By Dan Falk
As a youngster growing up in Regina, Ross Upshur was a budding naturalist, “on the path to being an ornithologist or an ecologist,” he says – until he discovered philosophy. He was immediately drawn to it, seeing philosophy as “the widest possible avenue to study things.” With an MA in philosophy from Queen’s University, and a medical degree from McMaster University, Upshur worked as a primary care physician before earning an MSc in epidemiology from the University of Toronto.
Upshur has been on the faculty of the University of Toronto since 1998, with appointments in the Department of Family and Community Medicine and the Department of Public Health Sciences, as well as the IHPST. He’s also worked extensively with Doctors Without Borders and the World Health Organization.
He recently co-authored Philosophy of Medicine: An Introduction (Routledge, 2018), together with Paul Thompson, an Emeritus Professor at the IHPST; the two have also co-taught an undergraduate philosophy of medicine course for several years.
Journalist and IHPST graduate Dan Falk spoke with Dr. Upshur recently about the surprising role that philosophy has played in medicine over the years – and how that relationship is likely to evolve. This is an edited version of that conversation.
Although birdwatching is a popular hobby, as a youngster you went a step further, and actually collected specimens?
Yes! I’d head out into the fields to see what that animals I could find. And as a child in Regina, there was a drought, and birds were truly falling off the wires. I would go and collect them, and wrap them; I had them all organized taxonomically in shoe boxes under my bed. And my mother one day was trying to figure out where this aroma was coming from! I had about 200 birds under my bed.
Although you earned a masters degree in philosophy, you decided to enroll in medical school. Did medicine seem like the more pragmatic choice?
At that time, in the early 80s, whoever was in charge of advising students would say, “If you study philosophy you will never be gainfully employed in philosophy.” But I also worked as an orderly in a hospital – and you know, if your mind is open, and you’re inquisitive, everything is there. So I’ve learned an awful lot about medicine by working as an orderly in a hospital. And then I heard about this medical school called McMaster, where it didn’t matter what your background was – so you didn’t have to do this classic pre-med curriculum, or write an MCAT. So I applied to medical school, and got accepted. And I said to myself, “I think I can always come back to philosophy, or continue thinking about philosophy – but having a medical degree would probably mean that I would be employed.” So off I went to medical school. And then I spent years trying to bring those two worlds – philosophy and medicine – back together.
Has the philosophical aspect of medicine been overlooked, historically?
The trick is for doctors to recognize that some questions in medicine are actually philosophical questions. And we don’t train physicians well to recognize those kinds of questions; questions that aren’t simply answerable empirically; that either have conceptual dimensions or normative dimensions that require a different style of reasoning to characterize or understand. And many of those are obviously philosophical questions.
In your book, you point out that philosophy of medicine is a relatively young field. Why did it take so long for philosophy of medicine to emerge as a field of study?
Since the 80s, there’s been a strong interest in bioethics, but not much beyond that. What changed in the early 90s was the notion of so-called “evidence-based medicine.” And then people started asking: How is it that a randomized trial sets up conditions for causal inference? How are diseases defined? Why is it that you use certain probability models, and not others? By the early 2000s, evidence-based medicine had taken off – it became quite arrogant and full of itself, to be honest. And so it attracted attention to itself. And very good philosophers of science like John Worrall and Nancy Cartwright started taking up some of those questions. As well, there were conceptual issues that evidence-based medicine had overlooked, that were amenable to further philosophical clarification. Then all of a sudden it became interesting – and now, just in the last five years, things have really taken off.
You point out that, because of our changing approaches to medicine, the way we understand certain diseases has changed. Can you give an example?
A good example is Helicobacter pylori as the cause of peptic ulcer disease. When I was working as an orderly in Winnipeg in the 70s, if you had a peptic ulcer, they did this huge work-up – blood tests, cardiogram, chest X-rays. And the most common operation at the hospital was to open up the abdominal cavity, isolate the vagus nerve, and snip it – because the vagus nerve stimulates acid production – then they would open up the pyloris, which became scarred by the ulcers. And then you go home on a diet of bread, boiled potatoes, and milk; and you’re told to and avoid stress. By the time I got to medical school, they discovered what are now called H2 blockers – cimetidine was a blockbuster drug in the 80s, because it blocked the H2 receptor that created acid; it alleviated symptoms but didn’t cure it. Meanwhile, there were some guys in Australia – Barry Marshall and Robin Warren – who had done biopsies of ulcers, and said, “maybe bacteria are causing this.” But because it was in Perth, and not Brigham and Women’s Hospital, or Harvard, people said, “nonsense, that’s crazy.” And so, even within my career, there have been changes in the conceptual structure and management of peptic ulcer disease.
And last week in The Lancet, there was a paper discussing how we might need to rethink our notions of asthma. How we define the disease and its clinical manifestations relates to all of the diagnostic strategies that we put in place to rule it in or rule it out. So our notions of what the concept of the disease is, has changed even within the very short time that I’ve been a physician.
In your book, you also discuss mental illness. Do illnesses of the mind present a different set of problems for philosophers, compared with ailments of the body?
I think there’s as interesting tension in modern psychiatry, which relies on the Diagnostic and Statistical Manual (DSM), which is pretty much criteriological and phenomenological. And there’s a large number of increasingly vocal, biological psychiatrists who just despise the DSM, and want to locate all mental illness or psychic suffering somewhere in some receptor system. Plus, we’ve had criticisms of the DSM approach, on the grounds that it over-inflates common behaviors by pathologizing them. So every couple of years, when the DSM is revised, there’s always a media story on how some condition is now a mental illness – you know, “liking ice cream too much,” or something like that – while of course certain illnesses have been dropped from the DSM over time. For example, I don’t think there is a jurisdiction anywhere, where medical associations pathologize people’s sexual preferences any more. You still have a large number of people who are wedded to the phenomenological, criterialogical approach to mental illness – but with the growth of neurobiology, with brain mapping, there’s a lot of people who are now investing heavily in brain science and mental health.
Even if every illness can be traced to a biological cause, you still have to begin with the patient’s own first-person account, right?
I think if there were a “grand synthesis” in medicine, then the phenomenological experience of patients and their symptoms would link up in some way, giving you some sort of biochemical account – but we’re still not there. For example, even with a very simple thing like pain. We have to believe a patient is in pain when they tell us they’re in pain. We say zero is no pain and 10 is the worst pain you ever had. Just imagine that they say “nine” – but then we do a blood test, and tell them, “No, dude, you’ve only got a two.” We just don’t have any objective measure of pain – just like we don’t have any objective measure of being depressed or anxious.
Some people imagine that with more data we’re going to solve all of this; we’ll have 100 percent predictive analytics. As Ian Hacking said [paraphrasing 19th-century philosopher and logician Charles Sanders Peirce], “We will turn the chanciness of our universe into a sure bet.” So then it’ll be a totally deterministic world, with this new biological understanding – at least, that’s what they’re arguing. But those are overstated promises.
There’s this famous assertion attributed to Richard Feynman, that philosophy of science is about as useful to scientists as ornithology is to birds. How do you see the relationship between philosophy of medicine and the actual practice of medicine?
My goal in all of this is to make sure that it’s relevant to practice, and to clinicians. But I fear that it will become an arcane scholarly discipline. For example, whenever I see a new philosophy of medicine conference, I look to see who’s on the speakers list. And sometimes I’ll ask the organizers, “That’s very nice; you’re getting a bunch of philosophers together to talk about medicine. Where are the physicians? Where the health care providers?” Because, arguably, philosophy of medicine, without any contact with the practice of medicine, is pretty useless. And it doesn’t take long for a very smart person to pick apart the self-certitude of a lot of the claims that medicine likes to make. So I think it’s in the best interest of health care as a profession, and as a discipline, to really engage with some of the philosophical issues that are raised. The same with the ethical issues. Ignoring them or pretending they’re not there just isn’t helpful. So philosophers and physicians need to stay in contact with each other. Our challenge is to show how contact with philosophy is actually going to aid in better decision making, and improve patient care.