E A M RICA

American Medical Association

Physicians dedicated to the health of America

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 616dc22 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 Philosophers Foreword by Robert Ennis, PhD . . . . . . . . . . . . . . . . . . . xiii Physicians Foreword by Suzanne Fletcher, MD . . . . . . . . . . . . . . . . . . . xv A Word From the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Readers 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

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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 Toulmins 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

CONTENTS

3.8

Conclusions: Implications of Logic for Medicine. . . . . . . . . . . . . 89

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

CHAPTER 4

Critical Thinking in a Nutshell

What Is Critical and What Is Not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 4.1 4.2 Definition of Critical Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . 101 A Checklist for Critical Thinking. . . . . . . . . . . . . . . . . . . . . . . . . 109
4.2.1 4.2.2 Problem identification and analysis: Whats 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

4.2.3 4.2.4 4.2.5 4.2.6 4.2.7

4.3

Practical Example of Critical Thinking to Solve a Health Problem: The Challenge of Complementary and Alternative Medicine (CAM) . . . . . . . . . . . . . . . . . . . . . . . . 118
4.3.1 4.3.2 4.3.3 4.3.4 4.3.5 4.3.6 4.3.7 4.3.8 4.3.9 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

4.3.10 Alternative methods of evaluating CAM claims 4.3.11 Summary remarks about CAM 133 4.3.12 Complementary and alternative medicine in medical education and practice 134

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4.4

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 5.1 5.2 Classification and Structure of Medical Articles. . . . . . . . . . . . . 150 Causes and Their Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
5.2.1 5.2.2 5.2.3 Historical milestones 153 154 Contributions of present generations

How a cause-effect relationship is demonstrated or refuted 157

5.3

Medical Articles as Arguments . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

5.3.1 5.3.2 Warrants for conclusions of a causal relationship 162 Arguments at the core of Discussion and Conclusions sections of medical articles 163

5.4 5.5

Fallacies in Causal Reasoning and Argument . . . . . . . . . . . . . . . 167 Conclusions and Remedies to Consider . . . . . . . . . . . . . . . . . . . 172

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
CHAPTER 6

Logic and Critical Thinking in a Clinicians Daily Practice: Talking and Listening to Colleagues and Patients
Am I Clear Enough? Youve Got It Right! . . . . . . . . . . . . . . . . . . . . . . . . . . 179 6.1 6.2 Patient Logic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Physician Logic and Reasoning . . . . . . . . . . . . . . . . . . . . . . . . . . 185
6.2.1 6.2.2 6.2.3 6.2.4 Building up the history of the case and making a clinical examination 186 Making a diagnosis Treatment 196 199 187

Prognosis and risk assessment

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6.2.5

Making decisions about a particular patient in a particular setting: phronesis in medicine? 202

6.3

Logic in Communication with Patients. . . . . . . . . . . . . . . . . . . . 206

6.3.1 6.3.2 Understanding patients statements and reasoning 207 Assessment and diagnosis of psychiatric patients 208

6.4

Logic in Communication with Peers . . . . . . . . . . . . . . . . . . . . . . 210

6.4.1 6.4.2 Verbal communication: rounds and consults Written communication: Hospital and office charts and reports 215 210

6.5

Conclusions: Logic in Communication with the Outside World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
CHAPTER 7

Communicating with the Outside World

Are We on the Same Wavelength? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 7.1 7.2 Our Points of Contact in the Community . . . . . . . . . . . . . . . . . 227 Physicians in Courts of Law: Their Contributions to Decision-making in Tort Litigation . . . . . . . . . . . . . . . . . . . . . . . 229
7.2.1 7.2.2 7.2.3 7.2.4 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

7.3 7.4 7.5

Argumentation About Cases Before Worker Compensation Boards and Other Civic Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . 241 Dealing with Health Problems in the Media and on the Political or Entertainment Stage . . . . . . . . . . . . . . . . . . . . . . 242 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

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, and applications of philosophy Architecture and building blocks of a classical categorical syllogism Toulmins modern layout of arguments and its six components: theoretical model Toulmins 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, suicide attempts and suicide Venns and Eulers 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, one true premise, deductively valid inference, true conclusion: a false premise does not necessarily mean a false conclusion One false premise, one true premise, deductively invalid inference, true conclusion: a false premise combined with an invalid inference does not necessarily mean a false conclusion True premises, deductively invalid inference, true conclusion: deductive invalidity with true premises does not necessarily mean a false conclusion False premises, deductively invalid inference, true conclusion: even an argument with everything wrong with it can have a true conclusion True premises, deductively valid inference, true conclusion: when the premises are all true and the inference deductively valid, the conclusion must be true Toulmins 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

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ILLUSTRATIONS

Figure 5-2

Toulmins 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) Toulmins 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) Toulmins 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, achlorhydria, and gastric ulcer to stomach cancer Toulmins modern layout of arguments and its six components: theoretical model Toulmins modern layout of arguments and its six components (clinical example: coronary artery disease management in invasive cardiology) Toulmins 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, experience, context, medical evaluation, patient values, 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, clinical practice, and communication with outside world Deduction, induction, 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

ILLUSTRATIONS

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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, knowledge, and experience in various settings of argumentation Criminality and causality: parallels between reasoning in criminal law and reasoning in medical research

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. Although all critical thinking dispositions, abilities, and principles apply in a large number of areas, including medicine, 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. Jenicek and Hitchcock are to be congratulated for this pioneering detailed work. As someone who has specialized for over 50 years in the nature and assessment of critical thinking, as the author of a general critical thinking textbook and coauthor of several critical thinking tests, and also as a medical consumer, I am strongly attracted by several features of this book:
1. its emphasis on seeking all the relevant justified obtainable information, and the inevitably concomitant need for alertness for alternative hypotheses, explanations, points of view, and interpretations; 2. its attention to the importance of, but also the problems and criteria involved in, securing expert opinion (the credibility of sources); 3. its attention to some contexts that are usually ignored in critical thinking books, such as the legal context (in which physicians might be testifying or challenged, as in connection with worker compensation boards), the context of consultation with medical consumers like myself, the context of challenge to their approach to the field (that is, the challenge to what they call evidence-based medicine by complementary and alternative medicine), and the context of communicating with the outside world in electronic and printed media; 4. its attention to the complexities of the concept of causation; and 5. the glossary at the end and the amazingly large number of citations of useful sources. In providing these features, as well as many others, Drs Jenicek and Hitchcock have set a standard that people in other fields, as well as the field of medicine, will have to strive to meet. I urge them to try. As critical thinking becomes more widely dispersed and exemplified (by physicians among others) in a variety of human activities, the more likely it is that, like a developing snowball, critical thinking will be employed and exemplified, making it more likely that our decisions about what to believe and do will be justified. That will include physicians decisions, which are the focus of this interesting book by Drs Jenicek and Hitchcock, and which are very important to each of us, including physicians.
Robert H. Ennis, PhD Professor Emeritus of Educational Policy Studies University of Illinois, Urbana-Champaign President, Association for Informal Logic and Critical Thinking, 20012005 May 2004

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PHYSICIANS FOREWORD
Few professions depend on thinking as much as modern medicine does. Medicine has long been described as an art based on science. With the advancements in the last half of the 20th century, many would argue the scientific base of medicine is increasingly important. It is impossible to be scientifically based without thinking; as the science of medicine grows, so does the need to think clearly. More and more medical interventions are based on medical researchresearch that requires at least some ability to discern validity. As diagnostic tests and treatments multiply, clinicians and patients must choose the best course to follow from an ever-expanding list of possibilities. Good patient care requires careful and rational consideration of the alternatives. For medical students entering the profession, at times medical thinking must seem comprised almost entirely of memorization. In truth, the science of medicine depends not so much on the ability to memorize (especially now with computers), as the ability to think logically. Pre-medical requirements in biology, chemistry, physics, and mathematics all are supposed to provide future physicians a foundation in scientific and logical thinking. Ironically, medical schools do not require a pre-medical course in philosophy, particularly its branches of logic and epistemology. Neither I nor most physicians I know have ever taken such a course. So, our understanding of the relationship of logic in medicine to logic and epistemology in philosophy is hazy at best. We understand even less the philosophical concepts of techne (relating to the skills and art of a practitioner, in this case, a health care provider) and phronesis in medicine (combining art and science to make decisions in the care of the individual patient). What we need is a textbook, one that lays out the fundamental concepts of logic in the field of philosophy, gives us a brief overview of the development of logic in human history, introduces us to its language, and demonstrates how logic is and is not used in medicine. We now have such a textbook in Jenicek and Hitchcocks Evidence-Based Practice: Logic and Critical Thinking in Medicine. With their succinct text, clinicians, as well as medical researchers and health planners, can understand better the worlds of critical thinking and evidence-based medicine and how they relate to classic philosophical thought. Readers learn how traditional activities of patient care and medical research intersect with logical thinking. They also see how medicines approach to logic has contributed to philosophy, especially its concept of cause, with the development of ways to avoid bias in medical observations, the hierarchy of strength of evidence, and understanding of the role of chance. Finally, readers learn how medicines logic is not always the same as that used by the rest of the world, especially in the legal profession, where the definitions of probability and cause are quite different from those in medicine. This book provides a unique introduction to those who would enjoy discovering the history and concepts of logic as it relates to medicine. 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
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logic. Perhaps it is understandable that few physicians spend much time thinking about such a fundamental medical activity as thinking. Perhaps, too, it is time to change. Logic is as important to physicians as water is to fishit surrounds us all and we swim in it every day.
Suzanne W. Fletcher, MD, MSc Professor of Ambulatory Care and Prevention Harvard Medical School and Harvard Pilgrim Medical Care March 2004

Feel smart! Be smart!

Science in medicine means questions, observations, measurement, analysis, and explanations.

Philosophy in medicine means thinking about medical thinking.

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.

If useful evidence in medicine is an egg yolk and the logical use of it is the white of the egg, this book is a scrambled egg made mostly of egg white. (The dieters will appreciate that!)

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A WORD FROM THE AUTHORS

Writing comes more easily if you have something to say. Sholem Asch, 1955

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

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patient, conducting research, handling health programs and policies in a community setting, interacting with society and the law, and, enhancing our own understanding as health professionals of whats going on and what to do. The shaded sections of the text are meant to draw readers attention to basic and important definitions when they appear for the first time in the text, key concepts, steps and stages of work to be followed, checklists to bear in mind, important conclusions, pitfalls to avoid, and recommendations for practice. The Readers Bookshelf, which appears at the end of this preface, is for beginners. It is intended to attract readers to additional readings without discouraging them by the complexity of the recommended references. We included encyclopedias and dictionaries where beginners usually start, 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. In fact, we do not want this book to produce some future full-fledged logicians in health sciences. Instead, 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, when reading and listening to medical information, or in conducting research, whether it is fundamental or oriented to bedside decision-making). Philosophy today may indeed be practical and down to earth! One of our graduate students, an outstanding pediatric intensive care specialist, said at the end of his course, . . . I dont know if Ive got everything, but boy, I feel smart! We wish the same and more for all our readers. In many parts of the world, there is no space outside clinical epidemiology for teaching critical thinking, as outlined in this book, to medical and other health sciences students. 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. 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, their converging trend might best be introduced by listing some important references published on both sides of the academic barrier. Some of them are quoted at the end of this message and used in greater detail in the chapters that follow. Joseph Wood Krutch once said teasingly that logic is the art of going wrong with confidence. His sting was even applied to evidence-based medicine, seen by Michael ODonnell as perpetuating other peoples mistakes instead of your own. 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. Some areas that have not been sufficiently tested are also quoted in this reading, such as fuzzy logic or chaos theory. 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.

A WORD FROM THE AUTHORS

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

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WORD FROM THE AUTHORS

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

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xxiii

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

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READERS BOOKSHELF

20. Fisher A. Critical Thinking. An Introduction. Cambridge, England: Cambridge University Press; 2001. 21. Govier, T. A Practical Study of Argument. 5th ed. Belmont, Calif: Wadsworth; 2001. 22. Bowell T, Kemp G. Critical Thinking. A Concise Guide. London, England and New York, NY: Routledge; 2002. 23. Copi IM, Cohen C. Introduction to Logic. 11th ed. Upper Saddle River, NJ: Prentice-Hall; 2002.

Encyclopedias and Dictionaries of Philosophy

1. Hughes GE, Wang H, Roscher N. The History and Kinds of Logic. In: McHenry R, ed. The New Encyclopaedia Britannica: Macropaedia/Knowledge In Depth. Vol 23. Chicago, Ill: Encyclopaedia Britannica, Inc; 1992:226282. 2. Blackburn S. Oxford Dictionary of Philosophy. Oxford, England and New York, NY: Oxford University Press; 1994. 3. Honderich T, ed. The Oxford Companion to Philosophy. Oxford, England and New York, NY: Oxford University Press; 1995. 4. Audi R, ed. The Cambridge Dictionary of Philosophy. 2nd ed. Cambridge, England: Cambridge University Press; 1999. 5. Bullock A, Trombley S, eds. The New Fontana Dictionary of Modern Thought. 3rd ed. London, England: HarperCollins Publishers; 1999. 6. Reese WL. Dictionary of Philosophy and Religion: Eastern and Western Thought. Expanded ed. Amherst, NY: Humanity Books; 1999. 7. Crofton I, ed. Instant Reference Philosophy. London, England: Hodder Headline; 2000. 8. Craig E, ed. Concise Routledge Encyclopedia of Philosophy. London, England and New York, NY: Routledge; 1999. 9. Martin RM. The Philosophers Dictionary. 3rd ed. Peterborough, Ontario: Broadview Press; 2002. 10. Bunge M. Philosophical Dictionary. Enlarged ed. Amherst, NY: Prometheus Books; 2003.

Books in Epidemiology and Medicine Related to Philosophy, Logic, Reasoning, and Critical Thinking
1. Feinstein AR. Clinical Judgment. St. Louis, Mo: CV Mosby; 1967. 2. Susser M. Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology. New York, NY: Oxford University Press; 1973. 3. Murphy EA. The Logic of Medicine. Baltimore, Md: The Johns Hopkins University Press; 1976.

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4. King LS. Medical Thinking: A Historical Preface. Princeton, NY: Princeton University Press; 1982. 5. Cutler P Problem Solving in Clinical Medicine: From Data to Diagnosis. 2nd ed. . Baltimore, Md: Williams & Wilkins; 1985. 6. Wulff HR, Pedersen SA, Rosenberg R. Philosophy of Medicine: An Introduction. Oxford, England: Blackwell Scientific Publications; 1986. 7. Albert DA, Munson R, Resnik MD. Reasoning in Medicine: An Introduction to Clinical Inference. Baltimore, Md: The Johns Hopkins University Press; 1988. 8. C Buck, A Llopis, E Najera, M Terris, eds. The Challenge of Epidemiology: Issues and Selected Readings. PAHO Scientific Publication No. 505. Washington, DC: Pan American Health Organization; 1988. 9. Rothman KJ, ed. Causal Inference. Chestnut Hill, Mass: Epidemiology Resources Inc; 1988. 10. Elwood JM. Causal Relationships in Medicine. Oxford, England: Oxford University Press; 1988. 11. Evans AS. Causation and Disease: A Chronological Journey. New York, NY: Plenum; 1993. 12. Phillips CI, ed. Logic in Medicine. London, England: BMJ Publishing Group; 1995. 13. Jenicek M. Epidemiology: The Logic of Modern Medicine. Montreal, Canada: EPIMED International; 1995. 14. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. EvidenceBased Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone; 2000. 15. Last JM, ed. A Dictionary of Epidemiology. 4th ed. Oxford, England and New York, NY: Oxford University Press; 2001. 16. Guyatt G, Rennie D, eds. Users Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice. Chicago, Ill: AMA Press; 2002. 17. Jenicek M. Foundations of Evidence-Based Medicine. New York, NY: Parthenon Publishing/CRC Press; 2003.

Other Professions and Domains

1. Gambrill E. Critical Thinking in Clinical Practice: Improving Accuracy of Judgment and Decisions About Clients. San Francisco, Calif: Jossey-Bass; 1990. 2. Aldisert RJ. Logic for Lawyers: A Guide to Clear Logical Thinking. 3rd ed. Notre Dame, Ind: National Institute for Trial Advocacy; 1997. 3. Waller RJ. Critical Thinking: Consider the Verdict. Englewood Cliffs, NJ: Prentice-Hall; 1988.

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

CHAPTER 1

From Philosophy to Logic, From Logic to Medicine: Fundamental Definitions and Objectives of This Book
IN THIS CHAPTER
1.1 1.2 1.3 1.4 1.5 1.6 Why Are Logic and Critical Thinking Needed in Medical 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 Can We Find Practical Applications and Practical Uses of Philosophy, Logic, and Critical Thinking and Their Expected Benefits? 17

In these days, we should be proclaiming the fact that uniformity and dull conformity are a crime against intelligence and are indeed the sad abortion of creation. 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, it is imperative that a place be found for philosophy and its business of inquiring into the meaning of things.
EARLE P SCARLETT, 1972 .

Philosophy is not a theory but an activity.

LUDWIG WITTGENSTEIN, 1922

Here is the beginning of philosophy: a recognition of the conflicts between men, a search for their cause, a condemnation of mere opinion . . . and the discovery of a standard of judgment.
EPICTETUS, CA FIRST CENTURY AD

Science is what you know, philosophy is what you dont know.

BERTRAND RUSSELL, 1959

The separation of philosophy as a discipline can seem to be an artefact of academic administration, rather than a reflexion of a clear division between using a concept and thinking about it.
SIMON BLACKBURN, 1996

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This book should help you reason logically and think critically in medicine and
other health sciences. But where does critical thinking belong, what is needed to think critically, how and where should we apply critical thinking, and what can we expect as the result of such an application? In this chapter, we discover through clinical and other scenarios the importance of logic and critical thinking in medical reasoning, in understanding health problems, and in making correct decisions about clinical cases and situations. We see how logic and critical thinking are as relevant to medicine as epidemiology or biostatistics. The remainder of Part One presents some basic notions, methods, and techniques of logic and critical thinking for readers who wish to learn more about this field. Those who have already mastered and understand these concepts will find practical applications in Part Two.

1.1 WHY ARE LOGIC AND CRITICAL THINKING NEEDED IN OUR PRACTICE, RESEARCH, AND COMMUNICATION? WHY READ THIS BOOK?
To answer these questions, let us first consider the following scenarios.

Scenario 1: Communicating with your patient In your practice, you see a sixty-year-old woman who has recently experienced fresh rectal bleeding. During this patients colonoscopy, the surgeon finds a cancerouslooking lesion. This is confirmed by the pathologist through an exploratory biopsy analysis. Together with the surgeon, you suggest to this patient the surgical removal of her lesion by colon resection and adjuvant chemotherapy, if needed. This patient is a highly intelligent and experienced businesswoman. She wants answers to several questions: How sure are you about your diagnosis? If you perform this surgery, how successful will it be? How would I specifically benefit from it? Are there any other alternatives to treat my problem? Will my prognosis, life expectancy, and quality of life improve? What about the chemotherapy? Ive heard so much about its terrible side effects! Answers to any of these queries do not only involve knowledge of evidence, results of clinical trials, or clinical outcomes. The answers also involve a logical discourse (argument) with the patient, to whom we must explain all of our considerations and decisions in plain, understandable terms. If you say, You are a good candidate for this treatment because your age, other characteristics, and your general medical history are comparable to those of the patients who participated in clinical trials proving the effectiveness of surgery/chemotherapy intervention, you base your recommendation on an argument by analogy. In past trials, the recommended intervention was effective for patients with a specified condition and specified characteristics. You have this condition and those characteristics. Hence (on

PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS

the basis of such premises), the recommended intervention will likely be effective for you (conclusion). All of our answers to any of the previously mentioned questions must be logically sound. Knowledge and experience are not enough.

Scenario 2: Communicating with your peers As a psychiatry resident, you discuss with your colleagues at morning floor rounds a patient you admitted overnight. The patients relatives, who brought him to the hospital emergency department, reported that he had attempted suicide earlier that day. You might be asked, Besides the suicide attempt and the patients withdrawal, are there any other findings and considerations that led you to admit this patient? Given the patients history and your clinical evaluation and findings, 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, where, and under what care? Again, answers to all of these questions are conclusions of a logical discourse in a medical setting based on general and specific experience, knowledge, and evidence. Scenario 3: Defending a health program in community medicine and public health As a specialist in community medicine and as a public health officer, you have been informed by your epidemiologist about the high occurrence of home accidents and ensuing injuries in school-age children in your community, as seen in the emergency services of your regional hospitals. You may ask yourself, 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, your experience, knowledge, epidemiological evidence, 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. What injury prevention and medical care program, if any, 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, experience from other comparable programs here and elsewhere, and an understanding of the epidemiology of injury. It requires an understanding of how all of these components fit together. A good logical argument is needed to solve the problem and questions raised. Scenario 4: Medicine and health in the courtscommunicating with and convincing men and women of law As a physician and epidemiologist specializing in environmental medicine and occupational health, you are invited to be an expert witness. In a class action, a group of citizens blame a new type of home insulation for respiratory and allergy

CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK

problems. The defendants 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. 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, 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.

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. 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 ones 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. Having good evidence about the health value of the local drinking water or foods is fundamental. What is equally important is how you will use this evidence to arrive at your conclusions and convince your listeners. Scenario 6: Writing a research article As an academic physician specializing in internal medicine, 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. The design of your trial was impeccable and all rules required by clinical epidemiology and biostatistics were respected. 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.
All six of these scenarios show the equal importance of the best evidence available and its uses in an ideally impeccable process of thought. The communication of good evidence and of the ensuing conclusions and recommendations (in other words, 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. Through the eyes of such scenarios, one might draw the following general picture of medical thought.

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1.2 MEDICINE AS ART AND SCIENCE

Medicine as both art and science is seen as evidence-based.1 Careful observations are made. A sense is given to these observations in terms of diagnosis or prognosis. Causes are studied and identified in terms of risk and prognostic factors. Effective treatment is chosen and its beneficial or adverse effects are determined. This process is fact-driven; new findings are sought and used. This process also is evidence-generating and evidence-driven. Another important aspect of evidence in medicine is how the evidence is used in the process of medical reasoning. Patients may be harmed because their diagnosis and treatment are based on poor evidence. They may also be harmed because the evidence, good or bad, is used inadequately. Hence, patients may benefit from good uses of good evidence, or they may be harmed by poor evidence or poor uses of evidence, good or bad. 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. They must be. You are intelligent enough to figure it out is not sufficient to avoid harm. Neither is a memorized volume of information about health and disease. Philosophy and its branchesin particular, logic and epistemology, which are the roots of critical thinkingare as vital for the good use of evidence as genetics, microbiology, physics, chemistry, biostatistics, and epidemiology are necessary for the production of evidence. Medicine is
the art and science of diagnosis, treatment, and prevention of disease, and the maintenance of good health.2 We add: in the care of individual patients and communities as well.

The art of medicine includes

sensory skills, and the systematic application of such skills and of knowledge in language, speech, reasoning, and motion, in order to obtain desired results.

The skills may be based on or reflect creative imagination, faithful imitation, innovation, or intuition. They bring gratification to the senses. We tend to consider skills that are hard to define and quantify as part of the art (and not the science) of medicine. Things like serendipity or flair are thought to fall into the category of either you have it or you dont. Other skills such as memory, listening to the patient, advising the patient, empathy, insight, equipoise, conceptualization, observation, and inference are thought to be learned and/or improved by experience, according to the motto, you will learn it somehow as you go along; just watch me! Acquiring such expertise through experience is an essential part of becoming a good physician (or an expert of any other kind). These skills cannot be taught based only on rules. Having said this, one of the authors of this book had in his past experience at the Montreal General Hospital an extraordinary teacher of

CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK

surgery who when working with patients, held a nonstop monologue describing what he was doing and why as an overview of debatable rules. One of his residents paid him the ultimate compliment by saying to us, Yes, he is a teacher! Should these skills be learned more systematically, as surgeons already do with sensory and manual skills? For the moment, it seems that our training in the scientific aspects of medicine is better structured, better defined, and more uniform across the profession than is our training in the art of medicine. In recent writings about the nature of medicine, some authors have proposed a third aspect that amalgamates both art and science. In terms of classical Aristotelian philosophy, the science of medicine is a kind of episteme, scientific, deductive knowledge. The art of medicine is a technea craft or productive skill of the practitioner. Making decisions in clinical practice requires adaptation of both episteme and techne to particular, ever-changing circumstances. Some authors have proposed naming the skill of adapting medical science and art to particular circumstances medical phronesis. (We return to this concept in Chapter 6.) Paralleling this to music, episteme would mean writing and reading sheets of music, knowing notes, harmony, and so on. Techne would mean the technical mastery of a musical instrument. For Tyreman,3 phronesis would mean musicianship: playing a sheet of music (using ones knowledge or episteme to read the score) on a musical instrument (using ones acquired techne), and conveying the soul of the music, whether to a gathering of family or friends, at a concert hall, or in a nightclub or stadium, is a phronetic endeavor. Phronesis, in this sense, plays an important role in the application of evidence to particular patients as a part of evidence-based medicine, or EBM. (See Chapter 6.) Science in general is
the study of the material universe or physical reality in order to understand it.4

The science of medicine involves the

discovery, creation, evaluation, and application of new evidence and the evaluation of the impact of its practical uses.

Psychiatry also includes in such uses of evidence how the patients mental functioning corresponds to physical reality in its broadest sense. Historically, medicine went through four stages: from prevailing belief to increasing shared experience, then to understanding, and finally to organized reasoning, evaluation, and decision-making as we know it today. Philosophy applies to this fourth and last stage.

1.3 PHILOSOPHY IN MEDICINE OR PHILOSOPHY OF M EDICINE ?

Philosophy is
the study of fundamental questions, that is, questions about concepts (What is health?) and principles (What fundamental ethical norms should govern medical practice?).

10

PART 1 ~ T HEO RY AND M ETHODOLOGICAL F OUNDATIONS

Among the topics philosophy studies are being, reality, thinking, perception, values, causes, principles of physical phenomena, and ethical principles.5 Four fundamental branches of philosophy are metaphysics, epistemology, logic, and ethics. Metaphysics involves exploring the nature of being and reality, epistemology studies knowledge, logic studies valid inference, and ethics studies values and conduct. Philosophy also has numerous fields of application: language, science (hence medicine), history, religion, politics, work, business, finances, military arts (war and peace) among others. Many of us have a fading memory, from high school or college, of philosophy as a dry and abstract discipline. As we see in this book, however, our mastery of its applications and uses in practical problem-solving and decision-making are vital, be it in medicine or elsewhere in the health sciences, and far more practical than we may think at first glance. Figure 1-1 illustrates the components and domains of philosophy in medicine and society. The main branches of philosophy address the following basic questions:

FIGURE 1-1

Branches, trends, 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

CHAPTER 1 ~ F UNDAMENTAL D EFINITIONS AND O BJECTIVES OF THIS B OOK

11

What is there? (Ontology and metaphysics.) How can we know? (Epistemology.) What follows? (Logic.) What are we to do? What is good, and what is bad? (Ethics.) These questions, and the answers to them, have a profound impact on decisionmaking, decisions themselves, and actions in various fields of human endeavor. From one endeavor to another, the magnitude of contribution of various branches of philosophy may vary. We may expect a lot of logic in the philosophy of science or the philosophy of economics, a lot of metaphysics in the philosophy of religion, and a lot of ethics in medical ethics. Some turning points in the recent evolution and history of philosophy have important implications for medicine, such as the principle of verifiability of causeeffect relationships by experience as advanced in logical positivism by the Vienna Circle; increasingly flexible views of argumentation; expansions of the classical Aristotelian model of reasoning and argument; chaos theory; and fuzzy logic vs traditional yes-or-no thinking. Physicians such as Murphy6 and Wulff et al7 see philosophy in medicine as a formal inquiry into the structure of medical thought. More precisely, from our perspective, philosophy in medicine means
the uses and application of philosophy to health, disease, and medical care. It is an activity whose aim is to study the general principles and ideas that lie behind our views, understanding, and decisions about health, disease, and care. Its objective is not a new or old finding (science follows this objective), but the understanding of the concepts and principles used to interpret phenomena that surround us and that concern us. Philosophically understanding our views of the physical world and of physical phenomena helps improve our biological understanding of health, disease, and care.

In other words, philosophy in medicine not only examines our daily ways of doing things and making decisions. It also examines the methods used by medicine to formulate hypotheses and directions on the basis of evidence, as well as the grounds on which claims about patients and health problems may be justified. For Schaffner and Engelhart Jr,8 the philosophy of medicine is a kind of philosophy . . . encompassing those issues in epistemology, axiology, logic, methodology and metaphysics generated by or related to medicine. Issues have frequently focused on the nature of the practice of medicine, on concepts of health and disease, and on understanding the kind of knowledge that physicians employ in diagnosing and treating patients. As we can see, their definition encompasses both philosophy of medicine (philosophical consideration of the nature of medicines own additional contribution to philosophy in general, such as clinical trials as proof of cause-effect relationships) and philosophy in medicine (uses and applications of philosophy regarding various problems in medicine). Across the medical literature, philosophy is scattered among various topics mainly covered by biostatisticians, epidemiologists, and a few clinicians. The latter shared their interest in these matters with real philosophers, logicians, and critical thinkers. In Philosophy of Medicine: An Introduction, Wulff et al7 make connections between various branches of philosophy and topics in medicine; in Reasoning in

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Medicine: An Introduction to Clinical Inference, Albert et al9 focus essentially on clinical inference. In other terms, philosophy in medicine explores the methods used by medicine, the ways in which hypotheses and decision rules and decisions themselves are formulated from evidence, and the grounds on which medical claims about a health problem and its handling are justified. A career philosopher is increasingly becoming a kind of vital and valuable partner to health professionals,10 as biostatisticians, economists, engineers, sociologists, economists, managers, and other specialists are already. Traditionally, since the times of the Hippocratic oath, most philosophy in medicine was devoted to medical ethics, which focuses by definition on the values of health, disease, and care, and on the morality of our actions, behavior, and conduct. Surprisingly, the Journal of Medical Philosophy is devoted almost exclusively to medical ethics. We deal here instead with the less developed and less structured domain of medical thinking itself. A neophyte may feel overwhelmed and puzzled by many terms: thinking, reasoning, logic, critical thinking, and others. Do these terms mean the same thing or not? They do not. Each term has its own significance and consequently its own raison dtre. In clinical research and epidemiology, we are almost obsessed by definitions, not only conceptual ones (What is hypertension?) but also operational ones (What values [eg, blood pressure] separate normalcy from a disease on which the clinician must act, make a more profound diagnostic workup, or prescribe a conservative or radical treatment plan?). Let us devote our attention similarly to some basic, mostly conceptual definitions in the realm of philosophy in medicine, as we do in epidemiology, biostatistics, clinical pharmacology, psychiatry, medical sociology, and elsewhere. What is logic? What is critical thinking? What is reasoning? Defining these concepts will help further explain the topics of this book. For whatever reason, many readers may not find this information in their basic training. 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. The practical importance of philosophy in medicine is much greater than one might expect. Pellegrino11,12 stresses the difference and complementarity of philosophy in medicine, philosophy of medicine, philosophy and medicine, and medical philosophy. Currently all of these terms are used across the medical literature. 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.

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.

Philosophy and medicine remain totally independent disciplines. A philosopher may use empirical data from fundamental and clinical microbiology to advance the conceptualization of body-environment reaction and adaptation. A physician will

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13

use the tools of formal and informal logic to elaborate a system of diagnosis, treatment decision analysis, and action prescription in the form of clinical algorithms. Consequently, this book is about philosophy and medicine, in particular about both logic and critical thinking and medicine.

1.4 PHILOSOPHY OF SCIENCE, SCIENTIFIC METHOD, EVIDENCE, AND EVIDENCE-BASED MEDICINE

Is there some relationship between philosophy of science, scientific method, and evidence? Definitely! Philosophy of science means the systematic study13(see also 27) of the inner workings and functioning of science, and the extent of its ability to gain access to the truth about the material world, and such concepts of scientific inquiry as laws of nature, causality, probability, and explanation. 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. Evidence in medicine means
. . . any data or information, whether solid or weak, obtained through experience, observational research, or experimental work (trials). 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, therapeutic, or care-oriented) made about the case. . . .1

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Evidence is not automatically correct, complete, satisfactory, or useful. It must be evaluated, graded, and used according to its own merit. What then is EBM? Three closely related definitions of EBM have been formulated: The process of systematically finding, appraising, and using contemporaneous research findings as the basis of clinical decisions.14 The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.15 The integration of the best research evidence with clinical expertise and patient values.16 In this sense, it is also applied closely to evidence-based public health.17-19 The steps for the practice of EBM closely reflect the above-mentioned scientific method as well as the steps of formulating, implementing, and evaluating any health program. 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, experience, and practice and with the patients values and preferences (integrated uses of evidence) Using the evidence in clinical care to solve the patients 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, science is here to produce high-quality evidence. Philosophy should contribute to its soundness, logical acceptability, and good use by fitting it into the correct way of thought. Philosophy has a much broader appeal for medicine than logic or ethics. Table 1-1 illustrates essential steps in EBM and some relevant domains of philosophy at each step. Logic is relevant at each EBM step (with epistemology, among others, helping us understand what is involved in the production of evidence), hermeneutics is relevant to understanding the patient, and ethics is relevant to the use of evidence. In addition to the application of classical domains of philosophy to medicine, some authors recently attempted to see certain medical activities as a reflection of

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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, hermeneutics, semiology Logic, epistemology, philosophy of science Logic, hermeneutics, epistemology Logic, phronesis, ethics

other, still controversial trends such as hermeneutics,20-22 which are for them the art of interpretation in its broadest sense or semiotics23,24 as the study of interpretation of signs or phronesis,3 which might be seen in medical terms as the best possible use of evidence in particular, concrete, and specific situations, patients, conditions, and settings. We can expect further development and evaluation of these recent views in the medical literature. Evidence-based medicine must make sense! To follow the objectives of EBM, medical science uses what philosophers call an object languagespeaking directly about clinical (bedside) and paraclinical (laboratory) observations. Philosophy in medicine uses a sort of metalanguage by focusing its attention on the meaning of what the object language provides. 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) salada statement in an object language. 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. We still dont always know or agree on meanings in the world of medical communication. Whereas the science of medicine bases its theories, understanding, and actions wholly on established facts, philosophy deals with conceptual issues and issues of principle that arise even where the facts have not been firmly established. In addition, philosophy also covers other areas of inquiry, where entirely satisfactory facts are not available.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.

1.5 THINKING, LOGIC, REASONING, AND CRITICAL THINKING

Good medicine not only relies on good evidence but also on how evidence is interpreted, understood, and used. How is evidence integrated within our reasoning,

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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, the meaning of the terms thinking, logic, reasoning, and critical thinking may seem obvious. Let us, however, make explicit their distinct meaning and their relationship. Thinking is a mental action, which, if verbalized, is a matter of combining words in propositions. For example, the premises and conclusion of a logical argument are propositions. Definition making has its proper rules,27 which are not always easy to follow. The more definitions we have of a given subject, the more we are uncertain about its exact context and demarcations. In fact, the term logic means different things to different people,28-30 and definitions of logic abound. 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 basic principles of reasoning developed by and applicable to any field of knowledge; the logic of science.31 Logic is not the science of belief, but the science of proof, or evidence (John Stuart Mill).32 Logic then, is
. . .a normative discipline, one that lays down standards of correct reasoning to which we ought to adhere if we want to reason successfully.29

Logic focuses, as we will see in more detail in the next two chapters, on the strengths and weaknesses of arguments and on how arguments are linked in their drive to the conclusion that should result from them. Logic as applied to medicine is then
. . .a system of thought and reasoning that governs understanding and decisions in clinical and community care. It defines valid reasoning, which helps us understand the meaning of medical phenomena and justifies clinical and paraclinical decisions on how to act in response to such phenomena.1

Reasoning itself is
. . .thinking directed towards reaching a conclusion. The reasons from which it begins are called premises; what they lead to and support is called the conclusion. . . .28

Ideally, reasoning is thinking enlightened by logic. . . .29

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Correct reasoning is
the result of applying logical principles to particular cases. . . .29

Fueled by satisfactory evidence, it produces knowledge. Common knowledge may be defined as

shared knowledge between individuals.

For example, the realm of common knowledge in medicine includes, among others, human anatomy, allergy, human genetics, and intensive care. Understanding common knowledge is one of the fundamental conditions of effective communication and consequent action (care) in medicine. Good decisions in practice and research require an organized combination of all the above, brought by modern philosophers under the umbrella of critical thinking. Hence, critical thinking means a broader framework that integrates and synthesizes all the above. Critical thinking was best defined by Ennis33 as
reasonable reflective thinking that is focused on deciding what to believe or do.

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, not for our personal intellectual satisfaction, but for the full benefit of the patient and the community. Sounds too theoretical? Our first overview of basic definitions is more familiar to arts and pure science than to the health sciences. 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.

1.6 WHERE IN MEDICINE MAY WE FIND PRACTICAL APPLICATIONS AND PRACTICAL USES OF PHILOSOPHY, LOGIC, 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. Medical practice and research also rely heavily on logic and critical thinking:1 In our research papers, discussion of our findings relies not only on the hard evidence of the findings themselves, but more importantly on their critical analysis and sound interpretation. So do our recommendations.

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

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confusion of the scientific and philosophical aspects of the mindbody problem, declining interest in a rigorously phenomenological discipline of psychopathology, virtual elimination of detailed idiographic or single-case studies, and insufficient attention to the interface of psychiatric theory and practice with sociopolitical and economic forces.36 Harper37 considers the use of philosophy in medicine as a kind of philosophical climbing frame, which makes better doctors. It . . . allows us to step out from underneath into a position where we have a better perspective. . . . 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, the ascent of which might be useful, interesting, or both. As we may now understand better, this book is not about EBM itself, but about how we see, read, interpret, use, and evaluate evidence in a larger context. Or rather, how we should do so. First, let us consider (in Chapters 2 and 3) some general remarks about logic, good reasoning, and good argument. Then (in Chapter 4), 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. This general background will enable us to apply principles of good reasoning and good argument to reading and writing research reports (Chapter 5), to clinical practice (Chapter 6), and to our interactions with the outside world (Chapter 7). Before moving any further, some readers may feel that they would benefit from a succinct background text about philosophy today. Popkin and Strolls Philosophy Made Simple38 is a good introduction for curious onlookers, including those in the health sciences.

References
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6. Murphy EA. The Logic of Medicine. 2nd ed. Baltimore, Md: The Johns Hopkins University Press; 1997. 7. Wulff HR, Pedersen SA, Rosenberg R. Philosophy of Medicine: An Introduction. Oxford, England: Blackwell Publishing; 1986. 8. Schaffner KF, Engelhardt HT Jr. Philosophy of medicine. In: Conscise Routledge Encyclopedia of Philosophy. London, England: Routledge; 2000:552. 9. Albert DA, Munson R, Resnik MD. Reasoning in Medicine: An Introduction to Clinical Inference. Baltimore, Md: The Johns Hopkins University Press; 1988. 10. Kamm FM. The philosopher as insider and outsider. J Med Philos. 1990;11:347374. 11. Pellegrino ED. Philosophy of medicine: towards a definition. J Med Philos. 1986;11:916. 12. Pellegrino ED. What the philosophy of medicine is. Theor Med Bioeth. 1998;19:315336. 13. Helicon Publishing Ltd, ed. Instant Reference: Philosophy. (Teach Yourself Books.) London, England and Lincolnwood, Ill: Hodder Headline PLC and NTC/Contemporary Publishing; 2000. 14. Rosenberg W, Donald A. Evidence-based medicine: an approach to clinical problem solving. BMJ. 1995;310:11221126. 15. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidencebased medicine: what it is and what it isnt. BMJ. 1996;312:7172. 16. Sackett DL, Straus S, Richardson WS, Rosenberg W, Haynes RB. Evidencebased Medicine: How to Practice and Teach EBM. 2nd ed. London, England: Churchill Livingstone; 2000. 17. Jenicek M. Epidemiology, evidence-based medicine, and evidence-based public health. J Epidemiol. 1997;7:187197. 18. Jenicek M, Stachenko S. Evidence-based public health, community medicine, preventive care. Med Sci Monit. 2003;9(2):SR17. 19. Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-based Public Health. Oxford, England: Oxford University Press; 2003. 20. Packer MJ, Addison RB, eds. Entering the Circle: Hermeneutic Investigation in Psychology. Albany, NY: State University of New York Press; 1989. 21. Cooper MW. Is medicine hermeneutics all the way down? Theor Med. 1994;15:149180. 22. Svenaeus F. Hermeneutics of clinical practice: the question of textuality. Theor Med Bioeth. 2000;21:171189. 23. Burnum JF. Medical diagnosis through semiotics. Giving meaning to the sign. Ann Intern Med. 1993;119:939943. 24. Nessa J. About signs and symptoms: can semiotics expand the view of clinical medicine? Theor Med. 1996;17:363377.

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25. The Columbia Encyclopedia [online]. 6th ed. New York, NY: Columbia University Press; 2002. Available at: www.bartleby.com/65. 26. Tonelli MR. The philosophical limits of evidence-based medicine. Acad Med. 1998;73:12341240. 27. Audi R, ed. The Cambridge Dictionary of Philosophy. 2nd ed. Cambridge, England: Cambridge University Press; 1999:213215. 28. Department of Philosophy, University of Guelph. Logic Outline. 7th ed, rev. Guelph, Ontario, Canada: University of Guelph; 2000. 29. Johnson DM. Reasoning and logic. In: Sills DL, ed. International Encyclopedia of Social Sciences. New York, NY: Macmillan Co and The Free Press; 1968:344349. 30. Hughes GE, Wang H, Roscher N. The history and kinds of logic. In: McHenry R, ed. The New Encyclopaedia Britannica: Macropedia/Knowledge in Depth. Vol 23. Chicago, Ill: Encyclopaedia Britannica, Inc; 1992:226282. 31. New Illustrated Websters Dictionary of the English Language. New York, NY: PAMCO Publishing Company; 1992. 32. Cooper DE. World Philosophies: An Historical Introduction. 2nd ed. Oxford, England: Blackwell Publishing; 2003. 33. Ennis RH. Critical Thinking. Upper Saddle River, NJ: Prentice Hall; 1996. 34. Jaspers K. General Psychopathology. Chicago, Ill: University of Chicago Press; 1963. 35. Task Force on DSM-IV and the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press; 2000. 36. Wallace E, Radden J, Sadler JZ. The philosophy of psychiatry: who needs it? J Nerv Ment Dis. 1997;185:6773. 37. Harper CM. Philosophy for physicians. J R Soc Med. 2003;96:4045. 38. Popkin RH, Stroll A. Philosophy Made Simple. 2nd ed, rev. New York, NY: Broadway Books; 2001.