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Reviewed by:
  • Making Medical Knowledge by Miriam Solomon
  • Stefan Timmermans
Miriam Solomon. Making Medical Knowledge. Oxford: Oxford University Press, 2015. xiii + 261 pp. Ill. $60.00 (978-0-19-873261-7).

Clinical medicine has a knowledge problem: specialized medical expertise is the hallmark of the professional authority of health care providers, but observers have demonstrated tremendous variation in the quality of the medical knowledge base. Certain interventions are effective even though no one understands why, while other less effective ones persist in spite of mounting evidence that the harms may outweigh the clinical benefits. Hence, over the past decades medical insiders have pushed new methods of medical knowledge production and consolidation. In this accessible, well-written book, Miriam Solomon reviews four interrelated but largely independent methods of medical knowledge production: the consensus conference, evidence-based medicine, translational medicine, and narrative medicine.

She approaches these methods from the perspective of applied epistemology, which comes down to critically examining the epistemic assumptions guiding the different methods. Her own epistemic logic is inductive: she situates and explains the different methods and evaluates their respective strengths and weaknesses, aiming for “epistemological equipoise” (p. 16). This leads not to an evisceration of the methods but to a charitable understanding of their respective aspirations within existing historical traditions while still pointing out ironies and shortfalls.

Consensus conferences usually consist of a number of experts reviewing the bio-medical literature on a pressing clinical topic. Solomon observes that this tightly orchestrated overture to collective expertise rarely settles ongoing controversies but has more a public relations function to show a united front suggestive of medical objectivity. Its purpose is generating trust and disseminating knowledge among medical ranks. Such consensus conferences, with their emphasis on expert authority, looked increasingly anachronistic when the medical field turned toward evidence-based medicine, and many consensus conferences have been retired, even though collective expertise as a means of producing medical knowledge has reemerged across medicine.

Evidence-based medicine (EBM), with its hierarchy of medical knowledge privileging the double-blind, randomized clinical trial and downplaying expert authority, aims to provide clinicians with objectively sound decision-making recommendations. EBM has accumulated a long list of detractors and supporters. Solomon pays close attention to EBM’s ignoring of biological mechanisms, which she takes not necessarily as a limitation but as an indication that EBM is insufficient as an epistemic foundation of medicine. She also examines the lack of reliability between EBM recommendations and the daily work in clinics, noting the continued need for background knowledge and clinical judgment in actual decision making and the limitations of pharma-sponsored clinical trials.

Translational medicine has been another top priority of health funders, but its imperative to facilitate the move from laboratory bench to patient bedside has been central to scientific medicine for more than a century. Solomon appreciates the rhetorical function of the new term, especially in the aftermath of disappointment with the clinical payoff of the human genome project, and the attention to [End Page 752] infrastructure and new methods, but it is less clear what the concrete manifestations are of translational medicine. Narrative medicine has a stronger identity, although it remains murky as a form of medical knowledge production. In a revival of humanistic ideals, narrative medicine aims to restore patient narratives as an essential component of patient care through listening, empathy, narrative puzzle solving, and meaning making. Solomon notes, however, that narratives may be misleading, formulaic, and fraudulent and mask broader structural problems in health care delivery.

Solomon sees these four methods of medical knowledge production in an uneasy relationship, alternatively complementing or conflicting. “All the methods . . . are indispensable, and all are fallible” (p. 224). Her conclusion of letting all epistemic flowers bloom reflects the limitations of her approach. Applied epistemology is a view from nowhere: neutrally examining knowledge for its strengths and drawbacks. Medicine, however, has picked a side: it promises health and wellness. Medical knowledge matters because it may lead to over-and undertreatment and systematically produce iatrogenic consequences. As a social scientist, I am less concerned with epistemological equipoise than with mapping the collateral damage and benefits of specific forms of knowledge implementation for patients, clinicians, and other stakeholders. Still, I found...

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