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 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)

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)

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)

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)

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)

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)

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)

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

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)

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.

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)

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)

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)

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)

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)

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)

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)

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 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)

There is much to learn from Durán and Jongsma’s paper.1 One particularly important insight concerns the relationship between epistemology and ethics in medical artificial intelligence. In clinical environments, the task of AI systems is to provide risk estimates or diagnostic decisions, which then need to be weighed by physicians. Hence, while the implementation of AI systems might give rise to ethical issues—for example, overtreatment, defensive medicine or paternalism2—the issue that lies at the heart is an epistemic problem: how (...) can physicians know whether to trust decisions made by AI systems? In this manner, various studies examining the interaction of AI systems and physicians have shown that without being able to evaluate their trustworthiness, especially novice physicians become over-reliant on algorithmic support—and ultimately are led astray by incorrect decisions.3–5 This leads to a second insight from the paper, namely that even if some AI system happens to be opaque, it is still not built on the moon. To assess its trustworthiness, AI developers or physicians have different sorts of higher order evidence at hand. Most importantly, …. (shrink)

In a controversial paper, David Seedhouse argues that medical ethics is not and cannot be a distinct discipline with it own field of study. He derives this claim from a characterization of ethics, which he states but does not defend. He claims further that the project of medical ethics as it exists and of moral philosophy do not overlap. I show that Seedhouse's views on ethics have wide implications which he does not declare, and in the light of (...) this argue that Seedhouse owes us a defence of his characterization of ethics. Further, I show that his characterization of ethics, which he uses to attack medical ethics, is a committed position within moral philosophy. As a consequence of this, it does not allow the relation between moral philosophy and medical ethics to be discussed without prejudice to its outcome. Finally, I explore the relation between Seedhouse's position and naturalism, and its implications for medical epistemology. I argue that this shows us that Seedhouse's position, if it can be defended, is likely to lead to a fruitful and important line of inquiry which reconnects philosophy and medical ethics. (shrink)

Evidence-based medicine has been rapidly and widely adopted because it claims to provide a method for determining the safety and efficacy of medical therapies and public health interventions more generally. However, as others have noted, EBM may be riven through with cultural bias, both in the generation of evidence and in its translation. We suggest that technological and scientific advances in medicine accentuate and entrench these cultural biases, to the extent that they may invalidate the evidence we have about (...) disease and its treatment. This creates a significant ethical, epistemological and ontological challenge for medicine. (shrink)

Evidence based medicine has been a topic of considerable controversy in medical and health care circles over its short lifetime, because of the claims made by its exponents about the criteria used to assess the evidence for or against the effectiveness of medical interventions. The central epistemological debates underpinning the debates about evidence based medicine are reviewed by this paper, and some areas are suggested where further work remains to be done. In particular, further work is needed on (...) the theory of evidence and inference; causation and correlation; clinical judgment and collective knowledge; the structure of medical theory; and the nature of clinical effectiveness. (shrink)

The goals and tasks of neuroethics formulated by Farahany and Ramos (2020) link epistemological and methodological issues with ethical and social values. The authors refer simultaneously to the social significance and scientific reliability of the BRAIN Initiative. They openly argue that neuroethics should not only examine neuroscientific research in terms of “a rigorous, reproducible, and representative neuroscience research process” as well as “explore the unique nature of the study of the human brain through accurate and representative models of its function (...) and dysfunction”, but also its responsibilities or social consequences. In our commentary, we would like to concentrate on problem selection, which is shortly noticed by Farahany and Ramos, and by BRAIN Initiative’s Neuroethics Report itself. The document raises an important issue related to problem selection, which is strengthening or perpetuating existing prejudices and biases by choosing a research subject: “scientists are prompted to consider how the questions they choose to study in the laboratory might amplify existing biases.” This leads to several further problems: what constitutes bias?; how biases may be embedded in the selection of research programs?; is it possible to conduct completely unbiased research?; who should be a gatekeeper in the case of research that may amplify biases? We try to notice possible answers to these questions in the context of the research on differences (e.g., cognitive, medical, behavioral) between human populations. (shrink)

This special issue on ethics and error in medicine reinvigorates a conversation that has been substantially dormant for twenty years. The papers in this issue elaborate and update that conversation in significant ways, particularly with regard to vulnerable populations and the epistemology of medical error. But this first paper is largely conceptual, laying out the motivation for caring about medical error in the first place, exploring what medical error is, and proposing a moral framework to help (...) us think about it. This paper therefore sets up those that follow—while, at the same time, remaining largely neutral about the substantive views advanced by those authors. The papers are therefore complementary and form a... (shrink)

This paper reframes the futility debate, moving away from the question “Who decides when to end what is considered to be a medically inappropriate or futile treatment?” and toward the question “How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?” It offers a pragmatist moral epistemology that provides us with a clear justification of why it is important to take best standards, norms, and physician judgment seriously and a (...) clear justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms. (shrink)

Robert Truog describes the controversial randomized controlled trials (RCTs) of extracorporeal membrane oxygenation (ECMO) therapy in newborns. Because early results with ECMO indicated that it might be a great advance, saving many lives, Truog argues that ECMO should not have been tested using RCTs, but that a long-term, large-scale observational study of actual clinical practice should have been conducted instead. Central to Truog’s argument, however, is the idea that ECMO is an unusual case. Thus, it is an open question whether (...) Truog’s conclusions can be extended to other areas of medical research. In this paper, I look at epistemological and ethical issues arising in the care of patients with chronic diseases, using ECMO as a starting point. Both the similarities and the dissimilarities of these two cases highlight important issues in biomedical research and support a conclusion similar to Truog’s. Observational studies of clinical practice provide the best evidence to inform the treatment of patients with chronic disease. (shrink)

While evidence-based medicine (EBM) is often accused on relying on a paradigm of 'absolute truth', it is in fact highly consistent with Karl Popper's criterion of demarcation through falsification. Even more relevant, the first three steps of the EBM process are closely patterned on Popper's evolutionary approach of objective knowledge: (1) recognition of a problem; (2) generation of solutions; and (3) selection of the best solution. This places the step 1 of the EBM process (building an answerable question) in a (...) pivotal position for the understanding of the whole process, and underscores a few aspects which are often overlooked in EBM courses. First in this step internal evidence (including personal expertise) must be appraised and integrated in the problem. Second, issues of applicability of the possible solution should be anticipated. Third, and possibly more important, the goal of the intervention should be set at this stage (typically by choosing the outcome in a PICO question). Depending whether or not goals depend on the goals of others, and whether they concern others' voluntary behaviour, goals may be classified as self-serving, moral, altruistic or moralistic. Thus, delicate ethical questions must be addressed at this stage, which means that patient preferences and values must be carefully sought, so that empathy, counselling and narrative medicine must be mastered to be able to formulate correctly an answerable question. The need to modify the current description of the EBM process to increase the recognition of implicit assumptions and increase the consistency of this model is discussed. (shrink)