Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0017
E. Montgomery
{"title":"Medical Solipsism","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0017","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0017","url":null,"abstract":"A conventional notion of knowledge is explicit and declarative statements of objective facts and principles. Procedural knowledge, such as riding a bike, is evidenced by it having to be learned. Knowledge includes the corpus of medical facts and principles as examples, but so is how the facts and principles are used. Medical facts and principles can be justified by referring to research and study. How does one justify how one uses facts and principles? The lack of clarity opens the discussion to solipsism—a claim is true because one believes it to be true. When involved, solipsism ends the discussion and with it any hopes of progress. The only protection is holding the person responsible for the consequence. There are many situations where solipsism may arise, including evidence-based medicine that recognizes only randomized control trials, governmental regulatory agencies, balkanized medical systems, and, most importantly, the individual clinician.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"85 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117265675","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0002
E. Montgomery
{"title":"What Are We to Make of Reasoning in Modern Medicine?","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0002","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0002","url":null,"abstract":"The suasive power of clinicians depends on the projection of certainty; with that suasive power, responsibilities to the patient have not diminished even if the clinicians’ authority has. Certainty is reflected in understanding, which is more than knowledge. Understanding allows reasoning beyond the specifics of knowledge, beyond the particulars. The variation in human manifestations represents either variation or diversity. In variation, all specific instances are variations on some canonical form. Diversity holds each instance as an entity unto itself. The epistemic choice of variety as variation or diversity determines medical reasoning. Biomedical research is confronted with the same challenges. The resort is to a special form of logic and epistemology that is organic, responding to needs, and synthetic, the product of humans. This evolutionary logic embraces a necessary use of logical fallacies. Science requires these fallacies, and thus scientism is limited and cannot replace medical reasoning.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"71 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132279464","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0003
E. Montgomery
{"title":"Epistemic Challenges and the Necessary Epistemic Responses","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0003","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0003","url":null,"abstract":"The practice of medicine is different from the practice of science, although some have argued that medicine must increasingly approximate science if progress in medicine is to be made. There is a myth that science medicine will eliminate uncertainty. Science can remain contingent and pending as individual patients demand action and medical decisions cannot be put in abeyance. Some extrapolate from this difference that science and medicine are fundamentally different, for example, maintaining a distinction between practical and scientific medicine. Yet medicine, practical or otherwise, still requires the use of logic and thus philosophical analysis. Indeed, on closer analysis, medical and scientific reasoning are not fundamentally different—only the consequences are different. Variations of logic to provide utility require an expanded sense of logic. However, with growing appreciation that most living biological systems are chaotic and complex, the logic used in medicine must continue to evolve.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129294221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/MED/9780190912925.003.0010
E. Montgomery
{"title":"The Centrality and Origins of Hypotheses","authors":"E. Montgomery","doi":"10.1093/MED/9780190912925.003.0010","DOIUrl":"https://doi.org/10.1093/MED/9780190912925.003.0010","url":null,"abstract":"Hypotheses are central to the hypothetico-deductive approach in medical diagnosis and to the scientific method in research. Arguably, hypotheses are central to induction as reflected in the a priori problem of induction. Yet conspicuously absent from discussions of medical reasoning is any explicit critical analysis of the origin and quality of hypotheses as they often are attributed to some psychological process. However, there are specific manners in which hypotheses can be generated, such as by interpolation among and extrapolation beyond known knowledge claims such as data. Interpolations and extrapolations in the causal mechanisms that underlie knowledge claims can also generate hypotheses. Metaphors are a source as well. Perhaps an unrecognized metaphor critical to reductionism that underlies rationalist/allopathic medicine and biomedical research is the process metaphor. Each approach has advantages as well as risks. The latter can be estimated by the notion of epistemic risk, which contains epistemic distance and epistemic degrees of freedom.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"15 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122229093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/MED/9780190912925.003.0012
E. Montgomery
{"title":"The False Notion of Intention, Choice, and Inhibition","authors":"E. Montgomery","doi":"10.1093/MED/9780190912925.003.0012","DOIUrl":"https://doi.org/10.1093/MED/9780190912925.003.0012","url":null,"abstract":"A ubiquitous metaphysical presumption in medicine, particularly in neurology, derives from Aristotle’s notion of contraries. The variety within a domain of phenomena can be considered as some mixture of a few components. For example, a grayscale continuum is not an infinite number of shades of gray but rather varying mixtures of black and white. This metaphysical presupposition provides an enormous economization of principles critical to allopathic medicine and research. Epistemically and ontologically, this results in methodological, ontological, and theoretical reductionism. The presupposition leads to one-dimensional push–pull dynamics. In neurology, this metaphysical presupposition resulted in a notion of hierarchy in the physiology of the nervous system affected by inhibition. This led to notions of potentiality, intention, and choice creating problematic notions and misunderstandings. For example, the popular notion that the role of the frontal lobes prevents antisocial behavior, suggesting its potentiality, leaves unanswered the question of what is inhibited by the intact frontal lobe?","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"74 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115554280","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0011
E. Montgomery
{"title":"Necessary Presuppositions","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0011","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0011","url":null,"abstract":"Metaphysics has been a pejorative term since rejection of the medieval scholastic natural philosophers by the early modern scientists. Since that time, there has been the presumption that “data” speak for themselves and that data are self-evident. Metaphysics was seen as just so much philosophical speculation—science was above that, as was the rationalist/allopathic physician. However, the antipathy to enjoining metaphysics likely is due to a misunderstanding of metaphysics. Any time a theory or hypothesis is invoked, it necessarily goes beyond the data and consequently is a metaphysical exercise. Indeed, responses to the epistemic conundrum are metaphysical choices. Importantly, the metaphysical presumptions shape observations, such as what observations are relevant to a clinical or research question (the a priori problem of induction). Notable examples of metaphysical presuppositions are seen in the development of the cell theory and the derivative pathological–clinical correlations that propelled allopathic medicine.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"34 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123041936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0005
E. Montgomery
{"title":"Deduction, Induction, and Abduction","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0005","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0005","url":null,"abstract":"Decisions can be explicated as logical arguments, often poised as deductive and conveying a sense of certainty. Yet these arguments often are logical fallacies, such as the Fallacy of Confirming the Consequence, otherwise known as abduction (e.g., the argument if the patient has disease A then test B would be abnormal; test B is abnormal therefore the patient has disease A). This is invalid. The patient may have disease A but it cannot be certain; hence the logical fallacy. The necessary use of the partial syllogism can be made more rigorous by the use of probabilities and further by analysis of the probabilities of probabilities that constitute statistics. Other fallacies used in medical reasoning include the Fallacy of Pseudotransitivity. Induction, a form of logic, also has limits and risks that require mitigation for sound medical reasoning. These fallacies can be rescued so that risks are mitigated.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123046034","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/MED/9780190912925.003.0015
E. Montgomery
{"title":"Medical Science Versus Medical Technology","authors":"E. Montgomery","doi":"10.1093/MED/9780190912925.003.0015","DOIUrl":"https://doi.org/10.1093/MED/9780190912925.003.0015","url":null,"abstract":"Until the 1940s, the relative advantages of allopathic compared to empiric medicine in patient treatment were not clear cut. The cell theory and the success of the pathological–clinical correlations advanced allopathic medicine; however, translation to superior medical treatments at the time did not vouchsafe allopathic medicine. It is tempting to look at the success of allopathic medicine as evidence of the fundamental soundness of the allopathic approach. Much of the history of medicine to date would suggest otherwise. Many medical therapies resulted from serendipity, “shot gunning” (trying everything without appeal to principles), or existing technologies looking for a problem. Experimentalism, the modus operandi of science, may be as much technical as it is science. Evidence-based medicine, as in randomized clinical trials, is more technical as tests of efficacy need not invoke causal mechanisms. Medicine and medical science, laid bare of its technological advances, may require viewing in a different light.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114899748","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/med/9780190912925.003.0009
E. Montgomery
{"title":"The Value of Statistical and Logical Thinking","authors":"E. Montgomery","doi":"10.1093/med/9780190912925.003.0009","DOIUrl":"https://doi.org/10.1093/med/9780190912925.003.0009","url":null,"abstract":"There is a perception that intuition, held important in some forms of medical reasoning, is somehow different from “scientific” medical reasoning. Such intuitions are arrived at quickly, suggesting no need to think about it as one might do in a logical deduction. Furthermore, intuitions typically are qualitative or ordinal in nature rather than cardinal if numbers are applied. Consequently, there is the presumption that statistics are not applicable in this form of medical reasoning, perhaps because numerical rules cannot be applied. However, the rules that guide statistical reasoning are not only numerical, they also arise from having to deal with necessary logical fallacies, such as the partial syllogism. Efforts to mitigate the risks of having to use logical fallacies find their way into the rules of statistical inference. However, these same efforts can be applied to nonnumeric analysis, such as intuition itself: hence their value.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"85 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122517172","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Medical ReasoningPub Date : 2018-10-01DOI: 10.1093/MED/9780190912925.003.0007
E. Montgomery
{"title":"Variability Versus Diversity in Variety","authors":"E. Montgomery","doi":"10.1093/MED/9780190912925.003.0007","DOIUrl":"https://doi.org/10.1093/MED/9780190912925.003.0007","url":null,"abstract":"Making sense of the enormous variety of patient phenomena creates the epistemic conundrum. Is each and every patient taken as a unique entity, or is there an economical set of principles and facts from which each and every patient can be reconstructed? Empiric medicine favors the former, risking Solipsism of the Present Moment. Rationalist/allopathic medicine favors the latter but makes application of knowledge to the individual patient problematic. The conundrum cannot be resolved by simply taking the “average” of all patients or some other measure of central tendency. While it is possible to find the average weight of animals in Dundas, Ontario, it would have little meaning, except perhaps in exceptional circumstance. A central question in statistics is whether the mean (average) reflects the true nature of the phenomenon or does its range (variance)? Assuming the former is greatly enabling in medical decision-making and research but may be misleading.","PeriodicalId":309216,"journal":{"name":"Medical Reasoning","volume":"80 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129757801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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