2506.9 Why Philosophy?
Why doctors (and their patients) should taste the lollipop of philosophy?
In the year 2003, Rajkumar Hirani, a film director, brought Murli Prasad Sharma, better known as Munna Bhai to the conscience of the Indian masses. The titular role was played by Sanjay Dutt with his unique combination of a local gangsta look and a disarming sense of care for his fellow beings. Munna Bhai is supported by his right hand man, Circuit, played by Arshad Warsi. The movie opens with a businessman being lured into the adda of the gang. Waiting for him is another man who had lent the businessman ten lakh rupees with the assurance that the money would be returned to the lender’s brother. The businessman had returned it to the brother, but the brother had eloped to Dubai, leaving the lender fending for his dhoti. But the lender didn’t give two hoots about his brother eloping away. He wanted his money from the businessman, no matter what. Upon hearing this, Munna Bhai, silences them and asks the businessman to leave the premises. He then hands over a cordless phone to the lender and asks him to dial the number of his wife. The lender is aghast. He asks why. Munna Bhai then explains to him that he is a social worker who helps people recover overdue debt but in this instance the lender was at fault, not the businessman. He instructs him to ask his wife to come with one lakh rupees ransom.
So, this is how we are introduced to Munna Bhai. A self-proclaimed Robinhood who sometimes uses unsavoury means to get work done. He is brotherly to the oppressed and ruthless to the oppressor. He uses whatever means available to justify himself. If there is one man whom he fears the most, then it is his father who resides in a far way village. Just so that his father won’t feel hurt, he had lied to him that he is a doctor in the city. Every time his father comes to visit him in the city, the adda is transformed into a charitable clinic.
On this particular visit, it is finally revealed to him that his son is a fraud. He is a goon, no less. The father leaves, never to return. Munna Bhai is exasperated and vows to get into a medical college. He gets in. Don’t ask me how, go watch the film.
The rest of the movie is about the meeting point of traditional medical education, ethics and practice with a brand of crude Robinhoodness. People who have watched the film are sure to recall Jhaado ki jhappi and the ragging of college seniors by the newly joined juniors. What you will probably not recall are the understatements behind some of the dialogues delivered.
Another character called Zaheer, played by Jimmy Shergil, is suffering from stomach cancer and he gets admitted to the same hospital. Due to the various playful shenanigans of Munna Bhai, Zaheer is enamoured by him and he believes he can be cured by this messiah. Just before Zaheer dies, he pleads Munna Bhai to give him a day worth of life to see his mother one last time. But Munna is aware that he can’t do this miracle. Zaheer dies in his arms moments later. This is almost the end of the movie, where Munna decides that he is not fit to be a doctor. If he couldn’t save Zaheer, then he is not qualified to do the same for anyone else. Dejected, he quits the hospital. But upon finally quitting, he admonishes the other doctors that they were incapable of prolonging Zaheer’s life for just one more day. He could have met his mother one last time.
It is highly probable that doctors couldn't have given him another day, but that’s not the point. The point is this. Sometimes, the wishes of a patient nearing death might not be another litre of oxygen, but how he might want to use his last breaths.
This essay is my way of conveying why reading philosophy can give you answers in such tricky situations. Philosophy can give you a radically different perspective. It can change how doctors view their patients on a daily basis. It can alter how people see their own body-minds.
The Roles of the Patient and the Doctor
A long time back, I had come across a sentence in an obscure book on medical philosophy which posited that the business of healthcare is as much as the job of the medical professional as it is of the patient himself. If the patient doesn’t assume his role, then the doctor-patient relationship is bound to falter. At the surface level, you might think the role of the patient is to adhere to the prescription given by the doctor and that’s it. But it is so much more than that. When I say the patient has to assume the role of a patient, it means how Daniel Day Lewis incorporates himself in his characters. Mr. Lewis is famous for getting into the skin of his characters. In fact, when he is off-camera, he continues to remain in the same headspace so that he doesn’t lose authenticity. The role of a patient, in this context, is to understand that they are at one receiving end of this (doctor by giving care is at another receiving end) exchange. It is not just about the act of ingesting a prescribed pill.
Let’s consider the relationship of a married couple who bring out the best in each other. After about two or three years of marriage, such a couple is bound to compartmentalise expressions of dominance and submission. While the husband may decide which house-help to hire, the wife may have taken an upper hand in deciding what food will be made on a given day. They usually agree to disagree and, with time, they begin to accept one-sided decisions because they have realised the strengths of each other. The strengths are wildly dissimilar and they capitalise on it. The strength of the patient lies in being the sole person who is aware of his discomfort. Doctors, however intelligent, can’t estimate it. They usually guess. All that a good doctor wants is for the patient to give him all that information in the rawest sense. Bringing out the story from the patient and examining him continues to be a bedrock of medical practice. But both patients and doctors are losing touch with this aspect of care. The real culprit is not lack of conversation but lack of trust. Patients don’t trust doctors, they no longer feel the need to open up. They have resorted to understanding themselves via the medium of numbers on their lab reports. Worse, even doctors have resorted to the same. I see at least ten patients everyday who, instead of starting with divulging their complaints, thrust their reports in my face and expect me to furnish a bouquet of drugs. Trust is not something that comes by reading textbooks or by mollycoddling the patient. Trust in a such a relationship is built up on the premise that we are in this together, just like husband and wife. The spouses, for themselves individually, may want separate careers and foreign vacations, but the bedrock of the relationship is mutual support. In this regard, it is the duty of both the patient and their doctors to be truthful to each other. If there is one place where I see the most decay in medical care, then it is this. Patients are no longer patient, they are litigious and revel in the misplaced notion that correcting the numbers of their body is the sole job of their doctor.
The Sick Role
A couple of months back I was having a chat with one of my juniors. She is a postgraduate student who is interested in the subspecialty of haematology. She will pursue it once she acquires her MD degree. We were discussing how annoyed we feel in our outpatient clinic, the reason being the overwhelming number of patients who come with psychological issues manifesting as headache, muscle pain and fatigue. When I asked her why she wants to pursue haematology, then this was a major reason. Almost all post-graduate students that I work with endeavour to do the same, albeit pursue different subspecialties. No one wishes to remain in general medicine now. I have decided to remain a generalist. When she gave her reasons, I said, But these patients comprise the bulk of our practice, which is a reflection of what’s outside the hospital. To me it seemed one of the most important reasons why we must not be annoyed with such patients. I still feel annoyed but I have developed ways to mitigate it.
While today it seems obvious that pain, fever, cough, fatigue and even sadness can be measured and categorised into disparate diseases, there was a time in our recent past when such symptoms were read as a breakdown of faith in God or of one’s willpower. Talcott Parsons (1951) gave us the concept of the ‘sick role’ wherein patients are attributed certain rights and responsibilities. These included temporary exemption from their social roles, expectation to see being sick as undesirable and feel the obligation to seek professional help. Doctors were also given a set of rules to follow. Lately, the sick role has been thrown away in the wastebasket, and doctors don’t feel the need to hold themselves at high standards either. While Parsons introduced the concept of the sick role to stop the potential proliferation of a subgroup of sick people in the society who would not seek help, my experience with patients has taught me that some of them have instead assumed another role. The ‘consumer role’. While the sick role placed the patient under the benevolent care of the doctor, the consumer-patient is a different breed. They still demonstrate deference to doctors, but it is feigned deference. They see doctors as automatons possessing knowledge of what is ailing them, knowledge that the patient doesn't have simply because they didn’t spend a decade or so acquiring it. The doctor is like an ATM machine. Put in your card, and get your cash. Doctors still consider themselves to be at the centre of the Earth, they still think they hold unbridled power, but they don’t realise their edifice is crumbling. When patients come to my clinic, I can see that a large proportion of them don’t give two hoots about my degree, they just want to get what they paid for and the energy they spent in seeking an appointment. Some of these folks will buzz with nervous energy right outside my door and keep looking at the seat of the patient in the cabin with hawk-eyes. No sooner, does my patient leave the cabin, they dart inside and throw their reports on my table. Not that I am hoping for any respect, but my hope is they would at least respect their own body-minds. When you convert this relationship into that of a service sector business, both the patient and the doctor lose. Doctors respond by pleasing their customers. Since customer is king and the king says the pain in their arms is because of the gas in their stomach, it must be so. No questions asked. Get your dose of gingko biloba and throw in a Viagra for some extra action in the bedroom. Add-ons are anyway the biggest gimmick devised by the industry. Doctors have capitalising on it.
The Gaze and the Language
The French philosopher, Michel Foucault had a unique way with his words. In fact it was so unique that Foucaultian experts often comment that his writings are a headache to make sense of. It appears so confused and verbose that it takes re-readings after re-readings to deduce it. Nevertheless, this frenchman had some real insight. In his book, The Birth of the Clinic (1963), he traced the history of the development of medical institutions in France. What was true of France then, was pretty much a facsimile of most Western nations. He introduced the concept of the gaze and the language. As he traced history, he concluded that right around the French and the American revolutions, a fundamental shift had occurred in the viewpoint of medical knowledge. While earlier anyone with an aristocratic guilt-graduation could practice medicine, the revolutions gave birth to a new kind wherein the graduate had to exhibit “proof of capacity”. In the guild system, there was no universally accepted body of knowledge but these “teaching hospitals” had to be uniform in their scheme. Also, there was a significant change in how doctors gazed their patients. This gaze was an objectifying lens with which doctors made sense of what is happening in the minds and bodies of their patients. The gaze devoid the patient of their personhood. While earlier patients and their doctors were at par (and unquestionably wrong) with how the human mind and body were to be made sense of, now the patient was assumed to be an idiot. Since he didn’t have the gaze, he was clearly not in a position to judge himself. This gaze required a new way of communication. The Language was born. Just like the gaze, the language became technical and was shorn of the embellishments that was staple of erstwhile literature. Every word had to have uniform meaning. The meaning had to be universally accepted. If the patient conveyed their predicament using “meaningless” words, they had to be discarded and be imposed upon by the new language.
To this day, doctors continue to have the gaze and use the language. When a patient arrives in our clinic, we are on a mission. The mission is to diagnose the patient’s illness by combining all the information from history, examination and investigation into a theoretically accepted paradigm and come out the other end with a diagnosis. Imagine diagnosis to be like a trophy you get at the end of a race. More interesting is the use of language. Since patients were never required to read our textbooks before they were given appointment, they use words which only make sense to them and at best to their pets. To the doctor it is a frustrating experience. Throughout the visit, the doctor tries to elicit the words he is comfortable with. And if there is no success there, then the doctor simply discards that complain and uses the rest of the information given to him to concoct the potion of diagnosis. Doctors feel triumphant at making diagnosis. That is where validation comes from anyway. What I have noticed is every community has their own set of words and actions with which they convey their illnesses. More importantly, what they consider to be illness could be entirely disconnected with what doctors do. That is a radical insight I have acquired after seeing many patients. While the swelling in the legs of a grandmother may be of no concern to her, overenthusiastic doctors get excited and can’t help themselves from reducing their swelling, even when that swelling was purely cosmetic. It was doing no harm and worst is that the drug they introduced is potentially going to be much more harmful. While some patients, specially the consumer kind, desire a battery of tests, there are others who want neither tests nor drugs, they don’t even want a solution; what they come for is a talk. A talk with a person whom they think has answers. But I see lengthy prescriptions by other doctors giving them exactly what they didn’t need. Sometimes, patients really don’t know what is best for them, and a doctor can be the only authority puting their predicament in the right context. Increasingly I am seeing this disconnect between the patient and myself. When I realised this obstacle a while back and started delving into the philosophy of Fritjof Capra, Alan Watts, Jiddu Krishnamurthi, Anton Chekov, T S Eliot, Larry Dossey, Werner Heisenberg, Friedrich Nietzsche, Arthur Schopenhauer, Car Gustav Jung and many others, it dawned on me that I was approaching my patient the wrong way. I was using the gaze and the language and doing nothing else. I continue to use the two, but I have softened and modified my approach. I try not to settle for a diagnosis if it doesn’t need to be made. I try not to satisfy myself and at a lot of times I don’t even try to satisfy the patient. The act of treating a patient can often transform into a discovery of the truth, the truth which clears the fog between the patient and myself, the truth which establishes lasting trust, the truth which cures the knots of confusion, and not necessarily their hunger for yet another drug. When you begin to understand yourself, you have the potential to change your physiology.
Evidence Based Medicine
In the 1970s, Christopher Boorse, a professor of philosophy in the University of Delaware, described disease as a deviation from the “normal”. It presupposed that there is a biological and statistical range between which normality lies. Any deviation from this range constituted disease. In fact, the French philosopher Claude Bernard claimed that individual variability was an obstacle to medical judgment. Thus the only mandate of the profession was to bring back the deviant individual to its pre-determined normal state. Czech philosopher, Jiří Vácha (1978) gave a taxonomy of normality. Frequent, average, typical, adequate. These words and their loaded meaning became the centrepiece around which the new field of evidence based medicine (EBM) was given birth by the epidemiologists in McMaster University in Hamilton, Canada in the 1990s.
Belgian mathematician, Adolphe Quetelet, set himself the task of identifying body types and came up with the Quetelet index. Today it is better known as the body mass index. The whole world was neatly divided into underweight, “normal weight”, overweight and obese individuals. Suddenly the “normal” physique became the hallmark of health. You can see its effect in the sheer number of advertisements and films which portray this same body type as aspirational. From aspirational we went to the ‘norm’ and no sooner it was etched into the public psyche (and that of doctors) that everyone who is on either side needs to be brought back in range. I had an interesting encounter with a brother-sister duo who had come to put the girl into the same bracket at any cost. You might find it interesting to read.
The favourite baby of EBM is the randomised controlled trial (RCT). At earlier times, whatever a doctor said was consider gospel truth. Today we call the same thing expert opinion, and in the hierarchy of evidence, it has been given the lowest place. RCT is regarded as the gold standard for considering a treatment to be approved status. In a RCT, generally two groups are made. One is the experimental group in which patients are given the new drug in question and the control group which is given the current standard of care or a placebo. The individuals in the group are matched in terms of age, sex, habits, diseases, etc and then the trial is conducted. At the end statistical calculations are applied to see if the new drug is superior and what is the chance that it will be useful in the population in the real world (which matches the population in the trial). If you were to go on the websites of the best medical journals in the world, you will find RCTs all over. Medical students are drilled during hospital rounds and in their examination about these trials. They must know and apply the results of the trial on their patients. It is considered best practice.
But here’s the issue. The trial gives you at best correlation, not causation. It tells you that the drug works in the test population, note necessarily the real population at large. It tries to tell if there is a possibility of the drug working in the real (and matched) population. But it says nothing about whether the drug will work on you. It is a statistical truth, dipped in error.
Further there is an argument that EBM places undue emphasis on statistical conclusions and it ignores patho-physiologic mechanisms. If you notice, the RCT doesn’t require any explanation as to how the drug works, just that it works (statistically). This is what Georges Canguilhem, a 20th century French philosopher wrote in his treatise Le normal et le pathologique (1943). He quoted Charles Darwin when making his point. He derided that 19th century statisticians and normalists had forgotten that evolution introduces variability in the characteristics of organisms. Thus, no matter how rare a trait an individual might have, it can be appropriate for the individual in his environment. Thus, variability must be viewed contextually. Body mass index is a good example to highlight the same. Body mass index is your weight per unit height (squared). It does not tell us about what constitutes the weight. It doesn’t differentiate between the weight of fat from that of the muscle. Arnold Schwarzenegger had a body mass index of 40 in his heydays of body building. When we use body mass index as a one-size fits all classification system, we lose such nuance.
EBM has done wonders in medicine and it continues to do so. Graduates and professors adhere to it like bees to flowers. But, do clinicians fully understand research articles written by dedicated researchers? Today, if you are a practising physician and if you were to read a research article on the website of a reputed journal, you will be flummoxed with the mathematics and computational analysis behind the simplest of trials. The language of statistics in research has become its own beast. It is becoming more complex and changing so fast than a clinician can never keep up with them. The bottom-line is trust. Clinicians do not have the time to read full articles, they resort to relying on authoritative journals and their pronouncements. Journals have become the new God. What is written is given veritable status until a completely contradictory statement is made by the same journal at a later point in time. Next time you read a journal article, read it with a pinch of salt. Your patient is not a test subject, just like you wouldn’t want yourself to be categorised this way.
The Sense of Time
There is a book by a practising doctor, Larry Dossey (1940—), called Space, Time and Medicine. Dossey is a physician based out of Texas, United States. In the 1980s, he came to the realisation that the current paradigm in medicine needs to incorporate elements from Eastern philosophy like that of Buddhism (specially Zen Buddhism), Taoism and Hinduism. In his 1982 book, which I came across by way of serendipity and my own deep dive into this paradigm, he talks about the relation of time and disease. He places special emphasis on the diseases that are prevalent now all over the world. The set of diseases we call chronic diseases, for example, cancer, diabetes and hypertension. He reviewed data on personalities of people afflicted with these diseases and with the foresight of an experienced physician he saw a similar trend in his own patients. He called some of these diseases “hurry sickness”. He noticed that individuals who are chronically stressed also have a warped sense of time. For them time seems to running faster. It also affects their physiology. Their blood pressure, heart rate, respiratory rate, body movements, visceral movements and their mental states have an underlying unity in terms of being faster and chaotic. These indivisals are predisposed to develop chronic diseases and even die earlier than average.
Imagine, you are walking down the footpath and a vicious dog bites your leg. The wound is deep and you are rushed to the emergency. You are in severe pain. If you have had such an experience or a similar one in which you had acute pain, you will recall that nothing mattered to you except that the pain should go away. You would do anything and as rapidly as possible, to have that excruciating pain alleviated. This is an evolutionary gift bestowed on us. If it were not so, we wouldn’t make the requisite effort to remedy it and more importantly, we woldnt’t act fast. Infectious diseases, trauma, bites and stings fall into this category. Contrast it with chronic diseases, wherein for the longest period of time, you have no clue that your body is corroding from the inside. Why? Because it doesn’t come up to the surface of consciousness. There are no symptoms, in other words. Thus, you don’t make any effort. While science has done a wonderful job of treating acute diseases, we are still treating chronic diseases at a very superficial level.
I see people sick with hurry day in and day out. They are under tremendous stress. I have talked about chronic stress elsewhere in my Substack. If you are interested, you might want to read it.
We need Munna Bhais
While it is evident that doctors never thought about the last wishes of Zaheer. But why did it matter for Zaheer to meet his mother one last time? What difference could that make? He couldn’t have become better. In fact, chance is all he would have witnessed is the agony of his mother in his last breaths. There is no logical benefit to his request.
Precisely. There is no valid logic in his request. That’s what patients are from time to time. While Adam Smith assumed a rational consumer and therefore sound economic demand-supply equations, the real man out on the street doesn’t always make decisions based on rationality. We are predominantly beings of feelings. We use heuristics and emotions to decide.
Why should our physiology not reflect the same?
Thank you for reading.