Philosophy Archives - Page 4 of 4

Phronesis

Michel AccadAugust 13, 2015December 13, 2016Ethics, Medical practice, Medical science, Philosophymedical decision-making3 Comments

I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.

In “The Paternalism Preference — Choosing Unshared Decision Making,” Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.

The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician. She remarks:

But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?

The answer to that question has to do with our understanding of what constitutes good medical decision-making. Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”Continue reading “Phronesis”

Evidence-based mania: an intoxication of the intellect

Michel AccadAugust 10, 2015December 13, 2016Medical science, Philosophyempiricism6 Comments

For many years, thoughtful commentators have highlighted the shortcomings of evidence-based medicine (EBM). Among them was Alvan Feinstein, one of the great pioneers and theoreticians of clinical research, and arguably one of the founders of the EBM movement.¹ But despite the increasing discontent with this mode of thinking, EBM remains an extremely prevalent intellectual vice that has captured the mindset of the medical community.

In the last few days, I came across some particularly striking examples of how EBM dominates the medical psyche.Continue reading “Evidence-based mania: an intoxication of the intellect”

How experts really decide

Michel AccadJuly 20, 2015December 13, 2016Medical practice, Medical science, Philosophymedical decision-making3 Comments

I opened my last post with a question I never came around to really answer: How should doctors make decisions?

That wasn’t an oversight. To try to provide an answer seemed daunting, plus I wouldn’t have resisted the urge to wax philosophical about praxeology or phronesis. And how sexy is that? Surely my Alexa ranking would have suffered!

Perhaps sensing my predicament, Dr. Saurabh Jha tactfully suggested a book which I have since ordered and read. (And what a great call that was. Thank you, @RogueRad!) The book is Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making by Gary Klein.

According to his Wikipedia entry, Klein is a cognitive psychologist credited with pioneering the field of naturalistic decision-making, a research endeavor where people’s decisions are examined in real life setting, not under contrived laboratory experiments.

The book, published in 2011 by The MIT Press, summarizes the fruits of his research. It’s a captivating work.Continue reading “How experts really decide”

How Western medicine lost its soul

Michel AccadJune 18, 2015September 10, 2021Philosophy22 Comments

[This article is now published by Taylor & Francis in The Linacre Quarterly under the same title and available online. It remains posted here with the publisher’s permission]

A few decades ago, the idea of medicine presented no difficulty. A patient who fell ill would go to the doctor to get treated. He might get better or he might not, but there was no need for him to consider at the outset what type of medical care he should choose for his ailment.

Today, someone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine. For most people, there is a clear distinction between the two. Sure, some licensed physicians claim to provide holistic care, but this usually means that they might add an alternative form of therapy to standard treatment, or perhaps that they strive to be exceptionally considerate. The holistic character of the care rarely, if ever, comes from Western medicine per se.Continue reading “How Western medicine lost its soul”

Three questions for the Missionaries of Quality

Michel AccadJune 3, 2015December 13, 2016Healthcare policy, PhilosophyFlexnerian medicineLeave a comment

Two thoughtful healthcare analysts (a physician and an economist) wonder about health care quality:

@ethanjweiss I agree. If nobody can assess quality or productivity in any way,* that’s a deep problem, isn’t it?

— Austin Frakt (@afrakt) May 26, 2015

They are not alone. Even though the Institute of Medicine’s 2001 epic poem mobilized legions of missionaries of quality, it is far from obvious that we have clarity about the overall aim of the crusade.

Our eyes may have been opened to the sins of medical errors, the shame of healthcare disparities, the wastefulness of therapeutic inefficiencies, and the guilt of runaway costs, but if quality care is in fact the goal, and not a pretext for bureaucratic do-goodism, agreement on its meaning seems to be of the essence lest the campaign to “cross the chasm” turn instead into a crossing of the Styx.Continue reading “Three questions for the Missionaries of Quality”

COI and empirical fundamentalism

Michel AccadMay 22, 2015December 13, 2016Ethics, Medical science, Philosophyconflict of interest4 Comments

Over at the Incidental Economist, Austin Frakt has published a thoughtful commentary on Lisa Rosenbaum’s NEJM series on the obsession over conflict of interest. Frakt is supportive of Rosenbaum’s position but also touches on a dimension to the story which I did not address in my admittedly polemical piece yesterday.

Frakt’s most important statement is actually not in the post itself but in a Tweet linking to it.

I view COI disclosure as (meta) data. Like all data it doesn’t self-interpret. This is the source of all COI-debate: http://t.co/qIyds8T6Bu

— Austin Frakt (@afrakt) May 22, 2015

Frakt is absolutely right and his statement points to a very fundamental assumption that underlies not only the COI concerns, but the legal practice of medicine in general. Namely, the assumption is that in science and medicine, we should “let the data speak for itself.”Continue reading “COI and empirical fundamentalism”

The clinical trial on trial

Michel AccadJuly 21, 2011December 13, 2016Medical science, Philosophyclinical trials, randomized clinical trial, statistics, statistics in medicine1 Comment

It is the mark of an educated man to look for precision in each class of things just so far as the nature of the subject admits.

Aristotle

UK gastroenterologist and fellow contrarian James Penston has published two books critical of mainstream clinical research methodology. The most recent one, called Stats.con, deals with the misuse of statistics in medicine and expands on the topic of his first book published in 2003 under the title Fiction and Fantasy in Medical Research: The Large-Scale Randomised Trial.Continue reading “The clinical trial on trial”

Risk-Factor Medicine: An Industry Out of Control?

Michel AccadOctober 30, 2010December 13, 2016Medical science, Philosophy1 Comment

I co-wrote this editorial with Herb Fred. We outlined how the concept of risk factor, initially borrowed from the life insurance industry by the Framingham investigators, has spun out of control since the early 1960’s. Published in Cardiology, but unfortunately not free online (but reprints available upon request).