Rodolfo J. Stusser, M.D.

Clinical Bioestatistics & Epidemiology Section

Havana University

Scientific Pole of the West of Havana

Clinical Research Center

34 # 4501 / 45-47, Kohly, Playa, Havana-13, Cuba.

Paper created in June 1994, and updated to August 1999.

The practice of medicine is about to reach at least to its ninth millennium of empirical and spontaneous development. Medical research using the powerful hypothetical-deductive method and the well proved analytical and reductionist approaches, is arriving at its fourth century of progress. Both, jointly, medical practice and research, have successfully overcome many diseases and have decreased many deaths, along with public health practice and research too, in the context of the organizational, technological, economical and social progress of the human civilization [1,2,3,4,5].

Nevertheless, in spite of the above and the numerous, useful but partial advances achieved through the first medical revolution, whose "applied the scientific method to medicine" [6]; these are still not enough to overcome many diseases and to strengthen health [1,2]. Because of this, a second medical revolution has been called for in order to "apply the scientific results to medical practice" [6]. However, it seems that at this stage the attainment of intrinsic integral advances is also lacking.

It has been contended that "there is a chasm between those with a central global vision of the world and those who pursue many ends and ideas without attempting to fit them into an overall perspective" [6]. The fact is that up-to-date dozens of clinical, laboratory and health sciences are being taught and practiced only to obtain those medical and health partial research results [5,7,8]. Consequently, medical and health sciences are still lacking an own unified body of scientific knowledge [9,10].

The hypothesis here is that some medical and health scientific general questions require integral answers that must go beyond the boundaries of each of the numerous medical and health scientific disciplines and of the simple articulation of their growing knowledge. The achievement of them must be preceded by a broad emergentist research strategy using an axiomatic-like method still to be proven. In a first step, the specific and interlevel theories and principles already developed about the scientific facts in medical and health sciences through the indispensable reductionist research program, should be synthesized and generalized, through an unconventional high level inductive reasoning. Thus, unifying principles within a general corpus of theory of a unified medical and health science might be obtained. In a second step, new emergent hypotheses might be revealed by an unorthodox way of logical deductive inference from the guiding principles, structuring and concluding them, along with the induction of accepted theories and data, through the use of the insuperable hypothetical-deductive method. The aim of this essay is to argue this emergentist research strategy to assist the formulation of unifying principles, medical and health integral hypotheses, and complement the reductionist research program.

Medical and health sciences can be divided into three main branches. The clinical sciences can constitute the trunk or primary branch and the health and laboratory sciences the two derived branches. They correspond to the clinical and experimental medicine, and the public health activities. There is a consensus in reference to the colossal amount of fragmentary results of investigations on disease achieved in the last fifty-five years, specially by the modern western medical and health subdisciplines [1,6,11]. Besides, fewer attempts of thorough outcomes but very rudimentary, continue being sustained by the eastern medical and health disciplines, as well.

There are many partial theories about different dysfunction, diseases, and disabilities, even for aging and dying. Their causes, well known by doctors, are not well understood by the patients, who need to be aware of the procedures for their protection, diagnosis, palliation or cure, if possible [11]. There are few integral theories about function, health and survival with good quality of life of the person, family and community. Still their causal webs have to be discovered, and better means to promote, diagnose and recover health, credible by the physicians and the individuals they take care of have to be created.

Today, basic and applied --technological and non technological-- research fields of scientific medicine, make up a mosaic of more than one hundred academic disciplines with a tendency to increase. Clinical medicine specialties work along with art and engineering in the same way as other practical sciences of particulars [12], but simultaneously they as sciences of generals, become more complex than experimental medicine, public health, an even agronomy, electronics and marketing do.

This is due to the abundance of clinical-pathological observations and confirmations in surveys and trials, with their biases not entirely controlled yet, even using placebo, elaborated blind and statistical designs, analyses and meta-analyses, powerful computers and communication technologies [13,14]. The statistical hypotheses beside the best software, at their empirical cognitive level, cannot reach the rational level required to formulate and prove even the partial scientific hypotheses and "laws" completely. Theory and practice of the traditional oriental and Islamic medicine, alternative and holistic medicine, which tend to be more integrative intrinsically, have been poorly studied along with modern western sciences, weakening the possibility to unify a thorough body of medical and health scientific knowledge.

When the results in the multicausality field of diseases are revised, there are still doubts about the accuracy, order and integrity of some causal chains or mosaics about simultaneous entities, which explain part of the still limited control achieved over them [13]. For instance: Hypertension, is cause or effect of atherosclerosis, or both are effects of unknown causes [15]? What relationships exist between the traditional risk factors of coronary artery disease, and the new ones such as homocysteine, C-reactive protein, and chlamydia pneumoniae [16]? Is helicobacter pylori, the real cause of so many "degenerative diseases" [17]? Is HIV a cause or opportunistic infection in-patient with AIDS due to other causes [18]? Are the biophysical and biochemical abnormalities in the brain of the schizophrenic patient, all causes, or some are partly consequences of other causes? Are the social and psychological alterations in its behavior, all manifestations, or some belong to its causes, interacting with other environmental and genetic ones [7]?

There are also hesitations regarding the efficacy and even certain damages of some diagnostic, therapeutic and protective means used to deal with some diseases. For example: Surgical treatment is not always effective because of the systemic nature of some cancers when first diagnosed [19]. Radiation and chemotherapy may accelerate death of the elderly cancer patient [20]. Radical prostatectomy and external beam radiotherapy have not been conclusively better in quality of life than has been watchful waiting for the treatment of men with localized prostatic carcinoma. Prolonged survival is not ultimate proof of the effectiveness of early detection by screening for prostate cancer, because, screening picks up proportionately many cases of slowly progressing disease [21]. There is an increase in asthma patients and deaths, in spite of the development of elaborated preventive and therapeutic measures --vaccines and drugs [22].

Besides, research on linear and nonlinear causal relationships of different health states or entities still have to do much more. Is cancer a physiological mechanism of natural selection, once genome deterioration is sensed [23]? Is asymptomatic atherosclerosis really a disease in the advanced elderly [13]? Is the structural progression-stabilization-regression process of atherosclerotic plaques, a physiological and/or pathophysiological process? Has this microscopic process nonlinear relation with the macroscopic functional manifestations and responses to the long-term pro-health lifestyle, lipid-lowering and antihypertensive methods? Which are healthy lipoprotein patterns? Are high risk blood cholesterol levels (more than 5.1 mmol/L) associated to more atherosclerotic patients and deaths [13], whereas low concentrations achieved by therapy (less than 3.9 mmol/L) are related to more deaths by cancer, suicide, violence, and in general too [24]? "Positive" or direct health causes as well as the means to help strengthen their actions, have to be investigated from inside a more comprehensive notion of health, and also from an outside stand point, closer to non medical concepts of the persons and public officials [25].

Human illness and suffering, well being, health and life, do not have so many conceptual networks, models and methodological research, to describe, explain and predict them, as do disease and death. There is lacking a unique doctrine of scientific medical and health general theory integrating and focusing all of them in the whole individual [26] and population [1,3,4,11,27]. Illness and suffering are still neither well understood nor handled [7,11,12]. Currently, individual health is still seen as a physiological state (without disease) where each clinical parameter value is within its normal interval, less as a state of minimal happiness felt when the vital goals are achieved by second-order abilities, in standard circumstances [1,3,11,27]. Population health is still perceived mainly as a social state with low indexes of mortality, morbidity and disability, by age and sex [1,2,11]. Up-to-now, health is still a unique and integral "well-being state", generally, opposite to thousands of partial diseases and illnesses "suffering states".

Few medical and health theories integrate the complex systems of cognitive levels that interact within and also with the main object of that general medical and health science, which is not only the organic molecule, human gene, cell, "meme", and consciousness, within a social organism, but also the healthy and sick individual as a whole-system [9,10,26]. Frequently, the biological, psychological, anthropological, sociological and economical theories are excluded among them or included as secondary or tertiary theories in the scientific explanations.

Medical and health concepts have been called for a reconstruction [26,27,28] and better interrelation of their meanings, centering them into the widest context of knowledge [11]. This must include the total exposition of the results of human genome and human brain projects along with others on the psychosocial phases of the life cycle of persons, families and communities, and even on the ethnological, ethical and economical causes of the wealthy and poor populations. This must cover a parallel re-evaluation of the main results of the powerful and successful empirical research [10,28,29].

In the 90ies, great international efforts have been made to increase the investments on the health research problems of the poorest populations in the countries of low and medium income, with the concepts, methods and technologies developed by the medical and health revolution of the 20-century [30]. However, for example, it seems impossible to overcome the microorganisms resistance to the drugs against malaria, tuberculosis, pneumonia, dysentery, and AIDS, within other problems, doing only basic research on their genome sequence. In addition, much more basic research should be done on the social organization and behavior of those populations in the 21-century. The main scientific problems of today should be focused integrally as complex systems intertwining very different and cognitive levels [31].

The ethical values, goals and frontiers of medicine also have been internationally reconsidered, as well as the main medical and health problems requiring more scientific research in all the world have been redefined [2,11]. Nevertheless, it is necessary to select the solutions with more consensus on the problems of philosophical anthropology: humanism-science dichotomy of medical and health sciences [7,8,10]; non technological-technological measurement and intervention on human phenomena [1,3,7], mind-body dualism of man [3,7,8,11]. Without the adoption of solid positions respecting these universal problems any global research strategy could be well designed and carried out.

The unified body of knowledge of medical and health science, in itself, should be developed without leaving out or replacing the existing medical and health sciences dominant paradigms governing today's research programs. These paradigms are as follows: empiricism, reductionism, static, linear, metaphysic, quantitative, algorithmic, black box, biomedical, disease, [3,7,8,9,11,25,32,33], and survival, which isolated from their pair paradigms distort the humane nature of these sciences. The core knowledge of each medical and health science should be synthesized and should include the couple paradigms as follows: rationalism, organicism (not vitalistic), emergentism, holism, dynamic, reticulate or nonlinear, dialectic, heuristic, Chinese boxes, biopsychosocial, infomedical, interpretative or hermeneutic, qualitative, illness, health [3,7,8,9,11,25,32,33], and quality of life, among others.

This research should be placed inside an integral framework of advanced concepts and models of the life and health of human beings within their physical, biological, cultural, economical, and social environments. All scientific theories and principles produced at every level of the clinic, health system and laboratory, ought to be coordinated in broader theories and precepts at the clinical science inter-level, between the more reducible biological subsystems of a whole and unique individual, and its less reducible psychosocial supra-systems. This would guarantee the filling in of the empty interdisciplinary and superdisciplinary spaces of the disciplinary matrix, now full of increasing subdisciplinary spaces.

The formalization required overtaking this unity, should be different from the first attempts of axiomatization made for classical --and even relativistic-- mechanics [34]. The Scottish physician John Brown with the very rudimentary biological knowledge obtained prior to 1780 attempted to provide medicine with the unit of physics. Brown’s system was sustained by some physicians, scientists, and philosophers of science such as Kant and Schelling [12,34,35], but criticized as empty formalism and metaphysical speculation by other physicians, and by Hegel, but within the context of the non-intelligent animals. Instead, Hegel made a useful logical speculation over that limited basis, not tried again in modern human medicine yet [35].

In the 19^th and 20^th centuries, similar thoughts have been debated, more in biology [28,29] than in psychology [31,32] and sociology [31,33]. On the one hand, an allied position arguing that biology needs inductive systematization through an axiomatic-like method to discover its own law-like generalizations and construct its self-theories [28,29,33,36]. On the other hand, an adversary skepticism arguing that in biology and in medicine, this formidable task will not be easy or helpful, because quite frequently typical biological and medical theories are best represented by families of analogically related and overlapping interlevel temporal models [37]. These representations occur very partially in human medical and health theories owing to the strong influence of the exclusive biomedical model, which divides the efforts to achieve their essences on an entire human level [7]. In the 90ies, this skepticism has been weakened by the pressure of the fundamental forces of the biopsychosocial, clinical, and health sciences.

The difficulty to achieve the unified medical and health science, greater than with an integrative biology, is not only the lack of perception of the need of an integrative reasoning to synthesize the abundant research results known of those "many things" into "one or few wider things" [6]. It is that the scientific knowledge of the individual as a whole, who is a complex biological being is also a complex psychosocial being, with much more complexity than that of the simple sum of both beings [31].

The central concepts, purely hypothetical states or idealizations of that medical and health unified science, must be studied by analogy with those of the most advanced sciences. Above all, the renovation processes needed by the quantum and relativist mechanics and physics, and by the contemporary free-market economy, regarding their classical stages of progress, must also be studied [4,33]. How did these theoretical forms emerge and re-emerge? How do they reflect reality? What methods and techniques did they use? Which have been their motions in time? Such means will help describe, explain and predict the deviations of the objects of reality from the ideal model, for example, considering highest quantity and/or quality of human health.

Something like a complex central hard core of medical and health scientific theories, law-like generalizations, and high-degree hypotheses, with an integrated protective belt of peripheral auxiliary hypotheses, ought to be established, as well as methodological rules to avoid --negative heuristic-- or to pursue --positive heuristic-- research paths to the central core [38]. That core, would be the link of the principles or "axioms of meaning" or law-like generalizations obtained inductively from the lowest to the highest-theoretical levels, and in the last instance from the empirical level [39], including all the main cognitive interlevels of the human being intertwined. Those basic premises would result from the progressive synthesis of the constellation of present and future specific principles, which would develop further in the measure that medical and health sciences continue their evolutionary progress.

The use of those similar structures of the mature sciences would allow the making of new types of creative inferences structuring new complexes of causes and meanings, by an inductive-deductive reasoning at new interlevels of cognitive content. This would assist the hypothetical-deductive method in the scientific formulation of two kinds of hypotheses and law-like generalizations. First, hypotheses of the highest and global theoretical level, and second, of medium and lower levels of generalization, always linked with accepted theories and facts. In addition, it will bring about the demand to develop new ways and means to verify these more or less integral hypotheses.

Afterwards, this new theoretical construction process could be strengthened researching for qualitative and/or quantitative, linear or nonlinear (chaotic) required mathematical re-constructions and new constructions [28,29,40]. To date medical and health sciences’ contents and methods use very few of these formalized constructions. This seems to be due to the lack of comprehensive human medical and health concepts and models besides other reasons. The formulation of the own theoretical and logical structure of medical and health science, will probably allow a greater and more efficient use of mathematics and informatics in medical research and practice, as well as of artificial intelligence [41].

The compilation of plenty information from publications, meetings and personal communications, exchangeable by Internet and other new telecommunication systems, handled by these systemic, axiomatic and interpretative heuristic methods, combined in a new rational and global approach, are needed to carry out this research. Multinational cross-disciplinary teams of experienced scientists in two or three main branches of medical and health sciences or other sciences; young scientists; and a program with an information network are required. The strong international research network cooperation, should be comparable in structure and power to the theory based network of biomedical research of the last fifty five years, and to the evidence based one of clinical research, which is still in its beginnings.

The expected results would be the basis of a unified concept of medical and health science, which will strengthen all the scientific activities at the clinic, health system, and laboratory, through the new emergentist research strategy and its results. They should be condensed in a primer-introducing handbook of medical and health scientific principles, for medical and health students. This typical theoretical dictionary and canon of essential concepts and methods would also be useful for medical doctors, health professionals and scientists trying to begin or to go deeper and/or wider into scientific research, allowing better understanding of their meanings. In addition, for 15 years a hypothesis discovery support system [42], now "Arrowsmith", using the Internet PubMed database [43] {and in the future maybe the database of the E-biomed project too [44]}, is needing the improvement of its target search-strategies making use of such unifying principles. Thus, the achievement of new integral solutions and even more partial ones to classical and new diseases, illnesses and health problems could be expected.

Without the motivation created in the author three decades ago, on the theory of science by the Engineer Ramón Ventoso, Professor of Physics (trained in the MIT, MA, USA), and on the theory of medicine by the Doctor Fidel Ilizástigui, Professor of Internal Medicine, this essay never would be written.

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