CLINICAL JUDGMENT: A CRITICAL APPRAISAL PHILOSOPHY AND MEDICINE Editors: H. TRISTRAM ENGELHARDT, JR. Kennedy Institute 0/ Ethics, Georgetown University, Washington, D. C, U S.A. STUART F. SPIeKER University o/Connecticut Health Center, Fannington, Conn., US.A. VOLUME 6 CLINICAL JUDGMENT: A CRITICAL APPRAISAL PROCEEDINGS OF THE FIFTH TRANS-DISCIPLINARY SYMPOSIUM ON PHILOSOPHY AND MEDICINE HELD AT LOS ANGELES, CALIFORNIA, APRIL 14-16, 1977 Edited by H. TRISTRAM ENGELHARDT, JR. Kennedy Institute of Ethics, Georgetown University, Washington, D.C., US.A. STUART F. SPICKER University of Connecticut Health Center, Farmington, Conn., US.A. BERNARD TOWERS University of California at Los Angeles, California, US.A. D. REIDEL PUBLISHING COMPANY DORDRECHT: HOLLAND / BOSTON: U.S.A. LONDON: ENGLAND Library of Congress Cataloging in Publication Data Trans-disciplinary Symposium on Philosophy and Medicine, 5th, Los Angeles, 1977. Clinical judgment. (Philosophy and medicine; v. 6) Includes bibliographies and index. I. Medical logic-Congresses. 2. Medicine, Clinical- Decision making-Congresses. I. Engelhardt, Hugo Tristram, 1941- II. Spieker, Stuart F., 1937- III. Towers, Bernard. IV. Title. R723.T7 1977 616'.001'9 78-26504 ISBN-13: 978-94-009-9401-0 e-ISBN-13: 978-94-009-9399-0 DOl: 10.1007/978-94-009-9399-0 Published by D. Reidel Publishing Company, P.O. Box 17, Dordrecht, Holland Sold and distributed in the U.S.A., Canada, and Mexico by D. Reidel Publishing Company, Inc. Lincoln Building, 160 Old Derby Street, Hingham, Mass. 02043, U.S.A. All Rights Reserved Copyright © 1979 by D. Reidel Publishing Company, Dordrecht, Holland Sof'tcover reprint of the hardcover 1s t edition 1979 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any informational storage and retrieval system, without written permission from the copyright owner. EDITORIAL PREFACE Over a period of a year, the symposium on clinical judgment has taken shape as a volume devoted to the analysis of how knowledge claims are framed in medicine and how choices of treatment are made. We hope it will afford the reader, whether layman, physician or philosopher, a useful perspective on the process of knowing what occurs in medicine; and that the results of the dis cussions at the Fifth Symposium on Philosophy and Medicine will lead to a better understanding of how philosophy and medicine can usefully challenge each other. As the interchange between physicians, philosophers, nurses and psychologists recorded in the major papers, the commentaries and the round table discussion shows, these issues are truly interdisciplinary. In particular, they have shown that members of the health care professions have much to learn about themselves from philosophers as well as much of interest to engage philosophers. By making the structure of medical reasoning more apparent to its users, philosophers can show health care practitioners how better to master clinical judgment and how better to focus it towards the goods and values medicine wishes to pursue. Becoming clearer about the process of knowing can in short teach us how to know better and how to learn more efficiently. The result can be more than (though it surely would be enough!) a powerful intellectual insight into a major cultural endeavor, medicine. The result can be better diagnosis and treatment of patients and more successful education of health care professions. Being clearer about ideas means also being clearer about the actions we take to be of great significance and which are directed by such ideas. And in this process not only is medicine enriched, but philoso phy is as well, by an investigation of substance and social importance - not to mention of conceptual interest. Though the term medicine is used throughout this volume, it is meant broadly - somewhat as philosophy is used in the degree Doctor of Philosophy. One should see it encompassing what is embraced by the more cumbersome phrase, "The health care sciences, arts, and technologies." It includes then not only medicine in sensu stricto, but such endeavors as nursing, occupational therapy, dentistry, veterinary medicine, clinical psychology, psychoanalysis, and the practice of physician assistants. All of these enterprises, as well as others, are concerned with categorizing the complaints of patients (clients) in v vi EDITORIAL PREFACE order to forward accurate prognoses and enter upon useful courses of treat ment. Moreover, they all share in the fact-value ambiguities of health and disease language. In describing individuals as ill or well, healthy or diseased, they also evaluate them. Moreover, in terming individuals sick, health care professionals cast patients (clients) into social roles with vast implications - consider for example Talcott Parson's sick role [I]. Clinical judgments are not only intellectual exercises with the usual practical consequences we envi sage (e.g., good or bad treatment). Clinical judgments also have consequences that impinge on general social goods; they respond as well to our evaluations and our social structures. As in the other volumes in this series on philosophy and medicine, we see evaluations intertwined in medical explanations. The result is that no adequate sense can be made of bioethical problems without understanding the particular enterprises of knowing which constitute medi cine. The essays in this volume are offered as one step in understanding the theory of knowledge in medicine. They are meant as a contribution to a philosophy of medicine that seeks to engage some of the more ambitious themes of the first volume in this series - Evaluation and Explanation in the Biomedical Sciences. Much more needs to be done, and will be done in this series, in the way of exploring such subjects as the role of evaluation in medi cal explanations, the value-laden character of the language of disease and health, and the hidden imperatives of the sick role. Much more must be undertaken with regard to understanding the ambiguities of disease language. This is particularly the case in coming to terms with nosography and the generation of nosologies in the use of computers in medicine. Moreover, the problem of the logic and the psychology of discovery in medicine remains almost untouched. This volume offers a first approach towards the analysis of the nature of clinical judgment. We are grateful for the support of the School of Medicine of the University of California at Los Angeles, the Research Foundation of the American Medical Association, the Franklin 1. Matchette Foundation, and D. Reidel Publishing Company, who made this beginning possible. Not only are we grateful for their financial support, but for their moral support as well, which enabled us to hold the symposium which was the ancestor of this volume. Moreover, we stand in special debt to the School of Medicine of the University of California at Los Angeles for the many ways in which its admin istration encouraged and made possible this meeting of clinicians and scholars interested in understanding clinical judgment. Many individuals labored un selfishly in the preparation and conduct of this symposium. We are deeply EDITORIAL PREFACE vii grateful to them all. Here we can name but a few: Sherman M. Mellinkoff, Robert Adams, Rodney Bluestone, Susan Engelhardt, Sharon Hill, Marjorie Huffman, Dwaine Lawrence, Norman Levan, Charles Lewis, Ruth Walker Moskop, Fritz Redlich, Arthur Rivin, Bernice Wenzel, Paula Wilkes, and William J. Winslade. A special thanks in this regard is due to Jane Backlund, who inherited the post-symposium red tape that comes in the wake of any large conference. We are also in debt to her for the careful preparation of the manuscripts of this volume and for the generation of many of the references. Finally, we must acknowledge our debt to the many individuals who attended this symposium on clinical judgment and helped through their discussion to frame the papers in the final form in which they appear in this volume. April 21, 1978 H. TRISTRAM ENGELHARDT, JR. STUART F. SPICKER BERNARD TOWERS BIBLIOGRAPHY I. Parsons, T.: 1967, Sociological Theory and Modern Society, Free Press, New York. T ABLE OF CONTENTS EDITORIAL PREFACE v H. TRISTRAM ENGELHARDT, JR. / Introduction xi SHERMAN M. MELLINKOFF / Prologue to the Symposium xxv SECTION 1/ INTUITIONS, HUNCHES, AND RULES FOR REASONING MICHAEL SCRIVEN / Clinical Judgment 3 AUTHUR S. ELSTEIN / Human Factors in Clinical Judgment: Discus- sion of Scriven's 'Clinical Judgment' 17 ELLIOTT SOBER / The Art and Science of Clinical Judgment: An Informational Approach 29 D. 1. ROSENHAN / When Does a Diagnosis Become a Clinical Judg- ment? Verifiability, Reliability and Umbrella Effects in Diagnosis 45 SECTION II / THE LOGIC OF HEALTH CARE EDMOND A. MURPHY / Classification and Its Alternatives 59 MORTON BECKNER / Comments on Murphy's 'Classification and Its Alternatives' 87 JOHN 1. GEDYE / Simulating Clinical Judgment: An Essay in Tech- nological Psychology 93 ERNAN McMULLIN / A Clinician's Quest for Certainty 115 JOHN L. GEDYE / A Reply to Ernan McMullin 131 PATRICK SUPPES / The Logic of Clinical Judgment: Bayesian and Other Approaches 145 MARTIN E. LEAN / Suppes on the Logic of Clinical Judgment 161 SECTION III / CLINICIANS ON CLINICAL JUDGMENT EDMUND D. PELLEGRINO I The Anatomy of Clinical judgments: Some Notes on Right Reason and Right Action 169 ix x TABLE OF CONTENTS MARJORIE GRENE / Comments on Pellegrino's 'Anatomy of Clinical Judgment' 195 ERIC J. CASSELL / The Subjective in Clinical Judgment 199 DANIEL I. WIKLER / Subjectivity and the Scope of Clinical Judgment 217 SECTION IV / JUDGMENT AND METHODS IN CLINICAL JUDGMENT ROUND TABLE DISCUSSION Stuart F. Spicker 229 E. James Potchen, Paul Wahby, William R. Schonbein, and Linda L. Gard 238 Sally Gadow 248 Thomas E. Hill 254 Bernard Towers 259 H. TRISTRAM ENGELHARDT, JR. / Closing Remarks 265 NOTES ON CONTRIBUTORS 273 INDEX 275 H. TRISTRAM ENGELHARDT, JR. INTRODUCTION Clinicus is also used for a physician - In regard [to I physicians [who I are much conversant about the beds of the sick. Clinic is now seldom used but for a quack; or for an empirical nurse, who pretends to have learned the art of curing diseases by attend ing on the sick. Ephraim Chambers, Cyclopaedia; or an Universal Dictionary of Arts and Sciences (1751) As the definition of clinician in Chambers' dictionary shows, being called a clinician does not appear to have always been an unalloyed compliment. We, though, take it to be unequivocally a term of honor, designating a physician skilled in the treatment of patients; consider the force of saying "he is no clinician". Chambers' skepticism concerning clinicians was due as the entry suggests to a suspicion of empirics, physicians who practiced without an adequate theoretical basis for their medical judgments. In part, current inter est in and criticism of clinical judgment stems from a similar distrust of the empiric. There is a suspicion that the judgments of clinicians would be more reliable if rendered more rational by following explicit rules and recipes for diagnosis and treatment. There is, as well, interest in clinical judgment in order to understand how to reconstruct its successes and have them matched by undertakings of artificial intelligence - computers. Yet others would see in clinical judgment, decisions made on the basis of an intuition born of years of bedside experience, and not reducible to explicit formulae. The interest in clinical judgment is thus diverse if not contradictory: there is interest among clinicians and others in reducing the basis of medical decisions to fonnal rules as well as interest in denying that such rules would match the success achieved by the intuitive decisions of clinicians. The phrase 'clinical judgment' is in other ways ambiguous. On the one hand, it may be taken to refer to a capacity to make medical judgments con cerning patients. One might think here of the famous line from Epidemics, "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things - to help, or at least to do no harm." (Epidemics I, 11 (11] .) Clinical judgment in this very traditional sense xi H. T. Engelhardt, Jr., S. F. Spieker and B. Towers (eds.), Clinical Judgment: A Critical Appraisal, xi-xxiv. All Rights Reserved. Copyright © 1979 by D. Reidel Publishing Company, Dordrecht, Holland