Intuition in medical and moral reasoning -- Moral intuitionism -- The place of Aristotelian phronesis in clinical reasoning -- Aristotle's practical syllogism: accounting for the individual through a theory of action and cognition -- Individual and statistical physiognomy: the art and science of making the invisible visible -- Clinical intuition versus statistical reasoning -- Contingency and correlation: the significance of modeling clinical reasoning on statistics -- Abduction: the intuitive support of clinical induction -- Conclusion: medical ethics beyond ontology.

The anthropological approach is the central focus of this study. Laboratories are looked upon with the innocent eye of the traveller in exotic lands, and the societies found in these places are observed with the objective yet compassionate eye of the visitor from a quite other cultural milieu. There are many surprises that await us if we enter a laboratory in this frame of mind... This study is a realistic enterprise, an attempt to truly represent the social order of life (...) in laboratories and institutes of research, just as they are. By bringing the philosophical issues to the surface as matters not of prejudgement but as matters of concern, Karin Knorr-Cetina has developed the first really positive challenge to the philosophy of science since the days of paradigms and internal definitions of meanings. (shrink)

How Doctors Think defines the nature and importance of clinical judgment. Although physicians make use of science, this book argues that medicine is not itself a science but rather an interpretive practice that relies on clinical reasoning. A physician looks at the patient's history along with the presenting physical signs and symptoms and juxtaposes these with clinical experience and empirical studies to construct a tentative account of the illness. How Doctors Think is divided into four parts. Part one introduces the (...) concept of medicine as a practice rather than a science; part two discusses the idea of causation; part three delves into the process of forming clinical judgment; and part four considers clinical judgment within the uncertain nature of medicine itself. In How Doctors Think, Montgomery contends that assuming medicine is strictly a science can have adverse side effects, and suggests reducing these by recognizing the vital role of clinical judgment. (shrink)

This classic remains one of Karl Popper's most wide-ranging and popular works, notable not only for its acute insight into the way scientific knowledge grows, but also for applying those insights to politics and to history.

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)

Helen Longino seeks to break the current deadlock in the ongoing wars between philosophers of science and sociologists of science--academic battles founded on disagreement about the role of social forces in constructing scientific knowledge. While many philosophers of science downplay social forces, claiming that scientific knowledge is best considered as a product of cognitive processes, sociologists tend to argue that numerous noncognitive factors influence what scientists learn, how they package it, and how readily it is accepted. Underlying this disagreement, however, (...) is a common assumption that social forces are a source of bias and irrationality. Longino challenges this assumption, arguing that social interaction actually assists us in securing firm, rationally based knowledge. This important insight allows her to develop a durable and novel account of scientific knowledge that integrates the social and cognitive. Longino begins with a detailed discussion of a wide range of contemporary thinkers who write on scientific knowledge, clarifying the philosophical points at issue. She then critically analyzes the dichotomous understanding of the rational and the social that characterizes both sides of the science studies stalemate and the social account that she sees as necessary for an epistemology of science that includes the full spectrum of cognitive processes. Throughout, her account is responsive both to the normative uses of the term knowledge and to the social conditions in which scientific knowledge is produced. Building on ideas first advanced in her influential book Science as Social Knowledge, Longino brings her account into dialogue with current work in social epistemology and science studies and shows how her critical social approach can help solve a variety of stubborn problems. While the book focuses on epistemological concerns related to the sociality of inquiry, Longino also takes up its implications for scientific pluralism. The social approach, she concludes, best allows us to retain a meaningful concept of knowledge in the face of theoretical plurality and uncertainty. (shrink)

The way in which knowledge progresses, and especially our scientific knowledge, is by unjustified anticipations, by guesses, by tentative solutions to our problems, by conjectures. These conjectures are controlled by criticism: that is, by attempted refutations, which include severely critical tests. They may survive these tests; but they can never be positively justified: they can neither be established as certainly true nor even as 'probable'. Criticism of our conjectures is of decisive importance: by bringing out our mistakes it makes us (...) understand the difficulties of the problems which we try to solve. This is how we become better acquainted with our problem, and able to propose more mature solutions: the very refutation of a theory - that is, of a tentative solution to our problem - is always a step forward that takes us nearer the truth. And this is how we can learn from our mistakes. As we learn from our mistakes our knowledge grows, even though we may never know - that is, know for certain. Since our knowledge can grow, there can be no reason here for despair of reason. And since we can never know for certain, the can be no authority here for any claim to authority, for conceit over our knowledge, or for smugness. The essays and lectures of which this book is composed apply this thesis to many topics, ranging from problems of the philosophy and history of the physical and social sciences to historical and political problems. (shrink)

In order to arbitrate conflicting propositional knowledge claims—such as when two individuals claim to know the height of a tree in the yard—there is a “fact of the matter” about who is correct. Experiential, non-propositional knowledge, on the other hand, is not so obviously mediated. For one, experiential knowledge is—at least partially—subjective; one of its virtues is that it matters what a person’s background is, socially, etc., when determining the legitimacy of their claims. But this suggests a question: How do (...) we decide whose experience of an event is right, when two individuals differ in their accounts of a single event?In this paper I present the concept of experiential knowledge, asserting that this knowledge is frequently nonpropositional. I argue that accepting experiential knowledge is fundamental to issues of social justice, specifically when it is precisely the claims of those who have the least social or political “authority” who are in danger of having their experiences and the knowledge gained from those experiences, discounted. I address worries over the arbitration of experiential knowledge, and conclude that in cases where necessary, arbitration is both possible and often morally required. (shrink)

How is medical knowledge made? There have been radical changes in recent decades, through new methods such as consensus conferences, evidence-based medicine, translational medicine, and narrative medicine. Miriam Solomon explores their origins, aims, and epistemic strengths and weaknesses; and she offers a pluralistic approach for the future.

In this work the distinguished physical chemist and philosopher, Michael Polanyi, demonstrates that the scientist's personal participation in his knowledge, in both its discovery and its validation, is an indispensable part of science itself. Even in the exact sciences, "knowing" is an art, of which the skill of the knower, guided by his personal commitment and his passionate sense of increasing contact with reality, is a logically necessary part. In the biological and social sciences this becomes even more evident. The (...) tendency to make knowledge impersonal in our culture has split fact from value, science from humanity. Polanyi wishes to substitute for the objective, impersonal ideal of scientific detachment an alternative ideal which gives attention to the personal involvement of the knower in all acts of understanding. His book should help to restore science to its rightful place in an integrated culture, as part of the whole person's continuing endeavor to make sense of the totality of his experience. In honor of this work and his The Study of Man Polanyi was presented with the Lecomte de Noüy Award for 1959. (shrink)

The philosophy of evidence-based medicine -- What is EBM? -- What is good evidence for a clinical decision? -- Ruling out plausible rival hypotheses and confounding factors : a method -- Resolving the paradox of effectiveness : when do observational studies offer the same degree of evidential support as randomized trials? -- Questioning double blinding as a universal methodological virtue of clinical trials : resolving the Philip's paradox -- Placebo controls : problematic and misleading baseline measures of effectiveness -- Questioning (...) the methodological superiority of "placebo" over "active" controlled trials -- Examining the paradox that traditional roles for mechanistic reasoning and expert -- Judgment have been up-ended by EBM -- A qualified defence of the EBM stance on mechanistic reasoning -- Knowledge that versus knowledge how : situating the EBM position on expert clinical judgment -- Moving EBM forward. (shrink)

The evidence-based practice and evidence-based medicine movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty (...) as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh’s taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case analysis is further developed by the use of the Canadian philosopher Bernard Lonergan’s theory about understanding and objective knowing. According to Lonergan it is not by getting rid of or even by reducing uncertainty, but by attending systematically to it and by relating to it in a self-conscious way, that objective knowledge can be obtained. The paper concludes that uncertainty is not a regrettable and unavoidable aspect of decision making but a productive component of clinical reasoning. (shrink)

Hierarchies of evidence are an important and influential tool for appraising evidence in medicine. In recent years, hierarchies have been formally adopted by organizations including the Cochrane Collaboration [1], NICE [2,3], the WHO [4], the US Preventive Services Task Force [5], and the Australian NHMRC [6,7]. The development of such hierarchies has been regarded as a central part of Evidence-Based Medicine, a movement within healthcare which prioritises the use of epidemiological evidence such as that provided by Randomised Controlled Trials. Philosophical (...) work on the methodology of medicine has so far mostly focused on claims about the superiority of RCTs, and hence has largely neglected the questions of what hierarchies are, what assumptions they require, and how they affect clinical practice. This thesis shows that there is great variation in the hierarchies defended and in the interpretations they are, and can be, given. The interpretative assumptions made in using hierarchies are crucial to the content and defensibility of the underlying philosophical commitments concerning evidence and medical practice. Once this variation is been identified, it becomes clear that the little philosophical work that has been done so far affects only some hierarchies, under some interpretations. Modest interpretations offered by La Caze [11], conditional hierarchies like GRADE [12-14], and heuristic approaches such as that defended by Howick et al. [15,16] all survive previous philosophical criticism. This thesis extends previous criticisms by arguing that modest interpretations are so weak as to be unhelpful for clinical practice; that GRADE and similar conditional models omit clinically relevant information, such as information about variation in treatments’ effects and the causes of different responses to therapy; and that heuristic approaches lack the necessary empirical support. The conclusion is that hierarchies in general embed untenable philosophical assumptions: principally that information about average treatment effects backed by high-quality evidence can justify strong recommendations, and that the impact of evidence from individual studies can and should be appraised in isolation. Hierarchies are a poor basis for the application of evidence in clinical practice. The Evidence-Based Medicine movement should move beyond them and explore alternative tools for appraising the overall evidence for therapeutic claims. (shrink)

Evidence-Based Medicine is a relatively new movement that seeks to put clinical medicine on a firmer scientific footing. I take it as uncontroversial that medical practice should be based on best evidence—the interesting questions concern the details. This paper tries to move towards a coherent and unified account of best evidence in medicine, by exploring in particular the EBM position on RCTs.

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five (...) distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

Scientists obtain a great deal of the evidence they use by observingnatural and experimentally generated objects and effects. Much of thestandard philosophical literature on this subject comes from20th century logical positivists and empiricists, theirfollowers, and critics who embraced their issues and accepted some oftheir assumptions even as they objected to specific views. Theirdiscussions of observational evidence tend to focus on epistemologicalquestions about its role in theory testing. This entry follows theirlead even though observational evidence also plays important andphilosophically interesting roles (...) in other areas including scientificdiscovery and the application of scientific theories to practicalproblems. (shrink)

For evidence-based practice and policy, randomised controlled trials (RCTs) are the current gold standard. But exactly why? We know that RCTs do not, without a series of strong assumptions, warrant predictions about what happens in practice. But just what are these assumptions? I maintain that, from a philosophical stance, answers to both questions are obscured because we don't attend to what causal claims say. Causal claims entering evidence-based medicine at different points say different things and, I would suggest, failure to (...) attend to these differences makes much current guidance about evidence for medical and social policy misleading. (shrink)

Evidence-Based Medicine is a relatively new movement that seeks to put clinical med- icine on a firmer scientific footing. I take it as uncontroversial that medical practice should be based on best evidence-the interesting questions concern the details. This paper tries to move towards a coherent and unified account of best evidence in medicine, by exploring in particular the EBM position on RCTs (randomized controlled trials).

American orthodox medicine consolidated its professional authority in the early 20th Century on the basis of its unbiased scientific method. The centerpiece of such a method is a strategy for identifying truly effective new therapies, i.e., the randomized clinical trial (RCT). A crucial component of the RCT in illnesses without established treatment is the placebo control. Placebo effects must be identified and distinguished from pharmacological effects because placebos produce actual but unexplained therapeutic successes. The blinding necessary for a proper placebo-controlled (...) RCT therefore introduces an epistemic bias into orthodox medicine: therapeutic successes that rely upon a direct link between knowing and healing, such as placebo effects, are discarded in favor of therapeutic successes that rely upon an indirect link between knowing and healing, such as pharmacological interventions. Where the capacity to produce therapeutic results once validated the method of clinical medical science, now method validates results. The clinical consequences of this method of testing therapies include a diminished vision of the therapeutic potential of the doctor-patient relationship and of the potential human resources available for healing. Keywords: doctor-patient relationship, epistemology, placebo effect, professionalization, randomized clinical trials CiteULike Connotea Del.icio.us What's this? (shrink)

Background: Randomised controlled trials (RCTs) are commonly viewed as the best research method to inform public health and social policy. Usually they are thought of as providing the most rigorous evidence of a treatment’s effectiveness without strong assumptions, biases and limitations. Objective: This is the first study to examine that hypothesis by assessing the 10 most cited RCT studies worldwide. Data sources: These 10 RCT studies with the highest number of citations in any journal were identified by searching Scopus (the (...) largest database of peer-reviewed journals). Results: This study shows that these world-leading RCTs that have influenced policy produce biased results by illustrating that participants’ background traits that affect outcomes are often poorly distributed between trial groups, that the trials often neglect alternative factors contributing to their main reported outcome and, among many other issues, that the trials are often only partially blinded or unblinded. The study here also identifies a number of novel and important assumptions, biases and limitations not yet thoroughly discussed in existing studies that arise when designing, implementing and analysing trials. Conclusions: Researchers and policymakers need to become better aware of the broader set of assumptions, biases and limitations in trials. Journals need to also begin requiring researchers to outline them in their studies. We need to furthermore better use RCTs together with other research methods. (shrink)