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Journal of Medicine and Philosophy, 38: 461–486, 2013

doi:10.1093/jmp/jht044


A Framework for Understanding Medical


Epistemologies

GEORGE KHUSHF*
University of South Carolina, Columbia, South Carolina, USA

*Address correspondence to: George Khushf, PhD, Department of Philosophy, University of

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South Carolina, Columbia, SC 29208, USA. E-mail: khushf@sc.edu

What clinicians, biomedical scientists, and other health care pro-


fessionals know as individuals or as groups and how they come
to know and use knowledge are central concerns of medical epis-
temology. Activities associated with knowledge production and
use are called epistemic practices. Such practices are considered
in biomedical and clinical literatures, social sciences of medicine,
philosophy of science and philosophy of medicine, and also in
other nonmedical literatures. A host of different kinds of knowl-
edge claims have been identified, each with different uses and log-
ics of justification. A general framework is needed to situate these
diverse contributions in medical epistemology, so we can see how
they fit together. But developing such a framework turns out to
be quite tricky. In this survey, three possible frameworks are con-
sidered along with the difficulties associated with each of them.
The essay concludes with a fourth framework, which considers
any epistemology as part of a practice that is oriented toward over-
coming errors that emerge in antecedently given practices where
knowledge is developed and used. As medicine indirectly advances
health by directly mitigating disease, so epistemology indirectly
advances knowledge by directly mitigating error.
Keywords: clinical reasoning, epistemology, error, evidence-
based medicine

I.  The task of developing a general framework

The task of developing a general framework for medical epistemology might


be initially posed as follows: casting our net broadly, we search diverse data-
bases for articles and books on the topic. As we do this, we also keep in mind

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462 George Khushf

conditions under which knowledge is developed and used in medicine; for


example, epistemic practices associated with management of a clinical case
or a population of patients. After utilizing multiple search strategies that are
informed by those medical epistemic practices we have in mind, we get a
large number of books and articles. How can we categorize these diverse
contributions, so we can get a relatively simple map of the topic and so we
can properly understand the relations between the different contributions?
As a first step in organizing the materials, we might group them under
some general headings. By such initial groupings, something like the follow-
ing list might be generated:
1. The patient history and physical exam as strategies for gathering

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evidence
2. Pattern recognition and expert knowledge
3. Heuristics and biases, and their role in clinical reasoning
4. Bayesian reasoning
5. Differential diagnosis
6. Causal reasoning
7. Mechanistic reasoning
8. How best to use information systems when you need knowledge
related to a specific case
9. Justification and use of guidelines and clinical pathways
10. Systems based approaches to eliminating error and advancing quality
11. Theories and practices of measurement and testing; their use and abuse
12. Knowing patients as persons, rather than just regarding them as
instances of diseases
This is meant to be just the start of a list, given with no prioritization, and
involving somewhat heterogeneous categories. It was generated by sifting
through some of the materials at hand, with an initial effort to organize
these under common headings that expressed something essential about
materials grouped under them. The categories used to group the materials
partly depend on the initial search terms that were used and assumptions
about the kinds of things that are important in a general account of medical
epistemology. To this extent, such categories only make explicit what was
initially implicit before the search was conducted. But new patterns are also
discovered, so there can be a refinement and development of the initial,
partial knowledge. For example, after presenting the list, we might explore
relations between items on the list. Some items on the list might better be
regarded as subcategories of others on the list; for example, mechanistic
reasoning as a species of causal reasoning. In that way, step by step it might
be possible to work out a rich texture of relations.
Anyone familiar with recent developments in medicine will be aware
that there is a huge amount of activity related to medical epistemology that
comes under headings like Evidence-Based Medicine (EBM) and Medical
Decision-Making (MDM), so these naturally offer themselves as general
A Framework for Understanding Medical Epistemologies 463

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

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should be of use in organizing the things in the partial list above, and it
should also enable proper sorting of any other categories that anyone else
might develop.

II.  First approximation: Descriptive, Normative,


and Meta-Epistemologies

As a first approximation, we might use a three-fold scheme similar to that


often used for ethics, where descriptive, normative, and meta-ethics are dis-
tinguished. Medical epistemologies might then be subcategorized as follows:
1. Descriptive epistemology involves empirical investigation into how peo-
ple come to know the things they know, and how they use this knowledge.
Here emphasis is on the actual reasoning and decision-making processes
used by epistemic agents. These kinds of studies might involve empirical
study of the differences between the way novice and expert practitioners
reason through a case, use of heuristics and their associated biases, and
psychological studies of the way physicians and patients appraise statisti-
cal information. Or one might study the way social systems and institu-
tions evoke certain patterns of reasoning. This descriptive work uses diverse
methods, ranging from introspective reflection of experts on their own rea-
soning processes to more traditional experimental methods used by psychol-
ogists for understanding cognitive and emotional processes and intelligence
(Chapman and Sonnenberg, 2003).
2. Normative epistemology involves accounts of how people ought to
arrive at knowledge and use it. Such accounts are often developed as refine-
ments and extensions of ordinary, given reasoning, and with an effort to
eliminate errors and unjustified beliefs. Here we might place many of the
contributions in EBM and MDM (Kassirer and Kopelman, 1991; Eddy, 1996;
Sackett et al., 2000; Sox et al., 2006). These contributions are normative in
at least two senses. First, they involve claims about how clinicians ought to
reason and make decisions. In doing this, they involve logics of justification
considered necessary for distinguishing genuine knowledge from presumed
464 George Khushf

knowledge (Jenicek, 2003). Second, EBM guidelines reflect substantive nor-


mative judgments about what is good and valuable and how to rank out-
comes (Mills and Spencer, 2003). There are ethical obligations to avoid harm
and to do what is best for the patient, which also inform EBM. How patients
and clinicians understand what is good involves background normative
assumptions. Similarly, EBM invokes the goal of avoiding waste and using
resources effectively. Efficiency judgments involve normative assumptions
about how to prioritize what is of benefit to individuals and populations
(Blumenthal-Barby, 2013). There can be tensions between the norms associ-
ated with the justification of knowledge and the norms that reflect judgments
about what is good, and a normative epistemology might work to clarify and
resolve these tensions.

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3. Meta-epistemology involves investigation into higher-order concepts
that are used in both the descriptive and normative epistemologies; for
example, the nature of knowledge and evidence, logics of justification of
knowledge, kinds of inferences, and so on. These are the issues normally
dealt with in philosophy under the heading of “epistemology.”1 The “meta-”
prefix was added to distinguish this more abstract and general reflection on
medical epistemology from both the traditional philosophical reflection, on
one side, and the descriptive and normative medical epistemologies, on the
other side (Ashcroft, 2003; Howick, 2011).
Such a three-fold division seems to capture something important. The
headings naturally map to the distinctive styles and methods of investigation
and argument we find in the heterogeneous medical literatures related to
epistemology. In areas like neuroscience, psychology, and sociology, and
in hybrid areas like cognitive science, empirical methods are used to make
sense of how humans know, how knowledge is used, and how real-world
agents function in real-world environments (or at least how they function in
the artificial, hypersimplified environments associated with some psycholog-
ical experiments). There is now an extensive body of such work associated
with the study of physicians and patients, and this work naturally fits under
the “descriptive epistemology” heading. Alternatively, much of what comes
under the headings of EBM and MDM seeks to prescribe how physicians
ought to reason rather than describe how they do reason. The prescriptions
are often developed as compensations for the ways ordinary medical reason-
ing goes astray. We then see a gap between what is and what ought to be,
and this gap has many of the same features found in the gap between actual
behavior and normative accounts of what should be done. An appreciation
of this similarity between what is given and ideal in ethics and epistemology
has inspired one prominent, so-called deontological account of the nature
of justification associated with knowledge (Alston, 1989). Finally, there are
higher-order questions usually not asked by physicians and biomedical sci-
entists, but of special interest to philosophers; for example, regarding what
counts as evidence, how claims are justified, what distinguishes genuine from
presumed knowledge, and the nature of causal and mechanistic reasoning
A Framework for Understanding Medical Epistemologies 465

(an outstanding example is given in Howick, 2011).These again have a style


that is distinctively different from both the descriptive and the normative
work, and they might naturally be associated with the meta-epistemology
(what is called epistemology in philosophy). Thus one of the advantages of
the three-fold schema relates to the way it helps us descriptively sort and
make sense of the diverse contributions associated with clinical reasoning
and decision making.
Another advantage of the three-fold classification scheme concerns the
role it might play in aligning classical philosophical work on epistemology
with those reflections that arise in medical and scientific contexts. One of the
most exciting developments in recent years concerns the way leading philos-
ophers of science have now moved to a consideration of medicine as a rep-

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resentative area where deep philosophical questions about science can be
explored.2 This work takes the actual reasoning and practices of physicians
and scientists seriously but at the same time brings to this work a refined set
of tools and critical capacities for reflecting on things like evidence, causal
analysis, and mechanism. But it has always been tricky to align this kind of
work in epistemology related to the philosophy of science and the classical
philosophical project of epistemology associated with justified true belief.
Efforts to carefully describe, understand, and critically refine the epistemolo-
gies of the natural sciences have often gone under the name of “naturalized
epistemology,” and since Quine (1969), they have been contrasted with the
traditional project in epistemology. But even strong supporters of Quine
have felt that there is something about the classical epistemological ques-
tions that is legitimate, and efforts at developing an epistemology grounded
on science often try to work out those accounts in relation to classical philo-
sophical questions in epistemology (Feldman, 2012).
By means of the three-fold schema of descriptive, normative, and meta-
epistemology, we have a framework that might be used to bring together
disparate sets of reflections that often have not been in communication with
one another. If we imagine the three subcategories as corners of a triangle
and take the sides of the triangle as lines of communication between these
subcategories of medical epistemology, then we could envision additional
edges that run from each node outward to nonmedical fields. The node
associated with meta-epistemology would run over to classical philosophi-
cal debates in epistemology. That associated with descriptive epistemology
would run over to more general empirical work in the cognitive sciences,
psychology, sociology, and anthropology. And the node associated with
normative epistemology would run over to areas like logic, statistics, com-
puter sciences, engineering, and business management. By reflecting on the
epistemologies integral to a specific set of practices like medicine, we can
see how all these general, nonmedical domains need to be aligned. Further,
we also can gain a critical perspective on what was incomplete when arm-
chair epistemology sought to make sense of knowledge without careful con-
sideration of how knowledge arises and is used in practice contexts. The
466 George Khushf

three-fold schema thus enables us to appreciate the contributions that clas-


sical epistemology might make to medical epistemology and, conversely,
the contributions that might be made by medicine to classical epistemology.
The value of such a dialogue cannot be overstated. In a strange way, the
extensive, vibrant empirical and normative work on epistemology in medi-
cine has until recently gone largely unnoticed by philosophers. There are
huge fields of medical decision making and whole industries associated with
organizing evidence so it is accessible to clinical practitioners. Medicine has
been one of the central areas where information systems have been used to
support complex tasks of reasoning and decision. And there are now major
efforts at organizing systems so they evoke, sustain, and refine the right
kinds of reasoning. With the exception, perhaps, of the military, business

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management, and use of information systems, there is no area where more
work has been done on epistemic processes related to a practice domain.
But all this valuable work has rarely been informed by, or informed, clas-
sical work on epistemology. Whereas the reasons for this are complex and
include a historically interesting antipathy of medicine toward philosophy,
one of the significant barriers has been the absence of a general framework
for bridging the classical philosophical and medical work. By providing such
a framework, the three-fold schema can help facilitate a dialogue that is
already emerging.
Despite these potential benefits of the three-fold rubric, there are some
significant problems with it. First, it seems to include too much. There was a
time when science was called “natural philosophy,” but no one would today
associate philosophy of science with the full range of contents associated
with science. In the same way, we cannot associate epistemology with the
full range of methods, strategies, and tools for advancing and using knowl-
edge in practice settings or for empirically studying these. Such an over-
reaching categorization would imply that much of psychology and cognitive
science are epistemology, and that physicians are trained in epistemology so
they can properly diagnose patients. Whereas the etymology of epistemol-
ogy might suggest such inclusive approaches to the study of knowledge, we
must today take a far narrower reading. As philosophy of science involves a
kind of second-order, critical reflection on science, so likewise medical epis-
temology (at least of the so-called naturalized variety) involves a kind of crit-
ical, second-order reflection on knowledge acquisition and use in medicine.
Here the “meta” is really already integral to the meaning of epistemology.
This narrowing of epistemology doesn’t by itself invalidate the three-fold
schema. We could refine it by again considering our triangle, with its spokes
extended outward from each node. Only now we introduce a third dimen-
sion, and have additional spokes descending from the nodes perpendicular
to the plane of the triangle. We now shift downward the contents originally
associated with each corner of the triangle, and we take descriptive, norma-
tive, and meta-epistemology as the second-order, critical reflections on those
A Framework for Understanding Medical Epistemologies 467

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-

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ratus for coming to know something is deployed in a double sense. First,
it is deployed in our effort to describe and categorize the diverse contribu-
tions made to medical epistemology. Second, it is deployed normatively, as
we present evidence and sift claims and organize contents so they cohere
in the right ways. In framing our descriptions of epistemic processes, we do
this in relation to our own norms regarding how knowledge ought to arise
and be used. These norms play a role from the start in how we select what
counts as relevant material. Alternatively, if we seek to advance a normative
epistemology, we do this by providing a kind of description, albeit often in
a rather artificial language and often in the subjunctive. In either case, all
accounts of epistemology take place at the intersection of the descriptive
and the normative. Even at the most abstract level, where the focus is on
justified true belief, we still see a shadow of the descriptive/normative dis-
tinction: first, belief is posited, arising from some fuzzy, unspecified process
(the descriptive, given level); then there is the question of how we discrimi-
nate that special set of justified, true beliefs arising from faculties somehow
fit for the circumstances.3 This second stage associated with justification is
explicitly normative. At this most abstract level of reflection the intricate
complexities of descriptive and normative epistemologies are lost, and these
are handled summarily under the headings of belief and the normative (or
technically nondeontic) machinery that assures such beliefs are true and jus-
tified or at least reliable. But when we consider the rich texture of epistemic
processes associated with a field like medicine, we can no longer handle
all this with sweeping summary terms. When we descend into the details, it
becomes clear that one’s own normative commitments inform any effort to
categorize contributions into the three domains.
The net effect of all this is that we are not going to fit fully intersubjective
categorizations of epistemologies into the three subcategories. What one
person takes as normative, another will take as descriptive. The three-fold
schema can thus, at best, be used as a rough first approximation. A quick
glance at the literature on EBM will immediately confirm this. For many
physicians, EBM is a catch phrase for the normative ideals regarding the
468 George Khushf

ways physicians should ascertain, sift, and utilize knowledge to effectively


manage the diseases of patients. General overviews of EBM often begin
with descriptive accounts of how physicians have traditionally approached
clinical decision making, and why such approaches are deficient. Then, in
response to these descriptions of problematic clinical reasoning, EBM is
advanced as a corrective. But for many philosophers, EBM constitutes the
given, real-world, knowledge-oriented practices they seek to describe. They
then critically reflect on the claims integral to EBM, for example, related to
notions of evidence or mechanistic reasoning (Howick, 2011). On the basis
of these critical reflections, a normative account is provided that is sup-
posed to refine EBM. Philosophical accounts thus relate to EBM in the same
way that EBM relates to the antecedently given, typical patterns of clinical

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reasoning. At each stage, a normative account provides a refinement of an
antecedently given set of knowledge-oriented practices. As soon as such
normative accounts inform the practices themselves, this reconstructed set of
practices becomes the target of new efforts at reconstruction. The process is
iterative and ongoing, and thus destabilizes any categorizations according to
the three-fold schema. What is normative at one stage becomes part of what
is taken as given and described in a subsequent stage.

III.  Second approximation: pure versus applied


epistemologies

For our second effort at developing a general framework for organizing


contributions to medical epistemology, we begin with a distinction between
pure and applied epistemologies and focus on the kinds of knowledge
deployed in medical epistemic practices.
Classical epistemology has focused on cognitive content and has assumed
that knowledge can be propositionally encoded. Beliefs are then associated
with the content of propositions, and the evidence that sustains beliefs is
likewise such that it can be expressed propositionally. Truth then concerns
the relation between the propositionally encoded content and worldly states
of affairs, and justification is understood in terms of the inference chains that
link up diverse propositions. We can take epistemologies concerned with
such inference chains as “theoretical” or “pure” epistemologies.
At the outside limit of such pure epistemologies, there is a kind of knowl-
edge that has a qualitatively different character. This is often associated with
the primitive, so-called atomic propositions that encode the bits and pieces
of evidence. For example, when a physician notices red blotches on the skin
while conducting a physical exam, this might be propositionally encoded as
“the patient has red blotches indicative of Herpes zoster.” This propositional
expression involves a complex combination of what is immediately seen—
the red blotches—and the diagnostic category that may be associated with it,
A Framework for Understanding Medical Epistemologies 469

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

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of the classical work in epistemology concerns the complex processes that
lead to the encoding of such primitive empirical relations and the inference
chains that link more complex propositions back to their evidential base.
When we consider the everyday contexts where medical knowledge is
deployed, it becomes immediately apparent that there are many kinds of
knowledge that do not fit within this theoretical account, where the only
nonpropositional knowledge concerns the primitive perceptions associated
with encoded evidence. A physician might know her way around a hospital.
She might know a patient personally, rather than just know of her case. She
might know how to perform a given procedure. Or she might not know
how to effectively use information systems as part of her regular clinical
management of patients. She might be poor at interfacing with other health
care professionals, and such failure might be partly due to an absence of
knowledge about what other professionals can do and partly due to some
moral trait such as pride. All of these kinds of knowledge cannot be cap-
tured by the standard epistemologies that focus on justified, true, proposi-
tionally encoded beliefs (the classical criticism is given in Ryle, 1949). But
all these kinds of knowledge are essential for the practice of medicine, and
many of the important developments in medical epistemology concern these
nonpropositional (or transpropositional) kinds of knowledge. Additionally,
it is important to remember: “Diagnosis is not knowledge for knowledge’s
sake. It is knowledge for the sake of action. Medicine exists in order to cure,
to care, to intervene, or in limiting cases, to know when not to intervene.
Medicine is not a contemplative science” (Mainetti, 1992, 79). We might
group epistemologies that are concerned with know-how and these exis-
tential, situated, and instrumental kinds of knowledge under the heading of
“applied epistemology.” This kind of knowledge was traditionally associated
with what has variously been called phronesis, practical wisdom, or the art
of medicine.
When we try to clarify how such situated knowledge and know-how count
as knowledge, then things get tricky. What exactly is known? In answering
this, we might again start with the classical mantra of justified true belief
470 George Khushf

and ask how this might be generalized to nonpropositional cases. “Belief”


involves a mental state that somehow relates to the way an agent takes a
stance in relation to the world. It thus has an “about relation” to some state
of affairs independent of the agent. “Truth” then concerns a match between
the belief and the state of affairs it is about. “Justified” then concerns the
grounds of belief, assuring that the truth of the belief is not an accident, but
somehow involves legitimate links or inference relations to those contents
immediately ascertained and encoded as evidence. Additionally, some kind
of contextual aspect is included that is supposed to assure that the per-
ceptive and reasoning apparatus is functioning reliably in the circumstance
under consideration.
Generalizing from this classical account, we can say that epistemology is

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concerned with the integrity of knowledge and its use. In any set of prac-
tices, a set of capacities is deployed that assures there is a fit between the
associated actions and the world within which these actions occur. From the
perspective of the agent, knowledge concerns one aspect of this fit between
the world, on one side, and the agent’s grasp of the world and actions within
it, on the other side. Epistemology is then concerned with the grounds and
justification of these given ways of knowing, including the know-how inte-
gral to action. At any stage, human agents seek assurance that their assump-
tions and practices relate in the right ways to the world within which they
act, so there are the right kinds of inference chains and practice chains.
The inference chains might be modeled in traditional theoretical terms, but
the practice chains involve sets of trial and error corrections over previous
practice schemas. In each case, there is a complex set of chains to the ante-
cedent grounds on which they are based. This normative question about
justification involves a complex alignment between agent goals and all the
things the agent takes as given. This second-order, normative component is
integral to epistemology. It involves an effort to assure that what is taken as
knowledge is aligned with the world in the manner called “true,” and that
know-how is aligned with ends in the efficient and effective way called “fit.”
We can now ask more specifically about what an agent knows, when an
agent knows something. How do we understand the about-relation in the
case of nonpropositional knowledge? And how might appreciation of these
nonpropositional contents of knowledge lead to refinements of epistemolo-
gies that are more narrowly developed in terms of the propositional contents
that are normally of interest to science? The first two essays in this journal
issue provide partial answers to this question.
Ashley Graham Kennedy (2013) considers two cases of differential
diagnosis where physicians too quickly move from limited information to
either a problematic dismissal of patient complaints or a premature closure
with respect to a diagnostic category. Her first case involves a controver-
sial diagnostic category—that of Lyme disease. The symptoms associated
with late stage Lyme disease are often nonspecific, the tests for the disease
A Framework for Understanding Medical Epistemologies 471

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

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category. Eventually the case was properly diagnosed and the patient rapidly
improved. Kennedy presents this as a problem of premature closure.
When initially considering her cases, we might try to understand the epis-
temic concerns in traditional terms, for example, as involving inferential
chains that are insufficiently grounded in the evidence that is available. Even
when viewed in such terms, there are some interesting aspects of her two
cases. Today, “successful” treatments have a highly ambiguous status in con-
firming a diagnosis, especially when the symptoms are largely self-reported
and nonspecific. But at an earlier time when there were fewer tests available
for confirming a diagnosis, effective treatment was explicitly taken as a prob-
abilistic confirmation of a diagnostic hypothesis, and trial and error was seen
as an integral part of medical management (Flexner, 1910, 55). Implicitly,
Kennedy takes the effective resolution of the presenting symptoms as a
confirmation of the diagnoses, especially in the case of Lyme disease. Such
pragmatic considerations are usually quite tricky to integrate into the stand-
ard accounts of knowledge. But for Kennedy, there are even trickier kinds of
knowledge at issue in these cases. Whereas it is hard to name exactly what is
known, this knowledge has something to do with the awareness a physician
has of uncertainty and his or her own limits in understanding the medical
conditions that patients have. The knowledge of one’s own limits then needs
to be deployed by the physician in what Kennedy aptly characterizes as a
“compassionate suspension of judgment.” She then associates this suspen-
sion of judgment with three virtues: a methodological virtue associated with
ongoing investigation; an epistemic virtue associated with humility; and an
ethical virtue associated with respect for patients.
In his essay on emotional intelligence (EI), James Marcum also focuses on
practical rationality. His “main thesis is that EI is a practicable or workable
form of intelligence, akin to Aristotle’s notion of phronesis, which affords
medical practitioners a robust cognitive resource for providing quality clini-
cal care.” (2013, 501) Emotions are organized human responses to events
that are judged to have a positive or negative impact on the well-being of
an individual (Salovey and Mayer, 1990, 186). Since humans often appraise
472 George Khushf

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

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patients and complex nonmedical events that may be at the root of problems
that initially present as medical problems.
Both Kennedy and Marcum consider cases where there is a complex
intersection of medical and nonmedical considerations, and where part of
the diagnostic task involves disentangling these strands of information. Both
seek to move beyond an epistemology that only registers biomedical facts
in ways that cannot be properly related to patients who must be encoun-
tered as people and not as instances of disease. In this effort to expand the
horizon of the epistemology, their contributions align with other important
efforts to incorporate kinds of knowledge that are not sufficiently appreci-
ated in current biomedicine (Engel, 1977a, 1988; Malterud, 1995). But there
is some tension between the lessons they draw from their different cases.
Kennedy is concerned about the way physicians might dismiss presenting
complaints as psychiatric or nonmedical, whereas Marcum highlights how
a physician’s EI enabled him to recognize the traumatic event of rape that
was behind a presentation initially worked up as irritable bowel syndrome.
This difference is sharp enough and their cases similar enough that one
might ask how Kennedy’s “compassionate suspension of judgment” and
her three virtues might have been (or were) applied to Marcum’s case and,
conversely, how Marcum’s EI might have informed management of the
cases that Kennedy describes. Beyond any possible tensions, both essays
clearly identify a kind of awareness a physician should have about himself
or herself as an embodied, limited agent who encounters another embod-
ied, limited agent in need of help. The deployment of cognitive capacities
that work with taxonomies of disease to categorize instances associated
with manifest signs and symptoms is in each case taken as just one aspect
of medical knowledge. Additionally, another kind of practical knowledge is
needed to properly situate and appraise the scope and limits of these cog-
nitive capacities, and order them rightly in relation to an effective clinical
encounter. The practical knowledge associated with an awareness of the
scope and limits of knowledge (Kennedy) and EI (Marcum) thus orients the
use of theoretical knowledge in ways that optimize the goal of the practice,
A Framework for Understanding Medical Epistemologies 473

which is to provide a fitting response to that person who comes to the phy-
sician for help.

IV.  Third approximation: Individual versus Social


Epistemology

Thus far we have developed epistemologies as if they concern what goes on


in the heads and hearts of individuals. Individuals are the ones who reason
and use information, and thus the ones who have knowledge of various
kinds. But when an individual physician works up a patient’s problem as a
biomedical disease, this isn’t an isolated event. That physician deploys an

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apparatus for making sense of disease in ways that are similar to other physi-
cians. These diverse physicians are conditioned to work up disease in those
distinctive ways promoted by educational systems, professional organiza-
tions, systems of health care practice, institutional payers and by the tech-
nologies available to support the epistemic activities of physicians. One of
the more distinctive recent developments in medical epistemology concerns
the new (or rediscovered; Fleck, 1979) appreciation for the role such social
systems and technology play, and how they even condition the way theo-
retical and practical knowledge are disentangled and related to one another
(Goldman, 1999).
As soon as one takes this social and material turn, a somewhat unruly lit-
erature related to medical epistemology gets downright unmanageable. This
turn has an especially destabilizing impact on discourse on truth and justifi-
cation (Rorty, 1979; for a social epistemology that seeks to preserve the dis-
course of truth, see Goldenberg, 2006). To ease our way into such a literature,
let us start again with the classical epistemology associated with justified, true
beliefs and try to extend it with small steps so that we can bring into view
the dependence relations between knowledge and social systems. Let’s call
“perceptive capacity” the sum of abilities an individual has to take in informa-
tion from the external world. This includes vision, hearing, touch, and so on.
“Perception” then involves a use of perceptive capacity, and we’ll assume that
this eventuates in a propositionally encoded piece of evidence that might be
considered by an epistemic agent. Let’s now define “reasoning capacity” in
a broad way so that it includes the full range of abilities an individual might
utilize to filter, organize, and extract some conclusion from multiple pieces of
evidence. In traditional theoretical or pure epistemologies, knowledge gen-
eration involves a special kind of coupling between the perceptive capaci-
ties, for example, evidence provided by vision, and the reasoning capacities.
Worries associated with justification involve constraints that assure the bits
and pieces all link up in the right way to get genuine knowledge.
In the light of this traditional epistemology, we can now identify an
important metaconstraint associated with justification. It is important that
474 George Khushf

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

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the accessible space of the epistemic agent, then this would fundamentally
alter the epistemology. Knowledge would then depend on some inaccessi-
ble condition that lies outside the agent, and it would require some account
of what happens in that social circuit and how those transformations assure
that belief dependent upon that circuit remains true and justified. We could
summarize this general condition by saying that the circuit between immedi-
ate perceptive evidence and knowledge needs to remain accessible to the
epistemic agent.
By introducing the notion of an accessible epistemic circuit, we provide a
tool for disentangling unproblematic from problematic kinds of dependence
on social systems. For example, language and concepts are obviously social
constructs and they play a crucial role in epistemic processes. But advocates
of traditional epistemologies would not find this problematic, because rec-
ognition of this kind of social dependence does not imply an inaccessible
epistemic circuit. Similarly, if certain kinds of technologies are used to aug-
ment perceptive capacities, this may or may not disrupt the accessibility of
an epistemic circuit. Whether it disrupts depends on the technology, cir-
cumstance, and use. Most physicians, for example, would not view use of
a stethoscope to mediate auditory signals as a disruption of the accessibility
of an epistemic circuit. There is thus some comfort with minor extrusions of
epistemic processes. The key question is then how far such extrusion might
run before an epistemic circuit is taken as inaccessible to the epistemic
agent.4
We will say that an inaccessible epistemic circuit involves at least one
disruptive extrusion. We will speak of three kinds of disruptive extrusions
that could take place: extrusions of perception, extrusions of reasoning, and
extrusions of value. The first two kinds are associated with the two core ele-
ments of traditional epistemology. In a disruptive extrusion of perception,
empirical evidence depends on capacities that extend beyond an individual’s
perceptive capacities. In a disruptive extrusion of reasoning, the chains that
link evidence to conclusions extend beyond an individual’s reasoning capac-
ity. The last kind of disruptive extrusion—that of value—is associated with
A Framework for Understanding Medical Epistemologies 475

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

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alter the way evidence arising from these augmented perceptive acts enter
into the reasoning process, that is, they are generally presumed to not involve
a disruptive extrusion of perception. A medical case is then presented as a
time sequence in which bits of evidence are acquired, with interim stages of
reasoning that present a physician’s conceptual train of thought, leading to
decisions about the next bit of evidence that is required or that spontane-
ously presents in the ongoing development of the case. Eventually, the case
description is appropriately resolved when a given disease category properly
makes sense of all the evidence in the case presentation.
Our question is now: can we sustain such a traditional account of clini-
cal reasoning or are there disruptive extrusions of perception, reasoning, or
value that have been insufficiently appreciated? In this journal issue, Leah
Mcclimans, Haley Faust, and Jennifer Blumenthal-Barby each address aspects
of this question.
Leah Mcclimans’s reflections on Quality of Life measures and Patient
Reported Outcome Measures (PROMs) can be contextualized by considering
the ambiguous status of patient testimony as evidence in medicine. In the
last section, we tried expanding the notion of epistemology so that it incor-
porated a broader range of contents, and so knowledge was deployed in the
right way to accomplish the goals associated with a clinical encounter. When
reviewing this expansion, we still placed our emphasis on the physician’s
knowledge, for example, a physician’s practical wisdom, which includes
awareness of uncertainty and limits, and thus doesn’t overreach evidence
or prematurely close off a case, or a physician’s EI. But when we presented
the epistemological concerns in that way, we only considered one aspect
of case studies presented by Kennedy and Marcum. In their case studies,
there was another very important element: patients also had knowledge!
Physician failures were not just due to their lack of some kind of knowledge.
Beyond that, they failed to listen. They did not regard patients as genuine
epistemic agents and thus discounted the epistemic value of their testimony.
Alternatively, the more attentive physicians appreciated that patient’s had a
kind of privileged, immediate access to their own medical conditions and
476 George Khushf

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

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has usually been associated with a biomedical disease concept (Engel,
1960, 1977b; Cassell, 1985). That disease concept is then associated with a
Cartesian mind/body split, where the structures and functions of the parts
and processes of the body are legitimate objects of scientific investigation,
whereas the patient’s experienced illness is regarded as a subjective matter
of mind (Toombs, 1992; Leder, 1992; cf. Simon, 2008). If we now consider
this same theme from the perspective of a traditional medical epistemology,
we see another driver of this reduction: if patient testimony is regarded as
reliable knowledge, a social epistemology is required. To preserve the tradi-
tional epistemology, patient testimony must be reducible, and that demotes
it to a lower status of evidence. Thus, with a biomedical model of disease
and traditional medical epistemology, patient testimony becomes a kind of
hearsay. It involves deficient access to the disease that a physician seeks to
understand in a scientific way (Reiser, 1978).
The problem here is not just whether a physician should take a good
patient history. All physicians would appreciate the need to do this, and all
would appreciate that the patient’s testimony provides important informa-
tion that should inform diagnostic reasoning and decision making. As Paul
Cutler, the editor of an influential book in EBM, notes: “Like an embryo, the
diagnosis is conceived, germinates, develops, and is most often delivered
during the dynamics of taking the history, and the entire drama of medical
problem solving may unfold without leaving the stage set of two chairs and
a desk” (1998, vii). But hearsay is also useful for a detective tracking down
evidence, and most of the cases handled by police are handled at the site of
complaint and without further incident. At the same time, such hearsay is not
admissible in some courts where higher standards of evidence are required.
The key question concerns how the patient’s testimony is to be related to
other kinds of evidence associated with direct observation, measurement,
and tests in cases where what the patient says and what the tests indicate
(or fail to indicate) diverge. Here we come to a problem that some physi-
cians associate with “the worried well.” That phrase itself indicates the pre-
sumed discrepancy between the patient’s concern about illness (or perhaps
A Framework for Understanding Medical Epistemologies 477

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-

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ments” are needed for disciplining the otherwise unruly evidence: thus the
PROMs McClimans studies.
McClimans (2013) begins by highlighting how the machinery of medical
measurements is usually black boxed. In EBM, a strong emphasis is placed
on statistics of mortality, morbidity, and quality of life. To get such statis-
tics, these outcomes need to be measurable. For that, reliable measurement
instruments are needed. There are a host of instruments out there, and they
are regularly used to report outcomes. These outcomes influence health
care decision making in many ways. But few attempt to open the black
box and critically reflect on the complex decisions implicated in any use
of the instrument (Baird, 2004). She seeks to do this with instruments for
measuring quality of life. In doing this, she poses a double challenge: first,
generally, she challenges the way evidence associated with measurements
and tests enter into clinical reasoning as bits of information. As soon as the
black box is opened, it becomes immediately apparent that measurements
don’t arise by a straightforward extension of human perception. There are
justificatory questions that must be resolved to get a valid measurement
instrument, and some measures fall far short of answering these questions.
Here there is a disruptive extrusion of perception, and much more work
is needed to clarify the social processes and the material work associated
with ascertaining those bits and pieces of evidence. Second, she notes that
there is something especially troubling about the effort to measure patient
reported outcomes related to quality of life. Here the patient’s own testi-
mony enters in a direct, irreducible way. The survey instrument provides
a tool to constrain and regularize that testimony so averages over popula-
tions might be developed. McClimans highlights how this can do violence
to exactly that which the measures are supposed to accomplish, namely,
ascertaining what makes a positive difference in the lives of patients. There
is additionally an extrusion of values: nontrivial social mechanisms and
decisions are implicated in the use of PROMs. By opening the black box,
McClimans brings into view these social mechanisms and submits them to
critical scrutiny.
478 George Khushf

Halley Faust (2013) focuses on problems associated with causal analysis


that arise in primary prevention. To appreciate the difficulties addressed by
Faust, we might start with a case where the causal logic integral to a preven-
tive intervention is not so distant from that causal logic associated with a
traditional therapeutic intervention. A physician wants to make causal infer-
ences about the possible interventions that might make a positive difference
in a patient’s life. Let’s assume a physician is considering a patient who has
had high blood pressure over several visits to the clinic. The physician might
initially recommend changes in diet and exercise and indicate that blood
pressure needs to be monitored. If there is no improvement, then some drug
may be prescribed to “control” the blood pressure. The pill is regularly taken
as prescribed, and on a subsequent visit a new measurement is taken, con-

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firming that blood pressure has been reduced to an acceptable level. Here
there is a simple circuit: something is measured, and the value of the meas-
ure is considered in relation to some norm. If that measure is outside the
norm, an intervention takes place and the measure is again taken. The inter-
vention involves or evokes some mechanism that is supposed to alter the
thing that is measured in some predictable way. Subsequent measurement
either confirms or disconfirms that this predicted alteration has occurred,
and subsequent medical decision making proceeds in a way that depends on
this outcome. This simple scenario can only occur because of much anteced-
ent work by biomedical scientists and clinicians who have constructed the
conditions under which the associated causal inferences and interventions
can take place.
As soon as we start to ask about blood pressure, instruments for measur-
ing it, interventions for correcting values outside the normal range, and so
on, we find that a host of nontrivial decisions needed to be made before
these simple cases of causal reasoning could ever arise (Schwartz, 2008). Is
the intervention to control blood pressure a treatment of a kind of inflam-
matory metabolic disease, hypertension, or is it a prevention of diseases like
cardiovascular disease and stroke? In this case, the act of prevention targets
some factor that is related by association or cause with diseases that involve
partial or catastrophic failure of vital organ systems. The prevention thus
mobilizes the same general notions of cause and disease that are mobilized
in other cases of medicine. But what happens if we move from secondary
and tertiary preventive efforts to cases of primary prevention where there is
no elevated risk in the individual who is part of the population that is the
target of the primary preventive intervention? If the intervention is success-
ful, there is what Halley Faust has identified as a double metaphysical bind:
“first confirming that something didn’t happen, and second proving we
caused the absence.” He speaks of these as “the two ‘hard’ questions of pre-
vention: (1) cause without an effect, and (2) absence of action as a cause”
(Faust, 2013, 540). For example, if one has a smoking prevention campaign
that works, this has the effect that people will be less likely to smoke.
A Framework for Understanding Medical Epistemologies 479

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

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proposes changing the way preventive medicine is understood. Instead of
focusing on a cause of an absence of a negative event, the disease, he thinks
preventive interventions should be seen as an advancement of a positive
event, optimal health. When a risk or susceptibility is reduced, then this
improves health from some lower state (H1) to some higher state (H2).
These health states are ordered in relation to some optimum, and the causal
mechanisms need to be understood in terms of the contribution an interven-
tion makes to some incremental increase in health.
Faust appreciates that there are a host of values integral to preventive
measures, but he seeks to bracket these questions and focus on the epis-
temic factors related to causal analysis. The huge shift from disease preven-
tion to health promotion is motivated by his concern as a scientist to create
the conditions under which causal claims can be properly made. Normally,
the logic of cause and its relation to interventions is simply taken for granted
as part of an explanatory scheme. In Faust’s deliberations, we see how a
master architect of preventive medicine seeks to create those conditions
where those explanatory schemes can be taken for granted. Here there is
an extrusion of the rationality integral to current preventive medical inter-
ventions, together with an effort to construct altered social conditions of
practice where the pathways of justification are more transparent. In inter-
esting ways, Faust’s analysis also links back up with that of McClimans and
highlights another important aspect of PROMs. Unlike measures of morbidity
and mortality, PROMs seem to get at something positive about a patient’s
well-being. “Quality of life” would presumably be an aspect of any measure
of optimal health. Advancement of Faust’s conditions for causal analysis thus
require a simultaneous advancement of measurement instruments like those
associated with PROMs.
In the final essay of this issue, Blumenthal-Barby (2013) considers sci-
entific and professional judgments about what tests or interventions have
value. The American Board of Internal Medicine (ABIM) Foundation has
advanced a “Choosing Wisely” initiative to identify and eliminate low-value
care. Several medical professional organizations have identified five tests,
480 George Khushf

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

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claims. Her study thus makes transparent the complex social processes asso-
ciated with any claims about what evidence-based practices should involve.
In net effect, she seeks to take more seriously the language of “wise choice”
in the ABIM initiative. With the extrusion of values associated with the ABIM
initiative, it is hard to recognize the nuanced balancing of factors integral to
practical wisdom. By attempting to make the social processes of justification
explicit, and by providing a framework for the normative judgments about
values, Blumenthal-Barby helps bring knowledge about the low-value care
options back within the awareness of those epistemic agents who must
make decisions about their use in the context of a clinical interaction.
Jointly, the contributions by McClimans, Faust, and Blumenthal-Barby
make clear how evidence and measurement, clinical causal reasoning, and
prioritization decisions regarding tests, treatments, and services all depend
on social mechanisms that are often incoherent and opaque. Each highlights
a different kind of disruptive extrusion of an epistemic circuit: McClimans
emphasizes an extrusion of perception, Faust an extrusion of reasoning, and
Blumenthal-Barby an extrusion of values. But each also advances criticism
directed toward creating conditions that are more favorable to an implicit,
partially expressed ideal regarding how clinical reasoning and decision
making ought to occur. They open the black boxes associated with meas-
urement, causal reasoning, and prioritization decisions and work to make
transparent and properly justify social practices that currently are at least
partly incoherent and insufficiently justified. In doing this, they each express
confidence that such critical scrutiny can lead to more reliable knowledge in
the domains they consider.

V.  A fourth framework? Epistemologies as compensations


for heightened risks of error

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

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epistemology is largely oriented toward providing a corrective to errors and
problems that arise in the existing practices.
With the extrusion of perception, rationality, and values into the social
sphere, the plurality seems to become irreducible—we no longer have an
epistemology but epistemologies. There are many and different social pro-
jects of construction that condition the way specific epistemologies settle
out. With this fragmentation, we also seem to lose track of a single discourse
on truth and justification. Our very effort to find an overarching framework
for an integrated epistemological discourse seems to be disrupted by those
same extrusions that disrupt what we have called the traditional, pure epis-
temology (Rorty, 1979, 8). This seems to suggest that the traditional epis-
temology and the effort to obtain a synoptic viewpoint on epistemologies
are co-implicated or perhaps jointly dependent on some other condition.
This condition seems to be undermined by social epistemologies which
then draw us into the intricate details of specific epistemic processes. With
McClimans, Faust, and Blumenthal-Barby, epistemological concerns seem
to be disruptively extruded from the heads and hearts of individuals and
inextricably intertwined with the specifics of measurement, causal analysis,
and prioritization, as each of these are worked out in relation to their spe-
cific application domains and by their associated communities. When over-
whelmed with the obvious relevance of these details for the questions being
addressed can we say anything useful about epistemologies generally? Or
do we need to just abandon our initial efforts at a synoptic view, concede
irreducible plurality, and then situate any discourses of justification and truth
in the appropriate social contexts where they are advanced? Does the social
turn wipe out any prospect for the classical project when we are concerned
with real-world practices like those associated with medicine?
Before revisiting this question, we can make an observation about all of
the contributions to this journal issue. None provides a synoptic vision of the
epistemological practices they consider. Instead, each advances a corrective
of more general epistemic practices that are largely taken as given and that
remain implicit in their discourse. Even in this introduction, when the task
482 George Khushf

of providing a synoptic vision was presented, there was a gesture toward


an empirical base: there were epistemic practices out there, taken as given,
and addressed in some way by that literature. This, it turns out, is a per-
vasive feature of all contributions to medical epistemology. Even the most
comprehensive efforts like those associated with EBM always start by taking
some antecedent set of epistemic practices as given. They then involve an
attempt to systematize and correct certain problematic aspects of the given
practices, so errors might be avoided. This, in turn, implies that epistemolo-
gies are better understood as strategies for overcoming error, rather than as
comprehensive accounts of how we attain justified, true beliefs.
When we view epistemologies as general strategies for error correction,
there is an interesting parallel between medicine and epistemology, one

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which George Canguilhem (1991) explicitly considered in one of the most
influential contributions to medical epistemology in the past century. In
the case of both medicine and epistemology, there is an ontic priority to
the positive goods: health and knowledge. But in ordinary practices we
are oriented toward these in unproblematic, taken-for-granted ways. When
healthy, we don’t worry about health. We simply “live life in the silence of
the organs” (this phrase is from Leriche, reviewed by Canguilhem, 1991, ch.
IV). Similarly, when our epistemic faculties and practices exhibit to us the
world in the natural way we normally encounter it, we don’t think about
knowledge and truth. Instead, we simply know things as they are given to
us in those ordinary interactions of life. In both cases, health and knowledge
only become objectives of critical reflection when they are lost or otherwise
at risk. Thus, although there is an ontic priority to health and truth, there is
an epistemic priority to illness and error. Medicine and medical epistemolo-
gies are the result of our efforts to overcome these failures. Medicine targets
illness in a form we can manage scientifically, that is, as disease. Medical
epistemologies then target errors, and they do this in relation to the given
practices already under development to target disease. Viewed in this way,
recent systems oriented efforts by the US Institute of Medicine to elimi-
nate error and advance quality might be regarded as social epistemologies
(Corrigan, Kohn, and Donaldson, 2000; Kohn, Corrigan, and Donaldson,
2001). Medical epistemologies are then oriented to strategic error manage-
ment, just as use of medical disease concepts are oriented to strategic illness
management.
Although the positive goods of health and knowledge are ontically first
things, epistemologically they are the last, and perhaps we never will have
anything more than a partial, explicit grasp of them. We can only come to an
approximation of the positive goods after extensive efforts to map organis-
mic and epistemic norms from the side of failures. But that shift to the posi-
tive end is extremely difficult to make, and it involves challenges that are
only partially appreciated and addressed. What is optimal health and how
might that inform preventive efforts to advance it? That question is strangely
A Framework for Understanding Medical Epistemologies 483

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,

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and this clearly overreaches the evidence and involves premature closure of
the discourse about epistemologies. Marcum (2013) already observed that
EI might involve one strategy humans have for managing complexity. There
are of course other epistemic management strategies that also help us make
sense of complex, convergent processes (Clark, 1998; Wimsatt, 2007). Here,
Ashley Graham Kennedy’s recommendations to clinicians might be general-
ized: we need to suspend judgment and keep open the pathways of inves-
tigation that are nicely exhibited to us in the diverse contributions to this
issue. Whether this discourse converges and, if so, how and to what—these
remain open questions in philosophy and in medicine. With our effort to
develop a framework for seeing the diverse contributions as part of a com-
mon project, we indicate our belief that the general project of an epistemol-
ogy is worth pursuit, as are the associated goods of knowledge, truth, and
practical wisdom.

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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