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liana Lowy Ludwik Fleck on the social construction of medical knowledge

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.

Introduction

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 & Illness Vol.10 No. 2 1988 ISSN0141-9889

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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.

Ludwik Fleck's philosophy and sociology of science

The problem of the impact of society on the genesis of medical knowledge was addressed as early as the 1920s and 30s, when a

Ludwik Fleck

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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

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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

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developed a very high logical-methodological standard for what was considered worthy of discussion in epistemology; Fleck's writings