by Rinaldo Octavio Vargas – sociologist BD

The post-ideological dream
Nowadays a collective euphoria spins around a magic rationalism that promises to dissolve the traditional oppositions that have defined medicine in previous eras: art to science, mind to body, idiosyncrasy to general pattern, reductionist mechanism to holistic inclusiveness.

Today, medicine is requested to provide categorical, not half-way, solutions for disease.

The assumption of this trend is that with "enough science", there would be no need for art and idiosyncrasy could be illustrated and managed in molecular terms, exclusively. The traditional clinician's "subjective educate judgments" would be replaced, finally, by an absolute scientific understanding able to predict and control diseases. The sickness randomness would be minimized, if not banished.

This is the promise that contemporary genetic medicine seems to offer: the dream of rescuing the human being form imperfection by means of a cure. Within the body's frustrating opacity lies a decipherable code, a potential key to life's innermost secrets, a key ultimately accessible to science. It is a vision that fits seductively in a world of chronic disease and an aging population.

Whether we regard this vision as utopian, it is culturally pervasive. In a context where physicians are constrained by bureaucratic guidelines and intrusive administrative oversight, the research of molecular mechanisms is a seductive aim. This would mean that the physician's need to determinate and justify individual decisions in terms of aggregate data and institutional constrains, in the form of management guidelines and disease protocols, would reach an end. Sufficient scientific knowledge would dictate every aspect of clinical decision making and physicians would be free from the responsibility of individual judgments and decisions. Understanding disease, exclusively, in molecular terms, would mean the possibility of using barcodes mandating treatment choice. This is a conjecture, definitely, a way of thinking a cultural reverie.

The reasons

In the rationale of transparent market economy, for any transaction, as expression of its utmost ethical behaviour, what client gets for money must be predefined and fail-safe. In such context, efficiency is essential and to provide a solution to the escalating economic and human costs of illness is part of such efficiency. For public care systems, and even for the private one, it is compulsory to cut the ever-increasing costs of ever-more-sophisticated techniques for monitoring & managing, not curing, diseases.

Most articles of medicine criticism emphasize the search of economic rewards while analysing the why of stem-cell research or molecular mechanisms models for mandating treatment choice. Usually they forget the administrative aspect and the physician's need to get free from individual clinical decision making. It is very understandable the physician's will of reducing his/her risk of failure. It is very understandable, too, that policy makers look for a medicine where there is no bedside or consulting room.

The paradox

Until today, significant investment have been done in molecular research, aimed at formulating univocal guide lines and univocal therapeutics choices. The story of such a magic rationalism goes on. Some points seem obvious paradoxes, however.

The most significant ills, measured in terms of incidence and mortality, as for instance, cardiovascular, renal disease, cancer, have thus far resisted simple mechanism-based explanation. This means that the narrative of searching for general mechanisms or patterns be unaware of the day-to-day practice of medicine or not yet sufficiently aware of this.

In determination of behaviour the tools and concepts of contemporary genetics have similarly proven inadequate to explain and dictate effective responses to emotional pain and socially defined deviance. This might mean that knowledge of particular physio-pathological mechanisms does not translate always and simply into socially useful clinical practice. Technology alone does not determinate clinical outcomes since what is often statistical truth is subject to the researcher's epistemological point of view or simply to his/her idiosyncratic perception.

The problem always arises. Likelihoods do not dictate decisions. What seems like a grave risk to one individual and his family might be ignored or evaded by another. Moreover, likelihoods are always subject to the physician's biased judgement. This aporia is illustrated by the history of the important conceptual tools of constitution and predisposition for physicians as they sought to explain and prescribe.

The history of significant conceptual tools

Physicians needed to rationalize, to provide hypothetical causes for ills that afflicted or threatened to afflict their patients. In this sense, notions about heredity were an essential tool in practitioners' conceptual arsenal. They helped explain differential susceptibility to infection and the often unpredictable course of disease. They helped provide a basis for therapeutics rationale in the from of an explanation for idiosyncratic response. Why, for example, did individuals respond differently to the same drug? And why did the clinical course of the same ailment vary so greatly among men & women who suffered from it? In either instance, constitutional uniqueness could help explain what might otherwise have been awkward inconsistencies in the physician's therapeutic practice and prognostic accuracy.

In this narrative that moves from steadily inward from the organism to the cell, from intracellular to molecular mechanisms, constitution has played a important role, for instance, in explaining differential susceptibility to Koch's tuberculosis bacillus. Constitutional assumptions helped create an explanatory framework to structure physician-patient interactions, they did not dictate uniform therapeutic choices or reimbursement patterns, mandate referrals and diagnostic procedures or demand the formulation of patient-sensitive ethical guidelines and governmental policy.

Heredity & constitution were then, genetics is now

Notwithstanding the euphoric hope in molecular models, the genetics promise is also cast in a more ambiguous and less euphoric light. It is illustrated by the history of our knowledge of the human genome and all its promises in therapeutics and disease prevention. This history exemplifies and constitutes an ultimate reductionism, a culmination of trends that have seen the patient objectified and medicine fragmented, commodified, and bureaucratized, a depersonalized would-be final solution to the problem of subjectivity and biological idiosyncrasy.

Physician has become a technician in a grid of laboratory findings, increasingly bereft of agency if not yet of social status. Basic science priorities foreground a handful of rare but scientifically intriguing diseases, whereas less reducible ills – the complex, the multifactorial, the chronic and the ubiquitous remain, managed at high cost.The need of employers, insurers, and would-be rationalizers of clinical decision making are articulated along ever-changing software pathways as both the physician's and patient's autonomy are reduced to laboratory and imaging findings – determining who is to be treated, how they are to be treated, and who is to survive at their scientific uterine environment – ultimately perhaps, who is to be hired or fired.

There is a compelling irony in the way in which our growing understanding of molecular mechanisms underlines the need for placing that increasingly intimate understanding of the body's molecular fabric in the largest and most interactive of social and political contexts. A physician or genetic counsellor must be aware that the set of choices that face both physician and patient are determined not only by our understanding of particular protein sequences or a molecular function but also by factors as diverse as patent law, lobbying, disease-oriented websites, specialty organization, drug-companies strategies & tactics, conflicts of interest, medicine as market actor and emotionally resonant cultural constraints.

The Spring season is antique – The aporia

The restoration of a lost social and intellectual world would be regressive, but we can learn useful lessons by looking at these seemingly antique notions of the body and the web of social relationships in which constitutional ideas functioned and were themselves reproduced.They were built upon the fundamental notions of process and the inclusiveness, linkages and contingency that the same idea of process subsumed. This model provides a useful way of thinking about disease in terms of interconnections and of particular outcomes reflecting a multiplicity of variables interacting over time, without preventing us from the current research.

Modern understanding of genetic mechanisms necessarily dissolve the notion of rigid boundaries between bedside and laboratory, between practice and politics, between the body and the social and material world in which it lives and adapts and evolves. The social implications and consequences of genetic research and its application cannot be simply be referred to an ethicist or ethics committee. Bioethics and policy without historical, social, economic and cultural context are incomplete and ambiguous.

The representations of the medicine world in this short dissertation regarding the searching of a barcode to mandate univocal therapeutics choices would seemly not mirror homeopathy. A glance from outside would be enough, however, to recognize homeopaths MDs arrayed behind techniques and technologies to "objectify the remedy" or behind doctrines of the individual decisions looking for the individuality, the simillimum, for a whole life, or the similar for a pathological pattern in an specific existential moment.

Even in this realm of individuality, the notions of constitution and idiosyncrasy are useful tools to improve the clinical practice and the miasma theory as well as the inductions regarding provings with "health" individuals and concerning the universality of the pathogenesis.

In the homeopathy world, as extraterritorial zone from medicine, the effects of deregulation and of its possible contradictions are not yet issues subject to studies. Similarly, the reference to the Organon der Heilkunst, in place of the Organon der rationellen Heilkunst, does not arise any public debate within the community of homeopaths. For the one that observes embodying the Geistzeit at least two images of homeopathy are recognizable: homeopathy, as depicted following the prints of the German Romanticism Restoration, and homeopathy arrayed in the French Enlightenment, sometimes wrapped in a Scottish mist, where David Hume looms up.

Even the Spring season is antique. The marketing, science, knowledge, practice and existence puzzles or aporia prevent the thinker from sparing him/herself. Pasolini considered that one comes to world to spend him/herself.
I hope this short dissertation stimulates you to correct my wrong perceptions and to go farther.

Bibliography
Christopher Lawrence & George Weisz, Greater than the Parts: Holism in Biomedicine, Oxford University Press, New York, 1998
Nicholas Wade, The Quest for the $1,000 Human Genome, New York Times, July 18, 2006
Andrew Pollack, The promise and power of RND, New York Times, November 10, 2008
Natalie Angier, Scientists and philosopher find that 'gene" has a multitude of meanings, New York Times, November 10, 2008
Carl Zimmer, Now: The rest of the Genome, New York Times, November 11, 2008
Carl Elliot, Better than well: American medicine meets the American dream, Norton, New York, 2003
Keith Wailoo & Stephen Pemberton, The troubled dream of genetic medicine, John Hopkins University Press, 2006