The Think Tank
The Think Tank
Why a theory specifically for General Practice?
The members of this multidisciplinary group, based at the General Practice Research Unit, meet three to four times a year and discuss topics pertaining to medical theory. The aim is to contribute to the development of a theoretical, conceptual framework of the human body and human sickness that is better suited to the tasks in General Practice than the current biomedical framework, which involves linear causality and a fragmented, mechanistic and reductionist approach to disease.
In General Practice, most patients present with ailments and health problems that are not easily explained within the organ and disease oriented system, conceptualised and categorized as it is into medical specialties which are further divided and classified according to whether they address somatic or psychiatric diseases. The typical patient in General Practice suffers from states of chronic, complex sickness referred to in the reductionist terminology as “multi-morbidity”. Typically, these kinds of bad health transgress, i.e. go beyond, the imposed limits of the somatic-psychiatric divide. The patients are diagnosed with “both” somatic and psychiatric diagnoses; in addition, their impairments include various combinations of so-called “medically unexplained symptoms” or syndromes, formerly conceptualised as “psychosomatic” or “somatoform”.
Such patterns or clusters of diagnoses are a source of much concern within General Practice. Inevitably, they present the patient’s GP with the challenging task of administering and monitoring the poly-pharmacy that emerges as a logical consequence of the mandate to treat each separate disease in accordance with guidelines elaborated by each respective organ speciality. Thus, a person consulting her or his GP may have a wide range of drugs prescribed, each of which has been deemed appropriate to treat the separate diagnoses – despite the fact that few of them had been scrutinized for potential drug interactions in correctly performed medical trials. Consequently, the moment a patient is prescribed drugs for “several” diagnoses simultaneously, the reasonable demand that “patients be treated according to best evidence” becomes impossible to meet. Trials are consistently designed for one drug at a time – two drugs if within the same therapeutic spectrum in order to allow comparison. Randomised controlled trials (RCT) – the gold-standard design for such testing – simply does not allow for a “mix” of drugs nor for a “mix” of diseases. As a result, a typical patient in General Practice will most probably never be eligible for any of the general, evidence-based prescription drug trials.
Another challenge, one of similar dimension, is the frequent presentation of ailments which cannot be objectified via technical examinations in specialist care which thus cannot be properly named. This “medically unexplained” category is not only the source of great frustration for both the patient and the doctor; it also creates the highly unsatisfactory situation in which trial and error generates much medical activity while providing little actual help. This becomes a source of anxiety for the patients as no clear answers emerge as to “why this problem?” and “what should be done to ameliorate it?” It is estimated that such “functional” problems, which often renders the patient “dysfunctional” in everyday life and at the workplace, are encountered in one out of every five General Practice patients. It is there they begin their search for treatment, and it is there they return after the specialists have “found nothing”. It is a paradox that GPs in such cases are often requested to treat the patients in accordance with guidelines that have been elaborated by the very specialists who were unable to resolve the problem within specialist care.
Thinking about theory specifically for General Practice
Thinking about theory specifically for General Practice
Where did we start?
Departing from the micro-level of macrophages, and acknowledging that these are hermeneutical agents since they are able to interpret signs and choose objects, we had to conclude that general biology, the initial master-science of biomedicine, does not account for the particularities of human beings.
T-cells need to have their existence and function confirmed by the thymus gland in order to “know” about themselves and thus become able to act as competent immunological agents. A parallel need for confirmation may be seen to exist in human beings, who also need to be confirmed, to be held and seen by others, in order to acquire a sense of selfhood and become competent social agents.
We recognized parallels between immunologically acquired and individually interpreted experience at the cellular level, and socio-culturally acquired and inter-subjectively interpreted experience at the symbolic level.
Recognizing such analogous characteristics opened our eyes to connections between levels of history as well, from evolution to world history, the history of Western ideas, the history of science, and individual, biographical history.
A phenomenon characterising all layers of history thus became visible: our world is structured through a multi-level activity of interpreting and attributing meaning to signs. As the scholar of the theory of sciences Jesper Hoffmeyer put it, “the world is strongly semiogenic”.
At this point, we understood:
There can be no split between what happens in the human body and what happens in the human mind – a message coming concurrently from a variety of leading research groups within the basic sciences. While remaining anchored in the ontology of natural laws, these groups contribute increasingly to an ontology of “emergence”.
Reading signs and interpreting them within the terms of meaning and significance is part of the essence of life and the living. This is as valid a statement regarding the relationship between intestinal microbiomes as it is for human beings. It is valid as regards the systems safeguarding bodily vitality and viability – the endocrine, immunologic and neurologic systems, both in their interplay and in their responding to the human lifeworld. The statement is also valid regarding all the relationships between human beings and their societies. On each of these levels there is agency, a bodily capacity and strength for self-maintenance.
A sign means something, and must be interpreted by somebody. Thus, signs imply relationships. Everything of interest in and for the living world concerns relationships. Since interpreting signs with regard to meaning is at the essence of life, life is, by necessity, characterised both by intrinsic values and by choices. This means that the living world is saturated with meaning. In other words: ethics are inherent within the living world.
Valid knowledge about the living needs to be informed by ethics, and consequently, the production of knowledge about the living must be guided by ethics. In the words of anthropologist and scholar of systems theory Gregory Bateson, there is no such thing as a value-neutral epistemology.
At this point, we acknowledged:
Our thoughts ought to be directed towards a meta-level, addressing the epistemological approach termed Abduction, described as early as by Aristotle as a “third way”. This involves transcending the classical dichotomies of Reduction and Induction, including, as termed by philosopher Wilhelm Dilthey, those within a framework of “explaining” as in the Natural Sciences, and in a framework of “understanding” as in the Humanities.
Abduction represents an epistemology in which the significance of a single case is acknowledged as a potential point of departure. This opens the way for an aesthetically oriented methodology, one that is guided by and attentive to patterns, and with the intention of identifying and describing deep structures within empirical data. The analytical approaches that are implicit here are anchored in theoretical positions, thus providing the researchers with options for both “explaining” and “understanding”.
This significant nexus of historicity, relationality, context and meaning for the production of knowledge about the living was formulated by microbiologist Elling Ulvestad: The patterns of human actions ought to be reflected upon in an integrative framework of the three structural levels of biography, evolution and the history of ideas. At the core of these three is Existential Experience.
Philosopher Arne Johan Vetlesen, referring to philosopher Georg Wilhelm Friedrich Hegel, describes the phenomenon of Experience in the following way:
Experience inaugurates the unknown, that which is new; the subject is displaced from its familiar patterns and is touched by something that makes the subject perceive itself in a new way, see itself from a new perspective. Experience implies a dynamic encounter since there is no experience without a subject and an object; without an object, there is no subject, reshaped and changed, informed by the experience. Consequently, experience is inevitably subjective, it “sticks” to the subject, so to speak.
At this point, we ascertained:
Recognition continues to grow of the impact of experience on the basic functions of human physiology, from the micro to the systemic levels. Thus, when attempting to identify valid knowledge regarding situated human beings, no method that is based on external observation, measurement, replicability and the presumption of unambiguity can possibly be applied. Considering also how inevitably complex, ambiguous, open, and subtle individual and sociocultural human phenomena are, it becomes apparent that the human being – that social agent who is experienced and experiencing, interpreting and intentional, who generates and conveys meaning – has been avoided, painstakingly, both methodologically and systematically, within biomedical research into human health. The question inevitably arises: What have been the consequences for the body of medical knowledge that precisely this subject has been “lost in abstraction”?
Bateson regarded Abduction in a methodological sense as the very premise of every scientific exploration or activity, although eventually to be integrated with inductive or deductive approaches. Abduction offers the possibility to gain insights from as yet incomplete processes that, even if ultimately proving to be in error, may nonetheless open up for a totally new idea, perspective, point of departure or hypothesis. Abduction as a methodological activity provides a potentially salient premise for “that which is new”.
Philosopher Charles Sanders Peirce defines Abduction within a pragmatic frame as an anti-Cartesian position in the theory of sciences. He attributes to it a central place as part of “a community of inquirers” into the reflecting subject, into someone who is in the world as a knowledgeable, cognisant, sensual-perceptive agent. Knowledge brought forth in this way is always changing and continually being integrated into, braided together and saturated with social activity and social life. Therefore, Abduction as a methodical research approach is characterised by sensitivity to patterns and structures (Bateson’s term: the pattern that connects) and by interpretations that transgress the empirical material.
At this point, we understood:
The growing documentation of a relationship between experienced adversity and manifest sickness calls for innovations in thoughts and concepts. Since experience is a vital source of sickness in general, a central premise for the medical appraisal of states of ill health must include a familiarity with the specific patient’s lifetime experience. This implies that medical research ought to immerse itself in the phenomena of the human lifeworld in order to gain valid knowledge about the human condition. Consequently, it becomes clear that a theoretical re-orientation is necessary, one that may be conceptualized as follows: The patient-subject, including her or his personal experiences, must be re-introduced into the body of medical knowledge and into its methodological repertoire.
Not only research methodology must be changed, but also the health professional’s relationship to each of her or his patients. Acknowledging personal lifetime experience in a specific patient requires an understanding for which empathy is the salient prerequisite. Phenomenology, in particular phenomenologist Edith Stein, conceives empathy as, “me, your fellow human being and, as such, your compassionate being.” Such a concept embraces the tension between “similar” and “different”; it involves appraising the other’s being as “other”, and, as such, as different, on her or his own premises.
The preconditions for genuine empathy are consciousness and self-consciousness. These phenomena are increasingly central within neuro-phenomenology, a research field integrating contributions from psychology, neurology, neurophysiology, systems theory, and evolutionist biology. Researchers in the field seek valid knowledge about the evolution of human consciousness. Biologist, philosopher and neuroscientist Francesco Varela’s contribution to the field was his attempt at conceptualising the central nervous system within a phenomenological framework without ignoring its biological aspects. He concluded that it represented an ecological system. Philosopher and scholar of the cognitive sciences Shaun Gallagher contributes a dual view of the human body: Body Image, comprising the concepts of self-understanding and self-consciousness, and Body Scheme, comprising the body’s capabilities, those which are innate and autonomous as well those which are learned and incorporated. Bateson understands the phenomenon, Mind, as not being bound to substance, but rather as relations, as interaction, facilitated by differences and understood as information. Within this framework, each living being has Mind that is independent of and not related to Brain.
At this point, we acknowledged:
According to Varela, Gallagher and philosopher Natalie Depraz, in an interpretation guided by phenomenology, professionals are able and mandated to integrate the 1st person voice of the experiencing, particular subject with the 3rd person voice of objective general science. What is subjective is thereby ascribed scientific validity.
The biological preconditions for consciousness include the necessary, though not exhaustive, premises for being self-aware and aware of one’s own and others’ mutual significance. Self-awareness in the sense of “knowing that I am” engenders the question “who am I?” Addressing this question about identity requires reflecting on one’s sociocultural contexts. The etymological root of identity includes the Latin terms ipse (self), referring to that which is separate from and opposed to an other, and idem (the same), referring to that which remains the same as opposed to changing. This underlying polarity within a single term, denoting difference and at the same time similarity, expresses both a constant tension and a dynamic balance. Identity is comprised of that which is “different from an other yet unchanging for itself” about an individual, who nonetheless remains her/himself, despite variations over time, and, as such, remains recognisable for her/himself as well as for others.
An exploration of identity on various levels from micro to macro reveals that one finds “identic” objects, in the sense of sameness, only on the level of genes. Genes are salient premises for life, but only as potentialities in that they are bearers of condensed information. Genes are not in and of themselves “alive”. Even on the cellular level, “identical” genetic information is influenced by context, which engenders difference. To be alive involves an understanding of oneself as oneself. This is valid for all life-perpetuating systems.
While preventive medicine aims at preventing disease at the individual level, study subjects are “identified” and thus grouped according to a few predetermined factors, which makes a statistical calculation of that group’s “risk” possible. These groups consist of people who are defined as “the same” with regards to only those few factors. However, these constructs of “sameness” demand that one maintain an ignorance and a systematic avoidance of all criteria for individual identity. Thus, group-based calculations are considered to have a high external validity despite their being flawed by having a very low internal validity. Nevertheless, results from such “experimental” research settings are translated into guidelines to be applied at the individual level – the level that is characterised by precisely that complexity of variation that has been methodologically avoided in the research setting.
From the perspective of psychology today, identity seems to be under a continually increasing threat as the traditional markers in the Western world of one’s own and others’ identity lose their dominance. Personal identity is no longer a “given” in the sense of being socio-culturally determined, but rather must be shaped by each individual. This carries the advantage of increasing each person’s degree of personal freedom; the disadvantage, however, arises from how increasingly dependent each individual becomes on the gaze of the other in order to confirm one’s own existence. Consequently, everyone competes with everyone else. This situation provokes continuous identity negotiations, with the inherent risk of a total breakdown of personal identity. In turn, such broken identity projects call out for new “diagnoses” which name the individual’s state of being. That ought, however, to be a last resort because, implicit in those very names would be a new, although highly ambiguous, identity of being a patient.
At this point, we understood:
Since personal identity is informed by exposure to context and to the gaze of others, society should equip the individual with norms and certain skills. If society fails to do so, the constructing of one’s identity becomes the individual’s own project. One option would be to build an identity based on sickness. Sickness, however, may carry with it an impaired personal integrity. The state of being when integrity is threatened and identity shattered can involve unbearable pain. This pain may eventually evoke the need to externalise it, for example: transfer it by imposing pain on fellow beings. Thus, a “pain in me” is transformed into “great evil for you”. Vetlesen offered this reflection in response to the actions which shook both the Norwegian society and the world as a whole July, 2011: the tragic killing and maiming of many people, most of them young, at the hands of a single, male murderer. Psychologist Tor-Johan Ekeland also commented that, although the mass murderer waved the flag of an extreme right-wing ideology he may well have been motivated by a stunning discrepancy between limitless hatred and a somewhat “limited” biography. If being identified as a Nobody were the ultimate mortification in our societies, the murderer has at least earned himself a place in the Annals of Evil.
In the wake of that mass murder, the Norwegian society witnessed and engaged in a crucial, heated debate concerning the impact of psychiatric diagnoses on the judicial definition of responsibility. The question became: Is this particular person sane – and thus responsible, or is he insane – and thus freed from being held responsible for his evil deeds? The first pair of psychiatric experts concluded that he was “insane” followed by other psychiatric experts who deemed him to be “sane”. Psychiatry itself was thus discredited, accused of being atheoretical.
From this public debacle sprang the question: What is wrong with medicine – and can the discipline be saved from itself? Evidence Based Medicine and Person Centered Medicine emerged as irreconcilably polarised, like a map that does not match the terrain, with statistically calculated probability on the one hand and encounters between two persons in the roles of patient and doctor on the other.
At this point, we acknowledged:
Preparing to elaborate on the topic of Evidence Based Medicine versus Person Centered Medicine, we acknowledged the necessity of first exploring the concept of personhood – and what it implies for medical knowledge production and clinical encounters. The current, much debated and frequently encountered term “Personalized Medicine” also needed to be elaborated with regard to whether – and, if so, how – it is different from Person Centered Medicine. Personalized Medicine is conceptualised as a form for medical treatment that is intended to be “tailor made”. Its proponents claim that it represents the most radical change from the increasingly criticised concept, “one size fits all”, and thus a genuine paradigm shift within health care.
An examination of the concept of Personalized Medicine, however, leaves no doubt that within that framework’s horizon there is no person. In other words: Personalized Medicine rests upon the traditional bio-scientific basis of the de-personalised human body, explored at ever increasing degrees of fragmentation – currently at a nano-level – and structured accordingly into “…omics” (genomics, epigenomics, proteomics, transcriptomics, etc.). Personalized Medicine relies entirely, in other words, on knowledge derived from a body devoid of history and experience: literally, no one’s body, a NON-person. Thus, it implicitly defines as “noise” all phenomena pertaining to the lived body other than what is bio-mechanical.
Any approach to the person as the “medical subject-object” must confront a variety of challenges. One of the greatest would be to develop a language that enabled health care professionals adequately to transgress the traditional dichotomies that structure modern biomedicine and which are deeply woven into current medical language. Since the premise for the traditional language is fragmentation, whatever is indivisible cannot be named, denoted or described appropriately. The implication here is that the phenomenon of integrity – what is whole, undivided and unmarred – lends itself neither to biomedical exploration nor, by logical extension, to being included in its body of knowledge. This is not only highly problematic in terms of the significance that preservation of integrity holds for personal health and function. It may also interfere with a proper understanding of medically relevant phenomena, both in research and in clinical practice. At best, Personalised Medicine may be able to individualise medical treatment based on biological data, but it cannot make clear what impact personal lifetime experience, that is, biographical data, have on a particular person’s health. Consequently, the label “Personalised Medicine” is a misnomer, suitable to highjack a “warm” word, perhaps even to neutralise the steadily growing criticism of a dehumanising medical practice.
At this point, we understood:
The phenomenon of “consciousness” needed to be explored to advance the development of a language for what is indivisible. Alva Noë, a philosopher and scholar of the history of ideas at the University of California at Berkeley, focuses on the philosophy of Mind, the cognitive sciences, and the theories of perception, language and art. He writes: ”The problem of consciousness is understanding how this world is there for us.” He claims that we can approach the question, “what is consciousness?” in the same way as we approach the question, “what is life?” In a departure from others’ concepts, Noë does not conceptualise consciousness as something “within” organisms or human beings, but rather as inherent within the dynamic process connecting the organism and the world. “Life is the way the animal is in the world,” he claims, which implies that consciousness is not simply a “function” of the human brain but rather is more wide-reaching. He opposes the conceptualisation of Mind = Brain, thus both materialised and localised. Consciousness is not something that “happens” to human beings but something that human beings “do”, something they achieve by means of movement and through their interplay with others and the world. Therefore, he states: “The point is that the thing shows up for me as something in a space of movement oriented possibilities”. Further on, he relates it to dance: “The world – three-dimensional objects arrayed in space, colors, shapes, etc. – only comes into focus for perception given the perceiver’s ability to exercise this kind of sensorimotor understanding.”
Noë claims that for animals and humans, the world and the brain cooperate in making “consciousness” happen. Thus, the noun is misleading, while “consciouning” would seem more suitable – a participle, the grammatical form denoting that which is not static, not thing-like, but happening, emerging, coming into be-ing. According to Noë, it is futile to search for consciousness in the brain since that is both the wrong place and the wrong analytical level. Rather, one should aim at encountering embodied life, the situated human. To be conscious means to interact with the world – being-in-the-world. Consequently, to explore the brain in a strict, experimental setting, in a “laboratory” from which the lifeworld has been excluded, is tantamount to “taking away life and then watching what happens”. This type of approach is flawed scientifically since, according to Noê, more than a brain is needed to engender consciousness.
Noë evokes Darwin when assuming that organisms actively inform their lifeworld. This situates him within a framework that reaches from philosopher Emmanuel Kant, to biologist Jakob von Uexküll for whom “Umwelt” impacts all organisms, and to philosopher Martin Heidegger who conceived of “lifeworld” as relevant for human interplay and experience.
At this point, we ascertained:
Explanations of life that are limited to the level of the individual (organism, human) are not adequate: the individual’s interactions must be included. Not in terms of “environment”, however, which is a misleading misnomer as it carries the dichotomous structure of Western thinking deeply within it, e.g. outer/inner; either/or; nature/culture; body/mind; genes/environment – as if life were difficult but science easy. Neither Umwelt or Lebenswelt can be translated as “environment”. Neither denotes that which is “around” or “outside”. According to Bateson, “mind is no thing” but rather a relational, interactive, communicative phenomenon. All organisms able to communicate beyond a boundary have “mind”. An openness to that which is “other” is inherent in and characterises life. The dead do not communicate any more.
When mind is defined, consciousness is not co-defined; it is “more” or “wider” than mere mind, comprising rather a meta-mind, a reflective level that also includes all that is “autonomic” in the organism, all that does not require conscious directing. Language and consciousness, however, are related, in a co-evolutionary way; the premises for language and perception involve more than simply “data provided by the senses”. To de-contextualise our perceptions requires ignoring that environment is always also “in-vironment”, meaning that it involves internalised and integrated systems of significance and meaning. This implies, in fact, that they are ecologically relevant for one another.
Our being-in-the-world is bound to relationships, perceptions and emotions, phenomena that allow for such constituents of life as patterns, interplay, openness and change. Consequently, the fundamental principles for living include aesthetics and ethics.
At this point, we acknowledged:
Attempts have been made recently within the Norwegian health care system to reduce the impact of New Public Management on physicians’ clinical practice in general and their encounters with patients in particular. However, this movement has left the core problem facing medical care unaddressed: the complex nature of the human being. Of course, that core problem could not be corrected by making administrative changes given the way the ontological and epistemological ground for valid knowledge regarding sick human beings has been conceptualised thus far. Nor could the shortcomings of the biomedical framework be compensated for by altering clinical structures.
There exists as yet no real criticism of the foundations of medical knowledge about the human condition, despite the growing awareness of how ambiguous and inappropriate the current assumptions prove to be when applied to a broad variety of human ailments and health problems. The discipline of medicine still struggles with even as fundamental a challenge as how to adequately distinguish the living from the non-living. Similarly, there is no clear differentiation between which aspects of the human lifeworld are “individual” and which are “social”, nor does science distinguish “is” from “ought”, that is, facts from norms. This distinguishing of the factual from and the normative, a concept developed by philosopher David Hume, generates questions as to whether or not there really exist genuine, unchangeable and exact facts, realities, zero-points, or baselines, in the world of the living. Or should such distinctions be modified to exploring not just what things ARE but also what they MEAN?
What things mean is a central issue in relation to human experiences, especially to those commonly referred to as “adverse”, denoting a spectrum of negative qualities from “unpleasant” or even “repulsive” to “violent” and ultimately “destructive”. The meanings that such experiences take on for individuals are not simply unwanted but also highly bound to context and consequently varied. The potential that adverse experiences hold to impact negatively on global health has become a salient topic within medicine. This is especially true for childhood adversity. Anthropologist Jörg Niewöhner has pointed to the phenomenon Early Life Adversity as a “growing epistemic object”, engaging an ever increasing number of researchers from within a wide variety of disciplines and fields. A consensus has now been reached that adverse experiences early in life – if not buffered by careful adult support – have pathogenic impact. The evidence documenting this fundamentally challenges traditional dichotomies, most particularly the dogma of the mind-body schism: we now know that experience can translate into sickness, in other words: mind has an impact on matter, or, even more precisely: Mind matters.
The crucial question that arises from this is: What kind of epistemological framework could effectively transgress the traditional dualistic concepts informing the medical approach to human sickness and suffering? We need to conceptualise new classifications that adequately reflect embodied life, i.e. how life manifests in the lived body, and embedded bodies, i.e. how bodies are woven into their historical-biographical contexts.
As a point of departure, phenomenology may provide a frame of reference for addressing the indivisibility of the mental and material phenomena that both constitute and represent human, bodily integrated lifetime experience. In this connection, the relationship between the universal and the particular needs to be addressed:
The universal = humans are social and relational beings.
The particular = humans can fall ill as a result of social and relational adversity, although each one in his or her specific manner.
At this point, we understood:
Physician and philosopher Eric Cassell has contributed the most comprehensive reflections so far on the concept of Personhood and its implications for medical settings and clinical encounters – i.e. meetings involving at least two persons, one person in the role of patient and one person in the role of doctor. Various perspectives on personhood have been described and discussed, usually focused on the person as a living human being with her or his everyday experiences as a member of a moral community. Seen this way, personhood holds a central significance in religious, political, judicial and pedagogical contexts, practices and institutions. Persons are not only characterised by their bodily and adaptive capacities but also in terms of their self-reflections and their socio-cultural contributions to society’s norms and structures.
Consequently, personhood is a central topic in the natural and social sciences as well as in the humanities. In other words: persons are biological-cultural hybrids and, as such, they link the bio-physical and the socio-cultural worlds.
The discipline that initially was most interested in the person was psychology. As the field strived to be recognised as a science, it gradually turned away from its focus on the person and its social context, and toward an objectification of the psyche. Increasingly, psychological research applied a scientific methodology of knowledge production in controlled experiments in laboratories – in which the subject was split from social context, exploring parts of mental processes in isolation from social life. Thus the person disappeared from psychology’s viewpoint and professional horizon.
Stripped of the status of person, and objectified in experimental settings that were based on approaches designed for the study of animals, human beings became objects of behavioural observation. Conclusions from these observations were classified to form the basis for methods for “correcting” deviant ways of being and for developing so-called “instruments” for translating mental processes into numerical scales, a discipline called Psychometrics. Reducing the person to a respondent, a typology of “personalities” was developed based on “batteries” of standard questionnaires aimed at identifying various “traits” on a group level. Thereafter, these “types of traits” were applied, both in clinical and therapeutic settings, on the individual level.
When the field eventually turned from behaviourism to cognitive psychology, the self was rediscovered, so to speak, and explored in terms of self-respect, self-understanding and self-appraisal. However, cognitive psychology valued humans highly as processors of information and as neural networks. Consequently, the person was again lost in the transformation of a discipline. Now, the language of digital technology seemed most appropriate for characterising human mental and emotional life, applying terms such as “coding, recall, saving”, etc., when measuring the activity in parts of the brain being visualised using neuroradiology. This engendered the phenomenon that neuroscientists talk nowadays about a person’s thoughts, experiences or actions as processes in ostensibly autonomous parts of the brain.
The history of psychology may be read as a continuous attempt to reduce the person to something that can be observed and measured. As the ideas changed, so did the ways of measuring them, such that the languages of computing and of neurophysiology dominate today. Such consistent reductionism has resulted in the person remaining a fundamentally incomprehensible object within psychological theory, research and practice. Thus, those disciplines leave people today without adequate grounds on which to base their perceptions of themselves as persons. There are signs, however, that a “psychology of personhood” might be evolving, with its proponents underlining, “the importance of the person as a concept that is necessarily central to the development and maintenance of any viable psychology.”
At this point, we determined:
The most crucial criticism of reductionism as the dominant epistemology in disciplines dealing with humans has focused on how limited its validity proves to be given the variety of aspects of the social world. In Norway, philosopher Hans Skjervheim was one of its sharpest critics. He coined the term “epistemological mistake” to describe approaches that subordinate their empirical field to the dominant methodology. Epistemological mistakes or errors are portrayed as attempts at grasping a particular phenomenon but placing it within an inappropriate framework (a popular illustration is trying to eat soup with a fork). Skjervheim argued that objectivism is not a valid framework if the aim is to understand the human lifeworld. He underlined that each researcher inevitably makes some impact on whatever is being explored, which implies that researching is not a process of “mapping” but of “influencing”. It also implies that the position of observer is itself an illusion. Skjervheim argued that researchers in the social sciences cannot study a society without also studying themselves since no researcher can stand outside of her or his social community.
Bateson came to an analogous conclusion regarding the natural sciences: researchers exploring nature can never stand outside it because they are a part of it. According to Bateson, every study of the living represents an encounter with Mind, which implicitly involves encountering phenomena such as relationship, communication, information, historicity, interpretation, choice and meaning. The knowledge engendered when exploring living beings is constituted by observations and systematised according to rules. Consequently, scientific acknowledgements can never be proven; the object of research contributes to the knowledge about it. Thus the Map cannot be identical to the Terrain. Bateson concludes that it is not only a fallacy that humans could control something of which they themselves are part, and if they could, it would be unethical. Despite it being impossible for us to stand outside nature, we nevertheless continue to construct and apply a framework promising that as being possible. We create our own vicious circle and ensure our own failure by maintaining that the solution to every problem engendered by our illusory belief is “just around the corner”.
At this point, we ascertained:
- Researchers in the social sciences can never study their society without studying themselves since they can never stand outside their social community.
- Researchers in the natural sciences can never stand outside nature to study it because they themselves are part of it.
- As long as researchers insist on applying theoretical frameworks that help to maintain the illusion, that humans could explore nature by viewing it from outside, they will perpetuate trusting in a self-referent vicious circle that promises that any moment now, a “solution” to all problems will be revealed.
Documentation from basic medical disciplines indicates that, as long as it continues to approach “nature” – also the assumed “nature” of the human body – in a reductive, fragmenting way, the current biomedical theory is and will continue to be an inappropriate and non-exhaustive framework within which to understand human nature properly. Scholars of the theory of sciences, such as philosopher Thomas Nagel, declared long ago that there is “no view from nowhere”. Acknowledging this leads logically to the question: In its struggle to “dismantle nature’s secrets” by means of research, has mankind crossed a line, not only in terms of exploration but also exploitation, such that there is no “nature” left? This is the central topic of Vetlesen’s book, The Denial of nature: Environmental philosophy in an era of global capitalism.
He goes on to claim: There is good reason to assume that we can succeed in understanding the nature of human beings in a more appropriate manner than is currently the case in biomedicine only if we first change our traditional assumptions as to the nature of nature. Humans emerge from and are embedded in nature. Moreover, we, and our fellow humans, are informed by and inform culture together. Being a sort of hybrid, humans are the only species on earth endowed with the capacity to inform nature to such a degree that our influence transforms nature into culture. It gradually dawns on mankind that what we used to think of and call ”environment” is influenced to such a degree that what we call “climate”, globally, can now be termed “man-made”. Thus “nature” has turned into “culture”. How does this impact us?
The relationship between humans and nature has been perverted primarily by means of abstraction. Implicit in the “mind-set” that facts can be separated from values is an unremitting destructive process, characterised by the degradation, deformation and, ultimately, extinction of nature. The dominant methodology of abstraction can only describe the external relationships between the phenomena it explores. Consequently, the inner connections of its “objects”, including the significance they hold for each other – i.e. their inherent values – are derivatives. The moment at which phenomena in nature are reduced to “facts” and defined as something “around” human beings but not within them, people become prey to manipulation, without having reflected on issues of ethical legitimacy. This paves the way for “use” as in “mis-use” or “ab-use” and also exploitation. The process is aggravated by ideologies and politics in which “growth” and “gain” are valued most.
Philosopher Freya Mathews addresses the urgent need to re-unite the “mental” with the “material” by means of recognising and acknowledging that nature is inherently mindful. This involves the appraisal both of nature’s value and humankind’s deep and inevitable belonging to it. Only thus can we comprehend that to degrade and exploit nature is indistinguishable from degrading and exploiting ourselves. Plainly stated: Our destruction of nature is not murder but suicide.
At this point, the members of the Think Tank convened a seminar entitled:
“Not yet, but soon. Medicine chasing progress.”
Here are the abstracts of the members’ lectures:
Jan Inge Sørbø: “A medical paradise on earth”
The ambitions that shape medical research programmes are so grand that one could imagine a life without the threat of sickness or premature death might be possible. How realistic are those images? And what actions might they engender? What happens if one aims at abolishing life’s randomness and uncertainty? Some of the worst acts of violence in human history have been associated with just that sort of ambition. In quests for a medical paradise, huge sacrifices have been demanded. Individuals were exhorted to step aside in the service of collective ambitions. The craving for human behaviour to be coordinated and controlled leaves traces of totalitarianism; the options to act freely are eradicated, replaced with the demand that production be determined in abidance with laws and rules.
Tor-Johan Ekeland: “When the solution becomes the problem”
Things may not turn out as planned; great ideas may even turn into their own perversions. Through our collective experience, such developments have been condensed into the proverb, “The road to hell is paved with good intentions.” In the same way, the ancient error of confusing means and ends is still with us, as in the reality that what might seem like a good idea for the moment may prove to be a problem in the long run. A well-developed historical awareness might possibly have prevented the frequent repetitions of these age-old phenomena. However, the nearly aggressive contemporary discourse regarding innovation tends to leave us blind to how the very “problem” that now demands change was itself, earlier, considered a highly appreciated “solution”. Examples of such connections can be seen in the health care system both for individuals and at the collective level, and their epistemological “patterns” may be analysed through applying such concepts as Bateson’s notion of “epistemic errors”.
Irene Hetlevik: “The tale of the promising drugs”
Statistically, hypertension is associated with the development of cardiovascular disease and was the first risk factor to be the object of preventive medical treatment of large populations. The threshold for what blood pressure measures warrant intervention and the start of treatment has steadily been lowered, and the size of the population considered to be at risk has steadily increased. The effect of treatment may be described in different ways, and discussions are on-going as to whether it has been large or small. New and more expensive drugs have come onto the market without their being more effective than the old ones. Expenses have skyrocketed. Hypertension is one risk factor, high cholesterol is another. Other organs have “their own” criteria, such as low bone density. All these considerations develop in the same fashion: thresholds for interventions are gradually moved to include the general population, and the number of health service providers prescribing drugs for an increasing number of risk factors is also rising. General practitioners are mandated to manage medication decisions. The knowledge base is complex, and so many voluminous clinical guidelines have been elaborated that they cannot all be implemented. This calls for a radical change of thinking.
Elling Ulvestad: “Might human beings step out of the paradox of life?”
For survival and by necessity, all organisms must seek to maintain a close relationship to their world, while at the same time, and in response to ever more critical risks, protect themselves against impulses coming from that same world. This paradox of life prevails whenever the organism searches for food or a mate, and is simultaneously inherent in their defence against predators and contamination. Seen from such a perspective, progress would involve changes that contribute to safety throughout the life-course. Science has contributed to a safer life for human beings. But humans are not the only living creatures on earth. Other organisms, such as contaminators, also seek to optimise their lives and their safety. These changes happen through evolution by means of natural selection. The degree to which human-made solutions are sustainable in the long run needs to be examined and discussed.
Anna Luise Kirkengen: “Has biomedicine forgotten something important?”
Evidence continues to increase confirming the fact that the human body is informed by experience. While this is apparently so for all kinds of experience, it seems to pertain in particular to adverse experiences early in life. This knowledge reflects an understanding that a person’s biography impacts that person’s biology, and an understanding of the human body that acknowledges the hybrid nature of human beings as informed and influenced by both nature and culture. Within a framework in which the body is lived and embodied experience, a direct connection becomes visible between violation and sickness, between imposed pain and perceived pain. Such a perspective facilitates insight into how being stigmatised, marginalised, harassed, discriminated, abused and subdued endanger health. Given that this kind of experience engenders sickness, medical professionals need to know what has happened to the diseased person or run the risk that health care may veil social wrong-doing by diagnosing violated people as if they were sick of “natural” causes.
Henrik Vogt: “Scientific control of life and health – not yet, but soon”
Systems medicine, the so-called ‘4 P Medicine’, represents the most advanced development in biomedicine in the wake of the decoding of the human genome.
P4 denotes “personalised, predictive, preventive and participatory”. The concept may be regarded as the strongest expression in contemporary science and medicine of the modern project of controlling human nature, sickness and health. Systems medicine is linked to sweeping promises, reflective of its history and its visions. The creation of expectations for achieving full control of humankind’s health is at the core of modern biomedicine. The slogan “not yet, but soon” is actively promoted.
Thor Eirik Eriksen: “What are we to do while waiting?”
Do we rely on “wonders” to such an extent that we have lost our capacity for wonder? Are we seeking to explain health problems scientifically to such an extent that, by the end of the day, we have explained away life itself? Are we so preoccupied with getting a handle on all the facets of life that we no longer can allow ourselves to be captivated by life itself? Such questions are important in a situation where the success of medicine is in danger of surpassing itself or overdoing its mandate of knowledge production. They are important in a situation where medical knowledge meets its limits, as is the case with “medically unexplained symptoms or syndromes” (MUS). What are we to do in such situations while we wait?
Arne Johan Vetlesen: “From Descartes to panpsychism”
Since Descartes, a range of dualisms – schisms – have characterised Western science and philosophy: mind versus matter, soul versus body, the organic versus the non-organic, nature versus culture, facts versus values, emotion versus ratio, subjectivity versus objectivity. The adverse impact of these dualisms and their endurance within science, economics and politics deserves reflection. On-going, man-made climatic changes, extinction of species and the exhaustion of resources illustrate how remarkably capable our societal order is of causing enormous and irreversible damage to nature, but remains (as yet) incapable of halting these effects, of revising any of the premises this destruction is grounded on and/or legitimised by. We need to question whether anthropocentrism – the view of humans as superior to all other beings in terms of abilities, intellect, mores and values – must be rejected and whether it ought to be replaced by a kind of panpsychism that discards all the above mentioned dualisms in favour of a holistic world view, judging humans as part of nature, not apart from nature.
At this point, we determined:
The medical profession needs to distance itself from the persistent illusion that methodologically established objectivity safeguards objective – in the sense of value- neutral – knowledge. This illusion perpetuates the belief that the results of research which applies objectifying methods, in accordance with proper conduct (informed consent), are not ethically compromised. It also supports the conviction that these presumably ‘value-neutral’ results become ethically ‘loaded’ only once they are applied in clinical practice. These beliefs mirror the primacy granted to one specific episteme over and above generalised ethics. More and more good reasons appear, however, to claim that ethics itself should be the paramount guide.
A discussion of how values and life, experiences and health are interrelated is highly overdue if we are to train medical students, future doctors and researchers-to-be in accordance with a primarily ethical framework.
In the meantime, today’s medical research seems almost frenetically preoccupied with exploring human beings and, especially, human brains, by applying perspectives of untangling and dismantling the technicalities of consciousness, thought, memory, skills and potentials. The stated ambitions driving this research are “to improve humans” with respect to longevity, capacities and health. The models for this endeavour in the neurosciences are strongly informed by computational concepts, and the border between life (the human body) and technology (computers, implants, prostheses) is rapidly becoming blurred. Brains are compared to computers, computers are modelled after brains, ‘neuro-IT-speak’ rules the professional discourse. The cognitive neurosciences have gained dominance as the master-science in biomedicine.
Commenting on the on-going Human Brain Project, sociologist Niklas Rose at King’s College, London, claims:
It is impossible to understand the human brain unless you recognize that the embodied brain is intrinsically, not just extrinsically, enmeshed in its social and cultural and experiential world – and that’s not just an add-on. It seems to me that it is crucial in the understanding of how human brains develop, how their capacities are shaped, how they are modulated both across the life course, and at any time. My argument would be that we need to get the social sciences engaged, firstly in setting the very research agenda, and the forming of the research problem, and secondly, in the actual scientific work that’s going on there. This is not a wish for the social sciences to get just a portion of the money, but it is a very real argument that unless you understand the social embeddedness of neurobiological processes, and of biological processes more generally, you simply won’t understand the phenomena that you are trying to explain.
Rose clearly states that understanding must precede explaining, the core distinction coined by Dilthey. His view accords with the intention of the Think Tank, namely to argue that the naturalist episteme in medicine – an explanatory methodology – should be superseded by a value-based episteme, in other words a social and culture-sensitive methodology that promotes the understanding of dynamic, complex phenomena.
At this point, we agreed to organise a conference, in collaboration with Danish colleagues, concerning the nature of medical knowledge production, entitled: “The diagnostic (un-)culture”
In preparation for this conference, some salient topics were delineated regarding the overarching question: What kind of knowledge is valid in medicine, and is this knowledge appropriate to the profession’s aim and mandate? The first aspect concerns the asymmetry of power inherent in the prevailing medical epistemology and the potential for injustice implicit in its dominance over other kinds of knowledge. The second aspect concerns the impact of this kind of knowledge, engendering a need for new kinds of competence.
Philosopher Miranda Fricker has introduced the topic of epistemic, testimonial and hermeneutic injustice as potential and logical consequences of ranked knowledge following ranked epistemologies or methodologies. Implicit here is that an injustice arises from a subordination of the 1st person voice of the suffering human being to the 3rd person voice of authoritative medicine that can deprive people of their right to know, testify and interpret.
The possibility of doing sick people an injustice by means of medical knowledge and in the name of medical goodness, indicates the necessity of developing new forms of medical knowing (theory) and new manners of medical doing (practice) – in other words, an increased sophistication of medical professionalism. This accords with biologist Edward Osborne Wilson’s statement: ”We are drowning in information, while starving for wisdom. The world henceforth will be run by synthesizers, people able to put together the right information at the right time, think critically about it, and make important choices wisely.”
The probability for epistemic injustice increases with an increase in specialisation and the fragmentation of knowledge, which, despite all the highly praised efforts of including patients in medical decision–making, makes them increasingly dependent on specialists in an ever increasing number of fields. Given the degree of fragmentation and the concomitant increase in the bits of information about the human body on a micro level, the need to learn to understand and interpret the results of clinical examinations and technical tests provides the justification for requiring long and extensive medical training. Doctors study for years in order to master the preconditions and rules of medical knowledge production and its validity. These highly specialised interpretations cannot be transformed easily into plain information that everybody can grasp. When these premises claim to define “all there is to know”, much of what is not considered to be of the same kind will, by logical extension, be deemed as irrelevant to the medical encounter. As such, it would rightly be ignored. If, instead, most of what is outside the medical scope were salient and significant for the suffering person, the dismissal of what was deemed as unimportant would become an uncontrollable source of error. Implicit in the increasing dominance of bio-techno-knowledge is a growing asymmetry of knowledge and power between the patient and the health care system. Consequently, this topic deserves our attention.
At this point, we acknowledged:
Philosophers Hannah Arendt and Hans Jonas have insistently admonished all citizens and all professionals to reflect on their personal responsibility and the judgments they make, in terms of their impact on society, their commitment to honourable human relationships and to the common good. Implicit here is a call to all researchers to be aware of the inherent potential for the results of their work to be misused.
In his reflections upon what he termed “Das Prinzip Verantwortung”, Jonas argued for research crossing the boundaries for what is possible to be met with values marking the boundaries for what is permissible.
Since scientists now “enter the brain”, actually and figuratively, the moral obligation to reject the illusion of value-neutrality becomes paramount. Nonetheless, authoritative voices, with unabashed vanity, have already initiated a search for consciousness within each individual brain rather than between organisms and between people. Combining traditional reductionist fragmentation with the bio-techno-framework and the language of the new master-science, “neuro-speak” is poised to colonise other domains and disciplines than medicine and psychology.
The current movement for “improving humans” by means of techno-biomedicine and computational engineering is often termed “transhumanism”. Its proponents claim to speak from a position of both philosophical and economic pragmatism. Transhumanists advocate that the mechanistic, biological and instrumental capacities of human beings should be focused on, improved, refined and sophisticated. And
since these lend themselves to numerical measurement, they can easily be argued for, promoted or “sold in”, as promising research and investment projects in the service of both the individual and the common “good”. Funding is apparently not a problem, and endeavours such as the Human Brain Project and the Human Connectom Project are well-supported.
People’s moral, relational, social and cultural capacities, however, are of less interest to transhumanists. They define certain kinds of life as being unworthy of living and thus open for being legally prohibited or terminated, while they consider life itself to be worthy of unlimited prolongation by means of technology, regardless the costs. Within this framework of manipulating life, bio-techno-medicine is placed in a central position. The question will be, however, to what extent medical professionals and researchers will find themselves comfortable with mandates that so utterly transgress the primary moral obligation of physicians: to alleviate suffering.
This crucial separating of facts from values in the scientific framework does not only fuel the enduring illusion that technical “solutions” to the problems engendered by the fragility and vulnerability of human bodies are on the brink of being solved. It also paves the way for the current tendencies in the neurosciences to disregard phenomena other than those within a bio-techno framework. The predictions for how soon AGI (Artificial General Intelligence) will produce intelligence that reaches human levels of intelligence show slightly more realism now than earlier. This is because, as researchers at UCLA (University of California Los Angeles) stated recently, the brain is ten times more active than previously measured; they deem this an important finding for understanding and treating neurological disorders and for developing brain-like computers. These researchers mention potential medical and technological aims side-by-side, as if they were on an equal level and held equal legitimacy. This means that the medical ethos has been placed level with the technological. In other words: facts have absorbed values.
At this point, we acknowledged:
We glimpse two parallel or at least similar developments that are worth considering and analysing, one within the humanities, notably philosophy and literature, the other in scientific medicine.
Postmodern criticism and the ensuing rejection of there being only One Truth – overarching and authoritative – about the human condition, may be regarded as having opened the door, so to speak, for “a coup” that actually high-jacked postmodernism’s core arguments, transforming them into a phenomenon currently referred to as “post-truth”. Now, “everybody” claims the authority to assert A Truth about the state of the world, locally and globally. One authority has been exchanged for many authorities, each of which seeks adherents.
This development resembles the initial protest of doctors and researchers against dogmatic, authoritarian medical proclamations as to how to understand human sicknesses and their origin, as well as how to treat them. By now, this movement, termed “Evidence Based Medicine”, has metamorphosed into yet another authoritarian regime, this one even more rigid than the last.
Not only philosophers and scholars of literature are concerned now about post-truth; physicians and researchers at The Center of Evidence Based Medicine in Oxford have also acknowledged that the critiques of EBM are becoming continually more explicit, detailed, qualified and justified. While certain groups find themselves comfortable when manipulating the truth by applying “alternative facts”, the leaders of the EBM-centre declare that they aim to correct the regime, to limit its quite comprehensive, unwanted “side-effects” and unintended “spin-offs”.
In biomedicine, an approach conceptualised as “bio-psycho-social” has recently been introduced as the profession’s response to the increasing critique of the de-humanised, or de-personalised, biomedical practice. As the “name” implies, the concept embraces three kinds of knowledge that are considered true in three disciplines: the scientific knowledge of biology, the humanistic knowledge of psychology, and the hermeneutic knowledge of sociology. Though some clinicians claim that they subscribe to this model, medical curricula do not yet mirror such adherence: there is still a lack of the systematic training of medical students regarding insight into the humanistic frameworks and methodologies, as well as regarding the basic rules of hermeneutics, that would be necessary to place them on the same level as the natural sciences. Thus it seems there is a lack of equivalence among these three frameworks as means for acquiring true knowledge. The scientific frame of reference trumps the other two. Thus, the concept’s name is misleading and its clinical application must be a pretence.
In philosophy, the problem of truth has traditionally been dichotomised, or polarised, between dogmatism and scepticism. Philosopher Jon Hellesnes recognised and delineated how the outermost positions, the dogmatist and the sceptic, show similarities: they both defend their own views systematically and insistently by means of being sceptical and dismissive of all other views. Generalised scepticism can become an habitual protection against what one does not want to know or learn.
The continuing dearth of scholarship in the humanities and in hermeneutics among medical professionals means that long overdue changes in medical research and clinical practice are not forthcoming. Medical professionals are socialised to think that scientific truth, knowledge grounded in the episteme of the natural sciences, is the most – or even, the only – reliable “ground” on which to base medical decisions. Within this frame of reference, the only possible positions are materialism (everything is matter) or dualism (matter is separate and different from mind). Consequently, philosopher Strawson considers “panpsychism”, the perspective that all living organisms might be endowed with mind, in the sense of mental aspects or qualities, to be, “the most plausible position by default”.
One might imagine that everything has mind and begin asking, as philosopher Thomas Nagel has done, “How is it to be a bat?” or asking, as philosopher David Chalmer does, “How is it to be a quark?” Reflections on what is mind and on what has mind seem appropriate. When applying the question, “How is it to be …” more broadly, one might assume it to be more likely to arrive at answers on behalf of animate objects than the inanimate world. However, with reference to philosopher Merleau-Ponty’s example of how a table bears a person’s memories (marks carved into it, ink splotched onto it…), one might ask: “How is it to be a table?” When “reading” a wooden table’s aspects of living – the tree having grown in a particular soil (spatial memory), been exposed to sun, rain, wind, drafts, ice and snow (temporal memory), transformed into a table by a skilled carpenter, and marked by particular people’s use over time (relational memory), it seems easy to think that the table has mind.
One might suppose that a critical reading of the way some contemporary researchers seek to grasp the nature of thought could prove fruitful for addressing questions of what is mind and what has mind. They have attempted to make thought visible in real time – examining the moment a thought is being thought. However, when studying the current documentation of this endeavour, it becomes clear that the researchers in the field have tended to conflate two classes of phenomena: what is demonstrated, visualised and measured are neuro-physiological processes (brain activity) but not meaningful representations (thinking, mindful reflections).
At this point, we ascertained:
The global community of researchers is collectively and individually responsible for the consequences of their activity. Their choice of methods for knowledge production impacts on the kinds of knowledge they contribute to or provide. Consequently, they do not, as has been assumed traditionally, depict, describe or dismantle a reality that is given. Rather, they create realities, since their choice of methodologies determines the shape of those realities. The responsibility embedded in the process of choosing a method and a particular perspective from which to grasp and observe a certain phenomenon has been cloaked, concealed, or even made unperceivable, by the objectivist dogma of value neutrality, as well as by the generalized validity granted to objectifying measures. This dogmatic position has long been challenged and ultimately invalidated by sociologists and philosophers critical of the positivist framework. Their fundamental critique, however, has not reverberated throughout many of the disciplines informing our contemporary societies, such as economics, engineering, the natural sciences and, not least, medicine. The biomedical engagement and involvement in genetics and its technological, industrial and economic spin-offs, currently being dominated by genetic manipulation, exposes how consistently medical researchers adhere to an illusory framework, undeterred, apparently untouched, by this critique. In other words: a debate of the theoretical foundations of biomedicine is overdue.
- Anna Luise Kirkengen, professor, MD, dr. med., Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway. (Discipline: Medicine)
- Tor-Johan Ekeland, professor, dr. philos., Faculty of Social Sciences and History, Volda University College, Norway. (Discipline: Social Psychology)
- Linn Getz, professor, MD, PhD, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway. (Discipline: Medicine)
- Elling Ulvestad, professor, dr. med., Department of Immunology, Haukeland University Hospital, Bergen, Norway. (Discipline: Medicine, Microbiology)
- Arne Johan Vetlesen, professor, dr. philos., Department of Philosophy, Classics, History of Art and Ideas, University of Oslo, Norway. (Discipline: Philosophy, Ethics)
- Edvin Schei, professor, MD, dr. med., Department of Global Public Health and Primary Care, University of Bergen, Norway. (Discipline: Medicine) 2008-2017
- Irene Hetlevik, professor, MD, dr. med., Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway. (Discipline: Medicine)
- Jan Inge Sørbø, professor, dr. philol., Faculty of Social Sciences and History, Volda University College, Norway. (Discipline: Literature)
Thor Erik Eriksen, special adviser, PhD philosophy, Department of Occupational and Environmental Medicine, University Hospital of North Norway, Tromsø. (Discipline: Political Sciences, Philosophy)