Fleck by Ilana Lowy

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<p>liana Lowy Ludwik Fleck on the social construction of medical knowledge</p> <p>Abstract The subject of the development and transmission of medical knowledge has remained, until recently, relatively little studied by medical sociologists. But as early as the 1930s the pioneering studies of Ludwik Fleck, a physician and historian of science, dealt with the evolution of medical knowledge and the genesis of medical facts. Starting with a reflection on his own experience as clinical bacteriologist and immunologist. Fleck developed highly original views on subjects such as the influence of patterns of specialization of physicians on the medical knowledge they produced, the impact of popular models of disease on expert ones, and the importance of the circulation of ideas between distinct, and - according to Fleck incommensurable 'thought collectives' (medical scientists, general practitioners and patients) for the development of innovations in medicine. The aim of this article is to analyze Fleck's vision of medicine and to select among his ideas those which may be of interest for sociologists of medicine today.</p> <p>Introduction</p> <p>The sociology of health and illness is concerned with a wide range of subjects dealing with the ways society takes care of its sick members. One subject is, however, often missing from the evergrowing list of topics studied by sociologists: the impact of society on the development of present medical knowledge. Until recently, sociologists dealing with medical subjects have usually separated issues concerning the behaviour of physicians and their knowledge. Although they have examined the infiuence of society on the development of medical knowledge in primitive and folk medicine and in the past, they have often made an absolute distinction between this 'non-scientific medical knowledge' and modem scientific Sociology of Health &amp; Illness Vol.10 No. 2 1988 ISSN0141-9889</p> <p>134 liana Lowy</p> <p>medicine. Modern medical knowledge has been viewed in many works of medical sociology as homogeneous, culture-independent and founded on objective observation and experimentation (King 1962: 93; Freeman, Levine and Reeder 1972: x-xi; Albrecht and Higgins 1979: 7-10). The hesitations of medical sociologists in applying their usual methods of investigation to the study of the formation and evolution of present medical knowledge refiected perhaps their lack of competence on medical topics on the one hand, and their professional strategy of aspiring to recognition by physicians on the other (Kendall and Reader 1972: 1-21; Strong 1984). In the last ten years, however, several studies have dealt with the influence of society on the evolution of medical science. The recent development of social studies of science, and increased interest in the social construction of scientific knowledge (Bloor 1976; Knorr, Krohn and Whitley 1981, Knorr and Mulkay 1982) have inspired studies dealing with the social construction of medical knowledge (e.g. Wright and Treacher 1982; Figlio 1982; Gabbay 1982; Amstrong 1983. For a review see Bury 1986; Nicolson and McLaughin 1987). Another recent evolution has been the formation of a new specialty: the philosophy of medicine. This deals, among other things, with the specificity of medical knowledge and its relationship to biology and the natural sciences in general (Gorvitz and Maclntyre 1976; MauU 1981, Schaffner 1986; Caplan 1986). The developments of the last years cannot, however, in my opinion, justify the idea that the sociology of biomedical research already exists. Rather, I would agree with Renee Fox who recently affirmed that: 'For many years, I have been amazed at the virtual absence of first-hand sociology of medical studies' (Fox 1985). Philosophers have attempted to define the overall conceptual framework of medicine and have not studied the impact of societal factors on the evolution of medical knowledge in concrete cases. Sociologists who have approached this subject have often been more interested in the relationships between social models of health and illness and the professional strategies of doctors than in the development of medical knowledge itself.</p> <p>Ludwik Fleck's philosophy and sociology of science</p> <p>The problem of the impact of society on the genesis of medical knowledge was addressed as early as the 1920s and 30s, when a</p> <p>Ludwik Fleck</p> <p>135</p> <p>highly original attempt to study it was made by a Polish-Jewish physician, Ludwik Fleck (1896-1961). Fleck, a bacteriologist and immunologist, combined strong philosophical and sociological interests with medical training and long practice in a clinical laboratory. For many years his works remained practically unnoticed by historians, philosophers and sociologists of science. They were rediscovered after the publication of The Structure of Scientific Revolutions., where in the introduction Kuhn cites Fleck's Genesis and Development of a Scientific Fact (Fleck 1935a) among the works that influenced his own thought (Kuhn 1962: viii-ix). In his epistemological works Fleck developed the notion that scientific knowledge is constructed. For him, alleged scientific 'facts' do not exist 'out there' in nature waiting to be discovered by objective and interchangeable observers. Rather, they emerge as thefinalresult of a social process: the 'genesis and development of a scientific fact'. The observer's training, his preconceived ideas, and his anticipations play a substantial role. Moreover, for Fleck scientific facts are constructed by distinct 'thought collectives', each composed of individuals who share a specific 'thought style'. Different and equally well-founded 'thought styles' can co-exist in a given domain, not only diachronically, in distinct historical periods, but also synchronically and within the same cultural universe. Fleck's approach was therefore at least partially relativist: not only is scientific knowledge constructed, but speaking of truth and falsehood is meaningful only within a specific thought collective and with respect to a given thought style. He was not, however, a complete relativist (although his work is sometimes represented as such). Fleck did not believe that observations are radically theoryladen and he considered science as capable of cumulative improvement (Fleck 1929; 1935c; Toulmin 1986). Today the majority of historians and philosophers of science agree that in science theory and observation are interdependent. This was certainly not the case in the 1920s and 30s, when epistemology and the philosophy of science in many countries (including Poland) was dominated by positivism. But not all historians and philosophers of science adhered to positivistic approach. A conventionalist approach to the philosophy of science, stressing the conventional nature of all scientific knowledge, was developed, probably as a response to the crisis in physics, at the beginning of the 20th century (H. Poincare, P. Duhem) and developed by historians of science (Metzger, Koyre). The conventionalist point of view also had adherents among Polish philosophers of science in</p> <p>136 liana Lowy</p> <p>the 1920s and 30s (K. Adjukiewicz, E. Poznanski, A. Wundheiler). Historians of culture, art and ideas of that period readily viewed science as but one aspect of the general creativity of human beings, and as such dependent on the wider socio-cultural context (Lovejoy 1936; Panofsky 1940). Some historians of science (H. Metzger, F. Enriques) shared this view and stressed the crucial importance of studying the science of past periods in its philosophical, cultural and social contexts. According to Metzger the historian of science should 'make himself the contemporary of the scientists he is studying' (Metzger 1933). Similarly, historians of medicine working in the 1920s in the influential Institute for the History of Medicine in Leipzig (H. Sigerist and his students, among them O. Temkin, E. Ackerknecht, and also the Polish historian of medicine T. Bilikiewicz) developed a similar approach. Influenced by German historicism, they claimed that the medicine of a given historical period should be studied only from the point of view of the period in which it was developed and that one should avoid the temptation of making modem judgments on past science (Temkin 1977). If conventionism in philosophy and historical relativism in the history of medicine existed already (albeit as minority trends) in the 1920s and 30s, and if representatives of these trends were present in Poland in the period during which Fleck published his major epistemological studies, why did his works remain practically unknown for such a long time? In the 1920s and 30s the history and philosophy of medicine were estabhshed academic disciplines in Poland. In all probabiUty, Fleck aspired therefore to be recognized by the historians and philosophers of medicine of his country. However, even the historians of medicine who acknowledged that past medical knowledge was strongly influenced by the cultural context in which it had been developed were not ready to accept Fleck's radical claim that modem, 'scientific' medicine is as dependent on social and cultural factors as the medicine of the past (Bilikiewicz 1939). As to the reason for the ignoring of Fleck's studies by Polish philosophers of science, several answers have been proposed: a) Fleck's approach was not new when considered against the background of Polish philosophy in the thirties: philosophers affected by the conventionalist tradition were in agreement with the conventionalist components of Fleck's philosophy, but felt that they had little to learn from him, while those who rejected conventionalism found his views unconvincing (Giedymn 1986); b) Polish philosophy of this period</p> <p>Ludwik Fleck 137</p> <p>developed a very high logical-methodological standard for what was considered worthy of discussion in epistemology; Fleck's writings could not satisfy this because his style of thought was incompatible with the dominant style of the Warsaw-Lwow philosophical school (Wolniewicz 1986). This last point merits further discussion. Why was Fleck's style so different from the one which dominated Polish philosophy of science in his time? The reason, I suggest, is that it was developed independently of this philosophy. Indeed, as I have argued elsewhere (Lowy 1986), Fleck's epistemology has its roots not in his philosophical training but rather in his scientific and medical practice. Taking his own clinical laboratory practice as a starting point for his epistemological reflections. Fleck did not ask what science must be, but attempted to investigate what science actually is and how historial processes and social institutions are related to the emergence of scientific 'facts'. In doing so Fleck broke radically with the idea, predominant in the philosophy of science in the 1920s and 30s, that philosophers are required to 'justify' science and to provide it with intellectual 'foundations'; instead. Fleck proposed an empirical research program for epistemology (Toulmin 1986). Fleck's preoccupation with the ways science in fact operates alienated him from the community of philosophers of science of his time. However, it is precisely this preoccupation that has made Fleck so relevant for the sociology of science in the last two decades. As Barnes and Edge put it: We do possess onefinepre-war work in the sociology of knowledge tradition which considered in detail the emergence of an accepted set of scientific doctrines and techniques. Ludwik Fleck's 'Genesis and Development of a Scientific Fact' (1935), recently rescued from oblivion, has been recognized as a major contribution. But that an extended study of such insight and importance was largely passed over upon its first appearance merely reinforces the point already made: there was widespread reticence to investigate the basis of anything considered to be genuine knowledge (Barnes and-Edge, 1982,65). And because the 'set of accepted doctrines and techniques' studied in great detail by Fleck in his magnum opus was, in his words, 'one of the best established medical facts: the fact that the so-called Wasserman rection is related to syphilis' (Fleck 1935a: xxviii), his studies are of special interest for sociologists of medicine.</p> <p>138 liana Lowy</p> <p>The importance of medical examples in Fleck's works</p> <p>Ludwik Fleck is viewed today as a pioneer of constructivist epistemology and of the sociology of the natural sciences. For this reason, although all his sociological and philosophical studies principally used examples taken from the history and the practice of medicine, his works are read almost exclusively by philosophers and sociologists of science, not by sociologists or philosophers of medicine. Even the few articles dealing with Fleck's views on medicine have discussed Fleck's general philosophical position and made no specific comments on his detailed descriptions and analyses of medical practice (Sadegh-Zadeh 1981; McCoullogh 1981), and medical sociologists have quoted Fleck's book as an example of a 'general discussion of the sociology of science' (Lipton and Hershaft 1985). The numerous medical examples in Fleck's works have been, as far as I know, examined only in the framework of studies of his overall epistemological thesis. In my opinion, this is unfortunate. Fleck was the author of original reflections on subjects such as the growth and the diffusion of medical knowledge, the influence of popular models of disease on expert ones, the relationships between laboratory and clinics, and the mechanisms of specialization in medicine. I consider many of these pioneering reflections of sufficient value to be studied for their own sake, and not only as illustrations of a general philosophical or sociological thesis. My aim is therefore to analyze Fleck's vision of medicine, and to select among his ideas those that I consider of interest for sociologists of medicine today. In doing so I am aware of the fact that my presentation of Fleck's reflections, which stresses the potential value of his ideas for the study of the specific problem of the growth of medical knowledge rather than the more general problem of the evolution of scientific knowledge, is not entirely faithful to Fleck's original intentions. Fleck based his reflections, at least as far as modern science is concerned, on examples taken almost exclusively from his own scientific discipline. His first epistemological study was an article on the specificity of medical thought. But later on, he enlarged the scope of his reflections to all the natural sciences and he used the formation of medical knowledge as but one example of scientific knowledge in general. Fleck himself recognized, however, that his reflections on the social origins of cognition were particularly well adapted to studies of the development of medical knowledge. For him 'medical problems, concerned as they are with Man's more</p> <p>Ludwik Fleck</p> <p>13...</p>