Philosophy, ethics, medicine and health care: the urgent need for critical practice

What is philosophy and should health practitioners, patients and policy makers take the subject seriously? A rudimentary acquaintance with the literature on a range of important topics, from the nature of clinical evidence to the management of health services, reveals that many would answer the second question with a resounding ‘no’, implicitly vindicating their refusal even to think about the first [1–6]. It is deemed acceptable to write about the nature of clinical knowledge and the proper relationship between scientific research and medical practice, while professing no interest in epistemology and the philosophy of science, as though underlying questions about the nature, limitations and role of science in clinical practice were just too obvious to merit serious consideration [2,7]. Even those who declare their area of expertise to be ‘ethics’ may openly eschew philosophical methods [8–12], treating ‘applied’ as distinct from ‘philosophical’ ethics: the former being neither ‘the offspring of’ nor ‘even dependent upon’ philosophy [3]. The term, associated for much of human history with the work of thinkers such as Plato, Aristotle, Hume, Kant, Mill and Sartre, has in the course of approximately 30 years been effectively appropriated by those who understand ‘ethics’ to be all about ticking boxes on forms, regulatory mechanisms and committee meetings, and by authors who think a really great work of ethics is a comprehensive set of ‘authoritative guidelines’, punctuated by handy ‘ethics check lists’ to facilitate compliance [5]. Consider the following quotations, separated by 14 years and addressing radically different topics. The first is about health management and responds to questions about the intellectual foundations of the author's approach to this subject. I certainly admire those who have spent their lives trying to improve the quality of thought but for those of us employed in more mundane processes of what is called ‘real life’ we must be forgiven for feeling that some intellectual ruminations are not to our purpose. [1] The second is from a text on evidence-based medicine (EBM) and berates ‘philosophers’ for questioning the epistemological foundations of EBM [13]. Complaining that such questions are ‘confusing rather than helpful’, the authors conclude: We are sure the intellectual ruminations would be fascinating – if only we could understand them. The debate is for philosophers, not busy healthcare practitioners. For now, all we want to say is this: if you're overwhelmed by the literature in healthcare, then it doesn't matter if you're a doctor, dentist, nurse, midwife or therapist, EBM is for you! [2, pp. 2–3] A couple of pages later the same authors ask if EBM is ‘a philosophy, a movement or even a scientific revolution’ and respond: ‘Let's leave the debate to philosophers. This book is for healthcare practitioners. We say it again – if you are drowning in medical literature, EBM is for you!’[2, p. 5] Despite the differences in time and topic, the underlying attitudes of the authors are strikingly similar. Both dismiss philosophical questions as ‘intellectual ruminations’ detached from the processes of ‘real life’, where people are too busy to address such ‘academic’ issues. The first quotation was prefaced by a comment implying it is ‘arrogant’ even to assume that people who work at universities (and are officially part of the ‘academic staff’ of a university, as was the author at the time) must be ‘academic’ and should therefore ‘rely on the processes of rational thought’[1]. The EBM authors' reference to ‘scientific revolutions’ was a reaction to questions raised by two philosophers [14] about the use by EBM protagonists of the language of ‘paradigms’, ‘scientific revolutions’ and other terms taken from the philosophical work of Thomas Kuhn [15]. The authors apparently found nothing unhelpful or confusing in the initial appropriation of this language, with scant explanation, by the founders of EBM [16]. Nor do they have any problem, it seems, with the fact that EBM literature has been peppered with this sort of terminology ever since. It is the raising of questions about it that they regard as a trivial academic exercise. It is not trivial to claim that EBM is a paradigm,1 but it is trivial to ask what that claim means and why anyone should believe it. What they seem to be saying to the practitioners they address is: ‘you are far too busy to think about the meaning and justification of the claims we invite you to accept, so just accept them!’[7] Thus their hostility to philosophy's ‘ruminations’ is a species of what might be called ‘moderate anti-intellectualism’. After all, the authors do not dismiss all intellectual ruminations as impractical and are happy to ponder at length, in their own work, the implications of the latest policy document, manual or handbook in their selected area, sometimes taking readers through a wide range of ‘what if’ scenarios to make sure they are ‘up to speed’. The intellect is, it seems, properly occupied in equipping people to follow the instructions of any selected text or policy document, and the authors seem remarkably untroubled at the prospect of practitioners ‘drowning’ in the sea of handy ‘how to’ texts to which they readily contribute. Intellectual exercise becomes improper when it is used to question the validity of the reasoning within the selected documents, or to raise questions about their underlying assumptions. Although few, if any, would accept this label (preferring to call themselves ‘pragmatists’, ‘realists’ or some other rhetorically more effective term) this moderate anti-intellectualism has many defenders, including some powerful voices in academia, where one might reasonably expect it to meet the most fierce resistance [5,17]. According to this view, thinking is permissible and sometimes highly desirable in working life, so long as you are thinking about ‘how to’ questions: how to follow the rules, how to accomplish tasks and achieve goals. But a truly ‘practical’ person has no interest in ‘why?’ questions: why should we work in this way? Why these rules, tasks and goals? What alternative approaches to practice are available? What justification has been provided for currently dominant approaches over such possible alternatives? Such questions are dismissed as spurious, as questioning the just-plain-obvious, as playing no role in ‘real life’. So if you want to know what is the best evidence in your area of practice, consult the relevant guidelines. How do you decide which published sources of guidance are relevant? As a general rule, find out which ones are currently recognized as relevant by whoever is funding your project or area. It is just a job of keeping up, making sure you know what the most recent advice is on the matter, and sometimes hoping that official advice does not change in the course of your carrying out your work. Similarly, if you want to know what is ethical in your area, then find and follow the guidelines issued by the ethics committee for your institution, the regulator for your area of practice or whoever it is with the power to pull the plug on whatever you are trying to do. Obviously, some would wonder whether a group of instruction-seeking, guideline-following workers of this sort represented the excellent, autonomous and thoroughly motivated professionals boasted of in the management mission and vision statements of so many health organizations across the world. Some might even question whether or not services might be better if provided by staff with the time and energy sometimes to think of thinking for themselves at all.2 But the people who wonder about such things would not include you, because you are a practical person, and you do not have the time to engage in such impractical thought experiments. There is, of course, no good reason to accept the conception of ‘the practical’ embodied by the version of moderate anti-intellectualism sketched above. Understood properly, philosophy is the antidote to this position. Far from being an other-worldly occupation, philosophy is a practice that all human beings engage in at some point in their lives – at the very least, when we are young and refuse to abandon a question until we have been given a sensible answer, meaning one that actually answers the question asked [7]. It is an extension of our everyday reasoning processes. We all have the experience of sensing that a conclusion does not follow, that a line of argument someone has presented to us is either incomplete or just plain spurious, and we may sometimes stop to think about why. Philosophers (at least, those fortunate enough to be paid to teach and write in the subject) simply do this professionally. By analogy, we all engage in physical exercise: the sportsperson does not exist outside of ‘real life’ but simply develops a set of skills that others may also aim to develop and improve. The philosopher aims to be intellectually fit in much the same way and is no less a part of ‘real life’ for so doing. Just about anyone can engage in sport, and similarly just about anyone can do philosophy. Philosophy is an activity, an intellectual discipline: you learn it by practising. Philosophical training helps you to think more clearly about any problem that confronts you and to distinguish sense from nonsense, good arguments from bad. To do philosophy is to learn to identify the logical structure of arguments, clarifying debates by exposing ambiguities and errors of reasoning. Far from being an alternative to practical thinking, it is essential, if thinking is to provide the basis for coherent practice, that logical confusions, about the meanings of terms and about the implications of statements, are identified in this way. The choice is not between practical and logical thinking, but between clear practical thinking and confused thinking [5]. There is certainly no credible evidence to the effect that tasks, as a rule, are performed more effectively if their performance is based upon confused thinking. Done properly, philosophy helps to foster the disposition to think critically. A student qualifying in philosophy should have come to expect, as a matter of routine, those who make assertions and issue instructions to be able to produce good reasons in support of what they say. Please note that the term ‘expect’ here should be read morally: she does not have the ‘naïve’ (empirical) expectation that such persons will, as a matter of fact, have good reasons for what they say. Rather, she thinks that they should do and will be prepared to challenge them to explain and defend their claims. It is for this reason that philosophers have, traditionally, been regarded as troublemakers by dogmatists and ideologues of all sorts, who prefer their assertions to pass unchallenged [5]. While Socrates was famously sentenced to death for asking questions that others preferred not to answer, a more standard rhetorical strategy is to misread the normative nature of the philosopher's challenge, to construe her instead as making an empirical claim and on that basis to treat her questions as revealing lack of familiarity with the ‘real world’. The author of the first ‘anti-philosophy’ quotation cited above states that ‘it is vain to criticise intellectual flabbiness’ in senior management and ‘unrealistic’ to complain about the basing of decisions on ‘vague and half digested ideas’, because in ‘real life’ that is in fact how decisions are made [1]. One does not need to have made an extensive study of Sartre's work on ‘bad faith’ to get a sense of what is wrong with this response [18]. It is reminiscent of an old joke told by the comedian Alexei Sayle. In the days before the widespread criminalization of public smoking in the UK, Sayle complained that many restaurants and shops in his native Liverpool habitually made false assumptions about his behaviour, because they kept placing signs on their walls saying ‘Thank you for not smoking!’ when, in fact, he invariably was smoking. There are, indeed, times when the thing is not to describe, but to change the world [19], and one of those times is when confronted with the news that decisions that affect services vital to the common good are being based on ‘vague and half digested ideas’! In addition to critiquing ‘intellectual flabbiness’ in others, the philosopher should expect her peers to hold her to account for the claims she makes and the positions she espouses. She should have been trained to identify and question assumptions, even ones presented as too obvious or too widely shared to be worth questioning; even those so fundamental that they have slipped out of sight, making their presence felt in a line of reasoning only when someone notices that they may indeed be questioned, and that without them an otherwise sound argument collapses [17]. So the characteristic method of philosophy (its ability to expose underlying and often unarticulated assumptions) explains why it so often seems to have a characteristic content, in that philosophers tend to address questions of a peculiarly ‘fundamental’ nature. Discussions (about the nature of knowledge and evidence, about the proper goals of practice, or indeed about the moral character of actions) can appear intractable because parties bring to the debate fundamental beliefs that they may rarely think about, and so may never have seriously questioned. In such cases it can come as a genuine shock to find that there are others who do not share those beliefs: such persons may initially appear just plain crazy, or wilfully perverse. Philosophy forces us to identify our basic assumptions, to characterize them as clearly and honestly as possible and to decide whether, once we have brought what may have been background assumptions into the foreground, we still wish to endorse them. The alternative to thinking critically about one's fundamental assumptions is to allow one's ideas and attitudes, and consequently one's behaviour, to be shaped and directed by forces that one fails even to perceive, let alone control. If that is my condition, it makes very little sense to speak of me as a person who ‘thinks for himself’ or who makes his own decisions [5]. A political culture that derides critical reflection is, as Mill noted [20], fertile soil for tyranny. In a culture characterized increasingly by ever more sophisticated approaches to influencing our beliefs and attitudes [5,17], a population unable to think critically and analytically about the suppositions underlying the messages it receives is at the mercy of those who control the media in a very real sense, because the way that population conceives the world is determined by forces that its members fail to understand or even consider. The way in which we conceive the world includes our conception of the moral relationships existing between ourselves and others: it shapes the values that determine how we live our lives, so such a population can in no meaningful sense be described as in control of its own destiny, and cannot plausibly be said to populate a ‘free’ society. The version of moderate anti-intellectualism outlined above is a very real threat to our freedom, as citizens and in particular as professionals. It threatens to turn autonomous workers in control of their own practices (cf. the initial meaning of the term ‘profession’) into technicians awaiting instructions from others, whose authority to issue them remains unquestioned, lying beyond the scope of properly ‘practical’ enquiry for the rest of us. The Journal of Evaluation in Clinical Practice has consistently recognized the central importance of philosophical rigour and the questioning of underlying assumptions in the analysis of clinical policy and practice. Its regular thematic editions on evidence-based practice have done much to restore the discussion of underlying questions about nature and value of health practices (questions some advocates of currently popular approaches would urge us to ignore or treat as already resolved) to their proper place in public discourse [21–32]. This first thematic edition of the Journal devoted explicitly to philosophy in medicine and health care continues this tradition. We present contributions from some of the most incisive, exciting and rigorous thinkers the discipline has to offer on a broad range of subjects of urgent practical import [33–61]. The key goal is to bring depth and clarity to the discussion of topics too often addressed superficially, even in some respected mainstream medical media.3 Another goal is to illustrate the impressive scope and variety of applications of philosophy: to topics ranging from the nature of evidence and reasoning in clinical practice to the politics of professional ethics, traversing en route such diverse intellectual territories as the nature of clinical judgement, expertise and tacit knowledge, the relationship between the language of science and narrative evidence in medical epistemology, homeopathy, personalized care, the nature of health and questions of intrinsic value as well as the debate of specific moral controversies, including the currently topical and always highly of and The with a and discussion by the philosopher of science, and her authors with the ‘what of evidence support of for health and care note that there is an on evidence from whose basic is that of method of including the regarded as the by of central is the much issue of the of from these of and they that validity is the wrong and that are always the But they that this argument has and implications for a variety of policy in health and care, the with the of an to in the and rigorous discussion is by very and impressive this one by who a of EBM upon an analysis of and that use as a of analysis rather than as the language of the science and that this the validity of claims. 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