The Laws of Medicine Read Free Page A

sensed that the profession itself had changed at the moment of our entry. . . . We became convinced, overnight, that nothing lay beyond the reach of the future. Medicine was off and running.” It was the birth of what Thomas called the “youngest science.”
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By the time I read The Youngest Science , the scientific transformation of medicine had deepened even further. Take heart failure again. In 1937, Thomas wrote, the only reliable means to affect a failing heart, aside from propping up its function with extra oxygen, was to alter blood volume by inserting a needle into a vein and drawing out a hundred milliliters of fluid from the body. To a cardiologist working in the late 1990s, this would be akin to lancing an abscess using a skin cup: it might work, but it was a decidedly medieval approach. This cardiologist would now have at his disposal not one, or two, but no less than a dozen medicines to subtly modulate the volume, pressure, and rhythm of the failing heart, including diuretics, blood-pressure mediators, drugs that open channels for salt and water in kidneys, or medicines that maintain fine control on heart rhythms. Added to this were implantable defibrillators (colloquially called heart zappers) that delivered jolts of electricity to “reset” the heart should it enter a lethal rhythmic cycle. For the most intractable cases of heart failure—such as the young man whose heart muscles were destroyed, bit by bit, by the mysterious deposition of iron, like the Tin Man of Oz—even more innovative procedures exist, such as the transplantation of a whole foreign heart into the body, followed by a salvo of immunosuppressive medicines to ensure that the transplanted graft remains functional and intact in the body afterward.
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But the more I read The Youngest Science that year, the more I returned to a fundamental question: Is medicine a science? If, by science , we are referring to the spectacular technological innovations of the past decades, then without doubt medicine qualifies. But technological innovations do not define a science; they merely prove that medicine is scient ific —i.e., therapeutic interventions are based on the rational precepts of pathophysiology.
    Sciences have laws—statements of truth based on repeated experimental observations that describe some universal or generalizable attributes of nature. Physics is replete with such laws. Some are powerful and general, such as the law of gravitation, which describes the force of attraction between two bodies with mass anywhere in the universe. Others apply to specific conditions, such as Ohm’s law, which only holds true for certain kinds of electrical circuits. In every case, however, a law distills a relationship between observable phenomena that remains true across multiple circumstances and multiple conditions. Laws are rules that nature must live by.
    There are fewer laws in chemistry. Biology is the most lawless of the three basic sciences: there are few rules to begin with, and even fewer rules that are universal. Living creatures must, of course, obey the fundamental rules of physics and chemistry, but life often exists on the margins and in the interstices of these laws, bending them to their near-breaking limit. Even the elephant cannot violate the laws of thermodynamics—although its trunk, surely, must rank as one of the most peculiar means to move matter using energy.
    But does the “youngest science” have laws? It seems like an odd preoccupation now, but I spent much of my medical residency seeking the laws of medicine. The criteria were simple: a “law” had to distill some universal guiding principle of medicine into a statement of truth. The law could not be borrowed from biology or chemistry; it had to be specific to the practice of medicine. In 1978, in a mordantly acerbic book called The House of God , the writer Samuel Shem had proposed “thirteen laws of