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Re, The behavioral management of pain: a critique of a critique.
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The method of 'principlism': a critique of the critique.
Several scholars have recently criticized the dominant emphasis upon mid-level principles in bioethics best exemplified by Beauchamp and Childress's Principles of Biomedical Ethics. In Part I of this essay, I assess the fairness and cogency of three broad criticisms raised against 'principlism' as an approach: (1) that principlism, as an exercise in applied ethics, is insufficiently attentive to the dialectical relations between ethical theory and mortal practice; (2) that principlism fails to offer a systematic account of the principles of non-maleficence, beneficence, respect for autonomy, and justice; and (3) that principlism, as a version of moral pluralism, is fatally flawed by its theoretical agnosticism. While acknowledging that Beauchamp and Childress's reliance upon Ross's version of intuitionism is problematic, I conclude that the critics of principlism have failed to make a compelling case against its theoretical or practical adequacy as an ethical approach. In Part II, I assess the moral theory developed by Bernard Gert in Mortality: A New Justification of the Moral Rules, because Gert has recommended his approach as a systematic alternative to principlism. I judge Gert's theory to be seriously incomplete and, in contrast to principlism, unable to generate coherent conclusions about cases of active euthanasia and paternalism.
A model for critiquing based on automated medical records.
We describe the design of a critiquing system, HyperCritic, that relies on automated medical records for its data input. The purpose of the system is to advise general practitioners who are treating patients who have hypertension. HyperCritic has access to the data stored in a primary-care information system that supports a fully automated medical record. Hyper-Critic relies on data in the automated medical record to critique the management of hypertensive patients, avoiding a consultation-style interaction with the user. The first step in the critiquing process involves the interpretation of the medical record in an attempt to discover the physician's actions and decisions. After detecting the relevant events in the medical record, HyperCritic views the task of critiquing as the assignment of critiquing statements to these patient-specific events. Critiquing statements are defined as recommendations involving one or more suggestions for possible modifications in the actions of the physician. The core of the model underlying HyperCritic is that the process of generating the critiquing statements is viewed as the application of a limited set of abstract critiquing tasks. We distinguish four categories of critiquing tasks: preparation tasks, selection tasks, monitoring tasks, and responding tasks. The execution of these critiquing tasks requires specific medical factual knowledge. This factual knowledge is separated from the critiquing tasks and is stored in a medical fact base. The principal advantage demonstrated by HyperCritic is the adaption of a domain-independent critiquing structure. We show how this domain-independent critiquing structure can be used to facilitate knowledge acquisition and maintenance of the system.
Extending computer-based critiquing to a new domain: ATTENDING, ESSENTIAL-ATTENDING, and VQ-ATTENDING.
The paper describes a research project which is developing expert computer systems to critique a physician's plan of medical management. In particular, the paper outlines the evolution of three computer systems: ATTENDING, a system designed to critique anesthetic management, ESSENTIAL-ATTENDING, a domain-independent system-building system, and VQ-ATTENDING, a prototype system implemented using ESSENTIAL-ATTENDING to critique aspects of ventilator management. The goals of the research project are to explore the critiquing approach in several different medical domains, to understand the design problems involved in implementing such systems, and to help other researchers build critiquing systems in further domains.
Computer-critiqued blood ordering using the HELP system.
Recently the medical risk of blood transfusions has emphasized the need to improve the safe use of blood products. For the past 2 1/2 years at LDS Hospital we have used the HELP computer system to assist and critique ordering of blood products "on-line" by physicians and nurses. This report details the computer methods used to order blood products and to critique the appropriateness of those orders. Physicians personally enter the orders for more than 45% of the blood products using computer terminals, whereas 7% are from physician standing orders. Nurses enter the remaining orders from written orders (26%), verbal orders (14%), and phone orders (8%). There were 3396 blood orders for 1043 patients generated by 273 physicians during the fourth quarter of 1989. Each order is justified at the time it is entered by selecting from a menu of physician-approved criteria. The criteria are linked to supportive data in the data base, i.e., laboratory results and clinical data. The computer verified that 82% of these orders met criteria. Quality Assurance nurses verified the remaining 18%. Of these 18% only one in eight required manual chart review. After computer and Quality Assurance review, only eight (0.24%) of the orders were found to be true exceptions to established criteria. Physicians and nurses have accepted the computerized critiquing system. Through use of the computer we provide "on-line" critiquing and improve the use of scarce blood product resources.
The research critique. General criteria for evaluating a research report.
General criteria for evaluating a research report are addressed. This outline of criteria can be used as a guide for nurses in critiquing research studies. A sample research report is summarized followed by a critique of the study. Readers have an opportunity to practice critiquing by doing their own analyses before reading the critique presented in the article.
Automated critiquing of medical decision trees.
The authors developed a decision tree-critiquing program (called BUNYAN) that identifies potential modeling errors in medical decision trees. The program's critiques are based on the structure of a decision problem, obtained from an abstract description specifying only the basic semantic categories of the model's components. A taxonomy of node and branch types supplies the primitive building blocks for representing decision trees. Bunyan detects potential problems in a model by matching general pattern expressions that refer to these primitives. A small set of general principles justifies critiquing rules that detect four categories of potential structural problems: impossible strategies, dominated strategies, unaccountable violations of symmetry, and omission of apparently reasonable strategies. Although critiquing based on structure alone has clear limitations, principled structural analysis constitutes the core of a methodology for reasoning about decision models.
Goal-directed critiquing by computer: ventilator management.
VQ-ATTENDING is an expert system which critiques aspects of the ventilator management of a patient receiving mechanical respiratory support. To use VQ-ATTENDING, the physician first inputs medical information describing a patient, a current set of arterial blood gas results, the current ventilator settings, and a proposed set of new ventilator settings. VQ-ATTENDING then critiques the appropriateness of the proposed settings. In its current developmental implementation, VQ-ATTENDING explores a particular expert system designed feature: the ability to assess appropriate treatment goals, and to use those goals to guide the system's critiquing analysis.
Critiquing the process of radiologic differential diagnosis.
ICON is a developmental expert system designed to critique the process of radiologic differential diagnosis. To use ICON, a physician outlines (1) findings observed in a chest radiograph, (2) a small amount of clinical information describing the patient, and (3) a proposed diagnosis. ICON critiques the appropriateness of that diagnosis in detail, analyzing why and how well the findings serve to confirm it, or to rule it out. ICON may also suggest further information to look for. ICON explores the design issues involved in critiquing the process of differential diagnosis, and is currently implemented in a limited domain: the radiographic diagnosis of a lung mass in a patient with Hodgkin's disease.
HYDRA: a knowledge acquisition tool for expert systems that critique medical workup.
HYDRA is a computer-based knowledge acquisition tool under development to assist in the creation of expert systems which critique medical workup. To use HYDRA, a domain expert first outlines the recommended approaches to the workup of a chosen medical problem, using the Augmented Transition Network formalism. From this model, HYDRA produces a list of the various conditions for which critiquing comments may be required to react to all possible approaches that might be proposed by the user of the critiquing system. Domain-specific constraints can be used to restrict the number of conditions suggested. In this way, HYDRA assists the domain expert by providing a model for structuring the problem, and by breaking down the domain expert's work into a set of small, easily understood tasks.
Schilder and Pavlov's theory of higher nervous activity. A critique and apologia.
In the late 1920s, the Viennese psychoanalyst Paul Schilder, after performing a conditioning experiment with human subjects, criticized I. P. Pavlov's concept of "experimental neurosis." Schilder maintained that subjective reports by conditioned human subjects were more informative than the objectively observed behavior of conditioned dogs. In 1932, Pavlov published a rejoinder to Schilder's critique in the Journal of the American Medical Association. Pavlov maintained that Schilder misunderstood the value and implications of the scientific, objective method in the study of experimental neurosis. In 1934, Schilder subjected Pavlov's theory of higher nervous activity to an incisive critique in a 1935 article in Imago. Schilder objected to Pavlov's narrow, reductionist conceptualization of the conditional reflex. Schilder reiterated his view that the psychological, subjective explanation of the conditional reflex is preferable to the physiological, objective explanation, and that the inference of cortical phenomena from experimental findings might be improper. Neither Pavlov nor any of his disciples replied to Schilder. The author provides an apology for the Pavlovian position, suggesting that Schilder was unfamiliar with early and late writings of Pavlov.
Exploring subjective vs. objective issues in the validation of computer-based critiquing advice.
Evaluation is an important part of the development of computer-based medical expert systems. Such evaluation may be particularly difficult when judging a critiquing system which responds to a proposed management strategy with a discussion of the advisability of that approach. DxCON is an expert system which produces a prose critique discussing the radiologic workup of obstructive jaundice. This paper describes DxCON, and its experimental validation by three independent judges. A central component of the validation involved allowing the judges to react to the system's advice in a quite flexible, unstructured fashion. This project provides a case study of how subjective issues impact both the design and implementation of a validation of a medical expert system whose output is explanatory prose.
The socialisation of nurses in clinical settings: a dual focus critique of a research study.
This is a two-pronged critique of a study of the socialisation of neophyte nurses in a neonatal intensive care unit in the USA. The authors, respectively an educationalist and a nurse researcher experienced in neonatal intensive care, agreed in finding that the study fell short of what it promised, but differed as to their reasons. They decided to publish their critiques as a complementary pair, in the hope that those supervising research students would benefit from seeing a disappointing study simultaneously in two perspectives, educational and clinical.
Double standards in the analysis of Marxist scholarship: a reply to Reidy's critique of my work.
This article is a reply to Reidy's critique of my work, published under the title, 'Marxist Functionalism in Medicine: A Critique of the Work of Vicente Navarro'. The first part of Reidy's article contains a lengthy list of what she defines as "the symptoms of the disease" and the second part includes the analysis and "definition of the disease; Marxist Functionalism". Her conclusion is that human liberation requires the elimination of my disease: Marxist Functionalism. She refers to my writings on Chile as yet one more proof of my disease. This article is an answer, case by case, and symptom by symptom, of Reidy's accusations and shows that it is the accuser--Reidy--rather than the accused--Navarro--who is guilty of misrepresentation and inaccurate reporting and her target of criticism is not Marxist Functionalism but Marxism. My article shows that Reidy's piece is an outcome of her maliciousness, limited knowledge of Parsons', Marx's and my own work and own political beliefs, intolerant of Marxist revolutionary positions. The article concludes that Allende's Chile proved me right, rather than wrong, as she indicated.
Medical Critique [Krytyka Lekarska]: a journal of medicine and philosophy-1897-1907.
Medico-philosophical reflections were developed in the 19th and the 20th centuries by three consecutive generations of Polish physicians, active in what was later named the Polish School of Philosophy of Medicine. The second generation of this school published its own journal, Medical Critique [Krytika Lekarska], from 1897 to 1907. Medical Critique included numerous articles on the nature of medical knowledge, the reductionism versus holism debate in biology and medicine, the importance of teleologically-oriented approaches in medicine, the influence of theories and of a priori ideas on clinical observations and on 'clinical facts', the problem of classification of diseases, the normative and ethical dimension of medicine, and the ion relationships between philosophy, history and medicine. The existence of a journal dealing specifically with theoretical reflections on medicine undoubtedly contributed to the propagation of original work in the philosophy of medicine in Poland.
Recurrent themes in ambulance critique review sessions over eight years.
For 8 years biweekly ambulance critique review sessions have evaluated performance and discussed management of cases brought to our hospital by ambulance. Over 500 cases reviewed have centered primarily on evaluation and care at the scene and its possible relation to outcome. Problems which have recurred on the scene include whether the patient would have benefited from less time in stabilization and immobilization; manipulation of deformed fractures for splinting; use of tourniquets; techniques of airway maintenance; and management of infrequently seen problems such as hypothermia and drowning. Interaction problems with physicians on the scene and in the Emergency Room (ER) come from questioning physician authority even without specific knowledge of the appropriate techniques of emergency care. A related problem is lack of ER staff familiarity with Emergency Medical Technician (EMT) procedures and ambulance equipment. The value of critique review sessions has been seen in improved rapport and interaction among ER staff and ambulance personnel. Improved outcome needs to be assessed in a carefully controlled study. The enthusiasm and attendance of ER staff and ambulance personnel has grown and endured over 8 years. The review sessions have spread to other area hospitals with some success.
Three-dimensional imaging in medicine. A response to a critique by surgeons.
In a recent article in this Journal (Vol. 20:1) two surgeons gave a critique in which they discussed the relative merits and disadvantages of three-dimensional presentation based on CT scan data. While most of their critique is unarguable, there are some aspects of it which are overstated and possibly misleading. This is a response of a computer scientist, which attempts to present the somewhat different perception of one who is involved in the development of the three-dimensional imaging methodology in medicine.