In this paper the author’s biographical choices and experiences of both medicine and philosophy are first described. Then, the concept of philosophy is briefly examined with special reference to medical education. Finally, various ways of teaching philosophy to medical students are illustrated in the light of examples from the author’s own teaching. It is argued that, whatever the form of teaching, somehow the content must be linked to the everyday medical world of the students.
- medical education
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My professional identity is that of a physician, not a philosopher. My relationship with philosophy has, however, lasted a quarter of a century and, in fact, began one year before my relationship with medicine. To paraphrase an old expression I might perhaps say that medicine has been my wife and philosophy my mistress. In my case, however, they have grown to tolerate each other very well.
In hindsight, the summer of 1976 was a significant turning point in my life, leading to studies and a career mainly in medicine but to some extent also in philosophy.
I hated biology at school. That attitude originally ruled out the idea of studying medicine, although already as a teenager I was somewhat fascinated by the idea of practising medicine in the future. So I chose another faculty and began my studies in computer science in September 1975. Even at that time this was a fascinating area. However, my first summer job as a computer operator in a major Finnish company made me reconsider my future. There seemed to be two alternatives: a career in the business world or in the academic world. The former did not sufficiently attract me and I was not talented enough for the latter. Again, I found myself wondering what I would like to do when I grew up.
I can still remember very clearly the warm August day in 1976, when I finally decided that, in spite of that disgusting biology, I wanted to study medicine and become a physician. The entrance examinations for Finnish medical schools take place in June and so my decision was too late for the immediate academic year. I knew that I needed several months of preparation for the following year’s examinations but that could wait until early 1977.
Now I had the chance of my life to study whatever I wanted, just for fun. I had never studied philosophy at school but had a budding interest in it, so it was an easy choice. During the autumn term I took several philosophy courses—and lost my soul to philosophy. I was previously registered as a master of science student majoring in computer science but at that time it was quite easy to change one’s main subject.
After some hard work in the spring of 1977 I was successful in the entrance examinations and ready to begin my medical studies. It was possible to be registered in two faculties and I kept my place in the philosophy department as well. Studying medicine was hard work and my progress in philosophy was slow. My philosophy teachers were very encouraging, however, and—for example, in seminars often turned to me asking: “How is this question dealt with in medicine”. Again, it was soon possible for me to concentrate on philosophy of medicine and medical ethics in my essays.
I graduated from medical school in 1984 and began my medical career, for the first few years working as a general practitioner (GP) and, briefly, in several specialties. In the late 1980s I finally decided that paediatrics would be my specialty. I almost gave up my philosophy studies but a letter from the university, which kindly informed me that my right to complete the degree would expire in 12 months, gave me the push I needed and I received the MSc degree in 1990.
The second part of my acquaintance with academic philosophy began in 1994, when I entered the Centre for Philosophy and Health Care at the University of Wales, Swansea, as a part time PhD student. I can say without hesitation that studying there and working with the staff was the most important thing in my intellectual life during that decade. Now, after all these years, I have finally realised how rich a source of philosophical questions even my little medical practice was.
Why have I written this lengthy autobiographical note about my route into philosophy of medicine? Because it demonstrates one way to become interested in the philosophical issues of a particular discipline. It also at least partly explains the rest of this paper: why I think of teaching philosophy to medical students in the way I do.
In what follows I shall briefly describe some personal views on the role of philosophy in medical education. These views are based on experiences as a student of both medicine and philosophy, a medical practitioner, a teacher of medicine and, lately, a teacher of philosophy in a medical faculty.
WHAT AND WHY
Philosophers do not agree about the nature of philosophy; but, perhaps surprisingly, neither is it so obvious what medicine is. One of the aims of medical education is, of course, to produce good practitioners. Medical schools, however, are situated in universities—hence at least some elements of critical thinking should be part of the curriculum. A traditional source of this kind of critical thinking has been philosophy.
The entry “philosophy” in The Oxford Companion to Philosophy opens: “Most definitions of philosophy are fairly controversial, particularly if they aim to be at all interesting or profound”.1 A few lines later, however, a short definition is given: “Philosophy is thinking about thinking”. D D Raphael, a British moral philosopher, has written that “the main purpose of philosophy, as practised in the Western tradition, is the critical evaluation of assumptions and arguments”.2 And Martyn Evans, a British philosopher of medicine, has suggested that “philosophy of medicine asks questions about the questions medicine asks”.
In my view, these three definitions describe nicely what philosophy, in general, and philosophy of medicine, in particular, are about. If we have an open mind, even a simple medical consultation reveals a multitude of questions that cannot be answered within medicine. “What is health”, “what do we mean by ‘cause’ in medicine”, and “what is the relationship between mind and body” are three obvious examples.
Apparently the answer to the question: “why should there be philosophy at all in the medical curriculum” is not independent of the question about the nature of philosophy. One answer has already been mentioned: philosophy can provide tools for critical evaluation of disciplines. Another answer is described by Bertrand Russell in the introduction to his History of Western Philosophy: “To teach how to live without certainty, and yet without being paralysed by hesitation, is perhaps the chief thing that philosophy, in our age, can still do for those who study it”.3 He wrote these words originally in 1945 but they have not lost their validity. Uncertainty is a crucial element of medicine—both of its theory and of its practice. Yet the doctor must act and not be paralysed. Studying philosophy may help the student live with this uncertainty. At least it has helped me.
If philosophy is “thinking about thinking” or “critical evaluation of assumptions and arguments”, then perhaps it could be said that more important than, for instance, philosophical theory would be philosophical attitude. This attitude is not dependent on academic philosophers, although their contribution is very welcome, since there is always room for more critical thinking in medical science and practice. But the representatives of medicine must first feel that these questions mean something. In the words of Brian Magee: “Unless it is about issues that are real to you, or could become so; about problems you actually have, or could have; about ways of thinking that really are yours, or are real options for you; then philosophy is existentially empty”.4
Below, four different ways of teaching philosophy to medical students are described. I have some experience of the first three, hence the personal comments on them.
Kant this but Schopenhauer that
A short series of lectures on the history, philosophy, and ethics of medicine was included in the curriculum when I was a medical student. The philosophy part was given by a young philosopher who spoke to us about—for example, Kant and Hegel, but without any obvious connection to anything else that we had been, or were currently, studying. He was probably a good philosopher in his own field but apparently he had not thought about the audience when he prepared his lectures. It is clear that traditional lectures on traditional questions of philosophy are not the way to do it. Whatever the form of teaching, somehow the content must be linked to medicine.
Mainstream philosophy of medicine
My bad experiences are not confined to being taught. During one of the first lectures I gave to medical students on philosophy I discussed the concepts of health and disease. Having considered the views of Nordenfelt and Boorse I read out the following passage: “Disease is a type of internal state of the organism which: (1) interferes with the performance of some natural function—that is, some species’ typical contribution to survival and reproduction—characteristic of the organism’s age; and (2) is not simply in the nature of the species—ie, is either atypical of the species or, if typical, mainly due to environmental causes”.5 Immediately after reading out the quotation I realised I had made a mistake in bringing it to the classroom at all. Although not incomprehensible, it did not touch the students’ world.
Academic philosophy of medicine was in this case too theoretical to be included as such into a compulsory curriculum. It is highly probable that these students do not find complex discussions on the concepts of health and disease, for example, very motivating.
Philosophy related to experience
A good starting point might be the clinical experience of the students themselves. The students may be asked the question—for example: “What is common among the following diagnoses: pneumonia, hypertension, fibromyalgia, depression, hypomania and schizophrenia”. There is neither a simple nor a “right” answer to this question and the point is that the students notice how their daily medical practice produces philosophical questions.
Ideally, philosophy would be taught not separately but would be fully integrated into the curriculum. Since a multitude of philosophical issues arise directly from the practice of medicine, the best place and time to deal with them would be in that same daily practice. Problem based learning is also a very natural way to locate not only the strictly medical questions (if there are any such) but also the philosophical questions that the cases create. Technically, however, such a fully integrated curriculum is very difficult to create and to keep alive, and teachers with expertise in philosophical issues of medicine should in any case be available.