Professional Documents
Culture Documents
doi:10.1093/jmp/jht044
GEORGE KHUSHF*
University of South Carolina, Columbia, South Carolina, USA
© The Author 2013. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc.
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462 George Khushf
headings. These categories have thus already been used to group a large
amount of the material we might identify, and standard textbooks on these
topics provide nice reviews of that material (Sackett et al., 2000; Jenicek and
Hitchcock, 2005; Sox et al., 2006; Guyatt et al., 2008). But these headings are
not sufficiently general for organizing all materials relevant to medical epis-
temology: they are both too broad, including things we would not want to
include, and they are too narrow, leaving out important areas that we would
consider important.
The question is now whether there is a higher-order general scheme that
can be used to sort all the various lower level groupings. The sought-for
general framework would provide a kind of synoptic overview that enables
us to see all the issues in proper relation to one another. This framework
lower level domains. Each of these relates to their base in roughly the way
that a philosophy of a special science relates to the special science it stud-
ies. Medical meta-epistemology then relates to epistemology in the way a
philosophy of a special science like physics relates to the more general field
of philosophy of science.
This seems to get us closer to the framework we need, but there is still
something that doesn’t quite work. The problem becomes clear if we move
to meta-epistemology and, from within that domain try to clarify the relation
between the descriptive and the normative. As soon as we do this, we notice
that the very distinction between descriptive and normative is implicated.
What are we doing when we seek to describe how human agents come to
know and use knowledge in practice settings? In doing this, our own appa-
and that is used to determine the perceived red blotches as a sign of a given
disease. The sign as categorized percept, implies a complex differential sys-
tem that sorts by inclusion and exclusion this instance of red blotches in
relation to other possible variants of red blotches. Somewhere in the midst of
this complex encoding, there is a primitive relation to an external world that
is mediated by the visual apparatus of the physician. This involves a kind of
knowledge of what is immediately given, and the function of atomic propo-
sitions is to encode this propositionally. There will then be propositions that
have this kind of immediate, qualitative, external support. These will be
associated with “evidence.” And there will be other propositions that arise
from complex inference chains associated with such evidence together with
various higher-order categories, empirical generalizations, and so on. Much
are not specific enough for conclusive diagnosis, and the treatment is rela-
tively expensive. When confronted with the nonspecific symptoms and the
absence of conclusive tests, a patient who has the disease can be dismissed,
with the inference that it is “all in his head.” Kennedy presents this as an
inappropriate overreaching of evidence. In the case she reviews, the patient
quickly responded to antibiotic treatment.
Kennedy’s second case concerns a patient with Addison’s disease. The
primary initial symptom was that of depressed mood in a patient who had
recently lost his spouse in a car accident. In this case, the presenting cir-
cumstances and symptoms naturally converged upon a diagnosis of depres-
sion. But when the symptoms increased and the patient repeatedly sought
medical assistance, physicians refused to reconsider the initial diagnostic
similar events in similar ways, and since they express their positive and neg-
ative reactions in similar ways (e.g., by smile or frown), emotions and their
expression provide important information about humans and their apprais-
als of their environment. They also play a role in regulating dispositions and
other cognitive processes associated with planning and action. EI is then
regarded as a general capacity to accurately monitor, identify, and distinguish
these organized human responses in the self and others, and also to utilize
this information in a purposeful way to guide thinking and action (Salovey
and Mayer, 1990, 189). Viewed in this way, emotions constitute important,
cognitively relevant information that needs to be detected and utilized when
considering and interacting with people. By following a complex medical
case, Marcum considers how EI might be used to discern information about
which is to provide a fitting response to that person who comes to the phy-
sician for help.
the perceptive capacities associated with evidence and the reasoning capaci-
ties that eventuate in some complex judgments remain tightly coupled in
a circuit whose transformations can be surveyed by the epistemic agent.
Behind the traditional epistemology, we have an intuition something like
that expressed by Edmund Husserl in his Logical Investigations (2001): it is
assumed that any complex, symbolically encoded proposition could only be
accepted as knowledge if it is possible to follow the chains back to primitive
acts of perception that are self-evident (Dummett, 1993). We can associate
this same view with a negative criterion: if the required chains of justifica-
tion run outward into some regions of the external world that cannot be
surveyed (an aspect of the social that is inaccessible to the epistemic agent)
and then, after some time gap, comes back transformed or augmented into
the practical kinds of knowledge considered in the last section. We say that a
social epistemology is required when there is at least one inaccessible extru-
sion, and thus the justification of the knowledge depends on social condi-
tions that are at least partly inaccessible to the epistemic agent.
Although a bit of a caricature, a physician’s clinical reasoning is often
presented in a way that roughly tracks traditional epistemology (for repre-
sentative examples, see the cases discussed in Cutler, 1998). The perceptive
component is expanded to include technologically mediated information, for
example, blood work or radiographic images. These expansions are often
regarded as straightforward augmentations of normal perceptions. Thus lab-
oratory microscopes and x-rays extend human vision, and stethoscopes and
ultrasound machines extend hearing. These extensions are not supposed to
thus could express knowledge that the physician could not directly obtain.
But this assumption about the evidentiary status of patient testimony is not
trivial. Alvin Goodman rightly notes how assertions about irreducible testi-
mony require a social epistemology: “the problem of testimony is a problem
of justification: what makes a hearer justified in accepting a report or other
factual statement by a speaker?” (Goldman, 2010, 627). From the perspective
of a traditional epistemology, testimony should be reducible. If it is irreduc-
ible, then there is an extrusion of the process that fixes the evidence, and
knowledge gets distributed among different epistemic agents.
Many studies have considered how the economy of medical knowl-
edge orients physicians in ways that discount patient testimony as relia-
ble (Canguilhem, 1991; Foucault, 1975; Engelhardt, 1996). This discounting
suboptimal health) and the physician’s judgment that the patient is, in fact,
well. Is the patient’s testimony simply the point of departure for other activi-
ties that get at the same evidence in a more direct way or, alternatively, is
the testimonial evidence irreducible? There is a kind of mismatch between
the testimonial evidence and the other kinds of evidence obtained by the
physician. Additional work is needed to bridge them. When physicians use
a traditional epistemology, priority is given to nontestimonial evidence and
an effort is made to reconstruct testimony so it better fits. When the patient
testimony is of value as an indicator of disease, then a physician can confirm
that evidence by finding other evidence that is independent of the patient’s
testimony. Alternatively, if the patient testimony is somehow irreducible as
evidence of an outcome of a medical intervention, then strange “instru-
The effect is thus an absence of action, that is, not smoking. This, in turn,
means there will be people who do not get cancer who otherwise would
have. The effect is then no effect in a double way: no smoking and no
cancer.
When primary prevention is considered in relation to diseases that are
prevented, Faust argues that we get a metaphysics of “causing not” that is
incompatible with general assumptions about cause in the scientific com-
munity. “The standard covariation theories of causation require that there be
a positive physical event in relation to the cause and effect. Or the standard
causal power theories require that some mechanism be in place to transmit
down a causal chain pathway. But how to reconcile that if nothing is done
then there is nothing . . .?” (Faust, 2013, 550). To avoid these problems, he
treatments, or services that are commonly used, expensive, and that do not
have a solid evidence base to support those uses. Blumenthal-Barby notes
how multiple criteria for what counts as low-value care might be used. “Low
value” might mean the test, treatment, or service has a small benefit, unlikely
benefit, or inefficient benefit. These meanings have different implications
for the way patients and physicians might be convinced to not utilize these
things that have low value. But in the “Choosing Wisely” initiative, these
value judgments are hidden from the public. Instead, we are just given
lists, and these are presented as evidence-based judgments of the profes-
sional organizations. Blumenthal-Barby seeks to make more transparent the
grounds for judgments of low value, so others might see the justificatory links
between the claims and the evidence and value judgments that justify these
The question is now how we can link these social epistemologies back to
the knowledge that resides in the heads and hearts of individuals, and that is
A Framework for Understanding Medical Epistemologies 481
concerned with truth and justification. As the perceptive act moves outside
individual perceptive awareness and into instruments like PROMs, Magnetic
Resonance Imaging procedures (MRIs), and pathology laboratories; and as
reasoning capacity moves outside of heart and head and into the informa-
tion systems and professional organizations that organize the bits of avail-
able knowledge and develop guidelines and clinical pathways that inform
clinical practices, questions concerning knowledge and its justification get
more complex. When the diverse ends of medicine and the practical reason-
ing that advances them are considered, yet another level of complexity is
added. With all this complexity, hopes for a synoptic framework for medical
epistemology seem to get more distant. Instead, we just seem to have many
provisional accounts of some part of an epistemic process, and any explicit
similar to the epistemic variant: what is knowledge and truth, and how are
these advanced in the arena of medicine? We try to get at these questions
by aggregating the hard won bits and pieces, but this effort at aggregation
gets overwhelmed when we reopen the black boxes associated with earlier
codifications and find the issues of justification were never quite cleaned up
in the manner we supposed. In the end, it is not clear whether the diverse
social discourses of justification might converge or not. Surely the discourse
is complex, and there are multiple strands that need to be accounted for
if any adequate account of optimal health or knowledge and truth is to be
obtained. But can we infer from this complexity that the plurality is irreduc-
ible and the pursuit of knowledge and truth subverted? Such inferences too
quickly move from our uncertainty to positive claims about what is possible,
Notes
1. Steup (2012) provides a nice overview of philosophical epistemology; Korcz (2013) and DeRose
(2013) provide annotated bibliographies.
2. Representative examples include Thagard, 1999; Solomon, 2008; Worrall, 2008; and Cartwright,
2011.
3. There are four conditions usually associated with knowledge: (1) justified, (2) true, (3) belief.
The last condition concerns (4) fitness of a faculty of knowledge to an environment or context. This con-
dition is needed to address what have been called Gettier problems (Gettier, 1963). Review of proposed
solutions to the problem is given in Ichikawa and Steup (2013).
4. The language of “extrusions of thoughts from the mind” comes from Dummett, 1993, ch. 4. He is
concerned with extrusions into language that do not deeply challenge traditional analytic epistemologies.
The more disruptive kinds of extrusions are a central concern in cognitive science, where they are associ-
ated with embodied cognition. Clark (1998) provides a nice review of these more radical extrusions.
Acknowledgments
This essay has greatly benefited from critical comments and suggestions made by Ana Iltis.
484 George Khushf
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