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Lessons Learned from Ignorance The Curriculum on Medical (and Other) Ignorance Marlys Hearst Witte, Peter Crown, Michael Bernas, and Charles L. Witte The greatest single achievement of science in this most scientifically productive of centuries is the discovery that we are profoundly ignorant . We know very little about nature and we understand even less. I wish there were some formal courses in medical school on medical ignorance, textbooks as well, although they would have to be very heavy volumes. —Lewis Thomas What lessons can be learned from ignorance and particularly from medical ignorance? Lewis Thomas’s novel idea for a course on medical ignorance struck a responsive chord. As an example, consider the state of ignorance about AIDS. After more than twenty-five years of fundamental discoveries, multiple clinical drug trials, and frustrating efforts at prevention, there has been little dent in the burgeoning global pandemic, and the prospect of effective vaccine development remains elusive. While much has been learned about AIDS, we still suffer from our ignorance. Perhaps an admission of ignorance, symbolized by a few blank pages in the section on AIDS in medical textbooks, might stimulate young minds to pursue new paths of investigation. The same approach holds for solid organ cancers, such as of the brain and the pancreas, where blank pages might more accurately reflect how little can be done practically to arrest tumor growth. Even artificial hearts and 252 Witte, Crown, Bernas, and Witte organ transplants, the miracles of modern surgery and biomedical engineering , attest to the fundamental ignorance of heart disease and other organ dysfunction. Indeed, surgery itself as a discipline is the ultimate medical exercise in ignorance—removing organs and “mutilating” the body. As the legendary surgeon John Hunter summed up several centuries ago: “It [operation] is like an armed savage who attempts to get that by force which a civilized man would get by stratagem.”1 Although an operation is often the best treatment currently available for many ailments , it is at the same time a stark testimonial to a basic lack of understanding —namely, ignorance—of the underlying disease process and an inability to prevent or arrest its progression by “natural” means. In this setting, we reasoned that courses on medical ignorance would not only enhance medical education but also be a potent stimulus for new ideas and fundamental research. As the Curriculum on Medical (and Other) Ignorance (CMI) evolved, the power and reach of the “ignorance paradigm” has progressively revealed itself.2 the philosophical shift from epistemology to nepistemology It is widely held in Western thought that knowledge and ignorance are polar opposites, as if ignorance is a synonym of stupidity and, thus, an insult.3 This can lead to the impression that knowledge represents light and progress and that ignorance is the enemy and an obstruction. We have learned to fear ignorance if knowledge is to triumph and humans are to advance. Quite the contrary. As Disraeli once wrote: “To be conscious that you are ignorant is a great step to knowledge.”4 Philosophers debating epistemology for the past three millennia have paired the study of knowledge with the study of ignorance, and, in the real world, knowledge and ignorance are not irreconcilable polarities . The Polish astronomer Copernicus’s view was: “To know what we do know and to know what we do not know, that is true knowledge.”5 In fact, knowing and not knowing are intertwined and symbiotic. Just as it takes knowledge to recognize ignorance, it takes an acceptance of ignorance to face and inquire about what we do not know.As William James noted: “Our science is a drop, our ignorance a sea.”6 From this point of view, ignorance is not a void, but, rather, the fertile space of the unknown that can provide the motivation to explore. Learning itself is a continuing encounter with ignorance. In fact, the more we understand Lessons Learned from Ignorance 253 something, the more we realize how little we know about it. As Pascal observed: “Knowledge is like a sphere, the greater its volume, the larger its contact with the unknown.”7 Seen in this light, ignorance is a dynamic force in learning and research , and its topography shifts with inquiry. There are at least six lands within the domain of ignorance:8 all the things we know we don’t know (known unknowns); things we don’t know we don’t know (unknown unknowns); things we think we know but don’t (errors); things we don...


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