Benjamin Chin-Yee

I and Thou: learning the ‘human’ side of medicine

This essay is a reflection on the doctor–patient relationship from the perspective of two medical students, which draws on the ideas of 20th-century philosopher Martin Buber. Although Buber never wrote about medicine directly, his ‘philosophy of dialogue’ raises fundamental questions about how human beings relate to one another, and can thus offer valuable insights into the nature of the clinical encounter. We argue that Bubers basic word pairs, ‘I–You’ and ‘I–It’, provide a useful heuristic for understanding different modes of caring for patients, which we illustrate using examples of illness narratives from two literary works: Tolstoys Ivan Ilych and Margaret Edsons Wit. Our essay demonstrates how the humanities in general and philosophy in particular can inform a more humanistic practice for healthcare trainees and practicing clinicians alike.

Underdetermination in evidence‐based medicine

This article explores the philosophical implications of evidence-based medicines (EBMs) epistemology in terms of the problem of underdetermination of theory by evidence as expounded by the Duhem–Quine thesis. EBM hierarchies of evidence privilege clinical research over basic science, exacerbating the problem of underdetermination. Because of severe underdetermination, EBM is unable to meaningfully test core medical beliefs that form the basis of our understanding of disease and therapeutics. As a result, EBM adopts an epistemic attitude that is sceptical of explanations from the basic biological sciences, and is relegated to a view of disease at a population level. EBMs epistemic attitude provides a limited research heuristic by preventing the development of a theoretical framework required for understanding disease mechanism and integrating knowledge to develop new therapies. Medical epistemology should remain pluralistic and include complementary approaches of basic science and clinical research, thus avoiding the limited epistemic attitude entailed by EBM hierarchies.This article explores the philosophical implications of evidence-based medicines (EBMs) epistemology in terms of the problem of underdetermination of theory by evidence as expounded by the Duhem-Quine thesis. EBM hierarchies of evidence privilege clinical research over basic science, exacerbating the problem of underdetermination. Because of severe underdetermination, EBM is unable to meaningfully test core medical beliefs that form the basis of our understanding of disease and therapeutics. As a result, EBM adopts an epistemic attitude that is sceptical of explanations from the basic biological sciences, and is relegated to a view of disease at a population level. EBMs epistemic attitude provides a limited research heuristic by preventing the development of a theoretical framework required for understanding disease mechanism and integrating knowledge to develop new therapies. Medical epistemology should remain pluralistic and include complementary approaches of basic science and clinical research, thus avoiding the limited epistemic attitude entailed by EBM hierarchies.

Re-evaluating concepts of biological function in clinical medicine: towards a new naturalistic theory of disease

Naturalistic theories of disease appeal to concepts of biological function, and use the notion of dysfunction as the basis of their definitions. Debates in the philosophy of biology demonstrate how attributing functions in organisms and establishing the function-dysfunction distinction is by no means straightforward. This problematization of functional ascription has undermined naturalistic theories and led some authors to abandon the concept of dysfunction, favoring instead definitions based in normative criteria or phenomenological approaches. Although this work has enhanced our understanding of disease and illness, we need not necessarily abandon naturalistic concepts of function and dysfunction in the disease debate. This article attempts to move towards a new naturalistic theory of disease that overcomes the limitations of previous definitions and offers advantages in the clinical setting. Our approach involves a re-evaluation of concepts of biological function employed by naturalistic theories. Drawing on recent insights from the philosophy of biology, we develop a contextual and evaluative account of function that is better suited to clinical medicine and remains consistent with contemporary naturalism. We also show how an updated naturalistic view shares important affinities with normativist and phenomenological positions, suggesting a possibility for consilience in the disease debate.

Historical thinking in clinical medicine: lessons from R.G. Collingwood's philosophy of history

The aim of this article is to create a space for historical thinking in medical practice. To this end, we draw on the ideas of R.G. Collingwood (1889-1943), the renowned British philosopher of history, and explore the implications of his philosophy for clinical medicine. We show how Collingwoods philosophy provides a compelling argument for the re-centring of medical practice around the patient history as a means of restoring to the clinical encounter the human meaning that is too often lost in modern medicine. Furthermore, we examine how Collingwoods historical thinking offers a patient-centred epistemology and a more pluralistic concept of evidence that includes the qualitative, narrative evidence necessary for human understanding. We suggest that clinical medicine can benefit from Collingwoods historical thinking, and, more generally, illustrates how a philosophy of medicine that draws on diverse sources from the humanities offers a richer, more empathetic clinical practice.

Clinical judgement in the era of big data and predictive analytics

Clinical judgement is a central and longstanding issue in the philosophy of medicine which has generated significant interest over the past few decades. In this article, we explore different approaches to clinical judgement articulated in the literature, focusing in particular on data-driven, mathematical approaches which we contrast with narrative, virtue-based approaches to clinical reasoning. We discuss the tension between these different clinical epistemologies and further explore the implications of big data and machine learning for a philosophy of clinical judgement. We argue for a pluralistic, integrative approach, and demonstrate how narrative, virtue-based clinical reasoning will remain indispensable in an era of big data and predictive analytics.

Health Inequalities, Social Justice, and the Limits of Liberalism

This path-breaking volume compiles a wide variety of research from numerous disciplines—spanning sociology, anthropology, philosophy, bioethics, public health, and medicine—inserting these disparate fields into Bconversation with each other to illustrate how different vantage points and starting assumptions can complicate widely accepted views on health inequality and justice^ [1]. The volume offers a compelling interdisciplinary analysis surrounding issues of social justice, equality, and healthcare reform, particularly in the USA, at a time of growing inequalities [2, 3]. By articulating the connections between unequal social resources, health inequalities, and justice, this volume also has broad relevance in urban settings in the USA and worldwide, where rates of poverty and inequality are often most pronounced and linked with health disparities [4, 5]. The book’s first section highlights the dominant normative debates surrounding health inequalities and establishes the intellectual terrain of the book. In chapter one, Paula Braveman defends the significance of conceptualizing health inequalities as a matter of social justice, employing a rights-based approach. In chapters two and three, Jennifer Ruger and J. Paul Kelleher advocate new frameworks to approach health inequalities and conceptions of justice in health, advancing theories of Bprovincial globalism^ and Brelational egalitarianism,^ respectively. In the final chapter of the section, Eva Kittay offers a compelling challenge to conventional assumptions of autonomy, which underpin liberal frameworks of justice. The second section includes three case studies that engage with specific instances of health inequalities, situating the previous conceptual debates within concrete examples. These include oral health disparities in the children of migrant workers in California, conceptions of risk in pregnancy, and forms of (dis)respect and involuntary treatment in mental health services. Finally, the third section unpacks policies within the US healthcare system as well as contentious methodological approaches in interdisciplinary research. The discussion ranges from analyses of patient-centered care and the Affordable Care Act (ACA) to racial disparities in the Healthy People Act, applying the central debates of the book to existing legislation. What is most notable about this volume is the dialog it generates between chapters, unpacking fundamental issues in philosophies of justice and key methodological issues in research related to health inequalities. From this dialog, a central theme arises related to the limitations of liberal theories of justice in defining, measuring, and addressing health inequalities. Throughout the volume, a divide emerges between the differing ways that authors interpret liberal theories of justice and inequality [6–10], and more radical social theories [11–15], to explain how gendered, racial, and class-based inequities J Urban Health https://doi.org/10.1007/s11524-018-0235-9

Three visions of doctoring: a Gadamerian dialogue

Abstract Medicine in the twenty-first century faces an ‘identity crisis,’ as it grapples with the emergence of various ‘ways of knowing,’ from evidence-based and translational medicine, to narrative-based and personalized medicine. While each of these approaches has uniquely contributed to the advancement of patient care, this pluralism is not without tension. Evidence-based medicine is not necessary individualized; personalized medicine may be individualized but is not necessarily person-centered. As novel technologies and big data continue to proliferate today, the focus of medical practice is shifting away from the dialogic encounter between doctor and patient, threatening the loss of humanism that many view as integral to medicine’s identity. As medical trainees, we struggle to synthesize medicine’s diverse and evolving ‘ways of knowing’ and to create a vision of doctoring that integrates new forms of medical knowledge into the provision of person-centered care. In search of answers, we turned to twentieth-century philosopher Hans-Georg Gadamer, whose unique outlook on “health” and “healing,” we believe, offers a way forward in navigating medicine’s ‘messy pluralism.’ Drawing inspiration from Gadamer’s emphasis on dialogue and ‘practical wisdom’ (phronesis), we initiated a dialogue with the dean of our medical school to address the question of how medical trainees and practicing clinicians alike can work to create a more harmonious pluralism in medicine today. We propose that implementing a pluralistic approach ultimately entails ‘bridging’ the current divide between scientific theory and the practical art of healing, and involves an iterative and dialogic process of asking questions and seeking answers.

Blood donation and testosterone replacement therapy

Polycythemia is the most common adverse effect of testosterone replacement therapy (TRT) and may predispose patients to adverse vascular events. Current Canadian guidelines recommend regular laboratory monitoring and discontinuing TRT or reducing the dose if the hematocrit exceeds 54% (hemoglobin ≥180 g/L). This threshold has been interpreted by some physicians and patients to indicate the need for phlebotomy or blood donation while on TRT.

The new medical model: why medicine needs philosophy

Philosophy of medicine has been defined as “a systematic set of ways for articulating, clarifying, and addressing the philosophical issues in medicine.”[1][1] This burgeoning field has featured in several recent issues of CMAJ , most notably in Jonathan Fuller’s latest article, “The new