Medicine involves specific practical expertise as well as more general context-independent medical knowledge. This raises the question, what is the nature of the expertise involved? Is there a model of clinical judgement or understanding that can accommodate both elements? This paper begins with a summary of a published account of the kinds of situation-specific skill found in anaesthesia. It authors claim that such skills are often neglected because of a prejudice in favour of the ‘technical rationality’ exemplified in (...) evidence-based medicine but they do not themselves offer a general account of the relation of practical expertise and general medical knowledge. The philosopher Hubert Dreyfus provides one model of the relation of general knowledge to situation-specific skilled coping. He claims that the former logically depends on the latter and provides two arguments, which I articulate in the second section, for this. But he mars those arguments by building in the further assumption that such situation-specific responses must be understood as concept-free and thus mindless. That assumption is held in place by three arguments all of which I criticize in the next section to give a unified account of clinical judgement as both practical and conceptually structured and thus justified in the face of a prejudice in favour of ‘technical rationality’. (shrink)

Rationality in medicine is frequently construed as hypotheticodeductive. This article argues that such a model gives a distorted view of the rational character of an enterprise that makes judgments about individual human well-being. Medicine as a science is a practical human science. Seen as such, its rational orientation is one that applies general knowledge to particular situations. It is argued that such an orientation is not deductive but interpretative. The Aristotelian concept of practical wisdom (‘phron sis’) is used as a (...) model of the rational orientation of clinical judgment. Keywords: clinical judgment, rationality, human sciences CiteULike Connotea Del.icio.us What's this? (shrink)

It is common for clinicians working in psychiatry and related clinical disciplines to be called on to make diagnostic clinical judgments concerning moral anxiety, which is a kind of anxiety that is closely bound up with decisions individuals face as moral agents. To make such a judgment, it is necessary to make a moral judgment. Although it has been common to acknowledge that there are ways in which moral and clinical judgment interact, this type of interaction has (...) remained unacknowledged. This raises questions as to the nature and limits of psychiatry—particularly concerning the extent to which psychiatric discourse ought to incorporate moral discourse, and the role of the clinician as an expert in identifying problematic anxiety. (shrink)

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

The question of the extent to which one can rationally reconstruct the process of medical diagnosis and reduce it to an algorithm is explored. The act of diagnostic insight is such that a computational program cannot ‘catch on’ in the way that a competent diagnostician can. Clinical diagnostic reasoning in a particular case requires as a necessary condition an extraordinarily complex and rich structure of background knowledge as well as an intuitive element, such as is manifest when one ‘catches (...) on’ to a joke. Computers cannot ‘catch on’ due to their limitations in the computational mode. As a consequence, there can be no computer simulation of an essential element in diagnostic procedures. Keywords: clinical judgment, computer diagnosis, intuition, medical decision-making CiteULike Connotea Del.icio.us What's this? (shrink)

The literature on bioethics is diverse and confusing in its treatment of appropriate components for decision making. As a result, the literature on teaching bioethics is also confusing, even contradictory, in presenting an ‘appropriate’ framework within which learners may come to understand the nature and process of bioethics. The article sets out five decision components which are seen as common to all decision making. These components are then shown to have a significant influence both on bioethics decision making and on (...) bioethics teaching. They are also shown to play a role in breaking down the separatism evidenced in contemporary bioethics literature aimed at individual professions. Keywords: bioethics, decision analysis, decision components, decision making, teaching CiteULike Connotea Del.icio.us What's this? (shrink)

Many physicians assert that new cost-control mechanisms inappropriately interfere with clinical decision-making. They claim that high costs arise from poorly practiced medicine, and argue that effective utilization of resources is best promoted by advancing the scientific and ethical ideals of medicine. However, the claim is not warranted by empirical evidence. In this essay, I show how it rests upon aesthetic considerations associated with diagnostic elegance. I first consider scientific rationality generally. After a review of analytical empiricist and socio-historical approaches (...) in the philosophy of science, a form of Kant's aesthetic is used to explain how scientific discovery and justification are linked, and to show how meta-theoretical considerations associated with the goals and method of science work together with exemplars of practice. This analysis enables us to understand how the ideals of medicine as a science guide the initial patient history and physical exam in such a way that a parsimonious use of tests is indicated. Aesthetic considerations unite the basic scientific and ethical commitments of the modern medical paradigm and are central for rightly understanding clinical judgment. (shrink)

This paper argues that healthcare aims at the good of health, that this pursuit of the good necessitates conscience, and that conscience is required in every practical judgement, including clinical...

The morally responsible practice of clinical medicine depends on many factors, the integrity of clinical judgment chief among them. Responsible clinical judgment requires that it be deliberative. The disciplines of the humanities, all of which contribute to clinical ethics—as the papers that follow illustrate—teach that deliberative reasoning includes critical self-awareness and self-scrutiny. Critical appraisal proves essential to achieving both. The papers in the 2013 Clinical Ethics number of the Journal provide distinctive critical appraisals of (...) class='Hi'>clinical judgment: concepts of race; narrative; stewardship; and the Rule of Rescue. By becoming commonplace, such critical appraisals of clinical judgment become essential to clinical ethics. (shrink)

Conscience and conscientious objections are important issues in medical law and ethics. However, discussions tend to focus on a particular type of conscience-based claim. These types of claims are based upon predictable, generalizable rules in which an individual practitioner objects to what is otherwise standard medical treatment. However, not all conscience based claims are of this type. There are other claims which are based not on an objection to a treatment in general but in individual cases. In other words, these (...) cases may involve practices which the doctor does not usually object to but does so in this instance on these facts. This paper will explore these types of conscience-based claims in two ways. First, it will explore whether these types of individualised conscience-based claims are really conscience claims at all. Second, it will explore how these claims interact with the other sorts of judgements we expect doctors to make in these cases. (shrink)

This article examines a population-based opportunistic screening practice for cognitive impairment that takes place at a hospital in Sweden. At the hospital, there is a routine in place that stipulates that all patients over the age of 65 who are admitted to the ward will be offered testing for cognitive impairment, unless they have been tested within the last six months or have been diagnosed with any form of cognitive impairment. However, our analysis shows that this routine is not universally (...) and mechanically applied. Rather, the health care professionals have developed and use an ethico-political judgment, concerning, for example,whomto test,whento offer the tests, andhowto explain and perform them. This article explores the role and practice of this form of judgment, emphasising its political and ethical nature. The analysis is based on qualitative interviews with professionals and patients, and draws on the theories of Aristotle and Hannah Arendt. (shrink)

Alasdair MacIntyre's recent thinking both about the concept of a practice and the existence of narrative unity in human life raises important questions about how we should view clinical medicine today. Is it possible for clinical medicine to pursue patient well-being in a society (allegedly) afflicted with what he calls modernity? Here it is argued that MacIntyre's pessimistic view of the individual in contemporary society makes his call for patient autonomy in the clinical setting pointless. Finally, recent (...) work in gerontology is cited to make three points: first, MacIntyre's pessimism about us is too extreme; second, the concept of a fictionalized personal history is closer to reality than either MacIntyre's notion of narrative unity or the ideas of his imagined opponent (Sartre); and finally, we should not expect clinical medicine to produce patient well-being, when this is understood narratively. (shrink)

Topics in Cognitive Science, Volume 14, Issue 3, Page 508-527, July 2022.

Philosopy of medicine focuses inter alia on metaphysics and epistemology that are instantiated in biomedicine as physicalism (or materialism) and empiricism. The Golubchuck case reveals how the clinicans failed to recognize the relation between medical science and medical ethics and made biomedical decsions devoid of medical ethics. That is, they failed to make medical judgments that by defintion include a normative ethical component.

Although rationing by clinical judgment is controversial, its acceptability partly depends on how it is practiced. In this paper, rationing by clinical judgment is defined in three different circumstances that represent increasingly wider circles of resource pools in which the rationing decision takes place: triage during acute shortage, comparison to other potential patients in a context of limited but not immediately strained resources, and determination of whether expected benefit of an intervention is deemed sufficient to warrant its cost (...) by reference to published population based thresholds. Notions of procedural justice are applied along with an analytical framework of six minimal requisites in order to facilitate fair bedside rationing: (1) a closed system that offers reciprocity, (2) attention to general concerns of justice, (3) respect for individual variations, (4) application of a consistent process, (5) explicitness, and (6) review of decisions. The process could be monitored for its applicability and appropriateness. (shrink)

What are the criteria for reasonable clinical judgements? The reasonableness of macro-level decision-making has been much discussed, but little attention has been paid to the reasonableness of applying guidelines generated at a macro-level to individual cases. This paper considers a framework for reasonable clinical decision-making that will capture cases where relevant guidelines cannot reasonably be followed. There are three main sections. (1) Individual claims on healthcare from the point of view of concerns about equity are analysed. (2) The (...) demands of responsibility and equity on professional clinical performance are discussed, and how the combination of these demands emerges into seven requirements that constitute the framework is explored. Since this framework is developed to assist in reasonable clinical decision-making, practical implications of all these requirements are also suggested. (3) Challenges concerning the framework are discussed. First, a crucial presumption that the framework relies upon is considered—namely, clinicians’ willingness to justify their decisions as requested. Then how public deliberation may influence clinical decision-making is discussed. Next is a consideration of how clinicians’ need to have confidence in their own judgements in order to perform in a manner worthy of trust would be compatible with adherence to the framework supported by public deliberation. It is concluded that fair distribution in the interplay between macro- and micro-level considerations can be secured by legitimising procedures on each level, by ensuring well-organised and continuing public debate and by basing individual clinical judgements upon well-justified and principled normative bases. (shrink)

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more (...) complete understanding of clinical judgement requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

The article reconsiders the nature and location of science in the development of genetic classification. Drawing on field studies of medical genetics, we explore how patient categorization is accomplished in between the clinic and laboratory. We focus on dysmorphology, a specialism concerned with complex syndromes that impair physical development. We show that dys-morphology is about more than fitting patients into prefixed diagnostic categories and that diagnostic process is marked by moments of uncertainty, ambiguity, and deferral. We describe how different forms (...) of evidence are brought into play and how patterns of physical features are identified as genetic or not. We suggest that clinical categorical work helps articulate the genetic as an emergent domain of medical classification and that moments of ambiguity and deferral create an imperative space that helps legitimate the need for more technoscience, and consequently, more clinical judgment with which to fix the genetic future. (shrink)

Three studies using the Dreyfus model of skill acquisition were conducted over a period of 21 years. Nurses with a range of experience and reported skill-fulness were interviewed. Each study used nurses’ narrative accounts of actual clinical situations. A subsample of participants were observed and interviewed at work. These studies extend the understanding of the Dreyfus model to complex, underdetermined, and fast-paced practices. The skill of involvement and the development of moral agency are linked with the development of expertise, (...) and change as the practitioner becomes more skillful. Nurses who had some difficulty with understanding the ends of practice and difficulty with their skills of interpersonal and problem engagement did not progress to the level of expertise. Taken together, these studies demonstrate the usefulness of the Dreyfus model for understanding the learning needs and styles of learning at different levels of skill acquisition. (shrink)

The paper outlines the role that tacit knowledge plays in what might seem to be an area of knowledge that can be made fully explicit or codified and which forms a central element of Evidence Based Medicine. Appeal to the role the role of tacit knowledge in science provides a way to unify the tripartite definition of Evidence Based Medicine given by Sackett et al: the integration of best research evidence with clinical expertise and patient values. Each of these (...) three elements, crucially including research evidence, rests on an ineliminable and irreducible notion of uncodified good judgement. (shrink)

A certain kind of externalism—"the view from nowhere"—lies at the heart of evidence-based medicine (EBM). As a consequence, the individual case glides out of focus. However, to judge to what extent external knowledge is applicable to an individual case, the clinician has to rely on some sort of knowledge of the case at hand. The article focuses on the tension between the externalism of EBM and the "internal evidence" one has to presuppose when making clinical judgments.

Mr. F. Smith was a 63-year-old man admitted to the Veterans Administration hospital with fever, respiratory distress, and a possible recurrent pneumonia. He had entered a community hospital with pneumonia approximately 18 months earlier. His 80 pack-year tobacco history and 10-year emphysema history complicated the clinical course on the first admission, and his status worsened to the point of respiratory failure. He suffered a cardiac arrest while on a ventilator in an intensive care unit. He was asystolic for approximately (...) 5 minutes but was resuscitated. (shrink)

Over the past several decades, conflicts between physicians and patients or patient surrogates concerning continued treatment or the withdrawal of treatment have received public and legal attention. In more recent years, there have been several prominent Instances in which physicians have refused to provide treatment requested by patient surrogates because such treatment was judged to be futile. The claim that a treatment is futile has far reaching consequences. It serves to justify the withholding or withdrawal of treatment and thus, perhaps, (...) to also justify the rationing of healthcare. It limits the autonomy of the patient or patient surrogate by reducing their participation in the decision making process. (shrink)

The feature of being ‘double blind’, where neither patients nor physicians are aware of who receives the experimental treatment, is universally trumpeted as being a virtue of clinical trials. The rationale for this view is unobjectionable: double blinding rules out the potential confounding influences of patient and physician beliefs. Nonetheless, viewing successfully double blind trials as necessarily superior leads to the paradox that very effective experimental treatments will not be supportable by best (double-blind) evidence. It seems strange that an (...) account of evidence should make a priori judgments that certain claims can never be supported by ‘best evidence’. So far as treatments with large effects go, the claim that they are effective is highly testable and intuitively they should receive greater support from the evidence. In this paper I argue that the two potential confounders ruled out by double blinding are often not actual confounders outside placebo controlled trials of treatments with mild effects and that have subjective outcome measures. (shrink)

Recent empirical work on the concept of intentionality suggests that people’s assessments of whether an action is intentional are subject to uncertainty. Some researchers have gone so far as to claim that different people employ different concepts of intentional action. These possibilities have motivated a good deal of work in the relatively new field of experimental philosophy. The findings from this empirical research may prove to be relevant to medical ethics. In this article, we address this issue head on. We (...) first describe a study we conducted on intention ascription. Drawing on recent work in experimental philosophy, we investigated the possibility that the ascription of intentions to clinical actors in clinical settings is influenced by prior judgments about the goodness or badness of the consequences of the action in question. Our study was modeled on experimental studies in other contexts that have shown that people, when presented with a range of scenarios, are more likely to classify a side effect of an action as intended if the side effect is negative or reflects poorly on the actor than if it is positive or reflects well on the actor. We investigated whether this asymmetry in intention ascriptions was also present among physicians who were asked to ascribe intentions to clinical actors in certain well-defined clinical scenarios. After describing the study and its results, we discuss its implications for medical ethics. (shrink)