Aspects of Methodological Diversity in Medical Sciences (I) *
On the next Wednesdays I will address some aspects of science related to the medical field in order to try to elucidate a debate and circumvent the risk of its eternal return. The need for this type of criticism and interlocution becomes urgent despite the systematic campaigns of disinformation that have frequented the media. Well, you don’t fight deceit and fraud with fanaticism, and they exist on all sides. The fanatic needs peremptory answers, axioms, and absolute certainties, science necessarily deals with questions, doubts and uncertainties. It, disinformation, will always exist and the discerning reader will know how to anticipate the motivations: often interests completely alien to science and the fruitful scientific debate. The absence of ethical criteria in this type of debate, although particularly disturbing since it involves public health and directly affects people undergoing treatment, is guided, above all, by an a priori decision — therefore not based on evidence. It is based on non-scientific assumptions — from revoking discussion to promoting a revival of anachronistic dogmas and promotion of “absolute certainties” inspired by an outdated neopositivism.
It would be assumed that those who dedicate themselves to producing scientific knowledge must be lucid enough to understand that the first certainty of the sincere researcher is to ensure that in matters of scientific research no conclusion is definitive or irreversible. It is worth noting that, in all available therapeutic arsenal, there are only 10 drugs with 1A certification, that is, undoubtedly efficient. Does this mean that doctors should limit themselves to prescribing only those on this list? No way. With ethics, responsibility and scientific security, we are always in the field of hypothesis testing. That is why epistemologists such as Karl Rotschuld classified medicine as an operative science, that is, there is always a dimension that we could classify as artisanal when the clinician interprets the symptoms and establishes the therapy that best suits each patient.
Scientific research must, therefore, necessarily be open to the counterintuitive and accept answers that contradict dogmas and the ideological-instrumental use of science, including unexplained conflicts of interest. .Despite the methodological shortcomings, there is already some evidence that, for example, acupuncture and homeopathy produce therapeutic results that surpass placebo, including results in veterinary, dentistry and even agriculture.
For this is what, for example, the World Health Organization has recently recognized with more emphasis, the important role played by integrative medicines, including homeopathy, acupuncture, yoga, meditation, massage and psychotherapy in their various modalities for people’s health. Therefore, it would seem inconceivable that in this first quarter of the 21st century, individuals and groups emerge, under the cunning cloak of an anti-obscurantist crusade, who have given themselves the role of omnipotent arbiters to define what is or is not “science”. And start to methodically, strategically and selectively attack any medical and/or therapeutic practice that does not seem to them, strictly and canonically, based on an epidemiology restricted to clinical results obtained through test tubes and quantitative results in groups of people. Interestingly, research points to the opposite side: qualitative studies that take into account individual responses have been increasingly valued.
Therefore, they lack criteria and, above all, clinical experience in medical practice to distinguish that the clinical logic has, in addition to the biocentric dimension, aspects that involve other perspectives such as constant monitoring of the mental state, valuation of subjective symptoms and preventive aspects in relation to mental health . And, last but not least, weighing the side effects of treatments and their corresponding costs — pecuniary and non-pecuniary — offered to the population.
One of the central issues in medicine has been underestimated and seems deliberately absent from most contemporary epistemological discussions. The advancement of techno-science in the production of pharmaceutical ingredients, associated with the growing – and welcome – sophistication of diagnoses, produced a harmful side effect: it displaced almost all questions related to mental suffering and the individualization of symptoms from medicine. The question is: How can medical practices reincorporate and deal with the subjectivity of each sick person?
Another concern is not only to circumvent the medicalization of life, but to seek to prevent patients from resorting to the systematic use and abuse of psychiatric drugs, particularly when these have no absolute indication. Therefore, a possible solution for the promotion of mental health, prevention and treatment of less serious psychic disorders may not only and primarily be training general practitioners to administer psychotropic drugs. The direction for the euphemism called “re-humanization of medicine” may be to give another approach such as rescuing an anthropological perspective for medicine and this rescue will take place exactly in the field of the doctor-patient relationship, the “medical friendship” as well defined by Lain Enteralgo.
This “ontology of the encounter”, based on a more comprehensive and generous semiology, and which is also processed in the doctor-patient relationship, can bring not only collateral therapeutic benefits, but an effective capacity to improve empathy and understanding of suffering. It is not an easy task. The doctor moves to meet another person with all his burden of subjectivity, and therefore needs to welcome and get involved, but without allowing himself to be psychically contaminated, that is, to remain within therapeutic objectivity.
The type of consultation, which is not a monopoly of homeopathy or other methodologies, but has always been part of an inclusive and welcoming technique, more detailed and comprehensive, where one investigates everything from eating habits to sleep characteristics, from hobbies to meteorological hypersensitivities, from personal idiosyncrasies to the family environment, creates, almost spontaneously, a closer relationship between doctor and patient and this produces additional benefits.
In this way, in the face of more intense and prolonged interviews, resulting from the requirements of the method itself, it is more than natural and a consequence of this proximity, that adherence to treatment increases, as well as the interest of those who are treated in following the therapeutic guidance proposed by the doctor.
That is why the aforementioned historian of medicine, Pedro Lain Entralgo. made a point of bringing a specificity: it is not a friendship as understood by common sense, but a “medical friendship”. Nor is it a stricto sensu form of psychotherapy – and one should even be careful with involuntary forms of wild psychoanalysis – but a transferential process that implies mutual commitment and shared responsibility.
It, the transference, is taken into account, even though some doctors have not yet been properly trained to use it properly. Do not confuse proximity and real identification (or complicity neurotic) with the patient (which can happen in either case) with the “friendship medicine”, a specific concept that involves refined listening skills associated with bonds of trust and solidarity. but there is always that natural barriers should be established so that borders are not confused.
Medical schools, even the best ones, generally focus on teaching physicians in the discipline of propaedeutics and semiology, on how to take an anamnesis, look for objective symptoms, catalog them, everything so that one can be able to form a plausible diagnostic picture to name and typify the pathology to be treated, and thus establish the most appropriate and effective therapy and prognosis.
If medicine wants to recover for itself the humanist tradition that was improperly and involuntarily giving way to the hypertrophy of biotechnology and armed propaedeutics applied to the health sciences, the rescue begins with the recovery of language and the meaning of suffering for each one. Since each person has a very particular way of getting sick and also a very particular way of being healthy. And as the French psychoanalyst Elizabeth Roudinesco explained, whenever new diseases appear, medicine also always finds new treatments. But, at the same time, when one pathology disappears, it gives way to another: “when syphilis was controlled, AIDS appeared, when psychotherapy found a way to treat hysteria, we witnessed an epidemic of depression” , wrote Roudinesco.
This also means that a physician must deal with the treatment in view of the specificity of the clinical complaint and the diagnosed disease. Now, this observation could be a way out, if and only if there was not a crisis in the health systems.
The WHO was right in what the report of a meeting held in Geneva, in 1988, predicted that in our 21st century we will have a prevalence of psychic disorders. After all, we would be entering what the text called the “depression century”.
In its latest report on June 17, 2022, the WHO made the biggest review of mental health since the turn of the century:
“In 2019, nearly one billion people – including 14% of the world’s adolescents – were living with a mental disorder. Suicide accounted for more than one in every 100 deaths, and 58% of suicides occurred before age 50. Mental disorders are the leading cause of disability, causing one in six years lived with disability. People with serious mental health conditions die an average of 10 to 20 years earlier than the general population, mostly due to preventable physical illnesses.”
The report also urges the health care community to adopt new approaches to mental health care:
“Establish community networks of interconnected services that move away from custodial care in psychiatric hospitals and cover a broad spectrum of care and support through a combination of mental health services integrated with general health care; community mental health services; and services beyond the health sector.”
There is, therefore, a dilemma in preventive medicine that warns, on the one hand, of the excessive cost of maintaining medical-hospital resources directed at already established diseases, and, on the other hand, dissatisfaction with the models of health services offered around the world.
As can be seen above, this aspect has worsened a lot during the recent pandemic due to multiple factors: social isolation, a major socioeconomic crisis, increased vulnerability of so-called risk groups and the enormous pressure exerted on children and adolescents during social distancing measures. According to the same report “Depression and anxiety increased by more than 25% in the first year of the pandemic alone.”
It can be tentatively stated that integrative and complementary medicine is not only necessary, it is inevitable.
Next Wednesday: The ethics of methodological plurality
References:
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______________Article Published in the Blog “Conto de Notícia” in the newspaper “O Estado de São Paulo”: “Will Hahnemann be current 266 years later? 04/10/2021. Access and read through the link https://www.estadao.com.br/brasil/conto-de-noticia/hahnemann-sera-atual-266-anos-depois/
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*Part of this article was part of a collection in a publication by the Technical Chamber of Homeopathy of CRM-SP entitled “Ethics in Homeopathy” Dantas, F.(Org.) et als. Recently Published by CREMESP. Access and read the book through this link:
https://www.cremesp.org.br/library/modulos/flipbook/etica_em_homeopatia/
Paulo Rosenbaum 