Reason and value: making reasoning fit for practice

Few would dispute the claim that sound reasoning in clinical practice is worth cultivating. That is, of course, because the claim is a platitude: it is hard to see how anyone could seriously maintain a contrary view. We might explain sound reasoning with reference to a number of evidently desirable qualities: we want practitioners who think critically, are reflective and perceptive, able to evaluate theoretical claims and evidence to assess their relevance in particular cases. We might add that this means understanding the value of particular outcomes to the care of individual patients, such that sound reasoning involves not just knowledge of causal mechanisms and the findings of research, but also an appreciation of and respect for the patient's autonomy and value. To leave such claims unanalysed is to make them barely worth asserting. These are things that, outside of a management 'vision statement', might 'go without saying'. This is not because the nature of good reasoning is well understood or that cultivating it in professional environments is a straightforward matter. The moment we attempt to go beyond the platitudinous, to say something with substantive implications for practice, we find ourselves confronted by controversies of a fundamental nature. Even if we agree that 'critical thinking' and 'reflective practice' identify important components of good reasoning, when we try to spell out precisely what we mean by these terms, in a way that could enable us to recognize and develop these qualities in real situations, any initial appearance of general accord soon evaporates. Not only is there no broad consensus on the essential components of good reasoning in clinical practice, but where there are differences, we lack a clear and agreed method for producing answers that all rational parties will accept. We have entered the traditional intellectual territory of philosophy 1, 2. As we have noted in previous editions of this journal, philosophy requires us to identify and question underlying assumptions that frame our thinking about a vast range of issues. Discussions about the nature of evidence, the proper goals of practice or the nature, scope and limitations of clinical reasoning, can appear intractable because we bring to them assumptions that may typically lie in the background, rarely subjected to critical scrutiny 1. It can initially come as something of a shock to discover that other apparently rational persons do not share assumptions that may have slipped so far into the background as to strike us as sheer common sense 2. Even so, if we are to say something on such important matters that is at once substantive (going beyond platitudes) and defensible (justifiable in principle to other reasonable people) – if we are even to understand the nature of our disagreements, let alone find realistic ways to resolve them – then we cannot avoid doing philosophy in this sense. This gives the lie to the much-touted opinion that philosophical questions have nothing to do with 'real life' 1. While it is of course possible to declare oneself too busy, too practical, too scientific or even too ethical to do philosophy 3-8, one does not thereby succeed in thinking without the assistance of any conceptual framework or background assumptions – rather one simply assumes a framework that one fails to defend or even adequately articulate 9, 10. Whether motivated by arrogance, intellectual laziness or some other moral or epistemic vice, there is nothing pragmatic – in any worthwhile sense of this term – about such a mentality. One is no less an inhabitant of the real world for being prepared to explain and justify oneself to its other inhabitants, even when doing so necessitates engaging with problems to which there is no ready-made solution, nor even a single, universally recognized method for finding the right solution 9, 11. The need for philosophy indicates, simply, that we have not reached the end of intellectual history 11-13. Whether or not it is possible for any human society to reach a point when all of the really important, fundamental questions about life and practice have been definitively resolved, an honest evaluation of our current understanding of the world and our place within it suggests that we, certainly, have not yet reached that point. As such, we need to be prepared continually to re-evaluate our underlying assumptions when making pronouncements upon matters of substantive import. A culture that eschews the open discussion of underlying questions of this sort is prone to dogmatism and intellectual stagnation 14, 15. It should not surprise the thoughtful person that the evolution of the human intellect did not reach its final conclusion at just the point when she appeared on the scene 12, and this fact presents us with an exciting opportunity. Just as we owe what insights we currently enjoy to the extensive 'labours of our ancestors' on whose 'shoulders' we stand 13, so we have the opportunity to continue that evolution, to contribute to the process of criticism and analysis in the pursuit of intellectual progress – to provide a platform upon which our descendants may stand when making further progress. Since its inception, the Journal of Evaluation in Clinical Practice (JECP) has cultivated the rigorous, incisive analysis of topics crucial to progress in medicine, including the nature of evidence and its relationship with clinical judgement, where necessary challenging the prevailing wisdom of the time and always reminding us that the major questions in these areas are by no means settled 16-26. It has produced two thematic editions devoted explicitly to philosophy in medicine and health care 1, 2 and in this, the third philosophy thematic, we present a thorough, comprehensive collection of original, penetrating articles on the nature of clinical reasoning, examining in detail a broad range of associated problems, concepts and relationships 27-60. These include the nature and status of medical knowledge; how we assess and apply research evidence; the role of intuition, tacit knowledge and perception in clinical reasoning; our understanding of causality, cognition, critical thinking, theory, data and inference; the role of normative judgements and the relationship between reasoning and value. Authors debate foundational questions about the basis for medical practice, the role of models in medical epistemology, the relevance of patient autonomy in rational decision making and the applications of concepts derived from biomedical theory and practice to psychiatric diagnosis. A particular concern is education and how to cultivate and sustain the right sort of dispositions in practitioners. Insights from virtue epistemology (presenting dispositional analyses of cognitive concepts) and historical epidemiology are used to cast light on our understanding of reasoning in practice. Discussion of such questions leads us finally to a series of debates about the nature of the inquiry itself, of the relationship between reasoning in medicine and the insights and methodologies of a number of academic disciplines – including the approaches of phenomenology, epistemology and ethics. The collection includes the products of a series of interdisciplinary workshops that addressed underlying questions about the reality of illness, identity, harm and value itself. These essays indicate the breadth of the topic considered in this issue, and invite us to challenge some of the traditional boundaries (for instance, between epistemology and ethics) that inform standard philosophical approaches to the problems of medical practice. Is clinical reasoning a manifestation of cognitive ability, logical analysis skills, interpretive sensitivity or narrative sensibility? Is it an amalgam of all of the above interspersed with the use of statistics and probability? These are important questions that begin to find answers in the papers of this volume. These papers open up horizons for future exploration and investigation on the various types of thinking employed by clinicians. The volume opens with an examination of the nature of critical thinking in medicine by Mona Gupta and Ross Upshur 27. Are critical appraisal, reasoning and thinking integral to the practice of medicine? Should medical schools and other health professions devote resources to teach and evaluate such skills? The authors note the importance accorded to critical skills in documents such as the Lancet Commission on Health Professionals and in the revised US Medical College Admissions Test, indicating these to be highly valued and necessary skills. Yet, a series of review papers in the medical and nursing education literature demonstrate lack of consensus on how they should be defined, what sorts of competencies they represent and how they should be evaluated in trainees. The authors argue that, despite the lack of consensus on these topics, critical skills can be identified when they are exemplified in practice. Using the example of the controversy surrounding the efficacy and safety of selective serotonin reuptake inhibitors in psychiatry, it becomes evident that using critical skills requires courage as it may entail some risk. Gupta and Upshur then provide a provisional account of critical skills in a virtue theory framework, drawing on both virtue ethics and virtue epistemology. They argue for a more sustained enquiry into the relationship between the virtues, medical education and critical appraisal, reasoning and thinking. Virtue theory and phenomenology come together in Hillel Braude's fascinating account of the perceptual foundations of clinical reasoning 28. Braude argues that neuropsychological reductionism fails to provide a sufficient basis for the epistemology of clinical reasoning. Rather, a phenomenological perspective is required to provide an adequate grounding of how clinicians reason. Phenomenology is required, in Braude's argument because it can provide a detailed account of first person experience and consciousness. Braude strives to conciliate cognition and consciousness through phenomenology. This is then exemplified through a detailed account of phronesis and empathy. Braude argues that 'medicine occupies a privileged, though somewhat ambiguous place between phronesis and techné.'1 He further seeks to elaborate how phronesis can provide a unified framework for the moral, ontological and epistemological components of clinical reasoning. This challenging and provocative paper opens up multiple lines of philosophical inquiry for future exploration. The idea of conciliating neuroscience with phenomenology as it relates to clinical reasoning is certainly novel and marks an advance in the field. Critiquing assumptions frequently made about the nature of knowledge, and looking at the processes of knowledge creation, Laura O'Grady asks the fundamental questions, 'what is knowledge and when should it be implemented?' 29 Knowledge, she explains, is an elusive construct. The current model of biomedical knowledge emphasizes quantitative research data and the explicit knowledge of health care professionals. However, O'Grady suggests that the kind of knowledge that is worthy of translation into clinical practice will only come with 'wisdom'. Knowledge, as wisdom, gives equal weight to quantitative data, qualitative findings and experiential and tacit understandings in medicine. Her paper combines perceptive analysis and critique of underlying assumptions about knowledge, reliability and value with pragmatic observations and suggestions, explaining how making the electronic health record accessible to clinicians and patients could provide a way to move towards wisdom. In another paper with challenging implications for the links between analytic and non-analytic aspects of reasoning and for the relationship between knowledge, thinking and dispositions, James Marcum draws on a dual-process theory of cognition and metacognition to propose an integrated model of clinical reasoning 30. Echoing the concerns of the other contributors to this section 27-29, Marcum discusses the role of cultivating the right 'states of mind' or 'thinking dispositions': reasoning in medicine is, or should be, characterized in part by careful, regular, critical reflection on practice. He stresses the importance of non-linear models such as his in capturing the complex feedback loops characteristic of clinical reasoning. One significant advantage of such models is that they help us to make sense of how and why some clinicians become experts while others simply gain experience without expertise. The debate about reasoning progresses with a series of papers examining the relationship between reason, theory, data and practice. While it is platitudinous to assert that clinical practice should be informed by research evidence 24-26, for too long the debate about the relationship between research and practice focussed insufficiently on making research fit for practice, with some authors preferring to diagnose any problems in the relationship between research and practice with reference to irrational or conservative 'resistance' to research evidence on the part of practitioners 3, 4, 9, 11, 61-64. Mark Tonelli's study of 'compellingness' approaches the issue from a different direction 31. Tonelli outlines 12 features of clinical research studies that affect how compelling the results will be to practising clinicians: prior knowledge/belief, biological plausibility, consistency/confirmatory, objectivity, applicability, effect size, value of outcome, safety, time to effect, alternatives, cost and ease of implementation. He suggests that an appreciation of these factors can and should affect decisions made by clinical researchers, insofar as they aim to produce evidence that is compelling to clinicians. Dana Tulodziecki's detailed study of the reasoning processes that led John Snow to draw his important conclusions about cholera is not a 'merely' historical study of epidemiological reasoning. By looking at the principles that informed Snow, the author provides significant lessons pertinent to the contemporary debate about data, theory and evidence 32. Dispensing swiftly with certain popular myths concerning Snow's methods, the author shows how a number of causal principles (especially Mill's Method of Difference and Mill's Method of Agreement) were epistemologically important to Snow, enabling him to draw conclusions that, at the time, were both non-verifiable and also against the popular view. She argues convincingly that the case of Snow shows the importance of these principles in guiding epidemiological reasoning, concluding that the assessment of medical hypotheses by health care practitioners ought to be not just data driven, but also informed by specific principles of reasoning. One fundamental assumption that has passed unnoticed in some influential discussions of medical practice 3, 61-63 is the idea that we need to find the right or best theoretical model of practice, and then set about promoting the use of that model to improve practice, defending the favoured model against all others. Advocates of particular models may typically claim that policy and practice should be 'based' on their model 'because it's the best' – an assumption Robin Nunn analyses and critiques in his contribution to this volume 33. In a discussion in some respects reminiscent of debates about the nature of science that dominated the philosophy of science for many years 14, 65-67, Nunn provides a summary of the many models that have been proposed for understanding (and improving) medicine and argues against the idea that we should attempt to unify these various approaches. Instead, he shows that there is good reason to think that a diverse collection of models is better than any single model could ever be. Also developing ideas about the role of models and theory in diagnosis, Maёl Lemoine looks in detail at the nature of inference in the diagnosis of mental disorder, challenging in the process some entrenched ideas about the relationship between observation, theory and value 34. Lemoine argues that mental health practitioners can legitimately determine that a patient suffers from a mental disorder before they have identified the particular mental disorder in question. In other words, practitioners can make general assessments without specific assessments. Her careful defence of this provocative position illustrates the tremendous value of exploring all features of 'real life' clinical reasoning, however counter-intuitive they appear at first, before pronouncing on the relationship between data, theory and practice in diagnosis and clinical reasoning. These challenging discussions are followed by a group of papers focussing specifically on the concepts of knowledge and causal reasoning. Katrina Hutchinson and Wendy Rogers argue that certain, now pervasive understandings of evidence-based medicine (EBM) rest on shaky epistemic foundations and fail to provide comprehensive support for clinical decisions 35. Despite the many and well-documented 'evolutions' of EBM 24-26, these authors find that the gap between the knowledge required by practitioners and that offered through EBM remains wide. This paper adds further fuel to the fire of those critical of the ways in which EBM has been taken up in various clinical settings and resonates with the concerns of Nunn 33 and Tonelli 31 about the relationship between research methodologies and practice. Holly Andersen's paper is an important addition to the debate over the role of mechanisms in EBM 36. She provides a clear justification for the claim that using information about mechanisms, instead of clinical trials, can tell us which treatments will work in a population. She argues, however, that knowledge of mechanisms plays an important role in applying the results of clinical research in the care of an individual patient. Cecilia Nardini, Marco Annoni and Giuseppe Schiavone compare the modes of reasoning associated with EBM and personalized medicine (P-Med) 37. They suggest that both modes represent distinct ways of conceptualizing the role of evidence-making in medicine. EBM venerates epidemiological evidence, whereas P-Med emphasizes personalized and 'mechanistic explanations of molecular interactions, metabolic and suggest the is sound but and is to be into a single model for clinical decision Instead, as modes of reasoning, EBM and P-Med ways of clinical practice, whose will the of clinical expertise. 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