Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine's epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi's theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine.

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Clinical reasoning has been defined as a form of cognition applied to evaluating and managing a patient's medical problem. As a kind of cognition, a product of the human psyche, it is logical to expect that clinical reasoning should be best understood through methods derived from psychology, neuropsychology and the cognitive sciences. However, the application of scientific methods to evaluating clinical reasoning is unable to analyse clinical reasoning in terms of first-person experience and consciousness. By reducing clinical reasoning to its cognitive components the cognitivist approach tends to ignore the larger context in which clinical reasoning occurs. By reducing its conception of clinical reasoning to its cognitive components, the neuropsychological approach fails to acknowledge clinical reasoning as a form of intentionality, a gestalt, grounded in human perception. A full epistemology of clinical reasoning requires a phenomenological analysis that can make sense of the relation between pre-reflective consciousness and explicit forms of knowing. In this paper I conciliate cognition and consciousness in medicine through analysing the phenomenology of perception in clinical reasoning. I compare the application of phenomenology to clinical reasoning with the attempt to model clinical reasoning on Aristotelian practical wisdom or phronesis. Finally, I analyse empathy as a type of perception critical for effective clinical interaction and exemplary for reflecting on perception as the intersubjective foundation of clinical reasoning.

The accurate diagnosis of urinary tract infection. in infancy and childhood based on examination of the urine is made difficult by the number of variables involved. These include the age and sex of the patient, method of collection of the urine, time interval between micturition and urine examination, and technique of examination employed. The method of collection of urine is most important and for two common methodsplastic adhesive bags and midstream specimens-we have suggested diagnostic levels for cell and bacterial counts related to the age and sex of the patient and the type of collection 'Braude et al., 1967).To determine the validity of these levels non-catheter and -atheter specimens of urine were obtained from 68 patients. MaterialIn most of the patients the suspicion had arisen on clinical grounds that urinary tract infection might be present-a suspicion based on suggestive symptoms such as abdominal pain, dysuria, frequency of micturition, enuresis, unexplained vromiting or anorexia, and, in the case of infants, unexplained failure to thrive. Also in a number of symptomless cases routine examination of the urine had suggested that infection might be present. Of the 68 patients 49 were female and 19 nale. The ages ranged from 9 days to 11 years (see Table). MethodsWith the methods described by Braude et al. (1967) operator holds the catheter in position an assistant slowly injects 2 ml. of solution. A return flow alongside the catheter should occur. (If it does not the catheter has been inserted too far and the solution is being injected into the bladder. This may modify bacteriological but not cytological results.) The catheter is then withdrawn and the patient left for half an hourIn young boys catheterization often causes discomfort and it is advisable to anaesthetize the posterior urethra before the second or main part of the catheterization procedure by introducing a little anaesthetic jelly (Duncaine) into the urethra immediately after the irrigation procedure.After half an hour has elapsed the operator again scrubs up.and, holding the labia apart or retracting the foreskin, using sterile swabs, the genitalia are resprayed with Polybactrin as described above and the patient is retowelled. The operator puts on sterile gloves and catheterizes the bladder, using a sterile disposable plastic tube size 9 F.G. (feeding or umbilical tube) and a non-touch technique. The assistant, controlling the other end of the catheter with forceps, directs the urine into a sterile container. Normally a few drops are collected into a first bottle, which is discarded, and the remainder of the urine into a second. In small babies there may be little urine in the bladder, and under these circumstances the first bottle has to be used for bacteriological examinations. Effect of Polybactrin Catheterization on Bacterial Growth in the UrineIn most cases the antibacterial activity of the urine obtained after catheterization was determined by means of indicator plates sown with an antibiotic-sensitive staphylococcus and filter...

Over the past several decades the 'affective revolution' in cognitive psychology has emphasized the critical role affect and emotion play in human decision-making. Drawing on this affective literature, various commentators have recently proposed strategies for managing therapeutic expectation that use contextual, symbolic, or emotive interventions in the consent process to convey information or enhance comprehension. In this paper, we examine whether affective consent interventions that target affect and emotion can be reconciled with widely accepted standards for autonomous action. More specifically, the ethics of affective consent interventions is assessed in terms of key elements of autonomy, comprehension and voluntariness. While there may appear to be a moral obligation to manage the affective environment to ensure valid informed consent, in circumstances where volunteers may be prone to problematic therapeutic expectancy, this moral obligation needs to be weighed against the potential risks of human instrumentalization. At this point in time we do not have enough information to be able to justify clearly the programmatic manipulation of human subjects' affective states. The lack of knowledge about affective interventions requires corresponding caution in its ethical justification.

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