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The explanations can be simplistic in nature, with only a few antecedent causes arranged linearly, or very complex, with multiple antecedent causes operating in a matrix of interrelated and integrated interactions. For example, causal explanations of cancer involve at least six distinct sets of genetic factors controlling cellular phenomena such as cell growth and death, immunological response, and angiogenesis.

Finally, Gilbert Harman articulated the contemporary form of inference to the best explanation, or IBE, in the s. Harman proposed that based on the totality of evidence one must choose the explanation that best accounts for or infers that evidence and reject its competitors.

Donald Gillies provides an analysis of it in terms of Kuhnian paradigm. Diagnostic knowledge pertains to the clinical judgments and decisions made about what ails a patient. Epistemologically, the issues concerned with such knowledge are its accuracy and certainty.

Central to both these concerns are clinical symptoms and signs. Clinical symptoms are subjective manifestations of the disease that the patient articulates during the medical interview, while clinical signs are objective manifestations that the physician discovers during the physical examine. What is important for the clinician is how best to quantify those signs and symptoms, and then to classify them in a robust nosology or disease taxonomy.

The clinician then narrows this set to one diagnostic hypothesis that best explains most, and hopefully all, of the relevant clinical evidence. The epistemic mechanism that accounts for this process and the factors involved in it are unclear. Philosophers of medicine especially dispute the role of tacit factors in the process. Finally, the heuristics of the process are an active area of philosophical investigation in terms of identifying rules for interpreting clinical evidence and observations.

Therapeutic knowledge refers to the procedures and modalities used to treat patients. Epistemologically, the issues concerned with such knowledge are its efficacy and safety.

Efficacy refers to how well the pharmacological drug or surgical procedure treats or cures the disease, while safety refers to possible patient harm caused by side effects. Although basic medical research into the etiology of disease mechanisms is important, the translation of that research and the philosophical problems that arise from it are foremost on the agenda for philosophers of medicine.

The origin of clinical trials dates at least to the eighteenth century but not until the twentieth century is consensus reached over the structure of these trials. Today, four phases define a clinical trial. During the first phase, clinical investigators establish the maximum tolerance of healthy volunteers to a drug. The following are topics of active discussion among philosophers of medicine: However, the most pressing problem is the type of statistics utilized for analyzing clinical trial evidence.

Some philosophers of medicine champion frequentist statistics, while others Bayesian statistics. Ethics is the branch of philosophy concerned with the right or moral conduct or behavior of a community and its members. Traditionally, philosophers divide ethics into descriptive, normative, and applied ethics.

Descriptive ethics involves detailing ethical conduct without evaluating it in terms of moral codes of conduct, whereas normative ethics pertains to how a community and its members should act under given situations, generally in terms of an ethical code.

This code is often a product of certain values held in common within a community. For example, ethical codes against murder reflect values community members place upon taking human life without just cause.

Besides values, ethicists base normative ethics on a particular theoretical perspective. Within western culture, three such perspectives predominate.

The first and historically oldest ethical theory—although it experienced a Renaissance in the late twentieth century—is virtue ethics. Virtue ethics claims that ethical conduct is the product of a moral agent who possesses certain virtues, such as prudence, courage, temperance, or justice—the traditional cardinal virtues.

The second ethical theory is deontology and bases moral conduct on adherence to ethical precepts and rules reflecting moral duties and obligations. The third ethical theory is consequentialism, which founds moral conduct on the outcome or consequence of an action. Finally, applied ethics is the practical use of ethics within a profession such as business or medicine.

Medical or biomedical ethics reflects applied ethics and is a major feature within the landscape of twenty-first century medicine.

Historically, ethical issues are a conspicuous component of medicine beginning with Hippocrates. Throughout medical history several important treatises on medical ethics have been published. Today, medical ethics is founded not on any particular ethical theory but on four ethical principles. The origins of the predominant system for contemporary medical or biomedical ethics began in In that year, the Public Health Service, in conjunction with the Tuskegee Institute in Macon County, Alabama, undertook a clinical study to document the course of syphilis on untreated test subjects.

The subjects were Afro-American males. Over the next forty years, healthcare professionals observed the course of the disease, even after the introduction of antibiotics. What made the study so atrocious was that the healthcare professionals misinformed the subjects about treatment or failed to treat the subjects with antibiotics.

To insure that such flagrant abuse of test subjects did not happen again, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research met from February , The outcome was a report entitled, Ethical Principles and Guidelines for the Protection of Human Subjects of Research , or known simply as the Belmont Report, published in The report lists and discusses several ethical principles necessary for protecting human test subjects and patients from unethical treatment at the hands of healthcare researchers and providers.

The next principle is beneficence or maximizing the benefits to risk ratio for the test subject. The final ethical principle is justice, which ensures that the cost to benefit ratio is equitably distributed among the general population and that no one segment of it bears an unreasonable burden with respect to the ratio.

One of the framers of the Belmont Report was a young philosopher named Tom Beauchamp. While working on the report, Beauchamp, in collaboration with a colleague, James Childress, was also writing a book on the role of ethical principles in guiding medical practice.

Rather than ground biomedical ethics on any particular ethical theory, such as deontology or utilitarianism, Beauchamp and Childress looked to ethical principles for guiding and evaluating moral decisions and judgments in healthcare. The fruit of their collaboration was Principles of Biomedical Ethics , first published in the same year as the Belmont Report, In the book, Beauchamp and Childress apply the ethical principles approach of the report to regulate the activities of biomedical researchers, to assist physicians in deliberating over the ethical issues associated with the practice of clinical medicine.

However, besides the three guiding principles of the report, they added a fourth—nonmaleficence. Moreover, the first principle became patient autonomy, rather than respect of persons as denoted in the report. Beauchamp and Childress articulate the final principle, justice, in terms reminiscent of the Belmont report with respect to equitable distribution of risks and benefits, as well as healthcare resources, among both the general and patient populations.

However, principlism is not without its critics. A fundamental complaint is the lack of theoretical support for the four principles, especially when the principles collide with one another in terms of their application to a bioethical problem. In its use, ethicists and clinicians generally apply the principles in an algorithmic manner to justify practically any ethical position on a biomedical problem.

What critics want is a unified theoretical basis for grounding the principles, in order to avoid or adjudicate conflicts among the principles. In response to their critics, Beauchamp and Childress argue that no single ethical theory is available to unite the four principles to avoid or adjudicate conflicts among them. However, they did introduce in the fourth edition of Principles, a notion of common morality—a set of shared moral standards—to provide theoretical support for the principles.

Unfortunately, their notion of common morality lacks the necessary theoretical robustness to unify the principles effectively. Although principlism still serves a useful function in biomedical ethics, particularly in the clinic, early twenty-first century trends towards healthcare ethics and global bioethics have made its future unclear.

According to many philosophers of medicine, medicine is more than simply a natural or social science; it is a moral enterprise. What makes medicine moral is the patient-physician or therapeutic relationship.

Although some philosophers of medicine criticize efforts to model the relationship, given the sheer number of contemporary models proposed to account for it, modeling the relationship has important ramifications for understanding and framing the moral demands of medicine and healthcare. The patient is not to question those orders, unless to clarify them.

In this model, the doctor represents a parent, generally a father figure and the patient a child—especially a sick child. Besides the paternalistic model, other doctor-centered models include the priestly and mechanic models. However, the paternalistic model, as well as the other doctor-centered models, ran into severe criticism with abuses associated with the models and with the rise of patient advocacy groups to correct the abuses.

Within the latter part of the twentieth century and the rise of patient autonomy as a guiding principle for medical practice, alternative patient-physician models challenged traditional medical paternalism. Instead of doctor-centered, one set of models are patient-centered in which patients are the locus of power. The most predominant patient-centered model is the business model, where the physician is a healthcare provider and the patient a consumer of healthcare goods and services.

The business model is an exchange relationship and relies heavily on a free market system. Thus, the patient possesses the power to pick and choose among physicians until a suitable healthcare provider is found. The legal model is another patient-centered model, in which the patient is a client and the guiding forces are patient autonomy and justice.

Patient and physician enter into a contract for healthcare services. Another set of models in which patients have significant power in the therapeutic relationship are the mutual models. In these models, neither patients nor physicians have the upper hand in terms of power-they share it. The most predominant model is the partnership model in which patient and physician are associates in the therapeutic relationship.

The guiding force of this model is informed consent in which the physician apprises the patient of the available therapeutic options and the patient then chooses which is best. Both the patient and physician share decision making over the best means for affecting a cure.

The nature of medicine is certainly an important question facing twenty-first century philosophers of medicine. One reason for its importance is that the question addresses the vital topic of how physicians should practice medicine. During the turn of the twenty-first century, clinicians and other medical pundits have begun to accept evidence-based medicine, or EBM, as the best way to practice medicine. Proponents also claim that EBM represents a paradigmatic shift away from traditional medicine.

Traditional practitioners doubt the radical claims of EBM proponents. One specific objection is that application of evidence from population based clinical trials to the individual patient within the clinic is not as easy to accomplish as EBM proponents realize.

In response, some clinicians propose patient-centered medicine PCM. While some commentators present EBM and PCM as competitors, others propose a combination or integration of the two medicines. The debate between advocates of EBM and PCM is reminiscent of an earlier debate between the science and art of medicine and belies a deep anxiety over the nature of medicine.

Certainly, philosophers of medicine can play a strategic role in the debate and assist towards its satisfactory resolution. Philosophers of medicine can certainly contribute to the resolution of these crises by carefully and insightfully analyzing the issues associated with them.

For example, considerable attention has been paid in the literature to the crisis over the nature of medical professionalism Project of the ABIM Foundation, et al. However, little consensus as to how best to define professionalism is palpable in the literature.

Philosophers of medicine can aid by furnishing guidance towards a consensus on the nature of medical professionalism. Philosophy of medicine is a vibrant field of exploration into the world of medicine in particular, and of healthcare in general. Along traditional lines of metaphysics, epistemology, and ethics, a cadre of questions and problems face philosophers of medicine and cry out for attention and resolution. In addition, many competing forces are vying for the soul of medicine today.

Philosophy of medicine is an important resource for reflecting on those forces in order to forge a medicine that meets both physical and existence needs of patients and society. Table of Contents Metaphysics Reductionism vs. References and Further Reading 1. Metaphysics Traditionally, metaphysics pertains to the analysis of objects or events and the forces or factors causing or impinging upon them. Holism The reductionism-holism debate enjoys a lively history, especially from the middle to the latter part of the twentieth century.

Antirealism Realism is the philosophical notion that observable objects and events are actual objects and events, independent of the person observing them. Causation Causation has a long philosophical history, beginning with the ancient Greek philosophers.

Epistemology Epistemology is the branch of philosophy concerned with the analysis of knowledge, in terms of both its origins and justification. Empiricism The rationalism-empiricism debate has a long history, beginning with the ancient Greeks, and focuses on the origins of knowledge and its justification.

Explanation Epistemologists are generally interested in the nature of propositions especially the explanatory power of those justified true beliefs. Diagnostic and Therapeutic Knowledge Diagnostic knowledge pertains to the clinical judgments and decisions made about what ails a patient.

Ethics Ethics is the branch of philosophy concerned with the right or moral conduct or behavior of a community and its members. Principlism The origins of the predominant system for contemporary medical or biomedical ethics began in Patient-Physician Relationship According to many philosophers of medicine, medicine is more than simply a natural or social science; it is a moral enterprise.

References and Further Reading Achinstein, P. The nature of explanation. The history of reductionism versus holism approaches to scientific research. Practice of physick , 2nd edition. Essay on the philosophy of medical science. The limits of reductionism in biology. On the distinction between disease and illness. Philosophy and Public Affairs 5: In Health care ethics: Temple University Press, pp. A rebuttal on health. In What is disease?

A comment on theory structure in biomedicine. Journal of Medicine and Philosophy Does the philosophy of medicine exist? The rise of causal concepts of disease: The nature of suffering and the goals of medicine , 2nd edition.

A critique of principlism. An essay on metaphysics. British Medical Journal From doctor to healer: The logical basis of metaphysics. Reflections on a theory of organisms: Johns Hopkins University Press.

Journal of American Medical Association The need for a new medical model: The foundations of bioethics , 2nd edition. In A guide to culture of science, technology, and medicine , P. In Encyclopedia of bioethics , 3rd edition, S. Evidence-Based Medicine Working Group. Annals of Internal Medicine Moral theory and medical practice.

A virtue ethics approach to moral dilemmas in medicine. Journal of Medical Ethics Hempelian and Kuhnian approaches in the philosophy of medicine: John Wiley and Sons. The tacit dimension of clinical judgment. Yale Journal of Biology and Medicine The limits of medicine: University of Chicago Press. Power issues in the doctor-patient relationship. Health Care Analysis 9: From detached concern to empathy: Perspectives in Biology and Medicine The inference to the best explanation.

The limits of medical paternalism. Aspects of scientific explanation and other essays in the philosophy of science. Studies in the logical of explanation. Philosophy of science The environment and disease: Proceedings of the Royal Society of Medicine The philosophy of evidence-based medicine. Causality in the sciences. A short history of medical ethics.

The web that has no weaver: Bayesian methods for health-related decision making. Statistics in Medicine The silent world of doctor and patient. The philosophy of medicine.

The minister as healer, the healer as minister. Journal of Religion and Health Medicine at the crossroads: The concept of health and disease. Medicine, Health Care and Philosophy 1: The challenges of evidence-based medicine: Medicine, Health Care and Philosophy 8: The measurement of health: The rise and fall of modern medicine.

Four approaches to doing ethics. Introduction to the symposium: Inference to the best explanation , 2nd edition. Cambridge Quarterly of Healthcare Ethics Holism and reduct ionism in biology and ecology: The philosophy and practice of medicine and bioethics: Metaphysical presuppositions and scientific practices: International Studies in the Philosophy of Science An introductory philosophy of medicine: The conceptual foundations of systems biology: An introduction to randomized controlled clinical trials.

Westminster John Knox Press. Clinical versus statistical prediction: University of Minnesota Press. Louis and the birth of clinical epidemiology. Journal of Clinical Epidemiology The logic of medicine , 2nd edition. Medicine, Health Care and Philosophy 4: On the nature of health: The moral education of doctors. Clinical wisdom and evidence-based medicine. Medicine, Health Care and Philosophy 5: A philosophical basis of medical practice: The virtues in medical practice.

Journal of Medical Humanities Medical professionalism in the new millennium: Defending principlism well understood.

The Journal of Medicine and Philosophy The patient-client as a consumer: Journal of Health and Social Behavior Patients that are treated in outpatient or hospital environments may receive different surveys, and the volume of responses will vary by question.

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Porous tantalum metaphyseal cones for severe tibial bone loss in revision knee arthroplasty: The Journal of bone and joint surgery. American volume 97 3: Comparative Epidemiology of Revision Arthroplasty: Clinical orthopaedics and related research 6: The Journal of arthroplasty 30 9: Clinical orthopaedics and related research Effect of angular deformities of the proximal femur on impingement-free hip range of motion in a three-dimensional rigid body model.

Bundled Payment in Total Joint Care: The Journal of arthroplasty 30 American volume 98 8: Bernese periacetabular osteotomy for hip dysplasia: Surgical technique and indications. World journal of orthopedics 7 5: The Journal of arthroplasty 31 The Journal of arthroplasty 31 9: Elevated levels of homocysteine compromise blood-brain barrier integrity in mice.

Common causes of failed unicompartmental knee arthroplasty: International orthopaedics 38 5: What's new in orthopaedic rehabilitation. American volume 92 8: The Journal of arthroplasty 29 4: The increased financial burden of further proposed orthopaedic resident work-hour reductions. American volume 93 7: Intensive care monitoring after total joint replacement.

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