Interpreting Clinical Judgment: Epistemological Notes on the Praxis of Medicine

  • Roberto Dell’oro
Part of the International Library of Ethics, Law, and the New Medicine book series (LIME, volume 26)


Clinical Judgment Clinical Reasoning Clinical Encounter Scientific Reasoning Intentional Dimension 
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  1. i.
    I see two different issues here. The first concerns the need and the plausibility of an overarching frame in a foundationalist fashion. The second question pertains to the epistemological status of philosophy of medicine as a separate discipline. See Edmund Pellegrino, “Philosophy of Medicine: Towards a Definition, The Journal of Medicine and Philosophy 11 (1986): 9–16, and more recently, idem, “What the Philosophy of Medicine Is”, Theoretical Medicine and Bioethics 19 (1988): 315-336.Google Scholar
  2. ii.
    For an interpretation of postmodernism as mood, or Stimmung — the term is, of course, Heideggerian in tone — see Richard J. Berstein, The New Constellation: The Ethical-Political Horizon of Modernity/Postmodernity (Cambridge, Mass.: The MIT Press, 1992).Google Scholar
  3. iii.
    According to Stephen Toulmin: “This movement shared, at least, the conviction that all earlier quests for a comprehensive system of knowledge, based on permanent, universal systems of overarching principles, were misguided from the start, and are by now discredited. Claims to philosophical universality and permanence can be ignored: their only interest lays in the ways that they could serve as a “cover” for the collective interests of the nations, social groups, or genders with which their authors — novelists, philosophers, or play writers — were affiliated”, “The Primacy of Practice: Medicine and Postmodernism” in Ronald A. Carson and Chester R. Burns, ed., Philosophy of Medicine and Bioethics: A Twenty Years Retrospective and Critical Appraisal (Dordrecht: Kluwer Academic Publishers, 1977), 41–42.Google Scholar
  4. iv.
    See Arthur L. Caplan, “Does Philosophy of Medicine Exist”, in Theoretical Medicine 13 (1992): 66–77.CrossRefGoogle Scholar
  5. v.
    Henk Ten Have, “From Synthesis and System to Morals and Procedure: The Development of Philosophy of Medicine” in R.A. Carson and C.R. Burns, ed., Philosophy of Medicine and Bioethics, op. cit., 107.Google Scholar
  6. vi.
    Alvan R. Feinstein, Clinical Judgment (Baltimore, MD: Williams Wilkins, 1967). Also H. Tristram Engelhardt, Stuart F. Spicker, and Bernard Towers, Clinical Judgment: A Critical Appraisal (Dordrecht: D. Reidel Publishing Company, 1979).Google Scholar
  7. vii.
    On this very point Marx Wartofsky, “What Can the Epistemology Learn from the Endocrinologists? Or is the Philosophy of Medicine Based On a Mistake?” in Carson and Burns, ed., Philosophy of Medicine and Bioethics, op. cit., 55.Google Scholar
  8. x.
    Max Scheler, Formalism in Ethics and Non-Formal Ethics of Values (Evanston, Northwestern University Press, 1973), 51–52.Google Scholar
  9. xi.
    Dietrich von Hildebrandt, What is Philosophy? (London: Routledge, 1991). The expression itself, however, is of Jacques Maritain. See the observations of Josef Seifert, Erkenntnis objektiver Wahrheit: Die Transzendenz des Menschen in der Erkenntnis, 2nd edition (Salzburg: Pustet Verlag, 1976), 28.Google Scholar
  10. xii.
    Pellegrino, “The Anatomy of Clinical Judgments. Some Notes on Right Reason and Right Action”, in Engelhardt, Spicker, and Towers, Clinical judgment, op. cit., 172. Also Italian philosopher of medicine Paolo Cattorini, “Sulla Natura della Bioetica: una nota epistemologica sull’applicazione dell’etica alla scienza e alla clinica”, in Elio Sgreccia, Vincenza Mele, and Gonzalo Mirando, ed., Le Radici della Bioetica (Milano: Vita e Pensiero, 1996), vol. 1, 77-83.Google Scholar
  11. xiii.
    H.G. Gadamer, The Enigma of Health: The Art of Healing in a Scientific Age (Stanford, CA: Stanford University Press, 1996), 35.Google Scholar
  12. xiv.
    See in particular Edmund Husserl, The Crisis of European Sciences and Transcendental Phenomenology: An Introduction to Phenomenological Philosophy, (Evanston: Northwestern University Press, 1970). For a general overview, Paul Janssen, Edmund Husserl: Einführung in seine Phänomenologie (Freiburg: Verlag Karl Alber, 1976).Google Scholar
  13. xv.
    For a general hermeneutics of the notion of Lebenswelt in Husserl see Paul Janssen, Edmund Husserl,op. cit., 135-145, Maurice Natanson, “The Lebenswelt”, in Erwin Straus, ed., Phenomenology: Pure and Applied, (Pittsburgh: Duquesne University Press, 1964), 75–104. Also Hans Georg Gadamer, Truth and Method,, 2nd edition (New York, The Continuum Publishing Company, 1994), 242-254; idem, “The science of the Life-world, “ in Anna-Teresa Tymieniecka, ed., Analecta Husserliana, vol. II (Dordrecht: D. Reidel Publishing Company, 1972), 173-185.Google Scholar
  14. xvi.
    For an historical account, see S. J. Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978). From a more theoretical perspective, Salvatore Natoli, “La costituzione dello sguardo medico: dal gesto terapeutico alla scientificità della medicina”, in Nuovi Saggi di Medicina e Scienze Umane (Milano: Istituto Scientifico San Raffaele, 1985), 31-70.Google Scholar
  15. xvii.
    See Edmund D. Pellegrino, “The Lived World of Doctor and Patient: A Phenomenological Perspective on Medical Ethics”, lecture at Yale University, April 11, 1996, Bioethics and Public Policy Symposium.Google Scholar
  16. xviii.
    H.G. Gadamer, The Enigma of Health, op. cit., 39.Google Scholar
  17. xix.
    See for instance, A.I. Melden, Free Action (London: Routledge and Kegan Paul, 1961) and Stuart T. Hampshire, Thought and Action (Notre Dame, IN: University of Notre Dame, 1983). Also Arthur Danto, Analytic Philosophy of Action (Cambridge: Cambridge University Press, 1973).Google Scholar
  18. xx.
    On this question see the observations of Paul Ricoeur, Oneself as Another, translated by Kathleen Blamey (Chicago: The University Of Chicago Press, 1992), 27–55.Google Scholar
  19. xxii.
    Donald Davidson, Essays on Actions and Events (Oxford: Clarendon Press, 1980).Google Scholar
  20. xxiii.
    A computer-assisted diagnosis is part of a larger trend in medicine leading to what Wartofsky calls the “technologization of the medical subject”. See “What Can the Epistemologists Learn”, op. cit., 61. Also Luigi Stella and Antonella Crescenti, “Principi di Informatica clinica”, In Nuovi saggi di Medicina e Scienze Umane (Milano: Istituto Scientifico H San Raffaele, 1985), 293–360 and Elliot Sober, “The Art and Science of Clinical judgment: An Informal Approach”, in Clinical Judgment, op. cit., 29-44.Google Scholar
  21. xxv.
    Max Scheler, The Nature of Sympathy, translated by Peter Heath (London: Routledge and Kegan Paul, 1954). Also Paul Ricoeur, Freedom and Nature: The Voluntary and the Involuntary, translated by Erazim V. Kohàk (Evanston: Northwestern University Press, 1996).Google Scholar
  22. xxvi.
    For the notion of “puzzle” see Thomas Kuhn, The Structure of Scientific Revolution, 2nd edition (Chicago, University of Chicago Press, 1970), 36.Google Scholar
  23. xxvii.
    H.G. Gadamer, Truth and Method, op. cit., 27.Google Scholar
  24. xxviii.
    For Gadamer the understanding of human health in terms of the natural condition of equilibrium (Gleichgewicht) implies a more fundamental understanding of nature as equilibrium: “If we presuppose this idea of nature, then medical intervention must be understood as an attempt to restore an equilibrium that has been disturbed”, Hans G. Gadamer, The Enigma of Health, op. cit., 36.Google Scholar
  25. xxix.
    I am aware of my not so implicit reliance upon Heidegger’s hermeneutics of Sorge as ontologicalexistential category, i. e., as defining the being of Dasein. Such reliance does not imply, however, a negation of the specific ethical meaning of care. For an overview of the discussion on the ethics of care see the accurate reconstruction of Warren T, Reich in the Encyclopedia of Bioethics, 2nd edition (New York: Simon and Schuster MacMillan, 1995) vol. 1, 319–343.Google Scholar
  26. xxx.
    E.D. Pellegrino, “The Healing Relationship: the Architectonics of Clinical Medicine”, in Earl Shelp, ed., The Clinical Encounter: the Moral Fabric of the Physician-Patient Relationship (Dordrecht: D. Reidel Publishing Company, 1983), 153–172.Google Scholar
  27. xxxi.
    Paul Ricoeur, «Le trois niveaux du jugement mèdical» Esprit, 12 (1996): 21–33, at 22.Google Scholar
  28. xxxii.
    Indeed, the patient’s narrative has not only a diagnostic, but even a therapeutic significance. According to Drew Leder the very ability to bring the disease to the level of language “counteracts two primary features of illness that give rise to suffering: senselessness and isolation... The fact of translating disease into a language begins to overcome this twofold alienation. What was a private pain is now made public, what was senseless and random is woven into a meaningful tale. The narrative context itself can have healing force, ” Drew Leder, “Clinical Interpretation: The Hermeneutics of Medicine,” Theoretical Medicine 11 (1990): 9–24, at 13.CrossRefGoogle Scholar
  29. xxxiii.
    See Drew Leder, “Clinical Interpretation”, op. cit.Google Scholar
  30. xxxiv.
    Martin Heidegger, Being and Time, trans. by John Macquarrie and Edward Robinson (New York: Harper and Row, 1962), 182–203. On the importance of Heidegger’s and Gadamer’s philosophy in understanding this claim see Richard J. Berstein, “From Hermeneutics to Praxis”, in Philosophical Profiles: Essays in a Pragmatic Mode” (Philadelphia: University of Pennsylvania Press, 1986), 94-114: “Implicit in Heidegger and explicit in Gadamer are two central claims: the ontological primacy of hermeneutics and its universality. We are thrown into the world as beings who understand; and understanding itself is not one type of activity of a subject, but may properly be said to underlie all activities, ” at 96.Google Scholar
  31. xxxv.
    See Richard Baron, “I Can’t Hear While I Am Listening,” Annals of Internal Medicine 103 (1985): 606–611.Google Scholar
  32. xxxvi.
    Heidegger, Being and Time, 206.Google Scholar
  33. xxxvii.
    In the process of understanding, a real fusion of horizons occurs — which means that as the historical horizon is projected, it is simultaneously superseded. To bring about this fusion in a regulated way is the task of... historically effected consciousness. ” H.G. Gadamer, Truth and Method, 307.Google Scholar
  34. xxxviii.
    M. Foucault, The Birth of the Clinic: An Archeology of Medical Perception (New York: Vintage Book, 1975), 107–123.Google Scholar
  35. xxxix.
    My observations are grounded in Gadamer’s analysis of application in Truth and Method, especially 307–311.Google Scholar
  36. xl.
    The hermeneutic relevance of Aristotle is, of course, recognized by Gadamer himself in Truth and Method, 312–324. For a commentary, see Richard J. Bernstein “From Hermeneutics to Praxis”, op. cit. and Paul Schuchman, “Aristotle’s Phronesis and Gadamer’ rmeneutics,” Philosophy Today 23 (1979): 41-50.Google Scholar
  37. xli.
    For an understanding of phronesis as a paradigm of clinical rationality see the study of Daniel Davis, “Phronesis, Reasoning, and Pellegrino’ Philosophy of Medicine,” Theoretical Medicine 18 (1997): 173–19.Google Scholar

Copyright information

© Springer 2005

Authors and Affiliations

  • Roberto Dell’oro
    • 1
  1. 1.Loyola Marymount UniversityLos Angeles

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