 So, is philosophy useful in medical practice? And this is a dialogue between a medical doctor and a philosopher, Richard Levy is a medical doctor since 1983, and he graduated from Karolinsk Institute, is a specialist in neurology and rehabilitation, and at the moment professor of neuro rehabilitation at the Link Shopping University Hospital. Welcome. Thank you. Thank you, Louise, and you are Louise de Miranda. You are a philosopher. You have a PhD from University of Edinburgh. You are currently at the Centre for Medical Humanities at Uppsala University. And in addition to that, and many other things, you are a philosophical counselor working at the Philosophical Parlor in Stockholm since 2018. So this is a question that is formulated in a way that we might not seem biased, although we have to perhaps confess for the sake of honesty that we do believe that the answer is yes. And I am the most, perhaps, suspicious of bias since I am a philosopher myself. So I will let you speak first. As a medical doctor, it is not very common to hear a medical doctor, you know, say that philosophy is useful in his practice. So could you explain to us how you came to that conclusion? Well, first of all, I am a little bit biased myself because I have had an interest in philosophy as a sort of hobby or, yeah, as a hobby, as an amateur since my youth. So that's maybe biasing a little bit. But secondly, I think it's a matter of maturity. You can say that I've been working in medicine now for almost 40 years. And in the beginning, you are very much created, recreated by the the medical education, which is, of course, and should be perhaps very biased towards science, natural science. It's not a humanistic education. It's a scientific education with a lot of basic science in the beginning with biology and chemistry and biochemistry and anatomy and physiology and pathology and so on. So you tend to it tends to affect you. Then you start meeting patients after a while, real people. First, you meet dead people, then you meet living people. And in the beginning, you are so scared, I would say, to make mistakes that would be fatal for the patient and thus also for yourself. You stick very much to the to the protocol, so to speak. But very soon, most of us realize that reality is different. People are not only parts of populations, they are also individuals. And individuals manifest their disease or illness in many different ways. And sooner or later, you find out that if you try to objectify your patient and try to understand them only through radiology and chemistry, you will never understand them properly. They will not like you and you will not get report report with them. So it grows on you more on some people than on others. But the lingering feeling that increases is that something is missing in your mode of communication. Something is getting lost in translation between reality and medical lingo. So that's that's where I come from. That seems to relate very much to a fragmentation that is present in all aspects of our societies, what I sometimes call the arithmomania, the the tendency to transform into numbers and statistics, all the aspects of the the human experience. And and of course, this misses the fact that the person in front of you is as a mind and emotions. And those are part of our experience, not only of life, but also of her condition. And so how did you practically, because, for example, in in my practice as a philosophical counselor, I find that there is a sort of a ground foundation, which is very simply what we could call deep listening and and and dialogue and what was called by Plato dialectics. And this enough is enough to create a basis for them, other forms of, of course, of analysis, dialogue and and opening to to certain possibilities. But just this fact of deep listening and dialogue, do you do how do you yourself experience that, open yourself to that? And is it is it easy to practice it in today's medicine? It's it's unfortunately, it's quite difficult to to because first of all, there is a pressure in time, a time limitation. This is especially true for the colleagues that are working in primary care, where you might have only 10 or 15 minutes or less for every given encounter. If you know the patient well, since before that makes it easier because you can add to the puzzle, to the jigsaw puzzle, you add pieces as you meet again and again and again. Also, you might need other, meet other members of the family or friends and so on. You can create this puzzle. But a continuity is also a problem. So it might be that you meet the person only once and only for 10, 15 minutes with a very nominally with this very specific problem, you know, like headache or pain in the back or whatever. And then you need to exclude the red flags and red flags are usually very scary conditions. So you put emphasis on excluding that and it becomes more like an interrogation rather than deep listening, unfortunately. But and the problem is that even if you get more time, which you have in the hospital, sometimes if you have a consultation, you might have even up to, let's say, half an hour to an hour for the meeting. You tend to get influenced by your time pressure. So maybe you don't even use that to listen. I think that one important lesson, very difficult for me and for most other colleagues is also to be quiet, to be to shut up and to listen, as you say. So that's already part of what we are discussing now, why I think philosophy is important. Philosophy is is not having monologues. It's more like a dialogical thing. And that includes listening. This aspect of the interrogation as opposed to dialogue. Isn't it this sort of a structural phenomenon in the sense that when we look at the definition of diseases in official textbooks and practices, we often see that diseases are defined by criteria. For example, depression, you have 10 criteria, some of which are considered primary, other secondary. And and there's sort of a greed and you sort of tick the boxes. And and so that created by the way, a process where often the medical care is associated with a teleology that is to give appeal to to give a medication, which I find is not necessarily the only function, of course, of a doctor. So how do we how do we keep time for what you are saying for for listening when there is this definition of the conditions that is itself very analytic, right, and and and is a sort of a process of this discrimination, like a decision tree of which the outcome seems to have to be, in a way, of another a form of often some form of intake or chemical protocol. Well, well, of course, you have to you have to adjust your your method to the to the actual situation. I mean, in an emergency department, I think philosophy is less applicable in the individual case, at least. Whereas in every practice, you have patients that are more difficult to get grip on. So some cases are pretty in straight forward. If you break a leg, you don't need the philosophical counseling. Primarily, you need a plastic cast or a surgery. And this is true for many conditions. But there is also a very large group of persons, patients, fellow human beings that have less well defined problems. This is typical for a large part of the psychiatric spectrum, where, as you say, the diagnosis are not based on chemistry and not based on radiology, because we don't we don't find anything there. So it's criteria based. And that creates very it sometimes very often you feel that you're trying to push a square peg in a round hole, so to speak. It doesn't fit very well. It's it's also the problem when you ask very general questions in terms of quality of life, like how how how much do you like your life from zero to 10? It's a bit naive to expect that somebody, if you if you reflect about it, how easy is it to answer a question like that? It's so multi-layered. So the point is that I think that you should remain open, especially in the so-called complex cases, that you might be missing the target and in order to find the target, the the crux of the matter. Yeah, I got the impression. You know, I got the association to I read about Diltay. I don't know if I pronounce it right. And he made this distinction between the nomothetic and the ideographic, you know, that some type of science is nomothetic, where you are generalizing to laws that apply to everything. And then you have the ideographic, which is more unique and historically based. And so maybe you could say something about that, because I think that this is exactly the distinction that you need to to make with a patient. Is this a person who has a very well defined, generalized, generalizable problem that you know you can go to the cookbook and you can solve it? Or is this a more unique situation in a way? Right. And so in philosophy, that corresponds to the moment where we let ourselves be surprised, right? Since Aristotle is often the beginning of philosophy, this idea of curiosity. And indeed, if we are in the process of interrogation and trying to feed people within a filter, we are not letting ourselves the opportunity to be surprised, astonished and grabbished, even to discover something new, which is not only a philosophical but also a scientific criteria. I want to ponder a bit with you the idea of emergency that you mentioned. This is very interesting because there are emergencies in of course, in hospitals, right? Accidents. But there are emergencies in life, right? When we suddenly have to take an important decision that does not necessarily come announced. And this happens quite often. And I realize when I have a dialogue about people and I do have dialogues about people who are usually not in, let's say, not in physical pain but they might be in existential pain, in some case. And one thing that I find interesting is that we tend to wait for emergencies to think. And when we have those existential emergencies, we do not have time. So in this sense, philosophical health, as I see it, is also a preparation and anticipation, a sort of a training, a form of martial art, even sometimes I say, so that when the big decisions come, we can take them in harmony with a worldview that has been thought of. Yeah. And in a way, we can say, well, I'm sure that there are some emergency moments, even in in the hospital environment that are actually philosophical, that depend on a certain worldview. I don't know. You're probably better at examples with me, but if donation of an organ or or, you know, acceptance of a certain surgery that might have chances like 50, 50 or 30, 60 chances of success or other other decisions that can be dramatic and that if we are not if we've not anticipated them by doing your work, and what do I really believe? What is my what is my view of the world and therefore, how should I live? These decisions then might be taken by default, in accordance to a certain, you know, set of belief that is the same. Standard normal one in in the society in which I live. For example, I suppose that we could also use the example of you know, assisted death. Should I? How long should a person suffer and with or without consciousness, etc.? So what what's your have you in your practice had those moments where the decision must be taken very, very quick. But in fact, you realize or even the patient realizes that she is not prepared to take that decision. Yeah, that's quite often actually the case. Not in the particular specialty I'm working right now, even though it occurs there too. But as I say that you can define emergency in many different ways. But I think typically that I agree with you that in many cases it would have been much better if there was a preparatory measures taken that that is exactly one of the important potentials for philosophy and medicine. Because when if we if we use the if we define emergency in the typical way of medicine, then it's very difficult to cram in there some sort of deep listening or or reflection or anything, you just need to do something. But there are there are aspects of emergencies that have I think have a natural philosophical side to it. And first of all, it's as you said, the preventative or the preparation, because I use this. I usually say to health care professionals when I lecture that the difference between the patients and us are that the patients are right now manifestly sick. And that's why they are here in the hospital. And we are right now not manifestly sick, at least. But we might very well have been manifestly sick or we might very well 100 percent likely to become manifestly sick sooner or later. So the question is, what can we learn from the patients even though they are sick right now or just because they are sick right now, we are not. So that's one aspect. The other aspect is the aftermath of an emergency. As we have discussed in other contexts, I meet a lot of patients who get ill or get damaged, get trauma very from nowhere, like a flash from the sky. And then they have a condition like a stroke or like a spinal cord injury or a traumatic brain injury that will have repercussions for the rest of their lives. So in that case, it's more about how to deal with the aftermath of the emergency. The emergency per se has its protocol, but the preparation and the aftermath are very much amendable to philosophy. Right. So we are seeing we're saying we are distinct making a distinction here between two aspects of philosophizing one, which would be the philosophizing of the patient and another one, which would be the philosophizing of the of the doctor. Right. And of course, if this is done in dialogue, this creates some sort of a space where if I understand you correctly, not only the patient would have time to reflect and indeed, I suppose that after a serious spinal cord injury, the entire, you know, structure of your your your life world, it needs to be reassessed and redefined and projects have now a new color and a new dimension. And but at the same time, the the doctor, I suppose, I suppose that sometimes some medical doctors feel like they are a cog in a machine, perhaps, and that they don't have themselves the time you work medicine as perhaps more or an anticipation of the future. Is that what you're saying when you're talking about the the the manifestation of the disease? Right. Something that it almost seems like you're you're entering in into a field, which is the phenomenology of medicine, which in which there's been interesting contributions since the fifties. I'm thinking, for example, of Ludwig Binswanger, who who saw care as a process of repossibilization. And so we we do allow the mind body, because in in his view, this is one, the set, the two aspects of one phenomenon, will allow the mind body to to assess in a form of, you know, your dynamic tension is like, I see possibilities in the future for me, even though my my relation to to space and to the others is impaired and not the same as it as it was before an accident. Yes, but since you you started from the example of or we started from the example of emergencies, I'm saying that there is a timing factor here. It's like most things in life that timing is very important. I mean, you you couldn't expect the person who broke their neck yesterday to be able to reflect on that because of psychological reasons. I mean, it's it's not doable. And it's not even advisable, I think. But there is, on the other hand, there is talking about the mental space that regardless of the fact that you didn't choose to enter this emergency, the emergency per se as such might open up. I sometimes say that life makes philosophers out of everyone sometimes. So this is the type of situation. That's that's one of the selling arguments for the philosophy in medicine is that not that everyone is a philosopher all the time, which is ridiculous to to to claim. But the fact that all of us will be philosophers in certain circumstances, as you said previously, that when things happen shit when shit happens, you tend to start to reflect, because it's not a philosophy. So you're talking about that philosophy in a certain way, but then again, most of us, most of us are true philosophers in certain circumstances, as you said previously, that when things happen. Shit, when shit happens, you tend to start to reflect because you you must reflect, because there is chaos, and people cannot accept chaos for a long time. So what I'm saying is that the emergency, there is a timing factor. cannot do that immediately. Then there is a distant factor where you stop reflecting. But between those two extremes, between those poles, there might be a space or a time space, so to speak, time and space for philosophy. It's opened up and it will close again. And we are bad at using that space for something else than the, let's say, nomothetical medical way of doing things. And it's interesting that you refer to the idea of chaos as something that is often perceived as negative, right? And we know that there is another take on chaos with the pre-socratic philosophers in Greece, but also to a certain extent, I regard it with Taoism. And in my own methodology, which I called Creolectic, I often refer to chaos as, with another word, I call it the Creole precisely because it's less negative, right? The Creole as in creative real. And sometimes a certain acceptance of the chaos might be a first step towards seeing the possibilities and the creative possibilities in that chaos, which leads me to a connection to the title we have given to our first conversation. It's philosophy useful in medical practice. And it's interesting because there is a sort of a linguistic trap there because we are already assuming, perhaps, that things need to be useful, right? And isn't that what many things in our society are about? This idea that it needs to be efficient, it needs to be measurable, it needs to be useful, but perhaps sometimes we have to reconciliate with the fact that some activity might not be useful in the sense that we normatively evaluate what is useful or not. So in our question, I think there needs to be also a moment where we are questioning the very norms of society in terms of what is useful. For example, very often we consider that a person needs to be able to work, right? And I've worked quite a bit with computer scientists on the topic of artificial intelligence. And very often there is this general reaction of the public, which is, oh, artificial intelligence will destroy a lot of jobs. And therefore we react as if it were chaos. And but another reaction could be, okay, so why not? Are we defined by our jobs? Can we imagine a society in which our presence in the world could be triumphant without necessarily implying a successful career in which we wake up at five o'clock and are still at the office at nine? Yeah, but I mean, talking about, I agree with you to some extent in terms of this usefulness or utilitarian, it's a bit restricting. But on the other hand, if we are realistic about medicine in even in our country, rich country, if you cannot discuss interventions in terms of some kind of usefulness, they will not be applied. It's the difference between need to have and nice to have. So if you want something nice, you can listen to music or go to the theater. You can of course argue that it's useful to go to the theater and to listen to music. I would claim so, but it's very indirectly useful. So in terms of usefulness in medicine or philosophy being useful in medicine, I think that one strategy would be to show that that even by using this very restricting standards, it is useful. People manage better. They feel better, they have a higher quality of life, more satisfied, blah, blah, blah, better return to work, whatever. If you can prove that, which remains to be done, but if we can prove that or someone can prove that, that will be the proof of concept. Then you can go from there and say that, well, real beauty of this is much bigger. It's so on. I think otherwise we will be, the philosopher will be in a very poor situation when you're starting to talk economics and politics. Yes, and I see that this seems somehow to go for a little bit of dialogue on the aspect of mental health in which I think philosophy can be very immediately shown to have very good effects. We know that even in a country like Sweden, the medication approaches to mental health and stress, for example. We're talking here, I'm talking here about, I'm not talking here about extreme cases, I'm talking here about, you know, the, but even some diagnosis that people use in relation to their identity, right? We have a lot of, I myself as a philosopher, counselor, meet people who have been diagnosed sometimes very early in life with, you know, bipolar one or two diagnosis or ADHD, etc. And they seem to relate that to who they are to the very philosophical question of identity. And that seems to impair, have impaired their perception of what they can do. And what I've seen in empirical protocol several times is that in very few sessions of philosophical counseling, they change their attitude towards the diagnosis. And they don't see it anymore as something that is a definition of themselves. They even, in certain cases, change their relationship to the medication, which seemed almost like an inevitable habit before, and which they sort of liberate themselves from. So, but that's very, of course, that's the that's the paradox of philosophy, right, is that it, it wants to be applied and it wants to be useful in the sense that people probably need, it's not only that they need meaning, is that they, they are their bodies and their minds already consciously or not worked and elaborated by meanings, ideologies, normativity. So they are there. So the philosopher is not saying, you don't have meaning, you need meaning. The philosophers say, you are more or less consciously, in very times, not that consciously, following patterns of thought and belief that might not be the best for you, but it might not be the ones that actually correspond to who you really are, who you really want to be, and what is your, really, your deep orientation. So that's, of course, the kind of paradox is that it's, those things are not measurable. So my question here is, fine, philosophy also wants to help people. I do as a philosopher, as a philosophical practitioner, but I'm, I'm also a little bit cautious and, and you know, questioning the possibility of, of an evaluation and a measurement, given the fact that I think that philosophy is sort of a bridge between these two extremes, the care for the whole, the careful for totality, right, in the world where most disciplines, they need to, to deal with the part and, and fix their, their, their part. And at the very opposite, the care for singularity. And here I mean singularity in, in the sense of subjectivity, the fact that each of us is, is unique and has a, the possibility of access to a unique destiny. Yeah, but I mean, yeah, I understand. And I think that, of course, we, first of all, it will be like mixing oil and vinegar to some degree. It, it has to be, because that's why we are, why we need to have this type of dialogues. It's better than eating oil and water. At least with vinegar, you can have a nice sauce. Vinegar, yeah. Yeah, but if you, yeah, but it will still, yeah, anyway, okay, oil and water is even better metaphor. But what I'm, what I'm thinking about is that, so it's not the point to get consensus exactly, but I think it's important to retain this aspect of usefulness. But it has to be qualified, what we mean by it. When you talk about diagnosis, I, I have a thought on that too, that I agree with you that in case that was the correct way we're interpreting you, that people tend to become their diagnosis or they, to look upon themselves as the diagnosis. And I have a remedy for that, or at least a way of, of, you know, making it more difficult by, by showing the absurdity. If you go to the diagnostic and statistical manual of mental disorders, the fifth edition, I think is the latest, you will find that anybody, including you and me, have at least three, four, five different diagnoses. We fulfill the criteria. Actually, it's impossible, I would claim, not to be diagnosed as having some sort of mental disorder because there are hundreds of them. And the criteria are created in such a way that they are quite inclusive, not all of them, of course. So, and there is the further. So, so, so this is again, I mean, shows the absurdity. If you go to the extreme, it's absurd. Secondly, humanity doesn't change very quickly. I mean, the human, human species is, you can still read Socrates and, you know, or read the Plato rather than Socrates, you can read about Socrates. And you can feel quite at home, or at least you get the impression that this is not people totally different from ourselves or Aristotle or whoever. So what I'm, what I'm aiming at is that nevertheless, a lot of diagnosis come and go. Some diagnosis are, are, are actually invented, you know, some you discover like tuberculosis, you need to know that there is organism that creates it, that creates the disease. That's a discovery, but you can also invent diagnosis. Right. You and, and, and those can be de invented. You can stop having that that diagnosis is, I mean, like, during the late 1900s century, there were quite some people that had this neurostenia, you cannot make the diagnosis of neurostenia today, but you have other alternatives. So you shouldn't get, we shouldn't get lost in these labels. Right. And those cultural, for example, neurostenia has been popular in China and in still he's to a certain extent, much, much more. So it has to do also with how a given culture response. But we do, I think I understand what you're referring to. We've seen in the 20th history of pathology, new conditions that were labeled. And, and, and that once the doctors agree that this actually should not be used anymore. We see also the curve of people affected by that condition. The curve goes down. So they are phenomenon of entrainment. But, okay, so I was trying to play a little bit the devil's advocate, because I do agree that philosophy could be extremely as not as a replacement, but as a, you know, a method that comes in compliment of certain practices, very useful in medical practice. And, and I think we could perhaps conclude today's conversation, because I think we will have more conversations. We can conclude today's conversation by saying that they are when we are curing and caring, we're dealing with a person. And that person's destiny and presence in the world and needs also to be assessed if we don't want to have a sort of dualistic division between a body that would be a machine and that we, we, we take care of as a car, basically. And, and, and the mind that would be disassociated. And, and that would be by the way itself treated as a machine that would need to be adapted to the norms and functional functionalism of a given society. So, under this abstract abstract words, what I mean here is that I would like you perhaps to conclude with a few examples of practice in which a dialogue that would be open to, to concepts, to, you know, ideals, meaning, where, why, where am I going with my life? What do I believe in? What are my values? This can be useful and practiced. So who could, who could give that touch? Is it, is it the nurse? Is it the, the medical doctor? Would it be a new form of training for philosophers? And we know that people who study philosophy are very often not in a very good position in the labor market. So is it, who do you think, or is it the collaboration between this actors? Yeah, I, I, very good. No, I think it's, I would say it, it should be ideally a collaboration and that requires that, that the philosopher learn a little bit more about medicine and the, the medical and paramedical and nursing, all of them need to know more philosophy. So you need to be able to speak with each other and you need to, to understand the vocabulary and so on. But I think it's quite simple in a way that, that, you know, philosophy, what is it? I mean, it's both a topic and it's a method, several methods. So for instance, what is psychotherapy? I mean, psychotherapy is rehashing, if I, I'm not a psychologist, but we will hate me, but some of them, but I mean, what is, what is psychotherapy? I mean, what is, you look at the stoics, the stoic way of Marcus Aurelius or Epictetus, this is psychotherapy. I mean, it's a way of preparing yourself for life and the hardships of life. So there you have it long before, long before it was called anything else. You have the existentialists talking about, you know, the predicament of life. You have, so it's already there, first of all. It's called something, it's called the cognitive behavioral therapy, it's called an act, it's called whatever it's called. Then you have critical thinking, which is a part of, and logic, which is also a part of philosophy definitely. And it's also a part of every type of science. If you don't have it, all type of intellectual activity requires some degree of logic and some, some degree of critical thinking, which is sorely needed everywhere. And of course, it's also important in medicine. So, and also conceptualizing things, also very important. What is the concept? How is it defined? So just by going through the history of philosophy, you find a gold mine that is already there. So I don't think we have to reinvent the wheel, but the problem is that in Sweden, especially in many other countries, we have forgotten that gold mine. It's not taught. So we are taught to be specialists, but we are not taught about the great history of philosophy, intellectual history that we could use now. Right. That's my hope. Yes. And this is more than a hope for the two of us. It is a, it is now a work that we're doing. And for example, through these conversations, which I hope we can make them monthly, we're trying to go deeper and deeper. This was a sort of an introduction, right, to our concern. And it was, I think, useful to you, likewise. And we'll talk soon. Thank you. All the best.