Medicine is Magic
So Don't Treat It Like Science
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Medicine is magic.
After tracing the structure of scientific revolutions with Thomas Kuhn and contrasting that with medical practice, that’s where we ended up at the end of my last essay.
I want to now suggest that the reason why blood pressure measuring machines caught on was because they’re magic that works. Only magic (or the law) would have the power to force physicians to do something they felt detracted from their mystique and prestige. Hughes Evans has been our guide through this history of blood pressure measurement. He documented the words of one zealous advocate for these machines as saying, “Thus an apparatus which not only gives in numerical terms an equivalent of existing arterial tension but also makes possible the graphic representation of its variations under treatment, puts the clinician in closer touch with the patient’s condition.”
So, seems pretty obvious and scientific. What’s magical about that?
Medical Magic
Consider this observation from C.S. Lewis:
The serious magical endeavour and the serious scientific endeavour are twins: one was sickly and died, the other strong and throve. But they were twins. They were born of the same impulse.
...
There is something which unites magic and applied science while separating both from the 'wisdom' of earlier ages. For the wise men of old the cardinal problem had been how to conform the soul to reality, and the solution had been knowledge, self-discipline, and virtue. For magic and applied science alike the problem is how to subdue reality to the wishes of men: the solution is a technique; and both, in the practice of this technique, are ready to do things hitherto regarded as disgusting and impious - such as digging up and mutilating the dead.
Whether we call it magic or science, the endeavor has been the same: to understand and harness the power of nature.1 Don’t believe Lewis? Let’s go back a bit further, to Francis Bacon himself.
Alexander Rosenthal-Pubul writes that,
Bacon will use quite aggressive language in describing the human relationship to nature. The secrets of nature [occulta naturae] must be as it were violently forced out of her if she is to be conquered and mastered for- ‘...the secrets of nature reveal themselves more readily under the vexations of art [vexationes artium] then when they go their own way.’
This was not a new way of conceiving humanity’s relationship with nature. Magicians had been talking like this for a long time - whether it be in predicting the future by reading tea leaves or swaying events through the casting of spells. Magicians want to understand and use the forces of nature. Rosenthal-Pubul quotes Bacon:
We here understand magic in its ancient and honorable sense - among the Persians it stood for a sublimer wisdom, or a knowledge of the relations of universal nature, as may be observed in the title of those kings who came from the East to adore Christ. And in the same sense we would have it signify that science, which leads to the knowledge of hidden forms, for producing great effects…
What are these great effects? Bacon didn’t believe knowledge should be sought for its own sake. In this, he broke with ancient Greek philosophers like Aristotle. He believed knowledge should serve “the relief of man’s estate.” To the extent that you take it for granted that learning anything should serve a greater purpose than merely knowing it (e.g., treating an infection, building a house, driving a car), you are a benefactor of Bacon’s philosophy of knowledge.
Magic was, is, and always will be the attempt to predict how the hidden forces of nature will behave and to harness that power for one’s own use. This is the muttering of an ancient magus to curse his enemies, the “secret power” of the physician to diagnose disease by palpating a pulse, and the microscopic work of chemistry to lower blood glucose, kill cancerous cells, or cure an infection. The history of medicine and the history of magic are one. This is also why medicine’s history of development doesn’t track exactly with the structure of scientific revolutions. Medicine isn’t science.
Bacon’s close association between science and magic is helpful for us as we seek to better understand what our technology is capable of doing and what we need to use it well. I’ve written before about how modern clinicians can sometimes fall into the trap of being like the sorcerer’s apprentice:
We control technology that, to the untrained eye, appears magical. We put that power to good work. We make many good things happen. It’s pretty awesome what we can do when we apply elbow grease and compassion to a problem. But then the power gets away from us.
Goethe’s poem about a young sorcerer who can unleash power but not restrain it is a warning against any magicians who would try to seize more than they can handle. But you might say that we made our technology, so we have power over it. Mary Shelley, writing Frankenstein, warned against finding solace there:
Victor Frankenstein, just like an apprentice without a master, was eager to control the ‘spirits’ that led to the creation of his monster. But under the gaze of the creature’s jaundiced eye, Victor realized that he had overstepped a boundary. Everything he studied hadn’t prepared him for this. The creature was beyond his control and it also knew where things stood: ‘Remember that I have power; you believe yourself miserable, but I can make you so wretched that the light of day will be hateful to you. You are my creator, but I am your master;--obey!’
Or remember the Ring of Power from J.R.R. Tolkien’s The Lord of the Rings. The Ring was created by an evil sorcerer to subjugate the world. Once lost, the story picks up when it has been recovered by an unlikely creature, a hobbit. Gandalf, a good wizard, accompanies a band of companions who would bear the Ring and decide what to do with it. But why should the Ring be left in the hands of this lowly hobbit?
‘You are wise and powerful. Will you not take the Ring?’
‘No!’ cried Gandalf, springing to his feet. ‘With that power I should have power too great and terrible. And over me the Ring would gain a power still greater and more deadly.’ His eyes flashed and his face was lit as by a fire within. ‘Do not tempt me! For I do not wish to become like the Dark Lord himself. Yet the way of the Ring to my heart is by pity, pity for weakness and the desire of strength to do good.’
Gandalf knew that there was power in this Ring (this technology, if you like, for that’s what it was) beyond his capacity to handle well. In fact, if he tried to use the Ring, he knew the Ring would use him instead. It would take advantage of his good will.
We need not retreat into fantasy to make the point. What we today call “science” wouldn’t be recognized as such to the geniuses of a thousand years ago; it would be magic (as Arthur C. Clarke knew). It has more effectively tapped the hidden powers of nature than ancient magic could do. Today’s science is real magic, in the sense people have always understood magic. It tells us reliable things about the patterns of the world and gives us tools to use hidden power. But there are still other hidden powers that the science of our day has yet to discern or control, and so in a thousand years time, there may be science that would have appeared to us as magic.
Given the power of modern science, clinicians can become overly enamored with it, lured by its power. Gandalf had it right: some powers we may be unprepared to handle just yet, and some we should forsake altogether knowing our hands can never wield them. How we know the difference is hard, unscientific work.
Medicine: A Science-Using Practice
Medicine is not science.
For some, this might be a banal observation. Of course clinicians need a host of other characteristics and skills to help their patients support and restore their health. In order to use science well, clinicians need to have compassion, wisdom, honesty… the list goes on, even if there’s some debate about what things belong on the list. They need to be able to communicate well and understand things beyond physiology and anatomy (e.g., a bit of healthcare economics). But this blithe dismissal underestimates the power of our tools to shape our perception. “When you’ve got a hammer, all you see are nails.”
Others might scoff at something so ridiculous. Medicine wasn’t medicine before the scientific revolution, not in any sense of the term as we now use it. Before the advent of modern medical science, they argue, all doctors did was sit by the bedside and hold dying peoples’ hands. Maybe they’d cut off a gangrenous leg here and there. Without science, medicine is nothing. But this zealous defense of science assumes a practice devolves to mere tool-use; that the practice of, say, carpentry is one and the same with the use of a saw.
You’ll remember that a scientific crisis starts with an anomaly that can’t be explained by a paradigm and neither can the paradigm accommodate itself to the anomaly. This is a crisis of knowing. Magic faces its own challenges. These can mount up into crises too. When confronted with the promise of power, magic can either be underestimated or exalted.
Underestimated Magic
Story after story recounts this theme. Maybe someone believes they’re immune to the negative influence of magic (e.g., Anakin Skywalker in Star Wars), thinks magic is taboo (e.g., the Dursleys from Harry Potter), or just doesn’t believe in magic (e.g., Matilda’s parents in Matilda).
Why is magic so easy to underestimate?
Stanley Reiser, writing in Medicine and the Reign of Technology, had this to say about medicine’s technology (i.e., its magic):
If physicians in general come to accept a fundamentally mechanical view of human beings, in a world that is more and more enamored of technology, the prospect for the future of medicine is extremely disquieting. To counter the fears of such a prospect, a myth has arisen in contemporary medicine that the more the machines can take over the performing of medical functions, the more the doctor will have time to deal with his patient as a human being. This reliance on technology is supposed to improve the doctor-patient relationship, to the benefit of both.
These are illusions. Machines inexorably direct the attention of both doctor and patient to the measurable aspects of illness, but away from the ‘human’ factors that are at least equally important. Insofar as technological evidence occupies the time and commands the chief allegiance of both doctor and patient, it diminishes the possibility that a close personal relationship will develop between the two. So, without realizing what has happened, the physician in the last two centuries has gradually relinquished his unsatisfactory attachment to subjective evidence - what the patient says - only to substitute a devotion to technological evidence - what the machine says. He has thus exchanged one partial view of disease for another.
Reiser wrote about how clinicians overestimated their capacities to sustain humane practice while they underestimated how distracting medical technologies could be. We underestimate magic in part because we overestimate ourselves. We fail to appreciate how vulnerable we are - not just to direct harm like magical fireballs, but also to more subtle influences. We can try to harness magic with the best of intentions, but soon we find we’re chasing after other things. Gandalf, because he knew himself, rightly appraised the deeper power of the Ring.
It’s not wrong to want “relief from our estate.” It’s not wrong to want better antibiotics or cancer treatments. In and of themselves, these innovations have offered amazing benefits. It’s not even wrong to want a better way to document the clinical encounter. Because they’re pharmakons, though, medical technologies are not all beneficial all of the time. We think our tools are entirely under our control, when instead they also exert control over us, focusing our vision here and blinding us there.
What do we, as human clinicians, need to handle our medical technology well? Philosophers have curated competing lists of virtues in an attempt to answer this question. Rather than reproduce such a list, I want to consider how, if we have a right-sized view of ourselves, we could have a right-sized view of our magic.
We have limits.
When I was a medical student, I didn’t want to accept that I had limits. I felt constant pressure to appear like I was more competent than I actually was, that I could do more with less rest. In reality, I needed to rest. I couldn’t know it all. I couldn’t be everywhere at once. I didn’t have perfect control. I made mistakes. Despite now practicing independently, these things are still true of me and I still struggle with them.
In one sense, projecting an image of effortless perfection was my own insecurity pecking at me. In another sense, there’s a culture in medical education that rewards clinicians and clinical trainees who behave like machines without limits. I’m not trying to shift blame onto the system for my pride, but only acknowledge that it’s bound up in a culture that rewards it.
The novelty of new technology overwhelms any suspicion that there might be burdens lurking in its wake. The EMR was trumpeted as a way of consolidating clinical information (no lost charts!), streamlining coordination of care (no deciphering handwriting! Instantaneous review of notes!), and collecting data (the computer will decipher the deep secrets of healthcare!). Having used paper charts in medical school, I can say that the benefits of the EMR far outweigh whatever benefits existed with paper. However, there were hidden costs that we didn’t fully appreciate until after using the EMR for a while. Clinicians now spend a lot of time at the computer. Sometimes the computer screen displaces the real patient during the clinical encounter. The data in the EMR overwhelms any one clinician’s capacity to comprehend it all. The EMR has been co-opted for the purposes of billing and compliance. The list goes on.
I’m not suggesting we should return to paper charts, nor that simply adding up pros and cons will yield an answer about whether to adopt or keep a technology. The EMR is here to stay, but it’s given us numerous challenges with which we must now contend. The proper response to those challenges probably isn’t more technology (e.g., using AI scribes). That, as Neil Postman observed, just leads to Technopoly: the use of technology to manage the information produced by prior iterations of technology, which will require even more technology to manage, and so on, until the whole system spirals out of human control.
Keeping the example of the EMR in view, what would have been different had we appreciated our limitations at the outset of adopting this new technology? Perhaps we would have kept our notes “human sized,” guarding against the bloat that was meant to serve for billing and compliance. This would have required pushing back against regulatory agencies and healthcare administrators, probably making an argument that the clinical encounter is for humans by humans and therefore needs to be legible to humans. If we try to make the EMR all things to all people, it doesn’t do anything very well. Now we find ourselves in a position where the humans are always trying to keep up with the technology, never feeling at home with the use of this tool. The encounter is de-humanized, not only in the subjective experience of those participating, but in the landscape of how the tools are used in service to metrics rather than humans.
Seeing and owning our limits may help us better handle our tools, seeing all the many ways we are vulnerable to being influenced by them.
Exalted Magic
I remember caring for people admitted to inpatient psychiatric units for whom the traditional battery of psychopharmacologic interventions just didn’t work. They might stabilize for a while so we could discharge them, but they’d be back soon or wind up in an emergency department elsewhere. In the early days of my training, I was frustrated with how unresponsive these patients were. Our medications were better than this. With time, disappointment corroded hope into cynicism. Cynicism isn’t an honest appraisal of medicine’s power. It’s betrayed, disappointed hope that set its expectations too high. Its sibling is naïveté.
When we underestimate ourselves, we overestimate the power of our magic. Even if we don’t think it’s going to save the world, we believe it’s going to save the profession. It is the profession. That is, prescribing chemicals and cutting into the body is itself the practice of medicine in its entirety. We are nothing before the power of our techniques, and we can be replaced as long as the techniques stay the same.
It’s advantageous in some ways to think like this. If the profession devolves to tool-use, then clinicians are mere tool-users. We become technicians. We can dispense with any appreciation for the moral valence of the clinician’s conscience and integrity. Clinicians don’t embody a particular tradition nor are they even individuals. This serves the utilitarian, bureaucratic purposes of modern medicine quite well, as argued by Jacob Blythe and Farr Curlin:
When componentiality is carried over into the practice of medicine, physicians and patients themselves become components, and each patient is conceptualized as a collection of increasingly minute components to be tinkered with at will. At each level of organization, these components are expected to serve the ends of the mechanisticity, predictability, reproducibility, and measurability. As such, each component’s function must be identical to that of its corresponding components. Unique entities are inimical to the componential mindset, as they threaten the aforementioned goods of mechanisticity, predictability, reproducibility, and measurability.
It’s the power of our magic, and our magic alone, that will carry the day. The EMR will fix it. No, this new medication. No, the robotic surgery. No, AI. Not that we’re so naive as to believe any one intervention will fix it all, but that, in total, this way of thinking will eventually fix us.
Right-sizing our understanding of magic requires that we have a right-sized view of ourselves. We’re limited, yes. But there’s more.
We develop.
Clinical training isn’t mere information transfer. It’s formative. You become the kind of person who can work as a clinician by the end of your training, and that’s due to more than what you consciously know. The “hidden curriculum” is a name for those forces in education that deform trainees contrary to the stated mission of the school. As a result, trainees adopt cynical, unreflective professional identities. Educators may say they want their students to be compassionate, but the hidden curriculum pushes them to remain aloof. Educators teach about the importance of “self-care,” but the hidden curriculum whispers that the real rock stars give their all to the hospital. Educators speak of the dignity of the patient, but the hidden curriculum chuckles with gallows humor. The hidden curriculum shows up in the null curriculum, in what’s not taught: the Krebs cycle is valued over whatever lessons could be gleaned from Frankenstein, for example, or learning about the Krebs cycle is required whereas Frankenstein is relegated to a medical humanities elective.2
Reflecting on all the many stories of magic, the lesson is rarely “never use magic.” The lessons instead are about becoming the kind of person who can use magic well. Yes, there are forms of magic that should be avoided (e.g., the Ring; the Dark Side of the Force; the Unforgivable Curses) but that’s not sufficient to use even good magic well. More is required, and it’s not a magical process. Technology can’t help us become what we need to become.
We should carry that lesson into medical education. Clinical education that acknowledged we are creatures who develop would guard against the belief that a white coat ceremony early in medical school and a PowerPoint on the principles of biomedical ethics would be sufficient to guide good medical practice for the rest of one’s career. It would guard against the belief that all the students are basically good and they just need the technical expertise to equip their compassion and serve the world well. It would guard against the complacency that suggests the hidden curriculum isn’t that big of a deal.
Instead, it would take seriously that a clinician needs to be made, not just taught. What are those characteristics that a clinician needs to develop in order to help their patients pursue health (i.e., virtues)? What are those characteristics that should be discouraged, even as we’re honest about their presence in our lives (i.e., vices)? How is this done? Shannon Vallor, drawing on ancient philosophical traditions, has attempted to describe how such moral formation would happen in a world laden with technology. She describes seven facets of this framework that are mutually reinforcing:
Moral habituation
Relational understanding
Reflective self-examination
Intentional self-direction of moral development
Perceptual attention to moral salience
Prudential judgment
Appropriate extension of moral concern
You could trace these just as well through any of the old stories about magic. They themselves aren’t magical, and any would-be magician needs to jump at any point to begin the process of becoming someone who can use magic wisely and well.
This is reminiscent of Iris Murdoch’s reflection on decision-making:
I can only choose within the world I can see … If we ignore the prior work of attention and notice only the emptiness of the moment of choice we are likely to identify freedom with the outward movement since there is nothing else to identify it with. But if we consider what the work of attention is like, how continuously it goes on, and how imperceptibly it builds up structures of value round about us, we shall not be surprised that at crucial moments of choice most of the business of choosing is already over. This does not imply that we are not free, certainly not. But it implies that the exercise of our freedom is a small piecemeal business which goes on all the time and not a grandiose leaping about unimpeded at important moments. The moral life, on this view, is something that goes on continually, not something that is switched off in between the occurrence of explicit moral choices. What happens in between such choices is indeed what is crucial.
Focusing too much on the moment of decision distracts us from all the processes that led the clinician (or magician) to become the kind of person who would make certain choices. When we do this, we treat clinicians like machines: what matters most is their output. We neglect our development, and overestimate our tools.
Vallor’s is just one way of thinking about moral formation, and it would need to be adapted for clinical education. The idea is to acknowledge that explicit methods of moral formation are necessary to allow for a right-sized appreciation of who we ourselves are, so we can have a right-sized appreciation of our tools, and use them for good purposes.
We are limited and we develop. Understanding which limits are permanent and which are temporary in the course of our development requires discernment. When we live in the tension between our limits and our development, though, between a realistic appraisal of who we are and who we could be (both as individuals and as a professional community), we’re in a better position to have a right-sized view of our medical magic. When that happens, we can better care for our patients without harming ourselves.
I admit I’ve gotten a little turned around thinking of these terms and how best to present them. Thomas Kuhn seemed to study what might be considered “pure science” - the study of things just to expand knowledge. This is different from so-called “applied science” ushered in by Francis Bacon. So to amend Lewis’s statement a bit, magic and applied science are twins.
Lessons I’ve learned from Frankenstein have been more relevant to my practice of medicine than anything I ever learned about the Krebs cycle. And I learned the Krebs cycle at multiple points during my education.
So Bacon is to blame for the tech-solutionism that plagues us now!