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)

This highly multidisciplinary collection discusses an increasingly important topic among scholars in science and technology studies: objectivity in science. It features eleven essays on scientific objectivity from a variety of perspectives, including philosophy of science, history of science, and feminist philosophy. Topics addressed in the book include the nature and value of scientific objectivity, the history of objectivity, and objectivity in scientific journals and communities. Taken individually, the essays supply new methodological tools for theorizing what is valuable in the pursuit (...) of objective knowledge and for investigating its history. The essays offer many starting points, while suggesting new avenues of research. Taken collectively, the essays exemplify the very virtues of objectivity that they theorize—in reading them together, the reader can sense various anxieties about the dangerously subjective in our age and locate commonalities of concern as well as differences of approach. As a result, the volume offers an expansive vision of a research community seeking a communal understanding of its own methods and its own epistemic anxieties, struggling to enunciate the key problems of knowledge of our time and offer insight into how to overcome them. -/- (Contributors: Alex Csiszar, Scott Edgar, Peter Galison, Ian Hacking, Sandra Harding, Moira Howes, Paolo Savoia, Judy Segal, Joan Steigerwald, and Alison Wylie). (shrink)

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)

Tōjisha research is a methodology intended to help psychiatric patients through dialogue. It was introduced in the context of community care in Bethel House (Hokkaido, Japan) in the early 2000s and later spread to other parts of Japan as well as abroad because of its originality and apparent therapeutic success. It offers patients a framework to investigate their own problems, symptoms, and delusions and to build a discourse around them. In this paper, I present a short account of tōjisha research (...) and I put it in the context of current debates over the benefits and drawbacks of narrative medicine. I argue that there is an original conception of the self and of empowerment of patients in tōjisha research compared to other models of narrative medicine. Finally, I mobilize these original aspects to address some rebuttals of narrative medicine. (shrink)

Despite an expansive literature on communication in medicine, the role of language is dealt with mostly indirectly. Recently, narrative medicine has emerged as a strategy to improve doctor-patient communication and integrate patient perspectives. However, even in this field which is predicated on language use, scholars have not specifically reflected on how language functions in medicine. In this theoretical paper, the authors consider how different models of language use, which have been proposed in the philosophical literature, might be applied to communication (...) in medicine. In particular, the authors contrast the traditional, indexical thesis of language with new models that focus on interpretation instead of standardization. The authors demonstrate how paying close attention to the role of language in medicine provides a philosophical foundation for supporting recent changes in doctor-patient communication. In particular, interpretive models are at the foundation of new approaches such as narrative medicine, that emphasize listening to patient stories, rather than merely collecting information. Ultimately, debates regarding the role of language which have largely resided in non-medical literatures, have important implications for describing communication in medicine. In particular, interpretive models of language use provide an important rationale for facilitating a more robust dialogue between doctors and patients. (shrink)

Ethics exists among beings that can relate to one another and who can create change in one another. Although this may appear as a simple truism, the implications of relation and change in bioethics are manifold. For instance, one can relate not only to others, but also can enter into self-relation by relating to oneself. Self-relation problematizes autonomy insofar as one does not have immediate access to all of oneself and so therefore also does not immediately fully determine oneself in (...) the way that an uncomplicated understanding of autonomy might imply. This article proceeds as a preliminary exposition of the concepts of relation and change as they apply to bioethics, particularly as they inform autonomy, action theory, and the porous subject. (shrink)

Selon l’une des thèses les plus répétées de la médecine narrative, la théorie littéraire, ou plus largement, la narration, permettrait aux membres du personnel médical d’appréhender les récits des patients et par là, de prendre en considération leurs expériences dans leur singularité absolue. Dans ma contribution, je soulignerai quelques limites de cette thèse. J’appuierai mon analyse sur un exemple de récit dominant de maladie, les récits portant sur le cancer du sein aux États-Unis au XXe siècle, à partir des analyses (...) féministes qui en ont été faites. Ainsi je montrerai d’une part qu’il est peu plausible que les récits des patients soient absolument singuliers et uniques, en un sens pertinent, et d’autre part que certains récits peuvent devenir dominants et marginaliser des récits qui voudraient s’en démarquer. (shrink)

Philosophical works on actual causation make wide use of thought experiments. The principal aim of this paper is to show how thought experiments are used in the contemporary debate over actual causation and to discuss their role in relation to formal approaches in terms of causal models. I claim that a recourse to thought experiments is not something old fashioned or superseded by abstract models, but it is useful to interpret abstract models themselves and to use our intuitions to judge (...) the results of the model. Recent research on actual causation has stressed the importance of integrating formal models with some notion of normality; I suggest that thought experiments can be useful in eliciting intuitions where normality is not intended in a statistical sense. The first expository part gives a short presentation of the notion of actual causation, summarising some typical problems of counterfactual approaches and how they are treated in causal and structural models. The second part focuses on the problems of model isomorphism and criticises some radical ideas opposing the role of thought experiments, claiming that they may also be of use in evaluating formal models. (shrink)

Philosophical works on actual causation make wide use of thought experiments. The principal aim of this paper is to show how thought experiments are used in the contemporary debate over actual causation and to discuss their role in relation to formal approaches in terms of causal models. I claim that a recourse to thought experiments is not something old fashioned or superseded by abstract models, but it is useful to interpret abstract models themselves and to use our intuitions to judge (...) the results of the model. Recent research on actual causation has stressed the importance of integrating formal models with some notion of normality; I suggest that thought experiments can be useful in eliciting intuitions where normality is not intended in a statistical sense. The first expository part gives a short presentation of the notion of actual causation, summarising some typical problems of counterfactual approaches and how they are treated in causal and structural models. The second part focuses on the problems of model isomorphism and criticises some radical ideas opposing the role of thought experiments, claiming that they may also be of use in evaluating formal models. (shrink)

Philosophical works on actual causation make wide use of thought experiments. The principal aim of this paper is to show how thought experiments are used in the contemporary debate over actual causation and to discuss their role in relation to formal approaches in terms of causal models. I claim that a recourse to thought experiments is not something old fashioned or superseded by abstract models, but it is useful to interpret abstract models themselves and to use our intuitions to judge (...) the results of the model. Recent research on actual causation has stressed the importance of integrating formal models with some notion of normality; I suggest that thought experiments can be useful in eliciting intuitions where normality is not intended in a statistical sense. The first expository part gives a short presentation of the notion of actual causation, summarising some typical problems of counterfactual approaches and how they are treated in causal and structural models. The second part focuses on the problems of model isomorphism and criticises some radical ideas opposing the role of thought experiments, claiming that they may also be of use in evaluating formal models. (shrink)

The past 10 years have seen considerable developments in the use of narrative in medicine, primarily through the emergence of the so-called narrative medicine. In this article, I question narrative medicine’s self-understanding and contend that one of the most prominent issues is its lack of a clear epistemological framework. Drawing from Gadamer’s work on hermeneutics, I first show that narrative medicine is deeply linked with the hermeneutical field of knowledge. Then I try to identify which claims can be legitimately expected (...) from narrative medicine, and which ones cannot be. I scrutinize in particular whether narrative medicine can legitimately grasp the patient’s lived experience of his or her illness. In the last section of this article, I begin to explore the potential usefulness of this epistemological clarification. This analysis allows for a further understanding of what is really at stake with narrative medicine, and thus to identify when it may be convenient, and when it may not. Furthermore, this clarification opens up promising new possibilities of dialogue with critics of the field. I conclude that narrative medicine finds its proper place as a possible tool available to mediate dialogue, which is at the heart of the clinical encounter in medical practice. (shrink)

Clinical ethics refers to an emerging field in clinical medicine that focuses on the process of ethical decision-making in a clinicalsetting. It has developed as a result of a growing awareness that modern medicine – characterized by technological progress, culturaldiversity and social challenges – is posing a range of new “ethical dilemmas” that medical science alone cannot solve. For thisreason, clinical ethics is often linked to “ethics consultation,” which consists of services provided by an individual ethicist, ethicsteam or committee to (...) address the ethical issues involved in a specific clinical case. Although clinical ethics developed in the beginningmainly as a methodological analysis to arrive at a justification for clinical ethical decisions, it quickly has become clear thatthe difficulty in clinical decision-making is only one aspect of wider ethical problems pertaining to the doctor-patient relationshipas a whole and, most likely, to the core value of the medical profession. The principles method is usually presented as the mostpopular methodological approach to an analysis of clinical cases. However, strong criticism of this model has been voiced, and otheralternative approaches are referred to, such as the casuistry model. Recently, significant contributions have been made by narrativemedicine and virtue ethics. According to these methodologies, sound anthropology and a good relationship with the sick person arekey elements required of any person engaged in medical practice who aims to be genuinely appropriate from an ethical perspective. DOI: 10.5294/pebi.2016.20.1.3. (shrink)