Medical Epistemology

This paper explores the characteristics of the professional identity of the Doctors of Korean Medicine (KMD), a medical profession in South Korea practicing traditional East Asian medicine. They play a primary care role in healthcare, notwithstanding the legally limited purview of their clinical and public health roles. This mainstream position came their way through biomedicalization that occurred in the profession in the context of the country's private sector-led health system. Based on data gathered among KMDs and in state-level policymaking scenes as an insider, this paper aims to illustrate the characteristics of KMDs' identity by attending to multiple levels of their presence as modern medical profession. In doing so, it draws on works that explored medical identity, Simon Sinclair's (1997) Making Doctors: An Institutional Apprenticeship in particular, to show that despite their similarities to biomedical practitioners, KMDs exhibit discriminating characteristics in their professional consciousness.

There are some philosophical questions that can be answered without attention to the social context in which evidence is produced and distributed. Abstracting away from social context is an excellent way to ignore messy details and lay bare the underlying structure of the limits of inference. Idealization is entirely appropriate when one is essentially asking: In the best of all possible worlds, what am I entitled to infer? Yet, philosophers' concerns often go beyond this domain.  As an example I examine the debate on mechanistic evidence and then reevaluate a canonical case study in this debate. I show that for the assessment of actual evidence, produced in a world that is far from ideal, omission of the social aspects of medical epistemology (e.g. commercial drivers of medical research) leads philosophers to draw the wrong lessons from cases they take as paradigmatic cases for their views. I close by arguing that social epistemology provides an avenue to incorporate these complications and provides the necessary framework to understand medical evidence.

Depuis l’Antiquité, on se livre à des calculs pour estimer la durée de la grossesse. Au fil du temps, la notion de terme gestationnel a changé de sens, passant de l’idée d’intervalle pendant lequel la naissance survient, spontanément (lorsque le « fruit est mûr »), à un concept normatif postulant une « durée optimale de grossesse » de plus en plus serrée et assorti d’une « date prévue d’accouchement ». Le passage d’une appréhension naturaliste à une construction logicomathématique du terme gestationnel, conjugué à la découverte de moyens de « produire la naissance » à la demande, a entraîné la pratique sans cesse en augmentation – dans le monde « médicalement occidentalisé » – du déclenchement artificiel de l’accouchement et de la césarienne programmée. L’article propose un examen critique de la rationalité sur laquelle s’appuie cette programmation et en présente les implications insuffisamment appréciées.

Plan de l'article

    ◀ Prévoir la durée de la grossesse : l’histoire d’un calcul et de ses implications
    ◀ Formaliser la durée « optimale » de la grossesse
    ◀ Produire l’accouchement
        ■ Méthodes
        ■ Incidence
        ■ Motifs
    ◀ La césarienne programmée, ou le déclenchement « chirurgical »
    ◀ Repenser le terme selon des paramètres biologiques, évolutionnaires
    ◀ Contrer la mortinaissance et la peur du ventre maternel... par la production iatrogène de prématurés
    ◀ Naît-on encore ?

Arguments that medical decision making should rely on a variety of evidence often begin from the claim that meta-analysis has been shown to be problematic. In this paper, I first examine Stegenga's (2011) argument that meta-analysis requires multiple decisions and thus fails to provide an objective ground for medical decision making. Next, I examine three arguments from social epistemologists that contend that meta-analyses are systematically biased in ways not appreciated by standard epistemology. In most cases I show that critiques of meta-analysis fail to account for the full range of meta-analytic procedures. In the remainder of cases, I argue that the critiques identify problems that do not uniquely cut against meta-analysis. I close by suggesting one reason why it may be pragmatically rational to violate the principle of total evidence and by outlining the criteria for a successful argument against meta-analysis. A set of criteria I contend remain unmet.

The collection of health data to support a diagnostic experience is as old as the creation of the first hospitals. However, the mass of data processed and the new capabilities offered by artificial intelligence are now opening the way to predictive medicine and even selection. If the short-term benefits seem obvious, what are the impacts on patient freedom, physician responsibility, solidarity of insurance and health systems? This study examines the political and ethical issues involved in the algorithmic processing of patient health data and critically questions the predictions that can be derived from it. These new information-processing mechanisms in the field of health require to distinguish between budgetary stakes, the alleged promise of an end to illness through the use of technology and its marketing grounds, and the real possibilities opened up by scientific research. This study finally proposes a new ethics of health care in the digital age capable of integrating the dazzling ICT developments of recent decades within a normative framework that is fully concerned with respect of human dignity.

The aim of this essay is to elaborate philosophical and ethical underpinnings of posthumous diagnosis of famous historical figures based on literary and artistic products, or commonly called retrospective diagnosis. It discusses ontological and epistemic challenges raised in the humanities and social sciences, and attempts to systematically reply to their criticisms from the viewpoint of clinical medicine, philosophy of medicine, particularly the ontology of disease and the epistemology of diagnosis, and medical ethics. The ontological challenge focuses on the doubt about the persistence of a disease over historical time, whereas the epistemic challenge disputes the inaccessibility of scientific verification of a diagnosis in the past. I argue that the critics are in error in conflating the taxonomy of disease (nosology) and the act of diagnosing a patient. Medical diagnosis is fundamentally a hypothesis-construction and an explanatory device that can be generated under various degrees of uncertainty and limited amount of information. It is not an apodictic judgment (true or false) as the critics presuppose, but a probabilistic (Bayesian) judgment with varying degrees of plausibility under uncertainty. In order to avoid this confusion, I propose that retrospective diagnosis of a historical figure be syndromic without identifying underlying disease, unless there is justifiable reason for such specification. Moreover it should be evaluated not only from the viewpoint of medical science but also in a larger context of the scholarship of the humanities and social sciences by its overall plausibility and consistency. On the other hand, I will endorse their concerns regarding the ethics and professionalism of retrospective diagnosis, and call for the need for situating such a diagnosis in an interdisciplinary scope and the context of the scholarship of the historical figure. I will then enumerate several important caveats for interdisciplinary retrospective diagnosis using an example of the retrospective diagnosis of Socrates for his lifelong intermittent neurologic symptoms. Finally, I will situate the present argument in a larger context of the major debate among the historians of medicine and paleopathologists, and discuss the similarities and differences.

This paper examines an early attempt to purge the medical field of commercial exploitation and promote rational therapeutics (one might say "evidence-based medicine").  The historical study of the origin of the double-blind RCT as a standard of therapeutic efficacy reveals that concerns which seem entirely modern, are actually deeply entrenched in the history of medical research.  Specifically, those whose primary concern was with ending the use of inefficacious, and sometimes positively dangerous drugs, found themselves in an ideological battle with those who benefitted financially from their use.

I would like to talk about Lorenzano's work in the field of philosophy of medicine with one caveat. César Lorenzano has written a lot about the most varied topics of medicine. About the causality, the medical diagnosis, about the basic sciences, about the incommensurability between the ancient and modern medicine, about the reference and representation and the medical interpretation. He made a reconstruction of biochemistry, immunology and physiology. He wrote about the structure of psychiatry and freudian hysteria. He spoke about the structure of medicine, about medical epistemology, he was involved in various works of education, and the social importance of medicine. He reconstructed the infectious theory of diseases.
Within the development of the philosophy of medicine, I recognize three parts that have evolved over time. The first is the pre-analytical, which in fact is not part of the philosophy of medicine, because in fact as such, did not exist. The second begins in 1976, when the first works that propose an analysis of the structure of medical knowledge appear. And the third, which is the last one, which is when the diagnosis and therapeutics are included, as territories of medical praxis. Why do I make this separation? Because in each of the two areas that correspond to the philosophy of medicine, the contributions of César Lorenzano were founding for its development.
This work seeks to be a very compact summary of his work in an specific area of the Philosophy of Medicine.

In decision-making concerning the diagnosis and treatment of patients, doctors have a responsibility to do this to the best of their abilities. Yet, we argue that the current paradigm for best medical practice - Evidence-Based Medicine (EBM) – does not always support this responsibility. EBM was developed to promote a more scientific approach to the practice of medicine. This includes the use of randomized controlled trials (RCTs) in the testing of new treatments and prophylactics and rule-based reasoning in clinical decision-making. But critics of EBM claim that such a scientific approach does not always work in the clinic. In this article we build on this critique and argue that rule-based reasoning and the use of general guidelines as promoted by EBM does not accommodate the complex reasoning of doctors in clinical decision-making. Instead we propose that a new medical epistemology is needed that accounts for complex reasoning styles in medical practice, and at the same time maintains the quality usually associated with “scientific”. The medical epistemology we propose  conforms the epistemological responsibility of doctors, which involves a specific professional attitude and epistemological skills. Instead of deferring part of the professional responsibility to strict clinical guidelines, as EBM allows for, our alternative epistemology holds doctors accountable for epistemic considerations in clinical decision-making towards the diagnosis and treatment plan of individual patients. One of the key intellectual challenges of doctors is the ability to bring together heterogeneous pieces of information to construct a coherent “picture” of a specific patient. In the proposed epistemology, we consider this “picture” as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient.

What proponents of evidence-based medicine (EBM) failed to acknowledge, in my view, is the fact that if the knowledge source of medicine is mainly derived from the results of randomized clinical trials (RCTs) —and being them mostly Big Pharma-funded—, the evidence base of medicine is biased or distorted in favor of the interests of the funder, instead of patients´ needs. Since a RCT is simply a technique and, as such ―in accord with Heidegger― is not neutral, the design and implementation of a RCT is an (expensive) act of investment in the service of the funder´s objectives, above all, a proper financial return. Big Pharma´s rationality is no doubt profit-maximization. Rather, medicine´s reason of being is, in principle, the singularity of the patient´s problems in the real world. This essay´s point of departure is the following question: How do doctors know what they know is really true? The main concern here is the means of formation of the medical knowledge base in an era in which the pharmaceutical industry —through its strong influence on medical education and medical publishing— controls (and manipulates) both the production and dissemination of medical “knowledge” thanks to its ubiquitous, worldwide apparatus of symbolic legitimation. In this sense, the analysis of the Vioxx case illustrates contemporary medicine´s profound dilemma and role in regard to a context where global firms ―under the evidence-based medicine´s disguise― tell practicing physicians what to think is true and which prescription drug to choose in each patient encounter. If medicine has to be evidence-based and the base of evidence is money-driven and industry-determined, how can the medical profession get away from its own adulteration?

In this paper I analyse the dissent around evidence standards in medicine and pharmacology as a result of distinct ways to address epistemic losses in our game with nature and the scientific ecosystem: an " elitist " and a " pluralist " approach. The former is focused on reliability as minimisation of random and systematic error, and is grounded on a categorical approach to causal assessment, whereas the latter is more focused on the high context-sensitivity of causation in medicine and in the soft sciences in general, and favours probabilistic approaches to scientific inference, as better equipped for defeasibility of causal inference in such domains. I then present a system for probabilistic causal assessment from heterogenous evidence that makes justice of concerns from both positions, while also incorporating " higher order evidence " (evidence/information about the evidence itself) in hypothesis confirmation.

Clinical equipoise (CE) has been proposed as an ethical principle relating uncertainty and moral leeway in clinical research. Although CE has traditionally been indicated as a necessary condition for a morally justified introduction of a new RCT, questions related to the interpretation of this principle remain woefully open. Recent proposals to rehabilitate CE have divided the bioethical community on its ethical merits. This paper presents a new argument that brings out the epistemological difficulties we encounter in justifying CE as a principle to connect uncertainty and moral leeway in clinical ethics. The argument proposes, first, that the methodology of hypothetical retrospection (HR) is applicable to the RCT design and that it can accommodate uncertainty. As currently understood, however, HR should give up its reliance on the assumption of uncertainty transduction (UT), because the latter assumes the principle of indifference, which does not accommodate uncertainty in the right way. The same principle is then seen to distort also the received interpretations of CE.

In this article, I deploy the notions of narrative and discernment as complementary support tools in understanding the moral significance of the first-person perspective in mental health. My aim is to develop and extend moral particularism’s emphasis on the significance of context and the general problem of relevance in understanding the dynamics of practical judgement and shared decision-making as applied to comprehensive diagnosis and integrated treatment. I argue that it is a mistake to think of the values embedded in responsible integrated care and patient involvement as either determined by the individual patient’s autobiographical narrative or as determined by the ‘top-down’ conception of health as presented in the biomedical model.  What is missing in accounting for the idea of clinical decision-making as a shared enterprise is a relational account of the person and the wider diagnostic treatment context in understanding the process of perspective-taking. Such reorientation of focus makes available a distinctive conception of clinical knowledge, in which claims to objective meaning in patient narratives are criticised not as false per se, but as failing to yield the insight into the problem it was the point of those claims to provide.

Background: Clinical empathy has been repeatedly shown to increase patient satisfaction and improve clinical outcomes; therefore it forms an important cornerstone of the physician-pa- tient therapeutic relationship. While some studies have shown that empathy in medical students decreases over the course of their education, other studies have contested these findings.

Purpose: This paper reviews studies and relevant litera- ture in order to explore the relationship between medical ed- ucation and clinical empathy, and in particular, the difference in results between those studies that demonstrated a decline in clinical empathy and those studies that did not.

Conclusion: Study design and methodology, differences in clinical culture, and differences in curriculum were identi- fied as three possible influences that explain the lack of con- sensus in the literature. This paper recommends a twofold approach to further research in the field of clinical empathy development. First, future studies examining this phenomenon should focus on longitudinal designs that incorporate objective measures and patient factors rather than relying exclusively on cross-sectional studies utilising self-assessment. Second, med- ical schools should be encouraged to adopt or develop tech- niques to assess the clinical empathy of their students and im- plement solutions to mitigate a decline in empathy if required.

The aim of this essay is to elaborate philosophical and ethical underpinnings of posthumous diagnosis of famous historical figures based on literary and artistic products, or commonly called retrospective diagnosis. It discusses ontological and epistemic challenges raised in the humanities and social sciences, and attempts to systematically reply to their criticisms from the viewpoint of clinical medicine, philosophy of medicine, particularly the ontology of disease and the epistemology of diagnosis, and medical ethics. The ontological challenge focuses on the doubt about the persistence of a disease over historical time, whereas the epistemic challenge disputes the inaccessibility of scientific verification of a diagnosis in the past. I argue that the critics are in error in conflating the taxonomy of disease (nosology) and the act of diagnosing a patient. Medical diagnosis is fundamentally a hypothesis-construction and an explanatory device that can be generated under various degr...

This paper presents and defends an integrated view of the placebo effect, termed " affective-meaning-making " model, which draws from theoretical reflection, clinical outcomes and neurophysiological findings. We consider the theoretical limitations of those proposals associated with the " meaning view " on the placebo effect which (i) leave the general aspects of meaning unspecified, (ii) fail to fully analyse the role of emotions and affect, and (iii) establish no clear connection between the theoretical, physiological and psychological aspects of the effect. We point out that a promising way to overcome these limitations is given by grounding the placebo effect on Peirce " s theory of meaning, in which the role of the meaning constitution and change is placed in logical and objective structures. We also show the connection between our theoretical proposal and the appraisal theory, and integrate it with emotion regulation.

The conception of contagious disease that Girolamo Fracastoro provides in his work De contagione et contagiosis morbis (1546), marks the origin of modern epidemiology and microbiology. This conception puts into play the Galenic and Aristotelian traditions of research, faced with its own conceptual limitations of the growing mechanistic thought of the time. According to Fracastoro, epidemic diseases spread by invisible living germs called seminaria (seedbed), begotten by corrupted humours. Fracastoro resorted to the old notions of "sympathy" and "antipathy" to respond to questions about how seminaria is transmitted from one body to another, and what is the specificity that limits its transmission to certain species and organs. Like Galileo and Descartes, Fracastoro tries to establish a dialogue in the field of medicine between the Aristotelian vitalism and the modern mechanistic perspective. The purpose of this paper is to highlight the ideological, theoretical and conceptual assumptions, both philosophical and scientific, assumed by Fracastoro with regard to the problem of contagion.

مقال عن تدهور الطب والتعليم الطبي في القرن الثالث عشر في العراق وسورية  كما وصف في كتاب عبد اللطيف البغدادي المسمى: كتاب النصحيتين (المولود والمتوفي في بغداد 1231م)
Decline and Decadence in Iraq and Syria after the Age of Avicenna? 'Abd al-La. tīf al-Baghdādī (1162-1231) between Myth and History n. p e t e r j o o s s e a n d p e t e r e. p o r m a n n Summary: 'Abd al-La. tīf al-Baghdādī's (d. 1231) work Book of the Two Pieces of Advice (Kitāb al Nas¯ı. hatayn) challenges the idea that Islamic medicine declined after the twelfth century AD. Moreover, it offers some interesting insights into the social history of medicine. 'Abd al-La. tīf advocated using the framework of Greek medical epistemology to criticize the rationalist physicians of his day; he argued that female and itinerant practitioners, relying on experience, were superior to some rationalists. He lambasted contemporaneous medical education because it put too much faith in a restricted number of textbooks such as the Canon by Ibn Sīnā (Avicenna, d. 1037) or imperfect abridgments.

This chapter explores AI through a philosophical and ethical lens. This includes an examination of how AI impacts on medicine in terms of uses and promises, limitations, and risks, as well as key questions to consider. While AI offers scope for complex and large-scale data processing, with the promise of an increase in efficiency and precision, some central limitations need to be highlighted. The use of AI also brings some pertinent and predictable, as well as unpredictable risks, such as those due to biases. Also considered is what may be lost where AI replaces established processes, not least those relational and interpersonal aspects that are central to healthcare. By covering these and related issues, this chapter offers ways to evaluate, and also balance, key benefits and risks arising from the application of AI to the medical sector.

Scientists tend to be interested in the nature and the behavior of kinds of things, such as accelerating objects and that what is considered scientific knowledge is of generalizations: for instance, propositions about all freely falling bodies, not about any particular one (Audi, 1998, p. 247). However, clinical knowledge has to do with individually considered facts, such as symptoms, signs, disturbances and diseases. This essay explores the epistemological nature of the medical knowledge in terms of the following questions: Is it art? Is it science? If it is science, what kind of science is medicine? Evidence-based medicine (EBM) tries to base medicine on scientific grounds, however, the results of “the gold standard” of EBM, i.e., the randomized clinical trial (RCT), are poorly generalizable. Thus, if medical knowledge cannot be based on clinical experience and judgement alone, someone else, out of the medical profession, is determining what is considered medical knowledge. This article discusses the scientificity of the Western medical practice and the singularity of the patients in relation to the current apparatus of knowledge production and dissemination in contemporary medicine.

The standard philosophical definition of placebos offered by Grünbaum is incompatible with Cartwright's conception of randomized clinical trials. I offer a modified account of placebos that respects this role and clarifies why many current medical trials fail to warrant the conclusions they are typically seen as yielding. I then consider recent changes to guidelines for reporting medical trials and show that pessimism over parsing out the cause of " unblinding " is premature. Specifically, using a trial of antidepressants, I show how more sophisticated statistical analyses can parse out the source of such effects and serve as an alternative to placebo control.

Wolfgang Herrndorf hat sein Weblog »Arbeit und Struktur« über drei Jahre lang während seiner Hirntumorerkrankung bis zu seinem Suizid geführt und selbst zur späteren Veröffentlichung in Buchform bestimmt. Gattungstheoretisch bedient sich der Text der Form des »Illness diary« bzw. des »Cancer blog«, doch sticht er zugleich aus dieser Gattung durch seine elaborierte, eigenständige Narration heraus und gehört zu den eindrücklichsten Beispielen für medizinisch-literarische Grenzgänge in der Gegenwartsliteratur. Diese Sonderstellung gründet vor allem in der Art, in der medizinisches Fachwissen (Fachartikel, Graphiken zur Überlebenswahrscheinlichkeit, Diagnostikwerkzeuge) eingesetzt, reflektiert und literarisch
entwickelt wird. Die Gestaltung ist nicht mehr eindeutig einer Sprache der Literatur oder einer Sprache der Medizin zuzuordnen und stellt insofern eine Herausforderung für beide Wissensbereiche dar.

This paper examines some neglected aspects of Hippocratic medicine, drawing special attention to certain methodological questions concerning the role of sense perception in the acquisition of medical knowledge. I argue that there is greater epistemological uniformity among the texts of the Hippocratic Corpus than is sometimes assumed. I provide a careful reading of seemingly inconsistent Hippocratic treatises in the light of a plausible and coherent epistemological model. The impression that we are dealing with different, indeed inconsistent, epistemological views can be explained by the specific dialectical contexts of each work and their historical background. Most importantly, a proper justification of this model will require us to delve into the epistemological foundations of Hippocratic medicine.

Within the evidence-based medicine (EBM) construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians’ primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the “best” evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients.

En médecine, l’outil statistique entre souvent dans la problématique complexe du rapport entre tout et partie. Ainsi, le dépistage sérique prénatal de la trisomie 21 repose sur la constatation statistique d'une corrélation entre le taux de certains marqueurs sériques maternels et la présence d'un fœtus atteint de trisomie 21. Le dosage des marqueurs permet alors un calcul de risque. Avec notre réglementation, 5% des femmes enceintes de moins de 38 ans appartiendront au groupe à risque. Après caryotype, seulement 1% des femmes de ce groupe verront leur risque confirmé (avec possibilité d'une IMG). Pour 99%, le test sérique actuel n’est donc pas fiable. L'importance des résultats « positifs » infirmés montre que la validité scientifique peut s'accompagner de malentendus médicaux entre patientes (parties) et puissance publique (totalité). Démarche globale et démarche particulière ne coïncident pas. Le hiatus, qui en 2002 a concerné 574.324 femmes, est donc à la fois un problème épistémologique complexe et un problème humain grave, facteur d’inquiétude, pour lesquels la philosophie de la médecine se voit interrogée. Le concept de pertinence peut être une clef intéressante.

Abstract: Evidence based medicine (EBM), the coveted standard of best practice in most areas of healthcare, holds the promise of systematizing clinical practice and improving patient care by making healthcare more responsive to research evidence. EBM's ...