Reason and value: making reasoning fit for practice

Few would dispute the claim that sound reasoning in clinical practice is worth cultivating. That is, of course, because the claim is a platitude: it is hard to see how anyone could seriously maintain a contrary view. We might explain sound reasoning with reference to a number of evidently desirable qualities: we want practitioners who think critically, are reflective and perceptive, able to evaluate theoretical claims and evidence to assess their relevance in particular cases. We might add that this means understanding the value of particular outcomes to the care of individual patients, such that sound reasoning involves not just knowledge of causal mechanisms and the findings of research, but also an appreciation of and respect for the patient's autonomy and value. To leave such claims unanalysed is to make them barely worth asserting. These are things that, outside of a management ‘vision statement’, might ‘go without saying’. This is not because the nature of good reasoning is well understood or that cultivating it in professional environments is a straightforward matter. The moment we attempt to go beyond the platitudinous, to say something with substantive implications for practice, we find ourselves confronted by controversies of a fundamental nature. Even if we agree that ‘critical thinking’ and ‘reflective practice’ identify important components of good reasoning, when we try to spell out precisely what we mean by these terms, in a way that could enable us to recognize and develop these qualities in real situations, any initial appearance of general accord soon evaporates. Not only is there no broad consensus on the essential components of good reasoning in clinical practice, but where there are differences, we lack a clear and agreed method for producing answers that all rational parties will accept. We have entered the traditional intellectual territory of philosophy 1, 2. As we have noted in previous editions of this journal, philosophy requires us to identify and question underlying assumptions that frame our thinking about a vast range of issues. Discussions about the nature of evidence, the proper goals of practice or the nature, scope and limitations of clinical reasoning, can appear intractable because we bring to them assumptions that may typically lie in the background, rarely subjected to critical scrutiny 1. It can initially come as something of a shock to discover that other apparently rational persons do not share assumptions that may have slipped so far into the background as to strike us as sheer common sense 2. Even so, if we are to say something on such important matters that is at once substantive (going beyond platitudes) and defensible (justifiable in principle to other reasonable people) – if we are even to understand the nature of our disagreements, let alone find realistic ways to resolve them – then we cannot avoid doing philosophy in this sense. This gives the lie to the much-touted opinion that philosophical questions have nothing to do with ‘real life’ 1. While it is of course possible to declare oneself too busy, too practical, too scientific or even too ethical to do philosophy 3-8, one does not thereby succeed in thinking without the assistance of any conceptual framework or background assumptions – rather one simply assumes a framework that one fails to defend or even adequately articulate 9, 10. Whether motivated by arrogance, intellectual laziness or some other moral or epistemic vice, there is nothing pragmatic – in any worthwhile sense of this term – about such a mentality. One is no less an inhabitant of the real world for being prepared to explain and justify oneself to its other inhabitants, even when doing so necessitates engaging with problems to which there is no ready-made solution, nor even a single, universally recognized method for finding the right solution 9, 11. The need for philosophy indicates, simply, that we have not reached the end of intellectual history 11-13. Whether or not it is possible for any human society to reach a point when all of the really important, fundamental questions about life and practice have been definitively resolved, an honest evaluation of our current understanding of the world and our place within it suggests that we, certainly, have not yet reached that point. As such, we need to be prepared continually to re-evaluate our underlying assumptions when making pronouncements upon matters of substantive import. A culture that eschews the open discussion of underlying questions of this sort is prone to dogmatism and intellectual stagnation 14, 15. It should not surprise the thoughtful person that the evolution of the human intellect did not reach its final conclusion at just the point when she appeared on the scene 12, and this fact presents us with an exciting opportunity. Just as we owe what insights we currently enjoy to the extensive ‘labours of our ancestors’ on whose ‘shoulders’ we stand 13, so we have the opportunity to continue that evolution, to contribute to the process of criticism and analysis in the pursuit of intellectual progress – to provide a platform upon which our descendants may stand when making further progress. Since its inception, the Journal of Evaluation in Clinical Practice (JECP) has cultivated the rigorous, incisive analysis of topics crucial to progress in medicine, including the nature of evidence and its relationship with clinical judgement, where necessary challenging the prevailing wisdom of the time and always reminding us that the major questions in these areas are by no means settled 16-26. It has produced two thematic editions devoted explicitly to philosophy in medicine and health care 1, 2 and in this, the third philosophy thematic, we present a thorough, comprehensive collection of original, penetrating articles on the nature of clinical reasoning, examining in detail a broad range of associated problems, concepts and relationships 27-60. These include the nature and status of medical knowledge; how we assess and apply research evidence; the role of intuition, tacit knowledge and perception in clinical reasoning; our understanding of causality, cognition, critical thinking, theory, data and inference; the role of normative judgements and the relationship between reasoning and value. Authors debate foundational questions about the basis for medical practice, the role of models in medical epistemology, the relevance of patient autonomy in rational decision making and the applications of concepts derived from biomedical theory and practice to psychiatric diagnosis. A particular concern is education and how to cultivate and sustain the right sort of dispositions in practitioners. Insights from virtue epistemology (presenting dispositional analyses of cognitive concepts) and historical epidemiology are used to cast light on our understanding of reasoning in practice. Discussion of such questions leads us finally to a series of debates about the nature of the inquiry itself, of the relationship between reasoning in medicine and the insights and methodologies of a number of academic disciplines – including the approaches of phenomenology, epistemology and ethics. The collection includes the products of a series of interdisciplinary workshops that addressed underlying questions about the reality of illness, identity, harm and value itself. These essays indicate the breadth of the topic considered in this issue, and invite us to challenge some of the traditional boundaries (for instance, between epistemology and ethics) that inform standard philosophical approaches to the problems of medical practice. Is clinical reasoning a manifestation of cognitive ability, logical analysis skills, interpretive sensitivity or narrative sensibility? Is it an amalgam of all of the above interspersed with the use of statistics and probability? These are important questions that begin to find answers in the papers of this volume. 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