"The Enlightenment is dead, Marxism is
dead, the working class movement is dead and the author does not feel very well
either."(1)
I came across a curious word the other day-credicide. The death
of belief. Not this or that one but all and every. Strictly speaking, of course, it means
the active killing of belief rather than just its simple demise. Some dark agent has been
out mugging belief in the night, jumping it, slicing it up while our eyes were turned to see
what the arc lights of the media were bringing us this time.
What is dying of course is
not just Progress, Education, Science, Justice, or God-though all these do look anaemic
shadows of their former selves. What is dying is the House of Belief itself. Down in the
basement the machines are getting too cocky by half. The foundations are changing from
carbon to silicon. Upstairs, uneasily aware that the world is changing in ways too deep to
fathom, we race the newest technological wonder, work out in the gym, sniff encephalins, or
tune into the latest version of reality. And deep in our hearts we suspect that it can only
be a matter of time before the House of Belief itself is franchised out to MacDonalds,
becomes a theme park, or simply slips like Atlantis beneath the waves of our accelerating
technoculture.
Medicine alone seems to remain curiously immune to these epidemic
uncertainties. Health is one of the few remaining social values that garners unambiguous
support.This is largely due to our continuing and communal belief that there is one truth
"out there" which can be known, understood, and controlled by anyone who is rational and
competent. The faith that we can accumulate an objective understanding of reality which is
true for all times and all places underlies our treatments and our clinical trials. Stating
this may seem unexceptional to doctors, yet this "modernist" view is in fact rather
unusual. Great swathes of the world increasingly act according to the rather different set
of assumptions of postmodernism.
In a postmodern world anything goes.(2) There are
no overarching frameworks to steer by. Instead, everything is relative, fashion and ironic
detachment flourish, and yesterday's dogma becomes tomorrow's quaint curiosity. To the
postmodern eye truth is not "out there" waiting to be revealed but is something which is
constructed by people, always provisional and contingent on context and power.
Within
medicine one response to the relativism and uncertainty created by postmodernism has been to
emphasise the evidence on which medicine is based. After all, if there are knowable medical
truths "out there" then we should get our act together and apply them. Evidence based
medicine promises certainty-do enough MEDLINE searches and you will find the answer to your
prayers. Read in this way, evidence based medicine is a reaction to the multiple, fragmented
versions of the "truth" which the postmodern world offers. It is also a serious attempt to
invent a new language that might reunite the Babel of doctors and patients, managers and
consumers. However, an evidence based approach will only work for as long as we all view
medicine as "modern"-that is, as making statements about an objective, verifiable
external reality.(3) To the postmodernist the question is whose "evidence" is this
anyway and whose interests does it promote?
So what is to become of us serious medical
technocrats in this postmodern age where multiple versions of the truth abound? Surely the
rationalist, scientific project of biomedicine is immune to all this postmodern relativistic
junk where one version of reality is as good as another. After all a diabetic coma requires
specific actions to be taken which can not depend on whim but are the same for all times and
all places. Yet dismissing postmodernism simply because the technology of medicine is
universally applicable is too easy for at least two reasons.
Firstly, until now medicine
has been glued together by a set of myths that everyone subscribed to: doctors battled
against death and disease, we lived under the one true church of the NHS, and Science lit
the way to a world of health for all. Today these comforting narratives are less believable.
In a very postmodern way, doctors have to juggle competing ways of seeing the same
situation. Clinical reality as perceived by clinicians has to be reconciled with patients'
beliefs, "resources" have to balanced against individual patient need, and ethical
dilemmas spring hydra-headed from medical advance.
Secondly, the anything goes nature of
postmodernism is being radically reinforced by the anything is possible nature of
technology. It is not only Marxism and the Enlightenment which are dead; utterly
unquestioned biological givens are disintegrating all around us: the stability of the
climate, the immutability of species, a life span of three score years and ten, the
unchangeable genetic make up of ones' unborn children. "Facts of life" melt away, and our
collective sense of bewilderment and wide eyed possibility rises.
As technology expands
the bounds of what it is possible to do, it seems inevitable that clinicians will become
agents of the postmodernism that they have so far ignored. Medical technologies will
increasingly be used for non-therapeutic ends.(4) Recreational drug use may come to be
matched by "recreational surgery"-perhaps an expanded plastic surgery or the augmentation
of natural capabilities via mechanical prostheses. At some point in this process medicine's
modernist centre fails. Doctors will no longer be able to comfort themselves with the hard
edged certainty that their work is "fighting disease." Instead they will have become
purveyors of choice-or agents of control-within the plastic limits of the flesh.
Postmodernism may seem altogether too hip and slippery for the staid old world of
medicine. Yet we are no more immune than the Amish or the makers of the Betamax to the
pluralistic, fragmented webs of power and knowledge that our accelerating technoculture is
creating. It is the nature of postmodern societies that no new over arching visions are
possible. The language is no sooner minted than it fractures into different perspectives,
and simultaneously we sense, somewhere in our bones, that it is certainty itself that has
ended.
Paul Hodgkin
General practice adviser
The FACTS Project,
Sheffield School for Health and Related Research,
Regents Court,
30 Regent Street,
Sheffield S1 4DA
References:
1 Neil Smith quoted in Parker M.
Post-modern organisations or postmodern organisation theory? Organizational Studies
1992;13:1-17.
2 Appignanesi R, Garratt C. Postmodernism for beginners.
London: Icon Books,1995.
3 Charlton B. Medicine and postmodernity. J Roy Soc Med
1993; 86:497-9.
4 Dery M. Escape velocity. Cyberculture at the end of the
century.London: Hodder & Stoughton,1996: 249.
