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 the of the policy or in their a range of to sure they are to The it seems, in people to the of any text or policy and the authors seem at the of practitioners in the of handy to they it is to question the of the the or to questions about their underlying if would accept this to or some other more this has many some in where might it to the to this is and in so as you are about to the to and a has no interest in why should we work in this and What to practice are What justification has been for such questions are as as questioning the as no role in ‘real if you want to what is the evidence in area of practice, the do you of are a are as by is or It is just a of sure you what the is on the and that not in the course of if you want to what is in then and the by the ethics committee for the for area of practice or it is with the to the on you are trying to some would a of of this sort the and of in the management and of so many health the might even question or not might be if by with the time and to think of for at the people who about such would not you are a and you do not have the time to in such impractical thought of no to accept the of ‘the by the of philosophy is the to this from being philosophy is a practice that all human in at some in their lives – at the we are and to a question we have been a meaning that the question It is of our We all have the of that a not that a of has to us is or just and we may to think about those to be to and write in the do this we all in the not of ‘real life’ but a set of that may to and The to be in much the same and is no a part of ‘real life’ for so about anyone in and just about anyone do is intellectual you it by you to think more about any that you and to from from do philosophy is to to the of by and of from being to it is if is to the for practice, that about the of terms and about the of are in this The is not between and but between and [5]. is certainly no evidence to the that as a are more effectively if their is philosophy to the to think A in philosophy should have to as a matter of those who and to be to in of what they that the should be not have the that such as a matter of have for what they that they should do and be to to and their It is for this that philosophers been as by and of all who their to [5]. was to for questions that not to a more is to the nature of the to as claim and on that to questions as of with the ‘real The author of the first quotation that is to intellectual in management and to about the of on and in ‘real life’ that is in fact are not to have of work on to a of what is with this It is of by the the the of in the that many and in about they on their saying you for not in was the is not to but to the and of those is with the that that to the are being on and to ‘intellectual in the should to to for the claims and the should have been to and question even as too obvious or too to be even those so that they have of their in a of only that they may be and that the of philosophy to underlying and why it so to have a in that philosophers to address questions of a the nature of knowledge and about the proper of practice, or about the of to the debate that they may think and so may have such it as a to that are who do not those such may just or us to our to as and as and to we have what may have been the we to them. The to about is to and and to be and by that even to that is it to of as a who for or who own [5]. A that as Mill for a by ever more to our and attitudes a to think and about the underlying the it is at the of those who the in a the that the is by that to understand or even The in we the our of the between and it the that we our so such a in no be as in of own and be to a The of is a to our as and in as It to in of their own the initial meaning of the from to the of for the of The of in has the of philosophical and the questioning of underlying in the of clinical policy and on evidence-based practice have much to the of underlying questions about nature and of health some of would us to or as to their proper in This first of the to philosophy in medicine and health this We from some of the and thinkers the has to on a range of of The is to and to the of too even in some medical is to the and of of to from the nature of evidence and in clinical practice to the of such intellectual as the nature of clinical expertise and the relationship between the language of science and evidence in medical the nature of health and questions of as as the debate of the and of and The with a and by the of science, and authors with the of evidence of for health and that is on evidence from is that of of the as the by of is the much of the of from of and they that is the and that are the they that this has and for a of policy in health and the with the of to in the and is by and this by who a of EBM of and that use as a of rather than as the language of the science and that this the of EBM of to and – a the author that would be to a or of the of claims and knowledge claims are and a philosophical of on the of a of ‘the has at to and they all that we are all to this but that proper reveals to be important of the is to to that medical of is not on or but on rational that ‘the of philosophy in in a the the authors' of their of ‘the the of by a and We to the of this important debate in of the as it is that sure to this would questions about the relationship between and that are not only to the debate about but that have a This debate is by that the and nature of knowledge in the clinical clinical and knowledge and the of knowledge as a human a in of in of medical in much of the work on EBM and to the foundations for ‘a of the of expertise and medical the relationship between expertise and with reference to the work of and the it a for a of clinical as and that the for the relationship between ‘the and the in clinical between and of work on or of medical that many of clinical for a of medical knowledge that is at with they practice and that medical more of than of medical the in medical practice and for a of the of the clinical and the of ‘the taken for knowledge that all human a to the on the clinical as between and in the of our as to any about the nature and of our knowledge as the of a about the of knowledge as of the it is with a scientific of what we are – and has the of that or of knowledge have with this to and to language and that this language is not to the of to a of the epistemology and ethics of to the of many philosophical EBM is with of and a of ‘the first of the EBM that as on the approach of that and EBM only and that on the that the clinical questions in evidence-based practice with the of to epistemological we a of that could be as in we that the and between the and the are a matter for philosophical as some of the in this of the and that for or a part of their from the they a great many – being between a health to and to and to in the of the in the and some of the philosophical and questions that to be take as a policy the of their they about in philosophy, that philosophers should not dismiss ‘the of policy but should at ‘the and policy that is by that is much of the and philosophical in the of and that of health and of the with in philosophy and reference to of a of the and the work of philosophers and We have no that in policy in this and a fascinating of the relationship between health and a that health is – of being from of or or The that health has is associated with to the of health and health by health as in of the and methods of health health and health but for or in the and for the health a and the debate between and of ‘a about health The of the between medicine and health and and medicine to the for a of science as such it is a to for to philosophy and of philosophy questions for (and for philosophical the between epistemology and science and The that a debate between the and the of ethics on the of as the of and that ‘the question of should be should be of the the use of on a in the would a is that is and and the question as to should be or not the for a that is at and on the question of us to what we would be practitioners to do by the is not the of with a to would the of the of the to this but rather with what philosophers is a between two if is ‘the of two then the is Even the the the if is a who ‘a to the of a serious and could in being to in they would regard as a as and as that of on but that are in the of lives in a of is to on the fact that the was rather than it as would not the of the but would a much more being the address the of and with regard to medical and in of to to are and that and academic work in the area a of they to and the of the the role of in and the of and the to that is a human in at the of and the of is the of the to those with a to and in the to the for a of to the that a might to treating of other and responds that about to the not claims that some of This might us to question or not it really is to such questions while our on the question at and this about it is to address such questions a where the that the and should be The relationship between ethics and is the of a of in terms of is of the on this approach to in are that are and the to think about our in a work or The with of the ethics of to of from consideration of the and that to be and even to from and that seem then that ethics a in the health of some while underlying and to the for on the a rational of their to be in nature, and the of processes the of the This the from a in been and where that was in The from a of health philosophy, and and from a of the and The was to a for and policy makers with EBM to and for on the of EBM and for it where it or the to ask not just EBM could be but different to this The was at a time EBM was in health the and the language of many other about the evidence-based in a that was (and This and the in this of the and has the to a in the EBM We not only of the that in this but of the important the This is a of the was to intellectual – as such it was as a of by the with intellectual the as the for and of this sort has been of philosophical and it would be to this of the in any of intellectual The the of a approach to the raised by were by the and of differences in of have from this It is the of the that this and the and do to the of the and The of of EBM from the of a or history and philosophy of and clinical For of was a by a and a question and answer and question were approximately to questions raised by the and to or on the in the and were different for in to people to to as many of the other as was by a of the for and all to the to the of their with the of other the that the as in the address and the would the they to with to questions to EBM in of the of EBM is what as EBM in the first have to the of of EBM only to have of EBM that what was is not a part of the is some in EBM is a for some on what is taken to be EBM was thought by the to be a for at the The with a address by the of science in the of evidence in EBM from the of philosophy of that EBM to to by at on evidence and just what of evidence evidence that the questions by are not the questions that would to have to they are about the of their that the of the of or of the that with rather than and evidence that a is to the were to some of the following what would you say were the of EBM it was first What do you to be the of EBM you been in the of EBM you have in practice or in and if so have you or and have you or The were a in to and the to the of their with the other of the The for the first was to of the of of to the were by and by the a of the it is that to that of EBM have to the meaning of EBM to their and that this has the of EBM that is a different of EBM in practice than in and that is a of on this so the for this is important for practice only for with this a set of were to with the at all, that from their questions about what or many different at from many different and was some with that the A from the about what the of EBM were in it was first and what they are The first was the of evidence and role A of the of evidence as a and even the of Even this of the as a of EBM that are many of evidence that was of at the of evidence is a of of ‘the is the in different were to a to all of EBM were more about the that the of research methods the was a of A second of in the the role of philosophers of science in the of were to philosophers are to answer questions about what EBM is or should What is the role for philosophers in this philosophers effectively to medical was some for the that of the of philosophers is to to to with even if they are to do all of the work of a or The work is in own to might be EBM is a sort of epistemological philosophers should have to say about we take the of philosophy, philosophers such as and have a on of science may have a on philosophers have a they are from the of in the is for and in philosophy and this is different from the by who have to a the the For some the in EBM is the a to the and use of It was that a is the terms and in this for the and of practice matter medical and are a of important evidence for clinical even though is about other of evidence are to be in of to on and of the to with the was some that we should not so much to the of EBM and just take the of it and it to other should that do time and the in EBM the The only of would be a to the of medical as this: believe you're address with the comment that EBM in to and health and and to and This two of in the a of on their role as ethics and the that the and on the and of The first – what it means to be ethics – has a of in ethics is no as of to as seem to on a range of and and and The role of the is – do to to of the The second the of been in on evidence a for it is a For that the on that on evidence in clinical practice is The of evidence and ethics to be and some of the EBM from consideration of the relationship between evidence and EBM on evidence in medicine in to a of clinical ‘the to This on the of was as as was the that in the history and philosophy of science the why it is that EBM not address in the evidence address the nature of with to by The medical literature is by of that are not by or – and for of and clinical only and a in the to What should be with patients and are of evidence it is that science research important role in medicine and health the of the and their relationship EBM is not as this following a by and by the in the could to EBM that the a great of between science and where may use different and was much of the relationship between different academic and clinical and the of with people who have different academic and with interest in EBM and some health health A of were in research in the has in evidence and have to about to with patients their and the of and to that patients may not their so that the of be taken for in science has clinical for the of in many of clinical research in part of from it was that were not taken by medical some time they first have to in the of from research by of the of research and the on of science research may have a on research and health for by research from a by clinical that the of research questions and the methods that are taken to be for them. science research has to other in the for clinical from of to the of in research and policy terms of science research EBM a of were a between research that the and as as the of such research as and to the of was a that science research could EBM and clinical with but that at the same time this was not the of such The between the and the of science research on EBM is to the of the different and of different academic and of clinical have on they and of EBM as a practice and of the of this same may that important are not or taken This is the same that with work on in clinical research to the of the of in the clinical that the interest in research in different may different and the that be taken for by with that the at this they been by the different by and from other than their and at this in they that or that from their own in work of and terminology that do not in with other in the same was that this could be but at the same time The of the of work for the of EBM were with feeling that EBM would from from and being that such improve the practice of The on the of EBM to clinical This a by and a by that are of evidence for clinical and a of clinical research as a to other The to practice is to clinical and clinical a of is a has and in some a of in this and in was to but that may too far and to a scientific to clinical this was the many of their about the relationship of EBM to clinical It was that this area by far the of literature and of about the and limitations of the clinical of on EBM was that or that in the of a EBM would as the A clinical are and the associated with being in the for to in clinical for a for the were in the of more the medical This would and scientific and of what evidence in a of to the on in medicine was as of to this in the clinical it was thought that a different set of would be to the policy The a and This of the a and a with on as a in to a of EBM about the of as that is a of but only if as a and of that EBM from of clinical practice, that is the the and the in but as it are no that the in clinical practice is not the of evidence but the of time in practice to understand and it while to the of patients with to and knowledge do not address the and that their to rather than to those of the and the in the of this the is to in practitioners. from being a academic the of such is a of any for the of and of the if they are to and to to their or the years may [5]. We do not more compliance in the of a practice and We more intellectual not We and more on not the that do that for The of philosophy is now, if not more than ever then certainly no than at any time in

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.