Different ways of Knowing

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Presented by Dr Tim Harlow at the Hospiscare Conference, Dugnity of Difference on the 5th November 2010.

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Different ways of Knowing

  1. 1. Caring in Devon
  2. 2. Caring in Devon The Culture of Science Different Ways of Knowing Dr Tim Harlow
  3. 3. Caring in Devon Today considered Culture in terms of faith, religion, belief • What about Science? • Is the dominant Western Scientific Paradigm relevant to End of Life Care? • Are there difficulties?
  4. 4. Caring in Devon Does this Matter? •Many of the people giving care at the end of life will fundamentally be scientists
  5. 5. Caring in Devon PARADIGM • “A typical example or pattern of something: a pattern or model: …a world view underlying the theories and methodology of a particular scientific subject.” (New Oxford Dictionary of English 1998)
  6. 6. Caring in Devon We are all In a Paradigm • To understand the Health Care System today, and why it might collide with different belief structures, we need to understand the underlying Paradigm
  7. 7. Caring in Devon The Scientific Method • Method of investigation involving observation and theory to test scientific hypotheses • eg-Tuberculosis caused by Mycobacterium Tuberculosis
  8. 8. Caring in Devon “All attempts to answer the question ‘What is man’ before 1859 are worthless and best discarded” • GG Simpson
  9. 9. Caring in Devon Great triumphs • Vaccination, Surgery, X-rays, Antibiotics, intensive care, dialysis • “Best scientific advice...medical science...gods in white coats...war against cancer” • Starting point of western medicine
  10. 10. Caring in Devon That’s it then? Well, no... 1- Science, like any culture is not a homogenous, uniform whole: actually subjective 2- Science cannot exist in a vacuum separate from society, from people, especially in matters of medicine
  11. 11. Caring in Devon PARADIGMS LIMIT, AND ENABLE OUR THOUGHT PROCESSES • We always know less than we think we do • Lavoisier –Genius- “ The idea that rocks can fall from the sky is ridiculous!”
  12. 12. Caring in Devon Ludwik Fleck (Polish doctor biologist 1930s) • Genesis and Development of a Scientific Fact “Thought Collectives” • Fleck noted the interest aroused by syphilis yet TB did vastly more damage • True creator of a new idea is not an individual but a thought collective
  13. 13. Caring in Devon “Thought Collectives” Where any “contradiction becomes unthinkable and unimaginable” -Flat Earth Science is a Thought Collective- where the ability to perceive is acquired only slowly “What we feel to be impossible is actually mere incongruence with our habitual thought style” Eg- Telepathy- Rupert Sheldrake
  14. 14. Caring in Devon Thomas Kuhn • ‘The Structure of Scientific Revolutions’ (leaning heavily on Fleck): Anomalies • Most of science is about making things fit into the paradigm • Anomalies – “Exceptions that prove the rule” are discarded or ignored –looked on as failures • Clearly vast amounts of knowledge that are within the paradigm –keep scientists busy for centuries
  15. 15. Caring in Devon ANOMALIES PRODUCE CHANGE Paradigm changes can be produced by collision with or awareness of anomalies This can be experimental –the earth moves round the sun- or theoretical –Relativity
  16. 16. Caring in Devon WHAT HAPPENS TO A PERSISTENT ANOMALY? Assuming it is so persistent as to be impossible to write off as a poor reflection of the experimenter there are 3 possibilities; 1-Normal science explains it- normal service resumed 2-The anomaly exists, but is left for future- better equipped- generations 3-A new Paradigm emerges and, after a battle, usurps the existing paradigm
  17. 17. Caring in Devon Kuhn states that the new paradigm replaces the old one • This is revolution- not just the cumulative effect of layers of knowledge • This is a moot point- when is it a revolution and when an evolution? • History and evolution appear to have direction, to be linear and cumulative. • This is only with hindsight- all much more piecemeal and haphazard at the time
  18. 18. Caring in Devon Shigehisa Kuriyama The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine (1999), • Compared Greek (became Western) paradigm with the Chinese. • Chinese took no notice of Muscles yet clearly described the “Mo” • Chinese- very advanced civilisation – astronomy, navigation, engineering.
  19. 19. Caring in Devon WHY IS THIS SO? • A lot to do with our being in a particular Paradigm, a thought collective, and the influence this has. • Thus we need to understand our own and other paradigms to allow us to understand much that is happening and give effective end of life care.
  20. 20. Caring in Devon TH Huxley 19th century • “It is the customary fate of new truths to begin as heresies and end as superstitions”.
  21. 21. Caring in Devon Max Planck •   “A new Scientific truth does not triumph by convincing it’s opponents and making them see the light, but rather because it’s opponents eventually die, and a new generation grows up that is familiar with it.”
  22. 22. Caring in Devon “ILLNESS” • Scientific and medical phenomenon- human being as a complex machine • Disease process- broken bone, damaged myocardium, tumour, deranged neurotransmitters (Wilber, K. Grace and Grit p40-52, Gateway 1991)
  23. 23. Caring in Devon “SICKNESS” • Construct of society, culture, family, personal journey • Changes over time- HIV attitude now wholly different from 1980s, Psychosis viewed as illness not weakness, Epilepsy was associated with Shamanism/prophesy, pain as purging or punishment
  24. 24. Caring in Devon Possible explanations of cancer- (illustrative not comprehensive) • 1-Fundamentlist religions -punishment • 2-New Age-lesson for spiritual growth • 3-Karma-harvest of past actions • 4-Psychological- repressed emotion causes cancer • 5-Gnostic- Illness as an illusion:spirit the reality • 6-Existential-without meaning • 7-Holistic-product of mind/body/spirit • 8-Buddhist- suffering inescapable part of existence • 9-Reductionist Scientific/biological-all specific causes not understood enough yet
  25. 25. Caring in Devon “Hurdles of significance” 2 dimensions “hurdles” of significance- • First- “is it real?” statistical significance • Second- “does it matter?” clinical significance • Third- “Personal significance” Takes account of patient’s suffering, style, circumstances and beliefs. Sweeney et al Lancet; 351 (9096): 134-136 1998 Jan 10
  26. 26. Caring in Devon Science meeting another paradigm Acupuncture • Western acupuncture- working on endorphins, gate theory pain, trigger points: essentially mechanistic and physical model • Traditional Chinese-using energy meridians, balance of scientifically inexplicable energies: entire system of medicine, feeling of 9 pulses at wrist
  27. 27. Caring in Devon Parallels -Religion and Paradigms • Dawkins sees Religion as enemy of reason • Locked in his Paradigm- only way to look at the world • “Can I dissect out these meridians?”
  28. 28. Caring in Devon Paradigms, including science (and Religions perhaps?) can be considered either as literal representations of truth, or perhaps more meaningfully as maps, as metaphors to help us explore the human condition
  29. 29. Caring in Devon How does it affect Healthcare workers? • Healthcare workers who consider and help patients’ spiritual needs have more job satisfaction. Cobb M, Robshaw, The Spiritual Challenge of Health Care. Churchill livingstone 1998
  30. 30. Caring in Devon • “I like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness.”(Broyard. Intoxicated by my illness: and othr writings on life and death. New York: Ballantine, 1992)
  31. 31. Caring in Devon Moment of highest reality? • Palliative Care: doctor and patient discuss “When is enough, enough?”. This will be the defining question for the next generation of doctorsKieran Sweeny, obituary BMJ: 2010; 340: C733

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