Here is a thoroughly updated edition of a classic in palliative medicine. Two new chapters have been added to the 1991 edition, along with a new preface summarizing where progress has been made and where it has not in the area of pain management. This book addresses the timely issue of doctor-patient relationships arguing that the patient, not the disease, should be the central focus of medicine. Included are a number of compelling patient narratives. Praise for the first edition "Well (...) written. . .should be read by everyone in medical practice or considering a career in medicine."---JAMA. "Memorable passages, important ideas, and critical analysis. This is a book that clinicians and educators should read."---New England Journal of Medicine. (shrink)

The purpose of this paper is to introduce an approach to clinical practice aiming to resolve the dilemma of choosing between a mechanistic and a phenomenological model. The approach is an extension of Polanyi's epistemology. Michael Polanyi, devised an epistemology of science which overcomes the problem of detachment, inherent in the mechanistic approach, and resolves the problem of subjectivity troubling phenomenologists. His epistemology is known as Personal Knowledge. An extension of this epistemology, a Neo-Polanyian proposal, is offered as a more (...) successful model for clinical practice than previous suggestions addressing the dilemma. (shrink)

Suitable for students and scholars, this title challenges the assumption that skepticism, rather than established belief, lies at the heart of scientific discovery.

In recent years, virtue theories have enjoyed a renaissance of interest among general and medical ethicists. This book offers a virtue-based ethic for medicine, the health professions, and health care. Beginning with a historical account of the concept of virtue, the authors construct a theory of the place of the virtues in medical practice. Their theory is grounded in the nature and ends of medicine as a special kind of human activity. The concepts of virtue, the virtues, and the virtuous (...) physician are examined along with the place of the virtues of trust, compassion, prudence, justice, courage, temperance, and effacement of self-interest in medicine. The authors discuss the relationship between and among principles, rules, virtues, and the philosophy of medicine. They also address the difference virtue-based ethics makes in confronting such practical problems as care of the poor, research with human subjects, and the conduct of the healing relationship. This book woith the author's previous volumes, A Philosophical Basis of Medical Practice and For the Patient's Good, are part of their continuing project of developing a coherent moral philosophy of medicine. (shrink)

Published very shortly before his death in February 1976, Meaning is the culmination of Michael Polanyi's philosophic endeavors.

“Evidence based medicine” is often seen as a scientific tool for quality improvement, even though its application requires the combination of scientific facts with value judgments and the costing of different treatments. How this is done depends on whether we approach the problem from the perspective of individual patients, doctors, or public health administrators. Evidence based medicine exerts a fundamental influence on certain key aspects of medical professionalism. Since, when clinical practice guidelines are created, costs affect the content of EBM, (...) EBM inevitably becomes a form of rationing and adopts a public health point of view. This challenges traditional professionalism in much the same way as managed care has done in the US. Here we chart some of these major philosophical issues and show why simple solutions cannot be found. The profession needs to pay more attention to different uses of EBM in order to preserve the good aspects of professionalism. (shrink)

The proposed practice of "evidence-based medicine," which calls for careful clinical judgment in evaluating the "best available evidence," should be differentiated from the special collection of data regarded as suitable evidence. Although the proposed practice does not seem new, the new collection of "best available" information has major constraints for the care of individual patients. Derived almost exclusively from randomized trials and meta-analyses, the data do not include many types of treatments or patients seen in clinical practice; and the results (...) show comparative efficacy of treatment for an "average" randomized patient, not for pertinent subgroups formed by such cogent clinical features as severity of symptoms, illness, co-morbidity, and other clinical nuances. The intention-to-treat analyses do not reflect important post-randomization events leading to altered treatment; and the results seldom provide suitable background data when therapy is given prophylactically rather than remedially, or when therapeutic advantages are equivocal. Randomized trial information is also seldom available for issues in etiology, diagnosis, and prognosis, and for clinical decisions that depend on pathophysiologic changes, psychosocial factors and support, personal preferences of patients, and strategies for giving comfort and reassurance. The laudable goal of making clinical decisions based on evidence can be impaired by the restricted quality and scope of what is collected as "best available evidence." The authoritative aura given to the collection, however, may lead to major abuses that produce inappropriate guidelines or doctrinaire dogmas for clinical practice. (shrink)

Matters of hospital management do not figure prominently on the medical ethics agenda. However, management decisions that have to be taken in the area of hospital care are in fact riddled with ethical questions and do have significant impact on patients, staff members, and the community being served. In this decision making process evidence based medicine plays an increasingly important role as a tool for rationalising as well as rationing health care resources. In this article, ethical issues of hospital management (...) and the role of EBM will be explored, with particular reference to disease management programs, diagnosis related groups, and clinical pathways as recent developments in the German health care system. (shrink)

In this paper we set out to examine thearguments for and against the claim thatEvidence-Based Medicine (EBM) will improve thequality of care. In particular, we examine thefollowing issues.

SummaryIt has been argued that clinical medicine should be regarded as a relatively autonomous science. While it draws upon other sciences which variously contribute to medical knowledge, it is not just an “application” of any of these, alone or in combination. Its contributions to medical knowledge are made within the context of patient care (the term “clinical medicine” is used here to emphasize this matter). It is distinct from other sciences in its domain of inquiry and its approach to this (...) domain, studying relationships between events and processes of many kinds and levels as they occur in the human organism. To the fullest extent possible (and to an extent not possible elsewhere) these relationships are investigated as they occur within the living organism. Arguments providing logical justification for this approach have been offered. The practical justification of its approach, and of clinical medicine itself, rests in its accomplishments. Various possible objections to the scientific status of clinical medicine have been discussed and found lacking in force. I have no doubt that there might be other objections. However, these would also, I believe, be found on examination to result from too restrictive definitions of “science,” unacceptable in their exclusion also of other recognized sciences, or from lack of familiarity with modern clinical medicine. (shrink)

The traditional medical epistemology, resting on a biomedical paradigmatic monopoly, fails to display an adequate representation of medical knowledge. Clinical knowledge, including the complexities of human interaction, is not available for inquiry by means of biomedical approaches, and consequently is denied legitimacy within a scientific context. A gap results between medical research and clinical practice. Theories of knowledge, especially the concept of tacit knowing, seem suitable for description and discussion of clinical knowledge, commonly denoted the art of medicine. A metaposition (...) allows for inquiry of clinical knowledge, inviting an expansion of the traditional medical epistemology, provided that relevant criteria for scientific knowledge within this field are developed and applied. The consequences of such approaches are discussed. (shrink)

The concept of skill is a neglected resource in the philosophy of medicine. Despite its near ubiquitous presence in discussions of medicine , skill has traditionally been passed over as a conceptual tool by those with a philosophical interest in medicine . It is argued that the philosophy of medicine, including its more applied areas , could benefit from a more developed philosophical concept of skill. ;I begin with a preliminary investigation into the nature of the concept of skill. Taking (...) Hubert Dreyfus's uses of skill as a point of departure, I tease apart two different senses of skill---an ontological sense and an epistemological sense. This is followed by a critique of current appeals to skill in one area of the philosophy of medicine . Skill is commonly used to explain three features of diagnostic expertise: its quantity, arationality, and immediacy. The appeals to skill---as a facility in dealing with contents of the mind, as an ability to make subconscious inference, or as a perceptual capacity for gaining foundationalist knowledge---are shown to be problematic. A cognitivist theory of the mind is suggested to be at the root of these appeals. An alternative framework for understanding skills and expertise is explored. Adapting Dreyfus's phenomenology of expertise to medicine, three classes of skills are identified and sketched: perceptual skill, preparative skill, and reparative skill. One of these skills is singled out for further development. It is argued that there is a tradition in philosophy that conceives of perception in skill-like terms and which finds medicine particularly useful for elucidating a notion of perceptual skill. Finally, the concept of skill under development is brought to a current debate within the philosophy of medicine: the internalist versus externalist debate. After reviewing some of the history of this debate, it is suggested that internalism could benefit from a more developed concept of skill. (shrink)

Book reviewed in this article: Talking with Patients. By Eric J. Cassell.

This article tries to present a broad view on the values and ethicalissues that are at stake in efforts to rationalize health policy on thebasis of economic evaluations (like cost-effectiveness analysis) andrandomly controlled clinical trials. Though such a rationalization isgenerally seen as an objective and `value free' process, moral valuesoften play a hidden role, not only in the production of `evidence', butalso in the way this evidence is used in policy making. For example, thedefinition of effectiveness of medical treatment or (...) health care serviceis heavily dependent on dominant individual or social views about thegoals of the particular treatment or service. There is also a concernthat a reliance on EBM in health policy will occur at the expense ofwidely shared social values like equity and solidarity. Moreover, thereis a concern that when economic considerations and rational proceduresbecome more influential, various `outside' groups third parties likeinsurance companies and policy makers will get a stronger influence onmedical practice which may lead to a change in the patient-providerrelationship. The authors conclude that social values and patientpreference should be explicitly addressed when health policy making isbased on economic and other scientific evidence. (shrink)