Medicine, postmodernism, and the end of certainty

Where one version of the truth is as good as another, anything goes

“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.