TIME Magazine: Living With Pain – The State and Nature of Medical Knowledge

By | March 2, 2011

I tell them that I can make probabilistic statements about their state of health and suggested course of treatment, with a moderately high degree of confidence, but absolute certainty is something reserved for the gods.

But before diving into the details of the first chronic pain case I think that it is important to understand the state of medical knowledge and the philosophical and logical underpinnings of medical decision making. Firstly, doctors are always asked to make decisions based on incomplete, inconclusive and uncertain information about the effects of a particular treatment on the expected course of some condition. The key concept here is uncertainty. Doctors rarely have the luxury of complete and reliable information, either because of constraints of time, money or limitations of technology. They must nevertheless make decisions, which may have grave implications.

I have always thought that there should be a formal course in medical school on epistemology. Epistemology is the branch of philosophy devoted to the question of knowledge, including how one comes by a particular piece of knowledge, how reliable that knowledge is and how one should use that knowledge. Modern advances especially in the last of these areas have been made by John von Neumann and others in the branch of mathematics known as game theory, but one is rarely able to go through a formal mathematical analysis in the consultation room and a somewhat rougher estimate of risks and benefits must be made.

Suffice it to say that when a patient comes into my office and asks me what is wrong with them or what they should do, I often, time permitting, tell them that I don’t really know. I tell them that I can make some probabilistic statements about their state of health and suggested course of treatment with a moderately high degree of confidence, but that absolute certainty is something reserved for the gods. I suggest that we proceed based on the best information available and their personal wishes, but that we constantly monitor their progress and reevaluate our conclusion if progress becomes less than satisfactory.


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