"Doctor Knows Best"

We often consider medical practitioners to be epistemic authorities: “Doctor knows best,” as the saying goes. The place of expert judgment in evidence-based medicine hierarchies, and the crucial role of patient preferences and values in medical decision-making, however, pose problems for making sense of such authority. I argue that there is an account of such medical epistemic authority that does justice to the complexities of the doctor–patient relationship, while maintaining that medical practitioners hold an epistemically privileged position. Such a view can better inform medical practice by clearly illuminating the distinct roles of patients and doctors in decision-making processes.

Dementia and the Boundaries of Secular Personhood

For many, dementia disrupts basic ideas about what it means to be human, raising profound philosophical and theological questions on the nature of personhood. In this article I ask what dementia might reveal about personhood in a “secular age.” I suggest that the ill-fitting relationship between Western bioethics, with its emphasis on autonomy, and dementia throws into relief the boundaries of a secular self, and I tease out the ethical implications of the limits of those boundaries by highlighting a biopolitics of secularism. Lastly, I offer a theological account of dementia that situates dependence as a central feature of the human condition, and enriches a secular biomedical understanding of this neurocognitive disorder.

Interpreting Patient-Reported Outcome Measures

Patient-reported outcome measures (PROMs) are valued in healthcare evaluation for bringing patient perspectives forward, and enabling patient-centered care. The range of evidence permitted by PROMs to measure patients’ quality of life narrowly denies subjective experience. This neglect is rooted in the epistemic assumptions that ground PROMs, and the tension between the standardization (the task of measurement) and the individual and unique circumstances of patients. To counter the resulting methodological shortcomings, this article proposes a hermeutical approach and interpretive phenomenology instead of generic qualitative research methods.

Abject Object Relations and Epistemic Engagement in Clinical Practice

The article engages with medical practice to develop a philosophically informed understanding of epistemic engagement in medicine, and epistemic object relations more broadly. I take point of departure in the clinal encounter and draw on French psychoanalytical theory to develop and expand a taxonomy already proposed by Karin Knorr-Cetina. Doing so, I argue for the addition of an abject type object relation, that is, the encounter with objects that transgress frameworks and disrupt further investigation, hence preventing dynamic engagement and negatively shaping our epistemic pathways. The article is primarily theoretical although partly grounded in qualitative fieldwork.

On the Brink of Disaster

The notions of at-risk and subthreshold conditions are increasingly discussed in psychiatry to describe mild, brief, or otherwise atypical syndromes that fail to meet the criteria for clinical relevance. However, the concept of vulnerability is still underexplored in philosophy of psychiatry. This article discusses psychiatric vulnerability to clarify some conceptual issues about the various factors contributing to vulnerability, the notions of risk and protection, and the idea that there are multiple ways of crossing the threshold to clinical relevance. My goal is to lay the groundwork for a finer-grained discussion on psychiatric vulnerability that reflects the complex nature of mental conditions and illustrates the kind of thinking needed in clinical practice.

Causal Inference, Moral Intuition, and Modeling in a Pandemic

Throughout the Covid-19 pandemic, people have been eager to learn what factors, and especially what public health policies, cause infection rates to wax and wane. But figuring out conclusively what causes what is difficult in complex systems with nonlinear dynamics, such as pandemics. We review some of the challenges that scientists have faced in answering quantitative causal questions during the Covid-19 pandemic, and suggest that these challenges are a reason to augment the moral dimension of conversations about causal inference. We take a lesson from Martha Nussbaum—who cautions us not to think we have just one question on our hands when we have at least two—and apply it to modeling for causal inference in the context of cost-benefit analysis.

Why Race and Ethnicity Are Not Like Other Risk Factors

Since early in the Covid-19 pandemic, there have been wide disparities observed between different US racial groups’ rates of Covid-19 infections and deaths. This challenges physicians and patients to untangle what these race-associated risks mean for an individual patient. I argue that this task of providing individualized risk advice requires physicians to apply two skills: structural competency (an understanding of how societal features affect health, since race-associated risks are the result of social conditions, not innate biological differences) and epistemic humility (being mindful of the limitations of individual knowledge and a habit of working collaboratively to get the knowledge that is needed).

Randomized Controlled Trials in Medical AI A Methodological Critique

Various publications claim that medical AI systems perform as well, or better, than clinical experts.However, there have been very few controlled trials and the quality of existing studies has been calledinto question. There is growing concern that existing studies overestimate the clinical benefits of AIsystems. This has led to calls for more, and higher-quality, randomized controlled trials of medicalAI systems. While this a welcome development, AI RCTs raise novel methodological challenges thathave seen little discussion. We discuss some of the challenges arising in the context of AI RCTs andmake some suggestions for how to meet them.

The trade-off between impartiality and freedom in the 21st Century Cures Act

Randomized controlled trials test new drugs using various debiasing devices to prevent participantsfrom manipulating the trials. But participants often dislike controls, arguing that they impose apaternalist constraint on their legitimate preferences. The 21st Century Cures Act, passed by USCongress in 2016, encourages the Food and Drug Administration to use alternative testing methods,incorporating participants’ preferences, for regulatory purposes. We discuss, from a historicalperspective, the trade-off between trial impartiality and participants’ freedom. We argue that the onlyway out is considering which methods improve upon the performance of conventional trials inkeeping dangerous or inefficacious compounds out of pharmaceutical markets.

On the Meaning of Medical Evidence Hierarchies

Evidence hierarchies are investigative strategies ordered with regard to the claimed strength of evidence. They have been used for a couple of decades in EBM, particularly in assessing evidence for treatment recommendations, but remain controversial. An under-investigated question is what the order in the hierarchy means. Four interpretations are discussed here. The two most credible are “typically stronger” or “ideally stronger.” The well-known GRADE framework seems to assume some “typically stronger” reading. Even if the interpretation of an evidence hierarchy were established, hierarchies are rather unhelpful for the task of evidence aggregation. Specifying the intended order relation may help to sort out disagreements.