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.

For the last forty years, two claims have been at the core of disputes about scientific change: that scientists reason rationally and that science is progressive. For most of this time discussions were polarized between philosophers, who defended traditional Enlightenment ideas about rationality and progress, and sociologists, who espoused relativism and constructivism. Recently, creative new ideas going beyond the polarized positions have come from the history of science, feminist criticism of science, psychology of science, and anthropology of science. Addressing the (...) traditional arguments as well as building on these new ideas, Miriam Solomon constructs a new epistemology of science. After discussions of the nature of empirical success and its relation to truth, Solomon offers a new, social account of scientific rationality. She shows that the pursuit of empirical success and truth can be consistent with both dissent and consensus, and that the distinction between dissent and consensus is of little epistemic significance. In building this social epistemology of science, she shows that scientific communities are not merely the locus of distributed expert knowledge and a resource for criticism but also the site of distributed decision making. Throughout, she illustrates her ideas with case studies from late-nineteenth- and twentieth-century physical and life sciences. Replacing the traditional focus on methods and heuristics to be applied by individual scientists, Solomon emphasizes science funding, administration, and policy. One of her goals is to have a positive influence on scientific decision making through practical social recommendations. (shrink)

A new, social epistemology of science that addresses practical as well as theoretical concerns.

Trust in the practice of rational deliberation is widespread and largely unquestioned. This paper uses recent work from business contexts to challenge the view that rational deliberation in a group improves decisions. Pressure to reach consensus can, in fact, lead to phenomena such as groupthink and to suppression of relevant data. Aggregation of individual decisions, rather than deliberation to a consensus, surprisingly, can produce better decisions than those of either group deliberation or individual expert judgment. I argue that dissent is (...) epistemically valuable, not because of the discussion it can provoke (Mill's and Longino's view about the benefit of dissent), but because dissenting positions often are associated with particular data or insights that would be lost in consensus formation. Social epistemologists can usefully pay attention to various methods of aggregation of individual opinion for their effectiveness at realizing epistemic goals. (shrink)

_The_ _Routledge Companion to Philosophy of Medicine _is a comprehensive guide to topics in the fields of epistemology and metaphysics of medicine. It examines traditional topics such as the concept of disease, causality in medicine, the epistemology of the randomized controlled trial, the biopsychosocial model, explanation, clinical judgment and phenomenology of medicine and emerging topics, such as philosophy of epidemiology, measuring harms, the concept of disability, nursing perspectives, race and gender, the metaphysics of Chinese medicine, and narrative medicine. Each of (...) the 48 chapters is written especially for this volume and with a student audience in mind. For pedagogy and clarity, each chapter contains an extended example illustrating the ideas discussed. This text is intended for use as a reference for students in courses in philosophy of medicine and philosophy of science, and pairs well with _The_ _Routledge Companion to Bioethics_ for use in medical humanities and social science courses. (shrink)

The work of Tversky, Kahneman and others suggests that people often make use of cognitive heuristics such as availability, salience and representativeness in their reasoning and decision making. Through use of a historical example--the recent plate tectonics revolution in geology--I argue that such heuristics play a crucial role in scientific decision making also. I suggest how these heuristics are to be considered, along with noncognitive factors (such as motivation and social structures) when drawing historical and epistemological conclusions. The normative perspective (...) is community-wide, contextual, and instrumental. (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)

Epistemic diversity is widely approved of by social epistemologists. This paper asks, more specifi cally, how much epistemic diversity, and what kinds of epistemic diversity are normatively appropriate? Both laissez-faire and highly directive approaches to epistemic diversity are rejected in favor of the claim that diversity is a blunt epistemic tool. There are typically a number of diff erent options for adequate diversifi cation. The paper focuses on scientifi c domains, with particular attention to recent theories of smell.

: A familiar criticism of bioethics charges it with being more conceptual than practical—having little application to the "real world." In order to answer its critics and keep its feet on the ground, bioethics must utilize the social sciences more effectively. Empirical research can provide the bridge between conceiving a moral vision of a better world, and actually enacting it.

The concept of a “validator” as a unit of evidence for the validity of a psychiatric category has been important for more than fifty years. Validator evidence is aggregated by expert committees (for the Diagnostic and Statistical Manual of Mental Disorders (DSM), these are referred to as “workgroups”), which use the results to make nosological decisions. Through an examination of the recent history of psychiatric research, this paper argues that it is time to reassess this traditional practice. It concludes with (...) specific suggestions for going forward. (shrink)

This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to (...) maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades. (shrink)

Across the world, an authoritarian and exclusionary form of populism is gaining political traction. Historically, some populist movements have been democratic and based on a sense of inclusive justice and the common good. But the populism on the rise at present speaks and acts otherwise. It is challenging constitutional democracies. The polarization seen in authoritarian populism goes beyond the familiar left-right political spectrum and generates disturbing forms of extremism, including the so-called alternative right in the United States and similar ethnic (...) and nationalistic political movements in other countries. The field of bioethics will be profoundly affected if authoritarian populism displaces constitutional democracy. But the field has a significant contribution to make to rebuilding the communal and civic foundations upon which constitutional democracy rests. (shrink)

Epistemic diversity is widely approved of by social epistemologists. This paper asks, more specifically, how much epistemic diversity, and what kinds of epistemic diversity are normatively appropriate? Bothlaissez-faireand highly directive approaches to epistemic diversity are rejected in favor of the claim that diversity is a blunt epistemic tool. There are typically a number of different options for adequate diversification. The paper focuses on scientific domains, with particular attention to recent theories of smell.

This essay summarizes key insights across the essays in the Hastings Center Report's special report “Time to Rebuild: Essays on Trust in Health Care and Science.” These insights concern trust and trustworthiness as distinct concepts, competence as a necessary but not sufficient input to trust, trust as a reciprocal good, trust as an interpersonal as well as structural phenomena, the ethical impermissibility of seeking to win trust without being trustworthy, building and borrowing trust as distinct strategies, and challenges to trustworthiness (...) posed by the contingent nature of science. Together, these insights stand to advance an area of research that we believe has been historically stymied by conceptual confusion and a long‐standing insistence on treating trust as a purely instrumental good. (shrink)

General science literacy contributes to good public decision‐making about technology and medicine. This essay explores the kinds of science literacy currently developed by public education in the United States of America. It argues that current curricula on “science as inquiry” (formerly the “nature of science”) need to be brought up to date with the inclusion of discussion of social epistemological concepts such as trust and scientific authority, scientific disagreement versus science denialism, the role of ideology and bias in scientific research, (...) and the importance of peer review and responsiveness to criticism. (shrink)

A familiar criticism of bioethics charges it with being more conceptual than practical—having little application to the “real world.” In order to answer its critics and keep its feet on the ground, bioethics must utilize the social sciences more effectively. Empirical research can provide the bridge between conceiving a moral vision of a better world, and actually enacting it.

This is an excellent book. It is written at the intersection of philosophy of medicine, social epistemology, science and technology studies, and public policy. It conceptualizes the phenomenon of vaccine hesitancy as an understandable attitude that, when sizeable enough, causes vaccine refusal. Its focus is on pre-COVID-19 vaccine hesitancy and primarily on parental decisions about childhood vaccinations. Its publication, one year into the COVID-19 pandemic, comes at a fortuitous time because it can help us view our urgent concerns about the (...) sorry state of vaccine uptake in the industrialized North in a broader context. It is an optimistic book with faith in the reasonableness of human beings, sympathy for the... (shrink)

“There's glory for you!”“I don't know what you mean by ‘glory,’ ” Alice said.Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”“The question is,” said Alice, “whether you can make words mean so many different things.”“The question is,” said (...) Humpty Dumpty, “which is to be master, that's all.”When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn? (shrink)

Social scientists regularly make use of multivariate models to describe complex social phenomena. It is argued that this approach is useful for modelling the variety of cognitive and social factors contributing to scientific change, and superior to the integrated models of scientific change currently available. It is also argued that care needs to be taken in drawing normative conclusions: cognitive factors are not instrinsically more "rational" than social factors, nor is it likely that social factors, by some "invisible hand of (...) reason," generally work to produce scientific success. A multivariate model of the biasing factors within a scientific community at particular times is developed. This model, which is an example of work in social epistemology, yields normative conclusions. (shrink)

“There's glory for you!”“I don't know what you mean by ‘glory,’ ” Alice said.Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”“The question is,” said Alice, “whether you can make words mean so many different things.”“The question is,” said (...) Humpty Dumpty, “which is to be master, that's all.”When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn? (shrink)

The Institute of Medicine has called on health care leaders to transform their health systems into “learning health care systems,” capable of studying and continuously improving their practices. Learning health care systems commit to carrying out numerous kinds of investigations, ranging from clinical effectiveness studies to quality improvement research and implementation science. There has been progress in realizing the IOM's vision, but also many challenges. One of these challenges has been lingering uncertainty about whether the data collection and monitoring central (...) to learning health care systems is actually research and if so, what kind of ethical oversight it should have. This is not a new question. Yet so far, there has been no foundational analysis of the fit between the existing human subjects protection framework in use in the United States and the new kinds of data collection activities that are being, and increasingly will be, undertaken by learning health care systems. Two companion feature articles in this volume, by a team at Johns Hopkins, fill this void. (shrink)

This paper advances a new paradigm in clinical ethics education that not only emphasizes development of individual cli but also focuses on the institutional context within which health care professionals work. This approach has been applied to the goal of improving the care provided to critically and terminally ill adults. The model has been adopted by about thirty hospitals and nursing homes; additional institutions will soon join the program, entitled Decisions Near the End of Life. Here, we describe the history (...) and rationale for this approach, its goals, pedagogical assumptions, and design. (shrink)

Prompted by a 2019 essay by Jonathan Moreno in the Hastings Center Report, the Center's board of directors undertook a careful examination of the name of its preeiminent award, the Henry Knowles Beecher Award, which has been given to twenty‐nine individuals who have made lifetime contributions to bioethics. citing new research that revealed that Beecher's earlier experimentation on drugs had involved nonconsenting adults, Moreno urged the Center to reevaluate honoring Beecher through this award. After reviewing the relevant published evidence and (...) holding extensive discussions, the board decided to rename the award. We also took the opportunity to reframe the award to emphasize quality of scholarship and impact on thinking, practice, and policy rather than lifetime achievement. The new name—the Founders’ Award of The Hastings Center—reflects our desire to honor not only the Center's cofounders, Daniel Callahan and Willard Gaylin, but also others who helped found the field of bioethics. With great pride, the Center has announced that Patricia King of the Georgetown University Law Center is the 2021 recipient of the Founders’ Award. A distinguished civil rights lawyer, King was instrumental in ensuring justice as one of the three principles of The Belmont Report. (shrink)

This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This multiauthored report offers wide‐ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of cultural and (...) political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people. (shrink)

Civic education that prepares students for principled civic participation is vital to democracy. Schools face significant challenges, however, as they attempt to educate for democracy in a democracy in crisis. Parents, educators, and policy‐makers disagree about what America's civic future should look like, and hence about what schools should teach. Likewise, hyperpartisanship, mutual mistrust, and the breakdown of democratic norms are perverting the kinds of civic relationships and values that schools want to model and achieve. Nonetheless, there is strong evidence (...) that young people want to be civically engaged and are hungry for more and better civic learning opportunities. Reviving the civic mission of schools is thus a win‐win‐win. Adults want it, youth want it, and democracy needs it. We propose three means by which educators and the public can reconstruct our common purpose and achieve civic innovation to help democracy in crisis: support action civics, strengthen youth leadership outside the classroom, and engage both students and adults with “hard history” and contemporary controversies. (shrink)

Quine claims to be "working from within" our conceptual scheme and proceeding scientifically. This description makes his views of interest to those who are skeptical of traditional metaphysical projects and to those with confidence in science. This study examines whether Quine is in fact starting within ordinary language and proceeding scientifically and, if not, how his views are to be best understood. I proceed by exploring some central doctrines in Quine's writing, most notably indeterminacy of translation, but also his views (...) on underdetermination of scientific theory, truth, reality and the dispensability of theory, and the nature of scientific method. In examining Quine's arguments for these doctrines, I find that they do not all issue from what we would ordinarily or scientifically say on the topics concerned. Instead, I find that most arise from an underlying view of the nature of language and knowledge, which I call natural empiricism. I argue that natural empiricism involves assumptions and dynamics of reasoning characteristic of metaphysical points of view, rather than of an ordinary or scientific stance. This is a result with consequences for a critical evaluation of Quine's views. ;I show that natural empiricism leads not only to the central doctrines in Quine's writing that I examine, but also to his general claim to be "working from within" our conceptual scheme and proceeding scientifically. I argue that there is a tension between natural empiricism and "working from within" that is the major tension in Quine's views, leading him to reach different conclusions on the same topic. Quine's views are unusual in that this tension is internal to natural empiricism; most metaphysical views, while they may conflict with the ordinary, do not also endorse it. Natural empiricism is also an unusual point of view in its thoroughgoing empiricism: I claim that it is an empiricist overreaction to the vestiges of rationalism in twentieth century logical empiricism. It shares with the views to which it reacts the need to ground language and knowledge, in a metaphysical sense. Thus Quine's position is particularly valuable for showing up the differences and common motivations in the analytic tradition. (shrink)

Two papers in this issue address the limits of surrogates’ authority when making life-and-death decisions for dying family members or friends. Using palliative sedation as an example, Jeffrey Berger offers a conceptual argument for bounding surrogate authority. Since freedom from pain is an essential interest, when imminently dying, cognitively incapacitated patients are in duress and their symptoms are not manageable in any other way, clinicians should be free to offer palliative sedation without surrogate consent, although assent should be sought and (...) every effort made to work with surrogates as harmoniously as possible. Ellen Robinson and her colleagues report on the implementation of a policy at Massachusetts General Hospital that supports do-not-resuscitate orders when cardiopulmonary resuscitation is likely to be ineffective or harmful, even if surrogates disagree. The “Doing No Harm” policy at MGH allows for what MGH calls a “medically indicated DNR” and what in some other places is called “a unilateral DNR”—the writing of an order not to provide cardiopulmonary resuscitation, regardless of surrogate disapproval. These kinds of DNR policies have emerged in some hospitals across the country and for much the same reason that Berger provides in his argument regarding palliative sedation. I support the reasoning and the policies in both the Berger and Robinson papers. However, as the authors would most likely agree, the problems they aim to remedy are not simply about the scope of surrogate and professional authority. They are also symptoms of inattention to professional obligations and system failures. (shrink)

As we write, U.S. cities and states with extensive community transmission of Covid‐19 are in harm's way—not only because of the disease itself but also because of prior and current failures to act. During the 2009 influenza pandemic, public health agencies and hospitals developed but never adequately implemented preparedness plans. Focused on efficiency in a competitive market, health systems had few incentives to maintain stockpiles of essential medical equipment. Just‐in‐time economic models resulted in storage of only those supplies needed then. (...) At the same time, global purchasing in search of lower prices reduced the number of U.S. suppliers, with hospitals dependent on foreign companies. There is still a possibility that the pandemic will be manageably bad rather than unmanageably catastrophic in this country. Immediate, powerful, and sustained federal action could make the difference. (shrink)

Philip Kitcher's The Advancement of Science sets out, programmatically, a new naturalistic view of science as a process of building consensus practices. Detailed historical case studies—centrally, the Darwinian revolutio—are intended to support this view. I argue that Kitcher's expositions in fact support a more conservative view, that I dub ‘Legend Naturalism’. Using four historical examples which increasingly challenge Kitcher's discussions, I show that neither Legend Naturalism, nor the less conservative programmatic view, gives an adequate account of scientific progress. I argue (...) for a naturalism that is more informed by psychology and a normative account that is both more social and less realist than the views articulated in The Advancement of Science. (shrink)

This article examines some current U.S. policies regarding the ethics of information control in scientific research, such as the requirements for “timely” publication and information sufficient for replication. The appropriateness of these policies is called into question by recent work in science studies, which suggest the importance of informal and nonlinguistic channels of information and the impossibility of exact replication of experiments. Policy change is recommended, but it needs to take into account considerations of privacy and enforceability.

The ethical dimensions of an aging society are larger than the experience of chronic illness, the moral concerns of health care professionals, or the allocation of health care resources. What, then, is the role of bioethics in an aging society, beyond calling attention to these problems? Once we’ve agreed that aging is morally important and that population‐level aging across wealthy nations raises ethical concerns that cannot be fixed through transhumanism or other appeals to transcend aging and mortality through technology, what (...) is our field’s contribution? We argue that it is time for bioethics to turn toward social justice and problems of injustice and that part of doing so is articulating a concept of good citizenship in an aging society that goes beyond health care relationships. (shrink)

A belief that high school students have the cognitive ability to analyze and assess moral choices and should be encouraged to do so but have rarely been helped to do so was the motivation for developing Exploring Bioethics, a six-module curriculum and teacher guide for grades nine through twelve on ethical issues in the life sciences. A multidisciplinary team of bioethicists, science educators, curriculum designers, scientists, and high school biology teachers worked together on the curriculum under a contract between the (...) National Institutes of Health and Education Development Center, a nonprofit research and development organization with a long history of innovation in science education. At the NIH, the Department of Bioethics within the Clinical Center and the Office of Science Education within the Office of the Director guided the project.Our overarching goal for Exploring Bioethics was to introduce students to bioethics as a field of inquiry and to enable them to develop ethical reasoning skills so they could move beyond “gut reactions” to more nuanced positions. (shrink)

In this paper we interpret a characterization of the Gödel speed-up phenomenon as providing support for the ‘Nagel-Newman thesis’ that human theorem recognizers differ from mechanical theorem recognizers in that the former do not seem to be limited by Gödel's incompleteness theorems whereas the latter do seem to be thus limited. However, we also maintain that (currently non-existent) programs which are open systems in that they continuously interact with, and are thus inseparable from, their environment, are not covered by the (...) above (or probably any other recursion-theoretic) argument. (shrink)

Because the idea of consensus in contemporary philosophy of science is typically seen as the locus of progress, rationality, and, often, truth, Mill’s views on the undesirability of consensus have been largely dismissed. The historical data, however, shows that there are many examples of scientific progress without consensus, thus refuting the notion that consensus in science has any special epistemic status for rationality, scientific progress (success), or truth. What needs to be developed instead is an epistemology of dissent. I suggest (...) that normative accounts of dissent be used as prototypes for theories of scientific rationality that can also be applied to episodes of consensus. Consensus in this case is to be treated as a special case of dissent, when the amount of dissent approaches zero. My main goal in this paper is to sketch how a normative account of dissent that aims to capture the idea of epistemic fairness can apply to situations of consensus. (shrink)