Herba Non Verba. Probing the Foundations of Medicine

To Fernando Gil, a friend, a philosopher, in Memoriam

“(…) Le pharmakon et l'écriture c'est donc bien toujours une question de vie et de mort (…)”. (p. 130)

“(…) C'est que la mort du père ouvre le règne de la violence. En choisissant la violence – c'est bien de cela qu'il s'agit dès le début – et la violence contre le père, le fils – ou l'écriture parricide – ne pu manquer de s'exposer lui-même (…)” (p.182)

“(…) But none of the arts theorize about individual cases. Medicine, for instance does not theorize about what will help to cure Socrates or Callias, but only about what will help to cure any or all of a given class of patients: this alone is subject to technique: individual cases are so infinitely various that no systematic knowledge of them is possible (…)”

The Art and the Plotting

Petrarca, in his Invective contra medicum gives us his admonitions:1

“Words change but things endure; and the sciences are based on things”

“Fools you measure everything by your own measure!”

These warnings will be read under the spell of the strange case of Derrida's parricide scripture. Some years ago, Thomas Szasz presented an interesting and rather straight forward classification of therapies demarcating the talking cure (verba) of psychoanalysis from the physical healing methods of conventional medicine (herba) and from psychiatry (verba and herba). He intended “(…) to draw a clear distinction between the physical (impersonal) cure of bodily diseases (exemplified by the surgical removal of an inflamed appendix, and the spiritual (personal) cure of souls in distress (exemplified by the Catholic confession and psychotherapy. (…)”, and said that these latter healings are only metaphorical treatments, adding that Breuer “realized that the ‘talking cure’ was not a genuine medical treatment and quickly abandoned its use”.2 Subscribing many of his arguments and values, I intend to propose an alternative version of clinical medicine (an idealized picture, I know). It is, like Szasz, in the name of human unity and dignity (the one of the Renaissance humanists) and also under the spell of the same Pethrarquian Invective, that I present this work-in-progress on the foundations of Medicine. Szasz's message may be summarily schematized as follows3:

HERBA OR VERBA?

Three main moments or plots have been duly conjugated to articulate the often antagonist medical discourses of the parts and the wholes (simplifying a lot): (i) inscriptions in the body (from the lesions and scars to the sorrows and complaints, the patient's first person narrative and first person authority), (ii) naturalistic descriptions (the clinical story and symptoms, and medical narratives of health, disease and disease mechanisms) and (iii) prescriptions (the medical and surgical armamentarium, scientific data and theories that allow a meaningful and participated evidence-based decision-making by the pair doctor-patient): 4,5

Medical Professional Scripts

These three objective instances or scripts have three subjective conditions of possibility, namely (i) diastolic attention, (ii) “systolic” representation and (iii) “epistemic” affiliation.6 Indeed, the clinical experience was defined as recta ratio agibilium et factibilium; aiming at a just and individualized measure, the plottings of the Art must overcome a certain narcissism of the arts of plotting and the physician's presence, mood, gesture and setting must be (taught as) a honest, responsible, modest, declined mirror7.

So, it seems obvious: whereas the complaint is a pure, natural paralinguistic or linguistic expression, a form of life “belonging” to and exhibited by the ill person, the symptom is the signature of the syndrome and of the disease, a diagnostic criterion, belonging instead to the medical logos.^8,9 It is from my practical experience as haematologist and, later, in palliative medicine, and as an occasional patient, that I try to show that current medical discourse exhibits often a fausse non-reconaissance10 and so it is often rhetorical in the worst sense, and merely perlocutory, impersonal and anomic. How are the patient, the narrator, the protagonist, the agency, the body, posited or evacuated and, also how are good, evil, temporality, subjectivity, and drama, posited or evacuated in the medical encounters?11

In the next section I propose a brief introduction to the phenomenological perspective in clinical medicine, limiting myself to a generic examination of the pain syndrome in fibromyalgia. I tend to agree with the French phenomenologist Jean-Luc Marion thinking that, much beyond the clinical experience and expertise, a deeply disturbing premise holds: every intense phenomenon threatens to abolish that same category of relation (and of substance, of causality, of community between substances) since it re-transmits only itself,12 so that no clinical bond or dialogue – no dyad – could ever be possible: the compassio, the empathy, and more basically, the clinical rapport would then fatally be an impossibility, a myth, a lie.

Mi Mal Es Tan Entero

Years ago Katheryn Hunter called our attention to the ablative connotation of medical diagnosis: the designation by doctors to his patients as (the naming of) parts of the body, as a case, the disease, as the place, even as a number.13 She was appalled by how pervasive this pars pro toto or metonymic process was, despite the unity and holism of the illness and the complaints themselves, of the experience of suffering, of the narratives, of the plots, of the body/mind: the pain as an ablative experience often aggravated by the insensitiveness of the doctor (we will see that it is a donation phenomenon as well). And, in agreement with Cheryl Mattingly, true clinical experience and intelligibility proclaim strongly that if “(…) narrative offers a homology to lived experience, the dominant formal feature which connects the two is not narrative coherence but narrative drama (…)”.14

Focusing here on the enigma of health and on the discourse of the Other, I will now comment a few lines of an autobiographical book by a public personna, M., who got a diagnosis of a new and contested nosological entity, namely, fibromyalgia. It is a joint venture between the patient and her doctor: the authors intended to promote a nationwide campaign for the public recognition of the disease as reumatological entity.15 In the back cover it is announced that fibromyalgia is a “clinical

entity that affects at least 200.000 Portuguese people”. It is with a few bitter wounded words that the book starts: it is dedicated to “the friends I've lost to fibromyalgia”.

The fibromyalgic syndromes are a kind of psychosomatic or functional processes classified according the following international criteria16:

Defining Fibromyalgia

DEFINITION: chronic generalized alodynia, normally with systemic manisfestations, including severe depression

“DIAGNOSTIC” CRITERIA (ARC, ): history of generalized pains (+fatigue, insomnia, etc.) +painful points to palpation: 11/18; no inflamatory signs.

Intensity of the pain: “…8/10…”

Time course > more than 3 mo.

NB – CO-MORBILLITY: Depression; Panic reactions, acute anxiety; PTSD; Lyme disease; Chronic Fatigue Synd.; Irritable Colon Synd. (“spastic colitis”); Migraine et tension cephaleias; Dysmenorheya…

To approach the problem of fibromyalgic chronic pain and other painful syndromes I must say that intense pain, total pain, is really wordless and voiced into cries, tears, gestures, or acted-out (or acted-in) into flight, revolt, sorrow, guilt. M.'s discourse frequently seems terribly and poignantly hyperbolic or periphrastic17:

– “(…) I always remember having pains. At least since I was ten years old (…)”.

– “(…) I do not want to speak badly of my parents for having brought me this way, although I do criticise aspects of their severity, which denied me options that could have given a different meaning to my life (…)”.

– “(…) I realize that approximatelly 80 to 90% of the time, I dined alone (…). My home is no longer part of the many that I had considered to belong to the family of my heart (…)”.

– “(…) The priority of someone suffering from a chronic illness has to be themselves (…)”.

– “(…) I do not know what my life would have become, if I had not made it public that I suffered from fibromyalgia (…)”

It would be preposterous and wild for me to try any kind of psychodynamic extrapolation or interpretation; I will only invoke here, en passant, the old medical concept of diathesis or constitution and recall the much more recent concepts of organ neurosis (Grodeck's) and Reich's work on the cuirassed character18. Indeed only the poet can, without betraying himself, articulate his pain in absolute perfection: “mira que peno por verte,/ y mi mal es tan entero,/ que muero porque non muero”19.

Pain is, of course, a most powerful elicitor of defence mechanisms and so also a promoter of reflex nociceptive response, of reciprocal attention and good will (of the kin or close carer), aiming at the structural and functional security and integrity of the individual, and also, when the coping mechanisms are strong enough, of personal endurance and selfconfidence. Let us listen again to M.'s account when she discovered that she “had” fibromyalgia20:

“(…) It's ever so urgent to emphasize the importance of keeping a bunch of friends even though they may be different from the ones we relied on before the illness (…). There'll always be days when exhaustion will recommend keeping reclusiveness. I've done a lot more of reading since I learned I was suffering from fibromyalgia (…)”

We like to put names on things; we do need rigid and not so rigid descriptors to fixate the references. But, is a disease a thing?21 Yes, rarely is the cause of a disease a “thing”: a venom, a micro-organism, an environmental toxic. Trivially: a disease is a nefarious or pathological process between an agent and a host in a specific ecological niche. M. seems to express the joy of finally embracing, with that diagnosis, some kind of new understanding of her true Self and to recover the hope of getting back not just some lost object, but empowerment, better days. To approach this need of double acknowledgment – by some renowned medical authority and by the anonymous scientific power – it might be helpful to try a study of the phenomenology of pain and suffering, because even when acute, local, brief, nociceptive, it affects the bodily oeconomia, touches the integrity of a person.

The best clinical reports of pain I know came, of course, from cancer pain and by the sensible intelligent voice of an extraordinary woman, C. Saunders: “(…) The concept of ‘total pain’ was spelled out in an answer given to me by one patient in 1963 when I asked her to describe her pain. She said, without further prompting, ‘-Well doctor, it began in my back but now it seems that all of me is wrong’. She spoke of several other symptoms and went on – ‘I could have cried for the pills and the injections but I knew that I mustn't. Nobody seemed to understand what I felt (…). My husband and son were marvellous, but (…)‘. Physical, emotional, and social pain and the spiritual need for security, meaning and selfworth, all in one answer (…)”.22 Somewhat against the clinical evidence,

I propose, in a very succinct, schematic presentation (inspired by the John Searle's Intentionality) the following characteristics for a definition of the phenomenalisation of pain as intensification or saturation:

PAIN AS A PHÉNOMÈNE SATURÉ EXPRESSIONS, MECHANISMS & MEANINGS OF PAIN AND SUFFERING

Such pain, such illness, such suffering, invites from any bystander, a reflex – and reflexive – symmetry: pain is also a donation experience (of surprise, attention, care, respect, solace, and, also, oh, how terrible!, of course, of soul, of inspiration, of poetry, of creativity…) – whose absence brings a tremendous loss24. How such a strong, screamed, self-donation – and donations – multiple because repeated, physical and moral, can be not heard, not listened to, is a mystery, a scandal, an outrage that one of ours (physician's…) intimate demons, our Mr. Hyde, inspires and probably explains. Clearly, what is missing is a listening and concerned presence and the… “rotation” of efficacious drugs.

The Triangle

To interpret correctly the patient's sensation/feeling requires more than empathy: it requires the art of finely weaving recognition25 and cognition – recognition of the other, a contradiction whose solution advocates, we now know, mirror neurons, analogy and philia, what the psychoanalysts call mentallization, a theory of (the other's) mind and of the other's intentionality: the doctor as pharmakon (Balint), meaning, the physician's body, physician's senses, as his first tool. 26

Mentallization, mimesis and contact:

Mirror neurons and internal immediate experience (since Avicenian inner sense to self-affection radicalized by Maine de Biran and Michel Henry): passio/repassio (Francisco Sanches), feeling (Whitehead); self-evidence; existential feelings; feelings of understanding (James); theory of mind and mimesis (Meltzoff, etc.); cognition of the other's actions, intention and emotions

Now, my strategy (in this forcefully brief discussion of medicine qua science of the individual) is to stress only a few aspects of the so-called Hippocratic triangle, the patient, the disease and the doctor in their very heterogeneous relationships. Let's see what its scope was and is:27

The Hippocratic Triangle

“In all dangerous cases you should be on watch for all favourable coctions of the evacuations (…). Coctions signify nearness of crisis (…) but crude and unconcocted evacuations (…) denote absence of crisis, pain, prolonged illness (…). But it is by the consideration of other signs that one must decide which of these results will be most likely.

Declare the past, diagnose the present, foretell the future; practice these acts.

As to the diseases, make a habit of two things – to help or at least to do no harm.

The art has three factors, the disease, the patient, the physician. The physician is the servant of the art. The patient must co-operate with the physician in combating the disease.”

The triangle allows us to indicate three basic ideal-types of physicians and of practice:

• first-person or patient-centered (as told, the concerned G.P., the Oslerian physician, the old “João Semana”)28,

• impersonal or disease-centered (the biomedical researcher and his science)29 and

• third/second-person or doctor (nurse)-centered (the Narcissist or vampire physician or nurse).

The Heart of the Meter

Where does it hurt? How do you feel? – these are probably the most commonly asked questions in every language in clinical encounters, before, during and after any kind of surgical treatment or medical prescription. Refusing dogmatism in (biomedical) epistemology and accepting (cultural) pluralism in clinical practice I propose here that inherent in the epistemic virtues of the clinician lies the ancient quest after metron as a measure for internal properties, felt as aisthesis, an inner feeling, a sense of rightness, one – maybe the first – criterion (as opposed to tool) for evaluating the adequacy of decisions in a context of uncertainty. The proper metric was described by the Hippocratic writer in Ancient Medicine as body feelings (somatos ten aesthesis). I will suggest an interpretation of it as a heuristic – a kind of “gut” feeling – that must converge with intra- and intersubjective standards.30 That is both the patient's and the physicians' or nurse's feelings and educated guesses must be not only co-reportive but also not dissonant – does it harm?,

does this action feel right? – were and are the first interrogations that qua agent every doctor ask also to himself.31

In fact, clinical medicine/nursing is not about metrics and funding or about meaning and rhetoric; clinical medicine/nursing is about common people, diseases, illnesses, suffering and their care, prevention, treatment and rehabilitation. But biomedicine, technomedicine, is both the Hippocratic Osler (G.P. or “João Semana”) and the Jekyll experimentalist (as an individual or, as nowadays, as a collective business). Nevertheless, at least for clinicians, doctors and nurses, as Richard Zaner wrote some years ago, the central rule of Medicine should be evident: “(…) ‘the clinical event governs’ (…) the interpretation of symptoms, clinical judgment, the social structure of clinical encounters, the multiple forms of responsibility, trust, uncertainty, and others. The focus on the clinical event suggests that the core theme for a philosophy of medicine is the physician-patient relationship. (…) Thus, one of the main phenomenological issues concerns (…) how best to understand the nature of clinical judgment within the structure of clinical encounters and the illness experience (…)”32.

Throughout the years, together with a bunch of dear colleagues and with the help of some patients (and their families), I was driven to the following convictions, without knowing exactly the reasons and the ways: (i) the modern movement toward the Humanities in medicine, comprehensive approaches, patient-centered care, narrative-based medicine (NBM), qualitative methods (like grounded theory and others) do represent today the best we can get of akribeia in the sciences of clinical practice and their evaluation and justification; (ii) evidence-based medicine (EBM), reinforced by the important and crucial developments on Darwinian Medicine, revives the ambitions of the ancient galenic axiomatic or dogmatic medicine, purposes quite legitimate and necessary when EBM recognises the limits of its “grammar”, power, scope and its

central amaurosis to the individual33. To qualify this view anthropologically (if I may use the term), and with an unequal depth I will defend the following hypothesis: that in the genesis of Medicine, of clinical practice, there is a primal violence; and that this violence has been erased by a decision about scientific intelligibility or meaning, a decision of causal nature supported by the rationality of the Hippocratic ethos and by the biological explanation of disease34.

Let's look now to the heart of the matter: the play between losses, griefs and gains, that is, toward the libido curandi game. After a brief presentation of M.'s case and a hint of its context (without even mentioning the paradox of indifference),35 I've shown the Hippocratic triangle and, now, I will focus on the need for a foundational analysis and stance.

I would like to suggest that the present global experimentum humanum – ruled too often “double-blindly” by the visible hands of the Big Pharma and the Academia –, may be revealed with the help of Dr. Jekyll's double predicament (and praedicamenta) and the Derridaean dualism, “l'écriture”/the pharmakon – they are my subtext and, certainly good to think with:36

THE STRANGE CASE OF DR. JEKYLL AND MR. HYDE

Rita Charon, in her very timely book on Narrative Medicine,37 with clinical insight, stressed four main health care existencial divides and confounders that may impose an evil silence and give way to bad faith (my words) between the patient and the professional carer, namely,

1. the relation to finitude and mortality,

2. the cultural and social context of illness,

3. beliefs about disease causality and mechanisms,

4. the emotions of shame, blame or fear.

They may distort and block the communication between the practitioner and the patient (and his family). Here I can deal only with a few aspects of the second and the fourth divides and let the others lie below. Indeed, falling sick is pathos, turbatio, illness – a distress, a dis-function. Suffering, pena, is passivity, being prey of some kind of strange power. And the spontaneous human reaction to these dangers is a call for help and it has always elicited sense and sensibility, sorrow and consolation.38 Now, coming back to our book on fibromyalgia, knowing that in some western countries the disease doesn't even “exist”, one wonders what to

make of the following statement: “(…) The pain in fibromyalgia is a real entity but completely independent of the interpretation that the patient and above all ‘third parties’ give it (…)”.39

Recall that the drama per se is more relevant than the story's consistency and its vicarious or putative closure:40 can fibromyalgia be just another expression of a stress-related disease, like PTSD?; or could it be just an iatrogenic construct? Why do we not confess our deep ignorance and great uncertainties about this diffuse myalgic syndrome?

And (K)Nots: Systemic Foreclosures

Finally I want to put forward a few foundational epistemic ideas, a bunch of (k)nots and yeses. Yeses: mysteriously “(…) Yes, doctors touch patients and do rather extraordinary physical things to them, but the textuality and not the physicality defines the relation. (…)”41 – or so it should be!42 Yes, also, to Hippocrates and not to Giges, as Zaner pointed accurately: “(…) if therapy is understood as Hippocratic, the grave moral issue persists as an abiding part of medicine's legacy: why ‘act in the patients’ interest' much less ‘do no harm?’ troubles every relationship with patients. The clinical encounter is haunted by the figure of Giges and its temptations to manipulate (…). Why Hippocrates and not Giges? (…)”.43 He sees that a sustained, consistent, fiat of the clinician interloqué (to use Marion's aptly term) attending to the patient's vulnerability with his own human precariousness, is the real ground of medical ethos: how to be the professional expert, keep the therapeutical distance and be helpful without putting oneself in somebody else's shoes? (K)nots: How to hide, how to neutralize, our Mr. Hyde alter-ego? Primo non nocere, was truly for ages the very convenient defence against all kinds of sliding slopes. Already in On the Art, we were told that “(…) the full reparation of the patient's disturbance, alleviation of the more violent infirmities and the refusal to treat the diseases that have already won” serve to define Medicine (…)“, and further that ”there is no Art that is not based on facts. (…)“44. Thus, the ancient doctors sought to distance themselves from herbalists (pharmacopouloi)

To bring this paper to a close, I will focus now more specifically on my answer to Szasz's challenges: it is really desperately obvious that much of the contemporary medical practice was captured by predatory ideologies, by the glamour of commodification, by the needs of management technosciences. To shorten the argument (time does not allow me more detail) I would modify a little Szasz's analysis, contemplating the two readings of the physical text (the bodily complaints and manifestations) by the doctor's body and senses and of the oral/written text (the meanings) by the doctor's soul and listening art46:

WHICH CURE IS (THE) WITCH?

Now I'll try to offer my tentative theory/therapy… It demands a patient/client empowering attitude as a main pillar in each clinical encounter and the rejection, by mere will of the iatrocentric, often “falocentric” (not masculine) and, Gigean authority. Accept then, I repeat, as work in progress, the following preliminary attempt to describe the main foreclosed and denegated epistemic obstacles to an expert, good, sound and clean clinical authority. It has at its core the Hippocratic triangle and takes the following premises or hypothesis, woven together – on three foundational knots – the three lines of the clinical agency treated here:

• the saturated phenomenon leads to the anonymity of my patient, a clinical (non)possibility inscribed in another paradox, the paradox of the dyad;

• the hyponymy (metonymy/metaphor) as an operator of the diagnosis, and so an operator of the disease's reification;

  45. See Appendix-3.

  46. Szasz, 1998; Charon, 2006, p. 110.

  Page 108

• the founding violence, including Hyde-Giges's temptations, as repressed and veiled by a word: the Hippocratic oath:47,48,

THE SYSTEM OF CLINICAL FORECLOSURES

I believe that these (k)nots and yeses conspire and reinforce each other to make system50. Let me indicate how they do make system. Earlier I introduced the following perplexing biased confession:

“(…) The pain in fibromyalgia is a real entity but completely independent of the interpretation that the patient and above all ‘third parties’ give it; the attitude of these ‘third parties’ (family, friends, colleagues, bosses / leaders, etc.) always has ‘secondary gains’ (…). For several reasons, and not always obvious ones, the patient can indicate a higher level of pain than the one perceived or vice versa (…)”

Recall Stevenson's strange case again: why did the expedient Dr. Jekyll turn away from the (subjective) gains of the caring stance? Had he lost his compass and the “milk of human kindness”? Because of the ambition of curiositas? Because reification (his own plotting himself as “guinea-pig”) brings, as always, a metonymic operator?51 – Perhaps, modern scientific education forecloses and forgets that knowledge is built around a few fundamental interrogations: why do I believe?; how do I know?; what is the question?; what do I mean?52 And triumphant doctors and nurses have lost a small fiduciary speech act: I don't know! Indeed, there are two sides to the foundational violence of science. Firstly, the construction of a Baconian object – “The secret operations of nature are better revealed under the torture of mechanical arts than in their own vulgar course.” (Bacon, Novum Organon, 1, 98)-, and secondly, the self-coronation of a repressed subject: “(…) After Descartes, no one better than Bachelard could have evaluated the price that the subject pays to raise himself to rationality (…). ‘(…) There is no scientific thought without repression. (…) All coherent thought is constructed on a system of solid and clear inhibitions. There is happiness in rigidity at the base of a culture (…)’ (…)”.53 Furthermore these transversal ties draw a system: a foreclosure, nullius in verba, conspires with the reification of the illness, the will to individualize fights against Jekyll's duplicity, and the oath, a word, contains Giges.

Many recent inquiries on the “re-foundation” of Medicine entail, generally, I think, the consideration of (at least) two main aspects: the illness perspective (M.'s pain, etc., that can only be sensed, hinted, “tasted” at the “bedside”) and the Galilaic perspective (fibromuscular and pain physiologies, etc.). EBM is today the latest pontifical mathesis and a statistical tool to inform clinical decision-making. We know that EBM with its totalitarian pretension has as many affinities with Derrida's letter (écriture) as with his and Girard's pharmakon and dangerous liaisons with the Big Pharma; its role-model could be Dr. Jekyll, no? Evidently, or may be not so, EBM is clinically the most demanding of the medical situations. This apparent paradox becomes obvious because some of its commandments are contra-natura and “cannibalistic” – not the least because of the “curse” of the statistical indifference principle, visible for

instance, in the current attack to the equipoise –, making virtually opaque, in those contexts, the defence of M.'s “best interests” as a patient54:

TWO ARMS FOR A BETTER PRACTICE?

Symmetrically, NBM is more demanding scientifically. We know that statistical hypotheses are not liable to be proved, as John Ziman wrote years ago, and that a statistical argument only tells us if the data are consistent with the theoretical hypothesis: a statistical argument per se (without the empirical and/or physio- or etio-pathological data), will never be enough to found a new knowledge, a new treatment. Nevertheless an empathic clinician, a virtuoso on communication skills and on narrative hermeneutics, briefly an expert on NBM, can't embrace the clinical mood or style and ignore the latest scientific facts: being the authentically prudent professional is hard and… what is not scientific is not ethical, as Prof. Jean Bernard insisted so often. So, the two modes are necessarily knitted and complementarily knotted. Only in this very carefully qualified sense and context may one say that medical practice should always be applied science and/or scientific research.55 I would suggest that the construction of fibromyalgia supports this view of the basis of medical (and, mutatis mutandis, nursing) experience and practice.

Conclusion

So, which are the moral conditions for the possibility of a science of the individual? How to develop the science of art of medicine?56 It does seem convenient to recall the two corresponding models or metaphorical sources of Kantian judgement: taste and perception. Iris Murdoch said beautifully that the mark of the moral agent is a just and loving gaze directed upon individual reality:57

The 2 arms of clinical judgement: ‘taste’ and perception

“The idea of a just and loving gaze directed upon individual reality. I believe this to be the characteristic and proper mark of the active moral agent”

The demands of clinical expertise and excellence depend on grafting the time-honoured clinical method with NBM and EBM, and so rebuild the Reflexive Clinical Medicine. Then the theoretical and practical dispute between Hippocratic traditions – clinical value-laden inscriptions, descriptions and prescriptions – against the hard philosophical and ideological Protagorean metrics, would be pragmatically solved. And resolved, responding to today's notorious epistemic pluralism. In the medical field, however, very interesting and difficult questions remain: why should Dr. Jekyll not try his pharmaka on himself?; how does that “master of truth” avoid being devoured by… Mr Hyde, by his own curiosity? How can he overcome the massive research anonymity and re-create a space for the realization of the Other in and at every clinically or research-oriented decision?58

Observing the clinical ethos being attacked and perverted by successive (medical and nursing) “governance” masters one does learn that, unless the clinical and the research teams work together with scrupulous consciousness and activate that forgotten inner Occam's moral razor – Cui bonum? – and expose publicly their own conflicts of interests… the patients' and the profession's losses will be irreversible. We all know how to be an excellent, devoted practitioner: “The secret of the care of the patient is in caring for the patient”,59 as told by Dr. Peabody, a Harvard physician, who wrote these words at the age of 35 while dying from cancer.

Appendix-1

On the Principle of indifference

The reductionist (and mechanicist) scientific imperative, and the homologous doxastic attitudes in clinical medicine, can be aptly defined as a curse, as the paradox of the indifference: (i) qua clinics, Medicine implies “the feeling” of the Other, of alterity, individuation and compression or

reduction of the indifference (that is philia and first person narrative); and (ii) qua research, Medicine does imply several metrics, error measurement, the “grammar” of probability, maximization of the indifference (null hypothesis, equipoise, randomization, double blinding, etc.), and so, it implies the occultation of the individual, and of the individuals, that is anonymity, samples, populations. Of course with this excision of the individuals goes also, necessarily, the amputation of the meanings. This is the curse and the power of Galilaic science. Still, the statistical proof is about hypothesis (or about differences, errors). What to say of the recent trend toward subjective or Bayesian statistics, faster and richer? Without dealing with this very pressing topic here, I want to give just one word on the ontological status of the “tsunami” of vital laboratorial tests and measurements which are continuously feeding the monitors and computers: an embarrass of richness seems unavoidable. According to modern social studies of science and to modern epistemology, there are two main questions60:

• (i) first question: about the objects/data gathering – from the perspective of the fundamentals, what about the status of the laboratorial data?;

• (ii) second question: on foundations – ethnomethodological and “grounded” analysis of bench practice do reveal foundational activities operating at the level of fixation of the scientific fact.

A few lessons are in order: the goodness, power and fascination of basic and clinical research and their benefits to Mankind are – generally speaking – not contested (at least by the Oslerian ex-physician and real patient or patient to be who writes these lines). (Its crescent merchantilizing deserves, however, enlightened independent criticism and close monitorization by concerned democratic institutions). Indeed, most of the diseases that affect mankind, from the common acute enteric viral infections to the rarer chronic myeloid leukaemia bcr-abl positive, are more or less complex stochastic events which should be faced simultaneously at several levels. In each concrete, special, singular case, what are the proper medical scale of “analysis”, the strategic level, the adequate ontology?; what is the appropriate complement analysis of top-down and bottom-up tactics?; what is the proper cut-off for each concrete condition, problem or situation? I believe that there is no blind, general and a priori answer, and that the clinically most urgent interrogation is this: do the clinical event, the patient's needs, the love of humanity still govern clinical (practice and teaching of) medicine and nursing?

Appendix-2

Marion's (1997, p. 13) definition of saturated or intensified phenomena: “(…) This paradox of the saturated phenomenon is excepted from the definition of the common phenomenon, because it frees itself from one of the essential traits of phenomenology according to Kant: relation. Every common-right phenomenon, according to Kantian principles, must inscribe itself in the regulated course of experience, hence of time, admitting in advance some relation with its precedents (be it a relation of substantial inherence, of causality, or of community between substances). The chair, instead of this, only refers to itself, in the undissociable unity between feeling and feeler; the chair refers to itself just as it affects itself. Consequently, the chair subtracts itself from any relation – my pain, my pleasure remain unique, incommunicable, irreplaceable – in an absoluteness regarding nothing, without bounds, without equal. Moreover, this absoluteness, virgin of any relations, constitutes precisely the privilege that enables it (the chair) to enclose me in my individuality. If the chair did not manage to absolve itself of all relations, it would not manage to accomplish what only the chair can accomplish – to devolve me to myself – in the double sense of assigning me my proper place and of making me feel its power there. (…)”.

Appendix-3

Narrative medicine aims to be a space of differentiation, a space of the realization of the subject – giving visibility and voice to the Other – with a plurality of stories and not just a phenomenology of the scarred body. Beyond that, NBM is today, probably, the via regia to explicit and objective “individuation” or “re-individuation” of the patient. It would be necessary another paper to test and qualify these affirmations with the alternative, still more opaque and inarticulate, mode of individuation, through (Michel Henry's) ipseitas, self-donation and insight, the social emotions and empathic affects:

Narrative-based Medicine (NBM): some characteristics

Narrating: schematizes, “fixes” affections, individuates.

Dissonance and surprise; sequence, plot, fabula

Dimensions of dramatization: actor, action, object, scene, instrument, temporality

Appendix-4

“(…) The relationships that develop in medicine, as it turns out, bear an uncanny resemblance to the relationships between tellers and listeners (…). What literary studies give medicine is that our intimate medical relationships occur in words. (…) Yes, doctors touch patients and do rather extraordinary physical things to them, but the textuality and not the physicality defines the relation. (…) In fact we are misled when we try to conceptualize medical relationships as if they were based on love, desire, power or commerce. They are based on the complex texts that are shared between doctor and patient, texts that encompass words, silences, physical findings, pictures, measurements of substances of the body, and appearances. (…)” (Charon, 2006, pp. 53f).