9/3/2023 0 Comments Judgment vs judgement![]() Technical Rationality – epistemology of practice Seen from this perspective, reliable personal judgement, experience and expertise appear to be a self-delusion. Concerning therapeutic effectiveness, the doctor seems to be totally dependent on external evidence. Not surprisingly, the classic article on evidence-based medicine restricts clinical expertise to diagnosis and to identification of the patient's perspective, and does not include judgement about the effects of care. This kind of judgement is obviously beyond the capacity of the singular practitioner. Īccordingly, if an individual doctor wants to judge a therapeutic effect, he/she will have to treat many patients with the respective therapy and treat many other patients with a different (or no) therapy and gain a sense of the average outcomes in both groups as well as of their difference – while taking into account spontaneous variations and effects of prognostic factors, adjunctive therapies, context factors, etc. Consequently, even when randomization cannot be set up, clinical epidemiology asks at least for a group comparison. Particularly important in the canon of these paradigms is Hume's seminal position that causality assessment requires repeated observations, and is not possible in single cases. Today's medical methodology is outlined accordingly: the assessment of therapeutic causality is claimed to require an interventional study (=experiment) of a cohort (=many repeated observations), with a control group (=comparison), and with random allocation of patients to the intervention or the control group (=randomization). Mill, 19th Century), randomization (Ronald Fisher, 20th century). The RCT incorporates paradigms of famous philosophers and methodologists who claimed causality assessment to be valid and reliable only on the basis of: experiment (Francis Bacon, 17th Century), many repeated observations (David Hume, 18th Century), comparison (John S. For the assessment of such therapeutic causality, the randomized controlled trial (RCT) has become the gold standard. When judging a treatment outcome, one is basically confronted with the causality question of whether the outcome is causally connected to the treatment manoeuvre. Yet this general discredit of personal judgement was not based on systematic investigations, but on anecdotal examples of naivety and error and on the general low esteem of personal cognition in the times of neopositivist and fallibilist epistemologies. ![]() ![]() ![]() A primary mission therefore became ‘to guard against any use of judgement’, and it was executed through clinical trials. It was presumed that personal judgement would be unable to go beyond a simple post hoc ergo propter hoc, and could at best accomplish something like simple, intuitive, low-quality correlational statistics. With the rise of modern research methodology, however, the fallacious aspects of clinical judgement were increasingly emphasized. Initially, the clinically skilled and scientifically competent doctors and their judgements were the main impetus for treatment decision, therapy assessment and medical progress. The reputation of clinical judgement underwent substantial transformation during the last century. The present article enters into this issue and highlights the interrelations of clinical judgement, therapy assessment, and medical professionalism.Ĭlinical judgement and positivistic therapy assessment They were, however, mainly restricted to the role of clinical judgement in communication, diagnosis and decision making, not taking into consideration its capacities for therapy assessment: its potential competence and validity, its susceptibility to error and bias, and the question of whether it could possibly be optimized and professionalized. However, there are also other views on clinical judgment which disregard it as notoriously fallacious, as an unfathomable and irrational black box: ‘a smokescreen for not having read this week's NEJM or Lancet’.ĭuring recent years, there has been a newly arising interest in this topic, and there has been an array of investigations on clinical judgement. It extends into all medical areas: diagnosis, therapy, communication and decision making. Clinical judgement is developed through practice, experience, knowledge and continuous critical analysis. It lies at the heart of the doctor's connoisseurship, expertise and skills, being ‘almost as important as the technical ability to carry out the procedure itself’. A basis of this profession is clinical judgement. The medical profession is ‘a vocation in which a doctor's knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being’.
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