Damage Done: Philosophy, Medicine, And The Preventable Harm We Do
Pro.R M Cocks

Between 1900 and 1907 Gustav Klimt painted the ceiling of the University of Vienna’s Great Hall. A triptych: one of the paintings was titled “Medicine.” However, in contrast to the popular contemporary image of the science – as one that has helped us to live longer and healthier lives – Klimt’s painting places the skeletal figure of death at its center, at least figuratively. Why?

The Hippocratic Oath, as everyone knows, says ‘first do no harm.’ This is ironic because doctors, as described by David Wootton in Bad Medicine: Doctors Doing Harm Since Hippocrates, for two thousand four hundred years, apart from setting bones, did almost nothing but harm. Medical procedures were restricted, for the most part, to bleeding patients, enemas and emetics, which usually merely weakened the patients’ ability to cope with their illnesses. Modern doctors cannot trace their lineage back two thousand five hundred years unless they want to associate what they do with only hastening the death of patients.

Doctors prior to the invention of scientific and good medicine were restricted to diagnosis and had almost no beneficial therapies to offer. According to Wootton, there was a near total disjunction between the increase in knowledge gained through dissection and vivisection and the growth of new effective therapies. Doctors started to get better at diagnosis, but in practice this mostly meant they got better at predicting whether a patient was likely to die or recover. E.g., doctors got better at identifying phthisis, later called tuberculosis, but had no cure until the 1950s.

Even until relatively recently, doctors routinely removed the tonsils of patients as a precaution at considerable risk of mortality to the patient and little or no benefit in most cases. The growth in interest in alternative and holistic medicine is partly due to the feeling, of a growing number of people, that doctors will operate on them when a change in diet or lifestyle, or just waiting, might be enough to resolve the issue. Doctors, like everyone else, want to justify their existence, and earn money, and are primed to be interventionist. Back surgery is generally useless, but continues to be performed. It’s lucrative. Plus, if anything bad does happen to the patient, the doctor can point to all the expensive tests, drugs and procedures he subjected the patient to and say he did his best, when in fact, the patient might have been better left alone. As Nassim Nicholas Taleb suggests in his book Antifragile: Things That Gain from Disorder, a great way to hasten someone’s death is to get them a personal doctor who will feel obliged to earn his salary and thus over-prescribe and intervene in the manner of Michael Jackson’s physician.

Preventable harm from medical practices is called iatrogenics. Taleb thinks the concept should be extended to multiple areas of life, particularly economics, but also to all forms of education.

Besides “Medicine,” Klimt’s Vienna “Faculty Paintings” consists of two other works: “Jurisprudence” and “Philosophy.” In the latter work we see a figure clutching his head as if in physical pain. It is, perhaps, an appropriate commentary. From what I have observed, the theories of philosophy frequently make students of philosophy stupider instead of smarter. In other words, philosophy is often iatrogenic. The cause of this harm frequently lies in the attempt to replace the mystery of pre-theoretical lived experience with explicit theory. Theory, at its best, can bring to consciousness aspects of lived experience for our consideration. What theory can’t do and shouldn’t attempt, is to be the cuckoo in the nest, presenting itself as a substitute for the real thing.

As an undergraduate in New Zealand I was asked to choose between the moral philosophy of Kant and Mill. Even as an eighteen year old, the choice seemed patently inadequate; all motives on the one hand and all consequences on the other. Since then I have taught both philosophers several times over the years and have not felt any the wiser for my knowledge of their theories. If they have not contributed to my moral understanding, they are surely unlikely to be of any use to students whose understanding will almost necessarily be worse than the person teaching them.

The situation seems comparable to David Kahneman’s experiment that demonstrated that professors of statistics and probability were unable to translate their theoretical knowledge to simple but practical situations in real life. This is related to the fact that knowledge tends to be domain specific. For instance, being good at strategies in chess or remembering positions on chess boards doesn’t therefore make one a good strategist in other situations or mean having a better memory in other contexts. If the professors teaching statistics and mathematical probability can’t apply their own theories, they should probably cease teaching their theories to students who again, necessarily, will have an even more inferior ability to use what they have been taught.

I suppose, to be fair, the same could be said of much classroom teaching. Given the domain specificity of knowledge, taking classes makes you better in the classroom, but not necessarily much else. Richard Feynman was horrified by his Brazilian physics students who had memorized definitions out of textbooks, but when asked to look out the window and apply what they had just recited back to him, proved completely unable to do so.

I suggest that for modern moral philosophy to make any sense it would have to offer an improvement over ‘Do unto others as you would have then do unto you.’ An expert on Kant, a friend of mine, told me that Kant sought to put morality on a rational footing. Since this is not possible (see my God or Moral Nihilism), such attempts are likely to encourage moral skepticism or moral nihilism which in practical effect amount to the same thing. ‘Do unto others…’ is a heuristic and when combined with ‘love your neighbor’ and ‘love your enemy,’ arguably can’t be improved upon.

If morality was a matter of theory then one would expect there to be masters of this theory and therefore experts. But, as James Franklin says in The Science of Conjecture, Johns Hopkins University Press, 2001, p. 64:

If rules for evaluating evidence in court seem natural to us, the idea that there should be rules for the deliberations of the internal forum of conscience is a very strange one. The modern attitude, at least before the widespread formation of ethics committees in medical research and the like, has been that there are no experts in morals. Everyone not warped by an unhappy childhood is presumed to be able to decide on what is right by an immediate intuition. Or if that is too absolute a view of morals, it is regarded as the right of all to decide their own paths. In either case, experts are not invited to give their views.

My contention is that Kant and Mill’s moral theories, among others, are next to useless and are likely to make one more immoral and not less. I suspect that any legitimacy the theories appear to have is based on people using their pre-existing pre-theoretical moral understanding to manipulate their application of the theories or the theories themselves to get the result their moral understanding suggests is desirable, such as introducing Act or Rule Utilitarianism, or a combination of both.

In order to test my eyes, I can count my fingers. In order to check how many fingers I have, I can use my eyes. But I cannot simultaneously doubt my eyesight and the number of fingers I have. One thing must be held steady. In choosing, modifying and evaluating a moral theory, our moral understanding must be held steady. I suspect that the eventual goal is to modify our understanding using the theory at some point. However, this is logically untenable. Any defects in our moral understanding will be reflected in the moral theory we have selected and it seems likely we will simply compound our confusion.

It’s similar to trying to remedy the defects of direct democracy using representative democracy. Many people are leery of direct democracy, with people voting on important issues, because people are often stupid and/or don’t take the time to educate themselves about the pros and cons of matters. However, the defects of direct democracy apply to representative democracy. The people who can’t be trusted to vote on issues can’t be trusted to elect representatives either.

So, why not jettison theory and rely on intuition or non-theoretical understanding?

One objection sometimes raised by students habituated to relativism is that our moral understandings can differ.  What if my moral understanding is that slavery is morally permissible or that anyone who does not subscribe to my religious faith is a pagan beyond the moral pale?

In response, first of all, both ‘moral understandings’ violate ‘love your neighbor’ and ‘do unto others.’ It’s true that for nearly two thousand years, many Christians and others failed to realize this. It’s not a defect in the heuristic, with which we can still agree, but in the realization of the full implications and an improvement in who counts as human and one’s neighbor.

Secondly, let’s imagine two scenarios. One concerns the behavior of Idi Amin or Stalin or some other moral monster. Is it likely that these men would have behaved differently if only they had been taught Kant or Mill? A psychopath has an awareness of what is considered right and wrong but no intention of acting on the basis of such. Theory won’t help. If Amin and Stalin weren’t psychopaths, they certainly had an inadequate moral understanding, but again, the fact that they took no college classes in ethics was not the problem. The other scenario is one where I am filled with good will towards others and yet for some reason I have no idea how to act. Would an introduction to Mill or Kant lead to a better outcome than ‘Do unto others’ and ‘love your neighbor?’ The question isn’t whether the Biblical suggestions lead to perfect behavior, but whether Kant and Mill offer an improvement.

I suggest that the results of simply replacing one’s moral understanding with either theory would be disastrous and thus deeply iatrogenic. Utilitarianism, by definition, cares nothing about justice or motives. Kantianism sets up rigid rules that are likely to do worse than Aristotle’s lesbian rule – the rule from the Island of Lesbos that bends to fit the shape of the actual structure one is working with.

Utilitarians can make themselves immune to counterexample by incorporating objections into their recommendations. An example of this kind of modification occurs in the fanciful case of a doctor who is trying to decide whether to kill one healthy patient to save five sick ones. A typical objection would be that if it ever came out that an innocent visit to a doctor could mean one’s opportunistic murder, few people would ever go again. The Utilitarian can simply say, oh yes, you’re right. In that case, doctors shouldn’t murder their patients. But that’s the wrong answer. The right answer is that it is immoral to murder innocent people, no matter how convenient it might be to do so. If the only reason you are not killing me is because it is currently not convenient to do so because the optimal consequence lies in some other direction, then you are a psychopath and I wish to avoid you.

The Utilitarian knows that doctors shouldn’t murder people, so the moral theorist makes sure his moral theory doesn’t recommend it. He fiddles with it to get the right result, which is disingenuous and redundant. It’s cheating. He’s pretending to rely on this excellent moral theory but is actually appealing to something much better – a flexible, profound, non-theoretical understanding. If one’s moral understanding is primitive and one cannot think clearly then one’s attempt to apply the theory will likewise be primitive and poor.

But if one has an alternative to the theory, a far more flexible, fine-grained, subtle and refined basis than any moral theory can provide, I suggest you leave your theory at home and do without.