Holistic thinking in medicine

EMERGING TRENDS IN MEDICAL THINKING

During the 20th century, the system of scientific medicine has made dramatic progress in curing and reducing the incidence of many diseases. There has been massive reduction in death rates all over the world resulting from the achievements of scientific medicine. Scientific medicine has been able to bring forth a large number of highly effective drugs that have been discovered through painstaking medical research. It has also brought about significant improvement in general public health and hygiene. The advances and success of scientific medicine in the field of surgery has truly been amazing. However, the modern scientific medicine has not proved very effective in handling a whole area of chronic illness and general, not very well defined, ill health. It is now increasingly being realized scientific medicine is not very successful in addressing the problems of ill health having their roots in psychosomatic, social, cultural, behavioural, environmental or occupational causes. It has been much more concerned with curing illness and bad health rather than in preventing them in the first place. It has not appreciated or understood the role of personal problems and social disorders that are often the root cause of illness. Indeed scientific medicine has concentrated far too much on treating the symptoms without seeking and dealing with the complex set of factors that are at the root of illness. Its major strength has become its weakness, in the sense that it places too much reliance on drugs and surgery, both of which many a times lead to side effects worse that the original disease. It is becoming increasingly clear that despite dramatic advancements, system of scientific medicine has serious limitations because its view of human existence and life is very narrow and restricted.

Various ancient, traditional and folk medical practices

Dissatisfaction with the deficiencies of the scientific medicine has lead to growing awareness and inquiry about various forms of the alternative and traditional methods of healing. Many techniques of alternative medicine are being explored ranging from ancient Chinese acupuncture and Indian Ayurved, through homeopathy, naturopathy and herbalism to radionics, psionic medicine, biofeedback and meditation. All these methods often show good to excellent results for a variety of health problems that have proved resistant to scientific medicine. Practitioners of these forms of medicine take great trouble to treat the human being as a whole rather than focus only on the removal or alleviation of particular symptoms. Despite the success of many of these systems, these systems also suffer from serious constraints. The practices and methods of these systems are based mostly on intuition and inner sense rather than on firm, observable and verifiable facts. The effectiveness of alternative medical therapies is notoriously difficult to research scientifically, using clinical trials. However, in the last few decades, serious efforts have been made in investigating these systems and attempts are being made to put their principles and methodologies on a firm scientific footing. The community of modern scientific medical practitioners is slowly, although grudgingly, coming to accept the usefulness of these alternative medical systems in many situations. The alternative medicine is slowly being used as complementary to scientific medicine. The diverse streams of alternative medicine are increasingly coming to be viewed as part of complementary medicine, as people and modern medical practitioners come to realize that these are indeed complementary to scientific medicine. In addition to these, there is also a vast range of techniques involving diet, exercise, massage, relaxation, yoga, psychotherapy etc. that are intermediate between orthodox and alternative ends of healing spectrum and, as such, also form parts of complementary medicine. The complementary medicine is also closely linked to preventive medicine. Therefore, it should be adopted more extensively for radical improvements in general health and its maintenance. Healers have used a variety of ‘energies’ since antiquity in dealing with problems of health and illness without more than an intuitive knowledge of what these ‘energies’ are and without any understanding of their status. Vibrational medicine attempts to heal illness by influencing these energy fields, by directing these energies into the body instead of manipulating the constituent parts of the body by drugs or surgery. Some of these energy fields may be physical but others seem to be subtler and of a paraphysical nature that is not understood by contemporary science. Richard Gerber in his remarkable book Vibrational Medicine (1988) has attempted to address in detail various questions about the nature of healing and healing energies in general. He has particularly explored the possible physical components of these ‘healing energies’ and possibilities of developing new technologies to detect and measure them. The book explores different medical paradigms and paradigms of the whole human being that are now being developed and considers how recent advances in physics and electronics can extend the frontiers of scientific medicine. Gerber introduces a new view of human being as a multicellular organism consisting of physical cellular systems interacting with complex regulatory energy fields. In some ways, this approach is similar to Rupert Sheldrake’s biological approach. Another important physical principle that has bearing on the vibrational medicine is the ‘holographic principle’. This principle states that every part of a ‘holographic system’, such as a human being, contains information about the whole and implies that every part can influence and is influenced by the whole. With the growing realization of the extremely complex nature of the human existence, there has evolved the concept of holistic medicine. The holistic medicine aims to treat the whole human being and understand the intimate links between the body, mind and spirit. It stresses that all the three have to be embraced to achieve lasting and effective healing. A closer examination shows that complementary medicine is quite similar and largely overlaps the holistic medicine. Both complementary medicine and holistic medicine give priority to making people feel that they are important and need to take responsibility for their own health. Both stress the undesirability and futility of being passively dependent on medical system for cure of illness and maintenance of health. In most of true healing, the patient consciously and actively cooperates with the therapist. The therapist only provides the necessary conditions that enable the patient to help oneself to get well again. In many, though not all situations, patients can ‘think themselves well again’ by practicing various forms of positive thinking. Holistic medicine is much influenced by the view of Abraham Maslow (1954) who has suggested that there is a heirarchy of human needs and every human strives to experience ‘peak experience’ at each of its levels. With such a view, it is evident that the important part of healing process is to release the human potentialities and to encourage the emergence of ‘peak experiences’ explored extensively by Maslow. Holistic approach to human health and medicine is vitally important because it suggests and encourages caring and can make extensive contributions to improving the quality of life and health among people of all ages. Emergence of holistic thinking

The primitive societies have an instinctive holistic view, which is derived from their knowledge of the local ecosystems in their environment. Each such society treats the local ecosystem as dominant and makes all human activities subservient to it. This approach is also observed in ancient and oriental civilisations. The holistic thinking continued to prevail in the western world in some or the other form up to the Renaissance Period. However, with the rise of scientific movement in the mid-17th century, the materialistic-mechanistic world-view and the reductionist approach to analysis became dominant. This led to shifting of focus from the whole to parts and the holistic thinking was gradually abandoned. The non-holistic nature of much of the modern education leaves most the people with conceptual frameworks that are too narrow to allow holistic thinking. However, there has been a decline in reductionist thinking in the last few decades. Serious attempts are now being made to build a synthesis of ideas and evolve holistic paradigms in every field. The 20th century has seen the emergence of a variety of new paradigms simultaneously in various scientific fields that that forced to philosophy to re-examine the reductionist approach resulting in the emergence of holistic thinking in philosophy. This new approach in philosophy together with new paradigms in various scientific and other fields provide the basis of modern holistic thinking. John Smuts has formulated the original version of ‘holism’ in his book HOLISM AND EVOLUTION. He believed that the new thinking and convergence in science and philosophy would lead to emergence of new points of view. There would be shift from mechanistic world-view to a wider view of finding ways to link concepts together. It would thus be possible to explore further the relationship between mind, knowledge and matter. Smuts worked out an ascending order of wholes, culminating in final values, which, when set free from human personality, are seen as the creative factors in developing ideas and spiritual values. This is an evolutionary and spiritual approach to holism having links with the concept of ‘noosphere’ given by Pierre Teilhard de Chardin. The concept of noosphere has been introduced within the broader evolutionary conceptual framework. The life is explained in terms of natural evolution of self-organizing matter. The evolution, however, is viewed as purposive, leading via man to an eventual ‘Omega point’, a sort of convergence between mankind, the noosphere, and God. A.N. Whitehead, in his book SCIENCE AND MODERN WORLD (1925) developed the theory of Organic Mechanism and proposed that the human life history is a part within the life history of some larger, deeper, more complete pattern (p. 109). In his book ADVENTURES OF IDEAS (1933), he developed integrated philosophical apparoach and pioneered a move towards systems thinking which views science and philosophy as different aspects of the human mind. J.G. Bennett in his four-volume book THE DREAM UNIVERSE (1956-1966) attempted to bring all scientific knowledge within the scope of one comprehensive theory of existence. Dealing with all branches of science, the theory shows the relations between them in terms of a set of fundamental categories derived from empirical observation, a geometry of six dimensions and a set of existential hypotheses defining the subject matter of the chief scientific disciplines. Oliver Reiser in the book THE INTEGRATION OF HUMAN KNOWLEDGE(1958) sought techniques for the integration of all human knowledge and offered a basis for both individual philosophy and a world philosophy. He advocated a synthesis of science and philosophy, and a re-evaluation of man’s knowledge of himself and of the sciences to develop a system of thought linking man to the universe. In COSMIC HUMANISM(1966), he presented a theory of an eight-dimensional cosmos, based on integrative principles from science, religion and art. In COSMIC HUMANISM AND WORLD UNITY (1975) he further developed the concepts of cosmic humanism stating that it “is a complete world view, a theory of knowledge, a cosmology and a possible universal religion” In the scientific field, some new paradigms have been major influences in emergence of holistic thinking. Important amongst these are Relatively Theory, Quantum Mechanics, Big-Bang theory of the origin and evolution of Universe, General Systems Theory, non-equilibrium thermodynamics, mathematics of chaos and fractals, Gaia-hypothesis etc. Ludvig von Bertalanffy, the founder of General Systems Theory, in his book PROFILES OF LIFE (1952) proposed an organic theory of life. He expressed the view that the phenomenon of life can not be resolved into elementary units, but depends upon interactions, organization and dynamic order. Arthur Koestler in rejecting the reductionist philosophy developed the concept of ‘HOLON’ as a system consisting of subsystems, which is also a subsystem of some supersystem. He further developed the concept of SOHO (Self-regulating Open Heirarchic Order), which is an explanation of a form of dynamic equilibrium (‘homeostasis’) that will occur only if the self-assertive and integrative tendencies of the components of holons counterbalance each other. If this does not happen, there will be disorder and chaos. His theory has profound implications for society and for understanding the human health in totality. The shift from reductionist to holistic thinking is obvious in various fields of knowledge but what about the consequent social change? Social change is usually evolutionary, but occasionally it is revolutionary and is accompanied by a social paradigm shift. A social paradigm is a constellation of attitudes, beliefs, values and experiences, shared by most of the members of a society and enabling them to communicate successfully and effectively with one another (Kirk McNulty, 1989). The last shift of social paradigm in Europe, from the ‘Medieval Paradigm’ to the ‘Industrial Paradigm’ started during Renaissance. The next shift seems to be a ‘Consciousness Paradigm’ that is underway now (Willis Harman, 1988). The direct observation of a variety of new paradigms provides an evidence for this paradigm shift. In addition, evidence for such shift is also provided by sample survey data about people’s attitudes and attitude shifts. The ‘Consciousness Paradigm’ seems to be very like the new holistic paradigm.

Concept of holistic health

In the context of human life, the shift from reductionist to holistic thinking may be seen in the following words of Peter Russell (1982): “For humanity to accomplish a profound shift in attitude, the skin-encapsulated model of the self needs to be augmented by the realization that the individual is an integral part of Nature, no more isolated from the environment than a cell in the body is isolated from the human organism. In the last quarter of 20th century, it has been gradually realized that before we can devise ways and means for making and maintaining a human being healthy, it is necessary to first understand what is to be accomplished. This means that we should first understand what is the meaning of health of a human being. To achieve a state of health, it is necessary to understand the development and functioning of cells and organs. However, in the broadest sense, it is also necessary that we understand the development and functioning of an individual in his/her personal psychological, familial, occupational, cultural and social environment as well as of the human species in the global environment. If health of a man is to fully manifest, it must prevail not only in the individual but in mankind also. Jonas Salk (1972) has defined the health as following: “The health is wholeness and sickness implies impairment of parts of the whole. Distinctions must be made and the relationship understood between the parts and the whole, so that attention may then be directed to maintaining or to repairing the health of each appropriately. The meaning of the health as a wholeness can be revealed only if distinction between the parts and the whole and the relationship between them is properly understood.” The problem of man’s health can not be dealt with by solving the problems of individual human body and the environment. Even if these problems are solved, it will still be necessary to deal with the health of the human species as a whole. A human being can attain and maintain a state of health only in a helathy biosphere, sociosphere and psychosphere. In this sense, human species needs to be studied from the viewpoint of health as wholeness. A science of holistic health, as distinct from the present science of curative medicine, needs to be developed to deal with the problems of sickness and misery arising in the bodies, psyche, society and environment of mankind. Jonas Salk has pointed out that for developing a system of holistic health, it is necessary to first think about the mankind in terms of highly ordered, differentiated system of individuals having widely different attributes, characteristics and requirements. Only by thinking in these terms can it be possible to focus attention on the relationship between the parts i.e. the individuals and the whole i. e. the human species. An understanding of the relationship of individuals to each other and to the whole mankind is the starting point. This shall lead to the comprehension that human health is not only a question of the health of one part to the exclusion of another or of one part functioning against another, but as the health of the whole. The Health Promotion Programme established by World Health Organization in 1984 firmly recognizes the need to adopt the emerging holistic thinking while dealing with problem of human health. The following five principles of health promotion were established in the WHO programme: It involves the people as a whole in the context of their everyday life. It is directed to actions towards the root causes of health, including the promotion of a total environment conducive to health. It combines different but complementary methods and approaches, in several areas of life. It aims especially as effective actual public participation. While it basically requires activities in the health and social fields, and is not a medical service as such, health professionals should develop their special contributions to health education and health advocacy, especially in primary health care.

Concepts of Ayurved

CONCEPTS OF AYURVEDA
Like any specialized body of knowledge, Ayurved is also based on specific concepts about the areas with which it deals. These concepts form the basis of organizing the framework of its practices. Ayurveda defines a human as the assemblage of the five great elements plus the "immaterial self".

Concept of Self
The Self, as this inner dimension of our nature is called in Ayurveda, is the central point of our being, the hub of the wheel. It is the true inner center of our diversified lives. Thought, feelings, speech, action, and relationships all originate here, deep within the personality. The whole person-and the whole field of interpersonal behavior-can be spontaneously enhanced by the process of self-referral, or looking within to experience the Self. This is analogous to the natural process by which all the branches, leaves, flowers, and fruit of a tree can be simultaneously nourished and enlivened by watering the root. The Self can be directly experienced. Those who do experience it find it to be deeply peaceful, yet a reservoir of creativity, intelligence, and happiness that spills over into all phases of living.

Concept of Panchmahabhuta (The Five Element Theory)
Ayurveda believes that everything in this universe is made up of five great elements (Panchmahabhutas) or building blocks. These are Prithvi (earth), Jal (water), Agni (fire), Vayu (air), and Akasha (ether).

Prithvi (Earth) represents the solid state of matter. It manifests stability, permanence and rigidity. Prithvi (Earth) is considered a stable substance. It is representative of the solid state of matter; it manifests stability, fixedness and rigidity. Our body also manifests this earth/solid-state structure. In our body, the parts such as bones, teeth, cells and tissue are manifestations of the Prithvi. Bones, cells and tissue are physical structures through which our blood courses and oxygen is transported.

Jala (Water) characterizes change and represents the liquid state. Jala is considered a substance without stability. It is necessary for the survival of all living things. Jala is a substance without stability. Jala characterizes change. In the outer world, water moves through the cycle of evaporation-clouds-condensation-rain. It moves around solid matter such as rocks and mountains and it eventually wears away solid, immovable matter. Jala carries dissolved soil and nutrients along with it. A large part of the human body is made up of water. The blood, lymph, and other fluids that move between cells and through vessels are manifestations of Jala. The blood, lymph, and other fluids move between the cells and through the vessels, bringing energy, carrying away wastes, regulating temperature, bringing disease fighters, and carrying hormonal information from one area to another.

Agni (Fire) is the power that transforms the state of any substance. Agni (Fire) is considered a form without substance. . It transforms solids into liquids, to gas, and back again. The heat of the sun melts ice into water that becomes vapor under its influence. Fire provides power to the water and weather cycles of nature. Agni (Fire) binds the atoms of molecules together in the living bodies. It converts food to fat (stored energy) and muscle and turns (burns) food into energy. Agni creates the impulses of nervous reactions, feelings, and even thought processes.

Vayu is mobile and dynamic substance. Vayu is the form of matter that is mobile and dynamic. Air is existence without form. We do not see the air that blows through the tree's leaves, but we feel it. It is a key element required for fire to burn. It can respond to energy, absorb it, and give it off as in a hurricane, typhoon or tornado. We feel air as it courses down our throats and into our lungs. It is most essential for the maintenance of life. Vayu is the basis for all transfer reactions within the body.

Akasha (Ether) is the space in which everything happens. It is the field that is simultaneously the source of all matter and the space in which it exists. Akasha is only the distances that separate matter. Akasha is the space in which everything happens, the distance between things -- that helps to define one thing from another. The chief characteristic of Akasha is sound. Here sound represents the entire spectrum of vibration. Like outer space with millions of miles between celestial bodies there is inner space of our bodies between the atoms.

According to the Panchmahabhutas (five elements) Theory of Ayurveda, the human being is a small model of the universe. What exists in the human body exists in altered form in the universal body. Ayurveda believes that everything is made up of Panchmahabhutas (five elements), or building blocks. Their properties are important in understanding balances and imbalances in the nature as well as in the human body. All substances can be classified according to their predominant Mahabhuta (element). For example, a mountain is predominantly made up of earth element. A mountain also contains water, fire, air and ether but the proportions of these substances are very small in it as compared to the earth. So, it is classified as the earth. In Ayurvedic philosophy, the Panchmahabhutas (five elements) combine in pairs to form three dynamic forces or interactions called Doshas.

Concept of Tridosha (Three dynamic forces)
In Ayurvedic philosophy, the Panchmahabhutas (five elements) combine in pairs to form three dynamic forces or interactions called doshas. The term Dosha means "that which changes" because doshas are constantly moving in dynamic balance, one with the others.. It is a word derived from the root ‘dus’, which is equivalent to the English prefix 'dys', such as in dysfunction, dystrophy, etc. In this sense, dosha can be regarded as a fault, mistake, error or a transgression against the cosmic rhythm. The doshas are constantly moving in dynamic balance, one with the others. Doshas are required for the life to happen. In Ayurveda, dosha is also known as the governing principles as every living things in nature is characterized by the dosha. Doshas are primary life forces or biological humors. They are only found in life forms (similar to the concepts of organic chemistry), and their dynamism is what makes life happen. The three active doshas are called Vata, Pitta and Kapha.

Vata (Va-ta) is conceptually made up of the elements ether and air. The proportions of ether and air determine how active Vata is. The amount of ether (space ) affects the ability of air to gain momentum, as expressed in Vata. In the body, Vata is movement (a dynamism of the combination between ether and air), and manifests itself in living things as the movement of nerve impulses, air, blood, food, waste and thoughts. Vata is a force conceptually made up of elements ether and air. The proportions of ether and air determine how active Vata is. The amount of ether (space) affects the ability of the air to gain momentum. If unrestricted, as in ocean, air can gain momentum and become forceful such as a hurricane. Vata means "wind, to move, flow, direct the processes of, or command". Vata enables the other two doshas to be expressive. The actions of Vata are drying, cooling, light, agitating, and moving. Vata governs breathing, blinking of the eyelids, movements in the muscles and tissues, pulsations in the heart, all expansion and contraction, the movements of cytoplasm and the cell membranes, and the movement of the single impulses in nerve cells. Vata also governs such feelings and emotions as freshness, nervousness, fear, anxiety, pain, tremors and spasms. The primary seat or location of the Vata in the body is the colon. It also resides in the hips, thighs, ears, and bones, large intestine, pelvic cavity, skin, and is related to the touch sensation. If the body develops an excess of Vata, it will accumulate in these areas. Vata has seven qualities viz. coldness, lightness, irregularity, mobility, rarefied, dryness, and roughness. These qualities characterise their effect on the body. Too much Vata force can cause nerve irritation, high blood pressure, gas and confusion. Too little Vata, we have nerve loss, congestion, constipation and thoughtlessness. When the movement of air is unrestricted by space (as in the open ocean) it can gain momentum to become hurricane winds moving at speeds of over 150 mph. When air is restrained in a box, it cannot move and becomes stale.

Pitta (Pit-ta) is conceptually created by the dynamic interplay of water and fire. These two seemingly opposed forces represent transformation. They cannot change into each other, but they modulate each other and are vitally necessary to each other in the life processes. In our bodies Pitta is manifested by the quality of transformation. Pitta is responsible for digestion of our food and the regulattion of our metabolism. In the mind, the Pitta is transforms impulses into understood thoughts. Too much Pitta can cause ulcers, hormonal imbalance, irritated skin (acne), and consuming emotions (anger). Too little Pitta causes indigestion, inability to understand, and sluggish metabolism The Pitta is described according to eight characteristics viz. hotness, lightness, fluidity, subtleness, sharpness, malodorousness, softness and clarity. When you boil water on a fire, if the fire is too hot, all the water boils away and the pot burns. If you put too much water into the pot, it overflows and puts out the fire. Pitta is a force created by the dynamic interplay of water and fire. These forces represent transformation. They cannot change into each other, but they modulate or control each other and are vitally required for the life processes to occur. (For example, too much fire and too little water will result in the boiling away of the water. Too much water will result in the fire being put out.). Pitta governs digestion, absorption, assimilation, nutrition, metabolism, body temperature, skin coloration, the luster of the eyes: and also intelligence and understanding. Psychologically, pitta arouses anger, hate and jealousy. The small intestine, stomach, sweat glands, blood, fat, eyes and skin are the seats of Pitta.

Kapha (Ka-pha) is the conceptual equilibrium of water and earth. Kapha is structure and lubrication. One can visualize the Kapha force as the stirring force to keep the water and earth from separating. For example, if we take a pot, fill it half with water and then add sand to it, the sand will gradually sink to the bottom of the pot. (It separates from the water). The only way to keep the sand in equilibrium with the water and separate is to stir the mixture continuously. The Kapha force can be visualized as this stirring force in our body. Kapha cements the elements in the body, providing the material for physical structure. This dosha maintains body resistance. Water is the main constituent of Kapha, and this bodily water is responsible physiologically for biological strength and natural tissue resistance in the body. Kapha lubricates the joints, provides moisture to the skin, helps to heal wounds, fills the spaces in the body, gives biological strength, vigor and stability; supports memory retention, gives energy to the heart and lungs and maintains immunity. Kapha is present in the chest, throat, head, sinuses, nose, mouth, stomach, joints, cytoplasm, plasma and liquid secretions of the body such as mucus. Psychologically, Kapha is responsible for emotions of attachment, greed and long-standing envy. It is also expressed in tendencies toward calmness, forgiveness and love. The chest is the seat of Kapha.


Concept of cause-effect
In the Ayurvedic organization of cause and effect, too much Kapha causes mucous buildup in the sinus and nasal passages, the lungs and colon. It creates rigidity, a fixation of thought and inflexibility in the mind. If not enough Kaph is present, the condition causes the body to experience a dry respiratory tract, burning stomach (due to lack of mucous, which gives protection from excess stomach acids), and inability to concentrate. The Kapha has the qualities of oiliness, coldness, heaviness, stability, denseness and smoothness.

When a handful of sand is thrown into a container of water, the two will separate as the sand settles to the bottom. Only by continuous stirring will the mixture remain in balance. The force of Kapha is like the stirring, maintaining the balance of Jala (water) and Prithvi (earth).

Like And Unlike

Anything that enters our body (microcosm) can exert three possible effects on the organism.

It can act as food. This nourishes the organism
It can act as medicine. This balances the organism.
It can act as poison. This disturbs the organism.
The five elements may exert one, two, or all three of these effects. The rule that governs the interaction between the environment and the organism is the Law of Like and Unlike. Like increase like. Unlike decreases like.

For example, when you lie in full sun, your body temperature goes up. Similarly, when you take bath in cold water, your body temperature goes down. Everything you experience, food, medicine, or poison, increases like parts of your microcosm and decreases those parts that are unlike it. Similarly, thought also enters your microcosm. Thought can be positive or negative and will influence your being. Positive thoughts increase while negative thoughts decrease the well being of personal self.

Knowing what is good and what is bad for the personal self enables one to make informed choices in the life. Harmonious thoughts and attitudes actually induce prosperity while disruptive thoughts and deeds lead to ultimate ruin of the microcosm that is an individual.

Concept of sickness
Ayurveda holds that specific disease conditions are symptoms of an underlying imbalance. It does not neglect relief of these symptoms, but its focus is on the big picture: to restore balance and to help create such a healthy lifestyle that the imbalance won't occur again. Living in health and balance is the key to a long life free from disease. Perhaps the most important lesson Ayurveda has to teach is that our health is up to us. Every day of our lives, every hour of every day, we can, and do, choose either health or illness. When we choose wisely, nature rewards us with health and happiness. When we persistently choose unwisely, nature, in her wisdom, eventually sets us straight: She makes us sick and gives us a chance to rest and rethink our choices.

This approach of Ayurveda is fundamentally huministic-holistic in stark contrast to reductionist-mechanist approach of modern scientific medicine.

Concept of Prakruti and Vikruti
According to Ayurveda, the basic constitution of a body is determined at the time of conception. This constitution is called Prakruti. The term Prakruti is a Sanskrit word that means, "nature," "creativity," or "the first creation." One of the very important concept s of Ayurveda is that one's basic constitution is fixed throughout his lifetime. The combination of Vata, Pitta, and Kapha that was present in the individual at the time of conception is maintained throughout his lifetime. This is the base point. Different persons can have different combination of Vata, Pitta and Kapha as their basic constitution or Prakruti. This is how Ayurveda explains the subtle differences between individuals. This also explains why everyone is unique and that two persons can react very differently when exposed to the same environment or stimuli. The Prakruti is unique to a person just as like fingerprint and DNA. Thus, in order to understand a person, it is necessary to determine his or her Prakruti. Ideally, the basic constitution should be maintained throughout the life. Unfortunately, this is not the case. Every person is subjected to constant interaction with his or her environment that affects the person's constitution at any given time. The body continuously tries to maintain a dynamic equilibrium or balance with the environment. The current actual condition of the body is called vikruti. Although it reflects the ability of the body to adjust to various influences and is always changing, it should match the prakruti, or inborn constitution, as closely as possible. If the current proportion of your doshas differs significantly from your constitutional proportion, it indicates imbalances, which in turn can lead to illness. Farther the Vikruti is from the Prakruti, more ill the body becomes. Ayurveda teaches that the Vikruti can be changed by various means such as diet and meditation so as to approach the Prakruti or the state of perfect health. The concept of Prakruti and Vikruti can be illustrated by reference to our body temperature. When healthy, we maintain an average body temperature of about 98 degrees F. Though different persons may have different base temperatures, it does not change much so long as the person is healthy. When we go outside on a winter day, our body temperature may go down slightly; but will pick right back up to the normal if we are healthy. Similarly, jogging on a hot day can temporarily raise our body temperature. When we are sick, or catch a cold, our body temperature will go up. This indicates that we are sick or outside our normal base condition. We may take medicine to bring the body temperature back to the normal range. In analogy to Ayurveda, our present temperature may be considered as Vikruti and the difference between the Prakruti (our normal temperature) and Vikruti (our present temperature) can determine whether any medical intervention is required. Just like an allopathic doctor will take your temperature and blood pressure routinely as the first step in diagnosing your condition, Ayurvedic practitioners starts with determination of Prakruti and Vikruti as the first step in diagnosing the condition of an individual. Hence, prior to embarking on a journey to perfect health and longevity, it is important to understand one’s Prakruti and Vikruti and determine how far separated these are. Armed with this knowledge, we can map a treatment strategy. This is the basic premise of Ayurveda.

Changing Tridhoshas
According to Ayurved, the three Tridoshas are constantly changing and balancing each other in living things. They make life happen. In a plant, the Vata is concentrated in the flowers and leaves (which reach farthest out into space and air). The Kapha is concentrated in the roots (where water is stored in the embrace of earth) and Pitta is found in the plants' essential oils, resins and sap (especially in spices which stimulate digestion). Different plants have different concentrations of Vata, Pitta & Kapha. Therefore, the use of different foods, plants, and specific plant parts can alter the body's proportion of Vata, Pitta & Kapha. Eating root vegetables, milk products, or sedating herbs like valerian, increases our Kapha. Drinking herbal flowers like jasmine, or eating dry grains, increases our Vata. Eating hot, spicy foods like cayenne, or concentrated protein like bee pollen, increases our Pitta tendencies.

Concept of The Six Tastes
Scientifically, finding out a balanced diet requires the understanding of the different food groups, nutrient values of the food and an understanding of the daily requirements of the. An unbalanced diet results in the deficiency or excess of the nutrients in the body. Ayurveda had developed a very simple system of identifying balanced diet for a body. This is called the system of six tastes. Ayurveda recognizes only six basic tastes. It postulates that all the important nutrients that are needed for life are contained in a meal that consist of all the six tastes. The six tastes are sweet, sour, salty, bitter, pungent, and astringent. All the food items are categorized according to their predominant taste. Any meal that contains food items from all these six tastes will be a balanced meal. It has all the nutrients for the proper functioning of the body and will balance all the doshas.

Ayurveda recognized how the six tastes affect the doshas. It, therefore, uses the taste of food items in bringing about the required modification in the dosha status of a body. In the Ayurvedic system, the taste of different food items has central place in coming up with a proper diet in case of imbalances in our doshas or vikruti. For example, a woman who is a few days away from her monthly period, will feel bloated from fluid retention. This is also accompanied by mood change and depression (we call this PMS). Ayurvedically speaking, these all mean that the Kapha is out of whack, an excess of Kapha in the system prior to menstruation period. In order to reduce Kapha, Pungent (onions, radishes, garlic, ginger, cumin etc.), Bitter (green leafy vegetables such as spinach, bitter greens, turmeric) and astringent foods (such as lentils, broccoli, cabbage etc.) are required. Sweet foods (candy bar) or salty food (such as potato chips, salted nuts etc.) obviously will make things worse. Similarly, for a person who feels very angry or irritated (signs of Pitta imbalance), foods that are sweet, bitter or astringent will be helpful. Herbs are also be used according to their taste.

Effect of Sweet Taste

Effect on Tridosha: Decreases Vata. Decreases Pitta. Increases Kapha
Property Cooling (Earth + Water)
Source/Example Fruits with natural sugar such as peaches, sweet plums, grapes, melons, and oranges. Vegetables such as sweet potatoes, carrots, and beets. Milk, butter, and whole grains such as rice and wheat bread. Herbs and spices such as basil, licorice root, red cloves, peppermint, slippery Elm and fennel. Ayurveda recommends avoidance of highly processed sweets such as candy bars and sugar, which also contain additives, food coloring, and preservatives.
Actions Sweet is the taste of pleasure. It makes us feel comforted and contented. It is one of the most important healing tools for debilitating weakness in Ayurveda. Nourishing and strengthening and promotes growth of all tissues, so is good for growing children, the elderly, and the weak or injured. Increases ojas and prolongs life. Good for hair, skin and the complexion, and for healing broken bones. Adds wholesomeness to the body. Increases Rasa, Jala and ojas. Relieves thirst. Creates a burning sensation. Nourishes & soothes the body.
Disorders In excess, sweet taste promotes Kapha imbalances and disorders such as heaviness, laziness, and dullness, colds, obesity, excessive sleeping, loss of appetite, cough, diabetes & abnormal growth of muscles.



Effect of Sour Taste

Effect on Tridosha: Decreases Vata. Increases Pitta. Increases Kapha
Property Heating (Earth + Fire)
Source/Example Yogurt, vinegar, cheese, sour cream, green grapes, lemon (and other Citrus fruits), Hibiscus, rose hips, tamarind, pickles, Miso(fermented soybean paste) and herbs such as caraway, coriander and cloves.
Actions Creates a feeling of adventurousness. Adds deliciousness to food. Stimulates appetite & sharpens the mind. Strengthens the sense organs. Causes secretions & salivation. Is light, hot & unctuous. Good for the heart, digestion and assimilation. Helps in dispelling gas.
Disorders Increases thirst, sensitivity of teeth, closure of eyes, liquefaction of kapha, toxicosis of blood, Edema, Ulceration, Heartburn & acidity. Causes weakness and giddyness. It also may cause itching, irritation, thirst, and blood toxicity.



Effect of Salty Taste

Effect on Tridosha: Decreases Vata. Increases Pitta. Increases Kapha
Property Heating (Water + Fire)
Source/Example Table salt, Sea Salt, Rock Salt, Kelp, sea weeds.
Actions A basic unit of electricity, salt helps retain moisture in vata. Helps digestion. Acts as an Anti-spasmodic & Laxative. Promotes salivation. Nullifies the effect of all other tastes. Retains water. Heavy, unctuous, hot.
Disorders Excess salt can aggravate skin conditions, weaken the system, cause wrinkling of the skin and graying and failing out of hair. It promotes inflammatory skin diseases, gout, and other Pitta disorders. Disturbs blood. Causes fainting & heating of the body. Causes peptic ulcer, rash, pimples & hypertension.



Effect of Bitter Taste

Effect on Tridosha: Increases Vata. Decreases Pitta. Decreases Kapha.
Property Cooling (Air + Ether)
Source/Example Dandelion Root, Holy Thistle, Yellow Dock, Rhubarb, bitter melon, greens such as Romaine lettuce, spinach, and chard, fresh turmeric root, fenugreek, Gentian root.
Actions Considered one of the most healing tastes for many kind of imbalances in the mind-body. Bitter foods and herbs are drying and cooling and create lightness. Promotes other tastes. Acts as an Antitoxic & Germicidal. Is an antidote for fainting, itching & burning sensations in the body. Relieves thirst. Good for reducing fevers. Promotes digestion. Cleansing to the blood and helps remove ama in system.
Disorders Too much bitterness can cause dehydration. It can also increase roughness, emaciation, dryness. Reduces bone marrow & semen. Can cause dizziness & eventual unconsciousness.



Effect of Astringent Taste

Effect on Tridosha: Increases Vata. Decreases Pitta. Decreases Kapha.
Property Cooling (Air+ Earth)
Source/Example Unripe banana, cranberries, pomegranate, Myrrh, goldenseal, turmeric, okra, beans, mace, parsley, saffron, basil, and alum.
Actions Astringent foods and herbs squeeze out water. Drying and firming, astringent taste stops diarrhea, reduces sweating, and slows or stops bleeding. Causes constriction of blood vessels & coagulation of blood. Anti-inflammatory. Promotes healing. Has a sedative action, but is constipative. Is dry, rough, cold.
Disorders Excess astringent is weakening and causes premature aging. Its drying effect causes constipation and retention of gas. Promotes dry mouth. Promotes Vata disorders such as paralysis and spasms. Obstruction of speech. Too much astringent taste can adversely affect the heart.



Effect of Pungent Taste

Effect on Tridosha: Increases Vata, Increases Pitta, Decreases Kapha
Property Heating, (Fire + Air)
Source/Example Onion, radish, chili, ginger, garlic, asafoetida, cayenne pepper, black pepper, mustard.
Actions Stimulates appetite and improves digestion. Gives mental clarity. Helps cure Kapha disorders such as obesity, sluggish digestion & excess water in the body. It improves circulation, is germicidal, stops itching, facilitates sweating and elimination of ama (toxic accumulations). Keeps the mouth clean. Purifies the blood, cures skin disease, helps to eliminate blood clots, cleanses the body keeping it light, hot & unctuous.
Disorders Too much pungent taste can cause weakness, feeling of weariness, impurities, burning sensations in the body. Increases heat, sweating, can cause a peptic ulcer, dizziness & unconsciousness.

Concepts of Rasayana-Tantra
Rasayana Tantra is one of eight major specialities of Ayurved. This branch refers to nutrition, natural resistance and geriatrics. According to the Ayurvedic concept, Rasayana can be a drug, a food or a life-style (Achara). Achara rasayana forms important part of the Rasayan Tantra. According to Ayurved, a Rasayana helps in strengthening Oja, Bala and Vyadhikshamatva.

Bhel Samhita clearly indicates that there are twelve types of Oja. The Oja is essence of all the Dhatus. It also indicates their sites. The Ahara, Vihara, and Manasa Bhava, if properly used, support Ojas but if abused, they have bad effect on it.

Three types Bala are recognized. These are Sahaj Bala– the power that is naturally present, Kalaj Bala– power that comes with passage of time i.e. season and changes in age and Yuktikrita Bala– power that is provided through therapeutic measures viz. Rasayan prayoga (use of Rasayana) etc. The Bala is influenced by a variety of factors. The Tridoshas i.e. Vata, Pitta and Kapha influence the Bala mainly through the Prakriti. The Agni is another factor influencing Bala. The Prana and Bala, both produced by Oja, are synonyms of Kshamatva.

The Vyadhikshamatva is capacity of the body to limit virulence of the factors producing disease. It is of two types namely Vyadhi-Utpad-Pratibandhakatva (the capacity to restrict the products of disease) and Vyadhi-Bal-Virodhakatva (the capacity acting against the force of disease). Dhatu-Sarat, especially that of the Shonit (blood), Mamsa (Flesh) and Asthi (bones) result in good Vyadhikshamatva. Samhat-Sharira i.e. a well-nit, compact and well-composed body has good Vyadhikshamatva and is said to resist the ill effects of a disease in efficient manner.

Concepts of modern medicine

CONCEPTS OF SCIENTIFIC MEDICINE
The modern scientific medicine as known today may be considered to have truly originated in the last century when medical scientists began to systematically investigate the structure and function of the human organism in its condition of health and disease. At that time, the break with previous traditions had caused considerable paradigmatic unrest, which had lead to much philosophical discussions in medical literature. However, towards the end of the last century, it came to be generally accepted that medicine was a branch of natural science and that the disease process should be examined in anatomical and physiological terms. This view lead to general acceptance of the biological theory (mechanical model) of disease forming the most important component of the paradigm of medical thought. Therefore, the most important concepts of modern scientific medicine are related to the questions of disease or illness in contrast to health and to the question of disease entity.

Illness and health are important medical terms as the aim of all medical activity is to eliminate illness and preserve health, but they are also important words in the ordinary vocabulary of any language. The medical practitioners tend to define these concepts in biological or mechanistic terms whereas these words in the ordinary language usually refer to the subjective feelings of the individual person. On the other hand, disease terms almost exclusively the medical ones. The disease terms have no precise meaning except in the context of medical science.

Biological theory (mechanical model) of disease
Successive generations of medical scientists have developed the biological theory of disease according to which disease is regarded as a fault in the 'biological machine' i.e. the human organism and, therefore, it is also called the 'mechanical model'. The philosophical position of this theory is that of biological reductionism i.e. it reduces the human beings to biological organisms and human medicine to a branch of biology. The theory assumes that if full specifications of the structure and function of human organism are known then it would be possible to establish in each and every case whether that human being is ill or healthy. The question of health, illness and disease is considered to be a purely biological question and not a question of the feelings or personal norms. The theory totally disregards such concepts as 'vital principle' or 'the soul'.

Concept of normality
It is quite obvious that complete specifications of the human organism are not available to medical science. This problem of specification is usually solved by resorting to the statistical concept of normality. However, it is quite unsatisfactory to equate health with statistical normality since it invites circular arguments. In view of this, it has been pointed out by various workers that biological concept of health presupposes a non-statistical biological definition of health or normality. Workers like Christopher Boorse, Alf Ross and G. Scadding have suggest that the biological organism is healthy if its body functions with atleast species-typical efficiency i.e. it functions according to the normal plan for the species. The species-specific design is regarded as the typical hierarchy of interlocking functional systems that support the life of an organism of that kind. Disease is regarded as a deviation from the typical species design. This means that the disease is the sum of the abnormal phenomena in association with a specified common characteristics displayed by a group of living organisms by which the group differs from the norm of the species. The difference from the species normal places the members of the group at a biological disadvantage.

The problem of threshold
The adoption of the biological yardstick of the state of health in the form of species-design or the normal plan for the species creates an intriguing problem. This yardstick requires prior decision as to how large the deviation from this species design should be taken to identify the illness condition. Scadding ( ) has conceded that the distinction between health and disease may require the insertion of carefully chosen, but more or less arbitrary, quantitative statements about the magnitude of deviation from the mean of normal values that will be regarded as abnormal. Medical professionals tend to view sickness or ill health as an obvious phenomenon defined as a temporary and easily recognisable departure from the natural state of health. However, it is gradually being realised from the experience of extending health services in Great Britain and Denmark that values of species normal for defining health or ill health are dynamic and not static. The experience has shown that the disease threshold falls when health service expands. This strongly suggests that the threshold of health and ill health depends on environmental and socio-cultural conditions also and a purely biological concept of health and disease fails to encompass all their aspects.

The problem of subjectivity of illness
The kind of biological reductionism that is implied in biological theory of disease leads practitioners of modern medicine to ignore their patients' subjective symptoms and regard them as secondary phenomena rather than the necessary constituents of the concept of disease. It should be kept in mind that the primary concern of clinical medicine is subjective disease and subjective health. People seek medical help when they feel ill. The demonstration of a biological (mechanical) fault in the human organism has no clinical importance unless it affects the well-being of the person concerned or serves to predict that the person's well-being will be affected some time in the future. Medical sociologists have shown that the subjective feeling of illness, or disease condition is again largely dependent on a variety of socio-cultural aspects.

While accepting the basic relevance of biological concept and in view of the failures of giving a subjective concept of disease, medical professionals have been forced into a deeper analysis of the concept of species design. Boorse and Ross ( ) have accepted that the species design concept has teleological overtones and a hierarchy of functions may be imagined, each of which serves a higher-level goal or telos. However, this thought process raises the question of the ultimate goals, which seem impossible to define in scientific terms. These highest-order goals are indeterminate and must be determined by a biologist's interests and, therefore, the concept of health and disease as value-free biological states. Further, purely biological approach seems to be insufficient in case of human beings as it ignores their subjective feelings, self-awareness, capacity of self-reflection and personal capability to decide the goal of life. Eric Cassell ( ) has pointed out that an understanding of the patient's suffering is not the same as knowledge of the character of disease and the side-effects of the treatment. Casswell proposes that human suffering can only be understood by taking into account all the aspects of the existence of a person. It has to include the lived past, the family's lived past, culture and society of the person, the body, the unconscious mind and the hopes of the future.

Thus, it has to be realised that the prevalent biological (mechanical) concept of health and disease is too narrow and the meaningful concepts of health and disease might transgress the bounds of scientific medicine.

Concept of disease entity
Until the end of 18th century, doctors could only classify their patients according to the clinical pictures and made diagnoses like dropsy, phthisis, diabetes, typhus etc. Even today, the disease classification comprises of many clinical syndromes that can be defined only by the clinical pictures of patients as not much is known about their underlying mechanisms. At the start of 19th century, doctors began to do routine autopsies and gradually the idea of identifying diseases with anatomical lesions became established. This had tremendous impact on medicine and even today, the majority of disease names are borrowed from the terminology of morbid anatomy e.g. gastric ulcer, myocardial infraction etc. A few decades later, doctors developed interest in human physiology that made them see physiological disturbances where before they had only seen anatomical lesions. This new mode also profoundly affected the disease classification and led to the establishment of new disease entities e.g. arterial hypertension. During the second half of the last century, foundations of modern microbiology were laid and patients with infectious diseases were reclassified according to the species of infective agent. This was a very important phase in the history of disease classification. For the first time, it became possible to define a large number of disease entities aetiologically and the dogma of unicausality (one cause - one disease) was further reinforced. In recent years, medical scientists have also become interested in immunology. These days immunologically defined disease entities are also being established. However, the nomenclature and classification of disease is still largely a mixture of disease entities, that are defined in anatomical, physiological and microbiological terms. Two contrasting attitudes towards the disease entitiy have developed among medical professionals with the development of disease classification and its use. These may be termd nominalist attitude and the idealist attitude.

Nominalist concept of disease entitiy
The philosophical position of nominalism is that a universal (e.g. a disease) is a name (nomen) which is attached to abundle of particulars. In medicine the idea has been expressed by the dictum attributed to Rousseau: 'there are no diseases, only sick people'. According to this view, disease names may be regarded as labels attached to groups of patients that resemble each other in those respects, which are considered medically important. This attitude stresses the point that disease classification is a man-made classification of individual patients, which was required in order to classify clinical knowledge and experience.

The pure nominalistic attitude can not be undertaken in medicine. Since two sick persons can never be identical as regards to their clinical pictures and the underlying causal mechanisms, classification and nomenclature would have to be arbitrary. However, Lockean version of nominalism also stresses the point that our classifications of natural phenomena are not arbitrary, as they must be moulded on the realities of nature. It further points that the particulars constituting a natural kind are grouped together and given a name. The particulars constituting a natural kind are considered to resemble each other in real essence in Lockean terminology. Quine ( ) believes that man has innate capability to recognise natural kinds and this ability is of fundamental importance to scientists though the sophisticated nature of their activities requires that they learn to recognise qualities which are not directly observable.

The doctors had started to classify patients according to their directly observable clinical characteristics and had found that some patients resembled each other in a number of aspects. Each such 'natural kind' was supposed to constitute a clinical syndrome and was given a name i.e. a disease entity was established. Though such syndromes (disease entities) were never well defined, the authors of medical textbooks took to describing the 'typical cases' of each disease. The clinicians began to diagnose these diseases when their patients resembled the typical cases. The purpose was inductive as clinicians expected that their patients, within the limits, would have the same prognosis and respond to the same treatments as the standard cases in the medical textbooks. Later, these clinical diagnoses were replaced by others which were defined on pathogenetic or aetiological levels as it was found that these new disease entities permitted more precise predictions and facilitated the development of specific treatments. However, the new disease entities were less homogeneous on the clinical level and for this reason, a multitude of refined diagnostic methods had to be introduced.

Idealist (Platonist) concept of disease entities
In contrast to Lockean nominalistic attitude, conversations between the members of medical profession reflect a very different attitude towards disease entity suggesting that the diseases are 'things' which exist in themselves and which are discovered by medical professionals. Diseases are talked of as if these are some sort of demons, which attack the people and cause suffering by manifesting themselves in the persons having been attacked. Interestingly this alternative view of the status of disease entity is also found in sophisticated analyses of clinical thinking. Feinstein ( ) writes that illness in the individual patient is the result of an interaction between a disease and a host. Such formulations confirm to Plato's position that universals are divine ideas which are real, eternal and unchangeable whereas particulars are merely transitory reflections of these ideas.

The particular disease, which according to Feinstein interacts with a host, may thus be interpreted along the Platonist idealist philosophy to represent an 'idea' whereas the illness of the individual patient is represented as the mere reflection of the idea. The typical cases described in medical textbooks are thought to be like Platonic ideas that are copied, rather unsuccessfully, by the patients seen by the clinicians on their rounds of wards. In fact, doctors do not really believe that diseases are demons that attack people or the doctrines of Platonist philosophy are true. Nevertheless, they tend to overlook the fact that the nomenclature and the classification of disease is man-made. They assume without reflection that somehow the disease entities have an independent existence.

The unreflecting Platonist view of the nomenclature and structure of the classification of disease implies that it can not be improved. Further, it is obviously more suited to hospital practice than to general clinical practice since it requires a multitude of highly specialised investigations to establish the real disease in the patient. However, the existence of a real disease entity in an individual patient can be established neither philosophically nor practically. The Platonist attitude also misses the point that disease classification serves a therapeutic rather than a preventive purpose. Traditional definitions of most of the diseases are pathogenetical. Medically prescribed interference at that level serves only to repair the disease damage without telling anything about the method of its prevention as we know very little about the aetiological causal factors (environmental or genetic) that elicit the disease process. In general, it can be imagined that the complex of aetiological factors which starts off the disease process differs greatly amongst patients and the hope of prevention of pathogenetically defined disease by some single measure is quite unfounded. For instance, all the efforts of epidemiologists to explore the complex aetiology of myocardial infraction have ended in finding a number of so-called risk factors. These may well be statistically significant, but do not point to any measure to prevent the disease with any degree of certainty in the individual person. On the other hand, infectious diseases may be regarded as both aetiologically and pathogenetically defined since the microorganism may be ragarded as an aetiological factor representing the external cause of the disease. The microorganism may also be regarded as a pathogenetic cause producing the disease inside the body. Therefore, microbiologically defined diseases are ideal for both preventive and therapeutic purposes and fit quite well the Platonist point of view. Since microbiological definition of disease entities has gained much importance in modern scientific medicine in recent times, the unreflecting Platonist attitude has also been implicitly accepted by medical professionals. Another important consequence of Platonist attitude has been that doctors tend to ignore or underestimate the temporal and geographical variation of the spectrum of illness because the world of ideas of Plato's philosophy is a static world. The assumption that the description of the typical case of a disease given in a medical textbook is the ideal and real description of that disease entity is untenable. This fact is becoming increasingly clear due to the studies of medical sociologists.

The above discussion points out that the philosophical problem underlying the contrary nominalist and idealist views of disease entities is the age-old dispute about the universals. Platonistic essentialism correctly underlines that any classification of natural phenomena e.g. disease must reflect the underlying realities of nature. However, it ignores the fact that the classification must also depend on our choice of criteria and that this choice reflects our practical interests and the extent of our knowledge. On the other hand, nominalism correctly stresses the human factor i.e. the individuality of patient but the extreme nominalism overlooks the fact that disease classifications are not arbitrary but must be moulded on reality as it is. It has been suggested that the Lockean theory, which combines both the views, may be particularly suited for the analysis of disease entities and disease classification.

Philosophy of Science & medicine

PHILOSOPHY OF SCIENCE The concepts and theories of every specialised body of knowledge and practices prevalent at any time in a culture are always rooted in the prevalent philosophy. Further, these also reflect the changes, conflicts and compromises in the philosophical paradigms. Therefore, to understand the concepts of modern scientific medicine, it is necessary to explore the developments in western philosophy that influenced and shaped them from time to time. For understanding the concepts of any specialised body of knowledge and practice, it is essential to understand the epistemological and ontological positions implicit or explicit in that system. Empiricism is an epistemological position and realism is an ontological position. In the concepts, theories and practices of modern science, both empiricist and realist trends can be discerned. Since modern medicine is also a scientific discipline, this is true for its concepts, theories and practice also. Before examining the impact of philosophy on modern medicine, it would be worthwhile to discuss briefly the ontological and epistemological questions and problems as they concern the science in general. PHILOSOPHICAL PROBLEMS OF EMPIRICISM AND REALISM Ontology is the theory of being and ontological questions are concerned with existence, reality and the true nature of things. Realism is the ontological position that the external world is real and it ‘exists’ independent of the human observer. This position also takes the view that the ‘really existing’ objects, structures and mechanisms of that world stimulate the sense perceptions of human observer. On the other hand, anti-realist position professes complete agnosticism as regard to ontological questions. Epistemology is the theory of knowledge and epistemological questions are concerned with what can be known about the world and methods of knowledge. Empiricism is the epistemological position that states that ultimately all the knowledge stems from the sense experience. On the other hand, rationalism is the position that, besides sense experience, reason is a source of knowledge. Empiricism on the epistemological level is usually associated with anti-realism at ontological level. On the other hand, justification of realism on the ontological level requires rationalism on the epistemological level. The rise of empiricist philosophy in Europe in 17th and 18th century was result of the changed intellectual climate following the 'scientific' achievements of men like Kepler, Galileo, Harvey, Newton etc. This school of philosophy is largely associated with philosophers like John Locke, George Berkeley and Auguste Comte. In the 20th century, the logical positivists of Vienna Circle and their successors analysed the logical consequences of empiricist thinking. Though there is disagreement on several important points, all the empiricists share the fundamental belief that all knowledge is derived from experience. Empiricists, although accept the laws of logic and mathematics, assert that logical and mathematical deductions are analytic which means that they do not generate new knowledge, but serve to analyse the existing knowledge. Further, anti-realism of empiricists makes it necessary to redefine the concepts like causality and objectivity in such a way that they do not presuppose any reality beyond observation. The ontological scepticism of empiricists, though seemingly counter-intuitive, is quite acceptable in advanced science. Scientists are generally concerned with the study of natural phenomena, which are not directly observable, by the use of ingenious instruments. Medical scientists have postulated the existence of specific receptors on the surface of brain cells based on sophisticated experiments. It is difficult is say whether such entities 'really' exist or they are creations of scientists' imagination that only serve to organise their ideas. Even medical practitioners depend on sense-extending instruments (e.g. X-ray equipment), detecting instruments (e.g. electrocardiograph) and complicated chemical analysis. They create a picture of reality by such indirect observations, which they can not perceive directly. Empiricists do not accept the generative theory of causality that implies that causal relation takes place in the external world independently of our observations. They propose the alternative succession (Humean) theory of causality in which idea of causality is explained in psychological terms. This theory points out that if we observe one event followed by second event several times, our expectation of the occurrence of second event after the occurrence of first event increases. The causal relationship is this expectation, a mental habit, which we erroneously extrapolate to an external world. The succession theory may be refined by analysing in detail the logical relationship between cause and effects. The usefulness of such analysis can be shown in discussion of the causation of disease. From the point of view of empiricism, the laws of nature do not tell us what really goes on in the world. Their function is the 'mnemonic reproduction of facts in the mind' i.e. these laws are only mental constructions that serve to describe as concisely as possible, the observations made. The term objectivity is used by empiricists in a very restricted sense. The term has ontological implications and refers to phenomenon believed to exist independently of the observer. Since empiricist position denies this interpretation, empiricists equate objectivity with inter-subjectivity. They assert that if exactly same observation is made by two different observers then the observation statement is said to be objective meaning that it is inter-subjective, public or verifiable. This assertion lead logical positivists of 20th century to formulate a demarcation criterion, which may serve to distinguish those propositions, which are meaningful from those that are not. They proposed a criterion of verifiability according to which only those statements are meaningful, which in principle could be labelled as verifiable. However, this criterion leads to quite serious consequences and difficulties: 1. According to this criterion, all attempts to discuss moral issues rationally are considered futile. This nihilistic attitude to moral philosophy is called emotivism. 2. The criterion itself is not verifiable and, therefore, must be regarded as meaningless by empiricist standards themselves. Thus, the criterion is self-defeating. 3. The criterion leads to the classical problem of induction since the criterion may well be applicable to singular statements. However, science is generally concerned with general statements, which can not be verified with absolute certainty by experience alone. The empiricism asserts that scientific process starts with observation. However, the leap from experience, which always consists of singular observations, to a 'law of nature' can not be logically defended as it can never be excluded that the next observation will prove the law to be false. This logical problem has always vexed empiricist philosophers and despite much effort by logical positivists in the last century, it has yet not been possible to logically define the jump from singular observation statements to general theory. Bertrand Russell has simply concluded that 'induction is an independent logical principle incapable of being inferred either from experience or from other logical principles, and that without this principle science is impossible'. Karl Popper has been the most influential philosopher of science of this century. He has made very important point that observation is always selective. It needs a chosen object, a definite task, an interest, a point of view, a problem. He asserts that the first step in scientific process is not observation but the generation of hypothesis, which may then be tested critically by observations and experiments. The goal of scientific effort is not verification but falsification of the initial hypothesis. As empiricists use the criterion of verifiability to distinguish between meaningful and non-meaningful statements, Popper used the criterion of falsifiability to distinguish between those theories that fall within province of science and those that may be labelled as pseudoscience. This thought and the criterion of falsifiability has influenced the modern scientific methodology to a very large extent. However, the criterion of falsifiability, despite its importance from the logical point of view, is not easy to handle in practice. Popper himself has pointed out that there is no such thing as pure observation. Therefore, a scientist who conducts an experiment and contradicts a theory can not be sure whether the theory has been falsified or the observation (or the experimental set-up) was at fault. Further, the biological and medical scientists mostly have to subject their observations to a statistical analysis. Here the final analysis depends not only on the observations but also on the convention as regards the choice of statistical tests and the accepted level of significance. Thus, Popper instead of solving the problem of induction, in a sense, has tried to bypass the problem. The scientists undoubtedly in many cases try to falsify hypotheses but in many other cases, they try to reason inductively. Medical research papers also contain numerous statistical calculations that reflect inductive reasoning. Despite the importance of empiricist philosophers' teaching regarding the importance of empirical evidence, it is obvious that from a purely philosophical point of view the radical empiricism leads to a dead end and creates insurmountable problems. It imposes a view of the world that is quite counter-intuitive. The empiricist belief that all knowledge is derived solely from the experience has not been established up till now to be fully consistent. The empiricist denouncement of realism has been unsuccessful in clarifying many of the philosophical problems. This forced inquiry along the lines of weakening the empiricist position. Immanuel Kant did not accept the Locke's idea that mind was originally like a blank sheet of paper. According to him, space and time are preconditions for the perception of something as an object and, therefore, human beings are 'programmed' to think in categories of quantity, quality, casualty, possibility, necessity, existence etc. A human being's picture of the actual world reflects this a priori organisation of his sense perceptions and his actual observations. Kant, is thus, a rationalist asserting that the empirical knowledge is organised according to a priori principles but, like empiricist, he does not accept the possibility of knowledge of things-in-themselves. Contemporary philosophers and psychologists have also given up the idea that the mind was originally a 'blank sheet of paper'. They also deny the existence of anything like pure observation. In medical examples, theory-dependence of observations can quite obviously be demonstrated. However, the role of empiricist philosophy in the development of science, including the scientific medicine, should be viewed in historical perspective. The metaphysical theories of pre-empiricist era were far too extravagantly rationalist and realistic. Therefore, it was only natural that empiricists felt that science must start afresh with systematic observations and establishment of the laws of nature. Popper has asserted that we can never be quite sure about our theories being true. However, the efficacy of modern technology, which is based to some extent on scientific theories, proves beyond doubt that in some areas Popper's 'approximation to truth' has been achieved. It is quite true that the development of modern science is inextricably bound up with empiricist philosophy, but philosophical reflections and the results of modern science suggest that the position of classical empiricism is quite untenable. It is more appropriate to accept the: ¨ realist point of view on the ontological level that the purpose of science is to explore what really goes on in the world and on the epistemological level, accept existence of pure observations but deny that the observations are the only source of knowledge, ¨ existence of causal relationships and deny the empiricist succession theory of causation, ¨ view that if one event generates another event through some or the other mechanism (as is quite obvious in some bio-medical situations) then a causal relationship between the two events exists and then these events may be said to follow the laws of nature and ¨ the view that causal relationships and laws of nature are objective in the sense that they exist independently of observation. Though the realist position does not solve the problem of induction, the knowledge of underlying mechanism sometimes makes the problem less troublesome. For example, the general statement that human granulocytes contain glycogen synthetase is not only the result of inductive inference, it is also based on existing theoretical knowledge. The philosophy of science has been dominated by empiricist thinking for the last few centuries, but during the last few decades, many philosophers (Smart, J.J.C., 1963; Harre., R., 1970; Hacking, I., 1983; Bhaskar,R., 1975) have favoured a realist theory of science which points out that scientific knowledge has both a transitive and an intransitive aspect. Knowledge in the form of a scientific theory should be regarded as a changeable social product, and as such, it is transitive. However, the object of that knowledge that does not depend upon the existence of observer, is intransitive. The importance of this observation is that it reveals the deficiency of different views of science including the medical science. Extreme realists disregard the transitive aspect of scientific knowledge while extreme empiricists disregard the intransitive aspect. It may be proposed that a balanced philosophy of natural science must take into account both the aspects and the relationship between them.

ONTOLOGICAL AND EPISTEMOLOGICAL POSITIONS OF MODERN SCIENTIFIC MEDICINE EMPIRICISM AND REALISM IN MODERN MEDICAL THOUGHT Philosophers of ancient Greece and medieval Europe were largely concerned with speculations about the nature of world, purpose of life etc. The Greek and medieval European philosophers were largely realists. In keeping with such philosophical atmosphere, medical theory in the western world up to two or three centuries ago, was to a large extent based on mere speculation. The philosophical position of Hippocratic humoural pathological theory describing four 'humours' (blood, phlegm, yellow bile and black bile) with different qualities and other similar theories may be described as speculative realism at ontological level and extreme rationalism at epistemological level. From realist position, these systems believed in the existence of an underlying real disease mechanism but being rationalists to an extravagant degree, they also believed that the nature of underlying disease mechanism can be ascertained by pure reasoning alone. It can be pointed out here that the philosophical position of various traditional/folk e.g. Ayurved, Unani) and newer unorthodox (Homeopathy) therapeutic systems can also be shown to be speculative realism and rationalism in varying degrees. Under the influence of empiricism the philosophers and scientists developed a sceptical attitude towards ontological inquiries and began to assert that one must rely entirely on one's senses. Empiricist demand for careful observation had some effect on medical thinking as early as 17th century. Thomas Sydenham stressed the importance of clinical observations at the bedside and described a number of disease entities based on their clinical manifestations. In the 18th century, following Linnaeus, the botanists who were also physicians, attempted to classify diseases like plants. These disease classifications were inspired by empiricist thinking as no attention was paid to the mechanism of disease. Being no more than divisions and subdivisions of ill-defined symptoms, such classifications of diseases had no lasting effect on the development of modern scientific medicine A few decades later, medical scientists developed an interest in human physiology. This made them see physiological disturbances where before this, they had only seen anatomical disturbances. This new mode of observation and consequent thought process had profound effect on the disease classification. The interest in physiology lead to establishment of new disease entities also. During the second half of last century, foundations of modern microbiology were also laid down. Identification of infective agent of disease had very significant effect on the philosophy of disease classification for two reasons. Firstly, it became possible for the first time to define a large number of disease entities aetiologically and, secondly, the dogma of universality i.e. one cause results in one disease was further established. However, this dogma can be shown fallacious in case of most of the infectious diseases, as the bacterium or the virus must usually be regarded as one of the many non-redundant causal factors in the individual patient. The disease classification is still largely a mixture of disease entities defined in anatomical, physiological and microbiological terms. In addition, a number of immunologically defined disease entities are also being established as a result of increasing interest in immunology. The anatomists, physiologists, microbiologists and immunologists work under the influence of empiricist philosophy as far as they pay great attention to their empirical observations in the laboratory. However, they are unknowingly following the realist philosophical position as they try to discover the underlying mechanism of disease forgetting or ignoring that true empiricist position denies this possibility. This is the underlying but ignored or not clearly understood schism between a realist and empiricist trends in modern scientific medical thinking still persisting today which had historically started in 1830s and 1840s. A highly significant analysis of the medical problems from the empiricist point of view was given by Gavaret (Gavaret, 1840). Gavaret's ideas were premature for his time and were not given much attention. However, a century later, in 1940s, time was ripe for the revival of his ideas in the form of new critical clinical school. At that time, the combination of new scientific knowledge and new technology resulted in explosive growth of new therapeutic and diagnostic methods which had to be tested critically in accordance with Gavaret's tenets which may be summarised as following: 1. The Laws of Logic are insufficient for judgement of the effect of a given treatment for a given disease. These are also insufficient for the ranking of those treatments that are recommended for the same disease according to the degree of their effect. 2. Only the Law of Large Numbers, which is applicable to therapeutic investigations, can solve these two important problems. 3. The death rate obtained by statistical calculations is never a precise and correct expression of the effect of the treatment in question, but larger the number of observations, closer the approximation. 4. A Therapeutic Law, obtained by comparing small number of facts may be so far from truth that it can never be trusted. 5. A Therapeutic Law is never absolute, but must always be expressed as a range. The range decreases as the number of observations increases and its width can be determined by those numbers on which the statistical calculations are based. 6. For determining the preference between two therapeutic methods, the results of preferred method must not only be better but the difference must also exceed a certain limit which depends on the number of cases. 7. When the number of investigations is large and the difference is low which does not reach this limit, it can be ignored as non-existent. 8. The same rules and same conclusions are applicable to the solution of problems connected with the theory of epidemic constitutions. 9. The same rules must be followed to ascertain whether the death rate in a disease varies according to age, sex and location. 10. In investigations of aetiological problems, the Law of Large Numbers only serves to prove the presence or absence of a presumed cause, regardless of its nature. The cause should be determined itself by means of considerations of a different order. This last question is outside the domain of statistics. The first nine tenets show radical empiricism while in the tenth tenet Gavaret suddenly retreats from this position. Empiricist theme is introduced in first three tenets i.e. doctors should study as many patients as possible and must not base their therapeutic decisions on speculative theories and logical deduction. In other words, they must discard theory and rely on positive facts. Tenets 4 and 5 clearly indicate the empiricist view of law of nature i.e. the demonstration of a law of nature is no more than the demonstration of a regular association between observed phenomena. Tenets 1 to 9 are almost similar to the recommendations of present day statisticians indicating that Gavaret was more than a century ahead of his times. It may also be pointed out that in 10 tenet, Gavaret points out the limitation of statistical approach and points out that statistics only serve to establish the presence or absence of a causal factor, regardless of its nature. He also seems to disapprove of the empiricist view of causality and assumes that a causal relationship is more than a regular succession of events and there is room for 'considerations of a different order'. Vast majority of Gavaret's contemporary medical practitioners, who were interested in science, ignored his views. They continued to explore the mechanisms of disease in the hope that the accumulation of enough such knowledge would enable them to deduce the correct treatment in the individual patient by means of the 'Laws of Logic'. It is thus clear that the vast majority of doctors at that time were realists but they accepted and applied the empiricist tenets of observation and experimentation.

CURRENT MEDICAL THINKING The contemporary medical thinking is also pervaded by both realist and empiricist approaches. For example, a modern lecture on a particular disease describes the observed symptoms or signs of the disease and gives a theoretical account of the underlying disease mechanism that fits a multitude of carefully executed experiments. It then concludes the logical treatment of that particular disease. It may be pointed out that for a disease, results of individual investigation are usually numerous figures that have been subjected to statistical analysis following the empiricist approach. However, these statistical truths are not regarded as an end in themselves. Rather, these are thought of as only a means to the establishment of a coherent theory, which is believed to reflect the reality behind the observations. This view of science has been labelled realism under empirical control (Wulff, Pedersen & Rosenberg, 1986). This current view differs markedly from that of radical empiricists like Gavaret and his modern followers whose sole aim is to formulate the statistical 'laws of nature' that may serve to predict future occurrences. Thus, the current medical thinking agrees fully with realist approach that medical knowledge largely depends on acquisition of more knowledge about the functions of human body in health and disease. However, it also believes in the great need of empiricist statistical approach in such matter. In the science in general, this mixture of realism and empiricism has lead to the recognition of distinction between pure science, technology and technique. In the modern scientific medicine also similar distinction between biological medicine (the scientific level), clinical medicine (the technological level) and clinical practice (the technical level) has been recognised. Members of the medical profession engaged in the biological medicine (e.g. basic research in the laboratory) are medical biologists. Those engaged in clinical medicine (e.g. testing of new drugs) are clinical researchers while those engaged in clinical practice (e.g. examination and treatment of individual patients) are medical practitioners. Medical biologists, just like physicists, seek true knowledge and their philosophical position is that of realism under empirical control. Though realism underlies the biological medicine, it should be pointed out that the biological variation exists at every level and this makes it impossible to make exact predictions in the individual case. The prognosis of the individual patient must always remain a statistical truth. Further, the course of a disease must usually be regarded as the result of a persistent interaction between the inner mechanics of body and the environment. Therefore, an exact prognosis requires extensive biological knowledge as well as full control of the stimuli from outside. There are numerous examples in the past of the introduction of wrong or worthless diagnostic and therapeutic methods due to unwarranted self-confidence on the part of biological scientists. These have clearly demonstrated that deductions from biological theory are often unreliable and that the techniques used in clinical practice must be tested empirically. The controlled therapeutic trial for the comparison of two treatments is the prototype of clinical research. The statistical result, which is a typical example of inductive reasoning, is what Gavaret calls a 'therapeutic law' and it serves a predictive purpose. Clinical researchers also test diagnostic methods according to similar principles. In this way, the philosophical position of clinical researchers may be described as empiricism on the methodological level. They do not follow empiricism in the original philosophical meaning as they do not accept the ontological agnosticism of Hume and the logical positivists. They fully accept that we know quite much about disease mechanisms but they emphasise the incompleteness of biological knowledge and impossibility of precise clinical predictions due to biological variation. The clinicians holding these views represent the critical clinical school, which revived the ideas of Gavaret in 1950s and 1960s. Further, it has been pointed out by many workers that clinical practice must not be regarded as applied biological medicine and it is necessary to adopt empirical approach for the solution of clinical problems. An important difference between realism under empirical control in biological medicine and methodological empiricism in clinical research should be noted. The statistical methods are also used in biological medicine but the end-product is always a theory considered to be a picture of reality, which may be true or false. On the other hand, the end-product of statistical methods in clinical medicine is always a statistical 'law of nature' which serves to predict future events. Thus, it may be pointed out that the empiricism as a philosophical position is untenable. Clearly, it is possible to reach some insight into the working of nature. However, the realist belief that medical theories will ever form a completely true and exhaustive picture of reality is also quite naive.