The Quest for Certainty
Medical rules have been invented to smooth out the real world; but the world won’t have it. Nature is untidy and unpredictable. We must learn to enjoy uncertainty and enjoy using our wonderful faculties of judgment. A physician and patient persisting in a quest for certainty, reaching for multiple tests and multiple specialists and every test and every specialist risks finding a spurious flaw that leads down another and another and another avenue of false hope, and the space for interpretation shrinks away until the tangle cannot be escaped.
“Don’t you see that the whole aim of Newspeak is to narrow the range of thought? In the end we shall make thoughtcrime literally impossible, because there will be no words in which to express it. Every concept that can ever be needed will be expressed by exactly one word, with its meaning rigidly defined and all its subsidiary meanings rubbed out and forgotten. Already … we’re not far from that point … Every year fewer and fewer words, and the range of consciousness always a little smaller…”
As Orwell wrote, we are already on our way to smaller consciousness, to a language unable to grasp or imagine the complexity of the human condition. The escape, whilst there is still time, is judgment. In an inspiring article entitled The place of judgment in medicine from 1994, James McCormick paints a picture of the ‘doctor’s doctor’ whose curriculum vitae was ‘not outstanding’ but who was valued by his colleagues, ‘not because of his learning and his skill, but because his actions were tempered by wise judgment’. It is the very quietness of this achievement that should make us take notice.
“The water in a vessel is sparkling, the water in the sea is dark.
The small truth has words which are clear; the great truth has great silence”.
Rabindraneth Tagore: Stray Birds 176
“Knowledge is proud that he knows so much; wisdom is humble that he knows no more.”
William Cowper: The Task (1785)
It is a more recent thinker that informs much of McCormick’s article: Theodore Fox, and in his famous lecture, The Purposes of Medicine, (1965) he included this sentence:
“Doctors, like other people are ‘hot for certainties in this our life’, and, like other people, they would welcome any commandment that could not be questioned and thus absolved them from painful decision.”
More from McCormick:
“Doctors, by a person’s decision to seek advice, are given a mandate to exercise judgment on that patient’s behalf. This, at least to some extent, flies against the popular movement to grant patients full autonomy and the right to share… There is a place for rules in medicine, rules which can only be broken in exceptional circumstances and which if ignored carry the possibility of grave harm… For the most part good rules are concerned with potentially life threatening situations… In a sense these are simple situations in which there can be no difference of opinion about the immediate necessities. Such simple situations are the exception and the notion that rules can be devised for medicine as a whole carries the danger of great harm.”
The place of judgment in medicine by James McCormick
“We don’t receive wisdom; we must discover it for ourselves after a journey that no one can take for us or spare us.”
And we don’t have to wait until we are as old as James Ward’s The Ancient Oak on the top page of this dimension. We are presented with opportunities every day of our life.
“No one ever told us we had to study our lives,
make or our lives a study, as if learning natural history
or music, that we should begin
with the simple exercises first
and slowly go on trying
the hard ones, practising till strength
and accuracy became one with the daring
to leap into transcendence, take a chance
of breaking down the wild arpeggio
or faulting the full sentence of the fugue.
– And in fact we can’t live like that: we take on
everything at once before we’ve even begun
to read or mark time, we’re forced to begin
in the midst of the hard movement,
the one already sounding as we are born.
From Transcendental Etude Adrienne Rich
Here are two young GP colleagues talking about wisdom:
Penny: I just think as a job we are relying an awful lot on our intuition and decision making that is not necessarily based on something that we have learnt in a book. As each day goes on I realise that actually … some things are just medical …
Eleanor: … and you can just move through …
Penny: … [ but many things are not, so ] it’s not a job that somebody who is just medically-minded could probably be satisfied with … and want to carry on doing. [later] They’re asking for advice, but it doesn’t come from textbooks whatever … [hesitantly] … it comes from … the advice they are seeking … I try to support and give, but often I can hear my dad talking, or my sister … I don’t think that’s a bad thing, so long as it’s not a prejudiced view … we learn wisdom from others.
So how can we help this learning of wisdom and the judgment enabled by it? We can do this by being self-caring and balanced in the way we live; so we are as much a member of the human community as we are the medical community.
“The need to relate the practice of medicine to the rest of the human world is unavoidable … When medicine is the only system of thought available to a doctor, when all available time and energy are spent on medicine, when the doctor is only an expert technical specialist then how can he or she become aware of the incompleteness and imperfection of medicine? Medicine must be seen in context, practised with wisdom.”
From Bruce Charlton, Holistic medicine or the humane doctor?
This challenge balancing is not new. The Classical Greek philosophers and poets were very well aware of the need for wisdom to combine both the hard technical and the soft feeling parts of humanity. Aristotle wrote that wisdom requires both Sophia and Phronesis. Sophia is theoretical knowledge (episteme) that is logically built up, teachable and sometimes equated to science. Phronesis is practical wisdom, related both to virtue and practical details. It includes techne, meaning a craft. So in Classical Greece, wisdom was a combination of knowledge (including universal truths) and practical, virtuous know-how.
This sort of journey towards wisdom and the balancing of very different kinds of knowing is beautifully described in Matthew Crawford’s book: The Case for Working with your Hands . Crawford was educated in physics, political philosophy and motorcycle engineering as a practical artform. This book is wonderfully inspiring. He is a testament to breadth of being and being Wise before being old!
An alternative, extended version of parts of this and the previous page is available HERE
To be continued ….