When Medicine Mistakes Confidence for a Cure

The ancient philosopher Heraclitus reportedly claimed that physicians were "just as bad as the diseases they claimed to cure." Hippocrates, often regarded as the father of medicine, is frequently associated with the observation that "to do nothing is also a good remedy." Timon, in Shakespeare's Timon of Athens, warned readers to " Trust not the physician; His antidotes are poison, and he slays." Even René Descartes wrote in 1637 that "medicine as it is currently practised contains little of much use." Then who could forget the famous proclamation, generally attributed to Voltaire, that "The art of medicine consists of amusing the patient, while nature cures the disease."Arya Anthony KamyabScepticism toward medicine is hardly a modern phenomenon. Long before evidence-based medicine, some of history's greatest thinkers questioned whether doctors truly healed the sick. And looking back, this pessimism seems understandable. Before antibiotics, insulin, or vaccines, medicine contained few reliable cures. Most treatments were ineffective, and some downright harmful. It is tempting to conclude that today these old sceptics have simply been proven wrong.Wrong because modern medicine has transformed human life. Smallpox is a thing of the past. HIV has become a manageable condition. Organ transplantation, anaesthesia, and antibiotics have extended both life expectancy and quality of life beyond anything previous generations could have imagined. But perhaps most importantly, medicine today is guided by one of humanity's greatest intellectual achievements: the scientific method. Treatments don't gain approval without controlled trials, statistical analysis, and peer review.Surely, if medical nihilism ever had a point, it no longer does.Jacob Stegenga, professor of philosophy of science at the University of Cambridge, England, disagrees and sets out his argument in his book, Medical Nihilism.The central claim is not that medicine is ineffective. Rather, it is that we have become spectacularly overconfident about how effective much of modern medicine actually is. The successes of 20th-century medicine have led us to assume that most diseases can be approached in the same way, merely as biological problems awaiting specific and targeted solutions. According to Stegenga, this assumption is where the issue lies.The argument begins with a question I've circled before — in a previous article for Medscape UK on the boundary between disease and illness — but it's worth setting out properly here: What exactly is a disease? What Counts as a Disease? Most of us assume disease is an objective biological fact. Either your body is functioning normally or it is not. Either disease is with us or it isn't. Yet this intuition quickly begins to break down. Biology alone cannot tell us whether a condition counts as disease, because biology alone cannot tell us whether a condition is harmful. Consider red hair. As strikingly beautiful as it may be, it is biologically rare or, dare I say, unusual, but no one considers it a disease. Equally, there are conditions that cause immense suffering despite involving no obvious biological abnormality, such as functional neurological disorders or even persistent tinnitus. Even the boundaries of recognised diseases shift over time. Homosexuality was once classified as a psychiatric disorder. It no longer is. In that time, our biology didn't change; our values did.Stegenga therefore rejects the idea that disease can be defined by biological dysfunction alone. Equally, he rejects the opposite view that disease is simply whatever society disapproves of. Instead, there is a middle ground, a hybrid approach. A disease exists only when two conditions are met: There must be biological dysfunction, and that dysfunction must be genuinely harmful. Disease is therefore partly a matter of scientific fact and partly a matter of human value. Medicine, despite its scientific aspirations, cannot escape philosophy.This distinction becomes important when we ask what it means for medicine to be effective.Stegenga says that there are two ways a treatment can genuinely help a patient. It can target the biological mechanism responsible for disease (eg, the bacteria causing pneumonia) or it can reduce the suffering produced by the disease, even if the underlying pathology remains. Antibiotics demonstrate the first; palliative care exemplifies the second. Both are valuable, but they represent different kinds of medical success.Modern medicine, however, has increasingly adopted what we can call the magic bullet ideal.The Magic Bullet Ideal The phrase originates with Paul Ehrlich's vision of drugs acting like perfectly aimed bullets. One identifies the cause of disease, hits it precisely, and restores health. This model describes some of medicine's greatest triumphs, such as penicillin destroying bacteria or insulin replacing a missing hormone. The problem is that these spectacular successes have become our template for understanding all diseases.Much of contemporary medicine bears little resemblance to infectious disease or type 1 diabetes. Take depression. Despite decades of research, there remains no consensus about its underlying biological cause. The boundary of diagnosis remains contested and its mechanisms poorly understood. Patients with the same diagnosis often respond very differently to the same medication. It's the same story for chronic pain, dementia, obesity, autoimmune disorders, and many other long-term conditions.In these cases, there is no obvious magic bullet because there is no agreed target to aim at.Crucially, this does not mean antidepressants or other complex interventions never work. Rather, it means that our confidence in how and why they work should be considerably more modest than it is. Medicine increasingly confronts illnesses whose causes are distributed across genetics, psychology, behaviour, environment, and social circumstance.A Plea for Humility, Not Nihilism Medical nihilism, then, is not a rejection of medicine. It is a plea for a bit of intellectual humility.No one would contest for a minute that we have come far in our understanding of medicine. Stegenga himself readily acknowledges that some medical interventions rank among humanity's greatest achievements. Antibiotics, insulin, vaccines, and modern surgery have transformed millions of lives. But these remarkable successes are not representative of medicine as a whole.Perhaps the greatest danger facing modern medicine is not that it knows too little, but that it too often mistakes partial knowledge for certainty. Progress in our scientific understanding has given us extraordinary tools, yet it has also encouraged the comforting belief that every disease has a discoverable cause and a corresponding cure. Stegenga's challenge is to resist that optimism. Medicine is at its best when it combines scientific ambition with a bit of philosophical modesty. Arya Anthony Kamyab is a speciality trainee doctor in clinical radiology working in Oxford University Hospitals. You can follow him on Instagram @aryak.writes.