Malcolm Parker

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise

Stewart and DeMarco’s economic theory of patient decision-making applied to the case of diabetes is flawed by clinical inaccuracies and an unrealistic depiction of patients as rational traders. The theory incorrectly represents patients’ struggles to optimize their management as calculated trade-offs against the costs of care, and gives an unrealistic, inflexible account of such costs. It imputes to physicians the view that their patients’ lack of compliance is unreasonable, but physicians are accustomed to the variety of human factors which contribute to suboptimal compliance, and work with patients to minimize their influence. By depicting patients as rational traders rather than human beings with a range of motivations and burdens, the economic theory distorts the proper function of informed consent.

The turn to empirical ethics answers two calls. The first is for a richer account of morality than that afforded by bioethical principlism, which is cast as excessively abstract and thin on the facts. The second is for the facts in question to be those of human experience and not some other, unworldly realm. Empirical ethics therefore promises a richer naturalistic ethics, but in fulfilling the second call it often fails to heed the metaethical requirements related to the first. Empirical ethics risks losing the normative edge which necessarily characterizes the ethical, by failing to account for the nature and the logic of moral norms. I sketch a naturalistic theory, teleological expressivism (TE), which negotiates the naturalistic fallacy by providing a more satisfactory means of taking into account facts and research data with ethical implications. The examples of informed consent and the euthanasia debate are used to illustrate the superiority of this approach, and the problems consequent on including the facts in the wrong kind of way.

The materials consist of a co-authored, peer-reviewed book, a co-authored, peer-reviewed book chapter, 30 single authored peer-reviewed journal papers, and 15 co-authored peer-reviewed journal papers, of which I was the lead author on 8 papers. There are 32 papers from Australasian journals, at least two of which are also regarded as international. 22 papers are published in international journals. The co-authored book was favourably described in his foreword by Justice Michael Kirby of the High Court of Australia. The refereed chapter is contained in an issue of the Australian Legal Monographs series. The papers constitute a body of work in Australasian and international contexts in a field which is relatively new to academic achievement, broadly understood as philosophy of medicine, medical ethics and health law. The journals in which the papers are published include two of the most highly regarded bioethics journals in the world, Australia’s leading medical journal, the two leading world medical education journals, Australia’s leading journal for health and medical law, and the Torts Law Journal, an Australian journal which is recognized as one of the world’s leading journals in the field of tort law.

The Australian Health Ethics Committee’s National Statement on Ethical Conduct in Research Involving Humans (1999) expanded the health and medical focus of preceding statements by including all disciplines of research. The Statement purports to promote a uniformly high ethical standard for this expanded range of research, and is endorsed by, inter alia, the Australian Academy of the Humanities, the Australian Academy of Science, and the Academy of Social Sciences in Australia.High ethical standards should apply to all research involving humans. However, uniformity in the review processes of disparate research endeavours is not a necessary condition for uniformly high ethical standards. Bringing the ethical review of all research under a model which has developed within the context of health and medical research ethics for over thirty years may be inappropriate and at times incoherent. The language, methods, nature and products of research in areas such as the Humanities are often very different from those of health, medical and other sciences.The Behavioural and Social Sciences Ethics Review Committee at The University of Queensland (UQ) had, since the mid-1980s, considered that the guidelines of the time did, in fact, cover all aspects of human experimentation. We describe the ways in which this position was implemented, how issues raised by the new wording in the National Statement have been recently managed by UQ’s research ethics committees, and point to outstanding questions.

An Anonymous DeathThe comet, a white haired traveller, hauls its tail behind, thereby hangs its tale. Its particulate history swings away into black time as it skirts you.A million times a million fissions, fires in Andromeda, a surge of ice across a steppe, the moon’s impacted skin. Events escape their birth and move out at the roar of light, hurtling endlessly nowhere and everywhere colliding stray worlds, spinning and groping.At night through cat’s eye domes watchmen on the world’s clearest ranges trap the begetting of suns or discern an ancient death when intercepted at the glass when Diplodocus started the journey into strata or when a hairy thing tottered erect and stretched out tool-seeking fingers. The watchers in the domes live half in a past older than the sun.I tended a white haired man and cry out for a lens to map him. His deeds curve short of my time sputting out in a brown river carrying a wiry oarsman in a sepia photograph. The deeds of friends are buried in a beach wir

They enterin curves and stoopslimping and tappinga file of bare armscreased faces upliftedred eyelids poutingeyes curtained in cataract.The syringes are magazined at his hip.A pinch of skinin a chill autumn morninga stinging spreads outat the borders of shouldersthe grim supplicationfor all his attentionthe trembling smileon his remembering a name.Swabs spent in bucketsthe names all collecteda shifting and amblingacross the lawns to their liveson small porchesand in dim echoing cells.Washing his handsof the short easy morningthose bird-bone armsgrow stars of Davidin the injected whealsand the upturned headspull at his neckfor a sparklet of mercyhe prodding them downinto the frostfrom the stinking trainsat the point of more serious weaponry.They are a herdfanning out to their winding down daysdark-eyed ones shuffling blindto other deaths, gassed and limed

Lennard Davis’s Biocultural Critique of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to patients who suffer from psychological distress. The history of medicine and psychiatry demonstrates that psychiatric diagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains

The convergence of complementary and alternative medicine (CAM) and evidence-based medicine (EBM) is a prominent feature of healthcare in western countries, but it is currently undertheorised, and its implications have been insufficiently considered. Two models of convergence are described – the totally integrated evidence-based model (TI) and the multicultural-pluralistic model (MP). Both models are being incorporated into general medical practice. Against the background of the reasons for the increasing utilisation of CAM by the public and by general practitioners, TI-convergence is supported and MP-convergence is rejected. MP-convergence is epistemologically and clinically incoherent, and it cannot be regulated. It is also inconsistent with developments in the legal determination of the standard of care for both diagnosis/treatment and disclosure. These claims concerning MP-convergence are justified by the fact that science is not a member of the group of perspectives or world-views which postmodernism treats as equally valid, and this is especially important for healthcare.

The United Nations Convention on the Rights of Persons with Disabilities urges and requires changes to how signatories discharge their duties to people with intellectual disabilities, in the direction of their greater recognition as legal persons with expanded decision-making rights. Australian jurisdictions are currently undertaking inquiries and pilot projects that explore how these imperatives should be implemented. One of the important changes advocated is to move from guardianship models to supported or assisted models of decision-making. A driving force behind these developments is a strong allegiance to the social model of disability, in the formulation of the Convention, in inquiries and pilot projects, in implementation and in the related academic literature. Many of these instances suffer from confusing and misleading statements and conceptual misinterpretations of certain elements such as legal capacity, decision-making capacity, and support for decision-making. This paper analyses some of these confusions and their possible negative implications for supported decision-making instruments and those whose interests these instruments would serve, and advises a more incremental development of existing guardianship regimes. This provides a more realistic balance between neglecting the real limits of those with mental disabilities and thereby ignoring their identity and particularity, and continuing to bring them equally and fully into society.

SenilityCalled from pleasuresI go tap-tapping down an old man’s backdown the skin of eighty summers wastingon a rib-ladder closingon a history of heart and lungs.These narrowly contracting bags I find, proclaim“Today his chest is clear as yours or mine.”This is the news requiredas the tide of vigilancelaps his sheets each surfacing dawn.“He’s doing very well.”He leans his gaze to the voice dintingthe routine of his roombut slides the focal point towards infinitypast those gatheredto the motes of memoryto wherepinned in the windthrough their age and bondher sacrificial flags go flutteringbattered and fastened into the room’s cornerhinged haggard to his unhinging.In this too a workless son and centrelessclock-bound slaveto the incontinent brain and its seepage.Two tight-wire walkerswell talked out by nine each bed-wet daythe backyard hoist their prayer-wheel creaking.The sheets flap up the scent of their detentions.Time in its time will track them round their modest cornernovice at the f