The authoritarian standpoint in medicine has been under challenge by various groups and researchers since the 1980s. The challenges have been ethical, political and medical, with patient movements at the forefront. Over the past decade, however, a deep challenge has been posed by evidence-based medicine (EBM), which has challenged the entire strategy of medical treatment from the point of view of a self-critical, anti-authoritarian and hereby also (it has been claimed) a more democratic medical practice. Previously, the challenges arose out (...) of the patient rights perspective. EBM, by contrast, was taken to challenge the way doctors consider their medical practice as a whole. The present paper puts this claim of democratization into a historical context. Two dimensions of the democratization hypothesis are discussed and it is argued that they are insufficient to capture the substantial changes going on in the intersection between medical practice, biomedical science and citizens. (shrink)

Fifty years ago, in 1961, Feinstein published his first path-breaking articles leading to his seminal work Clinical Judgement and to the establishment of clinical epidemiology. Feinstein had an Aristotelian approach to scientific method: methods must be adapted to the material examined. Feinstein died 10 years ago and few years before his death he concluded that efforts to promote a person-oriented medicine had failed. He criticised medicine for not having recognized that only persons can suitably observe, evaluate and rate their own (...) health status. Feinstein’s position was—as in Clinical Judgement—methodological. He didn’t espouse ethical principles. He pointed to methodological deficiencies in clinical epidemiology and evidence-based medicine. In this article we’ll provide a framework for understanding and justifying Feinstein’s call for a person-oriented medicine which recognizes patients as co-actors in clinical reasoning. It’s argued that craftsmanship and practical wisdom are integrated in clinical judgement and reasoning and that clinical reasoning is not only about means to achieve the end, health. We do also reason and deliberate about ends. The ‘defining end’ of medicine (health) has continuously been negotiated and so been the object of deliberation. For centuries among professionals, in recent years among professionals and patients. These negotiations and deliberations lead to ongoing specifications of health as a ‘guiding end’, i.e. an end guiding clinical reasoning about what to do in particular situations. Feinstein’s self-critical account to clinical epidemiology at the end of his professional career reflects the fact that patients during the last 30–40 years (i.e. in the period after the publication of Clinical Judgement) widely have been recognized as persons with rights to autonomy. Feinstein’s lesson is, however, that espousing and recognizing ethical ideals is not enough. A change of clinical practice and its methods is necessary. His critique also implies that clinical epidemiology and evidence-based medicine as practiced haven’t provided such a turn. (shrink)

Applying the concepts of dynamical systems theory to explain cognitive phenomena is still a fairly recent trend in cognitive science and its potential and consequences are not nearly mapped out. A decade ago, dynamical approaches were introduced as a paradigm shift in cognitive science and in this paper I concentrate on how to substantiate this claim. After having considered and rejected the possibility that continuous time is the crucial factor, I present Kelso's model of a near-cognitive phenomenon which invokes self-organization (...) as the guiding principle. Then, the explanatory strategy implicit in this approach is explicated and its underlying assumption presented. Finally, I discuss how we should characterize this explanatory framework using the notion of emergence. (shrink)

In the last decade several prominent critics have charged that invocation of representations is not only not essential for cognitive science, but should be avoided. These claims have been followed by counterarguments demonstrating that the notion certainly is important in explanations of cognitive phenomena. Analyzing some important contributions to the debate, Anthony Chemero has argued that representationalists still need to explain the significance of the notion once there is an available formal account of a system and has, accordingly, challenged representationalists (...) to provide such an explanation. This paper's first part explains why the representationalist should take an interest in Chemero's challenge. It discusses William Bechtel 's account of the representational structure of the Watt Governor, which, among other things, was motivating Chemero to question the relevance of a representational account once a dynamical one is available. The second part contains the answer to Chemero's challenge. It is motivated by the thought that only a representational account of the Watt Governor with a comparable level of detail could possibly add explanatory value to a dynamical account. However, accepting the account also means that it becomes difficult to understand dynamical and representational accounts as rivals. Instead, it would be more adequate to speak of a dynamical account of the representational structure. (shrink)

Applying the concepts of dynamical systems theory to explain cognitive phenomena is still a fairly recent trend in cognitive science and its potential and consequences are not nearly mapped out. A decade ago, dynamical approaches were introduced as a paradigm shift in cognitive science and in this paper I concentrate on how to substantiate this claim. After having considered and rejected the possibility that continuous time is the crucial factor, I present Kelso’s model of a near-cognitive phenomenon which invokes self-organization (...) as the guiding principle. Then, the explanatory strategy implicit in this approach is explicated and its underlying assumption presented. Finally, I discuss how we should characterize this explanatory framework using the notion of emergence. (shrink)