One might anticipate that Intuition in Medicine is about clinical reasoning, given how that recent empirical studies have highlighted reason’s limits, intuition then justly claims a central role in understanding how clinicians make choices. Indeed, a rich literature has developed about how we think (consciously and, even more importantly, unconsciously) and these could profitably be applied to the medical scenario. For instance, heuristics/bias theory, mental models theories (ie. map-like representations in semantic form), mental logic theory (ie. reason reflects an innate logical capacity) and rational choice theory might have been compared or individually applied as a framework of this study. However, such a cognitive or psychological orientation makes no appearance here and, instead, Braude has provided a philosophical defence of clinical reasoning.
The title is provocative. What exactly requires a defence? Although awareness of misjudgements and errors has gained headlines and a communal self-consciousness, this embarrassment is not the motive behind this study. Nor is the general educational commitment to rational, evidence-based medicine Braude’s concern. Instead, he offers a philosophical defence of clinical reasoning, one informed by Aristotelian phronesis – that is, ‘practical wisdom’. And that wisdom is a form of cognition, which challenges a positivist view of clinical thinking to argue that judgements also require diverse subjective evaluations and considerations. In other words, ‘intuition’ categorises the pre-representational modes of thought such as emotional responses, unconscious desire, prejudice, memory and, most importantly from Braude’s point of view, the moral valence of the doctor–patient encounter. So, again, what is defended? Simply, the ‘contamination’ of positivist objectivism by the subjective, which is demanded by the ethical response to the ‘other’. The moral imperative of medicine subordinates the science and technology to this ethical call and drives medicine from a science to a techne.
The synthesis of medicine’s scientific persona with its primary ethical mandate (what I call a moral epistemology) makes clinical reasoning a complex amalgam, one requiring different perspectives to capture its character. Braude has joined those who, over the past forty years, have inveighed against the positivist aspiration of defining and utilising a universal form of knowledge acquisition and interpretation. Beginning with Thomas Kuhn and Paul Feyerabend, critics have assembled a vast array of evidence showing that scientists think pragmatically and employ diverse forms of logic (especially ‘inferences to best explanations’) to interpret investigative findings and draw generalities about the derived facts. Those facts take on various meanings as determined by the larger context in which they sit, which include both epistemic and non-epistemic values. That general orientation is easily applied to medicine, which over the past century has modelled itself on the bench sciences and still aspires to a reductive ideal in which disease equals illness.
Braude understands that the ‘impersonalism of universal reason’ (p. xiii) cannot be the philosophical answer to the challenge of caring for the patient, and emphasises instead ‘embodied reason’ (p. xvi) of pre-reflexive thought. One might well agree that the intuitive domain does, indeed, play a crucial role in clinical reasoning, but to what degree? And, perhaps more salient to a philosophical discussion, what is being intuited? With regards to the mental processing of information and the logic of drawing conclusions, this study eschews the literature that addresses this question. So for those seeking a cognitive approach to inform their intuitions about intuitive judgement, they must go elsewhere. Instead, Braude makes a philosophical plea for a synthesis of medicine’s epistemology and underlying moral philosophy. The intuition he promotes is moral intuition about the patient viewed as a person, and the relationship that grounds the clinical encounter. In sum, he maintains that, to have philosophy fruitfully contribute to medicine, a ‘moral image of the world’ (p. xvii) is required. How to philosophically conceive an amalgamation of that moral world view and the science of medicine constitutes the body of his book.
Braude engages a diverse group of philosophers who have debated the character of medicine’s epistemology and, more particularly, its interface with moral reasoning. Thus he appropriately critiques Baruch Brody and Edmund Pellegrino within the confines of philosophy of medicine proper, and then, developing his own phenomenological approach, he couples Aristotelian practical reasoning with the philosophies of Edmund Husserl and Emmanuel Levinas to define the moral encounter at the base of clinical reasoning.
Intuition in Medicine is a dizzying account. Proceeding at break-neck speed from ancient philosophy to C.S. Peirce to Alvan Feinstein, the uninitiated reader might feel a bit overwhelmed. And for those engaged in these matters, more depth could reasonably be demanded. However, Braude must be congratulated for offering a grand synthesis that his topic deserves. I must acknowledge that he has engaged this subject in a manner closely aligned to my own writings, which leads me to endorse his effort to illustrate (and defend) the nature of the clinical encounter as a complex combination of epistemological and moral elements. Not to disparage the science of medicine, he still maintains that a ‘defence’ is required for a more eclectic composite view of clinical reasoning. Lingering positivist conceits and the over-reliance on evidence-based medicine not only potentially interfere with the humanism that should guide clinician behaviours, but such ostensible objectivity distorts the way we understand how doctors think. Indeed, algorithms go only part way. More, if physicians do, in fact, aspire to deliberate solely in scientistic terms, such a calibration will drive clinical medicine off its moral course. In this sense, Intuition in Medicine is a renewed call for an ethical medicine, broadly construed, and in offering a philosophically informed defence of morally grounded praxis, Braude provides an intellectually enriched account of what truly threatens humane medicine and what is required for authentic reasoned clinical care.
