The concept of the art of healing is intrinsically connected with the idea of healing powers. There are at least three possible approaches to that idea and all of them have different implications for the problem of medical wisdom. These are: the idea of the healing powers of nature, the idea of the healing powers of science, and the idea of the healing powers of physician's personality. Having critically discussed those ideas I sketch an ideal of a wise physician as (...) someone who has a particular kind of knowledge, good judgement, and self-trust. Medical knowledge is certainly a necessary condition of being a wise doctor but it is not the sufficient one. And this is why patients generally prefer to seek help of “naturally wise physicians”. (shrink)

The question of whether old age should or should not play a role in medical decision-making for the elderly patient is regularly debated in ethics and medicine. In this paper we investigate exactly how age influences the decision-making process. To explore the normative argumentation in the decisions regarding an elderly patient we make use of the argumentation model advanced by Toulmin. By expanding the model in order to identify normative components in the argumentation process it is possible to analyse the (...) way that age-related value judgements influence the medical decision-making process. We apply the model to practice descriptions made by medical students after they had attended consultations and meetings in medical practice during their clinical training. Our results show the pervasive character of age-related value judgements. They influence the physician’s decision in several ways and at several points in the decision-making process. Such explicit value judgements were not exclusively used for arguments against further diagnosis or treatment of older patients. We found no systematic “ageist” pattern in the clinical decisions by physicians. Since age plays such an important, yet hidden role in the medical decision-making process, we make a plea for revealing such normative argumentation in order to gain transparency and accountability in this process. An explicit deliberative approach will make the medical decision-making process more transparent and improve the physician–patient relationship, creating confidence and trust, which are at the heart of medical practice. (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)

The article defines a comprehensive concept of cognitive objectivity applied to embodied subjects in health care. The aims of this study were: to specify some necessary conditions for the definition of a CCCO that will allow objective descriptions and assessments in health care, to formulate criteria for application of such a CCCO, and to investigate the usefulness of the criteria in work disability assessments in medical certificates from health care provided for social security purposes. The study design was based on (...) a philosophical conceptual analysis of objectivity and subjectivity, the phenomenological notions ‘embodied subject’, ‘life-world’, ‘phenomenological object’ and ‘empathy’, and an interpretation of certificates as texts. The study material consisted of 18 disability assessments from a total collection of 86 medical certificates provided for social security purposes, written in a Norwegian hospital-based mental health clinic. Four necessary conditions identified for defining a CCCO were: acknowledging the patient’s social context and life-world, perceiving patients as cognitive objects providing a variety of meaningful data, interpreting data in context, and using general epistemological principles. The criteria corresponding to these conditions were: describing the patient’s social context and recognizing the patient’s perspective, taking into consideration a variety of quantitative and qualitative data drawn from the clinician’s perceptions of the patient as embodied subject, being aware of the need to interpret the data in context, and applying epistemological principles. Genuine communication is presupposed. These criteria were tested in the work disability assessments of medical certificates. The criteria were useful for understanding both how objectivity fails during work disability assessments and how it can be improved in the writing of certificates. The article specifies four necessary conditions for the definition of a CCCO in health care and social security medicine and the corresponding criteria for its application. Analysis of the objectivity of work disability assessments in medical certificates for social security confirmed the usefulness of the criteria. (shrink)

The main purpose of this article is to present the methodological characteristics of a diagnostic process. A proposal is put forward to treat that process as a specific type of a research investigation. The research investigation can be represented in the notional systems of various concepts of the question logic. In this article I attempt to formulate a preliminary notional description of the diagnostic process with the use of terms being questions. Adopting this perspective of deliberations, I maintain that during (...) a diagnostic process a doctor employs a specific type of reasoning, where questions constitute lingual formulations of diagnostic problems. The article describes the structure of a diagnostic question which is used to incorporate diagnostic problems. I provide arguments for a thesis that such questions are meant to correlate information obtained on a patient’s condition. Pointing at various aspects of temporality of a diagnostic process, I intend to present its preliminary characteristics in terms of a research investigation. My deliberations are based on exemplifications in the area of medical diagnostics, mainly in cardiology. (shrink)

The present paper deals with the problem of evaluating empirical evidence for therapeutic decisions in medicine. The article discusses the views of Nancy Cartwright and John Worrall on the function that randomization plays in ascertaining causal relations with reference to the therapies applied. The main purpose of the paper is to present a general idea of alternative method of evaluating empirical evidence. The method builds on data analysis that makes use of rough set theory. The first attempts to apply the (...) method show that it is an interesting alternative to randomized controlled trials. (shrink)

This paper presents and evaluates a methodological approach aiming at analysing some of the complex interaction between patients and different health care practitioners working together in teams. Qualitative health care research describes the values, perceptions and conceptions of patients and practitioners. In modern clinical work patients and professional practitioners often work together on complex cases involving different kinds of knowledge and values, each of them representing different perspectives. We need studies designed to capture this complexity. The methodological approach presented here (...) is exemplified with a study in rehabilitation medicine. In this part of the health care system the clinical work is organized in multi-professional clinical teams including patients, handling complex rehabilitation processes. In the presented approach data are collected in individual in-depth interviews to have thorough descriptions of each individual perspective. The interaction in the teams is analysed by comparing different descriptions of the same situations from the involved individuals. We may then discuss how these perceptions relate to each other and how the individuals in the team interact. Two examples from an empirical study are presented and discussed, illustrating how communication, differences in evaluations and the interpretation of incidents, arguments, emotions and interpersonal relations may be discussed. It is argued that this approach may give information which can supplement the methods commonly applied in qualitative health care research today. (shrink)

Clinical diagnostic medicine is an experimental science based on observation, hypothesis making, and testing. It is an use dynamic process that involves observation and summary, diagnostic conjectures, testing, review, observation and summary, new or revised conjectures, i.e. it is an iterative process. It can then be said that diagnostic hypotheses are also ‘observation-laden’. My aim is to enlarge on the strategies of medical diagnosis as these are meshed in training and clinical experience—that is, to describe the patterns of reasoning used (...) by experienced clinicians under different diagnostic circumstances and how these patterns of inquiry allow further insight into the evaluation and treatment of patients. I do not aim to present a theory and illustrate it with examples; I wish rather am to let a realistic example, similar to actual clinical scenarios, direct the exposition. To this end, I introduce an account of medical diagnosis—briefly comparing and contrasting it to other accounts—in order to focus on discussing the process of diagnosis through a detailed clinical case. (shrink)

The measurement of diagnostic accuracy is an important aspect of the evaluation of diagnostic tests. Sometimes, medical researchers try to discover the set of observations that are most accurate of all by directly inspecting diseased and not-diseased patients. This method is perhaps intuitively appealing, as it seems a straightforward empirical way of discovering how to identify diseased patients, which amounts to trying to correlate the results of diagnostic tests with disease status. I present three examples of researchers who try to (...) produce definitive diagnostic criteria by directly inspecting diseased and not diseased patients. Despite this method’s intuitive appeal, I will argue that it is impossible to carry out. Before researchers can inspect these patients to discover definitive diagnostic criteria, they must be able to distinguish diseased and not-diseased patients; and they do not know how to do this, because this is what they are trying to discover. I suspect the intuitive appeal of directly inspecting patients makes this difficult to appreciate. To counter this difficulty, I present this problem as a manifestation of ‘Meno’s paradox’, which was described in classical antiquity, and of ‘the problem of nomic measurement’, described more recently. Considering these philosophical problems may help researchers address the methodological issues they face when evaluating diagnostic tests. (shrink)