The importance of theories in health care
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7164.1007 (Published 10 October 1998) Cite this as: BMJ 1998;317:1007
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Priscilla Alderson is concerned to show how implicit theories can
work unnoticed to clarify or confuse, to obscure or reveal new insights.
The practical doctor has the difficult task of working within the
framework of
various theories and the wonder is that so many doctors manage this
remarkavly well. Post modernist theory, sceptical of what truth is, can
bring a healthy challenge to a purely positivist approach to medicine.
Medicine as an art is about giving pre-eminence to the the individual and
post modernism can enhance this. Unfortunately it brings confusion rather
than clarification to the scientific basis of medicine on which the
delicate and ever changing art of medicine is founded. Let us be certain
that between functionailsm, social construction, critical theory and post
modernism we do not lose our way. Our scientific method does lack
philosophical cerainty but these other theories can not offer a more
satisfactory model on which to base
our continuing struggles towards the achievement of clinical excellence.
Gwen Parr FFPM
Lordings
Station Road
Pulborough
W. Sussex
Competing interests: No competing interests
EDITOR - Many doctors will not have read Sokal's famous pastiche of
post-modern writing about the natural sciences1, so the BMJ's publication
of a similar hoax2 was very welcome. I particularly enjoyed the opening
paragraph, containing the totally unsubstantiated "widespread view" that
"medical journals and research funders are mainly concerned with practical
factual research, not with research that develops theories", which set the
tone for the whole article. Some of the subsequent howlers were a little
too obvious, such as the idea that Darwin's "theory of evolution" was a
refutable Popperian scientific theory. Some of the statements were
perhaps a little too bizarre to be taken seriously: "The four hourly
hospital drug round expresses positivist beliefs that clinical norms and
standard treatments can be set for effective pain control." Nonetheless,
the punchline ("positivist medicine is effective . . . in diagnosing and
treating angina, whereas within social construction and critical theory,
research and practice can look more broadly at how angina is . . . , in
the longer term, prevented") was a delightful parody of the idea that
scientific beliefs are simply one narration or social construction among
many others. Will the other five articles in the series also be spoofs?
Ian Collis
Department of Psychological Medicine
University College Hospital
London WC1E 6AU
1 Sokal AD Transgressing the boundaries: Towards a transformative
hermeneutics of quantum gravity Social Text 1996; 46/47: 217-252.
2 Alderson P. The importance of theories in health care. BMJ 1998;
317: 1007-10.
Competing interests: No competing interests
Physicians should become social constructivists, postmodernists, or critical theorists?
Dear Editor:
So Alderson suggests that social construction, postmodernism, and
critical theory should be given equal weight to more traditional
approaches to medical research (1). Further, she suggests that these
wonderful new approaches will allow us to better answer such questions as
"how angina is exacerbated, experienced, interpreted, managed, and in the
longer term, prevented." What a
delightful notion for researchers! No longer do we have to toil with the
intricacies of study design, data collection and analysis when trying to
answer important clinical questions. No longer do we have to design
expensive, tedious, cumbersome randomized controlled trials to look at
such issues as how to manage and prevent common illnesses. We can become
social constructivists, who believe that truth is only a social
construction, so that there is no external truth out there. Thus my
opinion about, for example, how to manage is as good as any other supposed
"truth" about the matter. Never mind that social construction is
internally contradictory: "The following sentence is true. There is no
such thing as truth."
No matter, we can become postmodernists, who are skeptical about the
existence of truth and knowledge, believe that the human body is
"constructed through discourse and power," and even that "life/death
certainties are challenged." What a brilliant idea, because now
discarding the notion of death itself, our careers could become eternal.
This may make us feel better when challenged by critical theorists who
believe that "doctors are partly agents of social control with divided
loyalties."
Does Alderson seriously suggest that physicians and medical researchers should become social constructivists, postmodernists, or critical theorists? What is the point of science in the absence of belief
that there is truth out there, even if it is hard to discover, and can
only be discovered imperfectly? What is the point of medicine in the
absence of distinctions, albeit limited and imperfect, between health and
sickness, comfort and pain, and finally life and death?
As an antidote to this silliness, readers of the British Medical
Journal in the UK are fortunate to already have access to Sokal and
Bricmont's trenchant critique of the postmodernist assault on logic and
evidence in the physical sciences (2). Unfortunately, as we(3) and
others(4) have warned, after making little progress remaking the physical
sciences, postmodernism is ready to take on medicine. Woe is us.
Yours truly,
Roy M. Poses MD
Associate Professor of Medicine and Community Health
Brown University School of Medicine
Memorial Hospital of Rhode Island
111 Brewster St.
Pawtucket RI 02860
USA
401 729-2557
fax 401 729-2950
email: royposes@brownvm.brown.edu
REFERENCES
1. Alderson P. The importance of theories in health care. Brit
Med J 1998; 317: 1007-1010.
2. Sokal A, Bricmont J. Intellectual Impostures: Postmodern
Philosophers' Abuse of Science. London, UK: Profile Books, 1998.
3. Poses RM, Isen AM. Qualitative research in medicine and health
care: questions and controversies. J Gen Intern Med 1998; 13: 32-
38.
4. Hodgkin P. Medicine, postmodernism, and the end of certainty:
where one version of truth is as good as another, anything goes.
Brit Med J 1996; 313: 1586-1589.
Competing interests: No competing interests