The value of Dialectic

The value of Dialectic

Ronald W. Dworkin

As the saying goes, the practice of anesthesia is ninety percent sheer boredom and ten percent sheer panic. I once watched a droplet (a.k.a. “snot”) dangling from the nose of my sleeping patient as he lay face down, his head jutting out past the edge of the operating table. As ludicrous as it may sound, I waited anxiously for an hour to see whether the droplet would finally fall to the floor or hold out a little longer against gravity. Most of anesthesia practice is composed of such dull interludes.
One of the purposes of the medical humanities field is to make doctors working in the trenches think more broadly. Within the field, the intellectual’s role is to oversee medical practice and look on as a connoisseur who explains to doctors the beauty and deep meaning of it all. The direction of influence is presumably one way, as run-of-the-mill doctors are thought to have little to offer the humanities about how to think about life. Indeed, most medical humanities departments are staffed with very few physician faculty and sometimes none at all.
This is shortsighted. Run-of-the-mill doctors are philosophical—more than even they know. People take health as a matter of course; it is the background that merges with the general well-being of life. Sic-kness, on the other hand, p-ushes itself forward as an alien, scaring people, and arousing in both doctors a-nd patients a multitude of soul-searchings and contradictory feelings. This is fertile ground for philosophizing.
Doctors have their foundation of philosophical knowledge in life lived. This is their source of useful advice for intellectuals on the art of thinking.
The Value of Experience
When I first learned to give spinal anesthesia for caesarian sections, I gave everyone the same dose: 1.4 cc of a drug called Mar-caine. As I did more cases and encountered complications, I learned to vary my doses depending on the p-atient weight, height, and so on. So refined became my system that by the end of my career my doses ra-nged from 0.7 cc to 1.7 cc, varying by 0.05 cc increments, depending on the situation.
All this is standard em-piricism and inductive reasoning, where observed ex-perience influences the co-urse of action. Yet doctors are not blind. They know the limits of such reasoni-ng. In popular parlance, th-ey know all about Black S-wans. But for doctors, there is no alternative. To give s-pinal anesthesia for caesarian sections, a dose of anesthetic must be given, somewhere between 0.7 and 1.7 cc. But the anesthesiologist never knows for sure the p-recise amount that will gu-arantee a good outcome in any given case. The unexpected can always happen.
Because they deal with people on paper more than with real people, intellectuals in the humanities can refine their thoughts slowly, based on experience, as doctors do, or they can ma-ke enormous mental leaps. Doctors typically seek memories of the past; they draw on previous cases for guidance. Intellectuals do the same, but they also look at life through the lens of theory, allowing them to imagine some wonderful future and emancipation from the ways of the past. Doctors deal with matters of life; intellectuals can discover a new style of life itself, including radical new ways of living.
The two ways of thinking produce two different kinds of personalities. With a foot in both camps, I have seen both kinds, and while the former may be limited, the latter invites trouble.
Doctors often begin their careers in chaos and high spirits. They imagine revolutionizing medicine and saving the world. Gradually they see the limits of what they can accomplish. They grow more sober-minded and methodical. Intellectu-ally speaking, by age 35 many of them take on a bourgeois existence. Their style of medical practice is occasionally informed by new impressions, but much is set in stone, and while s-ome transformation is still possible, it always occurs alongside stability. Their sense of order heightens an-d reaches a peak at the end of their careers. At its best, their way of thinking produces someone with patient wisdom and a bright, alert, critical sagacity.
Intellectuals sometimes move in the opposite direction. They set out at old age. Before they enter the academy, many of them are conservative in a psychological sense; a crude understanding of human nature gleaned from childhood gives them a sense of order. Under the influence of theory and without the usual restraining influences of daily life, they grow more overheated, more impatient, more vehement, and more revolutionary. Their sense of chaos sometimes reaches a peak at the end of their careers—the very opposite of physicians. At its best, their way of thinking preserves a capacity for radical transformation; while many doctors can only be enriched, intellectuals can also be renewed. But their way of thinking can also lead to ferocious idealism, unreality, and extremism.
The advice of doctors to intellectuals is to remember to look at each life event as something stand-alone. In literature, for example, many novels talk about love. Rather than absorb the different versions of love into some general theory about love, one ought to penetrate into the labyrinth of the human heart and dissect love in 0.05 cc increments, so to speak. Respect each variation as illuminating in its own right. Such is a useful habit to cultivate before venturing into real life, as theory tends to over-generalize, while also forcing people to live in the word, sometimes leading to a compassionless severity.
Like the best physician, the best intellectual is a keen-sighted chronicler of the human condition, knowledgeable but humble, aware that the study of life is an eternal struggle, never an end, always a relentless beginning—in the case of romantic novels, studying one love affair at a time. Be cautious in the natural urge to reduce events to some least common denominator, while remaining open to the new event that surprises.
The Value of Dialectic
All doctors learn the word iatrogenic. And they learn to fear it. The word refers to patient injury arising from physician error or negligence. But doctors know the word covers more than just that. Almost every medical maneuver comes with the risk of some complication. Instead of benefiting patients, doctors know they may end up hurting them by accident.
The notion leads to an odd way of thinking where one and the same brain believes something and yet does not believe something. For example, during anesthesia, when I give the drug succinylcholine to break a vocal cord spasm to help a patient breathe, I am constantly aware that I might not be able to breathe for the patient after all, and that instead of helping, the temporary paralysis induced by the drug might cause the patient to suffocate. As I in-ject the medicine, I almost forget the good reason for doing so and what I had intended. This kind of doubled thinking suggests a total division of consciousness, a fading in and out of brain functions, as if playing a game against oneself. The whole notion seems absurd, or at the very least a paradox, as when trying to jump over your own shadow.
This way of thinking has a basis in philosophy, called dialectics. A problem exists requiring a solution. This is called the thesis. Then comes the complication, an unwanted event. This is called the antithesis. Born out of these two phenomena is a third force, the synthesis, which takes into account both the original problem and the complication, and solves everything. But the synthesis generates its own complication, its own antithesis, requiring a solution. And so it goes, on and on. It is often how medical practice proceeds.
Inexperienced doctors often forget this. Modern medicine is allopathic medicine where problems are treated with their opposite. An acid stomach is treated with alkali. A high blood pressure is purposely lowered. Problem solved. But experienced doctors know better. A host of new problems can arise with treatment, some of which cannot even be foreseen. Too much alkali, for example, can lead to poor digestion, while too low blood pressure can cause a heart attack or stroke. These new problems demand new solutions, which then lead to more problems. This is the origin of the doctor’s divided consciousness.
The very essence of the dialectical process helps doctors become better doctors. Today’s success becomes tomorrow’s complication. Success reassures. Complication disturbs. Yet it is a complication that prods a doctor to refine his or her approach, or to try a different one altogether. The same may be said about medical science generally. Eternal complications are the pledge of eternal movement forward, of inventing a new and better approach.
Social scientists, especially economists, tend to think dialectically. They offer solutions to social problems, while also recognizing that those solutions may create new problems. The more ideological or partisan social scientists are, the harder it is for them to think dialectically and the more risk they pose to society. They believe their solution is the best and final one, that no new problems will arise going forward, and that anyone who says otherwise is a heretic.
Because intellectuals in the humanities often have no particular scientific or social science expertise, those who expound on public policy tend to do so purely as ideologues or partisans. Hence the old saying: An intellectual is someone who happily comments generally on every issue, but with no particular knowledge of any issue. This is not wrong. In a democracy, everyone has a right to her opinion. But not only do ideologues fail to see that their solutions will likely produce new problems (as all solutions do), they also tend to condemn those who do see.
Doctors usually feel ambivalent toward heretics. Like most people, they dislike those who threaten to force them out of their comfortable rut. But they also know that heretics keep medical science alive. Without heretics, medical science would sink into the earth and fail to move ahead.
Ideologues and partisans feel this ambivalence less. Without dialectical thinking, they believe in a last number, a finite universe. This is why their idea, no matter how brilliant, revolutionary, or good-willed, often turns boorish and anti-intellectual when it triumphs, as no further debate is allowed. Such hatred of freethinking is the surest sign of anti-intellectualism.
There is irony here. Politically speaking, medicine has reactionary content. Getting your appendix out will not change society. Through an over-reliance on inductive reasoning and case experience, doctors are also reactionary in how they think. But medicine itself has a revolutionary form. The dialectical proce-ss drives change. In internal medicine, for example, therapies often change every year. In my own field of anesthesiology, big changes come more episodically—typically once a generation—but when they do come they change everything, and very abruptly. An example is the introduction of carbon dioxide and oxygen saturation monitors in operating rooms during the 1980s. Constant inspection of a patient under general anesthesia, mandatory for decades, fell by the wayside almost overnight.
In contrast, the humanities have revolutionary content. Whole new ways of li-ving are promulgated. New theories of existence are proclaimed. But without the dialectical process, the humanities take on a reactionary form. The ideas qu-ickly become philistinism.
Doctors’ advice to intellectuals is to start thinking dialectically again. When proposing a policy to improve society, remember that some negative consequence will undoubtedly occur, so lessen your arrogance and strengthen your vigilance for what might come.
The Value of Practice
Another word that doctors learn early on in their training is idiopathic. The word refers to a disease of unknown origin. For doctors the word is exciting but also unsettling. It means there is still a frontier with a bit of nature lying beyond their control waiting to be discovered and civilized. Yet it also means there exists a world beyond scientific explanation, a kingdom of darkness, that attests to doctors’ helplessness and weakness.
The very existence of idiopathic diseases sometimes causes doctors to live between two ages. Their minds are half-modern and half-medieval. When discussing the diseases they do know the causes of, they speak matter-of-factly abo-ut the scientific order of th-ings. But when they conjecture on the causes of idiopathic diseases in ways that later prove to be as absurd as using a horoscope, they seem like superstitious triflers. At such moments it’s as if both astronomy and astrology enjoyed a place in medicine, and were given equal values.
Some idiopathic diseases are called syndromes. They are known only as clusters of symptoms, and not by their origin. Many syndromes are named after their discoverers—just as new territories beyond the frontier were once named after theirs. In medical practice, there also exist a number of small, discrete truths called pearls. These are rules-of-thumb that have no explanation, but which are nevertheless useful pieces of knowledge.
The observation that an elderly woman will ignore fixing her hair only when she is in extremis, necessitating emergency action, is a pearl. In anesthesiology the observation that big, strapping young men are usually the ones who faint when approached with a tiny intravenous needle, reminding doctors to first lie them down, is another pearl. The observation that women are more likely than men to talk while under anesthesia is also a pearl. To keep them from saying embarrassing things, I would often keep the chattiest women at a deeper level of sedation.
Pearls have no explanation. We may never know their scientific cause. But that does not devalue them in doctors’ minds. Pearls remain useful in everyday practice. In contrast, many intellectuals look askance at small bits of information that have no connection with each other, let alone to any theory, and no underlying cause that can be identified. Because they do not have an “everyday practice,” intellectuals tend to conflate theory with practice, and demand to know the origins of all things, or at least to understand the forces that move things, including isolated bits of knowledge. Otherwise they will not recognize such knowledge as knowledge, even when the knowledge is useful. Timeless traits in human nature are examples of such knowledge that intellectuals sometimes spurn.
Intellectuals trained in history, philosophy, and theology, in particular, have this elemental drive to find a cause, in part because they insist on giving someone or something moral responsibility—so they can blame—and in part because they want to know whether something is fated, thus rendering judgment on the relative power of the human will. To them, pearls are crude stereotypes, caricatures, examples of lazy thinking—or worse.
But as Aristotle observed, there exists an independent realm of practice that has its own kind of knowledge, separate from that which governs the realm of theory. By ignoring this realm and this knowledge, intellectuals risk serious missteps when trying to re-organize society along new lines.
Doctors’ advice to intellectuals is to give the realm of practice its due.
Medicine is a unique synthesis of opposites. It is old, and yet always new; based on science, but with lots of variables that one can never put a finger on; mechanical in its structure, yet vitally dependent on a doctor’s imagination; filled with algorithms but almost unlimited in its permutations; always developing, yet ever sterile, in the sense that death can never be postponed indefinitely. Medicine is also the one discipline that belongs to every era and every society. We don’t even know its beginning and end. Any person can go on the internet and learn its principles. Plenty of amateur “google docs” try their hand. Yet the field has also bred great masters, geniuses with insight, vision, and technique that combine as in great artists.
To sum it up in a different way, medicine is the most human of disciplines. It is not always praiseworthy, only somewhat; it is never perfect, only almost; it is never exact, only approximate. All this shapes how doctors think. This way of thinking, which guides them as they live in life, has something to offer those who live in thought.

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