What has postmodernism ever done for us?

All letters are subject to editing and may be shortened. General letters can be sent to bjgpdisc@rcgp.org.uk (please include your postal address for publication), and letters responding directly to BJGP articles can be submitted online via eLetters. We regret we cannot notify authors regarding publication.

For submission instructions visit: bjgp.org/letters

Many thanks to Margaret McCartney in October’s issue for unpacking for us the potential of postmodernism for deforming our appreciation of truth, and in turn harming our patients.¹ And to David Misselbrook for replying and pointing to more moderate philosophical frameworks in which we need to take our patients’ perspectives seriously while not using them as sole arbiters of the truth.²

It is shocking, but I think undeniably true, that medicine has no explicit philosophical framework. I think that there is a gathering consensus which both acknowledges this and recognises that this is a deep and immanent crisis. It is time to state our terms of reference, to say something about the framework from which we view the world. David Misselbrook is right that a middle-ground ‘realist’ approach is our best way forward.

Whatever framework we adopt has no easy task: it must uphold, as Margaret says, that basics of science and the experimental method, while, as David reminds us, that recognising this is only a partial account of the suffering of a patient, which in addition has a conscious, experiential aspect to it. Everyday clinicians know that a patient’s blood tests, and their mental state, are important: These material and perceptual realities interact, they are part of the same being, and therefore our philosophical framework must accommodate both molecules and ideas as part of objective reality.

It is time we in medicine faced up to this crisis and defined our terms. It is no longer good enough to lurch from the excesses of postmodernist theories, which are harming patients, to evidence-based approaches based on random controlled trials and outdated 19th-century hypothetico-deductive theory, which carry the potential for equal and opposite harms.

With others we have recommended Roy Bhaskar’s ‘Critical Realism’ as the best approach for medicine, and indeed the human sciences.³ Bhaskar’s Critical Realism provides a sound basis for the appreciation of both the physical and conscious/experiential realities that we see so clearly coexist in our patients. Without this we will continue to talk at cross-purposes and fail to understand the basic flaws, and the potential for harm, in our ungrounded and implicitly accepted philosophies.