Following Foucault’s work on disciplinary power and biopolitics, this article maps an initial cartography of the research areas to be traced by a genealogy of pharmacological practice. Pharmacology, as a practical activity, refers to the creation, production and sale of drugs/medication. This work identifies five lines of research that, although often disconnected from each other, may be observed in the specialized literature: pharmaceuticalization; regulation of the pharmaceutical industry; the political-economic structure of the pharmaceutical industry; consumption/consumerism of medications; and bio-knowledge. The (...) article suggests that a systematic analysis of these areas leads one to consider pharmacological practice a sui generis apparatus of power, which reaches beyond the purely disciplinary and biopolitical levels to encompass molecular configurations, thereby giving rise not only to new types of government over life, but also to new struggles for life, extending from molecular to population-wide levels. (shrink)

To date, studies of the relationship between technology and its consumers have used the constructs of traditional paradigms of production and consumption as the foundation for analysis. These studies have served to reinforce traditional concepts of gender and hierarchy in the nursing–technology dichotomy. To propose a new and more relevant framework for analysing the technology–nursing relationship, the analysis of gender within the methodology of the social history of technology will be used. Healthcare will be viewed as a technologic network, and (...) within that network multiple knowledge domains reside and interact. These domains, in turn, are socially constructed and historically contingent. This paper operationalizes this argument by examining the domain of the early nurse practitioner movement of the 1960s as part of a gendered technologic system. The findings of this study illuminate the agency of nurses in the shaping of traditionally male knowledge domains and as a crucial factor for understanding the evolution of not only the particularities of the nurse–technology relationship, but also the generalities of the gendered ways of knowing within the healthcare–technology relationship. Perhaps most importantly, different sets of questions can be formulated to analyse the history of the nurse practitioner movement from a technologic perspective that will provide new standpoints for the nursing‐technology dichotomy in the millennium. (shrink)

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired moral attitude of physicians. In a series of three articles, three of the discussed concepts are presented in an interpretation that is meant to characterise the morally emotional part of this attitude: “empathy”, “compassion” and “care”. In the first article of the series, “empathy” has been (...) developed as a mainly cognitive and morally neutral capacity of understanding. In the second article, the emotional and virtuous core of the desired professional attitude—compassion—has been presented. Compassion as a professional attitude has been distinguished from a spontaneous feeling of compassion, and has been related to a general idea of man as vulnerable and solidary being. Thus, the dignity of the patient is safeguarded in spite of the asymmetry of compassion. In this article, the third concept of the triad—“care”—is presented. Care is conceived as an attitude as well as an activity which can be directed to different objects: if it is directed to another sentient being, it is regarded as intrinsically morally valuable; implying (1) the acceptance of being addressed, (2) a benevolent inclination to help and to foster, and (3) activity to realize this. There are different forms of benevolence that can underlie caring. With regard to the professional physician’s ethos, the attitude of empathic compassion as developed in the two previous articles is proposed to be the adequate underlying attitude of care which demands the right balance between closeness and professionalism and the right form of attention to the person of the patient. ‘Empathic compassionate care’ does not, however, describe the whole of the desired attitude of a physician, but focuses on the morally-emotive aspects. In order to get also the cognitive and practical aspects of biomedicine into the picture, ‘empathic compassionate care’ has to be combined with an attitude of responsibility that is more directed to decision-making and outcome than a caring attitude alone can be. The reconstruction of the desired professional attitude in terms of “empathic compassionate care” and “responsibility” is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions. (shrink)

Use of humanities content in American medical education has been debated for well over 60 years. While many respected scholars and medical educators have purported the value of humanities content in medical training, its inclusion remains unstandardized, and the undergraduate medical curriculum continues to be focused on scientific and technical content. Cited barriers to the integration of humanities include time and space in an already overburdened curriculum, and a lack of consensus on the exact content, pedagogy and instruction. Edmund Pellegrino, (...) physician and scholar of the latter twentieth century, spent much of his professional life promoting the value and importance of the humanities in medical education, seeking the best way to incorporate and teach this content in clinically relevant ways. His efforts included the founding of multiple enterprises starting in the 1960s and 1970s to promote human values in medical education, including the Society for Health and Human Values and its Institute on Human Values in Medicine. Regardless of his efforts and those of many others into the current century, the medical humanities remains a curricular orphan, unable to find a lasting home in medical education and training. (shrink)

In his influential theory of health Nordenfelt bases the concepts of health and illness on the notions of ability and disability. A premise for this is that ability and disability provide a more promising, adequate, and useful basis than well-being and suffering. Nordenfelt uses coma and manic episodes as paradigm cases to show that this is so. Do these paradigm cases (and thus the premise) hold? What consequences does it have for the theory of health and illness if it they (...) do not? These are the key questions in this article, which first presents the relationship between pain and disability in Nordenfelt’s theory and the paradigm cases he uses to argue for the primacy of disability over pain. Then, Nordenfelt’s concepts of illness are outlined, highlighting its presumptions and arguments. The main point is that if you do not have an action-theoretical perspective, it is not obvious that disability is the core concept for illness. The compelling effect of the paradigm cases presupposes that you see ability as the primary issue. To those who do not share this presumption, people in coma may not be ill. There are alternative well founded arguments for the primacy of first person experiences for the concept of illness. Hence, we need better arguments for the primacy of disability over first person experiences in illness, or first-person experience should be more primarily included in the concept of illness. (shrink)

Modern medicine faces fundamental challenges that various approaches to the philosophy of medicine have tried to address. One of these approaches is based on the ancient concept of phronesis. This paper investigates whether this concept can be used as a moral basis for the challenges facing modern medicine and, in particular, analyses phronesis as it is applied in the works of Pellegrino and Thomasma. It scrutinises some difficulties with a phronesis-based theory, specifically, how it presupposes a moral community of professionals. (...) It is argued that Pellegrino and Thomasma's concept of phronesis corresponds to a Hippocratic concept of t�chn�, and that this latter concept seems to address many of the challenging issues Pellegrino and Thomasma also address. Thus, if modern medicine is to find its philosophical model in ancient concepts, it appears that the Hippocratic t�chn� is closer to the ancient concept of medicine than the Aristotelian phronesis, and that it might avoid many of the pitfalls of a phronesis-based approach. (shrink)

The impact of managed care on nurses’ workplace learning and teaching This paper examines the impact of managed care on the informal learning process for nurses in a major US‐based health organisation. Through the analysis of focus group data we report the nurses’ view of the effect recent changes have had on the nurse/patient/care relationship. Managed care, our research indicates, has transformed the learning milieus for nurses with two effects. First, nurses have seen their need for informal learning increase while (...) the time and context for that learning has diminished. Second, the process of teaching patients and families has also been adversely affected even as managed care creates the need for more patient education. We report the analysis of the data collected at group interviews involving nurses working in both hospital and community settings of a leading US‐based HMO. All interviews took place during September of 1997 at various sites in California. This study is part of a larger Social Science Research Council of Canada funded investigation into managed care in the US and Canada. (shrink)

The ways in which ethical issues arise in making clinical judgments are briefly discussed. By showing the topography of the role of value judgments in medical diagnostics it is suggested why clinical medicine remains inextricably a value-infected science.

Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is demonstrated through (...) analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine’s epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi’s theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine. (shrink)

The objective of this article is to analyse the value-ladenness of technology in the context of medicine. To address this issue several characteristics of technology are investigated: i) its interventive capacity, ii) its expansiveness and iii) its influence on the concept of disease, iv) its generalising character, v) its independence of the subjective experience of the patient. By this analysis I hope to unveil the double face of technology: Technology has a Janus-face in modern medicine, and the opposite of its (...) factual face is evaluative. (shrink)

In the present article I have surveyed several approaches to modeling the clinical diagnostic process. I have argued that at this point of the field's development, logics which simulate the reasoning patterns and knowledge base of expert clinicians represent research programs that are most likely to succeed. No logic of diagnosis has yet attained the status of being definitive; in spite of striking progress much more research and testing is required. On the basis of various existing logics, I have attempted (...) to articulate a number of desiderata which an ideal diagnostic logic should satisfy. In spite of these criticisms, I would maintain that programs such as MYCIN and INTERNIST have already matured to the point where they are useful both in consultations and in teaching diagnostic reasoning. (shrink)

The evidence-based medicine movement advocates basing all medical decisions on certain types of quantitative research data and has stimulated protracted controversy and debate since its inception. Evidence-based medicine presupposes an inaccurate and deficient view of medical knowledge. Michael Polanyi’s theory of tacit knowledge both explains this deficiency and suggests remedies for it. Polanyi shows how all explicit human knowledge depends on a wealth of tacit knowledge which accrues from experience and is essential for problem solving. Edmund Pellegrino’s classic treatment of (...) clinical judgment is examined, and a Polanyian critique of this position demonstrates that tacit knowledge is necessary for understanding how clinical judgment and medical decisions involve persons. An adequate medical epistemology requires much more qualitative research relevant to the clinical encounter and medical decision making than is currently being done. This research is necessary for preventing an uncritical application of evidence-based medicine by health care managers that erodes good clinical practice. Polanyi’s epistemology shows the need for this work and provides the structural core for building an adequate and robust medical epistemology that moves beyond evidence-based medicine. (shrink)

How do people make difficult decisions in situations involving substantial risk and uncertainty? In this study, we presented a difficult medical decision to three expert physicians in a combined “thinking aloud” and “cross examination” experiment. Verbatim transcripts were analyzed using script analysis to observe the process of constructing and making the decision, and using referring phrase analysis to determine the representation of knowledge of likelihoods. These analyses are compared with a formal decision analysis of the same problem to highlight similarities (...) and differences. The process of making the decision resembles an incremental, sequential‐refinement planning algorithm, where a complex decision is broken into a sequence of choices to be made with a simplified description of the alternatives. This strategy results in certain kinds of relevant information being underweighted in the final decision. Knowledge of likelihood appears to be represented as symbolic descriptions capturing categorical and ordinal relations with “landrhark” likelihoods, only some of which are described numerically. Numerical probabilities, capable of being combined and compared arithmetically, were not observed. These observations suggest an explanation for the heuristics and biases in human decision making under uncertainty in terms of the processes that manipulate symbolic descriptions of likelihoods and construct plans of action for situations involving risk and uncertainty. (shrink)

Sadegh-zadeh [23] has proposed a theory of the relativity of medical diagnosis in terms of the time at which a diagnosis is accepted, the patient to whom the diagnosis applies, the physician who renders the diagnosis, the medical knowledge used, the diagnostic method applied, and the set of patient observations. Use of classical formal logic as the diagnostic method may result in three paradoxes: the paradoxes of consistency, completeness, and justifiable ignorance. These paradoxes may be resolved by the addition of (...) two non-classical operators, the certainty and effort operators, akin to the non-classical operators of modal logic. (shrink)

Debates about how knowledge is made and valued in evidence-based medicine (EBM) have yet to understand what discursive, social, and historical conditions allowed the EBM approach to stabilize and proliferate across western medical education. This paper uses a genealogical approach to examine the epistemological tensions that emerged as a result of various problematizations of uncertainty in medical practice. I explain how the problematization of uncertainty in the literature and the contingency of specific social, political, economic, and historical relations allowed the (...) EBM approach to become a programmatic and pedagogical focus of the Faculty of Medicine at McMaster University and beyond. (shrink)

The measurement of diagnostic accuracy is an important aspect of the evaluation of diagnostic tests. Sometimes, medical researchers try to discover the set of observations that are most accurate of all by directly inspecting diseased and not-diseased patients. This method is perhaps intuitively appealing, as it seems a straightforward empirical way of discovering how to identify diseased patients, which amounts to trying to correlate the results of diagnostic tests with disease status. I present three examples of researchers who try to (...) produce definitive diagnostic criteria by directly inspecting diseased and not diseased patients. Despite this method’s intuitive appeal, I will argue that it is impossible to carry out. Before researchers can inspect these patients to discover definitive diagnostic criteria, they must be able to distinguish diseased and not-diseased patients; and they do not know how to do this, because this is what they are trying to discover. I suspect the intuitive appeal of directly inspecting patients makes this difficult to appreciate. To counter this difficulty, I present this problem as a manifestation of ‘Meno’s paradox’, which was described in classical antiquity, and of ‘the problem of nomic measurement’, described more recently. Considering these philosophical problems may help researchers address the methodological issues they face when evaluating diagnostic tests. (shrink)

Intuition is frequently used in medicine. Along with the use of existing medical rules, there is a separate channel that physicians rely on when making decisions: their intuition. To cope with the epistemic problem of using intuition, I use some clues from Wittgenstein's philosophy to illuminate the decision-making process in medicine. First, I point to a connection between intuition as functioning in medicine and Wittgenstein's notions of "seeing as" or noticing "aspects". Secondly, I use Wittgenstein notion of empirical regularities hardened (...) into rules to suggest that there are two stages that should be addressed in the analysis of medical practice: the first concerns the accumulation of cases and the second pertains to the setting a rule based on these cases. I argue further that the medical context is exceptional in that the two stages are intertwined and, and explain the consequences of this fact for the physician's work. Finally, inspired by Wittgenstein's rule-following conundrum, I argue that medicine is particularly prone to difficulties in applying a general rule to a specific case represented by an individual patient. Recourse to intuition is reflects the physicians' efforts to bridge this gap. (shrink)

The ontology of medicine—the question of whether disease entities are real or not—is an underdeveloped area of philosophical inquiry. This essay explains the primary question at issue in medical ontology, discusses why answering this question is important from both a philosophical and a practical perspective, and argues that the problem of medical ontology is unique, i.e., distinct, from the ontological problems raised by other sciences and therefore requires its own analysis.

Fifty years ago, in 1961, Feinstein published his first path-breaking articles leading to his seminal work Clinical Judgement and to the establishment of clinical epidemiology. Feinstein had an Aristotelian approach to scientific method: methods must be adapted to the material examined. Feinstein died 10 years ago and few years before his death he concluded that efforts to promote a person-oriented medicine had failed. He criticised medicine for not having recognized that only persons can suitably observe, evaluate and rate their own (...) health status. Feinstein’s position was—as in Clinical Judgement—methodological. He didn’t espouse ethical principles. He pointed to methodological deficiencies in clinical epidemiology and evidence-based medicine. In this article we’ll provide a framework for understanding and justifying Feinstein’s call for a person-oriented medicine which recognizes patients as co-actors in clinical reasoning. It’s argued that craftsmanship and practical wisdom are integrated in clinical judgement and reasoning and that clinical reasoning is not only about means to achieve the end, health. We do also reason and deliberate about ends. The ‘defining end’ of medicine (health) has continuously been negotiated and so been the object of deliberation. For centuries among professionals, in recent years among professionals and patients. These negotiations and deliberations lead to ongoing specifications of health as a ‘guiding end’, i.e. an end guiding clinical reasoning about what to do in particular situations. Feinstein’s self-critical account to clinical epidemiology at the end of his professional career reflects the fact that patients during the last 30–40 years (i.e. in the period after the publication of Clinical Judgement) widely have been recognized as persons with rights to autonomy. Feinstein’s lesson is, however, that espousing and recognizing ethical ideals is not enough. A change of clinical practice and its methods is necessary. His critique also implies that clinical epidemiology and evidence-based medicine as practiced haven’t provided such a turn. (shrink)

This paper argues that Adolf Gr nbaum's evaluation of the scientific status of psychoanalysis is marred by its failure to locate Freud's notion of natural science. Contrary to his claims, Griinbaum does not assess Freud's theory on Freud's own terms. The presuppositions that Griinbaum brings to the question of the scientific status of psychoanalysis are problematic and his criticisms and methodological restrictions may not be defensible when psychoanalysis is taken to develop methodologically out of medical science rather than out of (...) physics. I question the adequacy of the epistemological and methodological norms that Griinbaum brings to his analysis and I examine his arguments against the scientific credibility of Freud's theoretical claims. I argue that Griinbaum fails to consider the tension between clinical practice and psychoanalytic theory, ignores the evolution of Freud's thought and distorts and simplifies the complexity of the domain under investigation. Therefore his conclusions regarding the scientific credibility and evaluation of psychoanalysis are questionable. (shrink)

ArgumentThis article describes how science and law were called upon (and failed) to resolve a controversy that created a painful rift between the Israeli State and some of its elite soldiers. The controversy, which came to be known as “the Kishon affair,” erupted in 2000, when veterans of an elite and secretive unit in the Israeli navy claimed that pollution in the Kishon River where they had trained and dived during their military service had been the cause of a rash (...) of cancers. The veterans demanded that the Ministry of Defense take responsibility for their illnesses, finance their medical treatment, and support their families if they die. The military denied the causal connection between the polluted river and the veterans’ cancers and rejected their demands. The dispute quickly escalated into a bitter public controversy, and a high-rank commission comprised of one of Israel's top jurists and two prominent scientists was called upon to study the disputed causal relation and reveal its true nature. However, after nearly three years of intense inquiry the jurist and the scientists reached opposing conclusions: the jurist found a causal connection while the scientists rejected it. (shrink)

As health care embraces the tenets of evidence-based medicine it is important to ask questions about how evidence is produced and interpreted. This essay explores normative dimensions of evidence production, particularly around issues of setting the tolerable level of uncertainty of results. Four specific aspects are explored: what health care providers know about statistics, why alpha levels have been set at 0.05, the role of randomization in the generation of sufficient grounds of belief, and the role of observational studies. The (...) essay concludes with recommendations to acknowledge the value permeation of outcome measures and suggests that attention to reasoning and argument analysis can augment traditional evidence-based approaches in providing a robust critical approach to medical knowledge. (shrink)

Medical decisions, including diagnosis, prognosis, and disease classification, must often be made on the basis of incomplete or unsatisfactory information. Data which are essential to the care of one patient may be unobtainable for technical or ethical reasons in another patient. For this reason the principles of controlled experimentation may be impossible to satisfy in human studies. In this paper, some formal aspects of medical decision making are discussed. Special operators for the intuitive concepts of certainty, demand, and effort, akin (...) to the operators of modal logic, are used to accommodate the technical and ethical limitations on human studies. Theorems are stated and proved which show how this system handles incomplete information. The embryogenesis of the human heart is presented as a sample problem in classification. (shrink)

In this paper I focus on the topic of chronic illness in the context of quality of life. I offer a conceptual explanation of these notions and then try to systematise the various species of suffering connected with chronic illness. Suffering in illness rarely attracts systematic analysis. Part of the reason for this is that the topic is in a way an aspect of common sense. It has an air of self-evidence and seems not to require analysis. However, it is (...) my contention that the nature of human suffering is not at all selfevident. In many ways we know very little about the content and extent of suffering. And, although it may not be sensible to borrow traditional scientific techniques for the study of suffering, we need as much intellectual penetration and rigorous analysis in order to clarify the nature of suffering as for any other scientific investigation. Moreover, there are good reasons for saying that we ought to direct much more of our attention to this humanistic aspect of medicine. We ought to remember that the existence of suffering is one of the main motives, if indeed not the most important motive, for undertaking the medical enterprise. (shrink)