Epistemic Humility, Justice, and Honesty in Clinical Care

When we sit down to write an article that we plan to submit for publication, it is usually because we have completed some piece of empirical or conceptual work that has led us to conclusions we wish to share with our scholarly communities. In this instance, though, my essay under discussion was itself the means by which I sought to draw some (at least preliminary) conclusions about my recent experiences. Contrary to my initial plans—and my custom—I began writing without a clear idea of where I would wind up. The commentaries, taken as a whole, affirm that my ambivalence about the topic at hand—fully revealed to me while formulating the article—came through, albeit in different ways to different commentators. And just as the process of writing the original piece was crucial to formulating my thoughts, constructing the present response is serving to clarify and expand them. For that I am grateful to the five eminent commentators.

The observations and formulations of several of the commentary authors lead me now to consider three distinct questions, and relations among them:

1. 1. How do we (physicians, philosophers, and the like) conceive of such interventions as craniosacral therapy (CST)—again, used here as an exemplar?

2. 2. How do those who develop, provide, and advocate for such interventions conceive of them?

3. 3. How should such interventions be portrayed to potential candidates for them?

I am motivated to distinguish those questions from one another due to their potential conflation, the problems such a conflation entails, and the lessons to be drawn from comparing their respective answers. Jason Thompson provides a compelling explanation of how the ontological status of the craniosacral rhythm need not (and presumably does not) depend on each of its three constituents (cranium, sacrum, and rhythm) sharing the same kind of "thinghood." Doug Porter urges a revision of the notion of "mechanism" as applied to such complex phenomena as pain relief. And Julian Hughes conceives of "the approach of complementary and alternative medicine" (CAM) as distinct from that of science. And, of course, I agree with them all. Moreover, I'm guessing most readers of this journal largely do as well. So much for question 1.

But what about the second question: How do people who actually perform and recommend CST think about it? While Thompson advises us that its centerpiece, the craniosacral rhythm, "must be the sort of thing that exists in a different way than other known biological rhythms," those at the Cranial Therapy Center in Toronto seem to be in diametric disagreement. As quoted in my target article, their website describes it as being as "measurable and tangible as our breath and heart rate[s]" (Schweitzer, 2009). Porter points out the limits of mechanistic explanations, while the Upledger Institute seems unequivocal in its assertion that, in order to address "changes that often cause body tissues to tighten," "the CST practitioner uses his or her hands to evaluate the craniosacral system by gently feeling various locations of the body to test for the ease of motion and rhythm of the cerebrospinal fluid pulsing around the brain and spinal cord," thereby "releasing restrictions in [relevant] tissues" (Upledger Institute, nd). The fact that the details of a mechanistic account are not provided does not, it seems to me, imply that a distinct form of causal explanation is being invoked.

There is, of course, nothing unusual about different people conceiving of a given phenomenon in different ways. But when matters of epistemic humility, epistemic arrogance, and (as Nancy Potter raises) epistemic justice are at issue, those differences must be identified and examined. Recasting the ontology of the craniosacral rhythm in terms that seem fundamentally at odds with those employed by its "discoverer" and devotees strikes me as analogous to a dispute in the philosophy of psychoanalysis from the 1980s. In his controversial work, The Foundations of Psychoanalysis: A Philosophical Critique, the philosopher of science Adolf Grünbaum (1984) took to task the continental philosophers Jürgen Habermas and Paul Ricoeur for their insistence that the psychoanalytic enterprise represents something other than what its...