Clinical Judgement Evidence in Practice

by Downie, R. S.; MacNaughton, Jane; Randall, Fiona

• ISBN13: 9780192632166
• ISBN10: 0192632167
• Edition: 1st
• Format: Paperback
• Copyright: 2000-04-27
• Publisher: Oxford University Press

Summary

There is a widespread view that modern medicine is primarily a scientific enterprise and that the decisions of clinicians follow from evidence-based science. In terms of this view the need for clinical judgement is minimal. The aims of this book are to make a case for the centrality andirreplaceability of clinical judgement, to identify the elements of good clinical judgement, and to suggest how these might be developed by using the humanities in medical undergraduate and postgraduate education. The authors argue that good clinical judgement requires both technical evidence and ahumane attitude. But technical evidence is not always quantifiable or even scientific; it can be like that of the detective or the literary scholar. A humane attitude involves ethical sensitivity, but also a broad educated perspective which can be derived from the arts. The authors illustrate theirargument by examining decisions made by doctors in clinical situations, in public health, and (in a chapter contributed by a hospital consultant) in resource management. About the authors: Robert S. Downie is Professor of Moral Philosophy at Glasgow University since 1969. He is a member of the BMAEthics Committee and co-editor of the Journal of Medical Ethics. He has published extensively in the field of medical ethics. Jane MacNaughton has recently taken the position of Director of Centre for Arts, Humanities, Health and Medicine at the University of Durham. Previously she was ClinicalLecturer in General Practice at Glasgow University and a part-time GP.

Author Biography

Jane Macnaughton has recently taken the position of Director of the Centre for Arts and Humanities in Health and Medicine at the University of Durham.

Table of Contents

Acknowledgements	viii
Preface	ix
Clinical judgement: a diagrammatic summary	xii
Judgement and science	1	(40)
Introduction	1	(1)
The nature of science: method	2	(6)
Evidence	8	(7)
Scientific aims	15	(2)
The scientific outlook	17	(4)
Science and the imagination: Adam Smith	21	(1)
Medicine and science	22	(15)
Is medical research scientific?	37	(1)
Judgement in medical research	38	(1)
Conclusions	38	(3)
References	39	(2)
Judgement in the clinic	41	(34)
Introduction	41	(1)
A clinical example	42	(5)
Individualized evidence	47	(4)
Anecdotes	51	(9)
Interpretation	60	(5)
Knowledge and skills	65	(1)
Communication skills	66	(1)
Clinical skills and the `art' of medicine	67	(2)
Consent	69	(2)
Clinical skills as an art	71	(1)
Conclusions	72	(3)
References	73	(2)
Humane judgement	75	(30)
Medicine as a profession	75	(2)
The Knowledge base	77	(1)
Service through a relationship	78	(10)
The humane attitude	88	(1)
Medical affectation	89	(5)
Consumerism	94	(5)
Insight and humane clinical judgement	99	(3)
Humane judgement and the humane attitude	102	(1)
Best evidence-based practice	102	(1)
Conclusions	103	(2)
References	104	(1)
Judgement in public health	105	(23)
Introduction	105	(1)
Public health medicine and its evidence base	106	(4)
Public health ethics and health care ethics	110	(1)
Prevention	111	(3)
Health promotion	114	(5)
`The organized efforts of society'	119	(5)
Evidence and judgement in public health	124	(1)
Conclusions	125	(3)
References	125	(2)
Editors' note to Chapter 5	127	(1)
Judgement and resource management	128	(25)
The necessity for rationing	128	(1)
Financial and justice arguments for rationing	129	(3)
Doctors' objections to rationing	132	(3)
Team responsibility and health professionals as trustees	135	(3)
Macro-allocation: some concepts	138	(2)
Macro-allocation: the QALY	140	(5)
How should macro-allocation decisions be made?	145	(3)
Micro-allocation	148	(3)
Clinical judgement and society	151	(1)
Conclusions	151	(2)
References	152	(1)
Educating judgement: the humanities	153	(30)
Introduction	153	(1)
Teaching ethics	154	(7)
Education and training	161	(5)
Medical ethos	166	(3)
Broadening the ethos	169	(1)
The humane attitude: practicalities	170	(4)
The humane attitude: components	174	(3)
Aims and objectives	177	(2)
Humane judgement	179	(1)
Conclusions	180	(3)
References	180	(3)
Conclusion: clinical judgement	183	(3)
Appendix to Chapter 6	186	(11)
Index	197