An Interview with Cornelius Borck on his recently published book, Introduction to Philosophy of Medicine (in German: Medizinphilosophie. Zur Einführung, 2016. Junius: Hamburg)
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Philosophy of medicine is booming. In the past decade or so, several special issues, textbooks and anthologies have been published that promise to chart the field. One of the most recent additions to this body of literature is The Routledge Companion to Philosophy of Medicine, edited by Miriam Solomon, Jeremy Simon and Harold Kincaid. While the editors strive to include a broad array of perspectives, their ‘predominant thread is the philosophy of medicine treated as part of the Anglophone philosophy of science tradition’ (p.2).
Earlier last year, Cornelius Borck, Professor of History of Medicine and Science Studies at the University of Lübeck in Germany, published a quite different book. Introduction to Philosophy of Medicine (in German: Medizinphilosophie. Zur Einführung) advocates a closer affiliation of philosophy of medicine with history, anthropology, and social studies of medicine, as well as with the phenomenological tradition in philosophy, moving it away from the predominant thread of analytic (and Anglophone) philosophy of science.
As more and more fields of life become medicalized, and indeed often seem to be inevitably medical, Borck urges his readers to stand back, and to look at the ‘functioning logics’’ (Funktionslogik) of evidence-based medicine, biomedicine, or palliative medicine from a critical distance. He puts the distinction between experiencing an illness and having a disease up front, and makes a strong argument that philosophy of medicine ought not be reduced to serving medicine in clarifying biomedical concepts of disease. Rather, philosophers of medicine should think about health and illness as phenomena of human life, for which medicine provides but one ‘pattern of interpretation’ (Deutungsmuster).
Borck exemplifies past and present approaches of medical reasoning. He opposes pre-modern doctors’ attempts of accompanying people through their illness to current trends of overly focusing on intervening medically into human conditions. Borck is not hesitant to make normative judgements, but they are carefully weighed, and they neither lend themselves to a general cultural pessimism nor to a naïve belief in technological progress. Drawing on a broad array of historical studies, the book rather wants to sensitize its readers to, first, an understanding of how medicine became the authority in providing, or at least searching for, scientific explanations for disorders of biological functioning; and, second, a critical engagement with this authority: birth, illness, pain, and dying became medical problems and to-be-solved ‘puzzles’ (Rätsel) of biomedicine. But are these really ‘problems’ that can, and should, be solved? Philosophy of medicine, in Borck’s reading, ought to be informed about medical developments, while propagating a philosophy of health and illness of its own that does not uncritically follow current medical trends. How does this interplay between closeness and distance work? And could this programmatic vision for philosophy of medicine work as an agenda for medical humanities? I put these questions directly to Cornelius Borck, during a conversation that took place in Berlin and Lübeck, over December 2016
Lara Keuck (LK): I read your book as an invitation to think about what medicine is good for. You distance yourself from other approaches to philosophy of medicine that seem to be united by the basic assumption that medicine (if practiced well and based on solid scientific grounds) is good per se. You identify these approaches with Anglophone philosophy of science and the German tradition of theory of medicine. Do you think that these traditions are in principle ill-suited to address the questions that you raise?
Cornelius Borck (CB): I very much like your description of my book as ‘an invitation to think about what medicine is good for. There can be no question that medicine deals very effectively with many different medical problems and that access to affordable medical treatment is a high common good. As a specialized branch of philosophy of science, philosophy of medicine can thus zoom in on the ways in which biomedicine structures and organizes its practice, how it generates knowledge and orders it to explanatory theories, how its concepts articulate with decision strategies, how access to treatment is regulated and costs and benefits are distributed, etc. Unlike most other sciences, however, medicine does not start with an open search for knowledge; it cannot start from scratch, so to speak, as it deals with human suffering and illness. Illness and suffering precede any science; they call for medical intervention, which in turn shapes and formats states of illness into medical problems. Philosophy of medicine as the reasoning about the fundamental problems medicine is concerned with, should not start with an analysis of the problems as defined in medical practice but open its analysis to the formatting of these problems by medicine. Illness and suffering obviously go far beyond the boundaries of medicine, and medical practice addresses them explicitly and in scientific ways. Philosophy of medicine should hence also comprise a reflection about how it addresses health and illness.
LK: A couple of years ago, you co-edited a book called Maß und Eigensinn (‘Rule and Obstinacy’) that presented historical studies on medical sciences inspired by the work of the French epistemologist Georges Canguilhem. Your new book ends with the statement that philosophy of medicine can help society to articulate its obstinacy (Eigensinn) vis-à-vis medicine. Obstinacy captures only part of the meaning of ‘Eigensinn.’ In German, the term can also be applied to a person who shows integrity and self-coherence in her stubbornness. What does the concept mean to you?
CB: Well spotted! You are probably right in pointing this out as an idiosyncrasy of mine. Here, however, I had in mind what I regard the biopolitical relevance of philosophy of medicine: because biomedicine is so deeply entrenched in the current understanding of life and health, it defines almost every health related issue as a biomedical problem and assigns its interventions as the only salient solutions. Biomedicine’s descriptions of life-and-health-related problems tend to be taken as imperative and peremptory, without asking whether they serve a meaningful understanding of life and health – which obviously transgresses the limits of medical definitions in most instances. In his famous treatise on The Normal and the Pathological, Canguilhem determined the living as that form of being which not only follows rules and norms but establishes them in the first place – because of its obstinacy. Without such an obstinacy and autonomy life would simply not exist. This was the core idea of the book he finished in 1943, the same time he was an active member of the Resistance – and I think this is still an important message.
LK: While your book urges for more critical distance within philosophy of medicine, it is also filled with much details about recent developments, for instance in evidence-based medicine and palliative medicine. Could you elaborate a bit on how this interplay between closeness and distance to your subject of inquiry works? Do you regard this as a general methodology for philosophy of medicine?
CB: Many thanks for this zooming-in as it provides me the opportunity to state clearly that I do not conceive of philosophy of medicine as the search for a completely different form of medicine or as a credo for alternative and holistic medicine. On the contrary, I want to open philosophy of medicine and bring in the ‘critical distance’ you mention for discussing how well it serves in addressing the needs of particular patients. Evidence-based medicine (EBM) is the currently dominating framework of biomedicine and there is probably hardly a better way of doing medicine than ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,’ as David Sackett and his colleagues defined EBM. However, patients suffer from many different diseases with particular conditions and under very specific circumstances. The available evidence from clinical trials and other studies certainly offers important information, but for systematic, epistemological and pragmatic reasons this cannot cover every condition. A proper analysis of the details of EBM thus brings in critical distance as it reveals, for example, how EBM turns complex clinical conditions into discernible, treatable disease states and measurable treatment effects. Intended as the most accurate picture of the problems biomedicine has to deal with, EBM exerts a tendency to mistake the composite of EBM units for the world of medicine. And on another, more political and health-systems level, EBM introduced new forms of governance and regulation that increased transparency by linking medical services to cost effectiveness. Transparency is an important issue for democratic governance, but instead of opening new arenas for political debates on the health system, the decision-making often gets delegated to the anonymous power of statistical data.
Palliative care is an important topic for my analysis for two very different reasons: as a form of medical practice in the absence of curative treatment, it offers to explore how biomedicine deals with its own failure – and here I see a highly problematic medicalization of terminal care and dying, following on from the medicalization of birth. At the same time, palliative care operates in situations when medicine is cut off from its routines of effectiveness and hence allows us to study forms of practice adapted to individual needs. Where medicine gets disconnected from the imperatives of the perfect cure, a plurality of practices surface, which generate forms of significance and meaning which got lost with biomedicine’s effectiveness. In the absence of effective curative treatment, palliative care provides a window onto some of the other dimensions involved in medical practice that EBM and biomedicine have pushed to the side. At stake here is an ontology of disease conditions and states of illness according to a tinkering logic of care rather then the epistemology of biomedicine. Here, I see a special potential for phenomenology and the phenomenological analysis of states of illness.
LK: You extensively draw on anthropological, sociological and historical work in your book. Why did you decide to flag it as an introduction to philosophy of medicine? You make clear that you are critical about the term ‘medical humanities.’ Yet, your book seems to me a prime example of both the fruitfulness of cross-talk between the meta-disciplines studying medicine and the importance of educating medical students (and society at large) to not only think about what is technically possible, but also about the limits of medical interventionism.
CB: I have already explained why philosophy of medicine should be more than the branch of philosophy of science specializing in medicine. As such a fundamental questioning, philosophy of medicine must build on the insights from science studies, anthropology and historical epistemology. If my book also serves as an introduction to medical humanities properly understood, I have no problems with that. In their present form however, ‘medical humanities’ often functions as a term describing an array of attempts to adapt biomedicine to the needs of patients without questioning the way biomedicine defines their problems. A good medical education must include some form of medical humanities and it should also offer some philosophical reflection on how biomedicine operates as a scientific practice – and in addition, philosophy of medicine should be the ‘cross-talk between the meta-disciplines studying medicine,’ as you just described it. Biomedicine has generated a wealth of possible and effective interventions. The problem with the technically possible is less the risks and costs involved, but the inherent tendency to foreclose a proper discussion about benefit. The limitations of medical interventionism transpire not along the limits of the technically possible but along their unlimited extension.
LK: Recently, Mark Zuckerberg, the founder of Facebook, and his wife, Priscilla Chan, advertised that they wanted to spend 100 billion dollars in biomedical (and bioinformatic) research, announcing the aim to eradicate all diseases by the end of this century. Your book reveals puzzle-solving to be the ‘working mode’ (Arbeitsmodus) of biomedicine and you argue that this is an ‘unattainable phantasm’ (uneinholbares Phantasma). You oppose philosophy of medicine to this reductionist understanding. Do you see a role for philosophers of medicine in publicly raising their voices in light of such news?
CB: The aim to treat more diseases and to treat them more effectively is very laudable. But it must be added that, on a global scale, the most pressing health problems are already now treatable and effectively manageable. Clean water, healthy food and good hygiene are still the most important factors determining health and disease epidemiologically. Any initiative to eradicate disease by fostering biomedical research and bioinformatics is hence a very Western and elitist program. But that is another problem and not your question. Living without disease is an old dream, the hope for a new paradise. My suspicion about the Zuckerberg and Chan vision is that to eradicate all diseases does not lead to utopia but to an inhuman dystopia of perfected life, mistaking the ‘absence of disease’ with proper health – to echo the famous definition by the WHO. Alas, my scepticism regarding the Zuckerberg and Chan initiative does not rely on the assumption that diseases are necessary requirements for a meaningful life; it revolves around the understanding that frailty and failure are part and parcel of life itself – and not only of its defective forms. Strictly speaking, life can only be perfected by bringing it to its end. Philosophy of medicine can and should explain why the aim to eradicate disease is good but the underlying vision mistaken; and by the way, the Companion to Philosophy of Medicine you mentioned in the beginning is a nice example of how also the Anglophone branches of philosophy of medicine open up to this.
LK: Imagine Zuckerberg and Chan, inspired by the Human Genome Project, decided to reserve 1 % of this 100 billion dollar programme for the medical humanities. What should be done?
CB: They should, indeed, decide so, but for the form of cross-talk you mentioned! Since the Humane Genome Project we have ELSI, the study of the ethical, legal and social issues of biomedical research. This is more than a mere ‘nice to have,’ because it is important to explore these issues together with the scientific projects. But as it is implemented today, ELSI research follows rather the scientific agenda than interacting with it, and hence, discussion has started about how ELSI research can be better integrated in and connected with on-going biomedical research. In a similar way, medical humanities should be conceived not only as a training program but as a research area, interconnected with biomedical research. A substantial proportion of the 1 billion dollars should be hence allotted to patient groups and for citizen science projects, for articulating, fostering and incorporating their views, needs and values into the biomedical research agenda. And I would apply to Zuckerberg and Chan for funding an interdisciplinary PhD program in philosophy of medicine, offering philosophical reflection in combination with social studies and an immersion in clinical and lab-based research. Instead of specializing philosophers in a subfield, the program would train a new generation of cross-talkers with a thorough understanding of the articulation of research, needs and problems of the many actors in the health system. Their expertise and mediation will be required.
Lara Keuck specializes in history and philosophy of biomedical knowledge. She leads a junior research group on “Learning from Alzheimer’s disease. A history of biomedical models of mental illness”. The group is based at the Department of History at Humboldt University in Berlin, Germany, and is funded through ETH Zurich’s “Society in Science – The Branco Weiss Fellowship”. Together with Geert Keil and Rico Hauswald she has just published an edited volume on Vagueness in Psychiatry (Oxford University Press, 2017).
Cornelius Borck studied medicine and philosophy and is director of the Institute of History of Medicine and Science Studies of the University of Lübeck, Germany. Before coming to Lübeck, he held a Canada Research Chair in Philosophy and Language of Medicine at McGill University in Montreal. Beyond philosophy of medicine, he works on the history of brain research between media technology and neurophilosophy and on the epistemology of experimentation in art and science.
Medizinphilosophie. Zur Einführung is out now from Junius Verlag.