Expertise as Argument: Authority, Democracy, and Problem-Solving
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- Majdik, Z.P. & Keith, W.M. Argumentation (2011) 25: 371. doi:10.1007/s10503-011-9221-z
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This article addresses the problem of expertise in a democratic political system: the tension between the authority of expertise and the democratic values that guide political life. We argue that for certain problems, expertise needs to be understood as a dialogical process, and we conceptualize an understanding of expertise through and as argument that positions expertise as constituted by and a function of democratic values and practices, rather than in the possession of, acquisition of, or relationship to epistemic materials. Conceptualizing expertise through argument leads us to see expertise as a kind of phronetic practice, oriented toward judgments and problems, characterized by its ability to provide inventional capacities for selecting the best possible resolution of a particular problem vis-à-vis particular expectations regarding the resolution of a problem. At its core, expertise thus comes to exist in reference not to epistemic but to dialogical, deliberative, democratic practice.
At the heart of any account of expertise lies an inescapable political dilemma (Turner 2003). Expertise is a kind of authority, and so stands in contrast to liberal democratic values; at its core, a democratic polity depends on its ability to keep a check on authority.1 Yet, we live in a late modern society characterized by the constant presence of risk (Beck 1992; Beck et al. 1994; Giddens 1999)—risks that are inherently probabilistic and unpredictable, and thus generate exigencies for decision-making that have both factual (what is the likelihood of harm?) and normative (how acceptable ought that likelihood of harm be to us?) components. We depend on specialized technical authority to help us assess empirical probabilities and provide solutions, yet we also have to depend on normative and practical political resources to judge which risks are important, and how acceptable they are (Douglas and Wildavsky 1983; Lowrance 1976). Practically, the question is not whether expertise should have authority, but what the bounds of that authority should be, and how inclusive they are.
it would be disastrous to solve the Problem of Legitimacy by dissolving the distinction between expertise and democracy. To do this would be to create a new Problem of Extension. We argue that expertise should feed into the decision-making process. (pp. 269–270) [emphasis original]
Yet if we return to the original question, the tension between the democratic and the technocratic impulses, we believe there may yet be another way to honor both more fully. We wish to explore what happens if we attempt to define expertise as a kind of argument, or argumentative practice. We think there are two moves that would allow us to reduce the tensions between expertise and democracy. First, understanding expertise not as, at its core, oriented toward a (specialized) subject matter but toward argument, as a deliberative process, redirects it from a focus on knowledge to a focus on judgment: expert judgments are those backed-up by a certain kind of argumentation. Second, this process of argumentation is called into being by a problem or exigence. The argumentation that constitutes expertise does not reside in the knowledge or experience of the arguer (thus argumentation is not simply a tool for asserting expertise), but relative to a problem; expertise invokes not a relationship to specialized knowledge but to the ability to respond appropriately to problems.2
This shift in the locus of expertise to argumentation is important because in political—both interpersonal and public—contexts there is a dimension of expertise distinct from the knowledge domains, that of values and interests, which exist dialectically to the epistemic dimensions. For example, while “risk” in genetic counseling, end-of-life decisions, or some patient-provider medical interactions may be highly technical, medical patients’ own values and interests are central to the choices these patients need to make, and interact materially with what counts as a “problem” and a “solution” and therefore must be part of the expertise that comes to bear on these problems. In public decisions, various stakeholders are, in the relevant sense, experts on their own interests, in that they can argue for what is best for them. The macro-scale version of this political problem of expertise (Lippmann 1922, 1925; Willard 1996) is always reproduced at the micro-scale, and vice versa, leading to the possibility of different viable resolutions. Danish consensus conferences (Einsiedel et al. 2001) on science policy intertwine citizens and experts, while the U.S. National Science Foundation has only very slowly begun to acknowledge the importance of public input. At the micro-level, interactions can take the form of dialogue, or they can be a relatively authoritarian, driven by the mismatch of education and knowledge-based expertise.
In order to account for how the articulation of values and interests helps dialogically constitute expertise, the political problem of expertise—its apparent opposition to democracy—cannot be elided, nor need it be elided. To that end, we offer an account of expertise within a democratic framework as complementary to the epistemic and disciplinary dimension of expertise. We believe there is a principled reason for choosing a democratic, dialogic argument paradigm for understanding expertise. Despite its complexity, expertise at some level remains a species of instrumental rationality, one of means more than ends. Given a focus on problem-solving as the locus of expertise, different actors will define differently, for any given concrete situation, the exact problem (and the values and interests that are part of it), and what would count as an acceptable solution. For expertise to produce “good” solutions would require a dialogic mechanism for including the input of the stakeholders in the outcome.
The democratic practices and values that provide the framework and exigency for our reconceptualization of expertise thus are constitutively connected to argument. Supporting claims with evidence is a core requirement of a democratic life, just as the testing and contesting of ideas is a functional and procedural tenet of democratic systems. If the sites of democratic practice are where expertise becomes both enacted and problematized, then any account of expertise must also contend with the substantive and process-oriented role of argument. Expert argument would not then just be one more tool for expertise, but would constitute it; such argument would originate from an orientation toward a problem and be undergirded by a process that facilitates involvement and that enables or disables legitimate participation. From this perspective, experts are people who can make arguments about things that best respond to a particular problem, and who possess an expertise consisting in their ability to make a case for a particular definition of problem or solution.
This line of thinking is not without challenges. Clearly, credentialed people must have knowledge about their area of expertise and so are distinguished from amateurs, but we are trying to gently resist the idea that expertise is exhaustively explained and defined by possession of knowledge. In particular, in situations where normative issues are deeply intertwined with factual ones, different parties would be in different positions with respect to mounting arguments, since their relationship to the norms is relative to the problem at issue. Expertise can thus be relative to one’s interests and stakes in the situation (which are themselves of course matters of argument, even expert argument). Some argument practices do not or should not typically include an account of interests and stakes (let us call them purely scientific); others do.
We ground this account of argument in expertise in Aristotle’s work, specifically in his discussion of the purpose of rhetoric and of phronesis as a form of reasoned judgment that we connect to the use of expert argumentation. We then provide an example to show how our understanding of expertise manifests itself around the treatment and management of a relatively common problem of the visual processing system; we aim not to provide an exhaustive account of argument in expertise, but to illustrate what purchase an argument-grounded perspective of expertise has on complex situations in which contingent risks require decision-making that invokes both technical/factual and value-based/normative dimensions.
2 Aristotle’s Phronesis as Resource for Conceptualizing Expertise Through Argument
Our account shifts the goal of expertise from simply an exercise of technical, well-informed reason to the justification of a judgment. Expert judgments are primarily deliberative, deciding a course of action vis-à-vis the resolution of a problem or the avoidance or harm. The materials of judgment are, thus, the products and processes of argument (claims, warrants, evidence, reasons; their testing and contesting), while its purpose is finding the most acceptable choices and actions for meeting expectations. We would like to draw on Aristotle here in thinking about these dimensions of judgment. We’ll proceed in two steps. First, looking at a passage in the Rhetoric, which shows that “working” or success is not as tightly related to the possession of a skill as one might think, and second by examining the concept of phronesis itself.
At first, this seems counter-intuitive, since one would have thought rhetoric were about successfully persuading; the sophists certainly make their money on this claim to expertise. Rhetoric is (as Aristotle [2004b] points out generally about judgments requiring phronesis), stokhastikê (1106b15). It properly aims at a goal, without necessarily achieving it, in the way that an arrow aims at the target: even if perfectly shot, a stray gust of wind may cause it to miss its mark. The fact that one cannot produce a given result every single time does not mean that one does not possess the knowledge or skill, since success depends on many things outside one’s control. Aristotle immediately gives a compelling example:
It is clear, further, that its function is not to persuade, but rather to discover the means of coming as near such success as the circumstances of each particular case allow. In this it resembles all other arts. (1355b)
We can imagine two oncologists, both of whose patients expire: in one case, the doctor made all the “right” choices and in the other the doctor made the wrong ones—with the same result. Expertise in medicine (or navigation or military command, his other favorite examples) cannot simply be making people well, but know how to articulate the possibilities to make people well. Or imagine two patients that recover, one having gone to an oncologist, the other to an astrologer. Would we be inclined to say that the result proved equal expertise on the part of both?
For example, it is not the function of medicine simply to make a man healthy, but to put him as far as may be on the road to health; it is possible to give excellent treatment even to those who can never enjoy sound health. (1355b)
This conceptualization of rhetoric can help us explain expertise as a deliberative, dialogical process—to crack the problem of how to broaden our conceptualization of expertise within a democratic framework, but do so without fatally weakening expertise. For the risk we encounter in broadening expertise beyond the bounds of accreditation is an unchecked pluralism that renders expertise completely relativistic, and reduces its democratic potential to individual subjective opinion. The bounds of expert authority narrowed to the individual enacting a personal version of expertise defeats the pragmatic function of expertise. We have addressed this problem by reading it through Wittgenstein (Majdik and Keith 2011), and here simply wish to draw attention to the risks of broadening the concept of expertise unchecked. But if expertise is to function at the places of the political where authority and democratic values meet, Aristotle’s criterion seems a promising one to reconsider our understanding of expertise: we possess an expertise when we can employ all the available or possible (or relevant) means toward a goal, whether they get us there or not. That would mean both knowing what they are, and being able to assign them relevance in a way that was rational, i.e. for which one could give an account.
We shall possess the method completely when we are in a position similar to that in which we are with regard to rhetoric and medicine and other such faculties (δυνάμεων); that is to say, when we carry out our purpose with every available means [ενδεχομενων…προαιρουμεθα; literally: with all “possible choices”]. For neither will the rhetorician seek to persuade not the physician to heal by every expedient; but if he omits none of the available means, we shall say that he possesses the science [επιστήμην: episteme] to an adequate degree. (I.iii)
Ultimately, phronesis is neither science nor intuition (1141a): it is not about theoretical knowledge as science is, but about recognizing the norms that impinge on a situation; it is not about extra-sensory perception as intuition is, but about the recognition of how perception relates to universals; it is about an inventional capacity for apprehending good choices with respect to the “ultimate particulars” of each situation.
People do in fact seek their own good, and think that they are right to act in this way. It is from this belief that the notion has arisen that such people are phronetic. Presumably, however, it is impossible to secure one’s own good independently of domestic and political science. (1142a)
Importantly, phronesis, much like other virtues, is characterized not by particular actions but by a disposition or state. As a virtue (rather than art or science), phronesis emerges less from the actual enactment of prudence as it does from one’s disposition and ability to act prudently should a situation arise that demands action. Aristotle states that “phronesis must be a true state, reasoned and capable of action in the sphere of human goods” (Nicomachean Ethics 1140b), distinguishing phronesis through an ingenious example from art in the following lines. The inclusion of “reasoned” and “capable of action” emphasizes the reflective, deliberative nature of phronesis: what matters is that (a) actions and choices, if enacted, are enacted after judgment (1140b) through reason, and (b) the function of phronesis is to prepare us to be capable of such action, rather than itself being a function of action. The deliberative, counterfactual characterization of phronesis—the ability to be aware of multiple kinds of viable responses to a problem or kind of problem, and able to select the best possible one—has implications for expertise, as expertise goes beyond simply knowing the possible choices for a given situation (that is technique) and requires a creative, unique-to-each-case, inventional ability to find these choices and to put them together.
With phronesis at the center of judgment in expertise, we can return to expertise, and to the question of how one can determine if somebody is an expert. In the Topics Aristotle gives the criterion of “all the possibilities”: If all the possibilities were considered and none omitted, then the person has the tekhne, the skill, in this case the skill of engaging a particular kind of argument for justifying a claim to the best possible solution to a problem. In situations of choice and decision-making, always in the face of risk, factual and normative judgments will both be part of the arguments made or accepted, and so bring together different argumentative practices. These are argumentative practices that respond to at least two important issues: First, whose interests are at stake, and so what norms ought to count? Second, did those with a stake in the resolution of a complex problem or the reduction of harm consider, with reason and from all relevant normative grounds, a set of choices before choosing what action to pursue?
In other words, the role of argument in expertise it is not just about providing good reasons and warrants for a claim to expert-authority. Arguments function more deeply, to the extent that expertise can be said to be a function of an argumentative tekhne that originates from a phronetic sensibility relative to specific problems expertise addresses. Expertise, thus, involves at once an orientation toward the specific practical and moral norms (Habermas 1984) against which the claims, warrants, evidence, and reasoning that establish best-possible responses to problems are to be judged and evaluated; and it involves an ability to negotiate the various normative contexts (technical/economical, religious, familial/traditions, etc.) that might bear on a situation in the form of technical knowledge but also public, interpersonal, and private values, interests, preferences, conventions, and expectations. Involving the complexity of normative dimensions we find in public or interpersonal practice in this way maximizes the available inventional resources that are pertinent to and impinge upon a given problem or situation.
Thus expertise, as argument, finds its pragmatic grounding in the political, and in democratic values specifically. An enactment of expertise should give us the best possible chance of working (viz., respond to a complex problem and/or reduce harm); and it should work according to standards of social intelligibility and correctness (cf. Wittgenstein 1953)—meaning that it can conceivably be explained through reasons and warrants, lest it lose its pragmatic potential to create precedence for future cases of a given type and for developing an understanding that can be projected on to future cases. The political value of “expertise” is not only that it “packages” a testing ground for judging, testing, and choosing the best available responses to exigencies about which our knowledge is contingent, but also that it yields a counterfactual resource for assessing how to respond to situations if they were to arise in particular contexts. Judgment thus relies on the problem-solver’s ability to determine whether a given application of skill, behavior, etc. works in a particular context, and whether its use-value can be legitimized and made intelligible. It is phronetic judgment, the ability to see which of all the complex and varied information are relevant to the problem at hand and to engage in an argument that puts the available information and values in dialogue with other values, norms, and information, potentially revising one’s judgment. This is not based simply on a particular outcome, but on one’s ability to process a set of possibilities. And this implies that non-disciplinary experts may in fact possess a type of expertise, relative to judgments that intertwine value and fact, and reflect their own values.
The following example illustrates how understanding expertise as a function of argument can help us understand decision-making in specific types of situations in which people encounter and respond to complex problems. We consider strabismus—a problem of the visual processing system—to capture how in some situations where there can be no certainty of outcome (i.e., where people encounter problems for which there is no one universally agreed-upon and acceptable solution), and where the subject matter is complex, personal preferences and values and interests become constitutive dimensions of good, expert decision-making.
3 Tradeoffs and Treatment Choices: The Function of Expertise in Strabismus Cases
Most people think of vision problems in terms of acuity deficiencies, being hyperopic (far-sighted) or myopic (near-sighted). Yet many other things are required for normal vision, and so many other things can go wrong with the visual system. In particular, since humans have two front-facing eyes, the eyes’ design requires them to work together, producing binocular vision. When eyes do not align properly, the resulting condition is typically called strabismus, Greek for “squint,” since squinting is the easiest way to (temporarily) cure the double vision that often results. The ambiguities of “good” vision and good treatment for strabismus patients illustrate the ways in which both the patient and provider bring expertise to treatment decisions.4
Strabismus can have many causes and many forms; it affects between 2 and 4% of children and adults in the US, and often runs in families. Strabismus can be treated in three basic ways, corresponding to different medical specialties and resources. For some strabismics, wearing convex lenses reduces their need to focus, and therefore their excess convergence. If excess convergence remains after patients have the maximum correction, their lenses can be ground as wedge prisms, which displaces the image inward, where the eyes are actually pointing, producing a single image. A second possibility is “vision training,” in which a series of exercises helps the person develop new habits of convergence and accommodation. Both of these therapies are administered by optometrists, who prescribe lenses, but cannot do surgery. A third possibility is surgery with an ophthalmologist. In some cases (especially when the surgery is performed on infants), the strabismus is permanently corrected; in other cases the eyes return to their original deviation. Each surgery produces scar tissue that makes each next procedure less likely to succeed.
Each of these treatments has experts on its side; each has risks, and advantages and disadvantages in terms of outcomes. Vision therapists accuse ophthalmologists of rushing patients into useless surgeries (Cooper and Cooper 2001–2011), while ophthalmologists worry that vision therapy will disrupt a functional suppression, resulting in permanent double-vision. Prismatic lenses, while alleviating diplopia, can induce distortions in acuity, and may not promote fusion and stereopsis. And none of these treatments is likely to reverse residual amblyopia.
In addition, there are cosmetic and social effects of strabismus. Some patients might prefer surgery to lenses, despite a less stable outcome, simply because their chances of looking “normal” (i.e., not visibly deviated) are higher. Some people claim they have never noticed the deviation in their eye alignment, others think about it constantly.
A 46-year-old mailman servicing a rural mail route came for surgical correction of an exotropia that had been present since childhood. He was concerned about his appearance, but had no visual complaints. His uncorrected visual acuity was normal, and he had a constant very large exotropia (outward deviation) at near and distance fixation. He strongly preferred his left eye for fixation… After surgical alignment the patient regained peripheral fusion without stereopsis. However, he was most displeased with the result. Before surgery he had been able to keep his left eye on the road when driving his truck while scanning the mailboxes with his right eye. After surgery he found his field of vision substantially decreased, and it took several months of adjustment before he was able to resume his profession. (von Noorden and Campos 2001)
What counts as good vision depends on a complex interactive judgment between patient and provider. Expert judgment about “good vision” is, thus, particular to a case, and oriented toward resolving a particular problem relative to the case. The problem invokes factual (what is possible, with what treatment?) but also pragmatic and normative (what do I want to accomplish; what do I need to accomplish it?) issues. What do patients want to do with their vision: play baseball, use a microscope, perform surgery, program computers, or learn prestidigitation? Read a schedule and ride a bus? How far is the patient willing to go to achieve one of these goals: deal with the stress of surgery, the expense of lenses that may change regularly if vision is unstable, or the expense and effort of vision training, which can take several years of dedicated effort? Different therapies may produce results better suited to some of these activities than others, with either more or less financial, physical, or time sacrifice. An understanding of expertise that takes specialized knowledge as its essential characteristics (at the exclusion of democratic values or practices) fails to capture the complexity of decision-making in cases like this, as the physician’s expertise cannot extend to expertise about which choice is best for the patient. This is not due to insufficient knowledge, but due to the limits of any one dimension of knowledge: when subjective elements (experience of vision, tolerance for pain, valuing comfort vs. length of life) and different possible use/outcome-purposes (that come out of professional, personal, or familial exigencies—the need to use a microscope, pursue an aviation hobby, or play catch with one’s children) become integral to the resolution of a problem, a generalized, specialized knowledge-grounded dimension of expertise alone cannot say that “This treatment will produce good vision,” both in terms of guaranteeing the outcome and that it meets the needs of the patient. To make the best possible choice that responds to the question of what treatment will produce good vision—with all the attendant problems of what constitutes “good vision” in strabismus cases—would require recognizing that the patient possesses a legitimate expertise that stands in (and is legitimized by) a relation not to generalizable specialized knowledge, but to the particular problem the patient and the physician seek to find a resolution for.
Recognizing this dimension of expertise does not replace expertise that comes from specialized knowledge (without doubt, such expertise is critical to problems in strabismus cases), but it also does not allow such knowledge to become a constitutive requirement of expertise. Our view is that the patient has a type of expertise that engages with the physician’s. This goes beyond the often pro forma ethical charge that a physician—or any specialized expert—ought to consult and interact with those they treat or advise. If in such interactions expertise (who is an expert, and what counts as expertise) remains characterized as a form of specialized knowledge, patients cannot but see their physician as their representative in the domain of expertise. They thus defer judgments and decisions to whomever possesses the specialized knowledge that, from this vantage point, can guarantee the best possible result. But if the patient’s own interests, preferences, and values become integral to what constitutes the best possible solution—as they do in strabismus and many other kinds of cases—the patient’s interests become partof the expertise required to address the problem, independently of how much specialized knowledge the patient has about the technical (and generalizable) dimensions of strabismus. To recognize the patient-dimension of expertise as valid and legitimate means to move away from expertise-as-specialized-knowledge6; it means to move toward an understanding of expertise where “expertise” consists of multiple dimensions—factual, value-based, etc.—and where these dimensions are all constitutive of a multi-dimensional expertise that can be used to make best possible choices. It is our contention that such a move is possible when we conceptualize expertise relative to problems and constituted by and within a framework of democratic values and practices, shifting our understanding of expertise to a place where expertise is built through the considering, challenging, and testing of the validity of claims about particular judgments made by those involved and invested in a problem, where criteria for the validity of these claims flow from (and only from) the requirement to resolve a particular problem.
Thus, in the kind of case we illustrate through strabismus, the patient is an expert in his or her own right: an expert on how to balance out the life activities with the inherent benefits and risks of each treatment modality. What is “better” and what is “worth it?”—what constitutes the best possible action—is not a judgment the physician alone can make, just like it is not a judgment that can be made if expertise is characterized (and limited) by exclusive reference to specialized knowledge. The patient’s judgment may represent a kind of expertise as well: not the entirety of the requisite expertise needed to best address a problem, but a central and indispensable dimension of it, generated by experience, interest, preference, and values. Once these dimensions enter into the resolution of a complex technical problem, standards of what experts would recommend cannot be determinative. Separating democratic values and processes from expertise does not give access to this dimension of expertise; understanding expertise and the problems it deals with as constituted by democratic engagement, and thus as a function of argument, does.
4 Implications and Conclusion
We began this essay through reference to the political dilemma expertise exposes: the tension between authority and democratic values that characterizes engagements with uncertain and contingent conditions of risk in political life. We sought to conceptualize an understanding of expertise that, rather than drawing lines of distinction between expert judgments and democratic engagements, sees expertise as constituted by—indeed, a function of—democratic values and practices. We found conceptual antecedents to this idea in Aristotle’s work, through which we could position expert judgment as a phronetic practice. This led to a perspective on expertise where expertise became characterized not by an epistemic dimension (i.e., who has specialized knowledge) but by an orientation toward a particular problem.
Our understanding of expertise here does not eschew the importance of knowledge, but challenges the view that the primary orientation of expertise is toward knowledge. At its core, expertise is about delimiting and defining available choices, lest an overabundance of choices render decision-making impossible. Where an expertise from specialized knowledge determines (through the cognitive, material, or procedural conditions available in and through a knowledge field) a range of choices from which people are asked to choose, an expertise oriented toward a problem determines a type of approach to selecting choices: in other words, knowledge-centric expertise creates a set of available choices, where problem-centric expertise sets expectations for how choices should be made. The distinction lies in how choices are limited: choices from the former perspective are factually bounded (“here are available options”); from the latter perspective they are normatively bounded (“here’s how we’ll determine options”).
Thus, our understanding of expertise argues that expertise is characterized by its ability to provide inventional capacities for the best possible resolution of a particular problem vis-à-vis particular expectations regarding the resolution of a problem. The problem-centric view of expertise accommodates a range of norms, from technical to personal, moral, or religious, to affect decision-making, and so operates within a framework that can reconcile points of tension between authority and democratic values in enactments of expertise. Our theory requires a twin set of judgments to emerge from expertise: Will my choice provide me with the best possible opportunity to solve the problem in ways that meet my expectations, and is my action socially intelligible in ways that it can be pragmatically useful in similar, future situations? Here, judgments from expertise invoke argument both as the ability to reasonably judge possible responses to a particular case by providing and judging reasons, evidence, claims, an warrants; and as a process, where the validity of my claims is tested, challenged, and engaged by the claims of others. Expertise, therefore, becomes a multi-dimensional container within which multiple, discrete norms that impinge on a problem—factual, practical, value-oriented, etc.—can be made visible, engaged, and reconciled.
Our perspective on expertise as a function of democratic engagement and argument has implications for democratic practice on two levels. First, it enlarges what can count as the reasons, evidence, and warrants available under the umbrella of expertise. This is a theoretical and philosophical question that hinges on the possibility of intersubjectivity, but it can also be an empirical question that, in the tradition of Wittgenstein, hinges on the actual uses of expertise. If we are taking the political to be an actual collection of people, we will need to ask what specific types of argument enable the enactment of expertise from the perspective we describe here, and what characterizes the kind of argument that disables it.
Second, our perspective provides resources for casuistic judgments, those that go beyond the particular case, particular problem, and particular normative context that expertise is oriented toward. We would like to point to how the problem-centric orientation equalizes different types of experts in the argumentative form called “casuistry,” as resurrected by Jonsen and Toulmin (1988). The range of choices or possibilities, which we identified above as central to exemplifying expertise (whether specialized or not), maps also onto their case method of moral reasoning. In this method, the current case, in all its particulars, is judged relative to a set of background cases which have already been decided. The burden of argument is to show which prior cases are most similar, for both practical and conceptual purposes, to the one at hand. This is where the possibility of “normative expertise” gets substance beyond the particular case. Being an expert means being able to summarize relevant cases and make the connections to the current situation; enacting expertise means creating resources from which future judgments can be drawn. The key to both is the ability to consider multiple normative sites that can impinge on situations where expertise is required. A physician may say that in her experience a particular type of strabismus is best treated through vision therapy, and her expertise lies in being able to connect this case, as a “type” or kind of case, to the paradigm cases that are successfully treated with vision therapy. A patient may be able to say that the advantages of vision therapy will not be enough to offset its risks and cost, or to match the goals the patient seeks to reach. His expertise draws from being able to connect the particular problem he seeks to resolve to prior successes or failures, either in treatment or in the uses to which he sought to put his vision. For both, prior enactments of expertise from their particular normative grounds act as resources that now help make judgments about the current problem. Thus, even if it seems virtually certain (to the optometrist) that some dimensions of vision will be improved through therapy, “improved” has to be relative the expertise of the patient in knowing what would count as an improvement in his life. Mutatis mutandis, the same considerations would apply to situations like the one described by Atul Gawande in a 2010 essay, who outlines the complexity of decisions in end-of-life care where patients and providers have to confront difficult, uncomfortable, and often wrenching tradeoffs, to genetic counseling, to land-use controversies, and to other situations where contingent risks present possibilities for improvement or for reduction of harm and where any response to these risks invokes a normative consideration of different people, groups, and institutions.
Here, problems are not a “given”: they have to be problems to or for somebody, and so the application of expertise would have to be argument which can include the relevant voices that define the scope of problems and their solution.
Earlier, he states that “phronesis is not concerned with universals only; it must also take cognizance of particulars” (1141b).
One of the authors (Keith) has been a strabismus patient since childhood, and his experiences, including his evolving translational expertise, provide the background for this section.
Certainly, improved vision is possible; while, for example, Dr. Barry had an amazing outcome (recovering her steropsis as well as effortless alignment and fusion), that is not likely for most adult strabismus patients.
For then, again, patients would either need to know the technical aspects of strabismus on par with their physician’s knowledge, or content themselves with deferring decisions to others, or acquire an alternative technical expertise whose knowledge-claims they can refer to strabismus, neither of which would be consistent with the fact that patient values and preferences are an irrevocable part of the judgments and choices in strabismus treatments.