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)

Contesting that a debate on evidence-based health care has taken place, this article charts three paths to the future: continuing avoidance of debate by proponents of evidence-based medicine (EBM); conflict, which the EBM movement courts and critics have espoused, and dialogue. The last portal allows for integration, which would end the disagreement between EBM and its critics and make a debate unnecessary. In search of integration, I sketch a bridge whose construction requires not compromise but a win- win approach. The (...) bridge is a medicine of meaning (MOM). Consolidating multiple pillars of evidence to unify questions that are not necessarily the same for protagonists and critics of EBM, a MOM contends that the purpose or meaning of medicine is always healing and helping, and each party finds meaning in medicine by contributing to this common purpose in its own distinctive way. (shrink)

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, (...) and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise. (shrink)