Judgement and the role of the metaphysics of values in medical ethics

Is the four quadrant approach to military medical ethics a cargo cult? A call for more unity between philosophers and practitioners

Moral theory should be practically useful, but without oversight from the philosophical community, the practical application of ethics by other institutions such as the military may drift into forms that are not theoretically robust. Ethical approaches that drift in this way run the risk of becoming 'cargo cults': simulations that will never properly fulfil their intended purpose. The four quadrant approach, a systematic method of ethical analysis that applies moral principles to clinical cases, has gained popularity in the last 10 years in a variety of medical contexts, especially the military. This paper considers whether the four quadrant approach is a cargo cult or whether it has theoretical value, with particular reference to the more popular four principles approach. This analysis concludes that the four quadrant approach has theoretical advantages over the four principles approach, if used in the right way (namely, with all four quadrants being used). The principal advantage is that the four quadrant approach leaves more room for clinical judgement, and thus avoids the charge of being too algorithmic, which has been levelled at the four principles approach. I suggest that it is the fourth quadrant, which invites the user to consider wider, contextual features of the case, which gives the approach this key advantage. Finally, I make a more general proposal that theoretical ethicists should work closely with those practitioners who apply ethics in the world, and I call for a symbiotic relationship between these two camps.

Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement

The paper outlines the role that tacit knowledge plays in what might seem to be an area of knowledge that can be made fully explicit or codified and which forms a central element of Evidence Based Medicine. Appeal to the role the role of tacit knowledge in science provides a way to unify the tripartite definition of Evidence Based Medicine given by Sackett et al: the integration of best research evidence with clinical expertise and patient values. Each of these three elements, crucially including research evidence, rests on an ineliminable and irreducible notion of uncodified good judgement. The paper focuses on research evidence, drawing first on the work of Kuhn to suggest that tacit knowledge contributes, as a matter of fact, to puzzle solving within what he calls normal science. A stronger argument that it must play a role in research is first motivated by looking to Collins' first hand account of replication in applied physics and then broader considerations of replication in justifying knowledge claims in scientific research. Finally, consideration of an argument from Wittgenstein shows that whatever explicit guidelines can be drawn up to guide judgement the specification of what counts as correctly following them has to remain implicit.Overall, the paper sets out arguments for the claim that even though explicit guidelines and codifications can play a practical role in informing clinical practice, they rest on a body of tacit or implicit skill that is in principle ineliminable. It forms the bedrock of good judgement and unites the integration of research, expertise and values.