Making Medical Knowledge by Miriam Solomon (review)

Robin Downie has distinguished between two enduring cognitive and practical attitudes that have determined the way that doctors and societies thought about medicine (Downie 2012). The Hippocratic tradition attached its faith to empirical observation and rational induction and deduction, while the Asklepian approach was holistic, intuitive and strongly spiritual. Hippocrates sought to generalize from individual observations, to generate rules and guidelines from pooled experience. Asklepian physicians believed that cure lay in understanding the personal experience of each patient, and in providing an ambience of healing centered on temples and sacred ground. Hippocratic medicine emphasized the empirical imperative for medicine’s epistemology. The Asklepian tradition stressed the humanistic and hermeneutic components of healing.

These two strands have repeatedly parted and intertwined since we have records of medicine as a discipline. And it still happens, as Miriam Solomon vividly reminds us in her recent book Making Medical Knowledge. Solomon sets the tone of her analysis early when she writes “Since the 1960s . . . [End Page E-10] the imprecise, messy, and non-logical (such as analogical and narrative) characteristics of all scientific methods, have been much better appreciated, at least by philosophers of science and others working in science studies” (3). She goes on to examine four discourses that have developed in 20^th and 21^st century medicine as modes of justifying epistemic activities in medical thought and practice—consensus conferences; evidence-based medicine; translational medicine; and what she calls ‘narrative medicine,’ which includes all the humanistic practices such as patient-centred medicine, person-centred medicine, mindful practice, values-based medicine, and so on. Her premise is that each of these discourses has something obvious about it and something odd. Consensus medicine is rational in the social epistemic sense, but not in a pragmatic sense because it seems unlikely that 20 experts can reach agreement on the ‘right’ answer in a few days. Evidence based medicine is eminently logical, but is restrained in its acceptance of what counts as ‘good’ evidence. Translational medicine is conventional in encouraging trial and error and allowing causal reasoning, unconventional because it plays down the centrality of controlled clinical trials. Narrative medicine is obviously good where it promotes sensitive interpretation of individual patient stories, odd because its main usefulness comes from making generalisations from the stories.

Solomon has written widely on social epistemology in the past, and she reviews very thoroughly the history of consensus conferences. (The review extends to 80 pages of 229 pages of text. Some may find this disproportionately long and detailed.) The data she provides is thorough, and reflects her long interest in consensus. Conferences can be held to address technical or “interface” issues, the latter referring to recommendations for practice. She distinguishes between an NIH model and a Danish model, where the Danish model includes non-experts on the panel, but she points to the general shortcomings of any consensus model. Time constraints, shortfalls in evidence, compromises that have to be negotiated, and the lack of imperative attached to the issued statements and guidelines have all meant that impacts on practice have been relatively small.

Solomon makes two further important points about consensus conferences. First, the bodies responsible for organising and running them have been disbanded in the US and some European countries. Second, they still happen, even without government endorsement. Meetings of experts are still convened when controversial matters arise—such as the value of screening for prostate cancer or for breast cancer between the [End Page E-11] ages of 40 and 49 years. Debate about these screening procedures still persists. So while consensus-seeking still goes on, it becomes clearer that the conferences are not good at resolving the really difficult issues, in which beliefs, values, and interpretations clash over the interpretation and meaning of evidence. How does one reach consensus when one party claims that a single life saved by screening makes the program worthwhile, while the other says that the financial and human costs of false positives make the program unsustainable? Solomon points out that consensus conferences may help to standardize medical practices, but may also simply highlight...