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Logic & Critical Thinking

Logic & Critical Thinking

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E A M RICA

American Medical Association
Physicians dedicated to the health of America

N

MEDICA
LA

SSOCI

EVIDENCE-BASED PRACTICE

LOGIC AND CRITICAL THINKING IN MEDICINE
MILOS JENICEK

DAVID L. HITCHCOCK

ION AT

AMA Press Vice President, Business Products: Anthony J. Frankos Publisher: Michael Desposito Director, Production and Manufacturing: Jean Roberts Senior Acquisitions Editor: Barry Bowlus Developmental Editor: Katharine Dvorak Copy Editor: Kathleen Louden Director, Marketing: J. D. Kinney Marketing Manager: Amy Postlewait Senior Production Coordinator: Rosalyn Carlton Senior Print Coordinator: Ronnie Summers © 2005 by the American Medical Association Printed in the United States of America. All rights reserved. Internet address: www.ama-assn.org No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Additional copies of this book may be ordered by calling 800 621-8335 or from the secure AMA Press Web site at www.amapress.org. Refer to product number OP842204. ISBN 1-57947-626-0 Library of Congress Cataloging-in-Publication Jenicek, Milos, 1935Evidence-based practice : logic and critical thinking in medicine / Milos Jenicek, David L. Hitchcock. p. ; cm. Includes bibliographical references and index. ISBN 1-57947-626-0 1. Evidence-based medicine. 2. Medical logic. 3. Critical thinking. 4. Medicine— Philosophy. [DNLM: 1. Evidence-Based Medicine. WB 102 J51e 2005] I. Hitchcock, David, 1942- II. Title. R723.7.J463 2005 616—dc22 2004007858 The authors, editors, and publisher of this work have checked with sources believed to be reliable in their efforts to ensure that the information presented herein is accurate, complete, and in accordance with the standard practices accepted at the time of publication. However, neither the authors nor the publisher nor any party involved in the creation and publication of this work warrant that the information is in every respect accurate and complete, and they are not responsible for any errors or omissions or for any consequences from application of the information in this book. “Tree Diagram” in Critical Thinking: An Introduction to the Basic Skills by William Hughes. Broadview Press, 2000 (3/e), p. 99. ISBN: 1551112515. Copyright © 2000 William Hughes. Reprinted with permission of Broadview Press. BP87:04-P-032:09/04

CONTENTS
List of Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Philosopher’s Foreword by Robert Ennis, PhD . . . . . . . . . . . . . . . . . . . xiii Physician’s Foreword by Suzanne Fletcher, MD . . . . . . . . . . . . . . . . . . . xv A Word From the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Reader’s Bookshelf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

Part 1 Theory and Methodological Foundations
CHAPTER 1

From Philosophy to Logic, From Logic to Medicine: Fundamental Definitions and Objectives of this Book . . . . . . . . . 3
1.1 Why Are Logic and Critical Thinking Needed in Our Practice, Research, and Communication? Why Read This Book? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Medicine as Art and Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Philosophy in Medicine or Philosophy of Medicine?. . . . . . . . . . . 9 Philosophy of Science, Scientific Method, Evidence, and Evidence-based Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Thinking, Logic, Reasoning, and Critical Thinking . . . . . . . . . . . 15 Where in Medicine May We Find Practical Applications and Practical Uses of Philosophy, Logic, and Critical Thinking and Their Expected Benefits?. . . . . . . . . . . . . . . . . . . . . 17

1.2 1.3 1.4 1.5 1.6

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
CHAPTER 2

Logic in a Nutshell I: Reasoning and Underlying Concepts
What Is Required? Does It Make Sense? . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.1 2.2 2.3 A Brief Historical Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Logic in General and Logic in Medicine . . . . . . . . . . . . . . . . . . . . 26 Reasoning and Arguments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

iii

iv

CONTENTS

2.4

Components and Architecture of Reasoning and Arguments: What Is Required?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.4.1 2.4.2 2.4.3 Classical layout of arguments: premises and conclusions 29 Toulmin’s modern scheme for layout of arguments 31 Reconstructing arguments from the natural language of daily life 36

2.5

Evaluation of Reasoning and Argument: Does It Make Sense? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.5.1 2.5.2 2.5.3 Criteria for good reasoning Sources of justified premises 41 46 49

Criteria for good arguments and good argumentation

2.6

Fallacies: Definition, Classification, and Examples. . . . . . . . . . . . 52
2.6.1 2.6.2 2.6.3 Definition of a fallacy Classification of fallacies Examples of fallacies 55 52 53

2.7

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
CHAPTER 3

Logic in a Nutshell II: Types of Reasoning and Arguments
How Can We Reason and Argue Better? . . . . . . . . . . . . . . . . . . . . . . . . . . 61 3.1 3.2 Deduction, Induction, and Abduction . . . . . . . . . . . . . . . . . . . . . 63 Classical Aristotelian Logic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.2.1 3.2.2 Testing categorical syllogisms by diagramming 70 Syllogisms in everyday communication 76

3.3 3.4 3.5 3.6 3.7

Contemporary Logic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Historical Note on Indian Logic. . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Uncertainty and Probability in Medicine . . . . . . . . . . . . . . . . . . . 79 Chaos Theory in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Fuzzy Sets and Fuzzy Logic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
3.7.1 3.7.2 3.7.3 Distinction between fuzzy logic and fuzzy set theory 83 Paradigm of fuzziness in medicine 84 87 Essentials of fuzzy reasoning in fuzzy logic

. . .7 4. . . . . 93 CHAPTER 4 Critical Thinking in a Nutshell What Is “Critical” and What Is Not? .1 4. .2 Definition of Critical Thinking .9 Identification of the problem Analysis of the problem 120 121 128 125 118 Clarification of meaning: What is CAM? Arguments for CAM interventions Explanations of the popularity of CAM Methods of investigating claims made by CAM proponents 129 Assessment of evidence in CAM studies Cause-effect reasoning in CAM studies Systematic reviews and meta-analyses of CAM research 132 130 131 4. . . . . . 118 4. .6 4. . . . .3. . . . . . .2 4. . . . .3 4. . . . . .2. .12 Complementary and alternative medicine in medical education and practice 134 132 . . . . . .2. 101 A Checklist for Critical Thinking. . . . .5 4. . .5 4.2. .1 4. . . . .3. .3. . . . .2. . . .3. .11 Summary remarks about CAM 133 4. . .3. .3. . . .10 Alternative methods of evaluating CAM claims 4. . 89 References . .8 Conclusions: Implications of Logic for Medicine.2. . . . . . . .3. . . . . .2. .3.8 4.4 4. . . 109 4. 99 4. . .4 4.2 Problem identification and analysis: What’s in focus? 110 Clarification of meaning: What kind of study for what kind of question? What does this mean? 111 Gathering evidence: What basic relevant information can we obtain? 112 Assessing evidence: How good is our basic information? 112 Inferring conclusions: What follows? 114 Other considerations: What else is relevant to the problem? 114 Overall judgment: What is our stand on the problem? 114 4. . . . . .6 4. . .3 Practical Example of Critical Thinking to Solve a Health Problem: The Challenge of Complementary and Alternative Medicine (CAM) . .CONTENTS v 3. . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . .3. . .3. . . . .3 4. . . . .7 4. . . . . . . .3. . . . . . . . . . . . . . . . . . .1 4. . . .2.

. . . . . .3. . . .2. . .2 Warrants for conclusions of a causal relationship 162 Arguments at the core of Discussion and Conclusions sections of medical articles 163 5. . . . . . . . . . . . . 167 Conclusions and Remedies to Consider . . 137 Part 2 Practical Applications CHAPTER 5 Logic in Research: Critical Writing and Reading of Medical Articles What Do These Results Really Prove? How to Write and Read Discussion and Conclusions Sections . 147 5. . . . . . . . . . . 185 6. . . . . .2 6. . 152 5. . . .1 6.2 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . .1 5. . . . . . . . . . . . . . . . . . .3 Medical Articles as Arguments . . . . . . . . . . . .4 5. . . . . . . . . . . . . . . . 161 5. . . . . 179 6. . .5 Fallacies in Causal Reasoning and Argument . . . . .2 Classification and Structure of Medical Articles. . . . . . . . . . . 150 Causes and Their Effects . . . . .2 Patient Logic . .2. . . .3 Historical milestones 153 154 Contributions of present generations How a cause-effect relationship is demonstrated or refuted 157 5. . . . . . . . 135 References . . . . . . . . . .3 6. . . 183 Physician Logic and Reasoning . . . . . . . . . . . . . 175 CHAPTER 6 Logic and Critical Thinking in a Clinician’s Daily Practice: Talking and Listening to Colleagues and Patients Am I Clear Enough? You’ve Got It Right! . . . . . . .vi CONTENTS 4. . . . . . . . . .1 5. . . . . . . . . . . . . . . .2. . . . . . . . . . . .2.2. . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . .1 5. . . . . . . . . . . . . . . 172 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 6.4 Conclusions . . . . . . . . . . . . .4 Building up the history of the case and making a clinical examination 186 Making a diagnosis Treatment 196 199 187 Prognosis and risk assessment . . . .2. . . . . . . . . . . . . .

. . . . .5 Argumentation About Cases Before Worker Compensation Boards and Other Civic Bodies . . . . . . . . . 206 6. . . . . . . . .1 6. . . . . . . . . . . . . . . 241 Dealing with Health Problems in the Media and on the Political or Entertainment Stage . . . . . . . . . . . . . . . . . . . . . . .2. . . . . . . . . . . . . .4. . . . . . . . . . . . . . . . . . . . . . . .5 Conclusions: Logic in Communication with the Outside World . . . . . . . . . . . . . . . . . . .3 Logic in Communication with Patients. . . . . . . . . . . . . . .2 Verbal communication: rounds and consults Written communication: Hospital and office charts and reports 215 210 6. . . . . . . . . . . . .4 7. . . . . . . . . . . . . . . . . 246 References . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . .4 Logic in Communication with Peers .2 Our Points of Contact in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 About the Authors . .1 6. .2 Understanding patients’ statements and reasoning 207 Assessment and diagnosis of psychiatric patients 208 6. . . . . . .4 What to expect when dealing with decision-making legal bodies 230 Cause-effect challenges: General and specific Emergence of clinical guidelines and their role in courts of law 239 Reflective thinking in courts of law 241 231 7. . . . . . 251 Glossary . . . . . . . . . . 219 References . . . . . . . . . .1 7. . . . . . . . . . . . . . 225 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . .1 7. . .3. . . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . .5 Making decisions about a particular patient in a particular setting: phronesis in medicine? 202 6. . . .CONTENTS vii 6. . . . . . . . . . . 219 CHAPTER 7 Communicating with the Outside World Are We on the Same Wavelength? . . . . . . . . . 281 . 227 Physicians in Courts of Law: Their Contributions to Decision-making in Tort Litigation . . .3 7. . . . . . . 279 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Conclusions . . . . . . . . . . . . . . .4. . . . . . . . 229 7. . . . . . . . . . . . . . . . . . .2 7. . . . .2. . . . . . . . . . . . . . .3 7. . . . . . 210 6. . . . . . . . . 246 Concluding Remarks . .3. . . . . . . . . . . . . . . .

true conclusion: a false premise does not necessarily mean a false conclusion One false premise. deductively invalid inference. deductively invalid inference. one true premise. true conclusion: a false premise combined with an invalid inference does not necessarily mean a false conclusion True premises. and applications of philosophy Architecture and building blocks of a classical categorical syllogism Toulmin’s modern layout of arguments and its six components: theoretical model Toulmin’s modern layout of arguments and its six components: practical application Algorithm for evaluation of reasoning Classification of inferences in logic “Architecture” and “building blocks” of a categorical syllogism: clinical example Circle diagram of subtypes of depression in psychiatry Circle diagram of relationships in psychiatry between affective disorders.ILLUSTRATIONS Figures Figure 1-1 Figure 2-1 Figure 2-2 Figure 2-3 Figure 2-4 Figure 3-1 Figure 3-2 Figure 3-3 Figure 3-4 Figure 3-5 Figure 3-6 Figure 3-7 Figure 3-8 Figure 4-1 Figure 4-2 Branches. trends. true conclusion: even an argument with everything wrong with it can have a true conclusion True premises. suicide attempts and suicide Venn’s and Euler’s diagram representation of various relationships between subjects and predicates in categorical statements Testing the validity of categorical syllogisms by using Venn diagrams Testing the validity of categorical syllogisms by using Venn diagrams “Excluded middle” concepts of classical logic vs fuzzy concepts A good argument needs both good evidence and a good inference One false premise. deductively valid inference. true conclusion: when the premises are all true and the inference deductively valid. deductively invalid inference. the conclusion must be true Toulmin’s modern layout of arguments: application to epidemiological research (theoretical framework) Figure 4-3 Figure 4-4 Figure 4-5 Figure 4-6 Figure 5-1 ix . true conclusion: deductive invalidity with true premises does not necessarily mean a false conclusion False premises. deductively valid inference. one true premise.

induction. and communication with outside world Deduction. medical evaluation.x ILLUSTRATIONS Figure 5-2 Toulmin’s modern layout of arguments in epidemiological research: practical example of conclusions about a cause in a study of lung cancer and air pollution (fictitious findings) Toulmin’s modern layout of arguments in epidemiological research: practical example of conclusions about the quantified importance attributed to a possible causal factor of interest (fictitious findings) Toulmin’s modern layout of arguments in epidemiological research: practical example of conclusions about strategies of further research (fictitious findings) Management of coronary artery disease in invasive cardiology: a simplified algorithmic approach to decision-making Circle diagram of diagnostic characteristics relating epigastric pain. experience. and gastric ulcer to stomach cancer Toulmin’s modern layout of arguments and its six components: theoretical model Toulmin’s modern layout of arguments and its six components (clinical example: coronary artery disease management in invasive cardiology) Toulmin’s modern layout of arguments and its six components (public health and community medicine example: surveillance and control of infectious disease in the community) Integrating evidence. and abduction in daily life and medicine Tarka methodological reasoning in Indian philosophy Component skills of critical thinking Attitudinal and dispositional components of a critical thinker Types of items in standardized tests of critical thinking skills Checklists for critical thinking Fundamental prerequisites and assessment criteria of causeeffect relationship Specific causal criteria proposed for some types of disease . and preferences in decision-making in evidencebased medicine Figure 5-3 Figure 5-4 Figure 6-1 Figure 6-2 Figure 6-3 Figure 6-4 Figure 6-5 Figure 6-6 Tables Table 1-1 Table 2-1 Table 2-2 Table 3-1 Table 3-2 Table 4-1 Table 4-2 Table 4-3 Table 4-4 Table 5-1 Table 5-2 Relevance of philosophy to evidence-based medicine Inference indicators (premise indicators and conclusion indicators) in reasoning and arguments in natural language Some fallacies in research. achlorhydria. context. clinical practice. patient values.

ILLUSTRATIONS xi Table 5-3 Table 6-1 Table 7-1 Table 7-2 Discussion section of fictitious medical article in natural language and interpretation in terms of argument building blocks Clinical rounds as dialogue with identification of argument components in physicians’ natural language Reasoning. and experience in various settings of argumentation Criminality and causality: parallels between reasoning in criminal law and reasoning in medical research . knowledge.

As critical thinking becomes more widely dispersed and exemplified (by physicians among others) in a variety of human activities. 3. the glossary at the end and the amazingly large number of citations of useful sources. the challenge to what they call “evidence-based medicine” by “complementary and alternative medicine”). the context of challenge to their approach to the field (that is. and principles apply in a large number of areas. Association for Informal Logic and Critical Thinking. the context of consultation with medical consumers like myself. Robert H. Although all critical thinking dispositions. In providing these features. as well as many others. and which are very important to each of us. and also as a medical consumer. as well as the field of medicine. including physicians.” and the inevitably concomitant need for alertness for alternative hypotheses. Ennis. its attention to the complexities of the concept of causation. 2. its attention to the importance of. securing expert opinion (the credibility of sources). the more likely it is that. but also the problems and criteria involved in.PHILOSOPHER ’S FOREWORD It was with great delight that I learned that Drs Jenicek and Hitchcock were doing a book on logic and critical thinking in medicine. and interpretations. abilities. and the context of communicating with the outside world in electronic and printed media. its attention to some contexts that are usually ignored in critical thinking books. Jenicek and Hitchcock are to be congratulated for this pioneering detailed work. and 5. I am strongly attracted by several features of this book: 1. such as the legal context (in which physicians might be testifying or challenged. its emphasis on seeking “all the relevant justified obtainable information. there are very few detailed attempts to exhibit the explicit application of these general aspects of critical thinking in a field of study or practice. including medicine. That will include physicians’ decisions. As someone who has specialized for over 50 years in the nature and assessment of critical thinking. which are the focus of this interesting book by Drs Jenicek and Hitchcock. as the author of a general critical thinking textbook and coauthor of several critical thinking tests. 4. making it more likely that our decisions about what to believe and do will be justified. points of view. critical thinking will be employed and exemplified. 2001–2005 May 2004 xiii . Urbana-Champaign President. explanations. as in connection with worker compensation boards). will have to strive to meet. I urge them to try. like a developing snowball. Drs Jenicek and Hitchcock have set a standard that people in other fields. PhD Professor Emeritus of Educational Policy Studies University of Illinois.

It is impossible to be scientifically based without thinking. the science of medicine depends not so much on the ability to memorize (especially now with computers). What we need is a textbook. and mathematics all are supposed to provide future physicians a foundation in scientific and logical thinking. especially its concept of cause. and demonstrates how logic is and is not used in medicine. at times medical “thinking” must seem comprised almost entirely of memorization. physics. With their succinct text. Finally. So.PHYSICIAN’S FOREWORD Few professions depend on thinking as much as modern medicine does. a health care provider) and phronesis in medicine (combining art and science to make decisions in the care of the individual patient). They also see how medicine’s approach to logic has contributed to philosophy. the hierarchy of strength of evidence. in this case. particularly its branches of logic and epistemology. medical schools do not require a pre-medical course in philosophy. one that lays out the fundamental concepts of logic in the field of philosophy. as the ability to think logically. Pre-medical requirements in biology. Neither I nor most physicians I know have ever taken such a course. Medicine has long been described as “an art based on science. many would argue the scientific base of medicine is increasingly important. especially in the legal profession.” With the advancements in the last half of the 20th century. can understand better the worlds of “critical thinking” and “evidence-based medicine” and how they relate to classic philosophical thought. clinicians and patients must choose the best course to follow from an ever-expanding list of possibilities. gives us a brief overview of the development of logic in human history. In truth. and understanding of the role of chance. For medical students entering the profession. This book provides a unique introduction to those who would enjoy discovering the history and concepts of logic as it relates to medicine. Good patient care requires careful and rational consideration of the alternatives. so does the need to think clearly. Ironically. We understand even less the philosophical concepts of techne (relating to the skills and art of a practitioner. As diagnostic tests and treatments multiply. chemistry. readers learn how medicine’s logic is not always the same as that used by the rest of the world. clinicians. It combines the perspectives of a physician who has spent decades writing about how to make medicine more rational and a classical philosopher who has spent decades thinking about xv . introduces us to its language. where the definitions of probability and cause are quite different from those in medicine. More and more medical interventions are based on medical research—research that requires at least some ability to discern validity. as the science of medicine grows. with the development of ways to avoid bias in medical observations. as well as medical researchers and health planners. our understanding of the relationship of logic in medicine to logic and epistemology in philosophy is hazy at best. We now have such a textbook in Jenicek and Hitchcock’s Evidence-Based Practice: Logic and Critical Thinking in Medicine. Readers learn how traditional activities of patient care and medical research intersect with logical thinking.

MD. MSc Professor of Ambulatory Care and Prevention Harvard Medical School and Harvard Pilgrim Medical Care March 2004 . Perhaps. too. Fletcher. it is time to change. Suzanne W. Perhaps it is understandable that few physicians spend much time thinking about such a fundamental medical activity as thinking.xvi FOREWORD logic. Logic is as important to physicians as water is to fish—it surrounds us all and we swim in it every day.

analysis. observations. Logic in medicine means correct reasoning in research and practice. Critical thinking in medicine means using logic to understand health problems and make reasonable decisions in patient and community care.Feel smart! Be smart! Science in medicine means questions. Philosophy in medicine means thinking about medical thinking. (The dieters will appreciate that!) xvii . this book is a scrambled egg made mostly of egg white. measurement. If useful evidence in medicine is an egg yolk and the logical use of it is the white of the egg. and explanations.

for better research. In any medical research paper. Training in philosophy is already well anchored in the areas of probability and ethics. This book contains two parts. Mastery and uses of logic and critical thinking are equally important in our daily dealing with health problems and their solutions. for the benefit of the patient. analyze. and experience to produce valuable evidence. He or she may be equally harmed by a logically flawless use of poor or poorly evaluated evidence. and what to retain from the whole message for better practice. These particular aspects of philosophy in medicine not only have an inherent value of “deep thought”. Science in medicine is about producing the evidence. Why? Because our entire professional life is a wide world of arguments. how to teach it. and the presentation of results summarize the scientific aspects of production of evidence. but a textbook that should guide its readers in choosing the objectives of teaching. The second part applies these principles to various fields of medical endeavor: working with the xix . on the most effective treatment and other kinds of intervention. Logic and critical thinking is about rational uses of evidence. on the best or worst prognosis. 1955 Science in medicine provides us with the best possible evidence on human risks. We received from our teachers a remarkable wealth of facts. and on the most rational ways to plan actions and make decisions. and most important. This book is not an essay. —Sholem Asch. They still await an objective explanation and this book intends to prove it. The first part offers the reader some basic and universally anchored principles and methods of logic and critical thinking. on diagnostic methods to use. If the interpretation of the evidence is not logically sound and if the evidence is used uncritically. The discussion and conclusions sections review. the patient may be harmed. Complete and methodologically impeccable evidence about a health problem is not enough to make valid and valuable choices. the introduction (formulation of a problem). They should provide us with a balanced view about our certainties and uncertainties pertaining to a health problem across presented findings and evidence. the material and methods section.A WORD FROM THE AUTHORS Writing comes more easily if you have something to say. and trace the meaning of evidence. what to teach. We need a similar enrichment of the proper uses of such evidence in daily practice and research. but also their practical implications and applications are immediate and essential for effective community and patient health care and for the solution of health problems. “Discussion” and “Conclusions” especially call for the mastery of rational thought and understanding as provided to us by logic and critical thinking. wisdom.

and recommendations for practice. . conducting research. We modestly hope that this outline will justify (and guide) future teachers to include logic and critical thinking in health sciences curricula as fully as other components of evidence-based medicine. In many parts of the world. Instead.xx A WORD FROM THE AUTHORS patient. We intend only to stimulate the curiosity of the reader and go beyond the established routine in this “unfinished symphony” of critical thinking in health sciences. We included encyclopedias and dictionaries where beginners usually start. . The Reader’s Bookshelf. as outlined in this book. when reading and listening to medical information. seen by Michael O’Donnell as perpetuating other people’s mistakes instead of your own. Some of them are quoted at the end of this message and used in greater detail in the chapters that follow. interacting with society and the law. Joseph Wood Krutch once said teasingly that logic is the art of going wrong with confidence. I feel smart!” We wish the same and more for all our readers. to medical and other health sciences students. checklists to bear in mind. said at the end of his course. but boy. there is no space outside clinical epidemiology for teaching critical thinking. an outstanding pediatric intensive care specialist. enhancing our own understanding as health professionals of what’s going on and what to do. pitfalls to avoid. Philosophy today may indeed be practical and down to earth! One of our graduate students. I don’t know if I’ve got everything. steps and stages of work to be followed. whether it is fundamental or oriented to bedside decision-making). handling health programs and policies in a community setting. We cannot disagree with Simon Blackburn that the separation of philosophy as a discipline seems to be an artifact of academic administration rather than the reflection of a clear division between using a concept and thinking about it. Although endeavors in critical thinking have developed rather independently in the arts and sciences and in medicine. or in conducting research. their converging trend might best be introduced by listing some important references published on both sides of the academic barrier. His sting was even applied to evidence-based medicine. The shaded sections of the text are meant to draw reader’s attention to basic and important definitions when they appear for the first time in the text. . important conclusions. It is intended to attract readers to additional readings without discouraging them by the complexity of the recommended references. and. In fact. we want to show the broadest possible array of readers how important it is to be better critical thinkers in their own professions (be it in daily practice. key concepts. Some areas that have not been sufficiently tested are also quoted in this reading. as well as many introductory readings on logic “outside the medical world” and some basic medical readings focusing on reasoning in medical thinking and decision. It is our desire to help the reader feel and understand that logic is the art of going right with confidence with meaningful evidence at hand. is for beginners. which appears at the end of this preface. we do not want this book to produce some future full-fledged logicians in health sciences. such as fuzzy logic or chaos theory. “.

Mrs. Later on. McMaster University). Jeanne Teitelbaum (neurology. As the saying goes. Readers are curious. attention. is an eminent physician. but also for the significant improvements they have made to this book. Nicholas Griffin (McMaster University). Fletcher. Nicole Kinney (Linguamax Services Ltd. We are indebted to all of them not only for their time. Ralph H. How did we do it? MJ conceived the idea and wrote the first draft. Calgary). The reader should be the foremost beneficiary of their contributions. Several experienced academic physicians-practitioners-researchers-teachers offered us invaluable help by assessing medicine itself in this reading. Pinto (University of Windsor). Jacques Cadieux (Université de Montréal’s Audiovisual Centre—infographics) smoothed out the message and made it pleasing for the eye as well as explicit and easy to understand for any inquisitive mind. University of Windsor). energy. Anthony Blair (University of Windsor). and professional with a lifetime of . McGill’s Montreal Neurological Institute and Université de Montréal’s Maisonneuve-Rosemont Hospital). Trudy Govier (independent scholar. DH revised the first draft of the present work. and experience our colleagues provided in critically reading this endeavor and guiding it in the right direction. Weinstein (Montclair State University). Robert H. Karl Weiss (clinical microbiology. and academic administrators and bureaucrats insist on recording properly all endeavors of their flock. Adler (City University of New York). J. Ennis (University of Illinois at Urbana-Champaign). the more “cerebral” of us (DH) chiseled the precision of the written word while the more “visual” in the couple (MJ) worked hard on the artwork (figures) to make our thoughts as explicit as possible in today’s cataract-ridden world of authors and readers as well.—text review) and Mr. attention. In this marriage made in heaven between a health professional and a philosopher. contributing in particular the bulk of the theoretical material in Chapters 2 and 4. This book is a joint project. editorial boards of medical journals wish more and more to have this point specified. and the relevance of this book for teaching: Professors Paul Grof (psychiatry. Johnson (FRSC. Each part of the book went back and forth several times until both authors approved every word. Madhu Natarajan (cardiology. Université de Montréal and Maisonneuve-Rosemont Hospital). and interest. Suzanne W. and Marianne Xhignesse (family medicine and Director of continuing medical education. academic.A WORD FROM THE AUTHORS xxi Curious where we have put our heart and soul (again)? Who has done what in this book? Today. time.” Our final word of thanks goes to our foreword authors. and most of the Glossary. We would like to express our appreciation for the advice. We should of course make clear that we alone are responsible for any faults that remain. and Mark L. “the best way to be noticed is to make mistake(s). One of them. Robert C. University of Ottawa). He started from Chapters 3 and 12 of his Foundations of Evidence-Based Medicine published in 2003 (see the Reader’s Bookshelf). These chapters had been revised extensively before publication in light of comments by DH. University of Sherbrooke). Several prominent logicians and critical thinking specialists of our day looked at the pages that follow: Professors Jonathan E.

If we. Their “medical” and “philosophical” forewords reflect the distinctive character of our book—the bringing together again of medicine and philosophy (logic and critical thinking in particular). The other. So. is the world’s leading authority on the definition of the concept of critical thinking for purposes of education and assessment. Robert H. all those in our care should benefit. Ennis. succeed in infusing critical thinking into theory and practice in health sciences.xxii WORD FROM THE AUTHORS experience in national and international health. Milos Jenicek and David Hitchcock June 2004 . readers and authors alike. is an introduction to logic and critical thinking in health sciences. here then.

Thomas SN. Engel SM. Weston A. 2000. 16. NJ: Prentice-Hall. Calif: Mayfield Publishing Company. 15. 1996. Paul. 18. 1995. Calif: Wadsworth Publishing Company. Popkin RH. Damer TE. 3rd ed. 7. Peterborough. NJ: Prentice-Hall. Englewood Cliffs. Englewood Cliffs. A Guide to Evaluating Information. 2nd ed. 4. New York. 1987. An Introduction to Reasoning. Harrison FR III. 3. 1998. Logic. Ennis RH. With Good Reason. Critical Thinking. Seech Z. NJ: Prentice-Hall. Martin Press. 9. Varzi A. Hitchcock D. 1981. 1983. NY: Macmillan. Toulmin S. Walton DN. NJ: Prentice-Hall. NY: St. Cambridge. Stroll A. 1989. Engel SM. Minn: West Publishing Company. England and New York. 1992. NY: McGraw-Hill. 2nd ed. 1986. Ind: Hackett Publishing Company. Belmont. Moore BN. 1993. New York. Pinto RC. Fallacies: Classical and Contemporary Readings.Ontario: Broadview Press Ltd. The Chain of Logic. eds. Informal Logic. Calif: Wadsworth Publishing Company. 8. Informal Logic. Calif: The Pennsylvania State University Press. 1987. 1963. 1986. New York. 1986. Nolt J. A Rulebook for Arguments. 5. Englewood Cliffs. Philosophy Made Simple. Hughes W. New York: Macmillan. 17. Practical Reasoning in Natural Language. Evaluating Claims and Arguments in Everyday Life. 2. Attacking Faulty Reasoning. Introduction to Informal Fallacies. Rohatyn D. 14. Upper Saddle River. An AVATAR book. Toronto. 2nd ed. Salmon WC. An Introduction to the Basic Skills. . 1987. Rieke R. 2nd ed rev. Schaum’s Outline of Theory and Problems of Logic. 2nd ed. A Made Simple Book. Indianapolis. NY: Cambridge University Press. Critical Thinking. NY: Broadway Books. 11. Michalos AC.. University Park. Hansen HV. NJ: Prentice-Hall. 1984. Critical Thinking. 1986. Practical Reasoning Skills. 1987. Schaum’s Outline Series. 12. 19. Canada: Methuen. 6. Critical Thinking. 2nd ed. Avatar Books of Cambridge. Janik A. A Handbook for Critical Argumentation.READER’S BOOKSHELF xxiii READER ’S BOOKSHELF Following is a health professional-friendly general bibliography by chronological order within each category. 13. Logic in Everyday Life. Englewood Cliffs. Belmont. St. Logic and Rational Thought. Logic and Critical Thinking 1. Palo Alto. 10. Improving Your Reasoning. New York. Copi IM. Parker R.

NY: Routledge. England and New York. Encyclopedias and Dictionaries of Philosophy 1. Feinstein AR. 1999. 3rd ed. Martin RM. Upper Saddle River. Louis. A Concise Guide. 1995. London. 22. Roscher N. ed. A Practical Study of Argument. Copi IM. NY: Prometheus Books. NY: Routledge. 3. 11th ed. Dictionary of Philosophy and Religion: Eastern and Western Thought. Baltimore. 6. Honderich T. Crofton I. England: Cambridge University Press. Amherst. 3. Cambridge. 1992:226–282. Wang H. Reasoning.xxiv READER’S BOOKSHELF 20. Vol 23. Belmont. Books in Epidemiology and Medicine Related to Philosophy. NY: Humanity Books. Critical Thinking. NY: Oxford University Press. T. Introduction to Logic. 1967. Mo: CV Mosby. ed. 10. 2. England: Cambridge University Press. 7. 1976. 21. 5th ed. Cambridge. England: Hodder Headline. NY: Oxford University Press. Expanded ed. NY: Oxford University Press. London. London. Bullock A. 3rd ed. Bunge M. Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology. 2003. 9. Audi R. Clinical Judgment. 2001. The History and Kinds of Logic. 2nd ed. eds. Critical Thinking. Ill: Encyclopaedia Britannica. Peterborough. 2002. NJ: Prentice-Hall. Oxford. St. Fisher A. 1994. The Philosopher’s Dictionary. Chicago. New York. 1999. Oxford Dictionary of Philosophy. Blackburn S. Cohen C. 8. 1999. England and New York. Amherst. Kemp G. Reese WL. 1973. ed. Instant Reference Philosophy. Murphy EA. . England: HarperCollins Publishers. Ontario: Broadview Press. England and New York. and Critical Thinking 1. 23. Oxford. 2000. Inc. ed. England and New York. 4. Bowell T. Trombley S. Concise Routledge Encyclopedia of Philosophy. 5. The New Encyclopaedia Britannica: Macropaedia/Knowledge In Depth. 2. In: McHenry R. Philosophical Dictionary. ed. The Oxford Companion to Philosophy. Calif: Wadsworth. The New Fontana Dictionary of Modern Thought. Govier. Susser M. Md: The Johns Hopkins University Press. 2001. 2002. London. Hughes GE. 1999. The Cambridge Dictionary of Philosophy. An Introduction. Logic. Enlarged ed. Craig E. The Logic of Medicine. 2002.

Jenicek M. Logic for Lawyers: A Guide to Clear Logical Thinking. Albert DA. Gambrill E. 1986. M Terris. England and New York. 1988. 1985. Oxford. Foundations of Evidence-Based Medicine. 1988. Montreal. Logic in Medicine. 505. 13. Baltimore. Medical Thinking: A Historical Preface. England: Blackwell Scientific Publications. 1988. Mass: Epidemiology Resources Inc. Causation and Disease: A Chronological Journey. England: BMJ Publishing Group.READER’S BOOKSHELF xxv 4. 7. E Najera. . 4th ed. Aldisert RJ. ed. Englewood Cliffs. 2nd ed. Md: The Johns Hopkins University Press. The Challenge of Epidemiology: Issues and Selected Readings. Philosophy of Medicine: An Introduction. Haynes RB. NY: Churchill Livingstone. Richardson WS. New York. England: Oxford University Press. Princeton. Resnik MD. 14. 8. Causal Relationships in Medicine. Wulff HR. Calif: Jossey-Bass. 2. Chestnut Hill. Straus SE. NJ: Prentice-Hall. Chicago. 6. 3rd ed. Other Professions and Domains 1. Causal Inference. 10. Rosenberg R. 1997. A Llopis. New York. Guyatt G. Critical Thinking in Clinical Practice: Improving Accuracy of Judgment and Decisions About Clients. Jenicek M. Pedersen SA. EvidenceBased Medicine: How to Practice and Teach EBM. 1982. eds. Baltimore. 1988. New York. 1995. Users’ Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice. NY: Parthenon Publishing/CRC Press. Oxford. King LS. Last JM. 15. Canada: EPIMED International. 9. . 1988. Ind: National Institute for Trial Advocacy. NY: Plenum. 2003. Reasoning in Medicine: An Introduction to Clinical Inference. Ill: AMA Press. DC: Pan American Health Organization. London. ed. ed. 17. Munson R. Md: Williams & Wilkins. 1995. NY: Princeton University Press. 2nd ed. Cutler P Problem Solving in Clinical Medicine: From Data to Diagnosis. 2002. Rennie D. Epidemiology: The Logic of Modern Medicine. 16. eds. Notre Dame. Waller RJ. Evans AS. C Buck. Phillips CI. San Francisco. NY: Oxford University Press. 1990. Oxford. A Dictionary of Epidemiology. Rothman KJ. PAHO Scientific Publication No. Washington. 5. 3. Critical Thinking: Consider the Verdict. 1993. Elwood JM. 2000. Sackett DL. 2001. Rosenberg W. 11. 12.

Part 1 Theory and Methodological Foundations CHAPTER 1 From Philosophy to Logic. From Logic to Medicine: Fundamental Definitions and Objectives of this Book Logic in a Nutshell I: Reasoning and Underlying Concepts Logic in a Nutshell II: Types of Reasoning and Arguments Critical Thinking in a Nutshell CHAPTER 2 CHAPTER 3 CHAPTER 4 .

and Communication? Why Read This Book? 5 Medicine as Art and Science 8 Philosophy in Medicine or Philosophy of Medicine? 9 Philosophy of Science. Reasoning. and Critical Thinking 15 Where in Medicine Can We Find Practical Applications and Practical Uses of Philosophy. and Evidence-based Medicine 13 Thinking. Logic.3 1.2 1. and Critical Thinking and Their Expected Benefits? 17 3 . From Logic to Medicine: Fundamental Definitions and Objectives of This Book IN THIS CHAPTER 1. Logic.5 1.4 1. Evidence. Scientific Method.6 Why Are Logic and Critical Thinking Needed in Medical Practice.CHAPTER 1 From Philosophy to Logic. Research.1 1.

CA FIRST CENTURY AD Science is what you know. 1996 . Philosophy is not a theory but an activity. it is imperative that a place be found for philosophy and its business of inquiring into the meaning of things. rather than a reflexion of a clear division between using a concept and thinking about it. . LUDWIG WITTGENSTEIN. and the discovery of a standard of judgment. EPICTETUS. a condemnation of mere opinion . EARLE P SCARLETT. we should be proclaiming the fact that uniformity and dull conformity are a crime against intelligence and are indeed the sad abortion of creation. . SIMON BLACKBURN. philosophy is what you don’t know. 1922 Here is the beginning of philosophy: a recognition of the conflicts between men. 1972 . BERTRAND RUSSELL. a search for their cause. 1959 The separation of philosophy as a discipline can seem to be an artefact of academic administration. At a time when science both inside medicine and without is increasingly concerning itself with practical affairs and is ceasing to be related in any way to the fundamental problems of the meaning and purpose of life.In these days.

the surgeon finds a cancerouslooking lesion. The remainder of Part One presents some basic notions. and techniques of logic and critical thinking for readers who wish to learn more about this field. in understanding health problems. methods. life expectancy. and your general medical history are comparable to those of the patients who participated in clinical trials proving the effectiveness of surgery/chemotherapy intervention.1 WHY ARE LOGIC AND CRITICAL THINKING NEEDED IN OUR PRACTICE. RESEARCH. how successful will it be? How would I specifically benefit from it? Are there any other alternatives to treat my problem? Will my prognosis. During this patient’s colonoscopy. understandable terms. you suggest to this patient the surgical removal of her lesion by colon resection and adjuvant chemotherapy. You have this condition and those characteristics. how and where should we apply critical thinking. if needed. Together with the surgeon. we discover through clinical and other scenarios the importance of logic and critical thinking in medical reasoning. you see a sixty-year-old woman who has recently experienced fresh rectal bleeding. AND COMMUNICATION? WHY READ THIS BOOK? To answer these questions. Hence (on . The answers also involve a logical discourse (argument) with the patient. other characteristics. If you say. Scenario 1: Communicating with your patient In your practice. and quality of life improve? What about the chemotherapy? I’ve heard so much about its terrible side effects!” Answers to any of these queries do not only involve knowledge of evidence. 1. But where does critical thinking belong.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 5 This book should help you reason logically and think critically in medicine and other health sciences. what is needed to think critically. or clinical outcomes. to whom we must explain all of our considerations and decisions in plain. the recommended intervention was effective for patients with a specified condition and specified characteristics. “You are a good candidate for this treatment because your age. and in making correct decisions about clinical cases and situations. She wants answers to several questions: “How sure are you about your diagnosis? If you perform this surgery.” you base your recommendation on an argument by analogy. This patient is a highly intelligent and experienced businesswoman. In past trials. results of clinical trials. This is confirmed by the pathologist through an exploratory biopsy analysis. We see how logic and critical thinking are as relevant to medicine as epidemiology or biostatistics. Those who have already mastered and understand these concepts will find practical applications in Part Two. and what can we expect as the result of such an application? In this chapter. let us first consider the following scenarios.

You might be asked. and good gut feeling and intuition are not enough. You must carry through a logical argument to convince all interested parties and stakeholders of the next steps to take. and evidence. “How did the epidemiologist obtain such information? Is this a problem specific to our community and medical services? Do we know its causes? Do we have the resources to implement justifiable prevention programs?” Again. and under what care?” Again. reported that he had attempted suicide earlier that day. you are invited to be an expert witness. “Besides the suicide attempt and the patient’s withdrawal. Knowledge and experience are not enough. Scenario 2: Communicating with your peers As a psychiatry resident. knowledge. In a class action. as seen in the emergency services of your regional hospitals. answers to all of these questions are conclusions of a logical discourse in a medical setting based on general and specific experience. All of our answers to any of the previously mentioned questions must be logically sound. you have been informed by your epidemiologist about the high occurrence of home accidents and ensuing injuries in school-age children in your community. should be implemented in the health services and the community? How should it be evaluated? Would it be cost-effective and cost-efficient? Justifying such a program as a priority and convincing other decision-makers to fund and participate in it requires more than current applicable legislation. if any. are there any other findings and considerations that led you to admit this patient? Given the patient’s history and your clinical evaluation and findings. and an understanding of the epidemiology of injury. You may ask yourself. A good logical argument is needed to solve the problem and questions raised. Scenario 4: Medicine and health in the courts—communicating with and convincing men and women of law As a physician and epidemiologist specializing in environmental medicine and occupational health. the recommended intervention will likely be effective for you (conclusion). Scenario 3: Defending a health program in community medicine and public health As a specialist in community medicine and as a public health officer.6 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS the basis of such premises). knowledge. What injury prevention and medical care program. your experience. a group of citizens blame a new type of home insulation for respiratory and allergy . The patient’s relatives. epidemiological evidence. what is your working diagnosis? What were the risks if you decided not to admit this patient and instead to refer him to outpatient care? What do you suggest we do now with this patient? Should we keep him here or should we discharge him? When. you discuss with your colleagues at morning floor rounds a patient you admitted overnight. who brought him to the hospital emergency department. It requires an understanding of how all of these components fit together. experience from other comparable programs here and elsewhere. where.

Scenario 6: Writing a research article As an academic physician specializing in internal medicine. . Scenario 5: Communicating with crowds You are a well-known family physician in your community and you are invited by a local radio station to talk to its listeners and answer their questions about various health problems that concern them. The communication of good evidence and of the ensuing conclusions and recommendations (in other words. does it apply equally to each of the plaintiffs? A good argument must lead to and contribute to the making of the right decision of the court in this matter. explaining it and having it accepted by your listeners in the clinical and community setting) is a priceless and learned skill making treatment and prevention successful. What is equally important is how you will use this evidence to arrive at your conclusions and convince your listeners. You realize that this new evidence and its uses will be accepted if you conceive your article as a flawless logical argument leading from what you have seen (premises) to your recommendation or rejection of this new drug for this type of patient. The design of your trial was impeccable and all rules required by clinical epidemiology and biostatistics were respected.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 7 problems. The defendant’s lawyer asks you to give your opinion on the following: How well-defined are the reported health problems? What do we know about the exposure? What do we know about the nature of the insulation material and its cause-effect relationship to the reported health problems? What can we conclude about the cause-effect relationship in the case of each individual plaintiff? How can the plaintiffs’ exposure to the insulation material in their homes and workplaces be explained individually and collectively? Answers to all of these questions depend heavily on how “logically” you arrive at your opinion. All six of these scenarios show the equal importance of the best evidence available and its uses in an ideally impeccable process of thought. Was the cause-effect relationship between the exposure to this insulation material and the health of individuals living in the insulated environment established and to what degree? If such convincing evidence exists in general. Having good evidence about the health value of the local drinking water or foods is fundamental. you ran a successful clinical trial to evaluate the effectiveness of a new anti-hypertensive drug designed for patients of an advanced age who have been diagnosed with uncontrolled and extremely high blood pressure. one might draw the following general picture of medical thought. Is the drinking water in the community well treated? Is drinking it a health hazard for a water-borne disease? Will eating organically grown fruits and vegetables improve one’s health? And how risky is it to eat genetically modified foods? All of your recommendations or warnings are conclusions of your reasoning leading from premises to your recommendations. Through the eyes of such scenarios.

speech. A sense is given to these observations in terms of diagnosis or prognosis. you will learn it somehow as you go along. and inference are thought to be learned and/or improved by experience. faithful imitation. one of the authors of this book had in his past experience at the Montreal General Hospital an extraordinary teacher of . The production of good evidence in fundamental research oriented to clinical decision-making as well as its uses through good reasoning and decision-making are learned experiences. and epidemiology are necessary for the production of evidence. empathy. These skills cannot be taught based only on rules. good or bad. patients may benefit from good uses of good evidence. Causes are studied and identified in terms of risk and prognostic factors. logic and epistemology. innovation. Medicine is “the art and science of diagnosis. Effective treatment is chosen and its beneficial or adverse effects are determined. and motion. listening to the patient. They may also be harmed because the evidence. Another important aspect of evidence in medicine is how the evidence is used in the process of medical reasoning. They must be. conceptualization. and the maintenance of good health. new findings are sought and used. or intuition. good or bad. and the systematic application of such skills and of knowledge in language.”1 Careful observations are made. equipoise. biostatistics.8 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS 1. advising the patient. Things like serendipity or flair are thought to fall into the category of either you have it or you don’t. Hence. just watch me! Acquiring such expertise through experience is an essential part of becoming a good physician (or an expert of any other kind). We tend to consider skills that are hard to define and quantify as part of the art (and not the science) of medicine. Having said this. which are the roots of critical thinking—are as vital for the good use of evidence as genetics. This process is fact-driven. Philosophy and its branches—in particular. is used inadequately. “You are intelligent enough to figure it out” is not sufficient to avoid harm. Patients may be harmed because their diagnosis and treatment are based on poor evidence. The art of medicine includes “sensory skills. reasoning. physics. according to the motto.” The skills may be based on or reflect creative imagination. and prevention of disease. insight.2 MEDICINE AS ART AND SCIENCE Medicine as both art and science is seen as “evidence-based. They bring gratification to the senses.”2 We add: in the care of individual patients and communities as well. microbiology. treatment. Other skills such as memory. in order to obtain desired results. This process also is evidence-generating and evidence-driven. observation. Neither is a memorized volume of information about health and disease. or they may be harmed by poor evidence or poor uses of evidence. chemistry.

held a nonstop monologue describing what he was doing and why as an overview of debatable rules. some authors have proposed a third aspect that amalgamates both art and science. as surgeons already do with sensory and manual skills? For the moment. Psychiatry also includes in such uses of evidence how the patient’s mental functioning corresponds to physical reality in its broadest sense. In recent writings about the nature of medicine.) Paralleling this to music. it seems that our training in the scientific aspects of medicine is better structured. Historically. Philosophy applies to this fourth and last stage. then to understanding. scientific. creation. that is. and application of new evidence and the evaluation of the impact of its practical uses. whether to a gathering of family or friends. is a phronetic endeavor. Phronesis. medicine went through four stages: from prevailing belief to increasing shared experience. he is a teacher!” Should these skills be learned more systematically. at a concert hall. the science of medicine is a kind of episteme. harmony. ever-changing circumstances. or EBM. .) Science in general is “the study of the material universe or physical reality in order to understand it. Making decisions in clinical practice requires adaptation of both episteme and techne to particular.3 phronesis would mean musicianship: playing a sheet of music (using one’s knowledge or episteme to read the score) on a musical instrument (using one’s acquired techne).” (We return to this concept in Chapter 6. evaluation. and finally to organized reasoning. knowing notes. and decision-making as we know it today. Techne would mean the technical mastery of a musical instrument. better defined. For Tyreman. The art of medicine is a techne—a craft or productive skill of the practitioner. deductive knowledge. in this sense. evaluation. In terms of classical Aristotelian philosophy. and so on. and conveying the soul of the music. 1. “Yes. plays an important role in the application of evidence to particular patients as a part of evidence-based medicine. Some authors have proposed naming the skill of adapting medical science and art to particular circumstances medical “phronesis. or in a nightclub or stadium.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 9 surgery who when working with patients. (See Chapter 6. questions about concepts (What is health?) and principles (What fundamental ethical norms should govern medical practice?). One of his residents paid him the ultimate compliment by saying to us.”4 The science of medicine involves the discovery. episteme would mean writing and reading sheets of music. and more uniform across the profession than is our training in the art of medicine.3 PHILOSOPHY IN MEDICINE OR PHILOSOPHY OF M EDICINE ? Philosophy is the study of fundamental questions.

finances. Many of us have a fading memory. science (hence medicine). logic. and ethics studies values and conduct. work. trends. Figure 1-1 illustrates the components and domains of philosophy in medicine and society. Metaphysics involves exploring the nature of being and reality. business. and ethics. religion. and applications of philosophy Main Branches Metaphysics and Ontology (being and reality) Epistemology (knowledge) Logic (inference) Ethics (values) Current Trends Semiotics (signs) Hermeneutics (interpretation) Phronesis (practical reasoning) Applications "Philosophy of " Medicine Literature Politics Natural Science Biology Religion Arts Society Law History Psychology Social Science Education Mathematics . of philosophy as a dry and abstract discipline. Philosophy also has numerous fields of application: language. however. and far more practical than we may think at first glance. and ethical principles. principles of physical phenomena. from high school or college.10 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS Among the topics philosophy studies are being. thinking. causes. be it in medicine or elsewhere in the health sciences. As we see in this book. epistemology studies knowledge. reality. epistemology. history. The main branches of philosophy address the following basic questions: FIGURE 1-1 Branches. our mastery of its applications and uses in practical problem-solving and decision-making are vital. perception. values. politics. military arts (war and peace) among others. logic studies valid inference.5 Four fundamental branches of philosophy are metaphysics.

and fuzzy logic vs traditional yes-or-no thinking. expansions of the classical Aristotelian model of reasoning and argument. chaos theory. From one endeavor to another. We may expect a lot of logic in the philosophy of science or the philosophy of economics. logic. For Schaffner and Engelhart Jr. such as the principle of verifiability of causeeffect relationships by experience as advanced in logical positivism by the Vienna Circle. Some turning points in the recent evolution and history of philosophy have important implications for medicine. logicians.) These questions. In other words. epidemiologists. a lot of metaphysics in the philosophy of religion. It is an activity whose aim is to study the general principles and ideas that lie behind our views.” More precisely. Across the medical literature. Physicians such as Murphy6 and Wulff et al7 see philosophy in medicine as “a formal inquiry into the structure of medical thought. and decisions about health. and care. Issues have frequently focused on the nature of the practice of medicine. understanding. and on understanding the kind of knowledge that physicians employ in diagnosing and treating patients. as well as the grounds on which claims about patients and health problems may be justified. decisions themselves. from our perspective. disease. on concepts of health and disease. and actions in various fields of human endeavor. . encompassing those issues in epistemology. philosophy is scattered among various topics mainly covered by biostatisticians. Its objective is not a new or old finding (science follows this objective). methodology and metaphysics generated by or related to medicine. and the answers to them. and a few clinicians. and what is bad? (Ethics. The latter shared their interest in these matters with “real” philosophers. and medical care. It also examines the methods used by medicine to formulate hypotheses and directions on the basis of evidence.8 the philosophy of medicine is a kind of philosophy “. but the understanding of the concepts and principles used to interpret phenomena that surround us and that concern us. and critical thinkers. . the magnitude of contribution of various branches of philosophy may vary. axiology. and a lot of ethics in medical ethics. in Reasoning in . their definition encompasses both philosophy of medicine (philosophical consideration of the nature of medicine’s own additional contribution to philosophy in general.” As we can see. disease. Wulff et al7 make connections between various branches of philosophy and topics in medicine.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 11 What is there? (Ontology and metaphysics. increasingly flexible views of argumentation. In Philosophy of Medicine: An Introduction. and care. have a profound impact on decisionmaking. such as clinical trials as proof of cause-effect relationships) and philosophy in medicine (uses and applications of philosophy regarding various problems in medicine). philosophy in medicine not only examines our daily ways of doing things and making decisions. Philosophically understanding our views of the physical world and of physical phenomena helps improve our biological understanding of health.) What are we to do? What is good.) How can we know? (Epistemology. philosophy in medicine means the uses and application of philosophy to health. disease.) What follows? (Logic.

make a more profound diagnostic workup. the Journal of Medical Philosophy is devoted almost exclusively to medical ethics. A neophyte may feel overwhelmed and puzzled by many terms: thinking. For whatever reason. Do these terms mean the same thing or not? They do not. philosophy and medicine.10 as biostatisticians. as we do in epidemiology. philosophy of medicine. logic. In clinical research and epidemiology. most philosophy in medicine was devoted to medical ethics. and on the morality of our actions. critical thinking. The practical importance of philosophy in medicine is much greater than one might expect. psychiatry. since the times of the Hippocratic oath. economists. blood pressure] separate normalcy from a disease on which the clinician must act. mostly conceptual definitions in the realm of philosophy in medicine. not only conceptual ones (What is hypertension?) but also operational ones (What values [eg. and elsewhere. or prescribe a conservative or radical treatment plan?).” Philosophy of medicine is “a philosophical inquiry into the nature of medicine with a view to elaborating some general theory of medicine and medical activities.12 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS Medicine: An Introduction to Clinical Inference. disease.” Philosophy and medicine remain totally independent disciplines. A career philosopher is increasingly becoming a kind of vital and valuable partner to health professionals. and the grounds on which medical claims about a health problem and its handling are justified. medical sociology. A physician will . Surprisingly. For Pellegrino: Philosophy in medicine means “uses of the formal tools of philosophical inquiry to examine the matter of medicine itself as an object of study. and conduct. Currently all of these terms are used across the medical literature. Pellegrino11. and medical philosophy. reasoning. Traditionally. In other terms. economists. behavior. engineers. managers. Let us devote our attention similarly to some basic. Each term has its own significance and consequently its own raison d’être. Albert et al9 focus essentially on clinical inference. many readers may not find this information in their basic training. sociologists. What is logic? What is critical thinking? What is reasoning? Defining these concepts will help further explain the topics of this book. we are almost obsessed by definitions. which focuses by definition on the values of health. philosophy in medicine explores the methods used by medicine. Many curricula still do not tackle these topics. either directly in an organized manner or as an integrated and integral part of training a physician. biostatistics.12 stresses the difference and complementarity of philosophy in medicine. and other specialists are already. A philosopher may use empirical data from fundamental and clinical microbiology to advance the conceptualization of body-environment reaction and adaptation. and others. and care. the ways in which hypotheses and decision rules and decisions themselves are formulated from evidence. clinical pharmacology. We deal here instead with the less developed and less structured domain of medical thinking itself.

This [sic] data or information must be relevant to some degree (more is better) either to the understanding of the problem (case) or to the clinical decisions (diagnostic. and evidence? Definitely! Philosophy of science means the systematic study13(see also 27) of • the inner workings and functioning of science. Consequently. . SCIENTIFIC METHOD. any data or information. and explanation. .4 PHILOSOPHY OF SCIENCE. treatment decision analysis. in particular about both logic and critical thinking and medicine. scientific method. and action prescription in the form of clinical algorithms. 1.”1 . probability. . obtained through experience. therapeutic. Scientific method includes as important components: • defining the domain and the problem of interest • critical review of the available evidence • formulating a hypothesis • observation and/or experimentation involving data collection and implying some kind of measurement • recording of the findings • analysis and interpretation of the findings using both quantitative and qualitative methods • confirmation or refutation of the hypothesis • generation of a new hypothesis and/or of directions for further inquiry and practice.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 13 use the tools of formal and informal logic to elaborate a system of diagnosis. . EVIDENCE. and • such concepts of scientific inquiry as laws of nature. whether solid or weak. or experimental work (trials). or care-oriented) made about the case. and • the extent of its ability to gain access to the truth about the material world. causality. . observational research. this book is about philosophy and medicine. AND EVIDENCE-BASED MEDICINE Is there some relationship between philosophy of science. Evidence in medicine means “.

It must be evaluated. and used according to its own merit. and evaluating any health program. and judicious use of current best evidence in making decisions about the care of individual patients. satisfactory. experience. hermeneutics is relevant to understanding the patient. Logic is relevant at each EBM step (with epistemology. or useful. science is here to produce high-quality evidence. complete. explicit. Table 1-1 illustrates essential steps in EBM and some relevant domains of philosophy at each step. among others. What then is EBM? Three closely related definitions of EBM have been formulated: • “The process of systematically finding. it is also applied closely to evidence-based public health. These EBM steps are: • Formulating the question concerning the patient that has to be answered (identifying need for evidence) • Searching for the evidence (producing the evidence) • Appraising the evidence (evaluating the evidence) • Selecting the best evidence available for clinical decision-making (using the evidence) • Linking the evidence with clinical knowledge.14 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS “Evidence” is not automatically correct. logical acceptability.”14 • “The conscientious. and ethics is relevant to the use of evidence. and using contemporaneous research findings as the basis of clinical decisions. In addition to the application of classical domains of philosophy to medicine. Philosophy should contribute to its soundness. graded.”16 In this sense. helping us understand what is involved in the production of evidence).”15 • “The integration of the best research evidence with clinical expertise and patient values. implementing. and good use by fitting it into the correct way of thought. Philosophy has a much broader appeal for medicine than logic or ethics. some authors recently attempted to see certain medical activities as a reflection of . appraising. and practice and with the patient’s values and preferences (integrated uses of evidence) • Using the evidence in clinical care to solve the patient’s problem (uses of evidence in specific settings) • Evaluating the effectiveness of the uses of the evidence in this case (weighing the impact) • Teaching and expanding EBM practice and research (going beyond what was already achieved) Hence.17-19 The steps for the practice of EBM closely reflect the above-mentioned scientific method as well as the steps of formulating.

conditions. and used. patients. philosophy also covers other areas of inquiry. and actions wholly on established facts.5 THINKING. “phronesis.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 15 TABLE 1-1 Relevance of philosophy to evidence-based medicine World and cascade of evidence Building ground for evidence (clinical data acquisition) Producing evidence (carrying out medical research) Evaluating evidence (evaluating results of research) Using evidence (putting results of research to use in clinical and community medical practice) Some relevant domains of philosophy Logic. medical science uses what philosophers call an “object language”—speaking directly about clinical (bedside) and paraclinical (laboratory) observations.25 Tonelli26 maintains that EBM should use philosophy to go beyond the empirical evidence at the core of EBM and investigate the complex variation of clinical judgment from one patient to another. where entirely satisfactory facts are not available. hermeneutics. understood.24 as “the study of interpretation of signs” or phronesis. How is evidence integrated within our reasoning. still controversial trends such as hermeneutics.20-22 which are for them “the art of interpretation in its broadest sense” or semiotics23. philosophy deals with conceptual issues and issues of principle that arise even where the facts have not been firmly established.3 which might be seen in medical terms as “the best possible use of evidence in particular. epistemology Logic. In addition. What does this mean? What kind of mental health problem does verbal salad represent? A metalanguage is needed to clarify and find the answer to these questions. Does it accurately reflect the reality it is supposed to describe? A psychiatrist may conclude that his or her patient produces only a “word (or verbal) salad”—a statement in an object language. hermeneutics. understanding. epistemology. Whereas the science of medicine bases its theories. 1. semiology Logic. REASONING. LOGIC. Evidence-based medicine must make sense! To follow the objectives of EBM. . AND CRITICAL THINKING Good medicine not only relies on good evidence but also on how evidence is interpreted. and specific situations.” ethics other. Philosophy in medicine uses a sort of “metalanguage” by focusing its attention on the meaning of what the object language provides.” We can expect further development and evaluation of these recent views in the medical literature. We still don’t always know or agree on meanings in the world of medical communication. philosophy of science Logic. and settings. concrete.

Logic as applied to medicine is then “. the meaning of the terms thinking. • The basic principles of reasoning developed by and applicable to any field of knowledge. what they lead to and support is called the ‘conclusion’. but the science of proof. is “.”29 Logic focuses. For example. if verbalized. one that lays down standards of correct reasoning to which we ought to adhere if we want to reason successfully.”1 Reasoning itself is “. the logic of science. Some of them are worth quoting in our context: • The normative science that investigates the principles of valid reasoning and correct inference.28 dealing either with conclusions that follow necessarily from the reasons or premises (deductive logic) or with conclusions that follow with some degree of probability from the reasons or premises (inductive logic). the term logic means different things to different people. on the strengths and weaknesses of arguments and on how arguments are linked in their drive to the conclusion that should result from them. which. is a matter of combining words in propositions. logic. “reasoning is thinking enlightened by logic. which helps us understand the meaning of medical phenomena and justifies clinical and paraclinical decisions on how to act in response to such phenomena. make explicit their distinct meaning and their relationship. however.thinking directed towards reaching a conclusion. The reasons from which it begins are called ‘premises’. or evidence” (John Stuart Mill). . Definition making has its proper rules. . .32 Logic then. . .28-30 and definitions of logic abound. . .31 • “Logic is not the science of belief.16 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS and how do we convey our conclusions to their intended recipients? How do we think about it? Is what we say logical? Does the path of our reasoning reflect critical thinking? When we ask such questions.a system of thought and reasoning that governs understanding and decisions in clinical and community care. It defines valid reasoning. reasoning. The more definitions we have of a given subject.”29 .”28 Ideally. the more we are uncertain about its exact context and demarcations. and critical thinking may seem obvious.27 which are not always easy to follow. In fact. the premises and conclusion of a logical argument are propositions. . . . as we will see in more detail in the next two chapters. . Thinking is a mental action. .a normative discipline. Let us.

6 WHERE IN MEDICINE MAY WE FIND PRACTICAL APPLICATIONS AND PRACTICAL USES OF PHILOSOPHY.”29 Fueled by satisfactory evidence. . Good decisions in practice and research require an organized combination of all the above. discussion of our findings relies not only on the “hard” evidence of the findings themselves.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 17 Correct reasoning is “the result of applying logical principles to particular cases. brought by modern philosophers under the umbrella of critical thinking. Understanding common knowledge is one of the fundamental conditions of effective communication and consequent action (care) in medicine. . among others. critical thinking means a broader framework that integrates and synthesizes all the above. but more importantly on their critical analysis and sound interpretation. Common knowledge may be defined as shared knowledge between individuals. So do our recommendations. It should help us understand more clearly the practical implications and applications of logic and critical thinking as they will be briefly outlined in the following chapters. . and intensive care. Medical practice and research also rely heavily on logic and critical thinking:1 • In our research papers. the realm of common knowledge in medicine includes. but for the full benefit of the patient and the community. .” Critical thinking in medicine is about ways of deciding and conveying well to others what we believe and what we are doing or intend to do. 1. human genetics. allergy. AND CRITICAL THINKING AND T HEIR E XPECTED B ENEFITS ? The answer is in both medical practice and medical research. Information and skills are not enough. Sounds too theoretical? Our first overview of basic definitions is more familiar to arts and pure science than to the health sciences. it produces knowledge. not for our personal intellectual satisfaction. For example. Critical thinking was best defined by Ennis33 as “reasonable reflective thinking that is focused on deciding what to believe or do. LOGIC. Hence. human anatomy.

medical ethics may play an important and often decisive role. we must convincingly explain our findings. If a physician does not adopt and apply philosophy in a practical manner in medical problem-solving. in critical care. by concerned individuals. • At business meetings on health programs and policies. we must justify health interventions “logically” as well as the commitment of human and material resources to the recommended actions. and in interactions with the “outside world” of non-health professionals. last but not least. in clinical practice. we should be able to muster good arguments for our position. for example.35 . and heuristics (“rules of thumb” for discovery).18 PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS • At scientific gatherings and in medical journals. In the specialty of psychiatry. different domains of philosophy will predominate in different fields of application. In working with patients. but they all want to win the case! We need to be on the lookout for tricky maneuvers. in genetic considerations. we must find common ground with our peers for the clinical evaluation and care of our patients. what do they want to say. we may be very interested in hermeneutics (ie. For example. Not all interested parties necessarily search for absolute truth. • In the clinical management of individual patients in daily hospital and family practice. For Jaspers. often involving stakeholders other than health professionals. in medical research.” • At clinical rounds. In the legal and quasilegal world. our arguments must be understood by not only health professionals but also the broader public.” There is a reason for this. • In litigation and in societal discussions involving occupational and environmental health issues for individual patients and whole communities. Elsewhere (eg. the domain of fallacies in argumentation is important. the Association for the Advancement of Philosophy and Psychiatry points out several important consequences of such neglect: • the naïve empiricism of the most recent entries in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) by the American Psychiatric Association. As expected. and public life that focuses on decision-making carried out by other decisionmakers and. we must “make ourselves understood and understand what the patient means and what he or she wants to say. several difficulties may occur. or in discussions of cloning humans). After two chapters covering some of the basics of logic and one chapter on critical thinking. • At any other forum “outside the hospital or medical office” in civic. what message do they convey?). political.34 “every doctor is a philosopher. we may be predominantly concerned with the best ways of studying and interpreting cause-effect relationships. we devote one chapter each to their applications in writing and reading reports of medical research.

. 2000. Med Health Care Philos.Louis.CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK 19 • confusion of the scientific and philosophical aspects of the mindbody problem. we can consider in a little more detail what critical thinking is and apply the process of critical thinking to the challenge posed to medicine by so-called complementary and alternative medicine. and evaluate evidence in a larger context. allows us to step out from underneath into a position where we have a better perspective. including those in the health sciences. First. Promoting critical thinking in health care: phronesis and criticality. or both.3:117–124. This general background will enable us to apply principles of good reasoning and good argument to reading and writing research reports (Chapter 5). Before moving any further. . . 2. References 1. and to our interactions with the outside world (Chapter 7).” As we may now understand better. interpret. 2003.” which makes better doctors. . but about how we see. 2000. 3. Popkin and Stroll’s Philosophy Made Simple38 is a good introduction for curious onlookers. 2nd ed rev. let us consider (in Chapters 2 and 3) some general remarks about logic. Available at: http://cancerweb.) London. . New York. Philosophy. some readers may feel that they would benefit from a succinct background text about philosophy today. Mosby’s Medical Dictionary. . Ill: Hodder Headline PLC and NTC/Contemporary Publishing. 1987. Then (in Chapter 4). St. It “. this book is not about EBM itself. use. good reasoning. England and Lincolnwood. to clinical practice (Chapter 6). interesting. (Teach Yourself Books. • virtual elimination of detailed idiographic or single-case studies.ncl. Tyreman S. 4. On-line Medical Dictionary. Thompson B. and good argument. NY: The Parthenon Publishing Group. • declining interest in a rigorously phenomenological discipline of psychopathology. read. how we should do so. Foundations of Evidence-Based Medicine.36 Harper37 considers the use of philosophy in medicine as a kind of “philosophical climbing frame. the ascent of which might be useful. Mo: Mosby.ac. Jenicek M.uk/omd. We will also be in a position to look beyond the confines of our own little medical world and see that there are other stockpiles and climbing frames. 5. Or rather. and • insufficient attention to the interface of psychiatric theory and practice with sociopolitical and economic forces.

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