If You Give a Clinician a Blood Pressure Measuring Machine
Of Scientific and Medical Revolutions
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Did you ever read If You Give a Mouse a Cookie growing up or to your kids? It’s one of many childhood stories I now share with my own kids. Surely it needs no introduction nor summary.
Cast in an allegorical light (that probably ruins its playfulness), the whole day is dictated by the latest item the mouse receives. The mouse’s possessions set the agenda. The poor kid, generous as they are, is running around trying to keep up.
Medicine is a bit like that. We rush around, trying to keep up with our stuff. The history of blood pressure measurement is like this childhood story. It’s a story about what happens if you give a clinician a sphygmomanometer. I think the story teaches us two things. The first we’ll discuss here, and the second we’ll tackle in the next essay.
First: medicine is not science.
Blood pressure, perhaps more than any other idea in the developed world, has come to represent “health.” In just two numbers, people gain rudimentary insight into their body’s functioning. Now, of course clinicians know how rudimentary an insight that is, but the belief seems intractable. Even when the time is dire, family members of a patient dying in an ICU whisper their disbelief: “But how can this be? Their blood pressure is just fine.”
Hughes Evans documents this history, writing that blood pressure machines…
…did not become a regular feature of medical practice until after 1910. The concept of high blood pressure as a disease was only introduced in 1913. It was years before this controversial notion of a virtually symptomless disease met widespread acceptance. In fact, the introduction of blood pressure machines, and hence blood pressure measurements, caused an uproar in the American medical community. Physicians felt threatened by the apparatus and the implications of incorporating it into medical practice.
If we study how science changes, we’ll see some interesting points of departure from medical practice that will help us understand their differences. We may then be in a better place to draw some helpful conclusions on how to use science wisely and well.
Normal Science and the Revolution
If you open a textbook in any field of science today, you might believe that progress has been the effort of one genius after another contributing blocks to the same house of knowledge. Thomas Kuhn, writing in The Structure of Scientific Revolutions, voiced his doubts:
…textbook-derived tradition in which scientists come to sense their participation is one that, in fact, never existed. For reasons that are both obvious and highly functional, science textbooks (and too many of the older histories of science) refer only to that part of the work of past scientists that can easily be viewed as contributions to the statement and solution of the texts' paradigm problems. Partly by selection and partly by distortion, the scientists of earlier ages are implicitly represented as having worked upon the same set of fixed problems and in accordance with the same set of fixed canons that the most recent revolution in scientific theory and method has made seem scientific.
Kuhn set out to understand how science operates and what happens when there’s a massive change in scientific practice, what he called a scientific revolution. What he described was unlike anything most people envision when they think about science.
The Mundane Work of the Humble Scientist
In the beginning, humans use their bare senses to gather data about the world. Kuhn admitted that this is an almost random activity. Why, for example, should we believe that observations in my corner of the world tell me anything reliable about what could happen in your neck of the woods? Why should this line of inquiry attract my attention and not another? Why assume that my testing something doesn’t change the outcome? But, alas, we’ve got to start somewhere.
Once that’s underway, we need some way of sorting relevant from irrelevant data. Kuhn called the orienting, cohering framework for thinking about the world a “paradigm.” It’s the theory, the story, we tell ourselves about our data. Paradigms are pre-hypothetical; they provide the structure for us to ask questions and form hypotheses (indeed, the idea of even forming a hypothesis belongs to a paradigm). Inquiry about the world involves competition among all sorts of paradigms that inform practices from, say, reading tea leaves to modern meteorology. Each paradigm sits on presuppositions about how the world works:
Paradigms gain their status because they are more successful than their competitors in solving a few problems that the group of practitioners has come to recognize as acute. To be more successful is not, however, to be either completely successful with a single problem or notably successful with any large number. The success of a paradigm —whether Aristotle's analysis of motion, Ptolemy's computations of planetary position, Lavoisier's application of the balance, or Maxwell's mathematization of the electromagnetic field — is at the start largely a promise of success discoverable in selected and still incomplete examples. Normal science consists in the actualization of that promise, an actualization achieved by extending the knowledge of those facts that the paradigm displays as particularly revealing, by increasing the extent of the match between those facts and the paradigm's predictions, and by further articulation of the paradigm itself.
At the outset, a paradigm may have only proven itself in one instance, and it requires faith for us to carry it further and elsewhere.
Each Scientist Scores Points for Their Paradigm
Normal science is the work done to support a paradigm. It usually doesn’t make headlines, but it’s necessary:
Closely examined, whether historically or in the contemporary laboratory, [normal science] seems an attempt to force nature into the preformed and relatively inflexible box that the paradigm supplies. No part of the aim of normal science is to call forth new sorts of phenomena; indeed those that will not fit the box are often not seen at all. Nor do scientists normally aim to invent new theories, and they are often intolerant of those invented by others. Instead, normal-scientific research is directed to the articulation of those phenomena and theories that the paradigm already supplies.
The work of normal science boils down to “determination of significant fact, matching of facts with theory, and articulation of theory.”
After Enough Work, A Scientist Can See Where Things Don’t Add Up
Doesn’t science discover things? That’s the whole point of science, right? Kuhn put it this way:
Discovery commences with the awareness of anomaly, i.e., with the recognition that nature has somehow violated the paradigm-induced expectations that govern normal science. It then continues with a more or less extended exploration of the area of anomaly. And it closes only when the paradigm theory has been adjusted so that the anomalous has become the expected. Assimilating a new sort of fact demands a more than additive adjustment of theory, and until that adjustment is completed — until the scientist has learned to see nature in a different way— the new fact is not quite a scientific fact at all.
Normal science makes it possible to see an anomaly. When confronted with this discovery, normal science works to smooth it out until it’s no longer anomalous. The paradigm now expects and explains what was once unexpected and inexplicable.
Unsolved Anomalies Are Bombs
What happens if there’s an anomaly the current paradigm can’t explain? These anomalies lead to a crisis. This provokes a feeling “that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which that paradigm itself had previously led the way.” All normal science, if you stick with it long enough, leads here.
Normal science brings the scientist to the crisis but can’t bring them through it. Crises “are terminated, not by deliberation and interpretation, but by a relatively sudden and unstructured event like the gestalt switch. Scientists then often speak of the ‘scales falling from the eyes’ or of the ‘lightning flash’ that ‘inundates’ a previously obscure puzzle, enabling its components to be seen in a new way that for the first time permits its solution.”
As long as a crisis persists, it bedevils the old paradigm’s scientists. They can’t test the fitness of their paradigm by itself from some neutral position; instead, a new paradigm will rise as a competitor. In the face of this crisis, some scientists will double-down in faith that their paradigm will win out over this anomaly in a way they don’t yet understand. Communication between two paradigms will be incomplete and fraught with tension:
Within the new paradigm, old terms, concepts, and experiments fall into new relationships one with the other. … The laymen who scoffed at Einstein's general theory of relativity because space could not be ‘curved’ —it was not that sort of thing —were not simply wrong or mistaken. Nor were the mathematicians, physicists, and philosophers who tried to develop a Euclidean version of Einstein's theory. What had previously been meant by space was necessarily flat, homogeneous, isotropic, and unaffected by the presence of matter. If it had not been, Newtonian physics would not have worked. To make the transition to Einstein's universe, the whole conceptual web whose strands are space, time, matter, force, and so on, had to be shifted and laid down again on nature whole.
This problem isn’t scientific, not in the way we’ve been describing science. Rather, it’s a deeper, social, even existential matter:
The transfer of allegiance from paradigm to paradigm is a conversion experience that cannot be forced. Lifelong resistance, particularly from those whose productive careers have committed them to an older tradition of normal science, is not a violation of scientific standards but an index to the nature of scientific research itself. The source of resistance is the assurance that the older paradigm will ultimately solve all its problems, that nature can be shoved into the box the paradigm provides. Inevitably, at times of revolution, that assurance seems stubborn and pigheaded as indeed it sometimes becomes. But it is also something more. That same assurance is what makes normal or puzzle-solving science possible. And it is only through normal science that the professional community of scientists succeeds, first, in exploiting the potential scope and precision of the older paradigm and, then, in isolating the difficulty through the study of which a new paradigm may emerge.
…
...paradigm debates are not really about relative problem-solving ability, though for good reasons they are usually couched in those terms. Instead, the issue is which paradigm should in the future guide research on problems many of which neither competitor can yet claim to resolve completely. A decision between alternate ways of practicing science is called for, and in the circumstances that decision must be based less on past achievement than on future promise. The man who embraces a new paradigm at an early stage must often do so in defiance of the evidence provided by problem-solving. He must, that is, have faith that the new paradigm will succeed with the many large problems that confront it, knowing only that the older paradigm has failed with a few. A decision of that kind can only be made on faith.
A scientific revolution happens when a critical mass of a scientific community switch to the new paradigm. This also coincides with the loss of support for the old paradigm. Sometimes this only happens with the death of the previous generation of scientists.
Where Does Science Lead?
By now you might be asking, if these scientific revolutions have occurred through a series of crises and leaps of faith, how in the world have we progressed? What does it mean to progress anyway? Kuhn’s perspective might make scientific development seem almost serendipitous. In a way, it is - but good luck comes to those who work hard. We can only arrive at the crisis that ushers in the next paradigm through a lot of normal science.1
Consider this: we don’t really say that the practices of painting, music, dance, or any other art “progress.” We don’t think of those things as moving in any direction.2 There are numerous (competing?) paradigms within these fields. Progress, if any were to be had, would be hard to see. The reason why we say science progresses is because we live in an age when a single paradigm has almost exclusively dominated inquiry:
With respect to normal science, then, part of the answer to the problem of progress lies simply in the eye of the beholder. Scientific progress is not different in kind from progress in other fields, but the absence at most times of competing schools that question each other's aims and standards makes the progress of a normal-scientific community far easier to see. That, however, is only part of the answer and by no means the most important part. … the reception of a common paradigm has freed the scientific community from the need constantly to re-examine its first principles, the members of that community can concentrate exclusively upon the subtlest and most esoteric of the phenomena that concern it. Inevitably, that does increase both the effectiveness and the efficiency with which the group as a whole solves new problems.
Kuhn concluded his reflection on the structure of scientific revolutions by claiming that science, too, lacks an aim:
Can we not account for both science's existence and its success in terms of evolution from the community's state of knowledge at any given time? Does it really help to imagine that there is some one full, objective, true account of nature and that the proper measure of scientific achievement is the extent to which it brings us closer to that ultimate goal? If we can learn to substitute evolution-from-what-we-do-know for evolution-toward-what-we-wish-to-know, a number of vexing problems may vanish in the process.
Science, in Kuhn’s estimation, has no telos. It’s not progressing toward anything. It’s always progressing from something.
Medicine: A Science-Using Practice
Medicine is not a science. It’s a science-using practice. Medicine uses science, but also requires clinicians to know how to make prudential judgments (leaps from population-level evidence to the individual patient in front of them), to communicate well in challenging circumstances, and to endure repeated contact with others’ suffering. Just like any other practice, medicine has a weak spot for being used by its tools. When you’ve got a hammer, everything can become a nail. How are clinicians are vulnerable to reducing medical practice to the use of science?
The Clinician’s Work Serves Health
Clinicians, like scientists, confront problems, ask questions, and test hypotheses. A paradigm guides them in their work. One facet of the clinicians’ paradigm is much like the scientists’, in that it tells them how the world is: this is the form of the human body and how it functions, these are the threats to its health. The clinician’s paradigm also tells them how the world should be, which is different from the scientists’ paradigm. That part of the paradigm is not scientifically derived but can be scientifically disrupted (in the same way a mouse can be drawn along by the offer of a cookie). Science exists to acquire an accurate understanding of the world. For medicine, knowledge is a means to an end.3
When they were invented, it wasn’t clear that the data blood pressure machines provided would be useful for healing. That is, after all, the whole point of the clinician’s work: to help their patients support and restore health. Clinicians of the time were even conflicted over the status of what the machines purported to diagnose: “…hypertension ‘is itself not a cause, but an effect; not an illness, but merely evidence of it; not pathological in meaning, but rather a physiological, mechanical adjustment to an unknown diseased condition; not a true, but a sphygmomanometric disease, frequently a compensating process and to a certain extent, therefore, life-saving.’” Never mind that these clinicians were ultimately wrong and history played out the way it did; one guiding principle for clinicians of that day was whether this would serve their patients’ health. This same principle orients modern clinicians too. The fact that blood pressure measurement won the day is evidence for how well it serves this purpose.
We run into trouble if clinicians get it backward, seeing the clinical encounter as first and foremost a puzzle. It is a puzzle (among other things), and solving puzzles can be satisfying, but that’s not why one practices medicine. Negotiation between science and medicine cannot dispense with the aim of medical practice. If we lose sight of that, then we fall into the trap of treating patients like they’re sitting on the research bench, as Alasdair MacIntyre argued:
Part of our inheritance from [the period of scientific advancement in medicine during the 20th century], in which successful medicine was successful applied science, is a view of the patient as essentially either an object for or an exemplification of the results of scientific research. Viewed thus, the patient is no longer envisaged as a whole person, but only as a body; and the body itself is envisaged as a collection of parts and subsystems, each of which may fruitfully be studied in isolation from the rest. According to this view of medicine, the physician reenacts with the parts of the patient’s body what the scientist had first achieved on the laboratory bench, and it follows that the specific complaints uttered by the patient and the care of the patient are not really part of the genuine practice of medicine at all.
When medical practice takes this turn, surrogate markers proliferate and are divorced from meaningful clinical outcomes as I’ve observed before:
Clinicians might declare “victory” when they’ve improved the surrogate marker of their particular disease or organ, but they’ve actually been playing a different “game” than one that benefits their patient. This maybe has happened because they’ve taken on an end for the sake of the means - they’re more enamored with the techniques of their work and the ends supplied by those techniques (“metrics”), than the more nebulous, harder-to-measure state of health of their patient which originally piqued their altruism.
A clinician cannot support and restore the health of a whole person if they cannot see the whole person. So while science has provided powerful tools for medical practice by looking across the hidden landscape of human anatomy and function, more needs to be brought to bear on the care of patients than chemistry and surgery.4
The Clinician’s Paradigm Serves Health
Medicine, like science, determines what facts are significant and matches those facts with a theory to tell a coherent story about what’s going on. That story, however, is in service to a patient’s health, and that story isn’t an explicit articulation of the theory. The history of present illness, the clinician’s translation of what is going on with their patient, is the clothing the theory wears through the patient’s experience. A clinician will learn to tell a story about chest pain in a particular way so that it leads to a differential diagnosis, justifies a diagnosis, and guides a treatment plan.
Clinicians run into trouble when they try to justify a paradigm through their clinical work, similar to how a scientist will justify their paradigm through their study. Chronic Lyme disease supposedly doesn’t exist - but something is going on with people who suffer from what they claim is this condition. Clinicians feel suspicious about fibromyalgia, chronic pain, personality disorders. Some clinicians invalidate the experience of people who suffer in these ways. The clinical encounter is used as an instrument to repel or control patients, rather than care for them.
Why would a clinician do this? Because they’re using the paradigm given them by science, unfiltered and unaltered by the purposes of medicine. They seek truth for truth’s sake. They fail to appreciate that the clinical encounter isn’t a scientific endeavor.
That doesn’t mean whatever self-diagnoses or treatment plans patients make are valid. That reverses the role of clinician and patient. Some clinicians stray down that path instead. Serving a patient’s desires, whatever they are, may not serve their health. When society becomes enamored with the promises made by medical technology, we all become tempted to use that power for our own purposes. The belief that medical practice should satisfy preferences is the product of a highly technical paradigm. Clinicians are those with expert knowledge and skills that make them instruments in the hands of their patients - nothing more. That literally de-moralizes the practice of medicine.
Medicine Confronts Anomalies
Medicine, like normal science, prepares the clinician to detect anomalies others might not perceive. Unlike normal science, though, the clinician seeks out anomalies and contends with them frequently.5 These anomalies are the signs and symptoms of disease. The daily work of the clinician is to help their patients navigate life in pursuit of health while avoiding, reducing, or eliminating disease.
If a clinician fails to accommodate an anomaly within their paradigm, they’ll probably reject it as relevant. This winds up a tension between clinicians and patients. The initial stage of the clinician’s work involves discerning the truth of the matter: what is the diagnosis? Or, absent the need to diagnose (e.g., preventative medicine), what is the need? The question itself is an empiric one, and a clinician might go about their work very much like a scientist. If this part of the work doesn’t yield an empiric outcome, some clinicians will falter and the patient will be frustrated. Yes, the patient wants the truth, but they want the truth so they can know what to do with their health, their body, their life.
Medical practice is shielded, somewhat, from the anomalies confronting normal science. A rigorous gauntlet of clinical trials stands between basic science research and the clinician’s decision-making. But anomalies can be felt in other ways. For example, anomalies detected in clinical trials can be translated, sometimes rapidly, into clinical practice without first resolving those anomalies. If a trial casts doubt on the standard of care, it could disrupt clinical decision-making. It’s up to a clinical trial to determine whether the standard of care serves its purpose, but it’s up to the clinicians to discern how to apply that evidence (or lack thereof) to any given patient.
Scientific innovation can be disruptive too. That’s what happened with blood pressure measurement (back to Evans):
At the same time that diagnostic instruments promised to place diagnosis on a sounder foundation, they threatened the professional ethos that valued artistry accrued over a lifetime. The physiologists who designed these instruments promoted objective over subjective data, quantitative over qualitative information, and precision over vagueness. In so doing, they stripped diagnosis of much of its mystique and suggested a new set of priorities for medical thinking. Ideally, the instruments would serve as an objective arbiter of the physician’s diagnostic skills and a predictable, standardized reference for the student learning diagnosis.
As Evans goes on to describe, there was certainly debate about the utility of machines that purported to measure blood pressure. This appears similar to the challenges faced by normal science all the time: what is the most accurate, most precise way to measure something according to the reigning paradigm? But there was also a challenge to medical practice in how to accommodate this new technology into the self-understanding of the profession.
As we’ll see, blood pressure measurement signaled not just an innovation, but a crisis of medical practice.
Medicine’s Many Anomalies and Crises
Remember that, according to Kuhn, a scientific crisis occurs when a paradigm meets an anomaly and there’s a “growing sense … that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which that paradigm itself had previously led the way.” The crisis is wed to the function of science: exploration of nature. That’s not the purpose of medical practice. Medicine supports and restores health. When medicine’s paradigm meets an anomaly it can’t address, a crisis arises. Of course, individual clinicians can have their own crises, just like individual scientists, but we’ll keep in view the crises that befall the whole field.
Because of its practical, human-centered focus, the anomalies confronting medicine are more varied than those facing science. For example, when clinicians, relying on their paradigm, fail to identify something objectively wrong with a patient who has a complaint, the clinicians may struggle to act. Their technical interventions are usually used to treat a diagnosis. This may become a crisis of utility: technical interventions may be used or withheld inappropriately, deepening the rift between patient and clinician, exacerbating patient suffering, and frustrating the clinician. Responses can vary from “There’s nothing I can do for you” to “Here, take this antidepressant.”
Medical crises can also involve scarce resources. In a situation where there aren’t enough resources to meet everyone’s medical needs, stewards of those resources need to make decisions about who gets access and who doesn’t, a decision that’s not part of normal medical practice. We’ve got a special name of this: crisis standards of care. Some healthcare systems became all too familiar with this during the COVID pandemic.
The negotiation between medical practice and healthcare funding is another slow-roiling crisis. This is perhaps uniquely acute in the United States, but it bedevils other systems like the UK’s NHS. How can we, as a society, satisfy demand and pay for all of it at the same time? Clinicians aren’t used to saying “no” at all, let alone saying “no” because a patient can’t pay. This form of crisis also shows how much more closely medicine interfaces with other parts of society than normal science.
Let’s return to blood pressure measurement to see another crisis.
It was scientific innovation that created a crisis in medical practice when blood pressure machines hit the scene. This wasn’t like the types of crisis Kuhn described because it involved questions of utility, not truth for its own sake. Were these machines as good as palpation? Would they be practical to use? Were these numbers reliably tracking anything about health or disease? Would these machines de-skill clinicians, or would they instead help hone the clinicians’ skills?
There were also questions about the social impact of these machines. Machines, like the then-prevalent stethoscope, could distance doctor from patient by putting layers of instrumentation between them. One physician claimed that “the discoveries of the stethoscope, the sphygmograph [blood pressure machine], and the thermometer had ‘dealt a death-blow to the painstaking study of the pulse.’”
Evans goes on to write:
At the heart of the issue was a perceived attack on one of the most basic and revered skills of the profession, that of palpating the pulse. Fathoming the intricacies of the pulse separated the amateur from the professional, the novice student from the experienced practitioner. The sphygmomanometer bridged this mysterious chasm between the initiated and uninitiated, threatening to break down barriers that were felt to be essential to both the hierarchy within the profession and professional status within society.
It wasn’t all about utility; it was also about professional identity and, yes, prestige and mystique. There’s something ineffable to the clinical profession and the relationship clinicians have with patients that the technology threatened to impair. There were indeed unseemly motives for this: “Using instruments of precision edged perilously close to performing manual labor and thus risked lowering a doctor’s respectability. They called into question the role of pulse palpation and in so doing threatened professional pride and identity.” But there was also a concern that by adopting machines into medical practice, clinicians would become unmoored from a tradition of healing that spanned history: “While instruments represented mechanization, efficiency, and scientific reasoning, the finger symbolized clinical experience, time-honored methods of physical diagnosis, and the sanctity of the doctor/patient relationship.”
Blood pressure machines won out over the physician’s palpating finger.6 Similar to revolutions in science, revolutions in medicine might occur rapidly for some clinicians, but the field moves slowly. The conversion of skeptics to believers was gradual. The availability of reliable and affordable instruments, the use of instruments in medical education, and an increasing emphasis on a scientific ‘rational’ approach to medicine were among the many factors which coalesced to convince doctors to purchase and use sphygmomanometers.
What’s the Difference Between Innovation and Revolution?
New products are being made all the time. Sometimes it’s not clear they’re truly innovative (e.g., the numerous cousins among the selective serotonin reuptake inhibitors (SSRIs)). These creations are occasionally announced with superlative fervor: “A blockbuster!” “A game-changer!” or even “This revolutionizes medical practice!”
But after tracing the idea of revolutions in both science and medicine, we might find the word is best reserved for uncommon, even rare, developments. A revolution is, as we observed, wed to the purpose of the practice. A crisis occurs when a paradigm no longer helps the practice contend with an anomaly that the practice should have been well-suited to face.
I want to suggest to you that revolutions in medical practice on this scale have been really rare, perhaps never having occurred since the advent of medical practice. Despite so much change through the centuries, and particularly since medical practitioners have adopted science as one of their major tools, the actual practice of medicine hasn’t changed that much. Medicine is basically one person (or several) attempting to help a sick person become well or, sometimes, helping a well person to stay that way. Even claimants for a medical revolution like the move from “paternalism” to “respect for autonomy” haven’t altered the main focus of medical practice.
That doesn’t mean there haven’t been attempts to revolutionize medical practice.
Eugenics was one such attempt. Thankfully, it failed. There were many reasons why it did, but we can see it had the hallmarks of a revolution: the old paradigm of caring about the health of the individual faltered in the face of chronic illness and didn’t serve the efficient purposes of the state. This changed everything about medical practice where eugenics reigned.
Now we face two crises. It remains to be seen whether medical practice will revolutionize (or perhaps already has). There’s the crisis of enhancement and the crisis of death.
The move toward using medical technology to enhance human form and function is the result of scientific innovation. “If you give a mouse a cookie…” Since clinicians are those with the greatest expertise in applying these technologies to the human body, their profession could be co-opted into a project to enhance in addition to healing. This need not apply just to the fantastical implantation of computer chips in brains, but also to the more mundane satisfaction of patient preferences. The promise of innovation shifts the whole aim of medical practice as it no longer serves health.
Ironically, the move toward adopting death as a goal of care has occurred because medicine has both over- and under-delivered. Medical technology is too good at keeping people alive. It has sustained people until they reach new heights of suffering that were never or only rarely encountered in bygone years; our ancestors would have died naturally long before these experiences. But medicine also under-delivers, in that it often fails to restore health even as it adds time and also fails to infuse meaning into suffering. Also in bygone years, people relied on their traditions and communities to help make sense of their suffering and cope with their circumstances. Modern medicine has subsumed nearly all aversive human experiences (at least related to the body) under its domain and has vacated many people’s capacity to find meaning amidst the suffering wrought both by their disease and its treatment. There is no meaning, only the next technical decision waiting to be made.
These two moves - toward enhancement and toward death - are crises. The paradigm of medical practice that would orient clinicians toward supporting and restoring health appears deficient in the face of the astounding promises of scientific innovation. It also appears deficient in the face of patient choice, suffering, and the afflictions wrought by medical treatment itself.
Where do we go from here? That’s what I hope to address next. If medicine isn’t science, then what is it?
Medicine is magic.
It’s no coincidence that some of the greatest scientists throughout history had faith that there was a metaphysical structure to reality that made it reliable enough to study. There’s something outside the physical world that imposes rational form and function on it, even if any given paradigm can only appreciate that incompletely. It’s what informs the faith both of old adherents to a paradigm and the recent converts to a new paradigm.
Just because art isn’t thought of this way doesn’t mean it can’t progress. If an art form has a purpose, something it’s trying to do or say, it can move toward or away from that goal. In that sense, we can claim it progresses (or regresses).
You might object here that this is only true of science as such, and not applied science. There are many fields of science that also have a vision of how the world should be, clinical research among them. The title belies what’s actually going on: those fields aren’t entirely science, but also science-using practices to apply the principles of scientific innovation to useful problems. In the case of clinical research, there are meta-questions about how to prioritize which research questions that aren’t necessarily scientifically informed.
This doesn’t mean the practice of medicine devolves into “the customer is always right” relativism, providing whatever the patient desires. Medicine serves health, but truth must serve medicine. It does this by intervening on the human body to support and sustain health through the goals of care.
Again, you might say that applied science doesn’t fit in Kuhn’s box. It’s true that applied sciences seek out these anomalies; they are purpose-driven practices.
Although in a pinch, you can estimate someone’s blood pressure by palpating their pulse at certain locations (e.g., carotid, radial, femoral).