In the era of evidence-based medicine (EBM), discussions of medical knowledge have been largely focused on the role of clinical trial research, though even the primary architects of EBM have always acknowledged that the results of such clinical research do not, and should not, dictate care. Although the most widely cited definition of EBM state that knowledge from clinical trials must be integrated with a physician’s clinical expertise, knowledge of physiology, and understanding of their patient’s values, proponents of EBM have provided sparse guidance on how this integration should occur. Solving this “integration problem” of EBM requires understanding how clinicians gain and demonstrate expertise, what kinds of medical knowledge can legitimately be brought to bear, and how knowledge of individual patients should be obtained and considered in clinical decision making. This book describes and defends a case-based approach to clinical judgment reliant on a broad and non-hierarchical view of medical epistemology.

Everyone agrees that clinical experience is important, but what it is and what it does are less clear. This chapter brings together different views and approaches to clinical experience to clarify the role it plays in medical decision-making. It starts with an overview of EBM’s view of clinical experience, then looks at several alternative roles experience can play in practice. First, individual clinical experience can sometimes be articulated in a way that allows it to serve as evidence for a specific clinical decision, and the collective knowledge of expert members of a medical community can also provide valuable evidence to inform clinical decisions. Second, clinical experience can be viewed as constituting clinical expertise and then used to describe how doctors make clinical decisions. The chapter surveys several ways of accounting for this second role of clinical experience, in light of the integration problem introduced in a previous chapter, and concludes that none of these approaches can solve the integration problem. Moreover, these approaches have tended to focus on diagnostic reasoning and have had less to say about treatment decisions.

This chapter presents a solution to the integration problem. EBM, the dominant approach to medical knowledge, focuses on the importance of clinical trials in providing medical knowledge. Other chapters in this book have argued for the importance of including knowledge of physiological mechanisms, a provider’s clinical experience, and understanding of patient experiences and values to clinical decision-making. The importance of all of these sources of medical knowledge makes solving the integration problem even more crucial. This chapter offers a solution to this problem that is rooted in case-based reasoning. It begins by describing the basic components of case-based reasoning, including construction of a target case and reasoning by analogy between that target case and one or more source cases. It then introduces a more detailed model of clinical reasoning that is based on Stephen Toulmin’s model of argumentation, and that allows clinicians to integrate the different kinds of knowledge in a way that responds to the needs of specific patients in specific situations. Using this model can help clinicians better understand their own reasoning—and better communicate that reasoning to trainees, colleagues, and patients. The case-based framework represents an explicit and practicable method integrate a plurality of medical knowledge into a particular medical decision.

This chapter introduces some recurring questions and debates about how medical knowledge is derived and used in practice. In different eras of medicine, different kinds of knowledge (theory, clinical observation, laboratory research) were prioritized and relied upon in medical decision-making. Regardless of the dominant kind of knowledge, two central tensions recur in each era of medicine: (1) Between rationalist versus empiricist approaches to medical knowledge, and (2) between knowledge of general scientific claims and knowledge of individual patients. After introducing these tensions, the chapter demonstrates how they played out at different times. Although this chapter focuses on medical history, the questions it raises are also crucial in medicine today, and the issues it introduces will be essential to the discussion in later chapters of what contemporary clinicians need to know and how they should utilize that knowledge.

This chapter focuses on evidence-based medicine (EBM), the currently dominant understanding of medical knowledge. It begins with a brief description of the origins and development of EBM, introducing and assessing related developments in medicine and medical research. It then introduces several criticisms of EBM levied by both clinicians and philosophers. Overall, EBM’s major achievements have been to draw attention to the importance of clinical research for medical practice, to contribute to improvements in the quality and reporting of this research, and to promote the teaching of skills needed to critically appraise clinical studies. EBM, however, has been less successful in developing practicable methods for using this knowledge in clinical practice. For the most part, EBM simply asserts that, after identifying and assessing relevant clinical research sources, clinicians must integrate this evidence with their clinical experience, their knowledge of biology, and their patients’ values. It does not, however, explain how to do this: EBM has an integration problem.

SourceURL:file://localhost/Users/mark/Desktop/PCMinICU.anon.doc The provision of intensive care medicine presents particular challenges for a person-centered medicine. The intensive care unit can be a dehumanizing place, where patients often fail to appear to be persons and where burnout and depersonalization on the part of providers is common. Most people who require intensive care are unable to participate directly in their own healthcare decision making. Incorporating individual patient goals and values into decision making, then, requires explicit and active effort on the part of intensivists to elicit that information from a variety of sources. In addition, clinical decision making in the ICU is highly dependent upon pathophysiologic reasoning and technical knowledge that is not readily accessible to individual patients and families. Access to and continuation of intensive care medicine is generally controlled by providers of the service. This locus of control, along with the fact that need for ICU level care generally occurs due to acute, severe illness, means that individuals may be denied or subjected to intensive care against their will. The provision of person-centered intensive care, then, places a high degree of responsibility upon clinicians to ensure that care is individualized and to respect patients as persons. Several practical recommendations to aid clinicians in achieving these goals are offered.

Philosopher Frank Ramsey died in 1930 aged only 26. There has been much speculation about the nature of his final illness and the sequence of events which led to his death. To prepare this case report, we traced Ramsey’s medical records and combined them with an extensive and unique dataset of contemporaneous sources. We use these to evaluate three possible explanations for Ramsey’s illness and its unexpectedly fatal trajectory—infectious (Weil’s disease), autoimmune (primary sclerosing cholangitis) and obstructive (gallstones). We explore how uncertainty surrounding each of these possibilities might have influenced Ramsey’s doctors’ thoughts and actions, including their ill-fated decision to perform the emergency operation that appears to have precipitated his final decline. We then reflect on the unfinished opus on which Ramsey was working when he died—on the nature of truth and how humans reason under conditions of uncertainty. We end with some thoughts linking Ramsey’s death to his philosophy.

Abstract Objective: Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions. Methods: A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record. Results: Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients’ age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient. Conclusions: Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.

Objectives:. Plans for allocating scarce healthcare resources during the COVID-19 pandemic commonly involve the activation of institutional triage teams. These teams would be responsible for selecting patients who are most likely to survive to be prioritized to receive scarce resources. However, there is little empirical support for this approach. Design:. High-fidelity triage-team simulation study. Setting:. Healthcare institutions in Washington state. SUBJECTS:. Triage teams, consisting of at least two senior clinicians and a bioethicist. INTERVENTIONS:. Participants reviewed a limited amount of deidentified information for a diverse sample of critically ill patients. Teams then assigned each patient to one of five prioritization categories defined by likelihood of survival to hospital discharge. The process was refined based on observation and participant feedback after which a second phase of simulations was conducted. MEASUREMENTS AND MAIN RESULTS:. Feasibility was assessed by the time required for teams to perform their task. Prognostic accuracy was assessed by comparing teams’ prediction about likelihood of survival to hospital discharge with real-world discharge outcomes. Agreement between the teams on prognostic categorization was evaluated using kappa statistics. Eleven triage team simulations (eight in phase 1 and three in phase 2) were conducted from December 2020 to February 2021. Overall, teams reviewed a median of 23 patient cases in each session (interquartile range [IQR], 17–29) and spent a median of 102 seconds (IQR, 50–268) per case. The concordance between expected survival and real-world survival to discharge was 71% (IQR, 64–76%). The overall agreement between teams for placement of patients into prognostic categories was moderate (weighted kappa = 0.53). Conclusions:. These findings support the potential feasibility, accuracy, and effectiveness of institutional triage teams informed by a limited set of patient information items as part of a strategy for allocating scarce resources in healthcare emergencies. Additional work is needed to refine the process and adapt it to local contexts.

IMPORTANCE The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. OBJECTIVE To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. MAIN OUTCOMES AND MEASURES Emergent themes describing the triage process and experience of triage team members. RESULTS Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. CONCLUSIONS AND RELEVANCE This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.

Click to increase image sizeClick to decrease image sizeThis article refers to:Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency MeasuresThis article is referred to by:Ethics Frameworks and Beyond—Advancing Our Understanding of the Contingency Phase to Improve Health Care Quality During Public Health Emergencies

Issue: Epistemology, the branch of philosophy that deals with the nature, value, and use of knowledge, receives little or no formal attention in medical education. Yet the understanding of medical epistemology - focused on what kinds of medical knowledge are relevant to clinical decisions, the strengths and limitations of those different kinds of knowledge, and how they relate to one another and to clinical expertise - represents a critical aspect of medical practice. Evidence: Understanding the meaning of the term "evidence" is one of the fundamental tasks of medical epistemology. Other foundations of the evidence-based medicine movement, such as the "hierarchy of evidence" and the concept of "best" evidence, rest upon epistemological assertions, claims regarding the appropriate kinds and relative value of knowledge in medicine. Here we rely upon the work of philosophers of medicine who have been engaged in debates regarding the epistemic tenets of the evidence-based medicine movement. We argue that medical students and physicians-in-training should learn basic terminology and methods of epistemology as they are being introduced to the concepts and techniques of evidence-based medicine. Implications: The skepticism and critical analysis encouraged by EBM can and should be applied to the underlying assumptions and primary tenets of EBM itself. It is not enough for philosophers to partake in this endeavor; students, trainees, and clinicians need to carefully and constantly examine the reasons and reasoning that coalesce into clinical acumen. Our role as medical educators is to give them the tools, including a basic understanding of epistemology, to do that over a lifetime.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

The clinical case has been central to the practice of medicine since its inception, but the perceived value of the case, both a source of knowledge and as the basis for clinical decision making, has declined in the era of evidence-based medicine. Thinking in cases, however, is necessary for the practice of person-centered healthcare, ensuring that the individuality of the case-at-hand is recognized and incorporated into diagnostic and therapeutic decisions. The case-at-hand will be compared to other cases, derived from clinical research, pathophysiologic understanding, and clinical experience, as these kinds of cases serve as the repository of medical knowledge. Utilizing analogy and argument, clinicians derive and negotiate warrants relevant to particular patients, in order to make diagnoses, recommendations, and decisions. Case-based reasoning provides a rigorous and explicit framework for delivering person-centered care to individuals seeking healing.

Within the evidence-based medicine (EBM) construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians' primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the "best" evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients.

While multiple versions of shared decision making (SDM) have been advanced, most share two seemingly essential elements: (a) SDM is primarily focused on treatment choices and (b) the clinician is primarily responsible for providing options while the patient contributes values and preferences. We argue that these two elements render SDM suboptimal for clinical practice. We suggest that SDM is better viewed as collaboration in all aspects of clinical care, with clinicians needing to fully engage with the patient's experience of illness and participation in treatment. SDM can only take place within an ongoing partnership between clinician and patient, both respecting the other as a person, not as part of an isolated encounter. Respect for the patient as a person goes beyond respect for their choice. Non-interference is not the only way, or even the most important way, to respect patient autonomy. Knowing the patient as a person and providing an autonomy-supportive context for care are crucial. That is, the clinician must know the patient well enough to be able to answer the patient's question "What would you do, if you were me?" This approach acknowledges clinicians as persons, requiring them to understand patients as persons. We provide examples of such a model of SDM and assert that this pragmatic method does not require excessive time or effort on the part of clinicians or patients but does require direct and particular knowledge of the patient that is often omitted from clinical decisions.

While the importance of mechanisms in determining causality in medicine is currently the subject of active debate, the role of mechanistic reasoning in clinical practice has received far less attention. In this paper we look at this question in the context of the treatment of a particular individual, and argue that evidence of mechanisms is indeed key to various aspects of clinical practice, including assessing population-level research reports, diagnostic as well as therapeutic decision making, and the assessment of treatment effects. We use the pulmonary condition bronchiectasis as a source of examples of the importance of mechanistic reasoning to clinical practice.

Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.

The philosophy of medicine as a specific academic discipline appears to be growing in interest, if not in influence, over the last decade or so. The International Philosophy of Medicine Roundtable, which seeks to facilitate collaboration of philosophers working in the field worldwide, now has over 300 members, a six-fold increase over the last 8 years, many of whom attended the outstanding 7th bi-annual conference of the group held this summer in Toronto. As if to announce its presence, the philosophy of medicine has seen the publication of several edited collections of essays on the subject over the last year.1-3 These efforts are largely aimed at an audience of philosophers, representing works in the field rather than works that engage the practice of medicine. Ultimately, such engagement with clinical medicine represents the next challenge for the burgeoning field. The Bloomsbury Companion to Contemporary Philosophy of Medicine (hereafter, the Bloomsbury Companion) collects over a dozen original essays from an international group of established and emerging philosophers of medicine focused on specific topics of ongoing debate within the philosophy of medicine.1 Edited by James Marcum, the collection exhibits some of the variability expected in a collection of invited essays, but the writing is uniformly concise and coherent. Each essay can stand alone, with quite minimal attribution or referencing of other chapters. The work does presuppose a working knowledge of philosophical terminology and argument, although a glossary is provided. The Bloomsbury Companion is bookended by two multi-authored broad overview pieces. The first, by Loughlin, Bluhm, and Gupta, represents an outstanding survey of the most salient philosophical challenges facing clinical medicine today. These include the philosophical assumptions and tenets that underlie various, and often competing, models of clinical practice, for instance, evidence-based, value-based, and person-centred medicine. The authors also introduce the broad problem of the relationship between science and medical practice as well as exploring medicine's search for a centre around or a base upon which to build the model of optimal clinical care. Closing the collection, Stegenga, Kennedy, Tekin, Jukola, and Bluhm discuss several of the new directions that the philosophy of medicine is taking, recognizing that most of the debates raised in the opening chapter remain ongoing concerns. Encouragingly, this final chapter does focus on issues directly relevant to medical practice, including the challenges applying research to health care policy, diagnosis in medicine and psychiatry, and improving the objectivity, if possible, of clinical research. In between these bookends, chapters take on more specific areas of current interest in the philosophy of medicine. Here the variability between chapters becomes evident, with some authors providing an overview of the topic being addressed, but several taking a specific stance or offering new analyses within an ongoing debate. In the overview category are chapters on epidemiology, evolutionary medicine, and the meaning of health and disease by Broadbent, Ruse, and Cooper, respectively. Each serves as a balanced survey of the topic area. Chapters dealing with humanism and phenomenology, by Tauber/Fiavola and Svenaeus/Gergel, respectively, present the overview from a position of confidence regarding the importance of these philosophical stances to the understanding of medicine. Braude, with a discussion of clinical reasoning, specifically emphasizes the importance of tacit knowledge and makes an explicit claim (which I agree with completely) that sound clinical decision making represents an example of phronesis, an Aristotelian concept often translated as “practical wisdom.” In discussing causation in medicine, Clarke and Russo use an overview to reinforce their argument that causation in medicine is complex and multi-faceted, and certain to include mechanism. For his part, Howick attempts to justify an epistemology of evidence-based medicine that distrusts and devalues mechanism, defending the increasingly indefensible notion of a hierarchy of evidence. In addition to editing the collection, Marcum authors a chapter that adds to an overview of the major models of medical practice, evidence-based medicine, patient-centred medicine and person-centred medicine, with an original analysis of the notion of health care personalism that results in clear preference for person-centred medicine. The essays in the Bloomsbury Companion represent some of the best of contemporary philosophy of medicine. Yet many of the essays in this work lack a clear connection to clinical practice. Such a connection is certainly not necessary; philosophy of medicine does not have to aim at application. But, I would argue, medical practice has the potential to benefit from more active engagement by philosophers of medicine. I would also suggest, with some caution, that philosophers of medicine might benefit at times from a clearer understanding of exactly what clinicians are asked to do. In their introductory chapter, Loughlin, Bluhm, and Gupta cite an article in which Toulmin was said to have claimed that medicine saved the life of philosophy. But Toulmin's title and claim were more specific, that medicine saved the life of ethics.4 While perhaps slightly hyperbolic, Toulmin clearly recognized that by engaging actively with medicine, philosophers and theologians focused on ethics could move arguments from academia to the “real” world, could influence practice and improve care, and could demonstrate the value of philosophy to the many who saw none. Bioethics is now ensconced within clinical medicine, from medical student education to clinical ethics consultation, from academic departments within medical schools to ethical dilemmas being presented in popular entertainment. So successful has bioethics become, with its own professional societies and publications, that the philosophy of medicine renounced any claim to it and must specifically exclude it from dedicated conferences and journals or risk being overwhelmed. It would seem too much to hope that the philosophy of medicine, sans ethics, will ever be able to insinuate itself into clinical medicine to the same degree as bioethics, but increasing engagement seems appropriate and wise. The bioethics movement offers some guidance in this regard. For the philosophy of medicine to impact the practice of medicine, several key steps need to be taken, some from within the philosophy of medicine, others from within clinical medicine. In the early days of bioethics, philosophers interested in medical ethics first sought to learn more about medicine. For example, a theologian by training, Al Jonsen sat through medical schools classes and joined rounds at a teaching hospital, learning the language and culture of medical practice long before attempting to instruct physicians regarding ethical decision making. Only by engaging with clinicians can philosophers understand the inchoate and unarticulated philosophical challenges faced at the bedside. That most physicians do not know the meaning of the word “epistemology” does not mean they do not face epistemic tests on a daily basis. Philosophers engaging clinicians is necessary for clinicians to understand that the practice of medicine rests upon often unrecognized philosophical assumptions. This is likely to be one of the most difficult challenges for philosophers of medicine, but absolutely necessary to impact clinical practice. Bioethics remains a philosophical discipline, with ongoing debate regarding a multitude of issues, but it has also managed to reach some consensus that can be conveyed to practitioners even while debates continue. The general importance of patient involvement in care decisions, the lack of distinction between withholding and withdrawing life supporting care, and the absence of whole brain function as a determinate of death all represent critical areas of consensus despite ongoing work clarifying and even challenging these stances. Clinicians are a practical lot. They do not have the luxury of debate for debate's sake; they must reach a decision in short order. Bioethics has recognized this, largely putting aside core disputes in ethical theory in order to help clinicians come to defensible conclusions. Not surprisingly, most works in the philosophy of medicine are written for other philosophers of medicine, in journals of which clinicians have never heard. This is certainly appropriate, but at some point the engagement of clinical medicine requires engagement of clinicians. The vast majority of medical students and physicians, at least in the US, focused on the sciences during their undergraduate education and have limited or no exposure to philosophy as a discipline. Writing philosophy for clinicians, then, requires abandonment of the philosophical patois and, at times, truncation of arguments compared to those that would be presented to other philosophers. The process represents more translation than “dumbing down,” and needs to be presented in a fashion where the relevance to clinical medicine is made clear. A recent introductory text offers such an approach.5 Early in my career, I had a manuscript reviewer for a medical journal justify a recommendation to reject the paper with a single sentence: “This is not science, this is philosophy!!” If philosophers are willing and able to write for a clinical audience, medical journals need to be willing to publish the work. Certainly one cannot expect all publications to follow the lead of the Journal of Evaluation in Clinical Practice, which has dedicated entire issues to the philosophy of medicine, but one can encourage editors to consider philosophical works that are directly applicable to the practice of medicine. Such pieces, regardless of their analytical rigour, will likely be confined to the sections of medical journals where “unscientific” work is allowed, generally under a label such as “Opinion,” “Viewpoint,” “Commentary,” or “Perspectives.” Early on, bioethicists sought out and cultivated interested and sympathetic individuals engaged in medical administration and clinical care to help them make an impact. These clinician champions led ethics committees, taught trainees, and advocated for broader inclusion of ethics and ethicists into education and clinical care. Philosophy of medicine, if seeking to impact clinical practice, will similarly need to develop clinician champions who understand the importance of the philosophy of medicine to clinical practice. These relationships can be mutually beneficial, giving philosophers access to clinical practice while educating clinicians in philosophical concepts and analysis. Engagement is not a one-way street. Government, institutions, and professional organization working to improve clinical care and advance health care policies should actively recruit and include philosophers of medicine in working groups, committees, and other deliberative bodies, as was done with bioethicists. In developing health care policy, in particular, careful analysis of underlying epistemic assumptions may be particularly valuable. Ultimately, both philosophers of medicine and medical providers need to recognize the value of philosophical analysis to the practice of medicine. In the final essay of the Bloomsbury Companion, the examples of future directions for the field included a clinical element. That feature is important and certainly was not guaranteed. By focusing on clinically relevant topics, it is hoped that the philosophy of medicine as a field will draw closer to clinical medicine, an engagement that is certain to be mutually beneficial.