Viewpoint: Moving beyond evidence-based medicine.

The evidence-based medicine movement has remained both well known and controversial since its inception. The authors reframe the evidence-based medicine debate by pointing out an underappreciated epistemological deficiency: evidence-based medicine as currently conceptualized cannot accommodate concepts that resist quantitative analysis and therefore cannot logically differentiate human beings from complex machines. The authors use Michael Polanyi's philosophy of tacit knowing (which refers to the taken-for-granted knowledge at the periphery of attention that allows persons to understand the world and discern meaning in it) as a starting point for rectifying this deficiency and for working towards an improved, person-centered epistemology of medical practice. The authors demonstrate that not only evidence-based medicine but also most traditional theories of medical practice need a concept such as tacit knowing to account for the kinds of knowledge human beings actually use. Polanyi's philosophy of tacit knowing is defined and briefly explained. A medical epistemology that can account for the tacit dimension of human knowledge and recognize physicians and patients as persons requires a revised conception of medical uncertainty and a recognition that clinician-patient interactions are central to medicine. The authors discuss practical implications of tacit knowing for medical practice, education, research, and health care policy and suggest ways for moving beyond evidence-based medicine towards a comprehensive epistemology of medical practice.

On evoking clinical meaning.

It was in the course of one particular clinical encounter that I came to realize the power of narrative, especially for expressing clinically presented ethical matters. In Husserlian terms, the mode of evidence proper to the unique and the singular is the very indirection that is the genius of story-telling. Moreover, the clinical consultant is unavoidably changed by his or her clinical involvement. The individuals whose situation is at issue have their own stories that need telling. Clinical ethics is in this sense a way of helping patients, families, and, yes, health providers to discover and give voice to those stories. In this way, clinical ethics is an evoking of meaning. Kierkegaard understood this well: Indirect communication is the language for the unique and the otherwise inexpressible.

A work in progress.

After expressing gratitude to each contributor, and briefly commenting on each, I probe several main themes of my work, addressing the question of the apparent difference between my earlier "philosophical" and later "clinical" writings. Central to both is the reflexivity of the human agent, and that each exhibits a form of practice regardless of the specific aims embedded in each. I then address the theme of narrative writing as my work has developed over the past several decades at the heart of which are questions of self and integrity.

The injustice of it all: caring for the chronically ill.

... While Spiegelberg emphasizes these "cosmic" -- perhaps more accurately, ontological -- features of birth and undeserved inequalities, it seems to us not inappropriate to suggest that what Douard terms "outrage" and Annas "instinct" go in the same direction. When impairment occurs without desert, something should be done to help. This is all the more true when, as in cases of chronic affliction that concern Douard or the case of the Siamese twins that fascinates Annas, something helpful can be done. Then, in Spiegelberg's words, what is "undeserved" demands redress. In these terms, each of these authors points to a deeply rooted sense of our common human lot. Or, in Albert Schweitzer's apt phrase, to witness such undeserved misfortune is to awaken "a moral sense that is usually dormant but that on special occasions can be brought to the surface." Chronic illnesses, we suggest -- no less than the "accidents of birth" that concern Spiegelberg -- are just such "special occasions" for awakening that "moral sense" suggested by Douard in his appeal to the "outrage" of doing nothing for, or refusing to help, the chronically ill.

A medical ethics issues survey of residents in five pediatric training programs.

Few pediatric training programs offer formal instruction or have ethics consultants to assist residents with ethical dilemmas. Moreover, even if such assistance were available, it is not clear that educators have an adequate understanding of (1) the range and frequency of possible ethical dilemmas residents may encounter, (2) residents' most troublesome concerns, (3) their use of resources to resolve issues, and (4) their own ethics belief systems. A sample of convenience (51 residents) at five midsouth residency programs was queried during 25-minute open-ended interviews to answer ethical questions; there were no refusals to participate. The "most troublesome" cases cited by the residents were related to life-and-death issues (withholding and withdrawing life support), child abuse and neglect cases, and disputes regarding patient care that arise between services. Two thirds of those surveyed indicated that they are still somewhat troubled by these difficult ethical problems. Surprisingly, residents stated that they relied on their peers more often than their attending physicians for effective assistance in resolving their most troublesome dilemmas. We support continuing education and research efforts to help residents and educators feel "more comfortable" in resolving ethical dilemmas.