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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.
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.
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.
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.
A diagnostic system for organic brain disorders: critique and suggestion.
Organic brain disorders (OBD) are among the most complex psychiatric diagnostic problems. A critique of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM II) and the proposed DSM III suggests that the diagnostic outline for organic brain disorders contained in these publications (Organic Brain Syndromes in the DSM II; Organic Mental Syndromes in the proposed DSM III) is inadequate to describe the potential range of organic-based behavioral disorders and their possible organic etiologies. A new diagnostic system is proposed, with examples, of its use, which should fit in with the DSM II and the proposed DSM III and be flexible enough to overcome the problems of the present diagnostic system.
Is Helicobacter pylori a cause of duodenal ulcer? A methodologic critique of current evidence.
INTRODUCTION: Helicobacter pylori (HP) in the gastric antrum has been strongly associated with both duodenal ulcer (DU) and chronic active gastritis (CAG). The relationship between HP and DU has been interpreted as causal by many observers. An alternate hypothesis is that HP coincidently colonizes CAG, which is independently associated with DU by some yet-unknown mechanism. PURPOSE: To assess the extent to which a causal relationship between HP and DU has been demonstrated, we performed a methodologic critique of published clinical studies. We carried out a literature search to identify clinical studies that included at least 25 subjects. Of the eight studies we identified, six used a cross-sectional design and two used a prospective cohort design. We applied methodologic criteria to assess causation: strength of association, biologic gradient, temporality, and experiment. METHODS: A strong association between HP and DU was demonstrated in all eight studies. Biologic gradient and temporality were not assessed in any study. In the two experimental studies of therapy, loss of antral HP was associated with a decreased rate of DU relapse; however, we did not interpret this as sufficient to support causality because the effect may have been due to a direct mucosal action rather than eradication of HP. CONCLUSION: We conclude that published evidence does not establish HP as a cause of DU. One approach to address causality would be an observational cohort study of ulcer relapse to assess the temporal relationships between HP, CAG, and DU.
Critique of the session on diagnostic testing.
During the session on diagnostic testing, various diagnostic tests used to identify the cause of chest pain were discussed. This critique of diagnostic assessments of the complex etiology of chest pain is presented as a contribution toward further investigation and clarification of this difficult clinical syndrome. The first step in the evaluation process is to exclude coronary artery disease. Patients with angina and normal coronary artery flow may have atypical disease, such as microvascular angina or syndrome X. The precise relationship between these disorders and esophageal disease or gastroesophageal reflux, as well as their possible involvement in chest pain of undetermined origin, requires further definition. A limitation of esophageal provocation tests is that they may identify the esophagus as the source of pain without determining the specific esophageal disorder that causes the pain. Problems associated with 24-hour pH and pressure monitoring include (a) poor correlation between reflux episodes and heartburn symptoms, (b) the lack of a good functioning swallowing signal, and (c) the huge amount of data that must be analyzed, along with shortcomings in computer-aided analysis. Nevertheless, the various available diagnostic tests can provide important information to the clinician.
A methodological critique of the current status of eye movement desensitization (EMD).
Eye Movement Desensitization (EMD) has been recently advocated as a rapid treatment for the elimination of traumatic memories responsible for the maintenance of a number of anxiety disorders and their clinical correlates. Despite a limited conceptual framework, EMD has attracted considerable interest among clinicians and researchers. The popularity and interest generated by EMD will likely result in wide usage. We present a methodological critique of it with reference to assessment, treatment outcome, and treatment process. We also provide guidelines for judging the methodological adequacy of research on EMD and suggest intensive research to assess effectiveness, treatment components, and comparisons with other procedures.
A critique of posterior lumbar interbody fusion: 12 years' experience with 250 patients.
A comprehensive long-term follow-up analysis of the clinical and radiographic results of posterior lumbar interbody fusion for lumbar disk disease is presented. This 12-year experience with 250 patients is compared with a previous critique of our surgical management of lumbar disk disease by laminotomy and diskectomy alone. The clinical results and complications rates are comparable. However, posterior lumbar interbody fusion significantly reduces the rate of recurrent problems requiring subsequent surgery. Careful technique and judgment are mandatory for success with posterior lumbar interbody fusion. Homologous tissue bank bone grafts were found to be as successful as autogenous bone. Posterior lumbar interbody fusion represents an improvement in the surgical management of lumbar disk disease.