Dear Marion,

This second portion of my reply is a second occasion for another round
of thanks for your letter.

The "guidelines and goals" of physicians' conduct in specified situations
which were discussed at the Continuing Education seminar which you attended
are a relatively recent, and to my mind very interesting and important
development in medical education and practice. Since guidelines are embryonic
regulations and since regulations are laws, the two issues taken up in your
letter, laws and guidelines, widely overlap and reciprocally shed much light
on each other. Guideline medicine is related to empirical medicine as Law 
is related to Equity. 

From an historical perspective, guidelines are adverse to and destructive
of traditional "Hippocratic" principles of medical practice.
According to the Hippocratic precepts: "one must attend in medical
practice not primarily to plausible theories, but to experience combined
with reason." A physician who ignores his observation and relies on
theory, is likely to do his patient great harm. The Hippocratics, of
course, had no CT or MRI scans and had no inkling of biochemistry,
molecular biology or genetics. They had no computers. They also thought
the earth was flat.  Times do change and with them, the human mind. 

For many years now, I have been fiddling with an epistemology which looks
to Hippocratic empirical medicine rather than to symbolical mathematics,
as the prototypical science that holds the secrets of human knowledge.
Admittedly, the reduction of (theoretical) physics, of chemistry, of
molecular biology to subjective individual experience (Erleben) is a
formidable project, unthinkable for any one not blinded by passionate
prejudice such as myself. But I find it a nice distraction to while away
the sunset years. It's an impossible project if I begin, in academic
style, with the presumption that the sciences exist as compelling patterns
of knowledge in which, even though personally ignorant, I may vicariously
participate by pledging allegiance and swearing loyalty. If, on the other
hand, I refrain from endorsing what I myself have not experienced, if I
refrain from pretending that there is for me knowledge which I do not
possess, if I candidly and unreservedly admit and profess my ignorance,
then there occurs an epistemologic peripateia: the universe of science
crumbles and the professors of knowledge appear as actors labeled with
Lessing's immortal epithet, "betrogene Betrueger".

The foregoing analysis makes "guidelines" look spurious. Traditional
precepts tell me what to think, then give me the opportunity to 
amalgamate what I have been taught with what I observe and understand.
Guidelines on the other hand, like laws, prohibit me from thinking.
Guidelines are a substitute for thought. They purport to tell me what
to do.

Activity which is a spontaneous expression of spirit is an art. Writing,
drawing, sculpture, architecture are all of them, inherently art. Practicing
medicine is an art. Practicing law, very much so. Guideline implementation 
is not an art but rather a bureaucratic ritual, analogous to toll collection
at a Turnpike booth.  Sometimes guidelines may do much good, sometimes they
will do much harm.  In my role of physician, I will try to outwit them, just
as, in my role of lawyer, I try to outwit the laws.

Jochen