This paper reassesses the role of sceptical thinking in the emergence of the new science of the seventeenth century, in the context of the seminal but contestable History of Scepticism by Richard Popkin. It investigates the anti-sceptical essay by Galen De optimo modo docendi, which was retranslated in the sixteenth century by Erasmus and later published as an adjunct to the works of Sextus Empiricus, in order to highlight the currency of ideas about hyperbolic doubt, and links this to the (...) long tradition of free enquiry in which doubting authority is seen as a profitable exercise closely associated with the independence of philosophy from theological domination; and it argues that this long tradition played an important role in the emergence of the new science. (shrink)

Savulescu maintains that our paper, which encourages clinicians to honour requests for "inappropriate treatment" is prejudicial to his atheistic beliefs, and therefore wrong. In this paper we clarify and expand on our ideas, and respond to his assertion that medicine, ethics and atheism are objective, rational and true, while religion is irrational and false.

Various meanings of “rational” implicitly and explicitly suggested in this issue's articles are abstracted and stated. Two accounts of rationality are shown to be able to explain most uses of “rational”: the “cool moment” account and a more objective account. The former is examined and modified, but still found inadequate. The objective account of rational is developed, taking “irrational” as the basic concept. “Irrational” is given content in terms of a list, and “rational” is subsequently defined (...) as “not irrational”. Reasons and motives are defined and distinguished. The advantages of the objective account are explored and some challenges to it are answered. (shrink)

This article tries to present a broad view on the values and ethicalissues that are at stake in efforts to rationalize health policy on thebasis of economic evaluations (like cost-effectiveness analysis) andrandomly controlled clinical trials. Though such a rationalization isgenerally seen as an objective and `value free' process, moral valuesoften play a hidden role, not only in the production of `evidence', butalso in the way this evidence is used in policy making. For example, thedefinition of effectiveness of medical treatment or (...) health care serviceis heavily dependent on dominant individual or social views about thegoals of the particular treatment or service. There is also a concernthat a reliance on EBM in health policy will occur at the expense ofwidely shared social values like equity and solidarity. Moreover, thereis a concern that when economic considerations and rational proceduresbecome more influential, various `outside' groups third parties likeinsurance companies and policy makers will get a stronger influence onmedical practice which may lead to a change in the patient-providerrelationship. The authors conclude that social values and patientpreference should be explicitly addressed when health policy making isbased on economic and other scientific evidence. (shrink)

RésuméCet article examine une brève présentation catéchétique de la doctrine médicale galénique des jours critiques composée par le traducteur et penseur duixesiècle Qusṭā ibn Lūqā (m. 912/3) et que l'on a trouvée dans un manuscrit iranien. Tout d'abord, on démontre que cette œuvre a été composée à partir du traité de Galien sur les jours critiques. Ensuite, on la discute section par section, sous forme de commentaire, pour élucider les doctrines médicales proposées par Qusṭā. Enfin, l'œuvre est comparée avec une (...) tentative antérieure, celle d'al-Kindī (m.c. 870), de décrire les jours critiques d'une façon mathématique. On discute les diverses doctrines présentes à l'arrière-plan du traité, comme les diverses approches de la méthode scientifique. L'article se conclut en mettant en contraste la méthode scientifique mathématique eta priorid'al-Kindī avec la méthode empirique eta posterioride Galien et Qusṭā, et il fait des suggestions concernant la chronologie des occurrences de ces doctrines et de ces textes en langue arabe. Une transcription du texte arabe est donnée en appendice. (shrink)

“Evidence based medicine” is often seen as a scientific tool for quality improvement, even though its application requires the combination of scientific facts with value judgments and the costing of different treatments. How this is done depends on whether we approach the problem from the perspective of individual patients, doctors, or public health administrators. Evidence based medicine exerts a fundamental influence on certain key aspects of medical professionalism. Since, when clinical practice guidelines are created, costs affect the content (...) of EBM, EBM inevitably becomes a form of rationing and adopts a public health point of view. This challenges traditional professionalism in much the same way as managed care has done in the US. Here we chart some of these major philosophical issues and show why simple solutions cannot be found. The profession needs to pay more attention to different uses of EBM in order to preserve the good aspects of professionalism. (shrink)

The article addresses the issue of rationing health care services, a topic currently being hotly debated in many countries. The author argues that the aspect of causal responsibility ought to play a decisive role in the allocation of limited medical resources. Starting out from Ronald Dworkin's distinction between option luck and brute luck, the appropriate and meaningful uses of the term causal responsibility are clarified first. A discussion of the conditions which might justify giving lower priority to patients whose illnesses (...) are the result of unhealthy behavior, like e.g. alcohol abuse, follows. Causal responsibility is then viewed in the context of private health insurance and the club model of organ donation. It is argued that individuals themselves are basically responsible for their decisions regarding insurance coverage and membership in organ donors' clubs. Causal responsibility is shown to be a more suitable criterion for rationing scarce medical resources than other criteria which might alternatively be considered, such as patients' age. (shrink)

In this book, Ingemar Nordin analyzes how not only scientific but also non-scientific knowledge is to be used in practice when establishing a rational technological and medical development.

On the 50th anniversary of the Willowbrook experiment's inception, in which Dr. Saul Krugman intentionally infected cognitively disabled children with hepatitis, it is worth reflecting on how our attitude toward research ethics of the past informs our current practices. In examining ethical violations in postwar medicine, we frequently turn to examples that shock and appall, thereby offering concomitant comfort as we measure their safe distance from our own medical context. And yet, which modern medical student has not heard a (...) variation of the phrase "This study would never have passed an ethics committee today" in reference to a classic experiment or a professor's very own work? Even with Nuremburg fresh in the .. (shrink)

In Wrong Medicine, Lawrence J. Schneiderman, M.D., and Nancy S. Jecker, Ph.D., address issues that have occupied the media and the courts since the time of Karen Ann Quinlan. The authors examine the ethics of cases in which medical treatment is offered--or mandated--even if a patient lacks the capacity to appreciate its benefit or if the treatment will still leave a patient totally dependent on intensive medical care. In exploring these timely issues Schneiderman and Jecker reexamine the doctor-patient relationship (...) and call for a restoration of common sense and reality to what we expect from medicine. They discuss economic, historical, and demographic factors that affect medical care and offer clear definitions of what constitutes futile medical treatment. And they address such topics as the limits on unwanted treatment, the shift from the "Age of Physician Paternalism" to the "Age of Patient Autonomy," health care rationing, and the adoption of new ethical standards. (shrink)

Solidarity is a fundamental social value in many European countries, though its precise practical and theoretical meaning is disputed. In a health care context, I agree with European writers who take solidarity normatively to mean roughly equal access to effective health care for all. That is, solidarity includes a sense of justice. Given that, I will argue that precision medicine represents a potential weakening of solidarity, albeit not a unique weakening. Precision medicine includes 150 targeted cancer therapies (mostly (...) for metastatic cancer), all of which are extraordinarily expensive. Our critical question: Must a commitment to solidarity as defined mean that all these targeted cancer therapies should be guaranteed to all within each country in the European Union, no matter the cost, no matter the degree of effectiveness? Such a commitment would imply that cancer was ethically special, rightfully commandeering unlimited resources. That in itself would undermine solidarity. I offer multiple examples of how current and future dissemination of these targeted cancer drugs threaten a commitment to solidarity. An alternative is to fund more cancer prevention efforts. However, that too proves a threat to solidarity. Solidarity, with or without a sense of justice, is too abstract a notion to address these challenges. Further, we need to accept that we can only hope to achieve “rough justice” and “supple solidarity.” The precise practical meaning of these notions needs to be worked out through a fair and inclusive process of rational democratic deliberation, which is the real and practical foundation of just solidarity. (shrink)

Now in its fourth edition, Rational Diagnosis and Treatment: Evidence-Based Clinical Decision - Making is a unique book to look at evidence-based medicine and the difficulty of applying evidence from group studies to individual patients._ The book analyses the successive stages of the decision process and deals with topics such as the examination of the patient,_the reliability of clinical data, the logic of diagnosis, the fallacies of uncontrolled therapeutic experience and the need for randomised clinical trials and meta-analyses. (...) It is the main theme of the book that, whenever possible, clinical decisions must be based on the evidence from clinical research, but the authors also explain the pitfalls of such research and the problems involved in applying evidence from groups of patients to the individual patient._ For this new edition, the sections on placebo and meta-analysis and on alternative medicine have been thoroughly updated, and there is more focus on insufficient reporting of harms of interventions. The sections on different research designs describe advantages and limitations, and the increased medicalisation and the effects of cancer screening on health people are noted. A section on academic freedom when clinicians collaborate with industry and ghost authors is added._ This essential reference work integrates the science and statistical approach of evidence-based medicine with the art and humanism of medical practice; distinguishing between data, sets of data, knowledge and wisdom, and their application. Such an intellectually challenging book is ideal for both medical students and doctors who require theoretical and practical clinical skills to help ensure that they apply theory in practice. (shrink)

Over the past several decades, we devoted much energy to generating, reviewing and summarizing evidence. We have given far less attention to the issue of how to thoughtfully apply the evidence once we have it. That’s fine if all we care about is that our clinical decisions are evidence-based, but not so good if we also want them to be well-reasoned. Let us not forget that evidence based medicine (EBM) grew out of an interest in making medicine ‘ (...) class='Hi'>rational’, with the idea that rational clinical evaluations should be evidence-based. I agree with the uncontroversial statement that the best decision is supported, at least in part, by the best available evidence. Rationality, however, is constituted by reasoning, not evidence. Complete arguments are necessary for rational evaluations, arguments that begin with general evidence and end in a conclusion about a particular patient. In order to traverse these inferential gaps, medicine must address the issue of how to establish, as an intermediate premise, what the evidence has to say about the efficacy of an intervention for particular patients in a particular practice setting. (shrink)

Commercial genetic testing offered over the internet, known as direct-to-consumer genetic testing (DTC GT), currently is under ethical attack. A common critique aims at the limited validation of the tests as well as the risk of psycho-social stress or adaption of incorrect behavior by users triggered by misleading health information. Here, we examine in detail the specific role of advertising communication of DTC GT companies from a medical ethical perspective. Our argumentative analysis departs from the starting point that DTC GT (...) operates at the intersection of two different contexts: medicine on the one hand and the market on the other. Both fields differ strongly with regard to their standards of communication practices and the underlying normative assumptions regarding autonomy and responsibility. Following a short review of the ethical contexts of medical and commercial communication, we provide case examples for persuasive messages of DTC GT websites and briefly analyze their design with a multi-modal approach to illustrate some of their problematic implications. We observe three main aspects in DTC GT advertising communication: (1) the use of material suggesting medical professional legitimacy as a trust-establishing tool, (2) the suggestion of empowerment as a benefit of using DTC GT services and (3) the narrative of responsibility as a persuasive appeal to a moral self-conception. While strengthening and respecting the autonomy of a patient is the focus in medical communication, specifically genetic counselling, persuasive communication is the normal mode in marketing of consumer goods, presuming an autonomous, rational, independent consumer. This creates tension in the context of DTC GT regarding the expectation and normative assessment of communication strategies. Our analysis can even the ground for a better understanding of ethical problems associated with intersections of medical and commercial communication and point to perspectives of analysis of DTC GT advertising. (shrink)

This paper argues that doctors ought to make all things considered value judgments about what is best for their patients. It illustrates some of the shortcomings of the model of doctor as 'fact-provider'. The 'fact-provider' model fails to take account of the fact that practising medicine necessarily involves making value judgments; that medical practice is a moral practice and requires that doctors reflect on what ought to be done, and that patients can make choices which fail to express their (...) autonomy and which are based on mistaken judgments of value. If doctors are properly to respect patient autonomy and to function as moral agents, they must make evaluations of what their patients ought to do, all things considered. This paper argues for 'rational, non-interventional paternalism'. This is a practice in which doctors form conceptions of what is best for their patients and argue rationally with them. It differs from old-style paternalism in that it is not committed to doing what is best. (shrink)

Although most theorists of healthcare rationing argue that rationing, including rationing that takes place in the physician–patient relationship is unavoidable, some health professionals strongly disagree. In a recent essay, Vegard Bruun Wyller argues that bedside rationing is immoral and thoroughly at odds with a sound view of the physician–patient relationship. We take Wyller to be an articulate exponent of the reluctance to participate in rationing found among some clinicians. Our essay attempts to refute the five crucial premises of his argument (...) yet build on his genuine insights. In our analysis, Wyller’s critique of bedside rationing is instructive both for harbouring some very common misconceptions that must be exposed and refuted, but also for offering important words of caution. In particular, bedside rationing must be performed in ways that do not harm the physician–patient relationship. Read irenically, Wyller’s critique is a reminder of what must not be lost in our painful endeavour to update the ethics of medicine to encompass the unavoidability of rationing. (shrink)

There is a venerable philosophical tradition that views human beings as intrinsically rational, though even the most ardent defender of this view would admit that under certain circumstances people’s decisions and thought processes can be very irrational indeed. When people are extremely tired, or drunk, or in the grip of rage, they sometimes reason and act in ways that no account of rationality would condone. About thirty years ago, Amos Tversky, Daniel Kahneman and a number of other psychologists began (...) reporting findings suggesting much deeper problems with the traditional idea that human beings are intrinsically rational animals. What these studies demonstrated is that even under quite ordinary circumstances where fatigue, drugs and strong emotions are not factors, people reason and make judgments in ways that systematically violate familiar canons of rationality on a wide array of problems. Those first surprising studies sparked the growth of a major research tradition whose impact has been felt in economics, political theory, medicine and other areas far removed from cognitive science. In Section 2, we will sketch a few of the better known experimental findings in this area. We’ve chosen these particular findings because they will play a role at a later stage of the paper. For readers who would like a deeper and more systematic account of the fascinating and disquieting research on reasoning and judgment, there are now several excellent texts and anthologies available. (shrink)

As practiced, medicine bumps along with the rest of us, doing its level best to cope with the contingencies of this often heartbreaking world. Yet it's a commonplace that much of medicine's self‐image, and a good deal of its cultural heft, come from its connection with the natural sciences and, what's more, from a picture of science that has a touch of the transcendental, highlighting the unmatched rigor of its procedures, its exacting rationality, and the reliability of its (...) results.In contrast, the very idea of “queer” carries with it a little taste of the uncanny. What we're inclined to label queer resists understanding, not so much because it's too complicated, but because it tends to be too slippery to capture neatly in our conceptual nets—that queer ache in your side, for instance, or your partner's queer notion of doing laundry. The outmoded use of “queer,” as a way to refer disparagingly to gay people, carried similar uncanny connotations: the unnatural, the perverse.One might think, then, that the reclamation of “queer” as an umbrella term referring to the lesbian, gay, bisexual, and transgender spectrum has a pleasing depth to its irony—not only does it wrench the customary direction of evaluation conveyed by the word from condemnation to celebration, but it also hints that what you find comprehensible depends a good deal on who you are and where you're standing. What from the perspective of many heterosexual and cisgendered people may seem opaque, exotic, threatening—erotic love directed toward someone with the same kind of body you have, lives lived in ways that challenge the immutability of birth‐assigned gender—are to LGBT folk not uncanny at all, but as familiar as breathing.I like this conceit, but alas, it is too simple. It slights the variety of difficulties associated with making sense of queerness that can vex deeply thoughtful people of undoubted good will—as I found out some years ago when I first talked about my efforts to understand my own transgender identity with a ferociously intelligent, highly sophisticated friend. (shrink)

This chapter examines some of Stone and Parker's “seepage,” looking at episodes that provide excellent cases of the core ideas of libertarianism. One reason for rejecting paternalism is that it causes unintended bad consequences. Libertarians argue that by legalizing illicit substances, supply will increase and, as a result, crime will decrease. Another way to argue in favor of libertarianism is based on the idea that each individual is a rational agent and, because of this, their decisions should be respected. (...) One must be clear when discussing what it means to “respect an individual's agency.” We must respect people because they are autarchic, but not necessarily because of their autonomy. We don't hold non‐autarchic people fully responsible for their actions, nor should we allow them to be fully free from paternalistic influence. (shrink)

Classical medicine operates in a climate of rational discourse, scientific knowledge accretion and the acceptance of ethical standards that regulate its activities. Criticism has centred on the excessive technological emphasis of modern medicine and on its social strategy aimed at defending exclusiveness and the privileges of professional status. Alternative therapeutic approaches have taken advantage of the eroded public image of medicine, offering treatments based on holistic philosophies that stress the non-rational, non-technical and non-scientific approach to (...) the unwell, disregarding traditional diagnostic categories and concentrating on enhancing subjective comfort and well-being, but remaining oblivious to the organic substrate of disease. This leads to questionable ethics in terms of false hopes and lost opportunities for effective therapy. (shrink)

Some philosophers have tried to establish a connection between the normativity of instrumental rationality and the paradox presented by Lewis Carroll in his 1895 paper “What the Tortoise Said to Achilles.” I here examine and argue against accounts of this connection presented by Peter Railton and James Dreier before presenting my own account and discussing its implications for instrumentalism (the view that all there is to practical rationality is instrumental rationality). In my view, the potential for a Carroll-style regress just (...) shows us that since instrumental rationality involves a higher-order commitment to combine our willing an end with our taking the necessary means, it therefore cannot, on pain of regress, itself be added as a conjunct to one of the elements to be combined. This view does not support instrumentalism. (shrink)

The introduction of the modern diagnostic and therapeutic procedures to the medical practice provided a new challenge for the medicine. The art of medicine, with its default purpose of acting for the benefit of health, is therefore required to derive from technological progress effectively and rationally. As a result, the medical ethics has been engaged with the rules of economy and management of deficit medical procedures as well as their rational and fair distribution. The above suggests, that (...) medics, given these recourses, should approach each patient with a consideration to their therapeutic rights. However, the physicians cannot just concentrate on the good of one particular patient, but must take into account joint responsibility for the good of a potential patient. This makes medical ethical dilemmas similar to the ethical issues of business. The notion of responsibility is the key for discriminating these two kinds of ethics. (shrink)

Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as “beneficial,” “effective,” or even “futile,” the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient (...) Greek philosophical conundrum known as the “sorites paradox.” I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing). (shrink)

This paper is an attempt to reframe the debate of whether medicine is an art or a science in the Aristotelian sense. The recent book of Pellegrino and Thomasma, A Philosophical Basis of Medical Practice, serves as the starting point. Taking clinical interaction as the distinctive feature of medicine, the resemblances of medicine with the characteristics of practical reasoning in the Aristotelian sense are further explored. This comparison proves especially useful in discussing the special status of medical (...) knowledge. Clinical reasoning, resulting in clinical judgments, shows strong similarities with practical reasoning. The application of general principles, instead of deduction from them as in science is essential to both. The ancient concept of practical rationality may therefore be more appropriate while trying to ascribe rationality to medicine than the modern concept of rationality, associated solely with scientific reasoning. (shrink)

Given the inevitability of scarcity, should public institutions ration healthcare resources so as to prioritize those who contribute more to society? Intuitively, we may feel that this would be somehow inegalitarian. I argue that the egalitarian objection to prioritizing treatment on the basis of patients’ usefulness to others is best thought of as semiotic: i.e. as having to do with what this practice would mean, convey, or express about a person's standing. I explore the implications of this conclusion when taken (...) in conjunction with the observation that semiotic objections are generally flimsy, failing to identify anything wrong with a practice as such and having limited capacity to generalize beyond particular contexts. (shrink)

Given the inevitability of scarcity, should public institutions ration healthcare resources so as to prioritize those who contribute more to society? Intuitively, we may feel that this would be somehow inegalitarian. I argue that the egalitarian objection to prioritizing treatment on the basis of patients’ usefulness to others is best thought of as semiotic: i.e. as having to do with what this practice would mean, convey, or express about a person’s standing. I explore the implications of this conclusion when taken (...) in conjunction with the observation that semiotic objections are generally flimsy, failing to identify anything wrong with a practice as such and having limited capacity to generalize beyond particular contexts. GPI Working Paper No. 3-2019. (shrink)

In ancient Greece and Rome magical and religious healing continued to be practised at the same time as a burgeoning of research and learning in the natural sciences was promoting a seemingly more rational and scientific approach to medicine. Was there, then, a dichotomy in medical treatment or was the situation more complex? This paper draws on historical textual sources as well as archaeological research in examining the question in more detail. Some early texts, such as the Egyptian (...) papyri from about 2,600 bc and the Hippocratic Corpus from the third and fourth centuries bc, contain an intriguing mixture of scientific and religious material. Archaeological evidence from, for example, sites of healing sanctuaries from ancient times, show medical prescriptions used as part of votive offerings and religious inscriptions on surgical instruments, while physicians were prominent among donators to shrines. Other archaeological finds such as the contents of rubbish tips, buried hoards, sepulchral deposits and stray artefacts from occupation levels, have also added to the archive of medical material available for discussion. The paper concludes that such intertwinings of religion and science were not only common in Roman medicine but, in fact, continue into the present time. (shrink)

This issue of The Journal of Medicine and Philosophy assesses the deep and abiding tensions that exist among the competing epistemic perspectives that bear on medicine and morality. Concepts of health and disease, as well as the theoretical framing of medical ethics and health care policy, intersect with an overlapping set of culturally situated communities, striving to understand and manipulate the world in ways that each finds explanatory, appropriate, or otherwise befitting. The articles explore the complexities of framing (...) public health care policy to guide bioethical decision making in the face of the plurality of ethical viewpoints and moral rationalities—including health enhancing supplements, continuous sedation until death, medical futility, the protection of vulnerable populations, and competing professional obligations. (shrink)

Clinical decisionmaking includes reasoning from prescientific or scientific theories, reasoning from uncontrolled or controlled experience, and reasoning based on empathic understanding and moral beliefe. The development of contemporary clinical thinking is discussed, and it is found that successive generations of medical practitioners have had different views of the rationality and relative importance of these modes of reasoning: that which is considered rational by one generation of doctors is sometimes denounced by the next. The author's book, Rational Diagnosis and (...) Treatment , which is an example of clinical thinking in the 1960s and early 70s, is used to illustrate one particular view of clinical decisionmaking. Keywords: rational, clinical decisionmaking, biological theory, controlled clinical studies, empathic understanding, ethical reasoning CiteULike Connotea Del.icio.us What's this? (shrink)

SummaryDavid Hartley's Observations provides an example from the history of medicine of the bearing of theories of the relationship between body and mind on the problem of morality and free will. Further, Hartley's solution requires a distinction between two understandings of what it means for morality to be rationally grounded. The kind of ethics which can be established for moral agents on the basis of medical knowledge alone (and for which Hartley's “Rule of Life” presents but one historical example) (...) has been termed ‘therapeutic’ It leads to a viewpoint in which it is difficult, if not impossible, to distinguish between the kinds of reasons for supporting morals and the kinds of reasons for supporting good teeth. The kind of ethics which requires additional grounds entering into the motivation of the agent himself has been termed “rational.” This distinction between therapeutic and rational ethics rests on the more basic distinction between general and particular grounds on which to establish a rational system of ethics. As a result, the initial problem of how any account of the body-mind relation might allow for the possibility of ethics leads to the more interesting problem of how a therapeutic interpretation of ethics, which is possible on the grounds of medical knowledge, might be reconciled with a fully rational interpretation of ethics which we require on philosophical grounds. “Medical ethics” has traditionally been viewed as the application of concepts from philosophical ethics to the specific problems presented in medical practice. In consequence of the second problem exposed here, it would be useful to extend the domain of medical ethics from the level of concepts and cases to the level of interpreting the rational grounds for those concepts. Otherwise one may fail to distinguish a medical view of ethics from an ethical view of medicine. (shrink)