Increasing medical dilemmas

Medical research promoting technological examinations and treatments increasingly influences general practice, creating and exacerbating conflicts that can be difficult to handle. Such technologies imply improved prognoses for some, but at the same time a growing number of risk diagnoses narrow the limits for normality, causing stress, dissatisfaction and ethical dilemmas in general practitioner's (GP) consultations.1 9 10 Guidelines, incentives and targets promoting higher biomedical standards may improve practice performance, but tend to undermine the traditional strength of general practice—the focus on dialogue and relationship building.11 12 Medicine seems to become more technologically competent, but may at the same time undervalue and dismiss the subjective experiences of health and health resources.13–15 Meanwhile, large numbers of people become ill with complex diseases, such as chronic fatigue or pain syndromes, which prevailing medical models fail to understand.4 15–17 Not only patients, but also doctors, may experience estrangement and health impairment.4 10 18

The conflicts outlined above have to be handled by individual GPs, who become responsible for interpreting science in a way that gives meaning and hope to the patient.11 16 Politicians are held responsible for the broader social and ethical assessment of medical science and the proper use of economic resources.4

While holding potential for improved practice, the development outlined above also carries inherent conflicts and dilemmas. Increased demands to diagnose, prevent and cure increase the costs.18 Other side-effects have been discussed, for example in terms of medicalisation, increased risk of harming and growing inequalities in health care.13 18 19 GPs, working at the crossroads between health care as a medical-technological and as a humanistic enterprise, are particularly exposed to conflicts arising from this development.1 2 20 21

Science has direction—and creates reality

A common metaphor for science is a cone of light illuminating an increasing part of a dark map. In this image of science—delineated and dismantled by Thomas Kuhn already in 1962—the scientist has no personal location, and is invisible, signifying objectivity and scientific freedom.5 Even if the scientist always is a person with a social, cultural and political identity, the scientific method is held to cleanse science of ‘external’ or ‘non-epistemic’ values.3 Thus, within this picture, scientific development is both neutral (in terms of its objectivity), good in itself (in terms of utility), and is expected to lead to continuous social progress (Figure 1).3 5 The most important consequence of this ‘functional myth’ is that the scientific community cannot be held responsible for what it simply ‘uncovers’.3 8 Therefore, the scientist has no moral responsibility other than that prescribed by norms of scientific honesty and methodology and traditional medical ethics such as embodied in the Declaration of Helsinki. We believe this concept still holds sway within the scientific community in spite of accumulating research showing the complex entanglements of economics, politics and culture with science.3 4 6

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Figure 1

A functional myth of medical scientific development. Reproduced with permission of Marie Sterte.

Sponsors of research budgets have huge influence on what is investigated, ie, on the direction of ‘the cone of light’. By funding academic research, the pharmaceutical industry has increased its impact on the design, evaluation and reporting of medical research.22 23 Among the most frequently cited medical articles, the proportion funded by the industry has increased during the past few decades.22 The same industry influences what is considered a disease, and which risks and diseases should be subject to medical attention.23 There is also cultural influence. Most influential research has affiliation in developed countries, above all the USA.22 Research from the west is attributed international significance, whereas research from non-industrial countries tends to be seen as local and mainly illustrating the influence of culture.24 The thinker, Michel Foucault, introduced the concept ‘power-knowledge’, rendering any analysis inadequate that treated power and knowledge as separable phenomena.25

The biomedical model and idea of specific aetiology, together with a pressure on researchers to produce results that are readily applicable, favour simplified explanations, followed by drug therapy or other technologically based interventions.4 26 Despite the inability of this model to meet challenges raised by modern research concerning causation, other directions are relatively neglected, leading to the production of ‘more of the same knowledge’ in many fields.4 26 This affects society's understanding of what is counted as a disease or as ‘at-risk’ status, and what is considered as cause, prevention and cure. It also affects people's perceptions of their own bodies and the world around them.1–4 9

Although mainstream medical science often presents itself as value free, on a larger scale European political institutions are beginning to question the detached view maintained by the scientific community, and ask for broader input under the label of governance of science. This applies particularly to ‘front line sciences’ such as biotechnology and the nanosciences. For example, the European Commission has produced a code of conduct for responsible nanosciences and nanotechnologies, in which the responsibility for sustainability, precaution and meaningfulness of research has been laid on the research community.27

Situated knowledges—a useful concept?

The image of the scientist neutrally uncovering the secrets of nature was described as the ‘God-trick’ by the biologist and philosopher of science Donna Haraway, likening it to a gaze that ‘sees everything from nowhere’.8 How then, can the self-understanding of science be informed? What new concepts could be used for this purpose? Haraway proposes the concept of ‘situated knowledges’ against that of ‘objectivity’. ‘Situated knowledges’ elucidate the limits and partiality of scientific knowledge, arguing that knowledge must be interpreted in relation to the context in which it is created. At the same time, the concept recognises the strengths that knowledge created from a particular perspective may possess. When scientists declare and reflect on their ‘situatedness’, it allows different findings and other forms of knowledge to be considered, opening up more fundamental scientific and public debate.6–8

Method for meta-reflection

As knowledge is situated, the context should be exposed to structured exploration. A method designed for this purpose has been further developed during seminars organised by the Philosophical Polyclinic in Bergen, Norway (http://www.uib.no/isf/filpol/). It also forms an integral part of the training component for PhD students at several faculties at the University of Bergen, as delivered by that university's Centre for the Study of the Sciences and Humanities. The method covers the entire research process, divided into three parts. The initiation, design and planning of a study are called ‘upstream elements’, and include prerequisites, assumptions and previous knowledge. The ‘midstream elements’ concern the execution of the study. The final part, concerning the potential consequences of the study—to individuals, health care and to society—is termed ‘downstream elements’. The idea is to elicit elements in each part relevant to the ethical, social and political aspects of the research.