Most American historians of medicine today would be very hesitant about any claim that medical history humanises doctors, medical students or the larger health care enterprise. Yet, the idea that history can and ought to serve modern medicine as a humanising force has been a persistent refrain in American medicine. This essay explores the emergence of this idea from the end of the 19th century, precisely the moment when modern biomedicine became ascendant. At the same institutions where the new version of scientific medicine was most energetically embraced, some professional leaders warned that the allegiance to science driving the profession's technical and cultural success was endangering humanistic values fundamental to professionalism and the art of medicine. They saw in history a means for rehumanising modern medicine and countering the risk of cultural crisis. While some iteration of this vision of history was remarkably durable, the meanings attached to ‘humanism’ were both multiple and changing, and the role envisioned for history in a humanistic intervention was transformed. Starting in the 1960s as part of a larger cultural critique of the putative ‘dehumanisation’ of the medical establishment, some advocates promoted medical history as a tool to help fashion a new kind of humanist physician and to confront social inequities in the health care system. What has persisted across time is the way that the idea of history as a humanising force has almost always functioned as a discourse of deficiency—a response to perceived shortcomings of biomedicine, medical institutions and medical professionalism.
- Cultural history
- medical education
- primary care
- primary care
- cultural history
- medical ethics/bioethics
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- Cultural history
- medical education
- primary care
- primary care
- cultural history
- medical ethics/bioethics
About 2 years ago, I sat down at a seminar table at a medical school in Taiwan to give an informal talk for faculty and students about experiences at my own university in teaching the history of medicine in a medical centre.1 I had not provided a title because this was to be a casual conversation, so I panicked when I saw on the table in front of me a flyer publicising the event with the English title: “Teaching Humanity in Medicine”. “But I don't do that!” I said in an apologetic whisper to my host, who quickly reassured me that it was just an artefact of translation and that it was in fact ‘medical humanities’ the group expected me to address. My nervous reaction to the title, though, as I realised on later reflection, arose from a deeper anxiety I have frequently experienced when confronted by the often unspoken expectation of medical colleagues that I and other historians of medicine somehow must assume that by teaching medical history we will ‘humanise’ medical students—that we will teach humanity in medicine.
My focus here is on this idea that history can and ought to serve modern medicine as a humanising force. Let me say clearly at the outset that most American historians of medicine today (and I include myself) would be very hesitant about any claim that medical history humanises doctors, medical students or the larger healthcare enterprise. As an historian, therefore, I find it particularly striking that the proposition that history should be a cornerstone of humanistic medicine first emerged at precisely the moment when modern Western biomedicine became ascendant; and that some iteration of this vision of history as a humanising force has been remarkably durable. I want to recount the inception of this idea, focusing narrowly on the USA, then to lightly sketch its longer trajectory across the 20th century. The idea of history as a humanising force has almost always functioned as a discourse of deficiency. There have been anti-science currents as well, but that is outside my focus here. Instead, I want to look at this idea as a revealing index of the changing ways in which biomedicine—while celebrated for its technical power—has been seen as insufficient for making good doctors, guiding good practice and directing socially responsible healthcare systems.
By the start of the 20th century, the embrace of the new experimental sciences was transforming American medical knowledge, practice and institutions. This new version of Western scientific medicine—biomedicine—privileged reductionism, specialisation, standardisation, precision, technology and a confident faith in the laboratory as the leading wellspring of medical progress. Experimental science offered both a technical tool physicians could use at the bedside and a powerful cultural tool they could use in the marketplace. The identification of the medical profession with this new scientific medicine, reinforced in the 1910s by the thoroughgoing reformation of medical education, helped propel the remarkable elevation of the status and standing of the profession in American society that ensued.
Seen in this context, it is all the more remarkable that at the very same medical institutions where the new version of scientific medicine was most prominently entrenched, some doctors began to warn that the allegiance to science driving the profession's technical and cultural success was also endangering humanistic values that were fundamental to professional identity, the art of medicine and cultural cohesion. Western medicine, more powerful than ever before, was at risk of cultural crisis. This was not a lament from the mass of general practitioners, but was voiced instead by some of the most eminent leaders of the profession, who welcomed—not resisted—the new scientific medicine. They looked to medical history as vehicle for rehumanising modern medicine, a counterbalance to reductionist hubris in the individual physician and a cohesive force binding medicine together in the face of the splintering tendencies of an increasingly specialised medical world. History was to be the cornerstone of a new humanism in medicine that would promote cross-cultural dialogue between the sciences and the humanities—a platform for addressing apprehensions about cultural disintegration sparked by the new dominance of biomedicine.2 3
During the final decades of the 19th century, particularly as more and more Americans travelled to German centres to study the new experimental laboratory sciences and clinical specialties, many had returned consecrated to the vision of a new kind of scientific medicine. The laboratory, as they depicted it, stood for exactness, rigour, precision and uniformity. And these ideals informed a plan to free medicine from its tedious preoccupation with the idiosyncrasies of individual patients. The ‘exact method’—the embrace of reductionism, mechanical objectivity and self-abnegation as an epistemic virtue—would make clinical medicine an exact science. What was new was the aspiration to liberate medicine from the doctor's individual observation and personal judgment.4–6 Each new technology was lauded for its promise of “eliminating the personal equation of the observer”.7
This program for a new scientific medicine also rendered irrelevant the role that history had long played in medicine. For centuries before the mid-1800s, history had been an integral part of Western medicine—a source of authority and a vehicle for articulating theory. But in the new order of things, it was experimental science, not history, that was to confer authority. Indeed, a deliberate break with the past was part of the creation of a modern professional identity. However, first in Germany, where the experimental laboratory sciences had become central to medicine earlier than in the rest of the West, the very end of the 19th century witnessed a renaissance in the history of medicine—but history of a new sort, accorded a different function. The sheer success of the reductionist program in reshaping medical knowledge and culture prompted many leading physicians to worry that the epistemological and technical gains of the new science might have been bought at a very high price.8 Theodor Puschmann, for example, professor of medical history in Vienna, called in 1889 for a rehumanisation of the physician in an age of scientistic ideals. He argued the medical history could play a crucial role in a medical education—that it would broaden future physicians, ennoble their character, prevent them from slipping into “superficial materialism” and lay a sturdy foundation for professional knowledge. He particularly urged that the need for the unifying influence of history was greater than ever before, bridging the growing gap between the laboratory and the clinic and across the fragmenting specialties.9
In the USA, there were no academic positions in medical history and the institutions of the new scientific medicine were much less developed than in Europe. However, as some American doctors who had studied in Germany began to proselytise for the new scientific medicine rooted in the experimental laboratory, other (often older) doctors vigorously opposed such a plan as not only simplistic but dangerous. A newly urgent celebration of the art of medicine expressed their anxieties about reductionist hubris.4 As one Philadelphia physician protested, “There is an art of medicine [that] completely eludes, or flatly contradicts science, by means of empirical facts, and gives the palm to sagacity and common sense over laws formulated by experiment” (Stillé, p 435).10 The proposal that experimental science could make clinical practice certain and exact—make it merely an applied science—jeopardised professional identity. It also seemed to redefine professional responsibility in terms so narrow as to be doubtfully ethical. In the 1880s, battles over the proposition that the new experimental sciences could make medicine an exact science split the American medical profession apart, with opponents rallied around an older conception of medical science and a new celebration of art, asserting, as one New York doctor did, that “medicine is a science of which the pervading principle is humanity” (Flint, p 527).11
Medical history, as some American doctors came to see it, offered a middle path in conceptualising medical professionalism—a framework that promised to accommodate the new sciences while preserving older values. It was at precisely those institutions where the new vision of scientific medicine was most ardently institutionalised, especially the German-modelled medical school opened in 1893 at Johns Hopkins University, that history began to be invoked as one means of harmonising science with art. Physicians like John Shaw Billings and William Osler—both active in founding the Johns Hopkins Hospital Historical Club in 1890—called for a rehumanisation of medicine. Representing medical history as a partial antidote to excessive reductionism, specialisation, commercialism and cultural disintegration, they cultivated an ideal of the ‘gentleman-physician’ well versed in the classic liberal arts.3 Billings urged that while the kind of “average” practitioner trained at most American medical schools could get along without formal instruction in medical history, for graduates of the Johns Hopkins Medical School—the cadre of teachers and researchers in the new scientific medicine he expected to lead the profession—a course on medical history would be indispensable as “a means of culture” (Billings, p 343).12 From the moment he started working at the Johns Hopkins Hospital in 1889, Osler integrated medico-historical issues and problems into his clinical instruction, using the examples of past physicians as a tool to inspire and to exemplify professionalism.13 14
The larger plea for history as a means of cultural reintegration was lucidly captured in an address Osler titled “The Old Humanities and the New Science”. Osler was speaking in Oxford in 1919, just after the end of the First World War and a year after the German sociologist Max Weber had gloomily proposed that science was stripping the world of all spiritual mystery and ethical meaning, leading to what he famously called “the disenchantment of the world” (Weber, p 155).15 “The extraordinary development of modern science may be her undoing”, Osler warned. “Specialism, now a necessity, has fragmented the specialties themselves in a way that makes the outlook hazardous” (Osler, p 49).16 He asserted that “the salvation of science lies in recognition of a new philosophy”, citing the programmatic call for a “new humanism” (Osler, pp 54, 55)16 issued a year earlier by George Sarton, who believed that the discipline he was pioneering, the history of science, would be the vehicle for “a humanization of science, a combination of the scientific and humanistic spirit” (Sarton, p 17).17
Osler was not protesting against the rise of reductionist science—quite the opposite—but he was calling for the retrieval of something else being lost to medicine in the process. It was a protest against cultural impoverishment—an insistence on art as well as science, on clinical judgment not subordinated to laboratory findings, and on an ideal of the clinician who embodied not only the precision of scientist but also the sensibility of the gentleman. The new humanism, as he conceived it, engaged with the classics of science and medicine and veneration of their authors to counter fragmentation—offering connectedness across time, place and specialist communities. There is a distinct resonance here with the wider interwar movement for holism, even the program for cultural “reenchantment” mounted under the banner of Wholeness.18 19
This was a very bookish kind of elite, homosocial professionalism. Medical history provided the platform for a humanism closely tied to medical historical libraries, bibliography and book collecting. Clubbish and exclusively male, the gentlemanly gatherings that cultivated this bibliophilic, literary humanism forged links between the physician's identity and liberal education, civility and moral wisdom.20 Old books in particular were tangible links tying present to past and, for American physicians with cosmopolitan aspirations, connecting the New World with the old Old World. Osler was but one such medical humanist (figure 1), yet both at the time and much more so in later memory, he was made to stand for the whole.
A decade later, in 1929, for the first time at an American university, a professorship in history of medicine was established—tellingly at Johns Hopkins, which remained the leading citadel of the new scientific medicine. Osler's mantle had fallen to the neurosurgeon Harvey Cushing (who studied at Hopkins before spending his career at Harvard and Yale). “Medicine has become so scattered and subdivided”, Cushing declared at the dedication ceremony, that “there is crying need for someone to lead it from the wilderness and bind it together”. In his vision, medical history and historical libraries had a “binding influence” on a “subdividing profession”, a place “where an interest in the history of our great profession will so flourish as to permeate into all departments of a much-divided [medical] school”. As he told the gathering, “In the modern development of the physician into a scientist, have we not lost something precious that may without risk of pedantry be brought back to Medicine? Not only has the art of healing, die Heilkunst, come more and more to be lost sight of as the doctor arrives at his diagnosis in the laboratory rather than at the bedside, but less and less does he care to be reminded that poetry, history, rhetoric and the humanities once had close kinship with natural philosophy when Doctores Medicinae took the lead among the Artisti” (Cushing, pp 30, 41–2, 38).21
Other speakers at the dedication ceremony, including some of the principal movers of the new scientific medicine, echoed Cushing. William Welch, the first dean of the medical school at Hopkins and the leading American spokesman for experimental laboratory medicine, depicted the new arrangement as “a center for medical culture”, suggesting that the history of medicine was “the one subject of humanistic study properly falling within the scope of medical teaching”. He asserted that “the need for emphasis upon this cultural, humanistic aspect becomes all the greater as medicine becomes more scientific and materialistic” (Welch, p 92).22 Abraham Flexner, architect of the educational reforms that infused the new scientific medicine into American medical schools, cautioned that “we can become so infatuated with progress in knowledge and control that we lose our perspective, lose the sense of relative cultural values”, leaving young doctors “culturally thin and metallic”. Medical history, as Flexner put it, would have to “pull against, not with… the current” (Flexner, p 96).23
Cushing was aware that the professionalisation of history of medicine had the potential to draw it away from the kind of integrative, humanising function that he, Osler and their cohort envisioned for it. He asked in a tone of caution, “Will this foundation merely mean still another group of specialists having their own societies, organs of publication, separate places of meeting, separate congresses, national and international, and who will also incline to hold aloof from the army of doctors made and in the making?” (Cushing, p 38).21 He also recognised that even as he proselytised for “a more humanistic attitude” in medicine, the very terms humanism, humanities and humanisation could be vague and their meanings fluid. “Humanism”, he noted elsewhere, “has become a word people conjure with” (Cushing, p 43).24
Instruction in the history of medicine grew more prevalent than ever—offered in nearly three-fourths of US medical schools, according to a 1937 survey—leading one physician-historian to urge that at a time when historians views were being “distorted by narrow nationalism” in Europe, American medical historians had a special responsibility “to keep the torch of medical humanism burning” (Sigerist, pp 649, 659).25 But while the idea that history represented a means of counterbalancing the reductionist, splintering tendencies of biomedicine never vanished, by the late 1930s this particular kind of medical humanism was fading in the rhetoric of leading American medical figures. It had always been elite and inward looking, and fewer doctors had the broad-based liberal education (in Latin and Greek, for example) required for engagement with the medical classics. The soaring prestige of the medical profession as a whole also fostered some measure of complacency with the biomedical status quo. In the mass media, medical history was more widely disseminated than ever before, but it was chiefly a triumphal celebration of experimentalism with little hint that the rewards of reductionism came at a price.26
Ironically, the portrait of the doctor that professional leaders most widely circulated during this period was an older image, presented not as history but as a smug affirmation that humanistic values suffused the doctor–patient relationship. This was English artist Luke Fildes's 1891 painting “The Doctor”, a sentimental depiction of a gentlemanly doctor watchful at the side of a sick child in a working-class cottage, devoid of any reference to the scientific and technological armamentarium of modern medicine. In the 1940s, this was the image the conservative American Medical Association (AMA) chose as the banner under which to rally its campaign against national health insurance. “There is something in that picture which represents one of the most priceless possessions you men of medicine have in your whole fight against assembly line medicine”, the public relations expert who designed the campaign told AMA leaders. “In that doctor's face there is compassion, there is personal concern for the welfare of his patient, there is personal loyalty to the patient as a human being” (Baxter, p 696).27 The image was displayed on millions of AMA pamphlets and posters circulated in doctors' waiting rooms across the country—along with the caption, “Keep politics out of this picture” (figure 2). This was not history, but a romanticised, wishful image of humanistic medicine that served the AMA in battling what it denounced as “socialized medicine”.28–30 While some doctors did object that this portrayal of American medicine was ‘dated’, the campaign leaders countered that it was no more dated than the Hippocratic Oath or the Bible. “‘The Doctor’ isn't just an out-dated painting”, the political consultant who spearheaded the AMA's campaign wrote in a private letter to a North Carolina physician, “it is a vivid portrayal of the vitally important physician-patient relationship which has made doctors something more than medical technicians. And that relationship is out-dated only in countries which have adopted socialized medicine”.31
The one important new current in medical history during the 1930s and 1940s was allied with social medicine, pursued by physician-historians like Henry Sigerist, Erwin Ackerknecht and George Rosen. This program for humanistic medicine tried to pull attention outward from the individual doctor and patient to the wider healthcare system and social determinants of health. Sigerist, as professor of the history of medicine at Johns Hopkins, shifted his own scholarly attention to the social dimensions of medicine, to the history of public health and to the economic conditions that shaped health services. Instead of engagement with the medical classics to cultivate a physician-gentleman, he turned towards a sociologically-inflected historical focus on social, political and economic problems and issues of social justice.32–35 Ackerknecht, in discussion that followed Rosen's talk on “The Place of Medical History in Medical Education” at the 1948 annual meeting of the American Association for the History of Medicine, both underscored the limitations of “the so-called ‘Oslerian method’” and insisted that “medical history is one of the few counterweights for 20 years of dehumanizing education” (Ackerknecht, pp 628, 627).36
In the USA, though, the social medicine movement remained weak compared with, say, the UK, and America's political climate sometimes made difficult even the writing of histories that drew attention to the social determinants of health. In a private letter to George Rosen, Sigerist, having just finished writing an introduction to Rosen's History of Miners' Disease, quipped that his editor “may perhaps find that it sounds too ‘red’ because I mentioned the working class several times”.37 Sigerist grew impatient with American physicians who cultivated a romanticised image of the doctor rather than assuming responsibility for bringing the fruits of scientific medicine to the entire population. “Trained as highly specialized and efficient scientists, they are unprepared to grapple with problems that are primarily social and economic. They have built for themselves a legendary, sentimental and romantic history of their profession to which they cling desperately” (Sigerist, p viii).38 His history advocated what he called “a new—a socialist—humanism”.39 40 But by and large, other Americans at the time did not follow his lead, and the Cold War went far towards suppressing a social medicine impulse. Indeed, in 1947, with the rise of anti-communist McCarthyism and the persecution of left-wing intellectuals, Sigerist resigned from Johns Hopkins and returned to his native Switzerland.32
When in the 1970s the idea of history as a humanising force in modern medicine prominently re-emerged, its nature and animus had altered fundamentally. During the 1960s, dehumanisation had become a key watchword in the radical critique of the medical establishment, one ingredient in the larger cultural critique of established authority. And this, in turn, involved a new, sceptical attitude towards the role and worth of science in medicine.41 42
Biomedical authority became one target for assaults upon the American healthcare system's social and economic ills. The modifiers ‘dehumanising’ and ‘dehumanised’ became commonplace, applied to students and practitioners hardened by medical institutions and to a healthcare system that made health and access to care a function of socioeconomic class.43 44 Health professionals and students, through organisations such as The Medical Committee for Human Rights (founded in 1964), assailed the AMA for ignoring racism in medicine and blocking moves to make healthcare a right—countering the AMA's claim to be “the voice of American medicine” by claiming themselves to be “the voice of humanistic medicine”.45 46
By the mid-1970s, medical ethicist and educator Edmund Pellegrino could rightly assert that “medical humanism has achieved the status of a salvation theme, which can absolve the perceived ‘sins’ of modern medicine”. “Humanism”, he noted, “has become a slogan, evoking a multitude of images of what we find good or lacking in the modern spirit”, a beacon to “lead physicians, patients, and all of us back from the brink of dehumanization” (Pellegrino, pp 9, 13, 10).47 This again was a discourse of deficiency. Pellegrino warned fellow doctors to heed the charge that “we neglect the teaching of human values and the art of medicine; that in our zeal for science we ignore liberal studies; and, most telling of all, that the patient care we provide in our teaching hospitals and clinics is itself dehumanizing”. To counter “the dehumanization of the student and the depersonalization of the patient”, he called for medical schools to train a new kind of “humanist physician” (Pellegrino, p 1288).48
It was in this context that medical history gained new salience as a platform for the cultivation of medical professionalism. Two overlapping but divergent programs emerged for a history-based humanistic intervention: one focused inward on the individual practitioner and doctor–patient encounter, and the other outward on the larger medical system.
On the one hand, history joined a larger constellation of disciplines in the ‘medical humanities’ movement. In the USA, this was closely tied with the emergence, starting in the 1960s, of biomedical ethics and was expressed in organisations such as the Society for Health and Human Values.49 50 The society proposed in 1970 to “identify explicitly the human values that are lacking or inadequately represented in the study and practice of medicine and to begin to remedy the deficit” (quoted in Fox, p 334).49 Clinicians, ethicists and clergy suggested that biomedical science and technology could strip medicine of important dimensions of healing, and sought to instil in medical practitioners the ‘human values’ they held to be wanting. As in the turn to history at the start of the century, the ‘medical humanities’ were portrayed partly as an antidote to mechanistic reductionism, with the aim of fostering empathic patient care and providing guidance to students in squaring their course as good doctors within the system more than on honing critical skills as citizens prepared to confront the larger failings of health promotion and medical care.51–53 Echoing Cushing's remarks of the 1930s, Pellegrino commented in 1976 that “the word humanism is seductive and vague enough to attract a variegated host of followers, each with a personal version of its meaning” (Pellegrino, p 9).47 Some historians began to brace at the expectation of medical colleagues that, as one historian put it, “since I talk about things they do not discuss much, they conceive of me as taking care of everything they leave out”, cautioning against “regarding the medical historian as the humanist with a capital ‘H’ who will take care of everything that is not taken care of in technical medical training” (Greene, p 41).54
Concurrently, the activist ‘new social history’ that emerged in that in the 1960s and 1970s sought to reveal the historical roots of medical dehumanisation. Instead of exploring the medical classics, it aimed at looking “beyond ‘the great doctors’”—the title young historians Susan Reverby and David Rosner gave a programmatic essay widely seen as a manifesto for this movement in the USA.55 56 Historiographically and politically, this was a very different vision of medical history as a humanistic force, propelled in part by a much harsher critique of biomedicine and professionalism alike.
The contrasting visions of medical history and its relevance to medical culture and healthcare were captured in the founding of two societies that took Osler and Sigerist, respectively, as their namesakes.57 The American Osler Society had its inception in the late 1960s, rooted in concern among some physicians about “the growing sterility induced by the prevailing emphasis on science in medical education”, as one founding member later explained. “The concern was not a reaction against science but rather with the apparently concomitant loss of humanity and humaneness in our profession” (Roland, p 1).58 Taking Osler as a humanist role model, another founder proclaimed in introducing the inaugural meeting, was “the reinstatement of humanism in medicine and the breeding of cultured, learned and devoted gentlemen” (Henderson, p 344).59 At the same time, this particular celebration of Osler as ‘a humanist role-model’ was also a conservative reaction against the emerging currents in the social history of medicine. “While students were clamoring for involvement and breadth, professional historians were becoming more detached and narrow”, one Osler Society physician-historian commented in 1982, looking back critically at the ‘new’ historiographic impulse that had gained momentum since the 1960s. “Earlier enthusiasms for medical history as a humanizing strategy waned” (Burns, p 37).60
The Sigerist Circle, on the other hand, embraced the new social history program and explicitly celebrated medical history as an activist social and political tool. Based in departments of history, history of science and medicine, or social medicine, and increasingly practiced by non-physicians, the newer strain within the history of health and healthcare tended to look outward to the larger healthcare system more than inward towards individual medical students and practitioners. It less often explicitly invoked the language of humanism, but was especially well calculated to counterbalance the splintering tendencies of reductionist medicine by showing medical ideas, technologies, institutions, economics and values interacting in a world in which race, class, ethnicity and gender are inseparable from understandings of health, illness and healthcare.
A new sense of crisis in American medicine at the turn of the 21st century has again revitalised discourse about medical history and humanistic values. Institutionally, it is expressed in overlapping programs in medical history, social medicine and medical humanities. In medical teaching, the bids of medical history for relevance are now rarely rooted in engagement with the medical classics and inspirational great doctors of the past. Instead, it looks both inward, offering the individual student a source of reflection on his or her own professional formation, and outward, offering a forum for discussing how values, prejudices and inequalities came to be built into the current medical enterprise—taking nothing for granted. For American medical students in particular, who collectively seem in some ways more idealistic than their counterparts of a generation ago, an ideal of humanistic medicine can also provide a sustaining sense of purpose in negotiating a healthcare empire in which the tremendous technical power of biomedicine often seems jarringly disconnected from inequities in access to healthcare.
Today, the term ‘humanism’ remains hugely imprecise, encompassing a whole host of meanings that are multiple and pliable. It is also easy to see that voiced commitments to health and human values, humane healthcare and medical service to humanity sometimes can be little more than a facile rhetorical flourish. Nor is there assurance that medical history—any version of medical history—will actually succeed in inculcating humanistic qualities: the Yale physician-historian George Rosen long ago offered the sobering reminder that “medical history was being taught in practically every university in Germany before World War II and apparently had little effect on the medical students at the time” (Rosen, p 50).52 61 Nevertheless, biomedicine and the idea that history might somehow offer one means of humanising it continue to be intertwined. Perhaps the multiple and changing meanings of ‘humanism’ are less suggestive than the heartening persistence of the conviction that somehow humanistic medicine—something beyond the raw, extraordinary power of biomedicine—is an aim worth pursuing.
I am particularly grateful to Zhang Daqing, Zhen Cheng, Zhang Qian, Claire Hooker, Angela Woods and the other participants at the Beijing Forum, and to Paul Ulhas Macneill and Naomi Rogers.
An earlier, shorter version of this paper, presented at the Beijing Forum, 6 November 2010, will appear in Chinese in The Journal of Peking University (Philosophy and Social Science).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.