The Hunt for the Holy Grail
Modern medicine has largely failed to live up to expectations, especially its own. With the exception of a very small list of interventions, we are yet to employ the use of modern technology to the benefit of human health, at least not to any significant degree. On the contrary, despite the advancements in basic science and biomedical technology — and they are substantial — health outcomes are, in many cases, actually declining. Given the immense progress we’ve made across almost every scientific vector, it would be reasonable to assume that said progress would translate to a healthier population — at the very least a more effective medical system. But alas, this isn’t what we find. This begs the question, Why? Why is that, contrary to the ideals and promise of the “science of medicine”, our health is deteriorating, while our tools and technology grow evermore sophisticated? And, if we accept that modern medicine is largely ineffectual at producing desired outcomes, as the evidence suggests, is there any reason to believe this might — at some point — change? Do the failures of modern medicine, in other words, reflect the inherent complexity of its end — human health — or rather underlying flaws in the means by which it seeks to procure it? And lastly, if a more effective medical system is indeed possible, by what means will we realise it? and what might it look like?
Perhaps it strikes the reader as somewhat unfair, the claim that medicine has largely failed to deliver on its promise of a healthier world. After all, what about antibiotics? Not to mention x-rays and MRI and vaccines and chemotherapy and double bypass surgery and how could you forget viagra! To be sure, medicine is not without its success stories, its accomplishments. Most impressive of all, since 1900 the average life expectancy in the US has increased by approximately 30 years. Not bad at all, right? As remarkable as this achievement is, however, it provides a slightly misleading picture as to medicine’s performance as an enterprise. In fact, while modern medicine is partially responsible for the increase in life expectancy, the majority of the gains are actually due to advances in public health, namely improved hygiene and sanitation (this raises the question, What even Is medicine? But we’ll get to that later). Indeed, barring what amount to outliers — the invention of penicillin and vaccines — if you remove the genuinely “modern” features of medicine, it’s not all that much of a stretch to say that the world would be largely unaffected. As it happens, health care — in the modern world — is only a very minor determinant of health. The most important factors (responsible for around 90% of health outcomes) being genetics, social context, environmental exposure, and general lifestyle. And yet, of these causal factors, health care receives the overwhelming majority of our financial and attentional resources. In the US, for instance, health care amounts to around 20% of GDP. So not only is health care a relatively insignificant factor in terms of procuring human health, it’s also really fucking expensive. At least if it was cheap…
Now this is not to understate the achievements of modern medicine, nor is it to dismiss the immense value that it provides certain individuals, everyday, the world over. State-of-the-art medical technologies are truly marvels of the highest order, testaments to the ingenuity of our kind, symbols of human potential — all that good stuff. And they even save lives, sometimes. Instead it’s simply to say that, in terms of producing the desired outcome — a healthy population — most of this technology has been for naught. While we deserve a pat on the back for our technical ingenuity, our technological difference has to date made very little difference to what matters: our health.
The less-than-perfectly-correlated relationship between medical technology and human health is reflected most saliently in the American health statistics. Despite having the most technologically sophisticated medical system, the US ranks 46th in the world in terms of life expectancy, and 42nd in infant mortality. In case you forgot, the US is the largest national economy in the world, in many respects the poster-child of (post)modernity, the world’s intellectual epicentre. We should therefore expect them to have the most effective health care system. And although you can’t win everything, 46th and 42nd respectively is just plain embarrassing. The reason for pointing this out, beyond simply beating up on the US for fun, is that in order to defend the modern health care regime/model/paradigm, one must first reconcile this fact, its most tragic failure. A tall order, to be certain.
Much has been written about the failings of health care, on every level, so I won’t bang on too long. But even if we limit ourselves to assessing the efficacy of medicine’s bread and butter — drugs — it’s astonishing just how dire the picture is. If America is the poster-child of modernity, drugs are the poster-children of modern medicine. And yet it’s a dirty little fact that most drugs don’t work all that well. Moreover, when they do work, they’re generally accompanied by a variety of undesirable side-effects or they’re incorrectly/inappropriately prescribed. What results from a sober, objective assessment of the efficacy of drugs — and medical interventions more broadly — is a kind of “medical nihilism,” a sense that, despite our scientific progress, we’re still living in the Stone Age of medicine. And so while science may be the means by which we develop and discover new medicines, medicine itself is scarcely more scientific than Galen’s humorism.
So why? Why, despite much scientific and technologic progress, is medicine still so ineffectual? The failure of medicine to make a meaningful positive difference to the health of humanity is systemic. Although medicine — and the health care system in which it is embedded — is a mosaic made of many interests, many of which are wholly at odds with one another, its structural flaws are fundamentally philosophical. Although there are indeed many vested interests that pervert the effecting functioning of the medical enterprise, the issue with the way we seek to procure health and manage disease runs much, much deeper. Indeed, it represents a variety of ontological, epistemological, and methodological assumptions, whether they’re simply implicit in how things are structured, or explicit and very much on the surface.
While it might sound a bit dramatic, it’s worth pointing out that it’s true almost by definition. If medicine is largely ineffective, even mildly sub-optimal, it is so because of the ideas, values and beliefs — aka the stuff of philosophy — it embodies. Therefore, any failing is fundamentally philosophical. Moreover, if medicine was the embodiment of any kind of “enlightened philosophy” we would expect, by definition, enlightened outcomes. Our health care system, of which medicine is the backbone, is many things. ‘Enlightened’ is not one of them.
The model of modern medicine can be understood, as scientist-physician-philosopher Siddhartha Mukherjee noted, as consisting of three steps:
1. Have disease
2. Take pill
3. Kill something
Now there is nothing prima facie wrong with this model. In fact it seems perfectly reasonable: take a physical problem, treat it with something, be done with it. It appears less reasonable, however, when considered it in light of the astonishing complexity of the human condition. At any given moment, there are billions of physiological reactions taking place. The entire modern pharmacopeia — the whole pharmaceutical kitchen sink — contains drugs targeted at approximately 250 of these. As a percentage, for you mathematicians and numberphiles, it works out to be rather small. Like, really small. Really really really small. Yep, that small. To be clear, that means of the billions of things that could possibly be going wrong at any given moment, we have tools for affecting a few hundred of them. Admittedly, the picture is a little more complicated than this. Although we only have drugs targeted at a few hundred of the total physiological reactions, given the interconnectedness/interdependency of biological systems, including our own, these drugs would modulate far more than a few hundred reactions. The essential fact remains, however, that pharmaceutical interventions represent a drop in the vast ocean of human physiology.
The lack of efficacy of modern medical interventions therefore reflects, in large part, the complexity of the object of intervention — the human body — and the highly reductive, grossly oversimplified means by which we attempt to intervene in said complexity. Why, then, do we do what we do? Why, if it’s such an uphill battle, do we persist in attempting to treat disease in such a manner? The first and most obvious reason for our ‘disease-pill-kill’ model is purely pragmatic. People get sick, and when they do, we are — or at least we feel we are — obliged to do something. While it would of course be preferable if disease were never to manifest in the first place, the reality is that, from time-to-time it does. And since what we are is chemistry, it stands to reason that any disease state is also, at root, a problem of chemistry. Ipso facto we should therefore treat chemistry with chemistry. Plus, what could be more convenient? Have disease — take pill — kill something; the appeal is self-evident. So intoxicating of an idea, it almost sounds too good to be true, doesn’t it?
Of course the punchline is that it is too good to be true. “Medical nihilism” isn’t a term of endorsement, after all. That it’s too good to be true isn’t the surprising — nor interesting — piece of this, though. Instead, that it’s effective even at all is a remarkable fact, both in terms of what it implies about what it is that we are, as well as our own ability to modulate whatever that is. The most salient example of the effectiveness of pharmaceutical intervention is obviously the invention of penicillin in the early 20th century and its subsequent use against a variety of infectious disease. That from a strain of mould grown in a petrie dish it would be possible to isolate a compound and then administer it to such profound effect — saving millions of lives — is itself an astonishing, most unlikely fact of our existence. Were it not so patently the case, it would be genuinely unbelievable. And yet it is the case. The discovery of penicillin and its application has saved innumerable lives, while simultaneously altering our conception of what we are as things/entities/organisms. But it hasn’t come for free. The “germ theory of disease” paradigm ushered in by the antibiotic revolution has enabled us to turn what were once life-ending ailments into entirely benign and treatable conditions. Unfortunately, however, it’s also directly led to the establishment of a “philosophy of medicine” that is, in practice, largely antithetical to the aim of human health.
So while the use of antibiotics to treat disease might seem like the real-world equivalent of a fairytale, it’s not the kind that ends happily-ever-after (at least not if the story ends here). Although it started out as one of humanity’s great moral victories, the scientific/philosophical paradigm that emerged from penicillin’s success is proving highly pernicious. So, what is this paradigm?
In broad strokes, the idea that defines the practice of modern medicine, an idea apparently affirmed by the “germ theory of disease”, is that disease states are fundamentally products of microphysiological processes, and as such, it is at this level that they are best understood and intervened on. If the central dogma of molecular biology is the role of DNA in the biological flow of information (DNA encodes RNA which makes a protein), this is the central dogma of modern medicine. Although this perspective seems harmless — perhaps even true — enough, implicit in this kind of reductionism is a deep and by no means self-evident set of philosophical assumptions. For one, it implies a very interesting ontology: that is, that biological systems are, in essence, constituted by nothing but molecules and their interactions. Even if it’s not explicitly acknowledged, it’s tacitly assumed by proponents of this kind of reductionism that these lower-level processes are somehow more “real” — certainly vested with more causal power — than their higher-level counterparts. This is what’s known as ontological reduction, and it’s the default ontology of modern medicine.
Accordingly, since What We Are is nothing but a collection of chemical interactions, it follows that higher-level features of our organism — our experience, for instance — should in principle be reduced to these lower-level, chemical processes. And not only should higher-level features be reduced to lower-level processes, it’s taken as a given that they can in practice. This is what’s known as epistemological reduction; the belief that higher-level processes can be understood in terms of lower-level ones. From this, it’s only a very small hop skip and a jump to the next level of reductionism, arguably the most salient feature of modern medicine: methodological reduction — the belief that, not only can higher-level processes be understood in terms of their lower-level parts, it is at these lower-levels that any system — here, biological systems — is most fruitfully investigated.
Together, these three beliefs form what we may refer to as “full-stack reductionism,” the philosophical superstructure in which modern medicine is practiced. At the level of scientific investigation, it’s a conceptual/philosophical framework that’s proven impressively valuable. Consider the success of modern physics. More germanely, in the field of biology, the reductionist program is responsible for the sub-field known as ‘molecular biology’, which directly led to the elucidation of DNA, the sequencing of the human genome and thus the “genetic/genomic revolution” we are currently living amidst. Importantly, these scientific discoveries have also translated to the field of medicine, leading to new and novel forms of effective treatment. So it’s a productive paradigm, no doubt. Hence its favour. For all its strengths, however, the reductionist paradigm — in the context of medicine, specifically — also has its deficiencies, deficiencies that have manifested themselves in the form of our highly ineffective health care system.
To begin with, the view that ‘disease is the result of microphysiological processes’ — aka the biomedical reductionist creed — lends itself to a kind of medical myopia, where we study/fine-grain the particular molecular instantiations of the perceived problem, at the expense of understanding the broader context in which the disease state arose. While we might gain some level of understanding into the molecular underpinnings that are associated/correlated with the disease state in question, we rarely gain any genuine insight into its actual etiology. In many respects, it only abstracts us further from the underlying cause, for we forget that the microphysiological process/dysfunction is the product of interactions taking place inside the broader context of a body which itself exists within the context of a world — our world. A most incredulous example of how this affects medical research is in the use of animal models, specifically, in the field of oncology. The dominant paradigm in cancer research is the study of mice. We take mice, infect them with cancer, and then study what goes down. Remarkably, however, many of the forms of cancer we study don’t occur naturally in mice at all. We therefore take a fundamentally human disease, literally force it into a non-human model, study its dynamics, convince ourselves we’ve figured it out, then invariably find ourselves deflated/perplexed when the findings don’t translate — and they almost never do — to humans. And yet we wonder why, 50 years and $500 billion later, we still don’t understand the roots of cancer.
Our fixation on microphysiological processes, and the ontological status we assign to them, greatly precludes us from understanding the broader causal dynamics of disease. Our medicines are largely ineffectual because we are intervening in the proximate causes of disease, rather than their ultimate or underlying bases. In many instances, we are intervening merely at the level of symptoms. Enamoured by the minutia of the trees we forget the essential fact of the forest. Until we reckon with the high-level, systematic interplay between body and world, we will never truly understand health or disease.
In order to understand the existing medical paradigm, it’s helpful to understand a bit about the history of biology. While medicine is not a new science, biology — as we know it — is. Today, the two disciplines are as one.
Although medicine long considered itself equal parts “art and science”, it wasn’t until the establishment of biology as a legitimate field of scientific inquiry — as opposed to a merely descriptive/taxonomic discipline — that medicine became a legitimately “scientific” practice. Medicine, today, is ostensibly applied biology. Given the intimate relationship between the two disciplines, it’s important to understand the context of biology, for it is biology that infused medicine with the form of reductionism that now characterises it.
For the majority of its history, biology was essentially taxonomy — the systematic classification and categorisation of flora and fauna. Although biology in the broader sense has existed as long as we have, it wasn’t until about the 19th century that it became a “serious science”. With the rise of the mechanistic world picture, which had been gaining steam since Descartes, life was slowly becoming increasingly amenable to scientific inquiry. The view that life was the product of some kind of supernatural, animating force began to be replaced by the belief that man was in fact nothing but a machine, the result of entirely natural — albeit highly complex — physico-chemical interactions. A seminal moment in the history of modern biology was in 1944, when the esteemed physicist Erwin Schrödinger published a book titled ‘What Is Life?” in which he speculated on a variety of big questions concerning the physical mechanisms that define life, including the structure of DNA. The book had a profound impact, inspiring a mob of physicists to get into biology, in search of the great mysteries of life. Even though Schrödinger postulated the potential existence of physical laws hitherto undiscovered, the physical sciences — it was implied — would eventually conquer the question of life. What ensued was the field of molecular biology, along with its crown jewel, the discovery of DNA — life’s blueprint.
With the discovery of DNA, the power of reductionist science was rendered unassailable. Physics and chemistry had, in effect, swallowed the field of biology. In fact, the most ardent proponents of reductionism declared that, in time, there would be no such thing as biology, for biological systems are, at bottom, physical systems. Since the most fundamental level of description is physics, if physics were to ever realise its full potential, it would mean the end of all the other sciences. There is only one Science, according to this line of thinking, and that’s physics.
The field of molecular biology can be understood, at least partially, as an attempt to emulate the success of physics, by reducing biological systems to their constituent parts. The philosophy of physics was brought to bear upon the animate world, and the result was nothing short of revolutionary. While molecular biology was demonstrating the effectiveness of reductionist inquiry, medicine was simultaneously undergoing a reductionist revolution of its own. The development of antibiotics towards the end of the 19th century along with the discovery/invention of other medicines such as aspirin were bringing biology and medicine together, causing them to converge on their belief in the ontological/causal primacy of microphysiological functions. Just as a single bacteria could be the cause of an infectious disease, so too could a faulty gene be the result of some physical or psychological ailment. All disease, it was inferred, must have as its basis some such underlying molecular dysfunction. The goal of medical science, it then follows, should be to ascertain the molecular basis of all disease states, and then develop chemical agents targeted at remedying them.
From this philosophy of biology/medicine, an entire system of health care follows. What began as a set of purely abstract premises for understanding the world, has thus manifested in the form of a highly tangible methodology for doing research and tending to one another, in sickness and in health (but mostly in sickness).
At the level of society, reductionist medical science — medicine’s implicit epistemology/ontology — translates to a very particular model of health care. Since the preferred level of causal explanation is micro-mechanisms, it is also — naturally enough — the preferred level of intervention. This is entirely logical. For if disease is taken to be ‘fundamentally’ the result of dysfunction taking place at the molecular level, it should follow that interventions should act on the molecular level. However, while it might seem reasonable enough, in principle, it also implies a medical system predicated on treatment, rather than prevention; a system which, as it happens, is highly sub-optimal — to put it mildly.
Just think about it. If we accept that disease is the product of dysfunction (is dysfunction) taking place at the molecular level, it follows that, so long as we can ascertain what exactly that dysfunction is, and so long as we can design a chemical fix for that particular dysfunction, we can treat it (by definition). In such a case, it is perfectly logical to invest a great deal of resources into understanding and investigating the molecular processes underpinning disease states in order to design or develop interventions for treating them. Treatment, in other words, is an entirely logical extension of medical reductionism. Indeed, it’s the only paradigm that makes sense. If, however, you take a non-reductive view of disease — and consider molecular dysfunctions to be merely proximate causes (or correlates) of disease — such emphasis on low-level processes — i.e. molecules/genes — appears far less sensible. Instead, the emphasis would be on ascertaining the ‘ultimate’ cause of disease, at whatever level of emergence, so that it may be addressed/treated directly. Within the non-reductive framework, higher and lower-level processes are on equal epistemic footing. The principle difference between the reductive and non-reductive approach to disease is that the latter views disease in its broader context, its ‘bio-pyscho-social’ context, rather than something that takes place in a physiological vacuum. Within this framework, prevention (as opposed to treatment) is both possible and preferred.
Due to its emphasis on treatment, our existing health care system is often referred to as “sick care”. Since disease states can only be ‘treated’ once they’ve arisen, we spend enormous sums of resources developing, diagnosing and ultimately ‘medicating’ them — to very little, and often adverse, effect. Through the non-reductive lens, this is entirely unsurprising. For what we are doing is not treating the cause of the disease state, merely its symptoms. Disease, within a more holistic framing, is the end result of a long, multivariate, and thus invariably complex causal chain. By the time the disease is manifest, nature has an inertia that is extraordinarily difficult to bend, irrespective of how powerful the medicine. Accordingly, the most effective point of intervention is earlier along the causal chain, before the disease has arisen, towards its ultimate point of origin. Thus “an ounce of prevention is worth a pound of cure,” as the adage goes. It’s this kind of holistic perspective that instilled in Hippocrates (or whoever was writing on his behalf) the medical/epistemic modesty expressed in the following aphorisms: ‘Natural forces are the healers of disease’, and ‘As to diseases, make a habit of two things — to help, or at least do no harm’. William Osler, a late-great giant of modern medicine, expressed a similar sentiment: “One of the first duties of the physician is to educate the masses not to take medicine”. Medical nihilism — or something like it — is thus not a new phenomenon, nor is it a rebuke of medicine as an enterprise. Presumably, neither Osler nor Hippocrates before him practiced medicine because they thought it was a sham, but rather because they believed in its potential. Their statements are not expressions of medicine’s futility, simply humble acknowledgements of the power of nature and our limited comprehension of it, and thus, our ability to control its whims. And though we’ve come a long way, the fundamental dynamics of this epistemic relationship — between man and nature — have changed very little. Yes, we might have translated a few more of its pages, yet we remain humblingly ignorant of the Big Book of Nature. Medical nihilism is thus a reflection of this fact, but it’s a contingent fact, that is one that’s subject to change. Indeed, medical nihilism implies nothing about the ultimate capacity or potential of medicine, construed broadly enough, to deliver us a healthier world. Rather, it is simply a reaction, based on the evidence, to the ‘philosophy of treatment’ and its historical performance/consequences. Though the past and present instills a sense of nihilism, the future is long and unknown. Nihilism may, in the end, turn to optimism. The past is not the future, and the future, whenever it comes, is prevention.
Of course, very few philosophers/physicians/people would disagree with the notion of prevention, in principle, nor would they contend the claim that there are causal forces operating before the dysfunction of a molecular process associated with any given disease state. Be that as it may, however, the bias towards reduction in biomedical science inevitably causes us to place less of an emphasis on the broader context of disease. A health care system that prioritises treatment over prevention is, in other words, a natural consequence of reductionism. Sick care is, in effect, nothing but an institutional embodiment of medical reductionism.
If reductionism is so unambiguously stupid, why, then, is it the dominant medical paradigm? Well firstly, reductionism isn’t stupid. On the contrary, it’s a powerful epistemological/methodological framework for advancing our understanding of the world, in medicine and beyond. This fact is beyond refute. The problem lies when it’s carried too far, when it’s taken to be the only effective way of doing things. So the question is not, why reductionism at all? But rather, why reductionism above all else? While we have already explored some of the philosophical assumptions that underpin reductionism’s predominance, there are many other factors, including pragmatic, economic, and even sociological/psychological forces that are responsible for its immense influence in the field of medicine. Although a comprehensive — let alone exhaustive — analysis of the philosophy and practice of reductionism in medicine is beyond the scope of this book, it’s worthwhile examining some of the more ‘causally significant’ dynamics.
As alluded to above, the success of reductionism in other fields of science, namely physics, has a lot to do with its current dominance in medicine. Reductionism simply works and that’s a fact. It’s ‘scientifically proven,’ as it were. Although it’s been successful almost across the board, to varying degrees, nowhere has reductionism been more demonstrably productive than in the field of physics. Physics, in a certain sense, is the science of reductionism. The whole enterprise is literally predicated upon reducing systems to their component parts. Things (objects), physics taught us, are made of things (molecules) which are made of things (atoms) which are, in turn, also made of things (elementary particles). By putting reductionism to work, physics gave us the modern world. It is only natural, therefore, that we would try and put it to work across the other branches of knowledge. And so we have. But biology isn’t physics, and it never will be. Though biological systems might be entirely consonant with the laws of physics, they cannot be understood in terms of them. For biological systems are systems defined by their emergent complexity, their ‘multi-layeredness’. Even if we were to know everything there is to know about any given biological system at the level of atoms, we would only know about one level, one dimension, of that organism. That is, we wouldn’t know it at all.
To be clear, there aren’t many claiming that all we need in order to understand ourselves is a complete account of the interactions between molecules at any given moment. But this has less to do with any fundamental philosophical objection to the idea and more to do with the pragmatic fact that we never will have such a description. If such a description were provided, whether by Laplace’s Demon or another obliging omniscient entity, all currently open questions within biology would be put to bed — so it goes. A complete physico-chemical account of a biological system would, according to the ‘anti-emergentist’ camp, amount to a full account period. Now folks do believe that. Quantum mechanical complications aside, the problem with Laplace’s Demon, in the realm of biology, is that its predictive/explanatory power is predicated on the existence of only one type of causation: that is, bottom-up. In other words, atoms affect molecules which affect tissues which affect organs which affect organisms — and not the other way round. However, there is good reason (if not good reason, certainly reason) to believe that the kind of bottom-up causation that is the hallmark of ‘simple’ and ‘closed’ physical systems — i.e. the domain of physics — is not the only causal force at work within ‘complex’ and ‘open’ systems — i.e. the realm of biology. Indeed it appears likely that ‘top-down’ causal forces are also at play within life, the equivalent of physical laws exerting influence at every level of hierarchical organisation, that cannot — neither in principle nor in practice — be reduced to their underlying microscopic processes. Rather than atoms and molecules, it has been suggested that the true language of biological systems — and the source of top-down causation — is information. Informational properties are of course a defining characteristic of biological systems. Think DNA. Thus the issue is not whether information is an inherent quality of biological systems, but rather whether they feature — prominently, or at all — in their causal dynamics. If information is in fact an emergent causal force, then the attempt to understand biological systems in terms of their molecular interactions will ultimately prove futile (if it hasn’t already), and will eventually be superseded by the use of alternative — most likely computational — concepts. To be sure, this is an open question; it’s not clear to what degree (if at all) information exerts causal influence over matter. If it does, however, it would at least partially explain the poor efficacy of the majority of existing medical interventions, while suggesting a possible, more productive path forward.
While there’s a definite philosophical logic behind reductionism, it’s by no means the only reason for its near-monopoly over the scientific — and by extension, medical — enterprise. Indeed, although there’s an ongoing and genuinely legitimate debate concerning the epistemic limits of reductionism, a debate which the reductionists are evidently winning, the dominance of reductionism — within the field of medicine, specifically — arguably has very little to do with it. In reality, far more mundane factors are at work. For one, economics. As is readily appreciable, a health care system oriented towards treatment is far more lucrative than one optimised for prevention. It is no coincidence, therefore, that what we have is the former. It is no coincidence, either, that the predominant treatment paradigm — the dispensing of drugs — is one perfectly aligned with the economic interests of its predominant interest: the pharmaceutical industry. A world where no-one gets sick is, quite simply, a world where no-one makes money from sickness.
Now this is not to say that everyone working within the pharmaceutical industry, or health care more broadly, are malicious greedy bastards leveraging human suffering for self-gain, charlatans selling hope pills in exchange for cash. Nor is it to suggest that economic interest is the only incentive driving the medical industry. Of course, there are many highly compassionate, well-intentioned individuals working within, or at the periphery of, the medical industry who are genuinely concerned with alleviating human suffering, with making the world a better place. The fact remains, however, that the most powerful force within health care is indeed economic interest, and therefore, the most powerful force within health is, by virtue of the industry’s economic dynamics, fundamentally misaligned with humanity’s best interests, not to mention the supposed aim of health care: our health.
Developing a medical system — and indeed society — that truly accords with humanity’s health, in the face of an economic logic that demonstrably perverts that end, will no doubt be one of the great challenges of the 21st century. Since the incentives of incumbent players are greatly at odds with our best interests, and given the ties between Big Industry and government, our prospects are largely dependent upon the intellectual and entrepreneurial dynamism of mission-driven organisations, and their efforts to develop new products, services and economic models that prioritise prediction, prevention and optimisation over the existing ‘slash-poison-burn’ model of treatment. Of course, much work will be done — and needs to be done — wholly outside of the economic sphere; whether that be on the public policy (public health) side of things, or on the cultural/educational front. Creating a healthier planet will, it should go without saying, require the effective coordination of the whole of our collective resources. Health, after all, is the human project; that which we all participate in.
The reductionist bias, in medicine as in science generally, is also a reflection of the institutional structures within which science takes place and the broader cultural trends which shaped them. Since the dawn of the scientific revolution, some hundreds of years ago, the university campus has been the principle setting of science. Among the modern university’s more salient features, certainly the most pertinent to any understanding of modern science, is the division/separation between academic departments. Physics, chemistry, biology, astronomy, art, history, philosophy, politics, economics etc. Each subject or field of inquiry has their own buildings, their own faculties, their own distinct ways of viewing the world. And for the most part, they keep to themselves. Physicists do physics, chemists do chemistry and so on and so forth, with very little talk between them. Every now and then, some idea may spill over from one discipline into the other, but for the most part, they exist as intellectual islands unto themselves. The left hand rarely talks to the right. While the neat separation of academic disciplines represents, on one hand, the intellectual impulse to categorise and classify — to make order of an otherwise chaotic world — it also reflects the more prosaic and overarching societal shift towards specialisation. Where once upon a time, a single human mind could comprehend the totality of human knowledge, today, even the most gifted, voracious mind can fathom only the most modest sliver. Accordingly, we have taken to “specialising,” that is, picking a narrow field of inquiry and pursuing it as far as one can, in the hope of adding a single leaf to the great tree of knowledge. Rather than breadth, we’ve opted for depth. Whether it be ultimately Good or Bad, specialisation is merely a pragmatic response to the rapid and concurrent growth in both information and population.
To the degree that specialisation’s a problem, it’s an awfully glamorous one; that we can’t know all there is to know is, after all, the direct consequence of the extraordinary historical success of the Knowledge Project. First world problem though it might be, it remains a legitimate problem nonetheless. On the individual level, we’re each having to learn to reconcile the abundance of information with the reality of our highly manipulable — and therefore increasingly scarce — stores of attention. We are confronted daily by the paradox of choice, forced to negotiate the finitude of our lives with the seeming infinitude of things to do, watch, be. In terms of our careers, in order to render ourselves economically valuable, we are seemingly obliged to choose a highly specialised technical/epistemic niche — accounting, software engineering, law, construction, medicine etc. — or else risk the abyss of uncertainty that is the ‘non-conventional’, or God forbid, ‘creative’ path. How we navigate this single decision, in the 21st century, is, in many ways, what defines us. We are either ‘professionals’ who followed the well-defined specialist track, or defiant (and likely poor) non-conformists who opted for generality, or if not generality, speciality of our own choosing.
In terms of how we do science, specialisation — for all its practical advantages — creates boundaries where, in reality, no such boundaries exist. Nowhere is this more harmful than in the field of biology. Although there are legitimate differences between the fields of physics, chemistry and biology — not to mention art, history, and philosophy — the distinctions we draw between them have more to do with the commercial realities and subsequent architecture of universities and the bandwidth constraints of any individual career, and less to do with any real, underlying epistemic separation. By drawing lines in the sand, we arbitrarily define our object of inquiry, rendering us blind to insights that may exist beyond the gaze of our magnifying glass. The study of biological systems, as inherently transcdisciplinary phenomena, is perhaps uniquely hindered by the historical fragmentation of knowledge. For the study of ourselves, specifically, requires engaging with the totality of our existence, from the physical facts of our organism, right up to the psychological and cultural phenomena that emerge from them. Each level of emergent phenomena has insight to impart on the next, inexorably tied and epistemically equivalent as they are. Understanding life — in all its complexity — will require our bringing to bear upon the subject the entirety of human understanding, tools, and techniques. It will require, in other words, the dissolution of artificial epistemic constructs; physicists, philosophers, psychologists, poets, computer scientists, historians, economists, anthropologists, and mathematicians all working together in unison. For there is only one Nature, after all, only we make of her many.
There is another, related reason why reductionism holds such sway over the scientific enterprise. That is, simply, that we know how to do it. Reductionism is a model that’s not only demonstrably effective, but well defined. In other words, we know how to reduce things to their constituent parts. We know how to study mechanisms, reduce complexity to simplicity. Thus we reduce because we know how, because we can. Moreover, it’s not immediately obvious how complex phenomena would be understood in any other way. If it’s complexity that makes a thing hard to comprehend, then it stands to reason, or so it would seem, that the only way to study said thing is by breaking it down, rendering it simpler. While this works, to a degree, too often we find ourselves substituting complexity for simplicity, at the expense of understanding — simply (no pun intended) because it’s easier. As complexity scientist/philosopher David Krakauer noted, “one of the great curses of the history of human intellection is simple thinking. Finding simplicity where it does not exist.” The way we have structured our education system is a reflection of this kind of intellectual crutch. Rather than engaging with phenomena in their natural state of complexity, we abstract their constituent features and study them in isolation. This is the dark side of reductionism. What transpires is a state of affairs where we can describe ad nauseam a system’s components, but exhibit very little genuine understanding (as measured in terms of, say, our ability to control a system). The field of economics is a perfect example. Despite being one of the most well-funded ‘sciences’, and despite having produced a bona fide mountain of literature, economics has to date provided us with next-to-no predictive power, let alone reliable ability to intervene. Medicine is, of course, another great example. Where Moore’s law describes the doubling of computational power roughly every 2 years since 1970, Emoore’s law (Moore’s law reversed) describes how drug discovery since the 1980s has become more expensive, slowed down delivery of drugs to those in need, and produced largely ineffective and on the whole doubtful remedies. Clearly, something about our approach isn’t working; and, similarly clear, our failure to make progress outside of the physical sciences — progress comparable to that of the physics — has much to do with our lack of a methodological framework for understanding/investigating complex, adaptive systems, and our current ‘one-size-fits-all’ to knowledge acquisition. If any of this holds true, the challenge of the 21st century, and the challenge of 21st century medicine/biology, will be learning to reckon with complexity, fully, without defaulting to simplicity.
So, what?
It is simultaneously one of the most hopeful and depressing facts about the state of modern medicine that the most powerful and demonstrably effective interventions we have at our disposal are almost entirely non-technological. Periodic fasting, sufficient exercise, quality sleep and nutrition are well recognised as the fundamental pillars of good health, the most consequential levers for cultivating wellness and staving off disease. This is hopeful, in that it means the tools required to ameliorate the current public health crisis are, by and large, available to us all. It is depressing, however, in that it means for all our investment in biomedical science and technology, all the promises of diet pills and superlative genetic therapies, we are yet to develop technologies as effective as, among other things, getting a good night sleep. This fact provokes two types of response. The first is that of the medical nihilists. Given the relative lack of success we’ve had developing effective ‘modern’ medical interventions, we should abandon the pursuit entirely — or at least scale back our investment considerably — and instead, invest in the kinds of preventative modalities — such as the above — so that we may avoid the need for more technological solutions in the first place. We tried the technology thing and it failed, the nihilists argue, so let’s go back to nature, let food be thy medicine etc. The second response, on the other hand, the broadly optimistic position, is that we simply haven’t tried hard enough, or that reductionism was a dead end and we should pursue a different approach, maybe a more ‘holistic’ systems-based approach à la the above. The two conclusions, I suggest, are not mutually exclusive. Indeed together they pave the path forward.
The difference between the two perspectives are, much as anything, differences to do with temporality; that is, with the time frames in which we are thinking. From a pragmatic, short-term perspective, it’s hard to argue with the nihilists’ calls for a more ‘gentle’ — or anti-interventionist — medicine. The majority of existing medical interventions are, as we saw, disconcertingly ineffective. Natural healing technologies such as quality nutrition and exercise, on the other hand, are comparatively far more efficacious, not to mention less costly and free of undesirable side effects. Therefore, it makes good sense to favour such ‘lifestyle’ medicines. Moreover, given its historical success, and given the fundamental significance of the environment in the human health equation, we should allocate more of our resources towards the public health side of things, and if it’s one or the other, less towards the strictly reductionist biomedical program. From cleaning up the environment of toxins/pollutants to improving the quality of our food and water supplies (subsidising real food and taxing sugar perhaps?), there is immense low-hanging fruit waiting to be picked. As in the 19th and 20th centuries, the greatest gains in human health in the 21st century, it appears almost certain, will come from efforts in the public health domain.
From a wider vantage point, science and technology appear poised to play a more pivotal role than such environmental/lifestyle modifications. For if what we desire is exponential improvements in our health — an ability to intervene in our own bodily systems orders of magnitude beyond our present — it will unequivocally require ‘unnatural’ aids. Natural modalities, after all, have natural limits. Though they are powerful, they only move the needle so far. Irrespective of how dialled in we have our lifestyles, we cannot render ourselves wholly immune to cancer, for instance. Nor can we live beyond the order of 120 years, or gain an additional 100 IQ points. While there is an interesting conversation to be had concerning whether or not we should in fact desire such things, if we hold that we should (as I suggest we ought to), then it follows that we must employ the use of science and technology to the fullest extent possible.
If what we are chasing is radical improvements to human health, we need science and technology. But as I just argued, science and technology has, to date, done very little for our health. So then what reason have we to be optimistic about its prospects moving forward? Why, in other words, should we expect the future to diverge from the past? The answer to this is manifold. Firstly, optimism is at least partially implied by the belief that reductionism is a flawed — certainly incomplete — methodology for understanding complex systems. Given how far we’ve taken reductionism in biology/medicine, imagine just how far we could go with a methodological framework that was actually well-suited to the investigation of complex phenomena. By pursuing non-reductive explanations, alongside reductionist/mechanistic ones, it seems highly plausible that we will make significant strides in understanding the emergent — yet equally fundamental — laws that govern life. With such an understanding, it seems equally plausible, will come a new and profound capacity for modulating the function of life, including our own. Moreover, by doing away with the disciplinary divide that currently hinders the study of all things, most of all complex things, we should expect an acceleration in our understanding to follow.
There is even reason to suggest that such a shift is already well under way. The new field of computational systems biology (CSB), for instance, represents the merging of mathematical techniques, computer science and biology; a promising example of transdisciplinary investigation in action. The field of synthetic biology, moreover, bearing many similarities to CSB, also harnesses the application of engineering principles to the study (and ultimately construction) of biological systems. In contrast to more traditional sub-disciplines within biology, CSB and synthetic biology explicitly embrace emergence as a concept and are on the whole suspect of purely reductionist investigation. Although it has been questioned whether CSB and synthetic biology are fundamentally divergent from other biological research paradigms or whether they’re merely extensions of molecular biology, however you slice it, they represent philosophical progress of a kind. That synthetic biology has, in its very short history, already achieved considerable success is, if nothing else, proof of the epistemic value of its transdisciplinary approach and unique methodological framework.
Prevention as research paradigm
While prevention rather than treatment should, on purely pragmatic grounds, be the aim from both an individual, as well as public health perspective, it also serves as a viable research paradigm. As we saw, part of the reason effective, targeted treatment is so notoriously difficult is the sheer complexity of biological systems and the subsequent opaqueness of the causal dynamics that underpin disease. Thus if the ability to reliably intervene in disease states requires our understanding the entire array of physiological processes that mediate them, such an ability may, perhaps, never materialise. If, however, there happens to be a small (or at least smaller) number of ‘higher-order’ processes that regulate the function of the majority of other processes, then perhaps all we would require in order to intervene in all or most disease is a comprehensive understanding of those few higher-order ones. If, for instance, all disease was the result of an imbalance of the four humors — à la Galen — then, so long as we understood how to modulate their balance, we would therefore have mastery over every ailment under the sun. Alas, a return to humorism is unlikely to prove productive. Seductive as the idea is, it’s not the most fruitful framework for understanding what we are. That said, there is good reason to believe that there’s such higher-order processes, if not literally resembling the humors at least conceptually similar, that are implicated in almost every chronic disease. Take ageing for instance. Age is the single greatest risk factor for almost every chronic disease. The older you are, the more at risk you are of having some debilitating condition. Age is also the single greatest risk factor for death. The older you are, the more likely you are to die. So whatever causes us to age, also causes us to get sick and die.
Thus ageing can — in some sense — be viewed as the ‘root’ cause of a great majority of diseases, certainly those which most afflict modern society. Rather than pursuing a comprehensive, mechanistic understanding of the myriad processes that underly all of the manifestations of ageing, it therefore stands to reason that we would be better off going after ageing itself. To the degree that understanding the processes that govern ageing requires understanding lower-level mechanisms, at say the molecular level, it should be embraced. Understanding mechanisms for the sake of understanding mechanisms, however, should be avoided. For given the scale of what there is to know about biological systems, there needs to be at least some self-imposed constraints for efficiently coordinating our research efforts.
Over recent years, this ageing-first approach to disease prevention has become increasingly popular. While ageing research has historically been viewed as a somewhat kooky scientific interest, it has increasingly come to be seen as a legitimate field of investigation. Recent interest in the field comes off the back of, among other things, calls for ageing to be viewed as a disease in itself. Critics of longevity science argue that ageing is a not a disease as it’s an entirely ‘natural and universal process,’ but as is frequently pointed out, so too are many other diseases. This speaks, in part, to the arbitrariness of nosology, the classification of diseases, and the social/cultural factors that influence our perception of what constitutes disease. In any event, recent efforts to uncover the causes of ageing have led to the discovery of a number of organism-wide processes associated with ageing, such as cellular senescence and DNA damage, as well as an ability to effectively mediate those processes in animal models. If nothing else, the view that ageing is indeed a disease, is therefore proven to have considerable ‘cash-value’.
Whatever the physiological processes that drive ageing, we know that ageing is fundamentally the result of the infamous second law of thermodynamics. That is, the tendency for things to go to shit over time. That life seemingly defies this most morbid of laws is, as Schrodinger identified, one of its hallmarks. By leveraging what he termed ‘negative entropy’ (or negentropy for short), life is able to stave off the second law — at least for a time. Food, air and water are the quintessential examples of negative entropy. However, all other things that promote health can also be understood abstractly as the same. Just as one’s health bar in a video game can be replenished by stumbling upon a care package or pressing buttons in a particular sequence, by ‘feeding on the environment’, so too can we replenish our own — by reversing the arrow of entropy. How exactly life accomplishes this miraculous feat was of great interest to Schrodinger, one of the central questions posed in ‘What is Life?’, and ultimately one of the reasons he posited the existence of ‘new laws of physics’ that might help explain the mysterium tremendum that is life. In all likelihood, what was perplexing to Schrodinger was not new laws of physics, necessarily, but rather the emergent, complex behaviour that comparatively ‘simple’ low-level laws, if not create, at least enable. What he was pointing to, in other words, was not new laws of physics at all, but the laws of biology. Whether you choose to call it negative entropy or free energy or information, that life can harness stuff from its spatiotemporal environment in order to regulate itself, reduce internal entropy, is key to its mystery. Understanding how this happens, what negative entropy ‘really is’, and ultimately, figuring out ways to artificially deploy it in vivo — our vivo — without fucking our shit up, is really the fundamental task of medical science. Somewhat ironically, after all this talk of complexity and emergence and non-reductionism, understanding ourselves may just require us to answer to certain basic features of the universe first.
