The epistemology of clinical decision-making : an epistemological analysis of reasoning in clinical practice, and the role of technological measurements

Baalen, Sophie van (2014) The epistemology of clinical decision-making : an epistemological analysis of reasoning in clinical practice, and the role of technological measurements.

Abstract:The goal of this thesis is to understand clinical decision-making regarding diagnosis and treatment and the role of different types of information, including measurements using technological instruments. From studying the history of medicine I conclude that the development of medical practice is intertwined with the development of science and scientific methods, and with the conceptions of disease and health, societal norms and the organization of care. Therefore, I divide the context in which clinical decision-making takes place, and within which it should be studied, into four groups (that are, of course, in reality related and intertwined): the contexts of the patient-physician interaction, the context of organization, the material context and the intellectual context. Reviewing the current epistemologies of medicine, two opposing views surface: evidence based medicine (EBM) and the “art of medicine”. In my view, both views fail to do justice to the actual work of doctors regarding reasoning about diagnosis and treatment. EBM epistemology because of its narrow view on what is scientific and its aim to prescribe clinical reasoning in formal guidelines, thereby promoting rule-based or algorithmic reasoning and confining it mostly to the “organization context”. Epistemologies that relate to the “art of medicine” (like those referring to “tacit knowledge”) often fail to provide an account of medical reasoning, making clinical decision-making an implicit and even mysterious process, and confining it mostly to the context of the patient-doctor interaction. Therefore, I reject a strict dichotomy between “objective” and “subjective” and aim to formulate an alternative approach to medical epistemology that overcomes this dichotomy and is able to include all four contexts. This alternative should be able to account for specific aspects of clinical reasoning, such as the gathering of relevant information, the integration of different types of relevant knowledge, the use of different types of reasoning styles, and the local and context-specific nature of clinical decision-making, while at the same time securing the desired “scientific” quality. I argue that the concept “epistemological responsibility” of doctors plays a central role in such an approach. This shifts the focus from the “general” and objectified, represented by guidelines, algorithms and rule-based reasoning, to the specific, the individual doctors and patients. Part of the epistemological responsibility of doctors is then to navigate within, and account for, all four contexts. To clarify the role of the material context, I propose a taxonomy of clinical decision making, based on Ian Hacking’s taxonomy of the element that are mutually adjusted in the practice of theory formation in the laboratory sciences. To understand the intellectual context, I argue that instead of understanding epistemology as “objective truth finding”, knowledge should be considered as an epistemic tool that allows doctors to ask questions and formulate hypotheses about their patients. Regarding technological measurements, I conclude that quantitative measurements have the reputation of being objective and therefore more reliable than other types of information. However, besides being enabling, they are also limiting. Furthermore, it is often overlooked that data acquisition and processing methods have an impact on the resulting measurement outcome and that the outcome directs diagnosis and treatment decisions. Therefore, I claim that doctors should develop a more epistemologically responsible attitude towards technological measurements by realizing that they are not as “objective” as they seem but rather provide a perspective on the patient and their disease, among other perspectives. Furthermore, for the development of innovative technologies for clinical practice, a detailed understanding of the role of a specific measurement in clinical decision-making is needed, in order to develop technologies that produce information that is relevant and fitting.
Item Type:Essay (Master)
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:08 philosophy
Programme:Philosophy of Science, Technology and Society MSc (60024)
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