There have recently been novel applications of medical systematic review guidelines to economic policy interventions which contain controversial methodological assumptions that require further scrutiny. A landmark 2017 Cochrane review of unconditional cash transfer (UCT) studies, based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE), exemplifies both the possibilities and limitations of applying medical systematic review guidelines to UCT and universal basic income (UBI) studies. Recognizing the need to upgrade GRADE to incorporate the differences between medical (...) and policy interventions, the GRADE Public Health Project Group (PHPG) was convened to enumerate and address these methodological challenges. However, in light of our analysis of additional methodological challenges that arise for UCT and UBI studies, we argue that the adaptation of medical systematic review guidelines to economic methodology is far from straightforward and is in fact more challenging than claimed by the PHPG. (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)

My title may suggest that I will address the activities of medical professionals as they go about their daily business of diagnosis, prescription and treatment. Certainly, that deserves attention, but it is not my target here. My concern is, on the one hand, with typical consumers of health and medical information, and, on the other, with the problems such consumers face in understanding, interpreting and applying the information available to them.

What clinicians, biomedical scientists, and other health care professionals know as individuals or as groups and how they come to know and use knowledge are central concerns of medical epistemology. Activities associated with knowledge production and use are called epistemic practices. Such practices are considered in biomedical and clinical literatures, social sciences of medicine, philosophy of science and philosophy of medicine, and also in other nonmedical literatures. A host of different kinds of knowledge claims have been identified, each (...) with different uses and logics of justification. A general framework is needed to situate these diverse contributions in medical epistemology, so we can see how they fit together. But developing such a framework turns out to be quite tricky. In this survey, three possible frameworks are considered along with the difficulties associated with each of them. The essay concludes with a fourth framework, which considers any epistemology as part of a practice that is oriented toward overcoming errors that emerge in antecedently given practices where knowledge is developed and used. As medicine indirectly advances health by directly mitigating disease, so epistemology indirectly advances knowledge by directly mitigating error. (shrink)

Although American philosophers and physicians are generally familiar with the writings of Claude Bernard (1813–1878), especially his Introduction to the Study of Experimental Medicine (1865), the medicial epistemology of Georges Canguilhem, born in 1904, is virtually unknown in English speaking nations. Although indebted to Bernard for his conception of the methods to be employed in the acquisition of medical knowledge, Canguilhem radically reformulates Bernard's concepts of ‘disease’, ‘health’, ‘illness’, and ‘pathology’. Contemporary exhortations to medical professionals and (...) class='Hi'>medical students that they “pay more attention to the whole patient” take on significance in working through the writings of Canguilhem; of crucial importance is the relation that obtains between a patient's unique symptomatology and the proper drug regiment that is required. (shrink)

Clinical trials play a prominent role today in medicine, but are not without controversy. These issues start from the day physicians begin their specialization process in medical school and continues onto their day-to-day practice as attendings with referral patterns and resulting financial incentives. This combined with the lack of training in basic issues of epistemology and statistics, allows poor interpretations of clinical trials to reign free. A proposal to integrate the notion of severity to help remedy these issues (...) are made by ensuring that studies are tested “As Severe As Reasonably Possible” will put P-values, multiplicity adjustments, and model checking in their rightful place. In light of this, multiple clinical trials are examined with an in-depth analysis of erroneous statistical inferences taken from phase III randomized trials, non-inferiority, early phase, as well as observational studies. Severe testing in the setting of medicine will help with alleviate some of the issues with the current misinterpretation of clinical studies. (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 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)

In this paper, we discuss epistemic and ethical concerns brought about by machine learning (ML) systems implemented in medicine. We begin by fleshing out the logic underlying a common approach in the specialized literature (which we call the _informativeness account_). We maintain that the informativeness account limits its analysis to the impact of epistemological issues on ethical concerns without assessing the bearings that ethical features have on the epistemological evaluation of ML systems. We argue that according to this methodological approach, (...) epistemological issues are _instrumental_ to and _autonomous_ of ethical considerations. This means that the informativeness account considers epistemological evaluation uninfluenced and unregulated by an ethical counterpart. Using an example that does not square well into the _informativeness account_, we argue for ethical assessments that have a substantial influence on the epistemological assessment of ML and that such influence should not be understood as merely informative but rather regulatory. Drawing on the case analyzed, we claim that within the theoretical framework of the informativeness approach, forms of epistemic injustice—especially _epistemic objectification_—remain unaddressed. Our analysis should motivate further research investigating the regulatory role that ethical elements play in the epistemology of ML. (shrink)

The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue (...) that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skilful conduct of clinical decision making. (shrink)

Medical terminology collects and organizes the many different kinds of terms employed in the biomedical domain both by practitioners and also in the course of biomedical research. In addition to serving as labels for biomedical classes, these names reflect the organizational principles of biomedical vocabularies and ontologies. Some names represent invariant features (classes, universals) of biomedical reality (i.e., they are a matter for ontology). Other names, however, convey also how this reality is perceived, measured, and understood by health professionals (...) (i.e., they belong to the domain of epistemology). We analyze terms from several biomedical vocabularies in order to throw light on the interactions between ontological and epistemological components of these terminologies. We identify four cases: 1) terms containing classification criteria, 2) terms reflecting detectability, modality, uncertainty, and vagueness, 3) terms created in order to obtain a complete partition of a given domain, and 4) terms reflecting mere fiat boundaries. We show that epistemology-loaded terms are pervasive in biomedical vocabularies, that the “classes” they name often do not comply with sound classification principles, and that they are therefore likely to cause problems in the evolution and alignment of terminologies and associated ontologies. (shrink)

In this chapter I explicate and evaluate the concept of medical error. Unlike standard philosophical approaches to analyzing medical phenom- ena in the abstract, I instead address medical error specifi cally within the context of an embodied social world. I illustrate how, as a deeply contex- tual concept, medical error is inextricably tied to the social conditions— and concrete, powerful interests—of the particulars in which it is found. -/- I begin with an analysis that demonstrates the (...) relational quality of medi- cal error, as a functional, outcome-oriented concept, evaluating the origin and context of the term’s emergence, and connecting it to a similarly contextual concept, “standard of care.” I move on to note the concern- ing implications of medical error identifi cation and measurement when viewed through an intersectional standpoint. To do so, I discuss what intersectional approaches can help reveal about our contemporary social world of medicine and public health. Intersectional approaches, as I will explain, focus on how intersections of social identity can unmask social structures that negatively impact groups and individuals. It appears, as -/- I will suggest, that disparities in social goods (e.g., social standing, edu- cation, wealth) complicate our identification of medical error, itself, and compound concerns of equity and access to medical goods for those who have diminished expectations for health. (shrink)

The complexity of cognitive emulation of human diagnostic reasoning is the major challenge in the implementation of computer-based programs for diagnostic advice in medicine. We here present an epistemological model of diagnosis with the ultimate goal of defining a high-level language for cognitive and computational primitives. The diagnostic task proceeds through three different phases: hypotheses generation, hypotheses testing and hypotheses closure. Hypotheses generation has the inferential form of abduction (from findings to hypotheses) constrained under the criterion of plausibility. Hypotheses testing (...) is achieved by a deductive inference (from generated hypotheses to expected findings), followed by an eliminative induction, constrained under the criterion of covering, which matches expected findings against patient''s findings to select the best explanation. Hypotheses closure is a deductive-inductive type of inference very similar to the inferences operating in hypotheses testing. In this case induction matches the consequences of the generated hypotheses against the patient''s characteristics or preferences under the criterion of utility. By using the language exploited in this epistemological model, it is possible to describe the cognitive tasks underlying the most influential knowledge-based diagnostic systems. (shrink)

Few empirical studies have explored how different types of knowledge are associated with diverse objectivities and moral economies. Here, we examine these associations through an empirical investigation of the public policy debate in Israel around medical cannabis, which may be termed a contested medicine because its therapeutic effects, while subjectively felt by users, are not generally recognized by the medical profession. Our findings indicate that beneath the MC debate lie deep-seated issues of epistemology, which are entwined with (...) questions of ethics and morality. Whereas some stakeholder groups viewed evidence-based medicine and mechanical objectivity as the only valid knowledge base, others called for recognition of a particular experience-based knowledge, championing regulatory, administrative, or strong objectivity. Stakeholders’ interpretations of what should be considered as ethical courses of action corresponded to their epistemological views, with most criticizing the regulators for relying on regulatory subjectivity instead of objectivity. Our in-depth mapping of this arena allowed us not only to shed light on the emergence of the new entity called “medical cannabis” but also to reexamine the link between epistemology, ethics, and action and to elucidate how heterogeneous groups view the validity and objectivity of knowledge and the interface between medicine, science, and policy. (shrink)

Evidence-based medicine has been the subject of much controversy within and outside the field of medicine, with its detractors characterizing it as reductionist and authoritarian, and its proponents rejecting such characterization as a caricature of the actual practice. At the heart of this controversy is a complex linguistic and social process that cannot be illuminated by appealing to the semantics of the modifier evidence-based. The complexity lies in the nature of evidence as a basic concept that circulates in both expert (...) and non-expert spheres of communication, supports different interpretations in different contexts, and is inherently open to contestation. We outline a new methodology that combines a social epistemological perspective with advanced methods of corpus linguistics and elements of conceptual history to investigate this and other basic concepts that underpin the practice and ethos of modern medicine. The potential of this methodology to offer new insights into controversies such as those surrounding EBM is demonstrated through a case study of the various meanings supported by evidence and based, as attested in a large electronic corpus of online material written by non-experts as well as a variety of experts in different fields, including medicine. (shrink)

Using the theoretical constructs “biographical disruption” and “limit experience” and also methodological frameworks from autoethnography and discourse analysis, we discuss the divergent ways in which language and healing are conceptualized and performed, first in an American medical clinic and then by traditional healers in Kwara‘ae (Solomon Islands). Discourses at the Dallas clinic draw on allopathic and complementary medicine and in emphasizing a scientific approach to talk about illness and treatment, were found to create ambiguity in patients’ sense of their (...) physical and metaphysical identities. In contrast, Kwara‘ae healing involves disappearing into silence, in which the physical and metaphysical are never separated, and where healing occurs. (shrink)

Social media has transformed how individuals handle their illnesses. While many patients increasingly use these online platforms to understand embodied information surrounding their conditions, healthcare professionals often frame these practices as negative and do not consider the expertise that patients generate through social media. Through a combination of insights from social epistemology and ignorance studies, this paper problematizes the distinctive understandings of social media between patients and healthcare professionals from a different perspective. A total of four ideas are introduced: (...) (1) healthcare professionals see embodied knowledge that arises from patients’ social media practices as uncomfortable knowledge; (2) healthcare professionals engage in several behaviours to preserve their authority and power in front of embodied knowledge created through these online platforms; (3) failing to consider embodied knowledge can have consequences not only in terms of trust between patients and healthcare professionals but also in connection with epistemological populism and the transition towards patient-centred care; and (4) media and digital health literacy could help healthcare professionals enhance the uses of social media in healthcare. Adopting this framework allows not only to offer valuable insights into how healthcare professionals manage patients’ social media practices, but also opens new avenues to improve healthcare digitisation. (shrink)

The use of black box algorithms in medicine has raised scholarly concerns due to their opaqueness and lack of trustworthiness. Concerns about potential bias, accountability and responsibility, patient autonomy and compromised trust transpire with black box algorithms. These worries connect epistemic concerns with normative issues. In this paper, we outline that black box algorithms are less problematic for epistemic reasons than many scholars seem to believe. By outlining that more transparency in algorithms is not always necessary, and by explaining that (...) computational processes are indeed methodologically opaque to humans, we argue that the reliability of algorithms provides reasons for trusting the outcomes of medical artificial intelligence. To this end, we explain how computational reliabilism, which does not require transparency and supports the reliability of algorithms, justifies the belief that results of medical AI are to be trusted. We also argue that several ethical concerns remain with black box algorithms, even when the results are trustworthy. Having justified knowledge from reliable indicators is, therefore, necessary but not sufficient for normatively justifying physicians to act. This means that deliberation about the results of reliable algorithms is required to find out what is a desirable action. Thus understood, we argue that such challenges should not dismiss the use of black box algorithms altogether but should inform the way in which these algorithms are designed and implemented. When physicians are trained to acquire the necessary skills and expertise, and collaborate with medical informatics and data scientists, black box algorithms can contribute to improving medical care. (shrink)

Medicine has been a very fruitful source of significant issues for philosophy over the last 30 years. The vast majority of the issues discussed have been normative—they have been problems in morality and political philosophy that now make up the field called bioethics. However, biomedical science presents many other philosophical questions that have gotten relatively little attention, particularly topics in metaphysics, epistemology and philosophy of science. This volume focuses on problems in these areas as they surface in biomedical science. (...) Important changes in philosophy make biomedical science an especially interesting area of inquiry. Contemporary philosophy is largely naturalistic in approach—it takes philosophy to be constrained by the results of the natural sciences and able to contribute to the natural sciences as well. Exactly what those constraints and contributions should be is a matter of controversy. What is not controversial is that important questions in philosophy of science and metaphysics are raised by the practice of science. Physics, biology, and economics have all drawn extensive philosophical analysis, so much so that philosophical study of these areas have become specialized subdisciplines within philosophy of science. Philosophy of medicine approached from the perspective of philosophy of science—with important exceptions (Schaffner, 1993; Thagard, 2000)—has been relatively undeveloped. Nonetheless, medicine should have a central place in epistemological and metaphysical debates over science. It is unarguably the most practically important of the sciences. It also draws by the far the greatest resources and research efforts of any area in biology. Yet philosophy of biology has focused almost exclusively on evolutionary biology, leaving the vast enterprises of immunology, cancer biology, virology, clinical medicine, and so on unexplored. Naturalized philosophy has emphasized the important interplay of historical and sociological aspects of science with its philosophical interpretation. Biomedical science as a large scale social enterprise is a natural target for such approaches. Relatedly, within philosophy there has been a growing interest and appreciation for the connections between issues of value and issues of fact in science (Kincaid et al., 2007). Biomedical science is a paradigm instance where the two intersect. The upshot is that biomedical science is a potential rich area for philosophical investigation in areas outside biomedical ethics. This volume seeks to show that promise and to encourage its exploration. (shrink)

Journal of Religious Ethics, Volume 49, Issue 2, Page 245-269, June 2021.

Medical semiotics, as a branch of general semiotics, has never really gained a foothold in either semiotics itself or medical science, despite the fact that the discipline of semiotics traces its roots to the medical domain in the ancient world and especially to Hippocrates. With several key exceptions, such as Jakob von Uexküll in 1909 and in the 1990s with Thomas A. Sebeok, there is no evidence that medical semiotics is a significant and growing area of (...) research either within semiotics or medical practice. The purpose of this book is to revive interest in this field examining the historical and epistemological principles that would make it highly relevant today in the global village where conceptions of disease and health are in constant flux. The book is written it in a non-technical way-that is, no assumptions are made on the part of the reader of technical semiotics. Our hope is that this book will bring out the importance of semiotics to the practice of medicine. It can be considered to be a textbook in the field of medical semiotics, constituting to the best of our knowledge the first of its kind. (shrink)

This article utilizes the case of Ms H. to examine the contrasting ways that surrogate decision makers move from simply hearing information about the patient to actually knowing and understanding the patient’s medical condition. The focus of the case is on a family’s request to actually see the patient’s wounds instead of being told about the wounds, and the role of clinical ethicists in facilitating this request. We argue that clinical ethicists have an important role to play in the (...) work of converting information into knowledge and that this can serve as a valuable way forward in the midst of seemingly intractable conflicts in the medical setting. (shrink)

Although typically implicit, clinicians face an inherent conflict between their roles as medical healers and as providers of technical biomedicine (Scott et al. in Philos Ethics Humanit Med 4:11, 2009). This conflict arises from the tension between the physicalist model which still predominates in medical training and practice and the extra-physicalist dimensions of medical practice as epitomised in the concept of patient-centred care. More specifically, the problem is that, as grounded in a "borrowed" physicalist philosophy, the dominant (...) "applied scientist" model exhibits a number of limitations which severely restrict its ability to underwrite the effective practice of care. Moreover, being structural in character, these problems cannot be resolved by piecemeal modifications of the existing model, nor by an appeal to evidence-based medicine (Miles in J Eval Clin Pract 15(6):887-890, 2009; Miles in Folia Med 55(1):5-24, 2013; Miles et al. in J Eval Clin Pract 14(5):621-649, 2008). Hence, the need for medical theorists to "partner with experts in the humanities to build a sui generis philosophy of medicine" (Whatley in J Eval Clin Pract 20(6):961-964, 2014, p. 961). In response, the present paper seeks to vindicate the merits of hermeneutically-informed template in providing the requisite grounding. While capable of correcting for the limitations of the applied scientist model, a hermeneutically-informed template is a "both/and" approach, which seeks to complement rather than exclude the physicalist dimension, and thereby aspires to reconcile technical mastery with patient-centred care, rather than eschew one in favour of the other. As such, it can provide a cogent philosophical template for current best practice, which does justice to the art as well as the science of medical care. (shrink)

This paper attempts to establish the epistemological import and limits of informed consent in clinical research. It points out that informed consent is a necessary requirement in clinical research because it ensures adequate participation of care receivers in issues relating to their health. Besides ensuring that care receivers have knowledge of whatever medical intervention they are consenting to, informed consent, as an ideal, provides assurance that care receivers and others are neither coerced nor deceived. While the question of the (...) value of informed consent in health care delivery is not so much controverted, in contest is the question of whether or not complete and wholly specifically informed consent can indeed be realized in medical intervention. Two orientations are identified in this debate. One insists that an individual will be able to make an informed decision and make reasonable choices amongst alternatives when fully informed. The other orientation sees as an epistemic illusion, achieving full informed consent, and rather opts for informed request. This paper examines this debate by clarifying the notion of informed consent, its components and its nexus with knowledge. The position of the paper is that informed consent is not only an ethical ideal in clinical research and health care; it is also an epistemic virtue that must be continuously strived towards. This paper establishes that health care receivers can only have an epistemic claim of their medical situation if all requirements of informed consent in health care delivery such as provision of adequate information, the risk and benefits of treatment, avoidance of vague/ambiguous statements, voluntariness, etc. are met. (shrink)

Different beliefs about the nature and justification of bioethics may reflect different assumptions in moral epistemology. Two alternative views (put forward by David Seedhouse and Michael H Kottow) are analysed and some speculative conclusions formed. The foundational questions raised here are by no means settled and deserve further attention.

ArgumentThis article uses four historical case studies to address epistemological issues related to the animal model of human diseases and its use in medical research on human diseases. The knowledge derived from animal models is widely assumed to be highly valid and predictive of reactions by human organisms. In this contribution, I use three significant historical cases of failure (ca. 1890, 1960, 2006), and a closer look at the emergence of the concept around 1860/70, to elucidate core assumptions related (...) to the specific practices of animal-human knowledge transfer, and to analyze the explanations provided by historical actors after each of the failures. Based on these examples, I argue that the epistemological status of the animal model changed from that of a helpful methodological tool for addressing specific questions, but with precarious validity, to an obligatory method for the production of strong knowledge on human diseases. As a result, there now exists a culture of biomedical research in human disease that, for more than a century, has taken the value of this methodological tool as self-evident, and more or less beyond question. (shrink)

A common epistemological assumption in contemporary bioethics held b y both proponents and critics of non-traditional forms of cognitive enhancement is that cognitive enhancement aims at the facilitation of the accumulation of human knowledge. This paper does three central things. First, drawing from recent work in epistemology, a rival account of cognitive enhancement, framed in terms of the notion of cognitive achievement rather than knowledge, is proposed. Second, we outline and respond to an axiological objection to our proposal that (...) draws from recent work by Leon Kass (2004), Michael Sandel (2009), and John Harris (2011) to the effect that ‘enhanced’ cognitive achievements are (by effectively removing obstacles to success) not worthy of pursuit, or are otherwise ‘trivial’. Third, we show how the cognitive achievement account of cognitive enhancement proposed here fits snugly with recent active externalist approaches (e.g., extended cognition) in the philosophy of mind and cognitive science. (shrink)

Assumptions about obesity—e.g., its connection to ill health, its causes, etc.—are still prevalent today, and they make up what I call the medical model of fatness. In this paper, I argue that the medical model was established on the basis of insufficient evidence and has nevertheless continued to be relied upon to justify methodological choices that further entrench the assumptions of the medical model. These choices are illegitimate in so far as they conflict with both the epistemic (...) and social aims of obesity research. I conclude the paper with a partial solution to these epistemic and social shortcomings. (shrink)

Medicine, as Byron Good argues, reconstitutes thehuman body of our daily experience as a medical body,unfamiliar outside medicine. This reconstitution can be seen intwo ways: as a salutary reminder of the extent to which thereality even of the human body is constructed; and as anarena for what Stephen Toulmin distinguishes as theintersection of natural science and history, in which many ofphilosophy''s traditional questionsare given concrete and urgent form.This paper begins by examining a number of dualities between themedical body and (...) the body familiar in daily experience. Toulmin''s epistemological analysis of clinical medicine ascombining both universal and existential knowledge is thenconsidered. Their expression, in terms of attention,respectively, to natural science and to personal history, isexplored through the epistemological contrasts between themedical body and the familiar body, noting the traditionalphilosophical questions which they in turn illustrate. (shrink)

The recent literature on the theory of knowledge has taken a distinctive turn by focusing on the role of the cognitive and intellectual virtues in the acquisition of knowledge. The main contours and motivations for such virtue-theoretic accounts of knowledge are here sketched and it is argued that virtue epistemology in its most plausible form can be regarded as a refined form of reliabilism, and thus a variety of epistemic externalism. Moreover, it is claimed that there is strong empirical (...) support in favour of the virtue epistemic position so understood, and an empirical study regarding the cognitive processes employed by medical experts in their diagnosis and treatment of epilepsy is cited in this regard. In general, it is argued that one can best account for 'expert' knowledge in terms of a virtue-theoretic epistemology that retains key reliabilist features. It is thus shown that understanding knowledge along virtue-theoretic lines has important implications for our understanding of how knowledge is acquired, and thus for the philosophy of education. (shrink)

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a (...) philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity. (shrink)

Medicalization was the theme of the 29th European Conference on Philosophy of Medicine and Health Care that included a panel session on the DSM and mental health. Philosophical critiques of the medical model in psychiatry suffer from endemic assumptions that fail to acknowledge the real world challenges of psychiatric nosology. The descriptive model of classification of the DSM 3-5 serves a valid purpose in the absence of known etiologies for the majority of psychiatric conditions. However, a consequence of the (...) “atheoretical” approach of the DSM is rampant epistemological confusion, a shortcoming that can be ameliorated by importing perspectives from the work of Jaspers and McHugh. Finally, contemporary psychiatry’s over-reliance on neuroscience and pharmacotherapy has led to a reductionist agenda that is antagonistic to the inherently pluralistic nature of psychiatry. As a result, the field has suffered a loss of knowledge that may be difficult to recover. (shrink)

How medical education and practice can move beyond a narrow focus on biological intervention to recognize the lived experiences of illness, suffering, and death. In Afflicted, Nicole Piemonte examines the preoccupation in medicine with cure over care, arguing that the traditional focus on biological intervention keeps medicine from addressing the complex realities of patient suffering. Although many have pointed to the lack of compassion and empathy in medical practice, few have considered the deeper philosophical, psychological, and ontological reasons (...) for it. Piemonte fills that gap, examining why it is that clinicians and medical trainees largely evade issues of vulnerability and mortality and, doing so, offer patients compromised care. She argues that contemporary medical pedagogy and epistemology are not only shaped by the human tendency to flee from the reality of death and suffering but also perpetuate it. The root of the problem, she writes, is the educational and institutional culture that promotes reductionist understandings of care, illness, and suffering but avoids any authentic confrontation with human suffering and the fear and self-doubt that can come with that confrontation. Through a philosophical analysis of the patient-practitioner encounter, Piemonte argues that the doctor, in escaping from authentic engagement with a patient who is suffering, in fact “escapes from herself.” Piemonte explores the epistemology and pedagogy of medicine, examines its focus on calculative or technical thinking, and considers how “clinical detachment” diminishes physicians. She suggests ways that educators might cultivate the capacity for authentic patient care and proposes specific curricular changes to help students expand their moral imaginations. (shrink)

There is a lot of conceptual engineering going on in medical research. I substantiate this claim with two examples, the medical debate about cancer classification and about obesity as a disease I also argue that the proper target of conceptual engineering in medical research are experts’ conceptions. These are explicitly written down in documents and guidelines, and they bear on research and policies. In the second part of the chapter, I propose an externalist framework in which conceptions (...) have both the explanatory power of psychological concepts and that of semantic concepts. It is likely, however, that human activities and practices distinct from medical research, and regulated by different practices and epistemic rules, call for different targets for conceptual engineering. I conclude with indicating an open agenda of problems for philosophers of medicine interested in conceptual engineering. (shrink)

Many extant theories of placebo focus on their causal structure wherein placebo effects are those which originate from select features of the therapy (e.g. client expectations or ‘incidental’ features like size, and shape). Although such accounts can distinguish placebos from standard medical treatments, they cannot distinguish placebos from everyday occurrences e.g. when positive feedback improves our performance on a task. Providing a social epistemological account of a treatment context can rule out such occurrences, and furthermore reveal a new way (...) to distinguish clinical placebos from standard medical treatments. (shrink)

This paper argues that epistemic errors rooted in group- or identity- based biases, especially those pertaining to disability, are undertheorized in the literature on medical error. After sketching dominant taxonomies of medical error, we turn to the field of social epistemology to understand the role that epistemic schemas play in contributing to medical errors that disproportionately affect patients from marginalized social groups. We examine the effects of this unequal distribution through a detailed case study of ableism. (...) There are four primary mechanisms through which the epistemic schema of ableism distorts communication between nondisabled physicians and disabled patients: testimonial injustice, epistemic overconfidence, epistemic erasure, and epistemic derailing. Measures against epistemic injustices in general and against schema-based medical errors in particular are ultimately issues of justice that must be better addressed at all levels of health care practice. (shrink)

Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM , the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological (...) challenges of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility. (shrink)

This paper argues that there exists a collective epistemic state of ‘Broad Medical Uncertainty’ regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and (...) unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a ‘Corrective Response’. We then consider some objections to this position, including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing. (shrink)

Scott Waterman's reflection on his experience with chronic pain and alternative treatments raises a fundamental question in medical epistemology: How can we know that an intervention will help people who are suffering?Waterman's details his trial of an alternative therapy with a dubious pathophysiological rationale. Despite the lack of research demonstrating its efficacy, and a lack of therapeutic benefit for him in particular, he acknowledges its benefit to others who were more attitudinally predisposed to it. This leads him to (...) conclude that one's personal beliefs and explanatory hypotheses play a role in the healing process. From this he concludes that data from clinical studies conducted according to... (shrink)