To the Editors:
Concerning R.S. Lewontin’s interesting review of Against Biological Determinism [NYR, January 20], if the statements in the Bignami-Rogers paragraph imply that the ideas described are held by “medicine,” they are false, as follows:
No competent clinicians/researchers believe that Parkinsonism is “caused” by dopamine deficiency. It is one effect, not the cause: it is part of a causal chain of processes many of which are still unknown. The fact of clinical relief indicates that “something” helpful has occurred.
Nor do competent physicians believe that TB bacilli “cause” tuberculosis; they are necessary, but hardly sufficient factors. Other necessary ones include transmission (only “fresh” droplets), duration and frequency of exposure, presence of other lung diseases (“lowered resistance,” etc.). Age is important: for example, below age five, TB is usually a rapidly fatal blood-borne disease. There is acquired immunity. There may be racial (genetic) factors: the sixty-year-old alcoholic Anglo-Saxon, walking about with “cheesy” lung fragments; the twenty-six year old Puerto Rican dying within six months, with “millet seed” pustules even in his eyes. (I believe Medawar, reviewing Illich in NYR, also criticized this very same canard.)
I have been a psychiatrist for thirty years; neither I nor my colleagues have ever believed that the “cause of behavior” is one (generic) entity, “modified by a pill or a scalpel.” There are behaviors, feeling states, sensations, etc. Empirically, certain medications, surgery, etc. have brought great relief to suffering humans, for example:
a. behavior (seizures): For example, Pen-field’s brilliant work in removing “scars” on temporal lobes, with cessation of seizures.
b. mood (involutional psychotic depression): I have been much moved when I witnessed withdrawn, self-dirtying patients, crying out that they deserved to die, totally free of symptoms and back at work (“feeling great”), following as few as four to six (under anesthesia) electro-convulsive treatments.
c. mental content: Paranoid delusions (sometimes with tremendous terror/rage) decrease rapidly with the use of the “antipsychosis” drugs.
While much is known about the above: surgery, ECT and psychopharmacologic agents, the precise processes are still unknown.
A last point:
I think most physicians remember the Hippocratic oath and the basic rule: “Do no harm.” I don’t know who Bignami’s and Roger’s “vulgar” (sic) reductionists are, nor which “state…repeatedly” uses psychosurgery to “cure” prisoners. Are they specifically identified in the book?
Francis J. Rigney, M.D.
Pacific Medical Center
San Francisco, California
To the Editors:
Lewontin’s article, “The Corpse in the Elevator,” is more like a political tract than a philosophy of biology. Lewontin attempts to define the limits of the reductionist approach and to argue that we will never be able to explain some biological processes in mechanistic terms. I would like to contest this view. The momentum of biology has always pushed back self-imposed limits to knowledge. The ingenuity of humans is indeterminate; hence extremely complex processes can, and will, be understood by using the reductionist method. However, even if we assume, as Lewontin does, that some phenomena are not amenable to a reductionist analysis, then where do we draw the line? In fact, is it fruitful to try to discover this line? I would say no to my second query. The reason is simple: as methodology and theory improve, more investigators will successfully attack problems that previously seemed to be unapproachable.
Lewontin correctly points out that embryogenesis, and indeed all life, is not simply a consequence of a program for development determined by genes. He implies, correctly, that beginning at the single cell stage of the embryo, the three dimensional organization of proteins, nucleic acids, etc., within the cell plays a critical role in development. He does not point out that many biologists appreciate the importance of the cell’s architecture or factory as he prefers to think of it, nor that the three dimensional organization of the stuff of life is exceedingly difficult to study, nor that scientists using more powerful techniques are studying the cell’s architecture and its relationship to development.
Lewontin assumes, wrongly, that the concepts associated with the gene and the central dogma are themselves dogmatic. For many years genes and gene products (principally proteins) were relatively easy to study and hence were studied preferentially. From forty years ago to the present this information has formed the basis for the theoretical synthesis of evolutionary biology and genetics, a cornerstone of modern biology. Within the last ten years modern recombinant DNA technology has made it possible to study the organization of all of the DNA in a cell. This is important because most of the cell’s DNA cannot be assigned to genes. That is, most of the DNA does not code for proteins. Biologists are open to the idea that as new information becomes available from the study of all of the cellular DNA some aspects of the combined evolutionary and genetical theories may be shown to be wrong.
I have developed these few examples to point out that (1) biologists are open minded and exploratory even though they use reductionist methods and (2) such an approach has paid off with results. There is no point in defining the limits to knowledge; these limits are fluid. Lewontin’s statement that “we will never understand the organization of the central nervous system at any but the most superficial level” makes no constructive point. It is a negation of the aspirations of scientists.
Thomas A. Kursar
University of Utah
Salt Lake City, Utah
R.C Lewontin replies:
Dr. Rigney and I are in some disagreement about what physicians and medical research workers say and believe about causes of disease. In part, Dr. Rigney may have wishfully transferred his own views onto his colleagues. The statement that no “competent physicians believe that TB bacilli ‘cause’ tuberculosis” is patently wrong. The germ theory of disease is universally taught as the greatest advance in medical science, and Robert Koch is one of medicine’s transcendent heroes. It is no accident that we have a National Institute of Allergy and Infectious Diseases that concerns itself with tuberculosis but do not have, say, a National Institute of the Social Causes of Disease. The leading textbook of medicine, Curtis Textbook of Medicine, among whose distinguished authors is the recent head of the National Institutes of Health, defines tuberculosis as “a chronic infection, potentially of life-long duration, caused by two species of mycobacteria,” and I’ll bet that if a student at the University of California Medical School offered on an examination “being Puerto Rican” as the cause of tuberculosis, he would get something less than full credit. Moreover, I suggest that Dr. Rigney ask, with a straight face, the first five of his colleagues whom he meets in the corridors next week what is the cause of tuberculosis. He may be shocked to find how many of them are, by his definition, not competent.
Indeed, Dr. Rigney’s discussion of the contributing factors in tuberculosis makes Bignami and Rogers’ point. His list of factors that enter into the probability of contracting tuberculosis and influence its severity are all individual properties: immunity, age, general health, ethnicity. Social class, real wage, work place conditions, availability of free health care are strikingly absent from his list. Had he considered them, he might have avoided the error of equating differences in ethnic or “racial” incidence and severity of TB to “genetic” factors. The genes for susceptibility to tuberculosis seem to have passed in less than a century from the Italians and Eastern Europeans into the chromosomes of Puerto Ricans.
Dr. Rigney’s remark that a deficiency of dopamine is an effect rather than a cause of Parkinsonism raises the problem posed by reductionist medicine of distinguishing diseases from their mere symptoms. Dr. Rigney regards the tremors and loss of motor control in Parkinsonism as mere symptoms, caused by a chemical deficiency, while the disease itself is something else which is the cause of the chemical imbalance. What the disease itself is he does not say, but presumably he has in mind a degeneration of brain tissue, the causes of which are currently unknown. (One popular theory has it that infection with an encephalitis virus is the ultimate cause of Parkinsonism.) To see the problem let us consider schizophrenia. Dr. Rigney apparently does not (indeed, cannot) disagree that a major school of thought claims that schizophrenia is caused by a chemical imbalance, some holding that the imbalance is itself ultimately caused by defective genes. What is schizophrenia? Is it the behavioral and mental states that psychiatrists use to diagnose it, or are these merely the symptoms, the outward epiphenomena of the real thing inside, unspecified? Is it really brain lesions (never observed), or perhaps schizophrenia is identical with the chemical imbalance, rather than either its cause or effect. We are back once again to the problem raised in the Bressanone Conference of the causal relation between brain states and mental states.
It is often asserted that the difference between an underlying disease and its mere symptoms becomes apparent in the act of treatment. If we treat only the symptoms, then when the treatment is suspended, the symptoms will recur because the disease is still there generating them, while a successful treatment of the disease itself puts an end to the business. Indeed, we speak scornfully of political actions that deal only with symptoms of social dislocation while ignoring their underlying structural causes. But things are not that simple. Let us take a case where the simple reductionist program of explanation has, in fact, been a success. Wilson’s Disease is characterized by a severe and finally fatal degeneration of tissues consequent on the accumulation of copper in the body. Copper accumulates because the enzyme normally responsible for removing it is defective because, in turn, the gene coding for the enzyme is defective.
Wilson’s Disease patients are successfully treated with a chemical, but the treatment must be continued indefinitely because the enzyme defect remains. Does it follow that the tissue degeneration is only a symptom of Wilson’s Disease and that the disease itself is really the mutant gene and the defective protein it codes? Such a notion totally collapses diseases into their causes and destroys any usefulness of the concept of disease. The same problem arises in cases of so-called “asymptomatic” disease. The famous “Typhoid Mary” was infected with Salmonella typhosa, but at the time she was located did not have the symptoms of typhoid. Was she “diseased” because she could be a cause of typhoid fever in others?
The confusion about diseases and symptoms is one consequence of the reductionist commitment to partitioning complex patterns of relationships into simple paths of causes and effects in which the arrows of causation point always in one direction. A better approach might be to regard the entire syndrome of infectious agents, chemical balances, anatomical changes and physiological functions in each case as the “disease” and to consider the total consequences of various interventions. The importance of considering such total consequences is nowhere greater than in electro-convulsive therapy and “anti-psychosis” drugs, which Dr. Rigney portrays in such benign guises. I hope that he has been as much moved by the awful destruction of memory, personality, and affect reported by electro-shock recipients as he is by those who have been able to go back to work. I note that he does not include in his list of aids to suffering humanity the immense numbers of lobotomies and amygdalectomies which also abolished paranoid delusions accompanied by tremendous rage, while converting their recipients into vegetables and their inventor (Moniz) into a Nobel prize winner.
If Dr. Rigney is in search of colleagues who hold simplistic theories of social behaviors, he ought to look up Professors V.H. Mark and F.R. Erwin at the University of California, who, when they were at the Harvard Medical School with Professor W.H. Sweet, asked in the Journal of the American Medical Association
…if stress conditions also determined and initiated riots, why are the vast majority of slum dwellers able to resist the temptation of unrestrained violence? Is there something peculiar about the violent slum dweller that differentiates him from his peaceful neighbor?1
They then go on to call for a program of “intensive research and clinical studies of individuals committing violence” to “pinpoint, diagnose and treat…people with low violence thresholds before they contribute to further tragedies.” The “treatment” they are talking about, as they make clear in a later book, is psychosurgery.2
As a last point, Dr. Rigney is quite right to challenge my reference to a state that reputedly uses psychosurgery to cure prisoners. In fact, the state of California “temporarily abandoned for administrative reasons” its plans for such treatment after a public furor was created, and instead carries out “aversive conditioning” as described in A Clockwork Orange. Prisoners are tortured with the drug Anectine which induces sensations of suffocation and drowning. The chief psychiatrist in charge of the California program says the subject feels “as though he were on the brink of death…. Even the toughest inmates have come to fear and hate the drug. I don’t blame them. I wouldn’t have one treatment myself for all the world.” 3 If Dr. Rigney wants to see how seriously the Hippocratic oath is treated by some of his colleagues, he should take an hour’s trip east on Interstate 80 to the Maximum Psychiatric Diagnostic Unit at Vacaville where aversive conditioning is practiced on prisoners.
There is not a great deal I can say in reply to Mr. Kursar. His letter is simply a concatenation of undemonstrable assertions about the unlimited power of biologists to solve all problems in the future. How does he known that “extremely complex processes can, and will, be understood by using the reductionist method” and that “investigators will successfully attack problems that previously seemed to be unapproachable”? To doubt that human ingenuity will necessarily conquer all obstacles may indeed be a “negation of the aspirations of scientists,” but what law of nature guarantees that scientists will achieve their aspirations? We cannot, alas, always have what we want. It is not historically correct to state, as Mr. Kursar has, that “the momentum of biology has always pushed back self-imposed limits to knowledge,” since, despite our best efforts, we are still in the dark about development and the brain, although of course we may crack these problems in the future. I did not write, as Mr. Kursar claims, that “we will never understand the organization of the central nervous system.” I wrote only that we must face that possibility. Only a fool would state dogmatically that something will never be understood. People, after all, are pretty clever. But a dogmatic assertion that we will understand everything is equally foolish. People, after all, are not all that clever, and time and resources are limited.
Mr. Kursar’s letter does raise, by implication, the question of the uneven development of the biological sciences. It lays siege to a series of cities and towns. Some are quickly taken, but others resist their besiegers for indefinite periods, so the army moves on, without actually taking them, to conquer easier territory. The unconquered remain behind, centers of resistance and annoyance. It seems to me that biology is much more characterized by this piecemeal conquest than are the physical sciences, because a failure of explanation in one domain of physical science has more immediate and powerful effects on other domains to which it is tightly linked. Biology, because it deals with a more heterogeneous and loosely connected set of phenomena, each of which is the nexus of a large number of historically contingent causal chains, can make great advance across its terrain without subduing every citadel. It remains an open question whether the armies of reduction will ever take the capital.