Whatever Happened to Speculative Thought? Some Historical Evidence Against Evidence-Based Medicine

Imagine yourself, at your age and your acquired wisdom level, returning to medical school. I had at least a few gray hairs when I less returned to than started medical school, after a previous academic career. My field of specialty was the Ancient Near East, specifically its influence on the Ancient Mediterranean. I find it interesting now how the intellectual freedom I had formerly enjoyed in a field that, in light of sparse physical evidence had little choice but to reward speculation, has been less squashed than simply unacknowledged in my newly chosen field of medicine.

Such was the inspiration for this essay. The idea originally occurred to me one night as I found myself absently wondering how an Ancient mind might interpret a randomized controlled trial. To the pre-Greek intellect-a nearly perfectly empirical mind-the end always far outweighed the means; the idea of clinical detachment was wholly incomprehensible.

For example, if a sick man swallows a pill and becomes healthy, then there is “magic” in that pill; if another sick man with the same manifestations of disease swallows a pill in every way like the first man’s and does not become healthy, then there is no magic in the second pill. To the Babylonian or Egyptian mind, there would be no issue: the gods favored one man and not the other. In fact, if one were to believe that a pill was all that was necessary to cure a man of illness, then one might indeed be considered mad in a world where the evidence changed daily.

But let’s say an especially observant ancient physician noticed over time that half of those who swallowed that pill recovered their former health, while the other half did not. Statistically, by current standards, this would be considered a pretty effective treatment; however, by ancient standards, this would be considered exactly what it is: the equivalent of a coin flip.

The Ancient Mesopotamians were exceptional classifiers, maintaining inventories of lists of every conceivable category. Much like early and late Enlightenment naturalists, such as Linnaeus and Darwin, cataloged the natural world as far as they could see, so did Mesopotamian and Egyptian scribes meticulously catalog the natural world around them. Was this science? If, at its core, science relies on empirical observations of the natural world, then there is no legitimate argument against it. Where the Enlightened and the Ancients part ways, however, is in the cataloging of the supernatural. The Mesopotamians especially, living in a more volatile environment than the Egyptians, along with their lists of fauna, flora, gods, kings, words, historical events, and laws, maintained extensive catalogs of omens. These were based on standardized interpretations of dreams, physiognomy, star alignments, oil-in-water patterns, miscarriages, and the internal organs of animals and humans.

Beyond the Enlightenment, how might one conceive of a scientific study to test the reliability and validity of such phenomena? The Mesopotamians essentially performed prospective cohort studies. Standard mantic texts, such as the Dream Book and the Diagnostic Manual, were compiled over centuries. These were conclusions based on centuries of observations that clearly indicated that if a man dreamed such and such, then such and such, more often than not, was likely to happen; that if a goat’s entrails displayed such and such, then such and such, more often than not, was the likeliest outcome. This is not religion, nor is it superstition. This is empiricism at its purest. And if the diviners were correct even one-third of the time, would that not validate their practice by current standards?

Have we deviated at all from these paths-what is medicine after all if not a mantic practice? When we treat a patient with a specific medication because that medication has been shown to be effective in half of all patients, are we not predicting the future? Do we not habitually reassure patients by saying, “Based on my clinical observation, this medicine will have you feeling better in a week”? Or, if the evidence is equivocal, do we say, “If this medicine does not have you feeling better in a week, we can try something else”? And of course, when all else fails, do we make the one prediction that is always correct, “You will die”?

Death, however, posed an interesting philosophical conundrum to the Ancients. The Mesopotamians distinguished at least 2 different types of death, that from natural causes and that from violence. This distinction was based on divinity: although the gods were exempt from natural death, they were not exempt from violent death. Ancient physicians wanted nothing to do with the dying patient when the cause of death was disease. Yet all manner of medicinal contrivance was used on the battlefield.

Much of the divination oeuvre is devoted to the prediction of death by causes other than the natural. This, however, should not be dismissed as evidence of primitive superstition; on the contrary, given the Ancient obsessiveness with classification and observation, this search for predictors of death is understood-as is our current search for predictors of death-as the ultimate attempt at imposing order. After all, any physician can predict death as the outcome of a fatal illness, but the physician who can predict death from among seeming randomness has certainly acquired a superior level of insight.

The mantic texts were created as study guides for practitioners, and the fact that these practitioners were also the inventors of writing must not be overlooked. Whether writing in cuneiform or hieroglyphs, those few in possession of that knowledge were in the process of creating abstractions from concreteness. For example, the pictogram of a hand is a concrete symbol, originally meaning “hand.” However, with pressures to expand the semantic range of script, the concrete representations soon took on more abstract meanings as well, such as “to give,” “to strike,” “to help.” This of course, depending on context, allows for a fair amount of ambiguity, a fair amount of individual interpretation of a text. Thus, writing itself was developed as an empirical tool, at its heart based in a deep-rooted realism, or phenomenology. What followed was, and is, the construct of abstraction, of theorizing, of the scientific process. To those more familiar with the much later Greek rationalism, early script may be likened to Plato’s “Forms,” the origins or prototypes from which all else derives.

Moving beyond death-where no modern physician likes to tread-in the Ancient literature, there is no agreed-on system of afterlife. Several attitudes are apparent from across the literature, ranging from ambivalence to agnosticism to disdain to hopes for paradise ever after-in other words, not unlike the range of attitudes still prevalent.

But the Ancients, it must be remembered, were without the benefit of any great charismatic religious leader. There were no prophets, no shared belief in a messiah. There was, however, a universal bond of shared experience, the common bond of living and dying, the sheer humanness that allows a 21st century scholar to overstep the barrier of historical context and place himself or herself firmly in the shoes of a 5000-year-old forebear. And lest one begin to draw the unsupported conclusion that the Ancients were especially humanistic, it is well to keep in mind that human nature being human nature, it is just as likely that the most pompous of Ancient scholars blew at least as much, if not more, hot air as the most pompous of their descendants.

This brings us back to my original query as to how an Ancient mind might interpret a randomized controlled trial. Statistics is a game of logic, and the Ancients were extremely competent logicians. But the predictive value of logic is minimal in a world governed by confounders. The Ancient mind, for all its superstition, could not divorce itself from the empirical, albeit magical, world. What is relevant for us is that as among the great religions that followed, there existed among the creators of the written record the need to record and transmit their accumulated knowledge.

Permanence and education were of prime importance-only the ambition was different. Evidence was collected and recorded not to discover etiologies but to predict the future. For nearly 5000 years, science advanced human understanding by relying on speculative thought as applied to the natural world. For the past 50 some odd years, science has relied more on statistical analysis as applied to a controlled world. As a once and future student of the humanities, I wish only to suggest that our knowledge has remained unbroken over these millennia, such that a 21st century scholar should have little difficulty in overstepping his historical boundaries. The world, after all, is still a confounding place.