So like every other British-Asian I tuned in to watch the six episodes of Citizen Khan. Can I see why it offended people? Yes. Do I agree with the criticism? Yes. I’m amazed that some of these following issues have not been raised:

So after how many years the BBC realises there is an existing Asian community in England. Well done. Hats off to them. They feel the need to fill that void with something – why not choose Citizen Khan? Fair enough, having blitzed it’s way though BBC circles and with the credibility of Adil Ray, it seems like a good choice.

Firstly let’s look at the cast of it. Running through the names we see only one Muslim name. I suggest that had there been an all-Muslim cast all catastrophe would have been averted. There would have been greater foresight about what might offend and dare I say, it might have been funnier too. This works on the basic knowledge that there are substantial differences in sub-continental culture. Elsewhere the BBC have done the same thing – let’s look at Eastenders. Some reprehensible storylines that have no basis in reality being portrayed by non-Muslims.

Now it might be said that this is all well and good. It’s only TV. Sure but don’t broadcasters have the slightest bit of responsibility? Were there more ‘Asian’ or ‘Muslim’ (whatever) time on air then I would have less of an issue. There would be a fair and more proportionate representation of this community <<<< just my thoughts though.

So it has been commissioned for a second series. Let’s hope it pans out well for everyone !

“If you see two Muslims, probably they belong to 3 parties.”

Abu Hāmed Mohammad ibn Mohammad al-Ghazzālī

Imam al-Ghazali contributed substantially to the development of a systematic view of Sufism and its integration and acceptance in mainstream Muslim ideology. He was a scholar of orthodox Islam. He belonged to the Shafi’i school of Islamic jurisprudence and to the Asharite school of theology. He was the student of the Abu’l Ma’ālī Juwaynī

 

Style

Ghazali essentially discovered philosophical skepticism that would not be commonly seen in the West until René Descartes, George Berkeley and David Hume. The encounter with skepticism led Ghazali to embrace a form of theological occasionalism: this was the belief that all causal events and interactions are not the product of material conjunctions but rather the immediate and present will of God. It was a rather unique style for a Muslim scholar to have.

Furthermore it must be mentioned that his work focussed on the criticism of philosophers who he felt arrived at erroneous conclusions. The three most serious of these, in his view, were believing in the co-eternity of the universe with God, denying the bodily resurrection, and asserting that God only has knowledge of abstract universals, not of particular things

Incoherence of Philosophers – vehement rejections of Aristotle and Plato. The book took aim at the falsafa , a loosely defined group of Islamic philosophers from the 8th through the 11th centuries. The most notable among them were Avicenna and Al-Farabi who drew intellectually upon the Ancient Greeks. Ghazali bitterly denounced Aristotle, Socrates and other Greek writers as non-believers and labeled those who employed their methods and ideas as those who would corrupt Islamic faith.

 

Atomism

Nothing accidental can be the cause of anything else, except perception, as it exists for a moment. Contingent events are not subject to natural physical causes, but are the direct result of God’s constant intervention, without which nothing could happen. Thus nature is completely dependent on God, which is consistent with other Ash’ari Islamic ideas on causation. This falls in line with the contingency argument of Western philosophy.

 
Influence 

It is also believed that Descartes’ ideas from his book called Discourse on the Method were influenced by Ghazali. So much so some call him dishonest for not crediting Ghazali at all.  It is clear al-Ghazali’s work had resounding reach throughout space and time.

An Exploration of Existentialism

Existentialism is a philosophical movement which posits that individuals create the meaning and essence of their lives, as opposed to it being created for them by deities or authorities or defined for them by philosophical or theological doctrines.

Foreshadowed most notably by nineteenth-century philosophers Søren Kierkegaard and Friedrich Nietzsche, though it had forerunners in earlier centuries. Fyodor Dostoevsky and Franz Kafka also described existential themes in their literary works

It took explicit form as a philosophical current in Continental philosophy, first in the work of Martin Heidegger and Karl Jaspers in the 1930s in Germany, and then in the work of Jean-Paul Sartre, Albert Camus, and Simone de Beauvoir in the 1940s and 1950s in France. Their work focused on such themes as “dread, boredom, alienation, the absurd, freedom, commitment, and nothingness” as fundamental to human existence

Walter Kaufmann described existentialism as “The refusal to belong to any school of thought, the repudiation of the adequacy of any body of beliefs whatever, and especially of systems, and a marked dissatisfaction with traditional philosophy as superficial, academic, and remote from life”

According to Sartre’s own account, however, this would rather be a kind of bad faith. What is meant by the statement is that man is (1) defined only insofar as he acts and (2) that he is responsible for his actions. To clarify, it can be said that a man who acts cruelly towards other people is, by that act, defined as a cruel man and in that same instance, he (as opposed to his genes, for instance) is defined as being responsible for being this cruel man

Existence
As Sartre puts it in his Existentialism is a Humanism: “man first of all exists, encounters himself, surges up in the world – and defines himself afterwards.” Existentialism tends to focus on the question of human existence and the conditions of this existence

Fear
It is also claimed, most famously by Sartre, that dread is the fear of nothing (no thing). This relates both to the inherent insecurity about the consequences of one’s actions (related to the absurdity of the world), and to the fact that, in experiencing one’s freedom, one also realises that one will be fully responsible for these consequences; there is no thing in you (your genes, for instance) that acts and that you can “blame” if something goes wrong

The Absurd
he notion of the Absurd contains the idea that there is no meaning to be found in the world beyond what meaning we give to it. This meaninglessness also encompasses the amorality or “unfairness” of the world. The notion of the absurd has been prominent in literature throughout history. Franz Kafka, Fyodor Dostoevsky and many of the literary works of Jean-Paul Sartre and Albert Camus contain descriptions of people who encounter the absurdity of the world.

Theistic Existentialism
Theistic existentialism is, for the most part, Christian in its outlook, but there have been existentialists of other theological persuasions, like Islam and Judaism. The main thing that sets them apart from atheistic existentialists is that they posit the existence of God, and that He is the source of our being. It is generally held that God has designed the world in such a way that we must define our own lives, and each individual is held accountable for his or her own self-definition.

Though nihilism isn’t existentialism, and existentialism isn’t nihilism, these two philosophies are often confused. While a sort of nihilistic existentialism does indeed exist, it isn’t as radical as pure nihilism. Another reason why these philosophies are often confused is that Friedrich Nietzsche is a central philosopher in both. Nihilists don’t believe in any meaning at all, existential nihilists only believe this in relation to any sort of meaning to life (though this position is implied in “regular” nihilism, and existential nihilists may also subscribe to the full nihilistic view, existential nihilism is a separate view). While other existentialists will allow for meaning in people’s lives (that meaning they themselves inject into it), existential nihilists will deny that this meaning is anything but self-deception.

Kierkegaard & Nietzsche
The first philosophers considered fundamental to the existentialist movement were Søren Kierkegaard and Friedrich Nietzsche, though neither used the term “existentialism” and it is unclear whether they would have supported the existentialism of the 20th century. Their focus was on human experience, rather than the objective truths of math and science that are too detached or observational to truly get at human experience. Kierkegaard and Nietzsche were also precursors to other intellectual movements, including postmodernism, nihilism, and various strands of psychology.

French Existentialism
Jean-Paul Sartre is perhaps the most well-known existentialist and is one of the few to have accepted being called an “existentialist. In the 1960s, he attempted to reconcile existentialism and Marxism in his work Critique of Dialectical Reason. A major theme throughout his writings was freedom and responsibility.

SUMMARY/ABSTRACT

This paper intends to explore the contribution of Islamic science to modern medicine. The paper’s argument can be summarised as follows: the advent of Islam created a knowledge-based society. This environment allowed for individual brilliance to shine. The cultured polymath in medieval Islamdom, whatever his personal beliefs, was given the academic space to pioneer many of the advances we take for granted in modern medicine.

The polymath did not however work locked away in the ivory towers of academia. There was an institutionalisation of healthcare which fostered education and training of these pioneers.

The paper will make allusion to the specific time periods where the Occident was able to benefit from the Orient. It was at the time of the Crusades where the Franks could develop an appreciation for the administration of hospitals, while the Renaissance saw the emergence of figures very much influenced by their earlier Islamic contemporaries.

The primitive medical practices of Arabia will be considered firstly. Then reference will be made to the advent of Islam and the medical implications that development entailed will be considered. Thereafter the paper identifies and deals with three separate locations in which the Islamic medical franchise thrived. The first centre was towards the east of the Islamic world in what is no modern day Iraq. It was here the brightest medical minds in Islamic history were produced, namely Rhazes (al-Razi) and Avicenna (Ibn Sina). Next, North Africa and the Central Islamic lands are considered. Here it was Ibn al-Nafis, who pre-empted Harvey’s discovery of circulation. Ibn Khaldun made strides in sociology while Avennathan (al-Haitham) advanced the field of ophthalmology. The last centre which the paper deals with is Islamic Spain, called Andalusia, which saw the rise of Albucasis (al-Zahrawi), Averroes (Ibn Rushd) and Ibn al-Baitar. They were responsible for significant advancements in the fields of dentistry, surgery and botany. The essay will then move onto a consideration of the institutionalisation of Islamic healthcare. It will be contrasted with its medieval counterpart in Christendom, as well as the modern equivalent.

The conclusion aims to bring the essay full circle back to looking at the topics dealt with as a whole. Hopefully, after the scene has been set one may appreciate the input of Islamic civilization into medicine. One should not underestimate the influence of Islamic thought on today’s medicine.

DEVELOPMENTS IN THE ERA OF THE ISLAMIC POLYMATH

The Greek fathers thought of medicine as more than just a functional discipline. Plato called it an art, while Paracelsus remarked “medicine is not only a science”. Modern medicine idealises uniformity – leading to Bynum’s definition of medicine as “a coherent structure of health beliefs” (1). Today, barring technical expertise and associated costs, medical practice is similar no matter what the location. Bynum’s evaluation is practical and thus it shall be used for the purposes of this essay.

This paper looks to examine the contribution of the Islamic civilization towards medicine. One may be surprised that the contribution of the Islamic world was so significant. The paper will begin by exploring the pre-Islamic era’s medical practices and then considering the shift in thinking that Islam brought about. From there, the three centres of learning, namely Persia, Egypt and Andalusia will be analysed. The Islamic academic world is distinctive in the study of intellectual history due to the number of polymaths that arose. The past greats engaged in the ‘art’ of medicine. With the disappearance of the polymath and the need for standardization, medicine would lose its spontaneous individual brilliance.

As with any science, medicine has evolved over the centuries. It has developed from a discipline founded and steeped very much in Greek culture to one of the Islamic natural sciences. It was from there that Europe emerged as a scientific power, pushing the discipline to its modern form.

Pormann believes that the term ‘Islamic’ best describes the culture that produced the medical advances in question. To be sure, there are issues with this label. Many of the greats such as Maimonides (1135-1204) or Hunayn b. Ishaq (808-873) were not Muslims. They were not all Arabs either. Yet the practitioners shared an environment steeped in an Islamic worldview. By the term Islamic medicine “we mean a certain society or framework which provides a backdrop in which people try to stay healthy” (2).

Days of Ignorance
Let us consider pre-Islamic Arabian custom. The pre-Islamic era was known as zamanat al-jahiliyyah – the period of ignorance . Sharif points out “Arabia at the birth of Islam… was a time torn by wars and family feuds. Ignorance was abysmal and education was not existent” (3). Tribal law governed, female infanticide was common and there are even reports of people marrying their own mothers. Medicine was “restricted to certain specialists – a conspicuous category of diviners, seers, befoulers and charm purveyors” (1). It was far behind the Greek practices that it was destined to equal because of its reliance on superstition and witchcraft .

The Advent of Islam
The advent of Islam revolutionized the Arab approach to knowledge. Muhammad, the Prophet of Islam was himself illiterate when he claimed to have seen an angel instructing him to ‘Read!’ Prophetic wisdom would spur intellectual curiosity – a famous saying (hadith) of the Prophet is “Seek ye knowledge, even if it be in China!” The Qu’ran further instructed believers to make study of nature. This provided religious motivation for the study of natural science. The foundation was established for the oncoming intellectual giants. Sharif points out that the “Arabs were fired with the zeal for knowledge” (3).

The book of al-Bukhari , a book of the sayings of the Prophet, contains the views of the Prophet regarding medicine . One tradition runs: “Healing is in three things: A gulp of honey, cupping and branding with fire (cauterizing). But I forbid my followers to use branding with fire (cauterizing)” (5). At that time, presumably these were the three principal techniques of healing. Nonetheless, the branding of fire was banned because of the pain it entailed. Sabri reasons that Muhammad “understood the use and value of medical arts; he recommended the practice of the medical arts” (6). Sharif documents that records show that al-Harith b. Kaladah was the “only know physician in the Prophet’s time” (2). He was trained at Jundishapur and under the orders of the Prophet he travelled to Persia twice to “engage in a dialogue of medicine” (1).

Persia & Iraq
Baghdad produced the first of the Islamic polymaths. A key reason for this was the fact that it was here where Greek to Arabic translations were undertaken. The aforementioned Hunayn b. Ishaq’s numerous translations of Greek works into Arabic, under Caliphal patronage, introduced Greek medicine to the Islamic world .

Newly found Greek wisdom was fervently admired by Baghdad’s physicians. Perhaps the most famous was al-Razi (854 -925?). His success is reflected by the fact that his works were “translated into several European languages”. Indeed, it is claimed his devotion to study in general led to his eyesight being impaired causing him to turn to medicine when looking for a cure (7). His assimilated notes led to Al-Hawa fi al-tibb (The All Inclusive Work on Medicine). However, his most celebrated work was his treatise, On Smallpox and Measles. Pormann highlights al-Razi’s skills for his case notes, use of the placebo effect and use of control groups. Although common today, these were all pioneering at his time (2). Sabri observes “Rhazes emphasises the importance of the doctor/patient relationship: the healing art” (6) . Al-Razi was not just a physician but also the real intellect behind Baghdad hospital commissioned by the Caliph, Harun al-Rashid. Additionally, he was also the chief physician of the hospital in his hometown of Rayy. Unfortunately as his medical prowess attracted attention, al-Razi came into conflict with the governing powers. Bynum (1) tells us on one occasion:

“Al-Razi proposed that in certain diseases a physician could eliminate within an hour symptoms which had been building up for days and months. This was met with amazement and disbelief among the assembled company”

Somewhat inevitably, his talents aroused jealousies leading to his downfall.

Al-Razi was eclipsed by Ibn Sina (980-1037). Born in Persia, he was self-educated in medicine by sixteen and claimed to have learnt everything he knew by the age of eighteen. His first appointment was to the Emir. After that, he constantly was relocating himself to serve different individuals in ever-changing circumstances . Sharif argues that “from the twelfth to the seventeenth century al-Razi and Ibn Sina were considered superior even to Hippocrates and Galen” (3). Interestingly both are considered outside the pale of orthodox Islam: Ibn Sina for his novel philosophy and al-Razi for his denial of Muhammad. Whatever his philosophical views, his medical expertise was to become the stuff of Muslim folklore: Inglis notes the opinion that “Avicenna was the equal of Aristotle” (8) . Though Ibn Sina’s medical work was all encompassing, one particular fascinating feature was his work on psychology. Sabri regards his achievements on brain localization as foreshadowing the twentieth century (6); in addition, he “analysed for the first time pathological and psychological phenomena”. A classical narrative regarding Ibn Sina is dictated by Inglis:

“There was a Prince suffering from delusion that he was a cow and Avicenna came in the capacity of a butcher. Examining the cow…Ibn Sina came to the conclusion he must be fattened. The prince… began to eat and gradually as he regained his strength the delusion disappeared”

Inglis notes that it was “not until a millennium later that Freudian psychoanalysts were to rediscover the technique of entering the psychotic’s fantasy, in order to provide a bridge for him to return to reality”. He adds that the “Qanun represented the early flowering of psychotherapy under the Caliphate” (8). Indeed it was this Canon of Medicine, a medical encyclopaedia that was his greatest contribution to natural science.

The Canon of Medicine was a “medical Bible for a longer period than any other work”, says Ahmad (7). The rationale for giving it such admiration is stated by Sabri: “The Canon was a mammoth undertaking, a careful classification and systemization of all the medical knowledge known to Arabs in the eleventh century” (6). Translations have ranged from Latin to Chinese showing its success – Inglis states that “the Qanun was to become a standard textbook in many European medical schools, where it held its place until the seventeenth century” (8).

North Africa, Egypt & Syria
Persia provided plenty of scholars and they lit the torch that was destined to now burn further afield. The intellectual focus was centred at Cairo because it was a lively city, to which many intellectuals ventured to for knowledge.

Let us first consider a sociologist of great repute. Ibn Khaldun (1332–1406) spent the majority of his life in North Africa after his birth in Andalusia and played crucial role in the formulation of social sciences . These, of course, can be considered within our remit if one recalls Bynum’s definition of medicine being a “coherent structure of health beliefs” (1). Scrutinizing social trends and community developments is essential for epidemiology and associated fields – a topic we will return to when considering the development of the Islamic hospital. Enan mentions that “Ibn Khaldun was the first man to study the social phenomena, to understand and explain the events of history and to deduce them from social laws, in such a wonderful scientific manner”. In Ighathat al-Umma bi Kashf al-Ghumma, Ibn Khaldun expressed the “short account of the misfortunes of the high cost of living and the scarcity of water”. Ibn Khaldun’s theories were later “treated by Machiavelli…Adam Smith, Vico, Montesquieu and Auguste Comte”; highlighting the lasting influence of his ideas. Unfortunately, the Berber himself was overlooked and has “remained in oblivion for centuries (9). Nevertheless, he was instrumental in the birth of sociology and the way he treated his art should be considered alongside the internal workings of healthcare services.

Another notable authority was the Iraqi born al-Haitham (965-1039), who migrated to Egypt . Seemingly, he never practised as a physician. Despite this, his tracts on ophthalmology were revolutionary. He taught that “impressions made upon the retina were conveyed along the optic nerve to the brain forming visual images on symmetrical portions of both retinas” (3). He is well known for rectifying Ptolemy’s accepted idea that “the eye sends out visual rays to the object of vision” (7). Sabri specifically points to where he demonstrated for the first time that the rays of light come from the external object to the eye and not from the eye itself impinging on external things” (6). Ahmad is of the opinion that “the influence of Alhazen’s Thesaurus Opticae may be traced to the optics written by Roger Bacon” (7). His study on the eye earnt him recognition as, perhaps, “the greatest student of optics of all times” (3)

Cairo was a bustling, cultural metropolis. Ibn al-Nafis was born in Syria, educated in Damascus and eventually journeyed to Cairo . Although Ibn al-Nafis accomplished various things , he is best associated for his correct adjustment of the Galenic view of circulation. Galen held the opinion that blood in the right side of the heart passed through invisible pores into the left side and was then distributed into the body. Ibn al-Nafis corrected this by stating that the “blood must pass from the right ventricle to the left ventricle by the way of the lungs” (10). This itself is extremely significant . Ibn al-Nafis held himself to be prevented from dissection by his faith and in a somewhat impressive, intellectual feat, deduced thus by means of logic . In addition to describing the pulmonary circulation, he also accurately depicted the coronary circulation – Sharif states that it was Ibn al-Nafis who recognised that “blood which is in the right side of the heart nourishes the heart”” (3).

Andalusia
Muslim Spain was known as Andalusia. S. Sharif records that Muslims were invited by the native people and Count Julian to “rescue their homeland from the cruelties of the Spanish kings” (11). After conquering Spain, tremendous advancement was made in technical knowledge. One city was exceptional – Inglis (8) tells us:

“Cordova shone with public lamps; Europe was dirty, Cordova built a thousand baths; Europe was covered with vermin, Cordova changed its garments daily; and with its fifty hospitals, not to mention its seventy public libraries, Cordova held an attraction for the aspiring doctor”

Al-Zahrawi (936-1013) hailed from this city and remained unsurpassed in his field of surgery and dentistry for many years . Ahmad attributes to him the invention of certain surgical instruments (7). One of his most famed was a medical compendium titled al-Tasrif. It contained “such new ideas as cauterization of wounds, crushing stone inside the bladder and dissection…deals with obstetrics and the surgery of the eyes” (3). Sabri believes “this work greatly helped to lay the foundation of surgery” (6).

A page of Al-Zahrawi’s illustration of surgical instruments (12: removed for copyright purposes)

The academic’s innovative nature helped introduce ideas suited for those times. However, he was most proficient in dentistry. His pioneering character mean that he was the “first to describe innumerable ideas and gadgets” (8) in the discipline. Ahmad observes that “his book is illustrated with dental instruments…he discussed oval deformities, dental arches and the formation of tartar”. He could “set an artificial tooth in place of a diseased one” (7). In the mould of a traditional polymath he did not feel constrained by specialisation – his works talked of “midwifery, cooking…and psychology” (1).

Another Cordovan (1126-1198) was Ibn Rushd . Early in life he was an apprentice to Ibn Tufayl. He succeeded him as physician to Abu Yakub Yusuf, the reigning Caliph at the time. Ibn Rushd is better known for his contribution to philosophy and judicial thinking. Nevertheless an empirical rational worldview was vital to his work. His Kitab al Kulliyat fi al-Tibb (The Complete Book of Medicine) has been called a “veritable encyclopaedia of medicine”. There were several Latin editions and the books was “translated twice in Hebrew” (3). It is worth remembering that a critically acclaimed work can have its success determined by the number of languages it appears in. Numerous compendiums were materializing at different times and they constantly were being reworked, re-edited, commented on and improved upon. Information was constantly being collated together to enhance medical knowledge of that time. Ibn Rushd’s controversial character “got him into trouble with Moslem fanatics when they came into power” (8). Al-Mansur banished him based on theological grounds . This echoes back to the times of al-Razi. It is an unfortunate truth that political affairs at times can dictate the products of science. This is poignant because “Averroes promised to be even more remarkable” than his contemporaries (8).

Finally, let us consider Ibn al-Baitar (1197-1248). As a botanist his discoveries provided advances in pharmacology. He is known for describing more than one thousand and four hundred drugs (12). Sari notes that “Ibn Baytar introduced 300 new drugs” (3). Ahmad utilizing Ibn al-Baitar’s Kitab al-Jami fi Adwiya al-Mufrada (The Encyclopaedia of Chique Medicines) calls him “greatest botanist of Islam and of the middle ages whose writings prepared the round for the development of botanical science during the modern times” (7). He was the first scientist to investigate the cure for cancer with any success. The Islamic school inherited the four tumours theory in regarding to diseases . In those times it was believed “the cause of cancer is black bile”. Hindiba was believed to help because it “cooled down the combustion of bile” (13). Although the theory itself is flawed, it is extremely probable that Ibn al-Baitar was aware what he had stumbled onto . His discovery was momentous and the European Patent Office patented Hindiba as a method for treating neoplasia in 1997 (14). It is incredible to believe that over a thousand years ago, he gave as an anti-cancer treatment. He was devoted his life to his work – he traversed Arabia, Damascus, Syria, North Africa and Constantinople to assemble his meticulous anthology .

The Muslims left Spain after much infighting and were pushed out by the Christian powers in 1492. When considering the evolution of Europe, the mark left on Spain is apparent – indeed the advances of Muslim academics were to provide the spark for the Renaissance in Europe (3). As the Muslims sailed out of Spain, many of the Jewish intellectuals opted to flee carrying the discoveries of Islam into Europe. Scholars from Leonardo da Vinci to Machiavelli were to be influenced by the academic output of the Islamic world.

The Development of Hospitals
It is the medieval Western hospital of Christendom that is the direct parent of its modern counterpart. Jones tells us that “hospitals have been in an existence since the medieval period…for people undertaking Christian pilgrimages”. However, certain charity hospitals, such as Guys (1725) and Middlesex (1746) were for the “poor, homeless and sick”. He (14) proposes that there has been “some continuous historical process of evolution” because:

“The function of hospitals began to change in early 19th Century. These social changes combined with specialist scientific knowledge led to the development of what would be modern hospital medicine”

This gives one an authentic context of Bynum’s ‘modern medicine’. The reason he suggests is that the change in function has come from “a change in character of disease from acute to chronic illness”, “growth of middle class” and the “formation of NHS after the NHS ACT in 1946” (15).

If the modern hospital can be traced to the institution of Western Christendom, where did the medieval Western hospital come from? The Crusades may have led to a face-off between the West and the East with resentment which lingers up to now, but it also meant that the Occident could observe the Orient. Sharif remarks that “the Arabs were not the first to build hospitals but they were certainly the first to improve them” (3). The government had a crucial role to play in this because they had to “maintain high standards in the public hospitals” (16). Indeed, the better hospitals had “streams of running water, pools and small groves of trees where patients could relax” (1). Sharif (3) adds that:

“The furniture, bedding and clothing at the Mansuri hospital Cairo, rivalled in their luxury and perfection those that adorned places of the Caliphs. Sometimes were musicians and singers were brought in”

In addition to the luxury of these environments, the healthcare extended beyond the hospital. Sharif notes there was also care in the penal system – ““physicians looked after prisoners” . He adds “first aid stations were established near mosques where large numbers congregated”; additionally, “small hospitals for the blind and lepers were built during the Umayyad period (3). Despite all the amenities, the focus remained on its standard purposes – the administration was well handled for there were “in-patient and out-patient departments” (1) and there was “a registered pharmacy attached to every large hospital”. The operation was not run ad hoc: There were “several books were written on hospitals and hospital management” (3).

Healthcare, of course, entails a tremendous amount of administration – a fact which the Islamic hospitals had to take account of. Quddusi (17) writes that in the caliphal reign (634-644) of Umar b. Khattab:

“Free hospitals were established and pensions sanctioned for the unemployed persons. Widows, invalid and physically handicapped persons were provided with suitable financial assistance”

In the major cities, the healthcare facilities were good – the hospitals “at Baghdad, Damascus and Cairo were the best known at the time”. Sharif also tells us that “in Andalusia there were over fifty hospitals in Cordova alone, besides those at Granada, Seville and Toledo” (3). Bynum elucidates that “efforts were also made to extend medical care to rural areas…small towns and large villages all seem to have had at least one, formal physician” (1). There then was a concerted effort to make healthcare accessible to all. Nevertheless, one must admit that it is only the modern nation state, as developed in the West which has successfully advanced the target of 100% coverage.

Institutions are all well and good but they need trained professionals working in them for them to be effective. According to Pormann, there were two main methods of education. The first was self-teaching while the second was being taught by the physicians themselves (2). Bynum says “Ibn Sina and Ibn Ridwan (988-1061) both claimed to be self taught” (1) – the former because he found medicine easy whilst, Ibn Ridwan was too poor to afford an education. The latter method, under a physician, was fairly common. It may have involved a respected physician signing off a student’s textbook when he had mastered that text . This type of education would have been complemented by facilities – Sharif contributes by stating that “every large hospital possessed a library of its own” (3). Within the hospital “the precinct included kitchen and pharmacy facilities, a bath, a library and lecture rooms”. The complex system of medical education could be compared with today’s because “clinical experience was available in hospitals”. Bynum specifies that “students would assume basic duties…and advanced students would undertake preliminary examinations” The students knowledge was enhanced by the doctors “regularly making rounds” and using “patient and library facilities to teach their students” (1).

Just as today the GMC monitors the etiquette of practitioners, in the Islamic world there was a similar scheme. Hodgson tells us that “the caliphal administration provided for the examination of physicians” (16). Bynum (1) gives an example of this:

“In 931 word reached the caliph in Baghdad one of the common folk had died at the hands of an incompetent doctor, so the ruler ordered that only physicians who had been examined should practise medicine”

No functioning health system could free its practitioners from the need for culpability.

Conclusion
Though Islamic culture brought much to medicine; its contribution remains “heavily understudied” (2). Sharif comments “a bare one percent” of the Islamic works have “been salvaged so far because of Mongol hordes and fanaticism of European conquerors” (3). The destruction of books, however, is not the only reason for our lack of knowledge. The modern Arabs disinterest in history has means that dozens of libraries across the Middle East house hundreds of unstudied manuscripts.

It was the Islamic polymath, a man who mastered several disciplines and thrived in the institutions of the literate, who was the crucial component for the advances in sociology, botany, pharmacology, ophthalmology, surgery, anatomy and pathology to name just a few. Should we then lament the loss of this polymath in today’s medicine? I do not believe so. Standardization has meant conformity, which is essential for efficient treatment. Nevertheless, we would be ill-advised to forget the cultured Islamic polymath. One can genuinely approve of Brifault, when he said “science owes a great deal to Arab culture” (5). Even Dante, who in his notorious Inferno cast Muhammad in the lowest fire of hell, said that:

“William Harvey will say 600 years after his death to his friend Aubrey; ‘Go to the fountainhead and read Aristotle, Cicero and Avicenna”

Many thanks must be given to Tarek Al-Yousaf for helping research and structure the article.

BIBLIOGRAPHY

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The media simply tells the people what it thinks will conduce to winning the war. If truth is good for winning the war, it tells them the truth. If a lie is likely to win the war, it tells them a lie

                                                                        Sir Ian Hamilton, British General in WWI

In modern warfare the military’s relationship with the media has become integral to gaining victory; Bruce Berkowitz in The New Face of War: How War Will be Fought in the 21st Century argues that assimilating and communicating information defines military power. The clearest example is how the British Ministry of Defence updates their war manual on public relations after each conflict (Knightley, 2004, p. 484).

This paper focuses largely on the U.S. government in relation to the Western media during the Gulf War I[1]. It is split into two sections.

Section I establishes the theory: firstly the historical context of the conflict is given. Next the relationship of the media and military is examined. Then two aspects of U.S. foreign policy are examined within the Gulf War context: (1) There was a wish to show a ‘clean’ war (2) The U.S. wanted to legitimise the conflict.

Section II builds on the foundation of Section I: the U.S. government implemented four main tools to manipulate the media for their two factors of foreign policy. Each of these elements will be defined and considered: (a) censorship (b) white propaganda (c) grey propaganda and (d) black propaganda.

The handling of the media resulted in a false reality being constructed. The conclusion is that this manipulation caused the media to not report the objective truth therefore it failed in its role.

 

Section I – The Media & The Military

Historical Background

It is 1990 in Iraq; Saddam Hussein is disputing with the Kuwaitis about oil resources. There are two issues at stake: (a) The Kuwaitis flooded the global market with low cost oil and this cost Iraq a great deal of money, especially when stability was needed after the Persian Gulf War (b) The Kuwaitis were taking too much oil from the disputed border between the two countries and demanded compensation. After Iraq invaded Kuwait, economic sanctions were enacted against Iraq. The U.S. forces were sent to Saudi and soon after an invasion occurred (Knightley, 2004, p. 485).

 

The Role of the Media The Military

This paper assumes that the U.S. military and U.S. policy are in sync with the government. This is a reasonable assumption; the rogue elements within the U.S. military do not pose an immediate threat say as the ISI do to the current Pakistani government.  It also presupposes that the role of the media is to portray the impartial facts about goings-on.

Soroka posits an interesting triad: the role of the media is to portray the objective truth to the mass public in regards to military operations. He places the mass media in between the policymakers and the public identifying media content as the most likely source for changes in individual foreign policy preferences. This is because foreign policy is almost always enacted without personal experience (2003, p. 28). Learning about it must involve media coverage. Kull agrees (2003, p. 570) an administration can distribute information directly and indirectly which the press then transmits.

The U.S. Implementation

I argue that the U.S. administration[2] used this triad to handle the media machine to fulfil two aims of foreign policy. Knightley believes the first and foremost important element in the military’s propaganda strategy was to show a ‘clean war’. He expands on this: they wished to “convince everyone that the new technology removed much of war’s horrors” (2004, p. 494-95). Sloyan corroborates that the US government wanted the “illusion of bloodless battlefields” (2002). Propaganda and censorship bore the brunt of this task.

The second aim was to win over public opinion to justify the invasion of Iraq because the war had become inevitable therefore early on it was necessary to win over public opinion to legitimise the imminent invasion; even after the war had started it was still important to maintain a justification. With economic sanctions imposed and U.S. troops dispatched to Saudi Arabia, war seemed imminent. Malek and Leidig (1991, p. 15 – p. 19) wrote:

The press behaved more like a propaganda arm of the government promoting the idea of the inevitability of war in the Persian Gulf

This involved demonising Saddam and conjuring terror stories (Hiebert, p. 244). Black propaganda played a fundamental part in this.

It is important to frame this argument – this paper does not focus on the media coverage in Muslim lands[3]. Still it is sensible to suggest that the same triadic dynamic would have been occurring in Muslim lands and that the Iraqi government and Muslim world would have had their own intentions and media implementation. This must be borne in mind at the outset of the essay. Nevertheless one more issue is worthy of note: obviously if the war was wholly legitimate there would have been no need for propaganda. If there was truly a ‘clean’ war with minimum deaths then there would be no requirement for censorship.

The Methodology of the Media

The media can form different relationships: public relations imply mutuality and a two-way relationship whilst encompass credibility whilst public communication is more one-way. Hiebert proposes that the majority of the latter involves propaganda (2003, p. 244) and this is what the U.S. media machine focussed on. Garth Jowett believes that the U.S. uses and used propaganda as much as any country – it is routine for the modern administration to “routinely manipulate and spin” (Hiebert, 2003, p. 247).

For the purposes of this argument propaganda shall be defined as the wilful manipulation of ideas to sway a certain audience to a position. Hiebert differentiates ‘white’ and ‘black’ propaganda; the former refers to truthful propaganda whilst the latter entails deceit and lies He acknowledges that the majority of propaganda probably falls into the category of grey (2003, p. 244). Combined with censorship, these four media tools helped the U.S. government achieve their two aims of (1) Showing a ‘clean’ war and (2) Trying to justify the war.


Section II

Censorship

Journalists are no longer peripheral observers but influential players in the theatre of war

                                                Martin Bell, The Death of the News, p. 222

 

The news that journalists report can sway opinions; the role of the news reporter should not be under-appreciated. Knightley believes (2004, p. 485) that the role of the media in the invasion of Panama[4] was a key turning point for it changed the way wars would be reported. Censorship[5] can provide great propaganda and shift public opinion. This was certainly employed in Iraq to show a ‘clean’ war.

One form of censorship employed during Gulf War I was the ‘pool system’; a limited number of correspondents would be picked for each pool and they would make their reports available to those who were not present in the pool (Knightley, 2004, p. 490). The Pentagon[6] implemented it for thus limiting the number of journalists that could cover the action; even then the correspondents were only those that could be hand-picked by the military[7]. This was an ingenious move because then infighting started amongst the journalists for places in the pools therefore they were unable to fight the system – an excellent example of divide and conquer (2004, p. 490). This meant the government were able to control the information that went into the public domain – the media was forced to pander to the selective broadcast policy of the government, for which they clearly had their own intentions, therefore they were unable to represent the happenings in Iraq[8].

This pool system can be defended: it can be argued that it was implemented for safety; for example during enemy fire there is a possibility a journalist might be shot or even specifically targeted. In addition the practical implications alone would cause problems – for instance how can soldiers take care of a journalist when their base is being raided? There is certainly strength to this argument. On the other hand there was no open discussion between the administration and the media about how to report. It was automatically assumed that the new guidelines would be accepted (Knightley, 2004, p. 491); at least an open discussion reaching a consensus would have been appropriate. This is what constructs it as censorship of a press that should be open.

Can censorship ever be justified? Petley focuses his argument of censorship particularly on the lack of graphical representation of the war. He appreciates that in certain circumstances censorship might be acceptable. For example up-close footage of the dead after a battle might not be shown due to guidelines – the BBC Producer’s Guidelines state that there needs to be a balance between the demands of the truth and the danger of desensitizing people (BBC, 1996: 75)[9]. It might not also be shown to cater for the audience – Petley (2003, p. 76) cites a recent study 42% showed that a battle scene should be shown from a distance whilst 43% thought it should only be shown after the dead have been removed. Knightley cites a figure of 80% who thought censorship was occurring and was a good idea (2004, p. 492). Morrison concluded that “very people really wish for the full horror of war to be shown” (Morrison, 1992, p. 33).  After all the broadcasters must show what wants to be seen therefore they must cater to their audience. Nevertheless the media has a responsibility to report objectively and should inform viewers of what their government is responsible for.

The U.S. foreign policy wished to dumb down the graphical representation of the war and censorship was a method to do that. Any defence for censorship can lead to an indefinite to-and-fro as to where the line of impartial reporting starts and moral responsibility finishes. Petley’s and Morrison’s arguments may appeal to some but I argue that ultimately broadcasters have an obligation to inform their audiences of the facts otherwise they shield their viewers from the true nature of war.

White Propaganda

You have to plan your media strategy with as much attention as you plan your military strategy

                                    Philip Knightley

According to Hiebert (2003, p. 244) white propaganda is based on truthful concepts; resultantly there is only so much manipulation of facts; the truth in itself might not always be enough to persuade the audience of a certain idea but an incident that has been hyped and has been built around emotion might be[10].

The language of reporting is able to influence the audience; it is subject to manipulation by interests. Certain phrases reinforce ideologies and can work well in promoting propaganda; in the Gulf War language was used to fulfil both aims of the U.S. foreign policy discussed in this paper: (1) A cache of phrases were used to portray a ‘clean’ war: terms such as ‘collateral damage’, ‘soft targets’, ‘surgical strikes’ were used to minimise the shock[11] (2) In order to justify the war comparisons were drawn of Saddam Hussein to Adolf Hitler. Knightley states that he was being painted as a ruthless fanatic, deranged psychopath that was hated by his own people and despised in the Arab world (2004, p. 486).This was supplemented by the terror stories that usually fell under black propaganda that are to be discussed later.

A cogent paradigm of white propaganda was based on the consequence of when oil had been found in the Gulf. Hype and emotion surrounded the reporting as Saddam Hussein was branded as an ‘environmental terrorist’. This label was added to the list of ‘lunatic’ and ‘barbarian’; all these labels helped construct the image that was favourable to the U.S. aims.

The role of the media is to stay impartial and although it might be acceptable or even useful at times to attach labels, it is clear that a reality was being constructed that was conducive to the U.S. foreign policy.

Grey Propaganda

The line of truthful white and deceitful black propaganda can merge when an incident occurs and facts are generated from it that might not necessarily be true. On February 13 two bombs were dropped in the Ameriyya district of Baghdad killing 270 civilians. This event took place so it fulfils the criteria to be white propaganda; at the same time it was claimed that Saddam Hussein had put those civilians there so they could be killed and this was highly questionable[12]. This constitutes it also as black propaganda.

The incident backfired on both U.S. foreign policy aims that have been discussed in this paper: (1) The ‘clean war’ image was weakened as the violent images that were shown around the world caused outrage[13] (2) Justifying the war was dealt a blow when eventually the Allied commanders admitted the bombing had been a mistake. (Knightley, 2004, p. 495). The Ameriyya bombing highlights brings an interesting point forth: sometimes propaganda can fail and the military can be left embarrassed.

Black Propaganda – Lies, Disinformation, Deceit

If you lose the war of words and images, you will lose the war of arms

                                                                        Martin Bell, The Death of the News, p. 229

One of the aims of American foreign policy was to legitimise the Gulf War- this involved conjuring up complete falsehoods otherwise known as black propaganda according to Hiebert (p. 244).

The atrocity stories drew great attention; the one that perhaps that had the most impact in politics and in the public sphere was the Kuwaiti baby story being tossed out of incubators in Kuwaiti hospitals. The fact that it was reported its sources varied from the Daily Telegraph, Los Angeles Times and Reuters gave it credibility. This story developed with Nayirah[14]; this 15 year old Kuwaiti girl stood up and voiced the atrocities. It later emerged that she was the daughter of a Kuwaiti ambassador (Knightley, 2004, p. 486-487). It is beyond belief that a constructed story was allowed to receive so much attention.

Similar incidents endorsed the idea that Kuwait needed to be liberated and justified the invasion but this had special significance. John Macarthur believes that the incubator story was the definitive moment in the campaign that prepared the American public to go to war. This supports the idea that black propaganda was integral to legitimising the war because potentially without it the war might not been accepted as it did[15].

 

Conclusion 

The Gulf War is over and the press lost

                                                            Barry Zorthian, Chief of Pentagon’s Public Affairs

Petley argues that recent technological developments such as the internet and 24 hour new channels have opened the channels for communication yet the world of warfare is becoming more and more limited (2003, p. 72). There certainly is room to argue this in the case of the Gulf War.

The triad of the influences of the (i) media (ii) military and (iii) public opinion upon each other could generate volumes; this paper showed that in this one case the military took charge. It was argued that in the case of the Gulf War the media became a tool for propaganda to: (1) portray a clean war and this was conducted by means of censorship and (2) to justify the invasion of Iraq and this was implemented through white, grey and black propaganda.

Interestingly Hiebert feels that given the current trends of the media, public communication is moving more and more towards black propaganda. The techniques of public relations and propaganda will become part of every war in the near future (2003, p. 254).

There is no shortage of those who feel that the wars are not covered as they should be: Hiram Johnson fittingly stated that the first casualty of war is the truth; Fisk who has covered the Middle Eastern conflicts over many decades bemoans at such media manipulation. Bell (2008) followed suit by writing an obituary to the free press.

It was stated at the start that the media is determined by their context and the audience they cater for. Indeed it is sensible to suggest the Muslim world had propaganda of its own; Bell (2008, p. 228) comments that most media outlets are owned by mega-corporations who see them as profit centres and not public services. This affects the very definition of news.  Nevertheless this does not relieve any moral responsibility from the Western media. The Gulf War is over. The media lost.

Bibliography

  • Bell M., (2008) The Death of the News, Media, War & Conflict, 1: pp. 222
  • Bell M., (2008) The Death of the News, Media, War & Conflict, 1: pp. 228
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  • British Broadcasting Corporation (1996) Producers Guidelines, p. 75
  • Broadcasting Standards Commission (1998), Codes of Guidance, p. 31
  • Fisk R., (2003) The War of Misinformation has Begun¸ The Independent, March 16 2003
  • Hiebert RE., (2003) Public relations and propaganda in framing the Iraq war: a preliminary review Public Relations Review 29: p. 244
  • Hiebert RE., (2003) Public relations and propaganda in framing the Iraq war: a preliminary review Public Relations Review 29: p. 245
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  • Knightley P., (2004) The First Casualty: The War Correspondent as Hero, Propagandist and Myth-Maker John Hopkins University Press:  pp. 484
  • Knightley P., (2004) The First Casualty: The War Correspondent as Hero, Propagandist and Myth-Maker John Hopkins University Press:  pp. 485
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  • Knightley P., (2004) The First Casualty: The War Correspondent as Hero, Propagandist and Myth-Maker John Hopkins University Press:  pp. 486 – p. 487
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  • Knightley P., (2004) The First Casualty: The War Correspondent as Hero, Propagandist and Myth-Maker John Hopkins University Press:  pp. 490
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  • Knightley P., (2004) The First Casualty: The War Correspondent as Hero, Propagandist and Myth-Maker John Hopkins University Press:  pp. 492
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  • Kull S., Ramsay C., Lewis E., (2003) Misperceptions, the Media and the Iraq War, Political Science Quarterly 118 (4) pp. 570
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  • Sloyan P., (2002) War Without Death, The San Francisco Chronicle, 17 Nov 2002
  • Soroka SN., (2003) Media, Public Opinion, and Foreign Policy, Press/Politics 8 (1): pp. 28

 


[1] There have been a few disputes in this region: (i) The Iran-Iraq War took place in 1980 – 1988, it is also known as the First Persian Gulf War (ii) The next conflict occurred from 1990 to 1991 when Western forces invaded Iraq. This paper focuses on this Gulf War (iii) The most recent conflict started in Iraq in 2003 and carries on until the present day.

[2] It should be noted that although this paper focuses on the handling of the media on a governmental level, private companies had a role to play as well. For example Citizens for a Free Kuwait was a public relations company that signed a $10 million contract with the public relations company Hill and Knowlton to campaign for American intervention. This PR company engineered some of the atrocity stories and were fundamental in the propaganda: their press kits were sent to members of Congress and reporters. They sent over 20 video releases to 700 different television stations (Knightley, 2004, p. 488).

[3] Word limit restricts this paper from covering  exactly how the Arab world covered the Gulf War

[4] The leader of Panama, General Noriega, was the target: he was being arrested on drugs charges. A pool system was supposed to be employed yet the only reports were from those correspondents detained by the military in the warehouse. Other journalists that accompanied the troops were told to turn back (Knightley, 2004, p. 485)

[5] This would not be the first time censorship would be employed – the US invaded Grenada in October 1983 and attempted to exclude media coverage as much as possible; so much so that the journalists who attempted to get to Grenada by speed boat were fired at by a US fighter plane (Knightley, p. 484)

[6] This ‘pool system’ was mimicked by the Ministry of Defence: additionally they added the clause that all items had to be submitted before they were aired (p. 491).

[7] Even then the pools were limited in what they could do: an ABC correspondent Judd Rose requested to see a Patriot anti-missile battery  with his pool but they were sent to a garage where trucks were being prepared (Knightley, p. 494)

[8]  Interestingly Fisk became a vigilante journalist in Iraq and ventured off to do his own reporting and looking for his own stories after the ‘pool’ system was announced (Knightley, 2004, p. 492)

[9] BSkyB’s guidelines are also quite similar: they state that “broadcasters should not shy away from showing the consequences of violence but must take care in the choice of accompanying words” (Broadcasting Standards Commission, 1998: 31)

[10] This idea carried into Gulf War II: for example the rescue of the American soldier Jessica Lynch  was played out as a daring raid from a hospital. The hype built up the rescue in the mainstream media (Hiebert,2003,  p. 247)

[11] This tactic carried on in Gulf War II.  The use of key phrases such as ‘crusade’, ‘axis of evil’ and the ‘war on terror’ were examples. Fisk (2003) prospectively outlined a common set of phrases he expected to be used in Gulf War II:

‘Stubborn’ or ‘suicidal’ – to be used when Iraqi forces fight rather than retreat.

‘Life goes on’ – for any pictures of Iraq’s poor making tea.

‘Remnants’ – allegedly ‘diehard’ Iraqi troops still shooting at the Americans but actually the first signs of a resistance movement dedicated to the ‘liberation’ of Iraq from its new western occupiers.

‘Newly liberated’ – for territory and cities newly occupied by the Americans or British.

‘What went wrong?’ – to accompany pictures illustrating the growing anarchy in Iraq as if it were not predicted.

[12] The media was shocked at the images that were broadcast. Brent Sadler of ITN said “I saw no military or strategic target in this vicinity”; the Los Angeles Times acknowledged that it was a propaganda coup for Iraq (Knightley, 2004, p. 494).

[13] For example The Mail on Sunday labelled as ‘truly disgusting’ and ‘deplorable’. The BBC was labelled as the Baghdad Broadcasting Cooperation by Conservative MPs.

[14] This story was engineered by Hill & Knowlton

[15] This continued to happen: the Persian Gulf War focussed on the rape of Kuwait whilst the Gulf War II centred on the finding of Weapons of Mass Destruction. The story of WMD was probably the greatest black propaganda piece in the last decade. The British lead was headed by Information Operation (I/Ops) – faked documents alleging a transfer from Niger to Iraq involving uranium were used as proof, even when the CIA knew that they were faked. When they were not found, the story changed to rescuing the Iraqis (Hiebert, 2003, p. 245).

Evidence Based Medicine (EBM) has been a controversial issue since it started – some heralded it as a revolutionary medical movement while others are deeply cynical of its ideology. Some of this has focussed around the claim that EBM is a new paradigm: Reverberi (2008) believes EBM is so important that it is not appropriate to label it as a paradigm shift any more[1] whilst Couto (1998) calls EBM a “transvestite non-theory”[2]. He further labels EBM enthusiasts as “Voltaire’s bastards”.

My Argument

In this word constraint it is not possible to look at the entire EBM establishment and label it as a Kuhnian paradigm or not; this paper only looks at the claim that the EBM medical teaching system as proposed in the landmark 1992 paper by the Evidence-Based Medicine Working Group (EBMWG) fits Kuhn’s incommensurability with the former paradigm it claims to have replaced. If the EBM medical teaching system and the former paradigm are incommensurable then EBM can called be Kuhnian.

Firstly Section I examines Kuhn’s and EBM’s ideology – there are some differences that do warrant an investigation for incommensurability. This paper takes a top-down approach -Section II then looks at the core values of EBM teaching and the claim of incommensurability. Then Section III focuses on the specific use of language in EBM and incommensurability.

The thesis statement of this paper is that EBM medical teaching is actually more complementary than incommensurable. Consequently it is incorrect to label EBM as Kuhnian. Each point is referenced with a regularly returned to example – this paper looks at the EBM claims so it uses the oft-cited case of Patricia Crowley’s meta-analyses on short-trial steroid use for premature mothers.

 

Section I: The Ideology

Kuhn’s Ideology

In The Structure of Scientific Revolutions Kuhn proposed that science functions under an overarching paradigm that is replaced when revolutions occur. A paradigm offers the structure under which scientists work.

Under the direction of the paradigm there is ‘normal science’ which focuses around ‘puzzle-solving’ and ‘mopping up’ problems in the paradigm; this phase is the longest. Kuhn labels disparities as anomalies – if too many occur then there is a crisis which can lead to a revolution and a new paradigm will arise[3].

The Two Paradigms

EBM claims that it has replaced the former paradigm[4] – this paper focuses on the two different paradigms of educational systems. The two paradigms in question: (i) the former paradigm EBM proponents believe it has replaced and (ii) EBM itself.

The Evidence-Based Medicine Working Group outline that the former paradigm[5] is about: (1) unsystematic observations from clinical experience (2) studying pathophysiology (3) traditional medical training and common sense are a basis to evaluate tests and treatments. The first paradigm in question is what EBM feels to have replaced that of clinical experience and basic pathophysiological mechanisms.

EBM claims to be a wholly separate paradigm and it is important to appreciate why EBM proponents believe its values are distinct. The key methodology is the critical appraisal exercise – this involves a number of steps:

  • Identifying the patient problem[6]
  • Identifying what information is needed to resolve the problem
  • Conducting an efficient search of the literature
  • Selecting the best and most relevant studies
  • Being able to present to colleagues
  • Applying it to the patient problem

The EBMWG cite Kuhn to construct the view that defects have accumulated within the existing paradigm and heralding a paradigm shift with EBM. Their proponents use Crowley’s example (Howick, 26, 2011) – her results were clinically and statistically significant. Her findings were generally ignored and further unnecessary trials were conducted costing time, money and lives. The reason was that current medical understanding is too based on questionable clinical authority therefore anomalies have accumulated; EBM proponents claims that their emphasis on evidence and Randomized Controlled Trials (RCTs) has caused a revolution. This is further explored as a core value in Section II.

Incommensurability & EBM

Kuhn proposes that competing paradigms are incommensurable – two paradigms are so different that it is not feasible to compare them[7]. Okasha (85, 2002) gives an example to clear the issue: ‘mass’ for Newton and Einstein meant something different. They were effectively speaking different languages.

After outlining the structures of the two paradigms there do appear to be differences therefore it is reasonable to examine the claim for incommensurability. Sections II and III further explore Kuhn’s idea incommensurability and apply it in to EBM. This argument hinges on the claim that if the claim of incommensurability is legitimate then EBM can be called Kuhnian.

 

Section II: The Core Values of EBM

With the top-down approach Section II examines the core values of EBM. These are: (a) its emphasis on RCTs (b) the values of sensitivity and (c) the importance of the basic sciences. It is argued that EBM is more complementary than incommensurable.

Core Value #1: RCT Emphasis

EBM proponents will say that the difference between the two paradigms is what they consider acceptable evidence to practise upon. The former paradigm is gives the highest source of knowledge to the expert whilst EBM declares it to be RCTs (Kulkarni, 2005). Howick (2011, 17) places RCTs at the top of the EBM hierarchy.

EBM proponents say the case of Crowley demonstrates that even though steroids were a statistically and clinically significant treatment, her results were ignored because clinical authority overrode the status of RCTs.  They will say if the EBM hierarchy was implemented in the medical curriculum lives, money and time would have been saved. It could be said that the status of RCT’s in medical education may have been negligible at one point? Is it a stretch to say that one time maybe the two paradigms were incommensurable? This point has two weaknesses.

Firstly even Crowley and EBM proponents admit that her ethnicity may have played a role in the dismissal of her results (Howick, 190, 2011). Even by EBM admission, the ignorance of her results was not wholly due to a lack of respect for RCT’s in the medical curriculum.

Secondly even if this argument is valid, it is only valid for a small window of time – current day medical curriculum actually inculcates teaching about RCTs and studies into their course. This is done via the Community Population Health or Personal Professional Development modules[8]. This is a common feature.

The weakness in the EBM claim is apparent; it seems this former paradigm and EBM are actually more complementary than incommensurable. Modern day curriculums show paradigms have actually merged so they are not incommensurable at all. It would be inappropriate to call them Kuhnian at this point.

 Core Value #2: Sensitivity

An application of the EBM medical system to the steroids case highlights the need for an emphasis on good patient-doctor relations. The case can be made if the medical establishment cared about the community then they would have been sensitive to patient needs and allowed steroid use. The EBMWG place great emphasis on the evidence-based physician needing to have sensitivity to the patient’s emotional needs. The question must be asked in what way is this different to the former paradigm? Would it be appropriate on this basis to call the two paradigms incommensurable and thus Kuhnian?

The GMC recommend that doctors must maintain good relationships with their patients, be honest, trustworthy and act with integrity (GMC Guidelines, 2011). The majority of medical education places a great deal of emphasis on patient-doctor relationship through scenarios, role-playing and patient interaction. It appears there is no incommensurability; in fact here the two paradigms basically share the same core values.

Core Value #3: Basic sciences

An argument can be made that EBM would have discarded basic sciences and utilised the evidence based results of Patricia Crowley. Indeed the EBMWG downplay the importance of the basic sciences – they state that the former paradigm is too focussed on it. At the same time they appreciate that it has a part to play: “a sound understanding of pathophysiology is necessary to interpret and apply the results of clinical research”. Aside from the question of contradiction, another question is raised: if EBM and the former paradigm share core values how can it be said they are incommensurable?

This question leads to the answer that these two paradigms are actually more complementary than incommensurable. Although RCT’s are top of the hierarchy this leaves EBM in no-man’s land. Consequently the case is strengthened for not calling EBM’s medical education Kuhnian.

Conclusion

Section I showed some surface differences that EBM claims to have. Section II showed that actually the two paradigms are more complementary than incommensurable. It is difficult to label EBM as Kuhnian based on its core values.

 

Section III: Course Specifics of EBM Education

The top-down approach of this paper first considered EBM’s general ideology to education. Now Section III looks at how language specifically carries out this education.

Incommensurability & Language

One aspect of incommensurability is that the scientists in different paradigms cannot communicate with each other at all (Kuhn, 1996, 198). In order to clarify Okasha (85, 2002) cites the case of Newtonian and Einsteinian physics: ‘mass’ implied something different in each school therefore a good comparison cannot occur; the scientists would be speaking different languages. If EBM medical education is to be considered a new Kuhnian paradigm then surely it must fulfil Kuhn’s own criteria of an impossibility of communication between EBM medical teaching and the mainstream? There are two main criticisms to this.

 Firstly the teaching outlined in Sackett’s work in no way proposes or even hints that a new language needs to be used. Sehon and Stanley concur that physicians in each paradigm would not have any problem understanding each other. Those practitioners of EBM have no problem understanding mainstream medical thought and vice-versa – the proof of this is that EBM articles are published in multiple medical journals. How could this be the case if there was a barrier in communication? Crowley’s article does not use ‘new language’ nor was there a problem in her results being understood. According to EBM they were just ignored.

Secondly there is a more intricate problem with Kuhn’s suggestion. His ideology states that there would be a difficulty in communicating because one feature of incommensurability is that meanings change – Kuhn (198) states that:

The vocabularies in which they discuss such situations consist however predominantly of the same terms, they must be attaching some of those terms to nature differently, and their communication is inevitably only partial

Admittedly the emphasis of certain words and ideas would be different – for example undergraduates and newly qualified doctors would need more appreciation of RCT analysis therefore a certain terminology will be more prevalent. Nevertheless this would not to the point where a whole new lexicon is arrived at. However meanings have not changed – where in Crowley’s example is any of her words being used in a new format? This is not the case.

Summary

The tag of incommensurability implies a revolutionised language system but both medical education systems share similar vocabularies. It cannot be said that there is incommensurability and EBM is Kuhnian. The ideas are actually more complementary than opposing.

 

Conclusion

Kuhn did identify evidence as a necessary component of the paradigm structure (Gunn, 2005, 106) however he did not concentrate much on medicine. Gunn believes this is fair as medicine is too complex a domain to be simplified (2005, 108). Kuhn rarely mentions the relevance of revolutions and medicine – when the originator of the theory makes little attempt to tackle an issue, it is unlikely successors will make much headway.

Section I showed some surface differences to warrant an examination of the claim for incommensurability. The top-down approach first looked at the core values in Section II whilst Section III specifically examined language. Overall the EBM medical education as proposed by the EBMWG is more complementary than incommensurable with the former paradigm therefore it is not Kuhnian.

Sehon and Stanley (2003) feel that when EBM proponents suggest it is a new paradigm, this fosters the impression that it entails a new set of beliefs, values, techniques and that it is different to what came before it. In reality EBM is not independent – it is an addition to existing medical education[9]; now curriculums do teach about RCT’s and the hierarchy. Medical education still very much heads the same direction it did before EBM although there are little nuances to the latter.

Does EBM medical teaching constitute a Kuhnian paradigm? This paper has shown that it does not. Sehon and Stanley (2003) concur that there is no immense change in doctrine. Ultimately they conclude that if EBM bases the former paradigm on physiological mechanisms of the body and biochemicals properties of drugs then EBM is not a paradigm shift; they further go on to say that it is not clear what a Kuhnian paradigm is[10].

The problem in labelling EBM as Kuhnian partly arises because of Kuhn’s ideology: (1) what really defines a paradigm? Kuhn himself admits (1996, 175) there are at least two separate definitions; Lyons (2009) notes that paradigm can potentially have a range of meaning (2) Section III showed that the language aspect of Kuhn’s incommensurability has real practical problems when applied.

This paper has tried to show that the medical teaching system of EBM is not incommensurable with the alternative medical paradigm. This is not a licence to label the whole of EBM as not Kuhnian but it has been shown that the EBM medical education has difficulties in being labelled as incommensurable with what it claims to have replaced.

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[1] Gunn localises e-health as a key reason for the EBM explosion: online publications, online resources and databases all have optimised the quality of performance (2005, 112)

[2] He feels EBM has dressed up something which it is not and it is a non-theory as its assumptions are absurd. Couto (1992) feels very strongly that EBM proponents have conjured up this former paradigm as a  “fantasy” for their “crusade” and that it never existed

[3] Kuhn’s theory has generated a lot of interesting issues: he has challenged the conventional idea that scientific knowledge is cumulative and that science moves towards an objective truth

[4] This paper only looks at the claim of incommensurability on the basis of what EBM claims. The word limit restricts from discussion about the legitimacy of whether or not EBM is a new paradigm, whether a former paradigm existed, whether it has been replaced and so forth.  Couto (1992) feels very strongly that EBM proponents have conjured up this former paradigm as a  “fantasy” for their “crusade” and that it never existed

[5] It is important to note that EBM as outlined by the EBMWG is taught in McMaster’s University in Canada whilst the majority of the world’s medical schools follow what EBM calls the former paradigm

[6] Recently the PICO questionnaire was proposed to help generate the question: P standing for patient, I for the intervention needed, C for comparison and O for outcome (Goldenberg, 2010)

[7] Incommensurability caused many problems: if theories cannot be compared then how can paradigm choice occur? It implied science is directionless. Kuhn also stated that old and new theories are incompatible; how can they be incompatible if they are incommensurable and un-comparable? Kuhn was forced to modify his position in the postscript where he admitted comparison would just be difficult. The word limit constrains further discussion on the legitimacy of incommensurability though it is important to note it is has its issues

[8] Some form of evidence-based medicine is taught across London medical schools – for example St. George’s, University of London teaches the hierarchy early on in the second year in these modules

[9] This is not to downplay the importance of EBM: RCT’s and meta-analyses offer statistically significant evidence that have and can saved lives

[10] Indeed this is a very veritable point but merits its own exploration