Intuition in Medicine: A Philosophical Defense of Clinical Reasoning

Braude, Hillel

Primary Category: Literature / Nonfiction

Genre: Treatise

  • Date of entry: Sep-21-2012
  • Last revised: Sep-22-2012

Summary

            Hillel D. Braude, a physician and a philosopher, has written an important, albeit dense and narrowly circumscribed, study. While “Intuition in Medicine” is the main title, the subtitle, “A Philosophical Defense of Clinical Reasoning” is a more accurate description of the book, which originated as a doctoral dissertation.  While some of the prose will appeal only to specialists, there are important and thoughtful analyses of such topics as Evidence-Based Medicine, modern dehumanized medicine, the relation of beneficence and automony, and principalist ethics in general. 

            Throughout, intuition is narrowly conceived and in the service of clinical reasoning, as it applies to standard, Western physicians and not to other healers (or nurses), and the emphasis is on interventive medicine to cure illness and relieve suffering more than on health promotion. 

            Braude writes in the introduction that intuition has long been understood to be “a direct perception of things,” but he resists a more precise definition: “Rather than defining and using a single concept of intuition—philosophical, practical, or neuroscientific—this study examines intuition as it occurs at different levels and in different contexts of clinical reasoning” (xviii).

            Eight chapters explore these different levels in such topics as moral intuitionism, Aristotle’s phronesis (or practical reason), the rise of statistics (a basis for Evidence-Based Medicine), and C. S. Peirce’s notion of abduction. Braude’s careful analysis traces historical and theoretical developments in analytic philosophy and how these may be applied to clinical reasoning.  He uses an impressive range of thinkers: Achenwall, Albert, Allan, Andre, Ashcroft, Aristotle, Bacon, Barrow, Barton, Beauchamp, Bergson, Bernard, Bichat, Black, Bottero, Bourdieu, Brody, Browne—just to take names headed by A or B.  

            Throughout, Braude puts in dialectic two poles on a spectrum arguing that they both have contributions to make. He believes that between them is an “ethical space,” where discoveries and applications can be made, but he clearly favors all the concepts from the lefthand list for medicine. In tabular form, we can list aspects of the two poles:

 

            Medicine                                               Philosophy

Aristotelian practical reasoning                        Kantian abstraction

Naturalist approaches                                    Nonnaturalist approaches

Primacy of beneficence                                  Primacy of autonomy

Fact and value joined                                    Fact and value separated

Case-based                                                 Evidence-Based Medecine

Individual patients                                        Large groups of patients

Narrative experience                                     Statistical correlations

Anthropocentric focus                                    Mechanist, positivist foci

Tacit, organic knowledge (Polanyi)                   Dualism (Descartes)

 

            Braude believes intuition is a cognitive process but has other dimension, the corporeal and the social. While these provide a grounding, intuition for him is generally rational. He also argues for medical care at the personal, face-to-face level, not through applications of algorithms. 

            A brief conclusion, “Medical Ethics beyond Ontology” clarifies some of the arguments and sketches some valuable notions from Husserl and Levinas. He writes “intuition . . . does appear to be fundamental for human judgment” because “an intuition faculty” can “extract universals from the particular” (p. 170).  Drawing on Husserl, he defines phenomenological intuition as “the primary means through which objects are presented to consciousness.” This affirmation includes the basic human, which is also the focus for medicine. For Levinas (and my summary is much too brief), “interhuman solidarity” is a source for medical care, a form of responsibility that is different from Foucaultian power relationships, ethical rules and priniciples, or “an uncritical acceptance of medical authority” (p. 177). 

Commentary

            This is timely, rigorously researched, and carefully presented argument. Braude calls for a “face-to-face” relationship of physician and patient that is, in itself, an ethical relationship. Instead of dehumanized, statistical approaches to medicine, Braude emphasizes personal encounters that include the individual specifics of each patient.

            His rigorous analysis of clinical reasoning allows for critiques of Evidence-Based Medicine and principalist ethics, not to mention industrial-economic models for delivery of medical care.

            As fine a book as this is, it is limited to the areas of analytic philosophy Braude has chosen, and to his procedural (and more or less logical) concept of intuition. It is a book for specialists in philosophy or medical ethics. The prose is dense, for example, “If intuitions do have epistemological validity with respect to clinical decision making then clinical equipoise is open to the ‘therapeutic critique,’ because clinical intuitions would comprise an important element of the fiduciary responsibility of clinicians to patients” (p. 163).

            Indeed the book, taken as a whole, is highly abstract. There is a small handful of welcome examples, one case study, and a description of Francis Galton’s discovery of correlation: “the idea flashed across me” (p. 149), which Braude sees as an example of intuition, but he doesn’t speculate about what faculties of mind and body are involved or how they are integrated. He writes that “intuition is fundamental in bridging the relation between the world and the mind” (p. 5), but his concept of intuition is so closely tied to reasoning that we miss the richness and mystery of, say, Baron von Kekule’s dream of a snake biting its tail that led to the model of the benzene ring. While Braude discusses (and criticizes) E. O. Wilson’s “sanitized” use of the myth of Ariadne, he own argument and evidence are typically logical and rational.             

            Clearly, there is more work to be done on intuition. There is the world of indigenous medicine that often uses what Westerners would call intuition; there are energy healers who have nuanced theories of intentionality and the role of subatomic particles; there are medical intuitives, such as Caroline Myss, who works nationally with Norman Shealy, M.D.; there is the complementary medical world including concepts of harmony from Chinese Traditional Medicine; there is the world of depth psychology, for example, C. G. Jung’s notion of intuition, a basic concept for his thought. 

            I wonder what relavent notions of intution might come from other fields: history, law, music, art, or literature—but that would suggest another, different book. 

Publisher

University of Chicago Press

Place Published

Chicago

Edition

2012

Page Count

232