The Rise of Science and Conscience

by Ian Magrath

Sir James Frazer, in his pioneering work on magic, mythology and religion, has much to say on the thought processes of early human communities. In The Golden Bough, he refers to the "primitive" magical reasoning that led to a broad range of ritual practices that enable humans to survive in the face of odds weighted heavily in favor of the natural forces that threatened them. Primitive or not, and fallacious or not, the fruits of this formative era of human culture continue to have a remarkable influence on our lives. A second type of reasoning, which we may refer to as scientific, has played an increasingly dominant role in human society; there are few corners of the world that have not been touched by its practical application, even though most of the world's population has had little scientific training. It would be pointless to discuss the pros and cons of each type of reasoning since both are part of the human condition, although it is surely correct to state that in the absence of scientific reasoning, humans would not have evolved beyond the stage of hunter-gatherers. Yet scientific reasoning alone provides an insufficient basis for the management of human affairs, since it does not involve emotion, conscience or morality. We may, then, surmise that human society results from a compromise between these two thought processes, just as it also depends upon a compromise between the needs of the community and those of the individual. Throughout human history, these closely related dualities have vied for supremacy.

In medicine, the threads of scientific reason have existed since the beginning of time, although buried for much of human history under the weight of magical thinking, or by tomes of medical wisdom, sacred or otherwise, inherited from the past. Any hint of a departure from tradition has been given short shrift. Paracelsus, for example, who rejected the notion that medical knowledge must be garnered from ancient texts, was barred from the university and in 1528 lost his position as Physician to the city of Basle. His holistic approach to medicine was roundly rejected in Europe for at least 400 years. In the 21st century, science is, at last, taking an increasingly prominent role as the basis for medical practice, but the hard edges of science must be blunted by compassion. For at its heart, it derives from individualism - that aspect of "Western civilization" which surged to center stage in the Renaissance era. But in this same era private conscience also emerged, leading to passionate discussions of the conflicting interests of individuals and society, and so to human liberty and human rights. Such ideas were alien to the primitive communities described by Frazer, who considered the individual as a representative rather than a member of society.

It is the duty of the physician to promote and safeguard the health of the people. The physician's knowledge and conscience are dedicated to the fulfillment of this duty. —Declaration of Helsinki, 2000

Killing and Eating Gods
In his chapter "Eating the God," Frazer describes how among the Acagchemem native American Indians of California, "The notion of the life of a species as distinct from that of an individual, easy and obvious as it seems to us, appears to be one which (they) ....cannot grasp." He describes how the life of a species of animal cannot be conceived of as "anything other than an individual life, and therefore exposed to the same dangers and calamities which menace and finally destroy the life of the individual." The Acagchemem worshiped the wild buzzard, and every year, at the feast of Panes, sacrificed one of these birds in order to preserve the species - for according to their rationale, killing a young healthy animal liberated the life force, which would then be reborn in another, equally vigorous bird. Not to kill, at intervals, one of these sacred animals at the peak of its health would result in the gradual loss of the vitality of the entire species, and eventually its extinction - with serious consequences for those who held it sacred. When the sacred animal or plant was also a critical dietary element (e.g., corn, or the bison) the link between the animals' well-being and the salvation of the community was direct.

Sometimes the vitality of the people and their world were closely allied to their King, who usually also enjoyed divine status. His enfeeblement and death must therefore be avoided at all costs - by killing him whilst still in his prime, in order to ensure that his still vigorous soul would be passed on to a younger successor. Plants, animals, or people were often used as surrogates, particularly as gods became more supernatural. Frazer records that "Twice a year, in May and December, an image of the great Mexican god Huitzilopochtli or Vitzilipuztli was made of dough, then broken in pieces, and solemnly eaten by his worshippers....." The Aztecs believed that by consecrating bread their priests could turn it into the very body of their god, "so that all who thereupon partook of the consecrated bread entered into a mystic communion with the deity by receiving a portion of his divine substance into themselves." In this, the Aztecs were entirely at one with their Spanish conquerors.

Science versus Tradition and Magic
Frazer's enormous scholarship and accumulation of volumes of evidence from all over the world had widespread implications for psychology, anthropology, mythology and religion. The primacy of magical thinking in meeting the needs of the community with respect to survival, accounts for the slow emergence of science, which required a degree of individual genius on the one hand, and tolerance by dominant societal forces (invariably threatened by new ideas) on the other. Moreover, in the absence of logical precepts, glaring contradictions bore little weight, and thus had no ability to undermine the magical basis of society. Predictably, the rise of science has been associated with legions of detractors, or overt opponents, and even today, there are many who argue against it (The Flight from Science and Reason, Ann NY Acad. Sci, vol. 774).

In the practice of medicine, the inability (or unwillingness) to perceive how knowledge based on clinical trials involving many participants can be applied in the service of the individual patient has constantly hindered the assimilation of the scientific method. This attitude, part of the backlash against science, has similar origins - discomfort with novelty, a perceived challenge to the supremacy of professional leadership, and, to a degree, an aversion to the need to acquire new knowledge. According to Murray Enkin's foreword in Alejandro Jadad's excellent book, Randomized Clinical Trials, practicing physicians confronted by the initial stirring of clinical science "were unwilling to hold their decisions in abeyance till their therapies received numerical approbation, nor were they prepared to discard therapies validated by both tradition and their own experience on account of somebody else's numbers."

Enkin describes how, in 1836, an article by the Frenchman PDA Louis in the American Journal of Medical Sciences, hailed by the editor as "the first formal exposition of the results of the only true method of investigation in regard to the therapeutic value of remedial agents," caused a storm of criticism. Comments such as "The physician called to treat a sick man is not an actuary advising a company to accept or deny risks, but someone who must deal with a specific individual at a vulnerable moment" and "Averages could not help and might even confuse the practicing physician as he struggles to apply general rules to a specific case." Louis' study, by the way, was on the role of blood letting in the treatment of pneumonia, a method widely accepted at the time, but which he clearly demonstrated to be useless. To be fair, the lack of understanding of the nature of disease must have had a lot to do with the inability of doctors to comprehend the value of clinical trials. Today, we must be equally concerned with the difficulty patients have in understanding the need for clinical studies, particularly randomized trials. This problem is frequently aided and abetted by the culturally-instilled presumption of the physician's omniscience, although doctors too, must bear some responsibility in this regard, for their frequent unwillingness to admit their ignorance.

Clinical scientists, of course, know that evidence from clinical trials rarely provides a precise ability to predict the outcome of a treatment or preventive method in a particular individual, but rather provides a reasonably accurate assessment of the likelihood that benefit or harm will accrue. It does have the ability to predict, within statistically defined limits, the outcome in a reasonably sized cohort or group of patients, assuming that the cohort in question is similarly structured, in terms of the patient population, to the cohort that participated in the clinical trial.

James Lind and Scurvy
The first documented controlled clinical trial of modern times is believed to be that of James Lind, a ship's doctor in the Royal Navy. Lind performed a study whilst at sea, which involved 12 sailors with scurvy (a disease caused by deficiency of vitamin C) and the use of six different remedies applied for two weeks. The many study arms related to the many traditional nostrums that needed to be refuted. He demonstrated the therapeutic effect of two oranges and a lemon given daily and reported his findings in A Treatise on Scurvy published six years after the trial (1747). Lind also provided considerable evidence that citrus fruits could both cure scurvy and prevent it. Yet it was not until 1795, approximately 50 years later, that the Royal Navy introduced citrus fruits or juices into the diet of British sailors, earning for them the nickname of "limeys" but greatly increasing their efficiency as a fighting force. This delay might be thought to have been unconscionable and even short-sighted - primarily in terms of the human suffering and death it caused, but also on account of its profoundly negative effect on the Royal Navy, the British economy and the ongoing colonization of the New World. Even today, however, the Institute of Medicine in Washington has estimated that the results of clinical trials take, on average, 17 years to become part of accepted medical practice! Controlling the treatment administered by health service providers in a non-research setting remains difficult, but the Royal Navy could have decreed that sailors should be protected against scurvy in the manner shown by Lind to be effective. Why did it take so long? While many factors may have played a role, the lack of understanding of the scientific method is likely to be an important one. But further insight may be gained by an experiment, also described in Lind's book, of another "clinical trial," carried out in the previous century, this time on scurvy developing in the course of lengthy sojourns in inhospitable places with no access to fruits and vegetables.

In medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society. —Declaration of Helsinki, 2000

As reported by Lind: "Whereas the first adventurers to that part of the world, who wintered in the same places, were almost all destroyed by the scurvy (1619 and 1631) … a set of sailors consisting of seven men, was left two winters successively, in the years 1633 and 1634, at Greenland and Spitzbergen, by way of experiment, but every man of them next spring was found to have died of the scurvy." Methods recommended to these luckless sailors "for preservation" included purging, anti-scorbutic potions and brandy, although these "infallibly increased the malady… and hastened their unhappy end." There could have been little thought for the rights of the sailors, nor, indeed, is there much evidence of concern for their suffering. Perhaps even more disturbing is the lack of any hint that the experiments might have been considered highly unethical. It seems as though the lot of these unfortunate men had been cast by their lowly status, rather than by the decision to perform such an ill-conceived experiment. Even the well-intentioned may have blind spots where cultural mores and received attitudes obscure principles that may, in another culture, time or place, appear glaringly obvious.

Dan Michel of Northgate
In 1340, an obscure Kentish monk, Dan Michel, wrote a book entitled Ayenbite of Inwyt. Michel's work was a rather poor English translation of an earlier French treatise, commissioned by Philip the Bold, on all known vices and virtues. Presumably, the title, which refers to the repeated gnawing (remorse) of inner knowledge (wit), implies that conscience, and the psychological pain engendered by ignoring it, are the determinants of moral behavior. Science, of course, and knowledge obtained by the scientific method, can be put to pragmatic use for good or evil. In this respect, scientific knowledge differs from received knowledge based on faith rather than evidence. For faith can be used only as inspiration or justification rather than a springboard for technical progress. Belief in a deity, it would appear, is insufficient to allow the creation of machines capable of flying across the Atlantic, reaching the moon, or raining high explosives on a perceived enemy - although it may be used to foster all of these activities. Thus it is that science, and only science, can advance the practice of medicine - by identifying the causal factors and mechanisms of disease, thus creating the opportunity to prevent them, by classifying diseases, thereby creating a basis for diagnosis and treatment, and by systematically identifying chemical, biological and physical methods of ameliorating or curing disease.
But science, born of individualism, is not enough. While the primary purpose of medicine is to relieve human suffering, there are many who make their livelihoods from its practice, with the consequent inevitability that their individual interests may on occasion be put before those of the patient. Multiple safeguards are necessary to ensure that the patients' interests (including their psychological well-being) are protected, particularly since patients are usually unable to assess the appropriateness and quality of care. Similar considerations apply in the sphere of public health. Ultimately, where risks are not perceived by the public, the only reassurance that the science of medicine is subservient to the general good, and that it is practiced with responsibility and compassion, is conscience - in part, the conscience of corporations and individuals involved in health care, and in part, the conscience of regulatory bodies. Regulations pertaining to clinical research are, in part, a codification of the consciences of thoughtful persons concerned about patients (and sometimes, lawsuits!), but their effectiveness is dependent upon the individual consciences of those involved at all levels of the delivery of health care. Regulations may be adequate or not, enforced or not, and obeyed or not. Moreover, the provision of medical care is minimally regulated (at least with respect to quality) at the point of service.

In 1758, Richard Price, a preacher and moral philosopher, published A Review of the Principle Questions in Morals, in which he argued that morality is an inherent characteristic of actions, and that good and evil could be distinguished entirely by reason, without the help of any "moral sense" or appeal to sentiment. Some 250 years later, we can safely conclude that either reason has not prevailed, or that Price was wrong. The atrocities that litter the history of mankind, instigated with the aid of scientific discoveries, seemed perfectly reasonable to their perpetrators, if not to others. One might conclude that a reversion to the tenets of magical thinking, and the preservation and promotion of "our community," however defined, had much to do with swamping the prick of the ayenbite of inwyt. Science does not beget conscience, but it surely needs it.

The year 1758 also saw the publication of the tenth edition of Linnaeus' work System Naturae, in which the Swedish naturalist classified humans, giving them the epithet Homo sapiens (wise man). He was presumably referring to the ability to reason - which unfortunately is not at all the same thing as wisdom. Science and conscience are combined in the context of clinical research, such that here, we hope, wisdom generally prevails. An expression of the relevant aspect of conscience may be found in the Declaration of Helsinki, a document that has become something of a sacred text for clinical investigators. So it should be, although its contents must not become frozen and allowed to whither with age. Instead, it should be subject to periodic revitalization. Le roi est mort. Vive le roi!