Disclaimer: This essay was planned and written in collaboration with Claude Sonnet 4, ChatGPT 4o and Gemini Pro 2.5. (A real party on this one.)
Modern medicine operates within a deep and persistent contradiction. It is animated by two distinct ways of knowing, each with its own history, its own criteria for truth, and its own vision of medicine’s purpose. One is a positivist orientation, born of the laboratory, which seeks objective, universal, and measurable truths about disease. The other is a pragmatist orientation, grounded in the clinic, which is concerned with effective action in the context of an individual’s life. This is not an abstract philosophical dispute; its tensions define the daily work of healing and the experience of illness.
The case of chronic pain illustrates the divergence. From a positivist standpoint, pain is a phenomenon to be quantified by standardised scales, its mechanisms revealed by neuroimaging, its reality validated by objective biomarkers. This approach aims to isolate a universally constant and replicable fact about the body, a specific biological disruption that can be targeted with a specific intervention.
Yet this framework frequently fails to capture the reality of chronic pain. Clinicians know that pain is irreducibly subjective; the same diagnostic label or pain score can signify vastly different worlds of suffering. A patient’s history, social circumstances, and the meaning they ascribe to their condition are not confounding variables but integral parts of the phenomenon itself. This leads to a different mode of practice, one aligned with a pragmatist understanding of knowledge. Here, the truth of a diagnosis or the value of a treatment is found in its practical consequences—its ability to guide action that alleviates suffering and improves a patient’s capacity to live. This clinical tradition prioritises judgment, therapeutic relationships, and interventions tailored to the specific problems of an individual. While often more effective, this approach struggles to justify itself within a medical culture that increasingly demands the kind of generalisable, statistical evidence championed by the positivist view.
This conflict is the product of specific historical developments. The positivist tradition in medicine gained ascendancy in the 19th century, propelled by figures like Claude Bernard, who established the experimental method as the foundation of a truly scientific medicine. For Bernard, medicine had to move beyond clinical observation to controlled experimentation that could reveal the deterministic laws governing the body's "internal environment." This vision was institutionalised by the Flexner Report of 1910, which revolutionised medical education by mandating a curriculum grounded in laboratory science and research. The report led to the closure of numerous schools and established the biomedical model as the gold standard, cementing the idea that legitimate medical knowledge is that which is empirically verifiable and objective. The result was a medicine that prized the discovery of universal facts about disease processes.
All the while, clinical practice retained its own distinct, pragmatist logic. The tradition of bedside medicine, with its focus on case-based reasoning and the wisdom of experience, was never fully displaced. This orientation found its philosophical voice in American pragmatists like William James and John Dewey. For them, the truth of an idea lies not in its correspondence to a static reality, but in its capacity to work, to solve a problem, or to guide action successfully through the stream of experience. In medicine, this manifests as the deep-seated reliance on clinical judgment—the recognition that therapeutic success often depends on factors that resist scientific measurement, such as rapport, hope, and the tailoring of care to a particular person in a particular situation. The tension between these two approaches has become acute with the rise of Evidence-Based Medicine (EBM). While laudable in its goal to ground practice in rigorous evidence, EBM has often been interpreted as privileging population-level data over individual clinical judgment, creating new conflicts by attempting to impose a positivist framework onto the pragmatic realities of the clinic.
A path beyond this impasse opens when both positivism and pragmatism are understood as forms of interpretive practice—as specialised ways of reading the signs of health and illness. From a semiotic perspective, the body is not a simple biological machine but a complex text. Every symptom, lab result, and therapeutic response is a sign that acquires meaning only within an interpretive framework. We need not worry about this leading to relativism, however, because, as the pragmatists insist, interpretations have real-world consequences. A misreading is corrected by therapeutic failure; a successful reading demonstrates its validity through healing. But it does mean that there is no unmediated access to a pre-interpretive biological reality. Both the laboratory scientist and the bedside clinician are engaged in hermeneutics. They are members of interpretive communities, each trained to read a different set of signs, or indeed, the same set of signs differently. The research scientist develops methods to make cellular and molecular processes legible, while the clinician develops skills to read the complex interplay of biological, psychological, and social signs in an individual patient. The conflict arises when these are treated as competing accounts of reality rather than as complementary readings.
This semiotic understanding provides the basis for a sublation, or Aufhebung, of the contradiction. This is a term the German philosopher Hegel introduced to describe the process of rising above or moving beyond a contradiction. But a sublation does not simply discard the opposing terms, it instead cancels, preserves, and elevates them into a higher synthesis. The semiotic framework cancels the claim of both positivism and pragmatism to be the sole pathway to medical truth. It preserves the positivist commitment to empirical rigor and the pragmatist focus on therapeutic efficacy in individual lives. And it elevates them into a more comprehensive model of medicine as a hermeneutical practice. This synthesis recognises that scientific evidence is not a self-evident truth but a text that requires interpretation, and that clinical judgment is not mere intuition but a sophisticated form of reading narrative and contextual signs.
Returning to the example of chronic pain, a synthesised, semiotic approach would integrate multiple readings to form a richer understanding. It would treat biological signs like neuroimaging data not as the ultimate truth of the patient's pain, but as one crucial set of signs to be read alongside others: the patient's phenomenological descriptions of their suffering, behavioral signs of functional limitation, and the social and historical signs that give the pain its unique meaning in that person's life. The goal is not to find the single "correct" reading, but to develop a multi-layered interpretation that can guide a more effective and humane intervention. This approach validates the scientific search for biological mechanisms while acknowledging that these mechanisms always operate within meaningful contexts. It preserves the clinical emphasis on individual assessment while providing a framework for integrating this with population-level knowledge. By understanding medicine as fundamentally about interpretation, we can move beyond the conflict between the laboratory and the bedside. The future of medicine lies not in choosing between them, but in cultivating the wisdom to read the complex text of human suffering and flourishing with greater skill.