My question in the chapter is this: could (and should) the role of the physician be construed as that of a friend to the patient? I begin by briefly discussing the “friendship model” of the physician-patient relationship—according to which physicians and patients could, and perhaps should, be friends—as well as its history and limitations. Given these limitations, I focus on the more one-sided idea that the physician could, and perhaps should, be a friend to the patient (a “physician-qua-friend model” of (...) the physician-patient relationship). I show that given recent developments in our understanding of the physician-patient relationship, this idea is far from asinine. I then make the case that the most plausible conception of the physician-qua-friend model incorporates the following components: (a) a common goal, that is, one that physician and patient share; (b) certain forms of equality between physician and patient; (c) an ideal of a caring physician. Finally, I show how the model can be instantiated in a certain type of physician-patient interaction, namely, in physician-assisted dying. (shrink)

ABSTRACT BEER, P. A. C. The matter of truth in knowledge production about psychic suffering: considerations from Ian Hacking and Jacques Lacan. 2020. 250p. Thesis (PhD) – Instituto de Psicologia, Universidade de São Paulo, São Paulo, 2020. The thesis aims to reaffirm the importance of the debate around the matter of truth in relation to the production of knowledge concerning psychic suffering. Its point of departure is the understanding that the matter of truth contains two main appearances: as employed to (...) legitimize produced knowledge while establishing normative patterns, and as presenting itself in a critical form as a disruptive element to established knowledge. As such, it is a discussion that embraces both an affirmation of knowledge’s necessary character and of its variability. It will be argued in the above sense that the term “truth” must be taken as an inclusive and reciprocal gathering of epistemological, ontological, ethical and political elements. Ian Hacking’s historicized understanding of science enables such a consideration of contingent bases to scientific practice, while still producing necessary knowledge. It thus becomes is possible to establish a field in which normative understandings about scientific praxis might be criticized without it resulting in any kind of refusal or disqualification of the relevant, produced knowledge. Hacking’s proposition of a “historical ontology” and of a “dynamic nominalism” also represents an important contribution to the accumulation of knowledge production about psychic suffering debate, by affirming the ontological effects of knowledge. The way as truth is mobilized within Lacanian psychoanalysis flows from that standpoint, seen as focused on three main elements: truth’s autonomy towards the subject, (truth speaks), the opposing and temporary character of a positivized truth facing established knowledge ,(truth as critique), and the negative dimension of truth which relates to the inexhaustibility of this dialectical process of negations, (truth as radical difference). It is argued that it is possible to sustain a particular reasoning style, (in Hacking’s terms), for psychoanalysis, which is based on radical negativity. It is further argued, that the above rationalities in question work with a historicized understanding of knowledge that does not have any external (nor internal) criteria to warrant its truth. However, psychoanalysis takes negativity — arguably the base of knowledge’s variability and of truth’s disruptive character — beyond Hacking’s philosophy of science, and can thus offer even wider possibilities of thinking about the causality of psychic suffering. Even if with different intensities, both approaches signal the necessity of ethical and political implication in knowledge’s production and employment. Once there is no epistemological warranty to knowledge, its production value reverts to social agreements and ethical positioning. There is, therefore, the necessity of considering power relations. Finally, it is argued that the radical negativity sustained from psychoanalysis locates the political as an actually necessary field, inescapable by the very fact that it is not possible to crystalize any form of truth which is not the affirmation of radical difference. It is maintained then that introducing the matter of truth has as horizon the production of a kind of knowledge about psychic suffering which puts into question, at all time, its epistemological, ontological, ethical and political assumptions. (shrink)

Within the evidence-based medicine construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians’ primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the “best” evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here (...) we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients. (shrink)

Advanced AI systems are rapidly making their way into medical research and practice, and, arguably, it is only a matter of time before they will surpass human practitioners in terms of accuracy, reliability, and knowledge. If this is true, practitioners will have a prima facie epistemic and professional obligation to align their medical verdicts with those of advanced AI systems. However, in light of their complexity, these AI systems will often function as black boxes: the details of their contents, calculations, (...) and procedures cannot be meaningfully understood by human practitioners. When AI systems reach this level of complexity, we can also speak of black-box medicine. In this paper, we want to argue that black-box medicine conflicts with core ideals of patient-centered medicine. In particular, we claim, black-box medicine is not conducive for supporting informed decision-making based on shared information, shared deliberation, and shared mind between practitioner and patient. (shrink)

The usefulness of machine learning algorithms has led to their widespread adoption prior to the development of a conceptual framework for making sense of them. One common response to this situation is to say that machine learning suffers from a “black box problem.” That is, machine learning algorithms are “opaque” to human users, failing to be “interpretable” or “explicable” in terms that would render categorization procedures “understandable.” The purpose of this paper is to challenge the widespread agreement about the existence (...) and importance of a black box problem. The first section argues that “interpretability” and cognates lack precise meanings when applied to algorithms. This makes the concepts difficult to use when trying to solve the problems that have motivated the call for interpretability. Furthermore, since there is no adequate account of the concepts themselves, it is not possible to assess whether particular technical features supply formal definitions of those concepts. The second section argues that there are ways of being a responsible user of these algorithms that do not require interpretability. In many cases in which a black box problem is cited, interpretability is a means to a further end such as justification or non-discrimination. Since addressing these problems need not involve something that looks like an “interpretation” of an algorithm, the focus on interpretability artificially constrains the solution space by characterizing one possible solution as the problem itself. Where possible, discussion should be reformulated in terms of the ends of interpretability. (shrink)

This article analyzes narrative illustrations in genetic counseling textbooks as a way of understanding professional habitus--the dispositions that motivate professional behavior. In particular, this analysis shows that there are significant differences in how the textbooks' expository and narrative portions represent Down syndrome, genetic counseling practice, and patient behaviors. While the narrative portions of the text position the genetic counseling profession as working in service to the values of genetic medicine, the expository portions represent genetic counselors as neutral parties. Ultimately, this (...) article argues that this ambiguity is harmful to the production of a professional habitus that is consistent with espoused professional values concerning respect for persons with disabilities and the promotion of psychosocial counseling. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

The aim of this article is to present a conceptual review and analysis of symptom understanding. Subjective bodily sensations occur abundantly in the normal population and dialogues about symptoms take place in a broad range of contexts, not only in the doctor’s office. Our review of symptom understanding proceeds from an initial subliminal awareness by way of attribution of meaning and subsequent management, with and without professional involvement. We introduce theoretical perspectives from phenomenology, semiotics, social interactionism, and discourse analysis. Drew (...) Leder’s phenomenological perspectives deal with how symptom perception occurs when any kind of altered balance brings forward a bodily attention. Corporeality is brought to explicit awareness and perceived as sensations. Jesper Hoffmeyer’s biosemiotic perspectives provide access to how signs are interpreted to attribute meaning to the bodily messages. Symptom management is then determined by the meaning of a symptom. Dorte E. Gannik’s concept “situational disease” explains how situations can be reviewed not just in terms of their potential to produce signs or symptoms, but also in terms of their capacity to contain symptoms. Disease is a social and relational phenomenon of containment, and regulating the situation where the symptoms originate implies adjusting containment. Discourse analysis, as presented by Jonathan Potter and Margaret Wetherell, provides a tool to notice the subtle ways in which language orders perceptions and how language constructs social interaction. Symptoms are situated in culture and context, and trends in modern everyday life modify symptom understanding continuously. Our analysis suggests that a symptom can only be understood by attention to the social context in which the symptom emerges and the dialogue through which it is negotiated. (shrink)

This highly multidisciplinary collection discusses an increasingly important topic among scholars in science and technology studies: objectivity in science. It features eleven essays on scientific objectivity from a variety of perspectives, including philosophy of science, history of science, and feminist philosophy. Topics addressed in the book include the nature and value of scientific objectivity, the history of objectivity, and objectivity in scientific journals and communities. Taken individually, the essays supply new methodological tools for theorizing what is valuable in the pursuit (...) of objective knowledge and for investigating its history. The essays offer many starting points, while suggesting new avenues of research. Taken collectively, the essays exemplify the very virtues of objectivity that they theorize—in reading them together, the reader can sense various anxieties about the dangerously subjective in our age and locate commonalities of concern as well as differences of approach. As a result, the volume offers an expansive vision of a research community seeking a communal understanding of its own methods and its own epistemic anxieties, struggling to enunciate the key problems of knowledge of our time and offer insight into how to overcome them. -/- (Contributors: Alex Csiszar, Scott Edgar, Peter Galison, Ian Hacking, Sandra Harding, Moira Howes, Paolo Savoia, Judy Segal, Joan Steigerwald, and Alison Wylie). (shrink)

Introduction: Clinical practice guidelines (CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale: I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated aims of these CPGs and (...) the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis: The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial (RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion: The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. (shrink)

For many years a debate has raged over what constitutes futile medical care, if patients have a right to demand what doctors label as futile, and whether physicians should be obliged to provide treatments that they think are inappropriate. More recently, the argument has shifted away from the difficult project of definitions, to outlining institutional policies and procedures that take a measured and patient-by-patient approach to deciding if an existing or desired intervention is futile. The prototype is the Texas Advance (...) Directives Act, but similar procedures have been widely implemented both with and without the protection of the law. While this method has much to recommend it, there are inherent moral flaws that have not received as much discussion as warranted. Because these strategies adopt a semblance of procedural justice, it is assumed that the outcomes of such proceedings will be both correct and fair. In this paper, I argue that there are three main irremediable defects in the policy approach: there is the potential for arbitrary decision-making about futility in specific cases; there are structural, pre-ordained consequences for ethnic minorities who would be disproportionately affected by the use of these procedures; and the use of rationing justifications to support the use of these policies. These flaws detract so much from any benefit that could be derived that they make such strategies more harmful than helpful. (shrink)

Despite technological innovations, clinical expertise remains the cornerstone of psychiatry. A clinical expert does not only have general textbook knowledge, but is sensitive to what is demanded for the individual patient in a particular situation. A method that can do justice to the subjective and situation-specific nature of clinical expertise is ethnography. Effective deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) involves an interpretive, evaluative process of optimizing stimulation parameters, which makes it an interesting case to study clinical expertise. The (...) aim of this study is to explore the role of clinical expertise through an ethnography of the particular case of DBS optimization in OCD. In line with the topic of the special issue this article is a part of, we will also use our findings to reflect on ethnography as a method to study complex phenomena like clinical expertise. This ethnography of DBS optimization is based on 18 months of participant observation and nine in-depth interviews with a team of expert clinicians who have been treating over 80 OCD patients since 2005. By repeatedly observing particular situations for an extended period of time, we found that there are recurrent patterns in the ways clinicians interact with patients. These patterns of clinical practice shape the possibilities clinicians have for making sense of DBS-induced changes in patients’ lived experience and behavior. Collective established patterns of clinical practice are dynamic and change under the influence of individual learning experiences in particular situations, opening up new possibilities and challenges. We conclude that patterns of clinical practice and particular situations are mutually constitutive. Ethnography is ideally suited to bring this relation into view thanks to its broad temporal scope and focus on the life-world. Based on our findings, we argue that clinical expertise not only implies skillful engagement with a concrete situation but also with the patterns of clinical practice that shape what is possible in this specific situation. Given this constraining and enabling role of practices, it is important to investigate them in order to find ways to improve diagnostic and therapeutic possibilities. (shrink)

BackgroundMedical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an ‘executive virtue’, offers a way to navigate the practice virtues for any (...) given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians.MethodsThe primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process.ResultsWe found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants’ ‘collective practical wisdom’, including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua.ConclusionGiven the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well. (shrink)

With twentieth- and twenty-first-century philosophy of science’s unfolding acceptance of the nature of scientific inquiry being value-laden, the persistent worry has been that there are no means for legitimate negotiation of the social or non-epistemic values that enter into science. The rejection of the value-free ideal in science has thereby been coupled with the spectres of indiscriminate relativism and bias in scientific inquiry. I challenge this view in the context of recently expressed concerns regarding Canada's death of evidence controversy. The (...) worry, raised by Stathis Psillos, is that as constructivist accounts of science demoted the previously secure status of evidence for drawing justified conclusions in science, we were left with no rational delineation between the right and wrong values for science. The implication for the death of evidence controversy is that we may have no rational grounds for claiming that the Canadian Government is wrong to interfere with scientific enterprise. But he does offer another avenue for reaching the conclusion that the wrong social values are directing the current stifling of some sectors of Canadian science. Psillos draws from standpoint epistemologies to devise a salient defence of ‘valuing evidence’ as a universalizable social value. That is, government bodies ought to enable scientific research via adequate funding as well as political non-interference. In this paper, I counter that non-epistemic values can be rationally evaluated and that standpoint epistemology’s universalizable standpoint provides an inadequate framework for negotiating social values in science. Regarding, I draw from the evidence-based medicine debate in philosophy of medicine and from feminist empiricist investigations into the science–values relationship in order to make the argument for empirically driven value arbitration. If social values can be rationally chosen in the context of justification, then we can have grounds for charging the Canadian leadership with being ‘at war with science’. I further argue that my recommended empiricist methodology is preferable to Psillos’s search for universalizable perspectives for negotiating social values in science because the latter method permits little more than the trivial conclusion that evidence is valuable to science. (shrink)

Evidence-Based Medicine (EBM) developed from the work of clinical epidemiologists at McMaster University and Oxford University in the 1970s and 1980s and self-consciously presented itself as a "new paradigm" called "evidence-based medicine" in the early 1990s. The techniques of the randomized controlled trial, systematic review and meta-analysis have produced an extensive and powerful body of research. They have also generated a critical literature that raises general concerns about its methods. This paper is a systematic review of the critical literature. It (...) finds the description of EBM as a Kuhnian paradigm helpful and worth taking further. Three kinds of criticism are evaluated in detail: criticisms of procedural aspects of EBM (especially from Cartwright, Worrall and Howick), data showing the greater than expected fallibility of EBM (Ioaanidis and others), and concerns that EBM is incomplete as a philosophy of science (Ashcroft and others). The paper recommends a more instrumental or pragmatic approach to EBM, in which any ranking of evidence is done by reference to the actual, rather than the theoretically expected, reliability of results. Emphasis on EBM has eclipsed other necessary research methods in medicine. With the recent emphasis on translational medicine, we are seeing a restoration of the recognition that clinical research requires an engagement with basic theory (e.g. physiological, genetic, biochemical) and a range of empirical techniques such as bedside observation, laboratory and animal studies. EBM works best when used in this context. (shrink)

Can doctors maintain good character? This paper shifts the focus from patient care to ethical considerations that bear on the physician and impact her as a person. By decentering patient care, the paper highlights certain factors that habituate a particular way of reasoning that is not conducive to inculcating good character. Such factors include, standards of professionalism, being influenced by external monitors, and emphasis on adherence to guidelines. While such factors may benefit patients, they often adversely affect the character of (...) physicians. (shrink)

Paperwork plays a key role in a how institutions accommodate, refuse, or manage disabled people. This article develops modes for reading paperwork that build on each other, beginning with (a) recognizing the institutional pressures at work in shaping bureaucratic practices, then (b) considering how a person's relationship to disability influences how they might encounter these practices, and ultimately (c) noticing how the encounter between disabled/mad people and an institution might create something new, what the author calls archival excess. These methods (...) for reading are in conversation with disability studies, medical humanities, and document studies, and ultimately work toward a goal adapted from the principles of Disability Justice: recognizing the wholeness of disabled subjects in institutional archives. (shrink)

Many experts have emphasised that chatbots are not sufficiently mature to be able to technically diagnose patient conditions or replace the judgements of health professionals. The COVID-19 pandemic, however, has significantly increased the utilisation of health-oriented chatbots, for instance, as a conversational interface to answer questions, recommend care options, check symptoms and complete tasks such as booking appointments. In this paper, we take a proactive approach and consider how the emergence of task-oriented chatbots as partially automated consulting systems can influence (...) clinical practices and expert–client relationships. We suggest the need for new approaches in professional ethics as the large-scale deployment of artificial intelligence may revolutionise professional decision-making and client–expert interaction in healthcare organisations. We argue that the implementation of chatbots amplifies the project of rationality and automation in clinical practice and alters traditional decision-making practices based on epistemic probability and prudence. This article contributes to the discussion on the ethical challenges posed by chatbots from the perspective of healthcare professional ethics. (shrink)

In this paper, we outline a framework for understanding the different kinds of knowledge required for medical practice and use this framework to show how scientism undermines aspects of this knowledge. The framework is based on Michael Polanyi’s claim that knowledge is primarily the product of the contemplations and convictions of persons and yet at the same time carries a sense of universality because it grasps at reality. Building on Polanyi’s ideas, we propose that knowledge can be described along two (...) intersecting “dimensions”: the tacit–explicit and the particular–general. These dimensions supersede the familiar “objective−subjective” dichotomy, as they more accurately describe the relationship between medical science and medical practice. Scientism, we argue, excludes tacit and particular knowledge and thereby distorts “clinical reality” and impairs medical practice and medical ethics. (shrink)

In a market place crowded with practical rhetoric books what educational value could a challenging work such as Kenneth Burke’s A Rhetoric of Motives possibly have? Burke knows but doesn’t use the terminology of the classical art and rather than analysing the persuasive rhetoric of well-known speeches to equip us with strategies, he weaves his way around literary texts, teasing out meanings that their authors something intended, sometimes did not. Yet, despite such difficulties, A Rhetoric of Motives is a practical (...) rhetoric book. It is just that its process of explication teaches us to think well. This essay tries to explain Burke’s rethinking of the purpose and contents of a traditional teaching tool—the rhetorical handbook—and defends the value of literary-rhetorical reading that aims to ‘equip’ citizens to think openly. (shrink)

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)

Epistemic trust is an unacknowledged feature of medical knowledge. Claims of medical knowledge made by physicians, patients, and others require epistemic trust. And yet, it would be foolish to define all epistemic trust as epistemically responsible. Accordingly, I use a routine example in medical practice to illustrate how epistemically responsible trust in medicine is trust in epistemically responsible individuals. I go on to illustrate how certain areas of current medical practice of medicine fall short of adequately distinguishing reliable and unreliable (...) processes because of a failure to systematically evaluate health outcomes. I conclude by articulating the devastating obstacles to the consilience assumption, which takes intellectual character as the standard for epistemic responsibility. (shrink)

Philosophers and others have questioned whether or not expertise in morality is possible. This debate is not only theoretical, but also affects the perceived legitimacy of clinical ethicists. One argument against moral expertise is that in a pluralistic society with competing moral theories no one can claim expertise regarding what another ought morally to do. There are simply too many reasonable moral values and intuitions that affect theory choice and its application; expertise is epistemically uniform. In this article, we discuss (...) how similar concerns have recently threatened to undermine expertise in medicine and science. In contrast, we argue that the application of values is needed to exercise medical, scientific, and moral expertise. As long as these values are made explicit, worries about a pretense to authority in the context of a liberal democracy are ill-conceived. In conclusion, we argue for an expertise that is epistemically diverse. (shrink)

A debate has simmered concerning the nature of clinical reasoning, especially diagnostic reasoning: Is it a “science” or an “art”? The trend since the seventeenth century has been to regard medical reasoning as scientific reasoning, and the most advanced clinical reasoning is the most scientific. However, in recent years, several scholars have argued that clinical reasoning is clearly not “science” reasoning, but is in fact a species of narratival or hermeneutical reasoning. The study reviews this dispute, and argues that in (...) a theoretical sense, the dispute rests upon a naïve—but very popular—caricature of what constitutes “science reasoning.” But, if the dispute rests upon just such a caricature, why is it so persistent? The study concludes by suggesting that we, as patients and as physicians, have deep psychological tendencies that incline us to adopt the very naïve “science” concept/model of diagnostic reasoning, even if (or when) we understand its inaptness. (shrink)

[1st paragraph] A philosophical discussion on evidence-based medicine (EBM) can be probably perceived almost as an oxymoron. How can “the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions” (Jenicek 2012: 23) be compatible with the critical and systematic examination of fundamental problems such as the nature of being, reality, thinking, values and perception? How can a scientific field focused mainly on the search and evaluation of evidence and aimed at solid quantifications of (...) hypotheses (Jenicek 2003: 70) be approachable from a perspective that is characterized by probable or defeasible arguments? The challenge of this special issue is to show how a philosophical perspective on evidence is not opposed to, but rather at the grounds of evidence-based medicine. (shrink)

There is a diversity of ‘ethical practices’ within medicine as an institutionalised profession as well as a need for ethical specialists both in practice as well as in institutionalised roles. This Brief offers a social perspective on medical ethics education. It discusses a range of concepts relevant to educational theory and thus provides a basic illumination of the subject. Recent research in the sociology of medical education and the social theory of Pierre Bourdieu are covered. In the end, the themes (...) of Bourdieuan Social Theory, socio-cultural apprenticeships and the ‘characterological turn’ in medical education are draw together the context of medical ethics education. ​. (shrink)

In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom (a modification of the Aristotelian phronèsis) has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to (...) be insufficient. However, this solution is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis. (shrink)

Robust clinical decision-making depends on valid reasoning and sound judgment and is essential for delivering quality healthcare. It is often susceptible, however, to a clinician’s biases such as towards a patient’s age, gender, race, or socioeconomic status. Gender bias in particular has a deleterious impact, which frequently results in cognitive myopia so that a clinician is unable to make an accurate diagnosis because of a patient’s gender—especially for female patients. Virtue epistemology provides a means for confronting gender bias in clinical (...) decision-making and for correcting or even preventing its impact. The medical literature on cardiovascular and coronary heart disease is used to illustrate the role intellectual virtues can play in redressing the deleterious impact of gender bias on clinical decision-making and practice. Finally, questions are considered surrounding the pedagogy of intellectual virtues for medical students and practicing clinicians in order to provide quality care for patients, regardless of gender. (shrink)

Illness narrative has often been found to play a positive role in both patients’ and providers’ efforts to find meaning in the illness experience. However, illness narrative can sometimes become counterproductive, even pathological, particularly in cases of medical mystery—cases wherein biopsychosocial factors blur the distinction between bodily dysfunction and somatizing behavior. In this article, the author draws attention to two examples of medical mystery, the clinical presentation of medically unexplained symptoms, and the popular reality television program Mystery Diagnosis, to demonstrate (...) the potentially harmful effects of illness narrative. The medical mystery’s complex narrative structure reflects and tends to reinforce providers’ and patients’ mistaken assumptions, anxieties, and conflicts in ways which obstruct, rather than facilitate, healing. (shrink)

This essay aims to broaden the understanding of the nature of the physician–patient relationship. To do so, the concept of medical philia that Pedro Laín Entralgo proposes is analysed and is considered taking into consideration the relational trait of the human being and the structure of human action as a story of the permanent tension that exists between freedom and truth, where the ontological foundation of the hermeneutic of the "Gift" and the analogy of “Love” as the central dynamic of (...) this action, helps explain the nature of the doctor-patient relationship as a "friendship relationship". This understanding offers a perspective differing from just the utilitarian considerations of current "patient-centred" approaches and proposed the redirection of the teaching of medicine to more humanistic approaches. The dynamic of the doctor-patient relationship proposed here in its most genuine essence is effectively expressed in physician concrete attitudes that the patient usually captures and relates as the “the doctor’s way of being”. Goya's painting, Self-portrait with Dr Arrieta (1820), can be taken as an outstanding artistic representation of this expanded dimension of the medical act, capturing the “medical friendship” in action. (shrink)

Courts are increasingly obliged to adjudicate upon challenges to allocative decisions in healthcare, but their involvement continues to be regarded with unease, imperilling the legitimacy of the judicial role in this context. A central reason for this is that judges are perceived to lack sufficient expertise to determine allocative questions. This article critically appraises the claim of lack of judicial expertise through an examination of the various components of a limit-setting decision. It is argued that the inexpertise argument is weak (...) when compared with other rationales for judicial restraint, such as the procedural unsuitability and lack of constitutional competence of courts. (shrink)

Effective person-centred care requires recognition of the personhood not only of patients but of practitioners. This chapter explores the consequences of this recognition for major debates in medical epistemology, regarding clinical reasoning and the relationship between research and practice. For too long these debates have been dominated by false dichotomies - subjectivity versus objectivity, judgement versus evidence, reason versus emotion. Based on flawed understandings of such core concepts as “objectivity” and “engagement”, this distorted dissection of the subject-object relationship has served (...) to depersonalise practice. The costs of this depersonalisation include over-regulation and micromanagement of healthcare processes by administrators and payers at the same time that information from clinical research remains under-utilized and the personhood of patients risks being ignored. Science is a human practice, founded in a broader conception of human reasoning, ontologically dependent on human beings living and engaging with the world in social, emotional and ethical contexts. After looking at different conceptions of epistemic hierarchies and their uses in the analysis and evaluation of reasoning in a range of practice contexts, we propose a “nested hierarchy” that effectively turns upside-down the flawed evidence hierarchies that have helped to depersonalise care. T.S. Eliot’s “wisdom, knowledge, information” scheme (to which we add “data” below “information”) provides a model for a person-centred epistemic hierarchy. This crucial, person-centred inversion represents levels of awareness that characterise more or less developed thinking and judgement on the part of the particular practitioner. (shrink)

For those interested in developing baccalaureate programs in health humanities, this essay draws on our experience of developing a minor in health humanities to share insights on what to expect, strategies that work well, and how to deal with obstacles. These insights range from how to explain the concept of health humanities to stakeholders to how to decide where to house a health humanities program. We share our insights in a way that promises to translate well to different institutional contexts. (...) That said, this paper is more relevant for institutional contexts where budgets are stressed and, consequently, proposals to invest in humanities programs are a difficult sell. This paper is divided into sections addressing how to earn institutional support, gain campus buy-in, identify benefits of the proposed program, decide where to house the program, calculate program cost, and secure external funding. We conclude with some final reflections on the current status of our program and why we are committed to health humanities education. (shrink)

Inclusion of the humanities in undergraduate medicine curricula remains controversial. Skeptics have placed the burden of proof of effectiveness upon the shoulders of advocates, but this may lead to pursuing measurement of the immeasurable, deflecting attention away from the more pressing task of defining what we mean by the humanities in medicine. While humanities input can offer a fundamental critical counterweight to a potentially reductive biomedical science education, a new wave of thinking suggests that the kinds of arts and humanities (...) currently used in medical education are neither radical nor critical enough to have a deep effect on students’ learning and may need to be reformulated. The humanities can certainly educate for tolerance of ambiguity as a basis to learning democratic habits for contemporary team-based clinical work. William Empson’s ‘seven types of ambiguity’ model for analyzing poetry is transposed to medical education to: (a) formulate seven values proffered by the humanities for improving medical education; (b) offer seven ways of measuring impact of medical humanities provision, thereby reducing ambiguity; and (c) --as a counterweight to (b) – celebrate seven types of ambiguity in contemporary medical humanities that critically reconsider issues of proof of impact. (shrink)

This article examines a population-based opportunistic screening practice for cognitive impairment that takes place at a hospital in Sweden. At the hospital, there is a routine in place that stipulates that all patients over the age of 65 who are admitted to the ward will be offered testing for cognitive impairment, unless they have been tested within the last six months or have been diagnosed with any form of cognitive impairment. However, our analysis shows that this routine is not universally (...) and mechanically applied. Rather, the health care professionals have developed and use an ethico-political judgment, concerning, for example,whomto test,whento offer the tests, andhowto explain and perform them. This article explores the role and practice of this form of judgment, emphasising its political and ethical nature. The analysis is based on qualitative interviews with professionals and patients, and draws on the theories of Aristotle and Hannah Arendt. (shrink)

This paper argues that “backstage” gallows humor among clinical mentors not only affects medical students’ perceptions of what it means to be a doctor but is also symptomatic and indicative of a much larger problem in medicine—namely, the failure to attend fully to the complexity and profundity of the lived experiences of illness, suffering, and death. Reorienting the discourse surrounding gallows humor away from whether or in what context it is acceptable and toward the reasons why doctors feel the need (...) to use such humor in the first place addresses this issue in a more illuminating way. (shrink)

Most clinicians take for granted a simple, reductionist understanding of medical knowledge that is at odds with how they actually practice medicine; routine medical decisions incorporate more complicated kinds of information than most standard accounts of medical reasoning suggest. A better understanding of the structure and function of knowledge in medicine can lead to practical improvements in clinical medicine. This understanding requires some familiarity with epistemology, the study of knowledge and its structure, in medicine. Michael Polanyi's theory of tacit knowing (...) is advanced as the basis for developing a more accurate understanding of medical knowledge. Tacit knowing, which explores the taken-for-granted background knowledge that underlies all human knowing, is explained in detail with a focus on its relevance for clinical medicine. The implications of recognizing tacit knowing in medicine and medical decisions are discussed. These include the ability to explain the importance of the clinical encounter in medical practice, mechanisms for analysing patient and doctor as persons, and the need for humility given the uncertainty that the tacit dimension injects into all medical decisions. This more robust medical epistemology allows clinicians to better articulate the nature and importance of patient-centred care, to avoid pitfalls inherent in reductionist approaches to medical knowledge, and to think more clearly about the relationships between medicine and health care at the individual and population levels. (shrink)