D A V I D C.

T H O M A S M A

APPLYING

GENERAL

INDIVIDUALS:

MEDICAL

KNOWLEDGE

A PHILOSOPHICAL

TO

ANALYSIS

ABSTRACT. Applying general and statistical knowledge to individuals is difficult either

on epidemiological or epistemological grounds. This paper examines these difficulties from
the perspective of computer registers of epidemiologicaldata.
Key' words: Abstract knowledge, Application of medical knowledge, Computer registers,
Decision making, Decision theory, Epidemiology, Experimental therapy, Individuals,
Philosophy of medicine, Quality of life, Statistical data, Values, Medical ethics.

1. I N T R O D U C T I O N

The problem of applying general or abstract knowledge to individuals is a

central problem in making clinical judgments. This philosophical problem
lies at the heart of differential diagnosis, confirmed diagnosis, prognosis,
and the construction of a rational treatment plan. In each of these
instances, abstract data and knowledge must be adjusted to fit the
particular circumstances of the individual's body, functions, and the course
of the disease, as well as the person's values. The epistemological status of
medical indications as a basis for treatment is also at issue in this
application. Are such indications merely an application of standard and
objective data to individuals, or are they themselves partially composed of
subjective, evaluative aspects? 1
Any attempt to apply general computerized records to individuals will
result in confronting the same problem. Epidemiological data culled from
some groups in society may not apply directly to others. In this instance,
social as well as individual judgments will be made, with the opportunity
for error correspondingly expanded beyond individuals to social groups.
Thus clinical judgment represents a micro version of the macro instance of
the problem occasioned by computerized record keeping.
Research and practice are logically distinct activities. "Research" refers
to a class of activities designed to produce generalizable knowledge,
whereas "therapy" describes a class of activities meant to benefit individual patients or a distinct group of patients. The distinction is important, as
research data is often applied to individuals who were not part of the
original set.
For example, clinical decisions about diabetes control may be made for
a chronic obstructive pulmonary disease (COPD) male patient based on
Theoretical Medicine 9 (1988) 187--200.
1988 by KluwerAcademic Publishers.

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research data done primarily on elderly female non-smoking patients. The

validity of the application is often disregarded in an appeal to the data.
Typically such an appeal is made at the bedside by a phrase like: 'A
recent study showed that . . . . "
I will take this disjunction and analyze it in terms of inductive cautions.
Rather than cover ground already explored by logical studies on inductive
reasoning in medicine,z my focus will be on the data used to help the
patient's decisionmaking and the problems associated with this in clinical
judgment. The exploration falls into the following five sections: The
abstract, concrete, and inference; the possibility of a science of individuals;
the psychology of choice; the bell-shaped curve; and quality of life
judgments. This exploration is designed to complement the ethical and
logical explorations of registers themselves found in this issue.

2. T H E A B S T R A C T , T H E C O N C R E T E , A N D I N F E R E N C E

The greater the abstraction, the less appropriate its appfication to concrete,
individual instances. This theorem holds true unless the inductive product
contains a set coextensive with the individual's characteristics, or at least
analogously so. It is only on the basis of this "set" that valid inferences can
be made. Some inferential cautions are required.
Inference from inductively gathered data can only be validly applied to
an individual if: (1) The individual's relevant characteristics are part of the
set; (2) The individual falls into a statistically secure field; (3) Some
common notes of all possible individuals are found in the inductive
product (or a "nature" of all the individuals is discovered and collated in
the inductive product); (4) The value assumptions of the abstract data are
de facto values of the individuals to which the data is to be applied.
What do these points mean for clinical judgment, however?
It is important that an attempt is made to clinically fit the patient into
the data pool of the research or epidemiological studies. An obvious
example occurs in the effort to control blood cholesterol levels. The
general public has learned of the research on this problem, and has
digested the news that fish oil can be beneficial in controlling such levels.
Apparently the initial epidemiological research on this problem comes
from studies of diseases among Eskimos. Although they do, in fact, have
less cardiovascular diseases than other adults in Western countries, they
also experience a much higher incidence of strokes, and a shorter lifespan.
Applying the data directly to other adults, and ignoring these other nasty

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189

side-effects of their lifestyle and diet, is an error. Many people, at the

urging of their doctors, rushed out to eat more fish in their diet and take
supplemental fish oil pills.
A recent meeting of the American Heart Association stressed the
dangers of this kind of extrapolation from the expanded studies based on
Eskimo research. First, while fish oil can be demonstrated to lower
triglycerides, it must be taken in large quantities to have any impact on
cholesterol. Second, many patients suffer cardiovascular disease from
other causes that contribute to the disease besides high cholesterol levels.3
This example demonstrates the problem of applying abstracted, computerized data to individuals who may not fit the class from which the data
set has been extrapolated (the first three cautions, above). It is assumed
that the arteries of urban persons respond the same way as those of a
tightly-knit, isolated society. Is there not an assumption of a common
human nature involved in such extrapolation? And is that assumption
accurate in this instance?
An example demonstrating the fourth caution is found in a story about
heart transplants. A heart transplant surgeon, Dr. Robert B. Karp of the
University of Chicago Medical Center, indicated that the operation was
nothing major: "There isn't a dramatic change in these people's lives. You
got a new heart . . . . It's simply a pump." One just exchanged one pump for
another. Yet patients saw the matter much differently, citing the intense
fears even after the operation, the dependency on medical intervention
and follow-up for the rest of their lives, and the assault on their values this
dependency caused. One patient said: "Getting a transplant is not like
taking a radio in and getting a new tube and then you go home and plug it
in and it's just as good as it ever was . . . . Tiffs is a different situation. It
requires a will to survive. It takes a lot of strength. It takes a positive
attitude because it isn't easy.''4 When the values of the patient are
neglected in the application of general knowledge (a theory of the heart
as a pump, for example), profound aspects of rejection, physical and
psychological, will most certainly surface. Body parts are not so easily
interchangeable and assimilated, because persons are their bodies in ways
that a general theory may not comprehend.
Other concerns lead to further questions about the propriety of applying
data to individuals in one class from individuals in another. Cardiovascular
disease, for example, arises from a puzzling complex of biological predisposition, environmental stress, lifestyle, and other factors. Even the
expanded studies have not proven the effectiveness of fish oil supplements,
because the mechanism by which the cholesterol is lowered is still not
thoroughly understood. Rejection, in the heart transplant example, may

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not be entirely a phsyiological problem, but also may involve the stresses
and strains of adjusting one's new life with one's values.
What is important in these examples, is that the fit between the
population studied and the population to which the data might apply is
often not accurate enough to warrant any kind of scientific certitude.
Undoubtably, further research will help gain a better fit. If this fit is not
equivocal, at least it can become more analogically accurate.

3. T H E P O S S I B I L I T Y OF A S C I E N C E OF I N D I V I D U A L S

MacIntyre and Gorovitz suggested some time ago that medicine might be
a science of individuals, in much the same way that environmental
scientists have discovered ways to predicate general statements of individual hurricanes. 5 I think that such a science is an impossibility. Rather it
should be called a techne, a discipline that combines science with the art
of dealing with the concrete. 6
The problem of the abstract and the concrete is an ancient one. As is
well-known, the problem of Ideas in Plato, the universals in Aris:otle, the
mediaeval debates about abstraction from nature, the late mediaeval
reaction to substances, and the modern disclaimer of any knowledge of
real world essences are only part of the picture.
William Desmond has studied this problem in detail. As he argues,
many philosophers since Hegel have been concerned about the charge
that philosophy (indeed, all abstract disciplines, including epidemiology,
I would add) inevitably favor sameness over otherness, identity over
difference, the abstract over the concrete. The Hegelian dialectic, for
example, subordinates difference to identity, not to speak of its materialistic cousin, the Marxist dialectic. Desmond argues that philosophy should
also be concerned with the "metaxological," a term he coins to describe
the betweenness in the dialectic, the active will to be both unique and
other. 7 A discourse about this intermediate realm is important precisely
because it involves the fit required between the individual and the abstract.
Pellegrino and I argued that philosophy of medicine must concern itself
with relationships, a fuzzy area of contemporary philosophy to be sure,
but essential if one were to examine the relation between the doctor and
the patient. 8 The epistemological question of applying generalized data to
individuals is certainly part of this needed exploration. It might take the
following lines.
Oliver Sacks quotes Ivy McKenzie as saying "The physician is concerned
(unlike the naturalist) . . . with a single organism, the human subject,

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striving to preserve its identity in adverse circumstances." 9 What is crucial

about this point is that the identity of the individual must help be
preserved by the application of abstract knowledge. Clinical judgment
then is an art of making that analogous fit. If the data is bad, the fit
cannot take place. If particularities of values and circumstances are
ignored in the abstraction of the data (the Eskimos' relatively peaceful
existence compared to city-folk), the same particularities are ignored in
the application to the individual. This latter point refers back to the fourth
caution. The individual's particular value-system is essential. For example,
in applying data about the advisability of lowering moderate blood pressure levels one must adjust this to concerns about concurrently lowering
sexual performance.
The paradigmatic and the abstract, then, can cloud the importance of
the narrative and the concrete for healing patients. Sacks argues later in
his book that "The concrete is readily imbued with feeling and memaing -more readily, perhaps, than any abstract conception. It readily moves into
the aesthetic, the dramatic, the comic, the symbolic, the whole wide deep
world of art and spirit." 10 It is hard to imagine that dealing with this realm
could be called a science of individuals. Nevertheless, the importance of
fitting the data to the individual cannot be gainsayed. That brings our
reflections to the psychology of choice, and the role of values in making
these choices.

4. THE PSYCHOLOGY OF CHOICE

Much of the machinery of modem medicine supports an impressive
armamentarium of surgical, chemical, and biological interventions. All of
these are the products of extensive research and the registration of patient
data on computers. I will focus throughout the rest of the paper on the
especially difficult decisions entailed by seriously ill patients, that is,
patients suffering from cancer or heart disease. This is done in order to
demonstrate more poignantly the difficulties associated with making
concrete decisions with abstract data. This approach also helps locate the
value dimension of these dilemmas. The data support surgical, chemical,
and biological interventions. All of these are posed for patient choices.
Among the surgical interventions for very ill patients are by-pass
surgery, transplants, shunts around cancerous tissue, laser brain tumor
operations, making new stomachs out of intestines, re-aligning the spine,
and placing feeding tubes directly into the stomach to support nutrition.
Among the chemical interventions are a wide variety of drugs to

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control both the electrical and plumbing malfunctions of the heart,

chemotherapeutic agents that are essentially poisons to kill cells, good and
bad alike, drugs that improve mental function, some that improve cardiac
output, pills to control high blood pressure, insulin to control diabetes,
and the chemicals used in kidney dialysis to replace the failed kidney
function.
Among the biological interventions are proposed genetic manipulations,
artificially created antibiotics, and the newer forms of cancer therapy,
especially Interleukin 2.
All have their own side-effects. For example, a patient with spreading
intestinal cancer may agree to an experimental therapy that, coupled with
radiation, will most certainly shut down one kidney. Such a patient may
protest that she does not want t o live the rest of her life with just one
kidney! Yet, she may have only months to live anyway. In addition, most
people can live with only one kidney for the rest of their lives. All of these
are value considerations.
Every time a new procedure or experimental therapy is announced, the
range of choice available for patients expands. This choice is complicated
by the fact that the procedure or experimental therapy has been found to
be effective but its effectiveness is in part a consequence of an abstraction
from the concrete circumstances each patient experienced. This raises the
ethical dilemmas so prominent today. But it also raises the epistemological
issues. In the past, the physician was expected to choose the best treatment
for the patient, and recommend it. Partly because of experimental therapies, this sort of traditional medical paternalism is fading. In its place,
increasing emphasis is put on patient decisionmaking and autonomy.
These two dramatic alterations in medicine -- its technological capacity
and ethical challenges -- create special difficulties for patients faced with
serious illness. Experimental therapy is, by definition, investigational. It is
unproven. Not only that. The physician cannot recommend an experimental therapy over standard therapy on the basis that it will be better. 11
It may not be. Rather the recommendation is based on a negative
judgment -- that previous therapy has not worked well. Further, the
physician cannot tell patients what to do in this regard. They must grapple
with their own values and courage.
Choices are influenced by values and goals. Choosing among therapies
starts by being a no-win situation. Typically, patients face the following
facts: They have a serious disease that will cause them to die; Standard
therapies have not been successful in either stemming the disease or
prolonging life; Experimental therapy is available; This therapy is based
on generalized conclusions of previous experimental studies, as well as the

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ANALYSIS

t93

experience of other patients in similar but not exactly the same circumstances; This therapy presents a greater risk than standard therapy; A
choice between standard therapies and experimental therapies is possible.
But what is the choice? The choice is between probabilities. The
probability is high that one will die soon. On the one hand, standard
therapies offer little to increase the probability of survival. On the other
hand, experimental therapies are untried and may or may not increase
survival. In fact, they may lessen it.
Many patients reason that taking the best shot means increasing their
risk at present by consenting to the study, on the chance that they may be
able to live longer. Experimental therapy in some fields, such as cardiology,
may not offer a greater chance at longevity, but rather a better quality of
life during the time remaining. Therefore other patients may choose the
risk in favor of a greater quality of life. Still others decide that, in a no win
situation, they would rather not put themselves at greater risk. Rather than
longevity, this group of patients seem to value quality of life to remain as
comfortable as possible while they die. Further still, others factor into the
decision helping medical research and future generations. These patients
want to make the best out of a terrible situation. Nonetheless, this is
usually a secondary consideration for most patients.
Of major importance in making choices is how they are framed. Here
the patient's values run headlong into those of the physician. If the
physician puts the possibilities for cure, remission, or improved function in
the most positive light, then the patient will tend to choose in favor of the
research protocol (some studies suggest 70% of persons will do this
consistently). If exactly the same possibilities are cast in a negative light,
about the same percentage of patients would choose not to participate. 12
Imagine a patient faced with a decision to accept an invitation to
participate in a study to test the ability of a new drug to increase her
heart's efficiency. She has a heart condition that does not let her get out of
bed, because she becomes so much out of breath. If the physician
encourages her to try this drug because she may regain more function, she
would tend to accept it (even if the benefits are probably only an ability to
shuffle toward the bathroom on her own, and then back into bed). By
contrast, if her physician discourages her from entering the study because
the benefits are so miniscule compared to the risks, then she would tend
not to accept the invitation.
The reasons for this phenomenon are not hard to find. Patients honor
and respect their physicians. Their physicians' advice is very important.
Many physicians "pre-judge" the clinical trial, and would not offer it to
their patients unless their suspicion is that it will improve upon the

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standard of care. 13 The problem with experimental medicine is, of course,

that the physicians' past experience and clinical hunches do not count. The
study is designed to scientifically compare therapies. A central feature of
the study is that previous research using animals or laboratory results
suggests one therapy may be better than another. But here is the rub. We
do not know in advance that this is the case when used in human beings.
Further, we do not know if the data from previous studies will exactly fit
the concrete circumstances of this particular patient.
Past experimental therapy for prostate cancer, for example, included
castration (called orchiectomy) and radiotherapy (x-ray treatment to the
prostate). A new study might compare this treatment with newer forms of
chemotherapy on a randomized basis. No one knows for sure if the newer
forms of treatment will be better than the old. That is the point of the
research itself. In addition, the patient consenting to the study, in effect
will have a computer choose whether or not he is to be castrated (which
arm of the study on which he is to be put). Although the consent form
might refer to this as a "simple medical procedure," most patients would
view it otherwise. Recall, too, that the consent to be treated in the study is
really a consent to participate in the comparison of therapies (which
sometimes include a placebo). One does not know in advance which
treatment will be offered. One only knows that past therapies have been
rather ineffective, i.e., one will die soon from the disease in any event.
This point is only slightly different when considering risky medical
procedures. In such cases, physicians can describe the risks and benefits
for us, but they cannot predict how we might react. If there is a ten
percent chance that we might die from the procedure, that "percentage"
only describes past experience with patients like us. The population to
which we might be compared in this risk might be favorable. We might be
45 years old, and most of the others in the past were over 65. Or it might
be unfavorable. We might be 45 and have significant heart disease and
diabetes, while others in the risk population did not have those complications. The physician then must weigh all the variables and still make a
suggestion about proceeding. His or her clinical hunches are only that.
They cannot accurately predict how patients will do after the procedure is
finished.
Further, experimental studies themselves often compare therapies by
assigning one or the other intervention by lot to the patient. Neither the
patient nor the physician know which therapy is being given. This is a
"double-blind" study -- both the patient and the physician are in the dark.
It is the preferred method for rooting out bias and the placebo effect a
physician might bring to the relationship with the patient -- healing just by

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195

being expected to heal. In some studies placebos may be given to eliminate

this effect; although patients are informed that they may receive a placebo,
neither they nor their physicians will know if this is the case) 4 Thus,
persons with proven hypertension might be asked to participate in a study
to evaluate new medication to control this disease. First, they might be
taken off their current medicine. Then they would be given the new "pill."
Some persons would receive sugar pills (placebos) while others would
receive their old medicine, now disguised to look like the new one. A third
of the persons on the study would receive the new medicine. All pills
would look alike.
Finally, many therapeutic studies use historical controls. This means
that the current therapy is initially judged to have such promise compared
to past (historical) therapy, that it will be studied against reports of
progress in the past. It will not be compared to another treatment in the
study itself. An example of this method was used in making a new drug,
AZT, available to persons suffering from AIDS. The drug was initially
being studied using an ineffective comparison drug (to eliminate bias), but
it quickly became apparent that it did produce enough of a benefit (it does
not cure the disease, but it does slow it down) that for reasons of
compassion, it was made immediately available to all. Now it is being
studied using historical controls. The problem with historical controls, o f
course, is that the control over the fit between current patients and others
is abandoned. The increased risk is that this analogous fit will not be
coextensive enough to make an impact on healing or stemming the fide of
the disease.
Another example is Interleuken 2 (IL2), mentioned earlier; a dramatic
new method of attacking incurable cancer. IL2 involves removing one's
blood, tagging certain cells as killer cells, and then re-introducing the cells
into the body. The risks include death itself, destruction of the kidneys,
hepatitis (at some centers studying the therapy) and other major problems.
Nonetheless, only patients who have cancers that are impervious to other
forms of treatment are accepted for this study. Their progress is measured
against historical experience with their disease using chemotherapy and
radiation. In return for the increased risk of morbidity and even mortality,
patients may possibly gain up to four months of additional survival
compared to past treatment.

5. T H E B E L L - S H A P E D

CURVE

Given the risky business of advising patients in the presence of so much

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uncertainty, some physicians help patients decide by describing "the bellshaped curve." This is a curve drawn on a graph of a population of
patients' experience with survival from the disease in question. A number
only make it a few days or weeks. Gradually more patients live several
months to one and one-half years. Then the number of patients who live
longer falls off dramatically. Only one or two make it five years. This is the
case with cancer of the pancreas, no matter what doctors do to treat it.
The shape of the number of patients, the population curve, looks like an
inverted bell.
When a patient is newly diagnosed to have pancreatic cancer asks how
long she has to live, the physician can remain "value neutral" about the
possibilities (and not unduly persuade the patient to accept or reject
therapies) by saying that some persons die in a matter of weeks, more last
from several months to a year, and a very small number survive beyond
one year. The physician would point out that the patient may fall anywhere along that path.
Then possible treatments may be discussed, the results of which also
represent bell-shaped curves. In the case of pancreatic cancer, interventions are rarely if ever successful. So the proper way of framing the
discussion is to indicate to the patient that any experimental therapy
carries its own risks of reduced survival and a high probability of only
extremely modest gains. The gains might be represented by shifting the
bell-shaped curve a few months forward towards longevity. That is to say,
rather than inadvertently holding out hope that a patient will gain some
survival by consenting to an experimental treatment plan, the physician
would only promise a possible improvement in the bell-shaped curve.
This is a sophisticated point. But it can be explained this way. No one
knows where the patient falls on the curve; no one knows if that placement will be affected by a new experimental therapy. The patient may die
earlier than anticipated. Or the patient may die earlier than he or she
would have had they not accepted the experimental therapy. Depending
on the disease (fortunately not all are as intractable to treatment as
pancreatic cancer), the percentage of probability of moving the curve
forward, not just one's own survival within the curves, should also be
discussed. Is it high or low? This is another way of stating the overall risks
of the procedure for all patients who have accepted it in the past.

6. QUALITY OF LIFE
Most of the discussion about results in experimental medicine revolves

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around longevity. This is a good example of how data is abstracted from

concrete circumstances. It is not value-neutral, since longevity is an
important value. Earlier we saw how this value determined the scientific
interest in the role of fish oil in reducing serum cholesterol. But the value
helps shape the degree to which other factors or circumstances will be
ignored in the registration of the data, its storage, and its eventual
application to other populations.
In a heart transplant program, the success rate is measured by the
percentage of patients who have lived one year, five years, and more. The
five-year survival rate is most often used as a benchmark for all experimental efforts, especially in cancer treatments. It is a convenient way to
compare therapies. One asks: how many patients made it five years on this
treatment?
Naturally, physicians, nurses, and other health professionals are concerned about the well-being and values of their patients. But these quality
of life factors are tess amenable to measurement than longevity is. Yet
quality of life is an important consideration for most patients. It is often
left out of the discussion of chemotherapeutic trials. As noted earlier,
however, it is a centerpiece of other research medicine, such as cardiology,
when only an improved function rather than increased lifespan, can be
offered.
Suppose one patient on a study lived five and one-half years, but during
that time, entered the hospital a total of ten times, spending over half of
those years confined in a bed. During that time, the patient's family spent
innummerable hours at the bedside in the hospital, and the economic
burden on the family was dramatically increased. On the same study,
another patient lived only 2 years and three months, but had to be
hospitalized only twice. She died at home, and her family was not unduly
stressed.
How can these two outcomes compare? In terms of longevity, the five
year survival rate, the second person fared much worse than the first. Yet
in terms of values, family and economic values held by the patient, the
second person might have had a more successful result from the therapy
than the first. This cannot be measured scientifically. Nor can it be
presented by discussion of probabilities of survival.
The use of probabilities is actually predicated on an assumed value, that
the patient, like most persons, wants to live as long as possible. But
patients often possess a complex of values, only one of which is longevity.
It is important to consider these other values in any dialogue with the
physician about experimental therapy and risky medical procedures. The
possibility of the treatment plan having a negative impact on other values

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besides longevity should be thoroughly discussed before proceeding. Thus,

a patient with pancreatic cancer may quite realistically choose not to
accept any further treatment and enter a hospice, so that he does not
become a burden on his family or use expensive medical resources that
might benefit others. These considerations are his values, values other
than longevity. Another patient with the same disease may choose an
all-out assault on it, because she has just started a veterinary practice and
wants to leave as much of a business as possible in place for the family
after she dies.
Decisions about medical treatments are sometimes made in the midst of
heart-rending uncertainty. The risks and benefits are not only difficult to
determine with any degree of certainty, but they are most often measured
in terms of longevity. Longevity may not always be the most important
value to be preserved when patients face almost certain death no matter
what they choose to do.

7. C O N C L U S I O N S

Research medicine is an important part of modern health care. Patients

should be encouraged to participate in this effort by minimizing their risks
and by public support, so that the economic burdens can also be decreased. But in the end, a choice for a better or a ldnger life rests on the
degree of risks the patient chooses. Patients weighing probabilities under
the advice of their physicians need support and guidance for their most
profound values. More than their lives are at risk. Their history and
circumstances are also in danger to being neglected in the application of
the general to the specific.
Further, philosophy of medicine should explore the problematic
"metaxological realm" along the lines suggested in this paper. Not only the
doctor-patient relationship, but also the relationship between abstract data
and particular individuals should be examined much more thoroughly than
it has been in the past. 15
I have made several claims and defended them:
(1) The epistemological problems of the general and the individual
cannot be encapsulated in the notion of a science of individuals. Instead,
the adjustments between data and individuals must take into account the
personal value history of the patients, their own need to preserve their
identity, and the circumstances from which the data itself was abstracted.
This adjustment appears to be a techne, a discipline aimed at doing right.
(2) When patients are asked to make a choice, it is most proper to

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discuss the m o v e m e n t on the bell-shaped curve w h e n discussing risks and

benefits.
(3) A b s t r a c t data m a y give a false impression of scientific certitude. If
it results f r o m too m u c h abstraction f r o m one individual population, it
m a y n o t apply so readily to a n o t h e r population.
(4) T h e abstraction f r o m the concrete m a y tantalize us into neglecting
the rich and i m p o r t a n t realm o f the particular. This c o n c e r n does n o t
apply so m u c h to the scientists interested in gathering general data, but to
the practicing physician w h o employs it. This e m p l o y m e n t can sometimes
be d a n g e r o u s l y inattentive to the concrete.
D A V I D C. T H O M A S M A
Stritch School of Medicine,
Loyola University Medical Center,
2160 South First A venue,
Maywood, Illinois 60153, U.S.A.

NOTES
1 D. C. Thomasma, 'Philosophical Reflections on a Rational Treatment Plan', Journal of
Medicine and Philosophy 11 (1986), 157--166.
z For example, see E. A. Murphy, E. M. Rosell, and M. I. Rosell, 'Deduction, Inference
and Illafion', Theoretical Medicine 7 (1986), 329--354.
3 B. Stokes, 'Reel in Facts Before SwallowSng Fish Oil', Chicago Tribune (1987), Sect. 5,
2.
4 C. Lauerman, 'Life After Transplant', Sunday: The Chicago Tribune Magazine (May 24
1987), Sect. 10, 10--15, 20--21.
5 S. Gorovitz, and A. MacIntyre, 'Toward a Theory of Medical Fallibility', Journal of
Medicine and Philosophy 1 (1976), 51--71.
6 E. Loewy, Ethical Dilemmas in Modern Medicine (Lewiston/Queenston: Edwin Mellen
Press, 1986), 6--8, discusses the notion of medicine as a techne, a skill aimed at a moral
end, rather than merely a skill. This is an important understanding for the fourth caution
noted in the text.
7 W. Desmond, Desire, Dialectic, and Otherness (New Haven: Yale University Press,
1987).
s E. D. Pellegrino, and D. C. Thomasma, A Philosophical Basis of Medical Practice (New
York: Oxford University Press, 1981), Ch. 2.
9 As quoted on the frontspiece of O. Sacks, The Man Who Mistook His Wife for a Hat and
Other Clinical Tales (New York: Summit Books, t986).
lo Ibid., p. 166.
11 K. Sehaffner, ed., 'Ethical Issues in the Use of Clinical Controls', Journal of Medicine
andPhUosophy 11 (1986),
12 A. Tversky, and D. Kahneman, 'The Framing of Decisions and the Psychology of
Choice', Science 211 (1981), 453-- 458.
13 D. Marquis, 'An Argument That All Prerandomized Clinical Trials Are Unethical',
Journal of Medicine and Philosophy 11 (1986), 367--384.

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14 H. Brody, Placebos and the Philosophy of Medicine: Clinical, Conceptual, and Ethical
Issues (Chicago: University of Chicago Press, 1980).
~5 See E. Cassell, 'Moral Thought in Clinical Practice: Applying the Abstract to the Usual',
in H. T. Engelhardt, Jr., and D. Callahan (eds.), Science, Ethics, and Medicine (New York:
Hastings Center, t976), 147--160.