In this remarkable book, Gary Wright focuses thirty years’ experience as a family physician, and his Ph.D. in philosophy, to address the nature of good medical reasoning. Wright folds cognitive science into a pragmatist framework developed by John Dewey; this alternative view of mind and medical judgment leads to a model of reasoning that offers realistic guidance for medical decisions, one that each of us would want our own physicians to adopt.
In this remarkable book, Gary Wright brings his thirty years of experience as a physician in pediatric and family medicine together with his Ph.D. in philosophy to address the important problem of the nature of good medical reasoning. His intimate experiential knowledge of the founding assumptions of managed health care in America today is abundantly evident in his powerful critique of the overly simplistic models of medical judgment that ground most of our health programs. Writing with exceptional clarity, heart-felt compassion for the physical and emotional suffering of patients, and deep philosophical insight into the nature of human cognition, Wright uses the conceptual tools of recent cognitive science to analyze and critique some of the most basic underlying conceptions of contemporary medical care. To make it clear why we desperately need a richer, more nuanced account of medical reasoning, Wright gives a brilliant analysis of the complex internal structure of our concepts of health and disease, showing that our present models are wholly incapable of dealing with the realities of actual human disease. He then shows the error of assuming that we always know in advance what the medical and moral ends are for any medical situation. This leads to a radical questioning of so-called "rational actor" or "economic" models of rationality that are popular in medicine today.
However, Wright’s project is not merely critical. More constructively, he draws extensively on empirical research coming out of the cognitive sciences concerning the nature of concepts, reasoning, and judgment, and he then appropriates this research into a broader pragmatist philosophical framework developed by the American philosopher John Dewey. Wright finds in Dewey’s theories of mind, thought, and experience a comprehensive account of human thinking that adequately captures the complexity of actual human conceptualization and reasoning. At the heart of this new view lies an acknowledgment of the central role of imagination and values in all of our thinking. He shows how we actually make sense of our experience by employing cognitive prototypes, metaphorically-defined concepts, radially structured categories, and other processes of imaginative reflection and evaluation. The result of Wright’s alternative view of mind and medical judgment is a practically useful model of medical reasoning that, although not specifiable by a set of fixed rules, can yet give realistic guidance for medical decisions. It is a sensitive model that each of us would want our own physicians to adopt.
Prof. Mark Johnson, Department of Philosophy, University of Oregon
'This is one of the best books I have read that addresses Dewey's method of intelligence in the context of practical, including clinical, decision-making. I loved it.'
Prof. Griffin Trotter, Center for Health Care Ethics, Saint Louis University, USA
Overview: Broad Considerations in the Relation of Means and Ends, Treating and Healing. 1. Cognitive Semantic Structures in Informal Means/Ends Reasoning. a. Formal as Opposed to Informal Approaches to Decision Making. b. Imaginative Structures Used in Informal Clinical Reasoning. c. The Embodied Basis of Valuation. d. Conclusion. 2. Health and Disease: Fluid Concepts Evolved Non-Literally. a. An Overview. b. Why and (Provisionally) How Disease Is a Radial Category. c. Central Members of the Disease Category. d. Non-Central Members of the Disease Category. e. Conclusion. 3. John Dewey’s Perspective on Means and Ends: the Setting which makes Informal Deliberation Necessary. a. Naturalism. b. Antifoundationalism. c. Qualities Unquantifiable. d. Qualities Fully Real. e. Values Interactional, Not Rigidly Compartmental. f. Broad View of Rationality. g. The Importance of Context. h. Conclusion.4. John Dewey’s View of Situations, Problems, Means and Ends. a. Situations. b. Tertiary Qualities. c. Settled and Unsettled Situations. d. Means and Ends. e. The Strengths of Dewey’s Theory, In Summary. f. Problems of Dewey’s Means and Ends Theory. 5. Preference, Utility and Value in Means and Ends Reasoning. a. Introduction. b. General Assumptions of Expected Utility Theory. c. The Axioms of Expected Utility Theory. d. Utility Is Not Fulfillment. Fulfillment Is Not Utility. e. Utility and the Past. f. Reasoning about Ends. g. Conclusion. 6. Full Spectrum Means and Ends Reasoning: its Place in Medicine. First Part: Informal Judgment and the Art of Medicine. a. Judgments. About the Setting. b. Defining the Problematic Situation. c. Judgments about the Problem.d. Judgments about Ends and Values. e. Judgments about Treatment. Second Part: Providing for the Art of Medicine. a. Medical Education and Health Care Education in General. b. The Course of Medical Care. c. The Integrity of the Health Care Profession. Third Part: General Conclusion.
Goes deeper than the usual medical ethics text in elaborating the basis of value in medical endeavors
Refutes claims that professional judgement can be industrialized or computerized
Proposes a Deweyan model that reinforces informal means/ends reasoning instead of trying to replace it with economic rationality
Concludes with positive recommendations for reform in medical education and care that strengthen caregiver-patient relationships and would help renew the art of medicine
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