Q J Med 2003; 96: 85-86
© 2003 Association of Physicians
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All doctors are liars
Probably the best way to stop doctors from reading an article is to end the first sentence with the word ‘postmodernism’. Assuming you are still reading, however, I will try to give an account of postmodernism, and why I think every doctor in 2003 needs to understand it.
Postmodernism isn't a single theory. It's more of an attitude that governs many people's thinking nowadays. The reason that postmodernism goes by that name is that it rejects the ‘modern’ claim that we can discover increasingly better truths about the world. Instead, it argues that all we can do is continually to produce different ones, each reflecting our own historical, political and cultural perspectives. All knowledge, say postmodernists, is perspectival.
Postmodernism challenges the authority of all the big traditional bodies of knowledge like science and medicine. It also challenges other bodies of knowledge that you may or may not care about, like Marxism and psychoanalysis. According to postmodernism, these are all just ‘grand narratives’—in other words, jolly good stories that a lot of people have agreed to believe for a period of time, but stories nevertheless. The only difference between these and fiction, say postmodernists, is that there are more people around who have decided to believe in the second law of thermodynamics, the Krebs cycle, progress, or the unconscious mind, than in Goldilocks and the three bears.
Now you may just sigh with exasperation and decide that only the French could come up with such silly ideas. (And it was the French—at least initially. Famous names involved include Foucault, Derrida and Lyotard.) However, it is worth remembering that all knowledge does indeed have a sell-by date. Typical examples in medicine are the many ‘diseases' like neurasthenia, which have ceased to be something that anyone believes in, or even bothers to try and understand, or remember. Or you can think on a bigger scale, and imagine what the ancient Egyptians, the Sumerians or the Minoans would have thought if anyone had told them that their systems of medicine, and indeed their whole ways of understanding the world, would one day be entirely meaningless. Then project yourself forward in your imagination, and it is not hard to conceive of a world in the far future where people unearth a copy of Gray's Anatomy and shake their heads in astonishment at the way we saw things. If indeed they think of themselves as having heads.
There are two very obvious objections to postmodernism, and you may already have thought of them. One is that postmodernism is ‘a claim to know truth that challenges all claims to know truth’ and therefore it seems to disqualify itself. In philosophical terms, this is similar to Epimenides' paradox. (Epimenides was the annoying Cretan who used to go around saying that all Cretans were liars.) Postmodernists respond to this objection by invoking irony. They point out that every statement that anyone ever makes should carry the self-effacing rider: ‘But of course I'm only saying this because of who I am...’. Their defence is that at least postmodernists are saying this openly. In other words, postmodernism supplies its own ironic nudge and wink, and urges us all to do the same.
The other obvious objection to postmodernism is along the lines of: ‘If you kick postmodernists, I bet they get bruises like everyone else.’ It can be very tempting to kick postmodernists and they do indeed get bruises, but I need to warn you that when they pick themselves off the ground they are liable to argue something like this: ‘I only got a bruise because, from my current perspective, I cannot yet imagine a world where something different happens.’
If you aren't yet tearing your hair out, I have some good news for you. There are ‘hard’ postmodernists but there are also ‘soft’ ones. This distinction is my invention, because I think it useful, but that's OK: the postmodernists would approve. Hard postmodernists will go on talking about perspectival knowledge even when you threaten to batter them to death, and if you are exceptionally unlucky, they will mutter something about death being only a cultural construction, as they expire. Soft postmodernists, however, will eventually say ‘It's a fair cop!’ They will admit that some kind of reality probably does exist ‘out there’, even though they will still try to convince you that most of the claims you make about it are irredeemably infused with subjectivity, vested interests and special pleading.
The reason that postmodernism matters to doctors is this. While ‘hard’ postmodernism has had very little influence outside the rarefied worlds of academic philosophy and social science, ‘soft’ postmodernism has had a huge public influence. It has changed people's conceptual landscapes irrevocably. To put it bluntly, fewer and fewer people think that we as doctors can offer them ‘the truth’. Increasingly, they believe that we are offering them one kind of truth among many available. Whether their perspectives are informed by consumerism, complementary medicine, feminism, multiculturalism, opposition to multinationals, or any of the other hundreds of streams of contemporary thought, the patients who sit in our waiting rooms are no longer likely to accept that the scientific and medical views of the world trump all others. They are, in effect, soft postmodernists.
As far as they are concerned, everything we say is prefaced by the phrase: ‘But of course I'm only saying this because I'm a doctor...’ Perhaps we would do better to say it ourselves.
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