Toward a Skills-Based Philosophy of Medicine

The concept of skill is a neglected resource in the philosophy of medicine. Despite its near ubiquitous presence in discussions of medicine , skill has traditionally been passed over as a conceptual tool by those with a philosophical interest in medicine . It is argued that the philosophy of medicine, including its more applied areas , could benefit from a more developed philosophical concept of skill. ;I begin with a preliminary investigation into the nature of the concept of skill. Taking Hubert Dreyfus's uses of skill as a point of departure, I tease apart two different senses of skill---an ontological sense and an epistemological sense. This is followed by a critique of current appeals to skill in one area of the philosophy of medicine . Skill is commonly used to explain three features of diagnostic expertise: its quantity, arationality, and immediacy. The appeals to skill---as a facility in dealing with contents of the mind, as an ability to make subconscious inference, or as a perceptual capacity for gaining foundationalist knowledge---are shown to be problematic. A cognitivist theory of the mind is suggested to be at the root of these appeals. An alternative framework for understanding skills and expertise is explored. Adapting Dreyfus's phenomenology of expertise to medicine, three classes of skills are identified and sketched: perceptual skill, preparative skill, and reparative skill. One of these skills is singled out for further development. It is argued that there is a tradition in philosophy that conceives of perception in skill-like terms and which finds medicine particularly useful for elucidating a notion of perceptual skill. Finally, the concept of skill under development is brought to a current debate within the philosophy of medicine: the internalist versus externalist debate. After reviewing some of the history of this debate, it is suggested that internalism could benefit from a more developed concept of skill