Introduction

Though this issue of The Journal of Medicine and Philosophy is technically a nonthematic issue, common threads run among each of the six papers. One essay focuses on the epistemic trust that pervades medical practice and considers both when such trust is justified and what features of current medical practice undermine such justification. Issues of trust also underlie concerns surrounding informed consent, and two essays take up this issue from the patient's perspective. Two other essays deal with questions surrounding when a physician can withhold her consent to provide a treatment based either on moral convictions or judgments of futility. And another paper challenges arguments limiting one's ability to make judgments regarding the ethical status of practices beyond one's own culture, with a particular focus on the practice of female circumcision.

In the first essay in this of JMP, entitled “Epistemic Trust, Epistemic Responsibility, and Medical Practice, Abraham P. Schwab examines the importance and prevalence of epistemic trust within medical practice. Noting that such trust not only characterizes the relationship between patient and physician but also between physicians/nurses and lab techs, between lab techs and makes of diagnostic tests, etc., Schwab seeks to explain how and when such trust can be epistemically justified. That is, when is such trust epistemically responsible? Using the case of a friend who was recently tested for HIV, Schwab demonstrates the unavoidable nature of epistemic trust that pervades the medical realm. For reasons ranging from limited knowledge, specialized expertise, standard practices of training and apprenticeship, to name a few, the necessity of epistemic trust is uncontestable. However, whether and, if so, when such trust is justified is another matter entirely. Schwab argues that appeals to reliability underlie our conception of epistemic responsibility. Though Schwab does not aim to provide a full defense of epistemic reliabilism, he does maintain that it is claims produced via reliable methods that are what we look for in medicine. He goes on to note six aspects of epistemically responsible (i.e., reliable) beliefs. First, Schwab argues that though there may be instances in which a belief-forming process that is more reliable than chance may not be available, this does not necessarily undermine the possibility of epistemic responsibility. Second, he acknowledges that epistemically responsible beliefs might not always be true beliefs. Third, he notes that epistemically responsible trust involves trusting those who employ reliable belief-forming processes. Fourth, Schwab acknowledges that since he bases his brand of justified epistemic trust on the foundation of reliabilism, it, too, must contend with one of the largest problems for reliabilism—the generality problem. Fifth, including reliability as a requirement for responsible epistemic trust provides a standard for evaluating the testimony of others. Sixth, and finally, Schwab maintains that one must evaluate epistemic responsibility strategically, for though utilizing maximally reliable processes might seem the best course of action—all things being equal—there may be circumstances or considerations that make the use of less (though still) reliable processes responsible. Ultimately, however, Schwab seeks to defend the claim that much of the trust that currently occurs within the medical settings is irresponsible due to both the lack of ongoing evaluation of medical practices and therapies and basing one's trust on unreliable standards. Concerning the former, Schwab notes that the introduction of randomized controlled trials was a major move forward in determining the efficacy of many therapeutic treatments. However, the lack of continued evaluation past the initial approval process and the frequent off-label use of medications undermines judgments of the reliability of such treatments and, therefore, undermines the epistemic responsibility of placing trust in either these treatments or reports of their efficacy. Concerning the former issue—basing one's trust on unreliable standards—Schwab notes that patients, in particular, and people, in general, are often encouraged to use an evaluation of a person's “intellectual character” as reliable measure of the level of trust to place in this person and/or his testimony. Schwab argues, however, that given the less than steady nature of character and the relatively minor things that can lead someone to act “out of character,” determining appropriate levels of trust based on such information is epistemically irresponsible and leads to epistemically irresponsible beliefs.