Schramme: Edmund Pellegrino’s philosophy of medicine

In his important contribution “Philosophy of Medicine: Problematic and Potential,” Edmund Pellegrino thoroughly discusses the possible relationships between medicine and philosophy. He categorizes these relations into three different types: Philosophy and medicine, philosophy in medicine, and philosophy of medicine.

Philosophy and medicine comprises the mutual considerations by medicine and philosophy of problems common to both (...). Some of the recurrent problems of philosophy — the mind-body debate; the meanings of perception, consciousness, language; the special or nonspecial character of chemical and physical laws in living things — are susceptible to this type of collaborative attack. (...) Philosophy in medicine refers to the application of the traditional tools of philosophy — critical reflection, dialectical reasoning, uncovering of value and purpose, or asking first-order questions — to some medically defined problem. The problems can range from the logic of medical thought to the epistemology of medical science as science, the problem of causality, the limitations of observation and experiment, and of course, the whole range of vexing issues in the active field of biomedical ethics. (...) When philosophy turns to the meaning of medicine as clinical practice and examines its conceptual foundations, its ideologies, its ethos, and the philosophical bases for medical ethics, then it becomes the philosophy of medicine. The questions examined by philosophy in medicine are then carried to the unique realm of the clinical encounter with a human being experiencing health, illness, neurosis, or psychosis, in a setting which involves intervention into his existence. The philosophy of medicine seeks explanations for what medicine is and ought to be (...) These three types of engagement are rarely separable in actual fact, and philosophers can, and do, engage in all three. We have dissected them free to underscore the central importance of the philosophy of medicine: the philosophical issues imbedded in the theory of medicine as a practical human activity. Ultimately, the more proximate issues dealt with by philosophy and medicine, and philosophy in medicine, must rest on the philosophy of medicine. (Pellegrino 1976, 19 ff.)

Pellegrino explicitly excludes biomedical ethics from philosophy of medicine. He also describes as an essential part of the philosophy of medicine a practical component, the clinical encounter. This practical element is especially important, according to Pellegrino, because it is its unique feature, in contrast to, say, biology. Medicine here has a set aim, in contrast to natural sciences, namely, health or healing of living beings. The personal relationship between doctor and patient in pursuing this aim turns medicine into a value-laden, a moral, activity. Hence, medicine cannot be reduced to other sciences, for instance, to a mix of biology and psychology (cf. Shaffer 1975). Pellegrino claims: “Medicine, then, is an activity whose essence appears to lie in the clinical event which demands that scientific and other knowledge be particularized in the lived reality of a particular human, for the purpose of attaining health or curing illness, through the direct manipulation of the body, and in a value-laden matrix. It is in this sense that medical [9] theory is a theory of practical reality and not just the theory of the sciences which contribute to it” (Pellegrino 1976, 17).

There are several issues that can be queried in this account of the philosophy of medicine. For instance, it can be queried whether cure of illness and promotion of health are really the essential or only goals of medicine. Relatedly, there is also a worry that Pellegrino has resolved an issue by stipulation that should be first clarified by a debate within philosophy of medicine: to determine the “nature” of medicine. It seems wrong to restrict philosophy of medicine to the practical realm of medicine by claiming the clinical encounter as the essence of medicine. To clarify what role the practice of medicine has in relation to the theory of medicine is a genuine task of the philosophy of medicine itself and should not be excluded by restricting the scope of the nature of medicine to the clinical setting.

Ten years later, Pellegrino revisited his three-partite distinction of the relationships between medicine and philosophy. Here, he advances a definition of the philosophy of medicine that does not rely on a particular interpretation of the essence of medicine from the outset, but sees a determination of such an interpretation as the outcome of doing philosophy of medicine. “The third mode of relationship, philosophy of medicine, concentrates on a philosophical inquiry into medicine-qua-medicine. It seeks to define the nature of medicine as medicine, to elaborate some general theory of medicine and medical activities.” (Pellegrino 1986, 10)

Later in the chapter, he gives a more substantial account of the distinctive problems discussed in philosophy of medicine:

Philosophy of medicine is more than philosophizing about the phenomena peculiar to medicine, i.e., philosophy in medicine. It seeks to understand and define the conceptual substrata of medical phenomena. Its agenda is a broad ranging one — it deals with such crucial notions as the ideas of health, illness, normality and abnormality, healing cure, care, suffering, and pain. What do these concepts embrace? What is the nature of medical diagnosis, clinical judgment and discovery? (...) Does the end of medicine modify the logic and the epistemology of clinical judgments? (...) What are the values that structure medicine? (...) Is health a value and in what sense? (...) Questions of this sort provide the agenda for the philosophy of medicine as a discipline. (Pellegrino 1986, 14 f.)

When reading this list of topics for the philosophy of medicine, it becomes less clear in what way it differs from philosophy in medicine. After all, philosophy in medicine has just been described as “philosophizing about the phenomena peculiar to medicine.” The key to Pellegrino’s understanding of the philosophy of medicine is that he believes in a distinctive nature of medicine, “medicine-qua-medicine,” that determines its agenda. This distinctive nature of medicine, for Pellegrino, is its practical focus with the related telos of health.

Philosophy of medicine makes the specific method and matter of medicine the subject of study by the method of philosophy. Philosophy of medicine seeks philosophical knowledge of medicine itself. It seeks to understand what medicine is and what sets it apart from other disciplines, and from philosophy, itself. (...) Medicine qua medicine comes into existence in the clinical encounter or in public health when the knowledge of the sciences basic to [10] medicine is employed for a specific end, i.e., for the cure, containment, amelioration, or prevention of human illness in individuals or in human societies. (...) Philosophy of medicine seeks to understand the nature and phenomena of the clinical encounter, i.e., the interaction between persons needing help of a specific kind relative to health and other persons who offer to help and are designated by society to help. (Pellegrino 1998, 326 f.)

In summary, for Pellegrino, philosophy of medicine is to be distinguished from other relationships between philosophy and medicine. For him, its focus is medicine as a distinctive discipline. On the one hand, he says that determining such nature of medicine is itself a task of philosophy of medicine; on the other hand, he repeatedly claims that indeed the distinctive feature of medicine is its practical nature, more specifically in the clinical encounter.