We are exhorted to make our medicine rigorously evidence based and yet robustly patient centred. We find ourselves having to square a circle. Why is it that these two aspects of medicine seem so determined to pull apart? And why is it that the scientific picture of evidence-based medicine always gets to play front of stage?
The US Philosopher Wilfrid Sellars describes two images or pictures of man. The scientific image of man is familiar to medics; it’s all about body tissues, genes, and biochemistry. But what if science is not the only valid way of knowing? Sellars sees the ‘manifest image’ of man as ‘the framework in terms of which, to use an existentialist turn of phrase, man first encountered himself’. The manifest image is connected to personhood and self-awareness, it is how I think of myself every day. Pascal said, ‘Man is but a reed, the most feeble thing in nature; but he is a thinking reed … But, if the universe were to crush him, man would still be more noble than that which killed him, because he knows that he dies and the advantage which the universe has over him; the universe knows nothing of this’. Consciousness, although contingent and frail, is qualitatively unique and is of great value.
Scientific knowledge is not the only sort of knowledge that is important to persons. ‘I love my wife’ is an important piece of knowledge to me, but it cannot be derived scientifically. It is an example of what is sometimes called ‘personalistic knowledge’.
Frank Jackson formally demonstrates the validity of such personalistic knowledge. If physical science can tell us all that can be known then a colourblind person must be able to know what it is to see red. We can construct this knowledge scientifically around a model of having the right sort of cones in the retina to perceive incident light with a wavelength of 650 nm. Yet if this person, in possession of all available knowledge about redness, were to be cured of their colour blindness then they will learn something new that they did not know before, what it is to see red. Jackson’s argument is a demonstration of something both profound and also obvious to all but the most extreme physicalist. What it is to be me cannot be contained within a scientific account of the self.
Sure, we could join a narrow band of neuroscientists and say that our consciousness is a cognitive delusion. The belief that the methods of natural science are valid in all fields of human enquiry is called ‘Scientism’. Scientism seems touchingly modernistic, and reminiscent of other imperialist systems such as Communism, or Hegel’s belief that in fact it is philosophy that defines and encompasses all truth.
Sellars claims that the scientific image of man is not able to encompass or comprehend the manifest image but that both are equally valid ways of knowing about man. As humans, personalistic knowledge is our fundamental concern. If science showed that in fact E = MC3 I would be surprised but not fundamentally disturbed. But mess with my personalistic knowledge and that affects me deeply.
CPD further study and reflective notes
The notes in Boxes 1 and 2 will help you to read and reflect further on any of the brief articles in this series. If this learning relates to your professional development then you should put it in your annual PDP and claim self-certified CPD points within the RCGP guidelines set out at http://bit.ly/14GS5NS.
Box 1. Reflective notes
Do you primarily use Sellars’ scientific image or a manifest image when thinking about yourself and those close to you?
Do we understand our patients fully via both a scientific image and a manifest image or do we just do biomedicine?
Does QOF make it easier or more difficult for us in keeping to a holistic view of our patients?
Box 2. Further reading
Primary source
Sellars W. Philosophy and the scientific image of man. In: Colodny RG (ed.). Frontiers of science and philosophy. Pittsburgh: University of Pittsburgh Press, 1962: 41. http://bonevac.info/303/PhilosophyandtheScientificImageofMan.pdf (accessed 30 Jul 2013). This is perhaps a challenging text for a non-philosopher — why not give it a go!
Further study
Polanyi M. Personal knowledge. Chicago: University of Chicago Press, 1958. (Modern reprints available).
If your reading and reflection is occasional and opportunistic, claims in this one area should not exceed 10 CPD credits per year. However if you decide to use this material to develop your understanding of medical philosophy and ethics as a significant part of a PDP, say over 2 years, then a larger number of credits can be claimed so long as there is evidence of balance over a 5-year cycle. These credits should demonstrate the impact of your reflection on your practice (for example, by way of case studies or other evidence), and must be validated by your appraiser.
- © British Journal of General Practice 2013