Science from our hearts and minds … with eyes wide open

Centuries ago a small group of brave and brilliant men ushered in our first Age of Enlightenment. They were an unusual breed, combining a strong faith in a higher power with an equally strong belief in the human ability to observe and reason. They worked with the evidence of their senses, subjecting these observations to the crucible of rational thought and the conviction of faith. When their work appeared to threaten religious dogma, René Descartes, one of their leaders in the fields of philosophy, natural sciences and medicine, negotiated a pivotal deal with the Pope. His compromise – dualism – split people into mind and spirit (the explicit domain of the Church) and a physical body (of legitimate concern for human science). The resulting explosion of knowledge led to the wide-open world of secular science we know today, and ultimately freed faith from the hegemony of Rome.

Unfortunately, this compromise was subject to the law of unintended consequences. While it freed us up to think for ourselves, the separation of mind and heart also put us at risk of thinking only for ourselves. Over the years this has contributed to systems of medical care that worship a posture of rational detachment and research that is all too often narrow, pragmatic, overly clever and highly susceptible to corruption by economic motives. We developed the rigorous model of a randomised, double-blind, placebo-controlled trial, and then collectively anointed this model as the only valid methodology for testing hypotheses and producing data we call scientific. We run the risk of turning our gold standard into a golden calf. How often do scientists now think to ask questions that cannot be answered using this somewhat narrow model? We may have forgotten that an epistemology is a choice, that we made such a choice and that we might retain the right to tailor an epistemology to the nature of the question(s) we want to ask.

It is easy to lose touch with why it was so important to ‘know’ in the first place. Is it more important to understand 85% of something that is really important or to understand 99% of something that may be trivial? We forget that the guiding principles of medical science spring from the interaction of healer and patient, not the NIH 5-year strategic plan. The big questions, the ones that lead to really important new ways of understanding, unfold gradually (and then sometimes in an instant) to those courageous enough to ask them, patient enough to watch and ponder in the face of something they do not yet understand, and humble enough to be a witness to ‘miracles.’ In short, asking these kinds of questions demands that we constantly straddle the division between clinical medicine and research. The first presents us with a never-ending stream of questions, and the second provides the tools to answer some of those questions and thus move science forward.

In our Cartesian universe the light of the intellect can be blinding. We are easily seduced by the facile elegance of linear causalities, logical certainties and the pleasures found in knowing. We run the risk of forgetting that the linear logic of the mind and the linear logic of economic reward are often quite similar, and that it is the logic of the heart that is different. It is the logic of the heart that keeps us focused on what is really important, that points ‘due north’ on our moral compass and that keeps us from drifting completely into a world in which the intellect rules to the exclusion of the heart, where shareholders are more important than patients and money trumps all.

The tradition of medical research, which began with clinician-researchers searching for answers to give their patients, a science born and raised in the crucible of the clinic, has lost its way and become something else entirely. We have only to look at pharmaceutical drug development and delivery, a discipline that was born to serve the clinician, to see where our current approach has left us. The history of single-molecule drug development is one in which researchers made monumental discoveries in the world of antibiotics and analgesics. They gave clinicians powerful tools for treating disease and easing pain. But this drug model then appeared to hit a wall, demonstrating very little real ability to deal with the complex chronic illnesses on which the USA alone currently spends approximately US$700 to US$800 billion annually. Rather than confront the reality of their drug model’s relative lack of efficacy, Western pharmaceutical manufacturers chose to reframe the dialogue. Now we somehow find ourselves talking about ‘disease management’ where we used to talk about cures, and the industry has moved into the production of ‘lifestyle’ drugs.

Finally they began to sell us the diseases for which they also wish to sell us drugs. We have attention deficit/hyperactivity disorders where we used to have little boys, and situational anxiety where we used to have shyness. We have colourful adverts in glossy magazines aimed at consumers that pitch the desirability of drugs, the implications of which they cannot begin to understand. Each drug prescribed by their physician (often unwitting to a patient’s existing prescriptions) creates its own set of iatrogenic effects for which more drugs must then be prescribed, and so on in a truly dismal spiral. Thus in the mid-1990s the USA achieved an ‘average Medicare type patient,’ one who presented with an average of 4.3 chronic illnesses and took 15–18 prescription medications in their lifetime. The costs of drug regimens like this have left elderly patients splitting pills and skipping meals just to pay the rent.

Pharmaceutical manufacturers follow the logic of the intellect and the logic of money. They protect their economic model by marketing aggressively to consumers, ‘investing’ in politicians and pursuing an ongoing process of industry consolidation. Meanwhile those of us who prefer to work from both the logic of the head and the heart do so at considerable disadvantage. Clinicians struggle to assist patients to heal in the shadow of a for-profit medico–industrial machine that knows neither bounds nor shame, and researchers find themselves caught between competing ‘realities’ with no clear path from one to the other.

During the classical age of the clinician-researcher we used to think in terms of the patient’s needs and which needs of the many were yet unmet. That clinician-researcher worked from that base of unmet need through a research issue to a product (or service) that would be useful to both patients and the clinician. Our current drug development/delivery system, on the other hand, has tipped this historical triangle upside down. They choose a potential drug candidate from a pool of possibilities, and then work its development forward to the largest possible market. The clinician-researcher determined the size of a potential need in one of two possible models: either there was a small group of people with an enormous need or a much larger group of people with a less urgent need. Potential profit was never part of the equation. While the clinician-researcher sought a cure, drug companies pursue a model of symptom suppression and a ‘customer for life.’

The job in front of us now is to return to the circle that came apart in our first Age of Enlightenment, repair it and reconnect the world of intellectual discovery to the heart of healing. Our best hope for this may lie in Europe and Asia, societies in which the clinician-researcher is not yet an endangered species. Such ‘multilingual’ scientists can be proud of their heritage and their potential to reframe this discussion. It is no surprise that the most innovative new drugs of the last decade came out of Europe, and some of the most interesting botanical research is now being funded by Taiwan and Hong Kong interests. In the USA the integrative medicine phenomenon makes it very clear where patients believe they find exceptional care. It is time to celebrate the clinician-researchers who lead these fields of inquiry. They represent medicine’s best future – a medicine in which head and heart are connected in the service of both patients and science. And when successful, not only might we restore the proper balance between service and commerce, but also usher in our own second Age of Enlightenment.