to country.

I’m not speaking of differences often referred to between Western medicine and Chinese medicine, or between “modern” and “traditional” or “folk” medicine; I’m speaking of differences between what is regarded as modern, “scientific” medicine in so-called developed countries. Anyone who has incurred similar illnesses in the United States and in Britain is likely to have encountered some of the differences I’m talking about here. When I’ve had urinary-tract (or other) infections in the United States, antibiotics were prescribed immediately; when I had one in Britain, the doctor told me that these are usually self-limiting, that it’s best not to use antibiotics unless absolutely necessary, and to come back if the infection hadn’t cleared itself within a few days. In the United States, my wife had been offered an hysterectomy whenever she was ready, because of occasional pain; in Britain, the gynecologist was aghast that anyone would contemplate so drastic an operation at so early a stage of occasional and minimal discomfort. At a time when acupuncture was still regarded as quackery in the United States, around 1960, a friend of mine was permanently cured of migraines by a practitioner of acupuncture in France. Nowadays, homeopathy is a respected technique in several European countries, but it’s viewed as quackery or pseudo-science in the United States.

When it occurred to me to footnote my earlier post with this to-me-new insight, it also occurred to me that it would be good to have something more than such anecdotes to support the assertion that medical knowledge is local whereas scientific knowledge is universal. I enquired of a former colleague, the medical historian Ann LaBerge, and was rewarded by being referred to a truly marvelous book on the subject: Medicine and Culture — Varieties of treatment in the United States, England, West Germany, and France by Lynn Payer. I recommend it unreservedly to all and sundry. One indication of its value may be that it was first published in 1988, revised in 1996, and remains in print (the author died some years ago, though).

As Payer herself acknowledges, medical practices change continually, and differences between nations don’t remain the same; thus acupuncture has gained a foothold in the United States, for example. But Payer does much more than delineate differences, she lends insight into the reasons. For instance, the attitude among Anglo-Saxons towards “natural dirt” is one of horror focusing on the “dirt”, entailing a great emphasis on disinfectants, frequent washing, and the like; whereas French medicine emphasizes the “natural” part and considers a certain degree of exposure to “dirt” as beneficial toward the acquisition of a robust immune system. Again, I would not have imagined that, 20 years ago, Germans would have been consuming 6 or 7 times as many heart medications as Americans, yet Payer has the data to prove it — as well as an intriguing suggested explanation rooted in cultural context.

Unfortunately, there don’t seem to be radical differences between countries regarding HIV/AIDS theory. There are some minor discrepancies as to “HIV” tests, of course; Val Turner has pointed out succinctly and clearly that there are about a dozen different criteria in use in different regions and laboratories for what supposedly constitutes a “positive” Western Blot [“HIV tests: danger to life and liberty“, 16 November 2007; for a very detailed critique, see “Valendar Turner’s evidence in chief” (1.2 MB pdf)].  There are also differences in criteria for an AIDS diagnosis: in Africa under the Bangui definition, clinical diagnosis doesn’t need the support of an HIV test; and few if any other countries agree with the CDC’s decision to regard, as AIDS patients, asymptomatic HIV-positive individuals with CD4 counts below 200. On the central mistaken points, though, that HIV causes AIDS and that HIV is sexually transmitted and that antiretroviral drugs are a good thing, there seems to be trans-national agreement.

Still, the general point, that medicine isn’t science, is fully illustrated by the sad tale of HIV/AIDS.