On What Evidence? Making the Case in Medical Decision-Making

In the era of evidence-based medicine (EBM), discussions of medical knowledge have largely focused on the role of clinical research, though even the primary architects of EBM have acknowledged that the results of such research should not alone dictate decisions about care for individual patients. The most widely cited definition of EBM states that knowledge from clinical trials must be integrated with a physician's clinical expertise, knowledge of physiology, and understanding of their patient's values. Yet proponents of EBM have provided sparse guidance on how this integration should occur. On What Evidence? aims to solve this "integration problem" by considering how clinicians gain and demonstrate expertise, what kinds of medical knowledge can legitimately be brought to bear, and how knowledge of individual patients should be obtained and evaluated in clinical decision-making. The authors analyze the types of knowledge necessary to provide effective care and examine the medical and philosophical literature on each. Fusing real-life practice and theoretical rigor, On What Evidence? describes and defends a case-based approach to clinical decision-making, one based on a broad and non-hierarchical view of medical epistemology.

1 - A Brief History of Medical Knowledge
2 - Evidence-based medicine
3 - Knowledge of Mechanism and Pathophysiologic Reasoning
4 - Experiential Knowledge
5 - Patient values
6 - Case-based reasoning

Robyn Bluhm is a Professor in the Department of Philosophy and Lyman Briggs College at Michigan State University. She received her Ph.D. in philosophy from Western University in Canada, and remained at Western for a postdoctoral fellowship in psychiatric neuroimaging. Her research examines the relationship between epistemological and ethical issues in medicine and neuroscience. She collaborates with clinicians and with researchers in other disciplines and publishes in a range of disciplinary and interdisciplinary journals. She is a co-editor of The Bloomsbury Companion to Philosophy of Psychiatry as well as of the journal IJFAB: International Journal of Feminist Approaches to Bioethics. Mark Tonelli is Professor of Medicine and Adjunct Professor of Bioethics and Humanities at the University of Washington in Seattle, where he is an academic pulmonary and critical care physician and medical educator. His scholarship has focused on applied medical epistemology, particularly the examination of the strengths and limitations of various kinds of medical knowledge for clinical decision making.