"First Published in 1992, Routledge is an imprint of Taylor & Francis, an informa company.".

Feminist epistemology and philosophy of science studies the ways in which gender does and ought to influence our conceptions of knowledge, the knowing subject, and practices of inquiry and justification. It identifies ways in which dominant conceptions and practices of knowledge attribution, acquisition, and justification systematically disadvantage women and other subordinated groups, and strives to reform these conceptions and practices so that they serve the interests of these groups. Various practitioners of feminist epistemology and philosophy of science argue that dominant (...) knowledge practices disadvantage women by (1) excluding them from inquiry, (2) denying them epistemic authority, (3) denigrating their “feminine” cognitive styles and modes of knowledge, (4) producing theories of women that represent them as inferior, deviant, or significant only in the ways they serve male interests, (5) producing theories of social phenomena that render women's activities and interests, or gendered power relations, invisible, and (6) producing knowledge (science and technology) that is not useful for people in subordinate positions, or that reinforces gender and other social hierarchies. Feminist epistemologists trace these failures to flawed conceptions of knowledge, knowers, objectivity, and scientific methodology. They offer diverse accounts of how to overcome these failures. They also aim to (1) explain why the entry of women and feminist scholars into different academic disciplines, especially in biology and the social sciences, has generated new questions, theories, and methods, (2) show how gender has played a.. (shrink)

The arguments in this book are informed at once by the moral-political implications of how knowledge is produced and circulated and by issues of gendered subjectivity. In their critical dimension, these lucid essays engage with the incapacity of the philosophical mainstream's dominant epistemologies to offer regulative principles that guide people in the epistemic projects that figure centrally in their lives. In its constructive dimension, ____Rhetorical__ ____Spaces__ focuses on developing productive, case-by-case analyses of knowing other people in situations where social-political inequalities (...) create asymmetrical patterns of epistemic power and privilege. (shrink)

The claims of randomized controlled trials to be the gold standard rest on the fact that the ideal RCT is a deductive method: if the assumptions of the test are met, a positive result implies the appropriate causal conclusion. This is a feature that RCTs share with a variety of other methods, which thus have equal claim to being a gold standard. This article describes some of these other deductive methods and also some useful non-deductive methods, including the hypothetico-deductive method. (...) It argues that with all deductive methods, the benefit that the conclusions follow deductively in the ideal case comes with a great cost: narrowness of scope. This is an instance of the familiar trade-off between internal and external validity. RCTs have high internal validity but the formal methodology puts severe constraints on the assumptions a target population must meet to justify exporting a conclusion from the test population to the target. The article reviews one such set of assumptions to show the kind of knowledge required. The overall conclusion is that to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have or can come to obtain. There is no gold standard. (shrink)

This paper explores the relation between rational authority and social power, proceeding by way of a philosophical genealogy derived from Edward Craig's Knowledge and the State of Nature. The position advocated avoids the errors both of the 'traditionalist' (who regards the socio-political as irrelevant to epistemology) and of the 'reductivist' (who regards reason as just another form of social power). The argument is that a norm of credibility governs epistemic practice in the state of nature, which, when socially manifested, is (...) likely to imitate the structures of social power. A phenomenon of epistemic injustice is explained, and the politicizing implication for epistemology educed. (shrink)

"First Published in 1992, Routledge is an imprint of Taylor & Francis, an informa company.".

Randomized controlled trials (RCTs) are widely taken as the gold standard for establishing causal conclusions. Ideally conducted they ensure that the treatment ‘causes’ the outcome—in the experiment. But where else? This is the venerable question of external validity. I point out that the question comes in two importantly different forms: Is the specific causal conclusion warranted by the experiment true in a target situation? What will be the result of implementing the treatment there? This paper explains how the probabilistic theory (...) of causality implies that RCTs can establish causal conclusions and thereby provides an account of what exactly that causal conclusion is. Clarifying the exact form of the conclusion shows just what is necessary for it to hold in a new setting and also how much more is needed to see what the actual outcome would be there were the treatment implemented. (shrink)

: Feminist epistemologists have found the atomistic view of knowers provided by classical epistemology woefully inadequate. An obvious alternative for feminists is Lynn Hankinson Nelson's suggestion that it is communities that know. However, I argue that Nelson's view is problematic for feminists, and I offer instead a conception of knowers as "individuals-in-communities." This conception is preferable, given the premises and goals of feminist epistemologists, because it emphasizes the relations between knowers and their communities and the relevance of these relations for (...) epistemic assessments. Furthermore, it provides a sense of epistemic agents as active reflective inquirers, capable of transforming and improving knowledge-seeking practices. (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)

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)

Evidence based medicine has been a topic of considerable controversy in medical and health care circles over its short lifetime, because of the claims made by its exponents about the criteria used to assess the evidence for or against the effectiveness of medical interventions. The central epistemological debates underpinning the debates about evidence based medicine are reviewed by this paper, and some areas are suggested where further work remains to be done. In particular, further work is needed on the theory (...) of evidence and inference; causation and correlation; clinical judgment and collective knowledge; the structure of medical theory; and the nature of clinical effectiveness. (shrink)

Surgical clinical trials have seldom used a “sham” or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken, and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled trial of arthroscopic (...) surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Surgical clinical trials have seldom used a "sham" or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled trial of arthroscopic (...) surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

This paper raises questions about the epistemological foundations of evidence-based medicine . We argue that EBM is based upon reliabilist epistemological assumptions, and that this is appropriate - we should focus on identifying the most reliable processes for generating and collecting medical knowledge. However, we note that this should not be reduced to narrow questions about which research methodologies are the best for gathering evidence. Reliable processes for generating medical evidence might lie outside of formal research methods. We also question (...) the notion of the knower that is assumed by EBM. We argue that EBM assumes an enlightenment conception of knowers as autonomous, substitutable individuals. This conception is troubled by the way that clinicians learn the role of anecdote in health care and the role of patient choice, all of which bring into play features of clinicians and patients as situated individuals with particular backgrounds and experiences. EBM's enlightenment conception of the knower is also troubled by aspects of the way evidence is produced. Given these limitations, we argue that EBM should retain its reliabilist bent, but should look beyond formal research methodologies in identifying processes that yield reliable evidence for clinical practice. We suggest looking to feminist epistemology, with its focus on the standpoints of individual situated knowers, and the role of social context in determining what counts as knowledge. (shrink)

This paper focuses on invasive therapeutic procedures, defined as procedures requiring the introduction of hands, instruments, or devices into the body via incisions or punctures of the skin or mucous membranes performed with the intent of changing the natural history of a human disease or condition for the better. Ethical and methodological concerns have been expressed about studies designed to evaluate the effects of invasive therapeutic procedures. Can such studies meet the same standards demanded of those, for example, evaluating pharmaceutical (...) agents? This paper describes a research project aimed at examining the interplay and sometimes apparent conflict between ethical standards for human research and standards for methodological rigor in trials of invasive procedures. The paper discusses how the authors plan to develop a set of consensus standards that, if met, would result in substantial and much-needed improvements in the methodological and ethical quality of such trials. (shrink)

Traditionally, surgical practice has been experiential and based on the contemporary understanding of basic mechanisms of disease. It was both a science and an art and depended to far too great an extent on the individualism and self belief of its main exponents. “Evidence based medicine” emerged in the 1980s and a new gospel of “Rules of Evidence” was introduced. There is no doubt that the net effect of EBM has been beneficial, but over reliance on randomised controlled trials and (...) the lack of generalisability of scientific evidence to individual patients has perhaps led to less enthusiasm for its tenets among surgeons. There are valid and spurious reasons for this that are discussed. The situation is improving but inevitable tensions remain between the surgeon committed to the individual patient here and now, and the clinical researcher whose focus is the benefit of future patients in the larger community. (shrink)

Medicine maintains a distinction between the medical symptom -- the patient''ssubjective experience and expression, and the privileged medical sign -- the objective findings observable by the doctor. Although the distinction is not consistently applied, it becomes clearly visible in the undefined, medically unexplained disorders of women patients. Potential impacts of genderized interaction on the interpretation of medical signs are addressed by re-reading the diagnostic process as a matter of social construction, where diagnosis results from human interpretation within a sociopolitical context. (...) The discussion is illustrated by a case story and empirical evidence of the gendering in the doctor-patient relationship. The theoretical analysis is supported by semiotic perspectives of bodily signs, feminist theory on experience, and Foucault''sideas about medical perception and gaze, and concludes that a medical diagnosis is seldom a biological fact, but the outcome of a process where biological, cultural and social elements are interwoven. Further deconstruction of the chain of signs from a feminist perspective, assigning validity to the voice of the woman patient, might broaden the understanding of women''shealth, illness and disease. (shrink)