Clinical Judgment: A Critical Appraisal: Proceedings of the Fifth Trans-Disciplinary Symposium on Philosophy and Medicine Held at Los Angeles, California, April 14–16, 1977

292 Pages·1979·8.056 MB·English

by  Michael Scriven (auth.), Hugo Tristram Engelhardt Jr., Stuart F. Spicker, Bernard Towers (eds.)

CLINICAL JUDGMENT: A CRITICAL APPRAISAL
PHILOSOPHY AND MEDICINE
Editors:
H. TRISTRAM ENGELHARDT, JR.
Kennedy Institute 0/ Ethics, Georgetown University, Washington, D. C, U S.A.
STUART F. SPIeKER
University o/Connecticut Health Center, Fannington, Conn., US.A.
VOLUME 6
CLINICAL JUDGMENT:
A CRITICAL APPRAISAL
PROCEEDINGS OF THE FIFTH TRANS-DISCIPLINARY SYMPOSIUM
ON PHILOSOPHY AND MEDICINE
HELD AT LOS ANGELES, CALIFORNIA, APRIL 14-16, 1977
Edited by
H. TRISTRAM ENGELHARDT, JR.
Kennedy Institute of Ethics, Georgetown University, Washington, D.C., US.A.
STUART F. SPICKER
University of Connecticut Health Center, Farmington, Conn., US.A.
BERNARD TOWERS
University of California at Los Angeles, California, US.A.
D. REIDEL PUBLISHING COMPANY
DORDRECHT: HOLLAND / BOSTON: U.S.A.
LONDON: ENGLAND
Library of Congress Cataloging in Publication Data
Trans-disciplinary Symposium on Philosophy and Medicine,
5th, Los Angeles, 1977.
Clinical judgment.
(Philosophy and medicine; v. 6)
Includes bibliographies and index.
I. Medical logic-Congresses. 2. Medicine, Clinical-
Decision making-Congresses. I. Engelhardt, Hugo Tristram,
1941- II. Spieker, Stuart F., 1937- III. Towers,
Bernard. IV. Title.
R723.T7 1977 616'.001'9 78-26504
ISBN-13: 978-94-009-9401-0 e-ISBN-13: 978-94-009-9399-0
DOl: 10.1007/978-94-009-9399-0
Published by D. Reidel Publishing Company,
P.O. Box 17, Dordrecht, Holland
Sold and distributed in the U.S.A., Canada, and Mexico
by D. Reidel Publishing Company, Inc.
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All Rights Reserved
Copyright © 1979 by D. Reidel Publishing Company, Dordrecht, Holland
Sof'tcover reprint of the hardcover 1s t edition 1979
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical,
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retrieval system, without written permission from the copyright owner.
EDITORIAL PREFACE
Over a period of a year, the symposium on clinical judgment has taken shape
as a volume devoted to the analysis of how knowledge claims are framed in
medicine and how choices of treatment are made. We hope it will afford the
reader, whether layman, physician or philosopher, a useful perspective on the
process of knowing what occurs in medicine; and that the results of the dis
cussions at the Fifth Symposium on Philosophy and Medicine will lead to a
better understanding of how philosophy and medicine can usefully challenge
each other. As the interchange between physicians, philosophers, nurses and
psychologists recorded in the major papers, the commentaries and the round
table discussion shows, these issues are truly interdisciplinary. In particular,
they have shown that members of the health care professions have much to
learn about themselves from philosophers as well as much of interest to engage
philosophers. By making the structure of medical reasoning more apparent to
its users, philosophers can show health care practitioners how better to master
clinical judgment and how better to focus it towards the goods and values
medicine wishes to pursue. Becoming clearer about the process of knowing
can in short teach us how to know better and how to learn more efficiently.
The result can be more than (though it surely would be enough!) a powerful
intellectual insight into a major cultural endeavor, medicine. The result can be
better diagnosis and treatment of patients and more successful education of
health care professions. Being clearer about ideas means also being clearer
about the actions we take to be of great significance and which are directed
by such ideas. And in this process not only is medicine enriched, but philoso
phy is as well, by an investigation of substance and social importance - not
to mention of conceptual interest.
Though the term medicine is used throughout this volume, it is meant
broadly - somewhat as philosophy is used in the degree Doctor of Philosophy.
One should see it encompassing what is embraced by the more cumbersome
phrase, "The health care sciences, arts, and technologies." It includes then not
only medicine in sensu stricto, but such endeavors as nursing, occupational
therapy, dentistry, veterinary medicine, clinical psychology, psychoanalysis,
and the practice of physician assistants. All of these enterprises, as well as
others, are concerned with categorizing the complaints of patients (clients) in
v
vi EDITORIAL PREFACE
order to forward accurate prognoses and enter upon useful courses of treat
ment. Moreover, they all share in the fact-value ambiguities of health and
disease language. In describing individuals as ill or well, healthy or diseased,
they also evaluate them. Moreover, in terming individuals sick, health care
professionals cast patients (clients) into social roles with vast implications -
consider for example Talcott Parson's sick role [I]. Clinical judgments are
not only intellectual exercises with the usual practical consequences we envi
sage (e.g., good or bad treatment). Clinical judgments also have consequences
that impinge on general social goods; they respond as well to our evaluations
and our social structures. As in the other volumes in this series on philosophy
and medicine, we see evaluations intertwined in medical explanations. The
result is that no adequate sense can be made of bioethical problems without
understanding the particular enterprises of knowing which constitute medi
cine.
The essays in this volume are offered as one step in understanding the
theory of knowledge in medicine. They are meant as a contribution to a
philosophy of medicine that seeks to engage some of the more ambitious
themes of the first volume in this series - Evaluation and Explanation in the
Biomedical Sciences. Much more needs to be done, and will be done in this
series, in the way of exploring such subjects as the role of evaluation in medi
cal explanations, the value-laden character of the language of disease and
health, and the hidden imperatives of the sick role. Much more must be
undertaken with regard to understanding the ambiguities of disease language.
This is particularly the case in coming to terms with nosography and the
generation of nosologies in the use of computers in medicine. Moreover, the
problem of the logic and the psychology of discovery in medicine remains
almost untouched.
This volume offers a first approach towards the analysis of the nature of
clinical judgment. We are grateful for the support of the School of Medicine
of the University of California at Los Angeles, the Research Foundation of
the American Medical Association, the Franklin 1. Matchette Foundation,
and D. Reidel Publishing Company, who made this beginning possible. Not
only are we grateful for their financial support, but for their moral support as
well, which enabled us to hold the symposium which was the ancestor of this
volume. Moreover, we stand in special debt to the School of Medicine of the
University of California at Los Angeles for the many ways in which its admin
istration encouraged and made possible this meeting of clinicians and scholars
interested in understanding clinical judgment. Many individuals labored un
selfishly in the preparation and conduct of this symposium. We are deeply
EDITORIAL PREFACE vii
grateful to them all. Here we can name but a few: Sherman M. Mellinkoff,
Robert Adams, Rodney Bluestone, Susan Engelhardt, Sharon Hill, Marjorie
Huffman, Dwaine Lawrence, Norman Levan, Charles Lewis, Ruth Walker
Moskop, Fritz Redlich, Arthur Rivin, Bernice Wenzel, Paula Wilkes, and
William J. Winslade. A special thanks in this regard is due to Jane Backlund,
who inherited the post-symposium red tape that comes in the wake of any
large conference. We are also in debt to her for the careful preparation of the
manuscripts of this volume and for the generation of many of the references.
Finally, we must acknowledge our debt to the many individuals who attended
this symposium on clinical judgment and helped through their discussion to
frame the papers in the final form in which they appear in this volume.
April 21, 1978 H. TRISTRAM ENGELHARDT, JR.
STUART F. SPICKER
BERNARD TOWERS
BIBLIOGRAPHY
I. Parsons, T.: 1967, Sociological Theory and Modern Society, Free Press, New York.
T ABLE OF CONTENTS
EDITORIAL PREFACE v
H. TRISTRAM ENGELHARDT, JR. / Introduction xi
SHERMAN M. MELLINKOFF / Prologue to the Symposium xxv
SECTION 1/ INTUITIONS, HUNCHES, AND
RULES FOR REASONING
MICHAEL SCRIVEN / Clinical Judgment 3
AUTHUR S. ELSTEIN / Human Factors in Clinical Judgment: Discus-
sion of Scriven's 'Clinical Judgment' 17
ELLIOTT SOBER / The Art and Science of Clinical Judgment: An
Informational Approach 29
D. 1. ROSENHAN / When Does a Diagnosis Become a Clinical Judg-
ment? Verifiability, Reliability and Umbrella Effects in Diagnosis 45
SECTION II / THE LOGIC OF HEALTH CARE
EDMOND A. MURPHY / Classification and Its Alternatives 59
MORTON BECKNER / Comments on Murphy's 'Classification and Its
Alternatives' 87
JOHN 1. GEDYE / Simulating Clinical Judgment: An Essay in Tech-
nological Psychology 93
ERNAN McMULLIN / A Clinician's Quest for Certainty 115
JOHN L. GEDYE / A Reply to Ernan McMullin 131
PATRICK SUPPES / The Logic of Clinical Judgment: Bayesian and
Other Approaches 145
MARTIN E. LEAN / Suppes on the Logic of Clinical Judgment 161
SECTION III / CLINICIANS ON CLINICAL JUDGMENT
EDMUND D. PELLEGRINO I The Anatomy of Clinical judgments:
Some Notes on Right Reason and Right Action 169
ix
x TABLE OF CONTENTS
MARJORIE GRENE / Comments on Pellegrino's 'Anatomy of Clinical
Judgment' 195
ERIC J. CASSELL / The Subjective in Clinical Judgment 199
DANIEL I. WIKLER / Subjectivity and the Scope of Clinical Judgment 217
SECTION IV / JUDGMENT AND METHODS
IN CLINICAL JUDGMENT
ROUND TABLE DISCUSSION
Stuart F. Spicker 229
E. James Potchen, Paul Wahby, William R. Schonbein, and Linda
L. Gard 238
Sally Gadow 248
Thomas E. Hill 254
Bernard Towers 259
H. TRISTRAM ENGELHARDT, JR. / Closing Remarks 265
NOTES ON CONTRIBUTORS 273
INDEX 275
H. TRISTRAM ENGELHARDT, JR.
INTRODUCTION
Clinicus is also used for a physician - In
regard [to I physicians [who I are much
conversant about the beds of the sick. Clinic
is now seldom used but for a quack; or for
an empirical nurse, who pretends to have
learned the art of curing diseases by attend
ing on the sick.
Ephraim Chambers, Cyclopaedia; or an
Universal Dictionary of Arts and Sciences
(1751)
As the definition of clinician in Chambers' dictionary shows, being called a
clinician does not appear to have always been an unalloyed compliment. We,
though, take it to be unequivocally a term of honor, designating a physician
skilled in the treatment of patients; consider the force of saying "he is no
clinician". Chambers' skepticism concerning clinicians was due as the entry
suggests to a suspicion of empirics, physicians who practiced without an
adequate theoretical basis for their medical judgments. In part, current inter
est in and criticism of clinical judgment stems from a similar distrust of the
empiric. There is a suspicion that the judgments of clinicians would be more
reliable if rendered more rational by following explicit rules and recipes for
diagnosis and treatment. There is, as well, interest in clinical judgment in
order to understand how to reconstruct its successes and have them matched
by undertakings of artificial intelligence - computers. Yet others would see
in clinical judgment, decisions made on the basis of an intuition born of years
of bedside experience, and not reducible to explicit formulae. The interest in
clinical judgment is thus diverse if not contradictory: there is interest among
clinicians and others in reducing the basis of medical decisions to fonnal rules
as well as interest in denying that such rules would match the success achieved
by the intuitive decisions of clinicians.
The phrase 'clinical judgment' is in other ways ambiguous. On the one
hand, it may be taken to refer to a capacity to make medical judgments con
cerning patients. One might think here of the famous line from Epidemics,
"Declare the past, diagnose the present, foretell the future; practice these
acts. As to diseases, make a habit of two things - to help, or at least to do no
harm." (Epidemics I, 11 (11] .) Clinical judgment in this very traditional sense
xi
H. T. Engelhardt, Jr., S. F. Spieker and B. Towers (eds.), Clinical Judgment: A Critical
Appraisal, xi-xxiv. All Rights Reserved.
Copyright © 1979 by D. Reidel Publishing Company, Dordrecht, Holland