Journal of Evaluation in Clinical Practice ISSN 1356-1294

The basis of medical knowledge: judgement, objectivity and the history of ideas*
jep_1318 935..940

Michael Loughlin PhD

Reader in Applied Philosophy, Manchester Metropolitan University, Crewe, Cheshire, UK

Keywords conceptual frameworks, evidence-based medicine, intuition, judgement, medical epistemology, objectivity, philosophical methodology, platitude, the history of ideas

Correspondence Dr Michael Loughlin Department of Interdiscipinary Studies Manchester Metropolitan University Crewe Cheshire CW1 5DU UK E-mail: m.loughlin@mmu.ac.uk

*Based on a lecture delivered by the author to the First Morgagni Lectures on The Light and Shade of Evidence-Based Medicine at the Istituto Superiore di Sanit, Universit La Sapienza in Rome on 20 October 2008. Accepted for publication: 26 August 2009 doi:10.1111/j.1365-2753.2009.01318.x

Introduction
Please dont be misled by the title of this lecture into thinking that I have anything profound or clever to say about the basis of medical knowledge. Despite one popular caricature of the philosopher as being somehow deep, the ones I know (coming mostly from what is known as the analytical school) make it a point of honour never to have anything profound or clever to say on any matter whatsoever. In fact, they consider it the hallmark of a good philosopher that one is always prepared to ask the sort of nave questions that others are too scared to ask, for fear of appearing ignorant. Thus, philosophers from Socrates to the present day have boldly revealed their ignorance in public on an impressive array of topics, from the nature of piety, courage, love, justice, knowledge, justication and belief to (in these more technically advanced times) perceptual content and its relationship with objective reality, complexity in natural systems, the distinction between science and non-science, sense and nonsense, the possibility of articial intelligence and the nature of clinical evidence. They have proceeded to ask questions that most seasoned contributors to discussions on these important topics regard as just plain irritating, insisting that assumptions be spelled out in laborious detail, even when they seem too obvious to most contributors to be worth mentioning, and childishly refusing to allow debate to move on until all such assumptions have been fully explained and justied. So while other speakers here today may bring a breadth of knowledge and intellectual sophistication, I bring to this debate a very basic ignorance, concerning the meaning of its fundamental terms, and a thoroughgoing intellectual naivety. I will say a little more about philosophical methodology after an illustration, but the simple idea that philosophers ask irritating questions is sufcient to be going on with like Le Petit Prince [1] in Saint-Exuprys

story, and like most children whose curiosity has not yet been civilized out of them, we do not drop a line of questioning until we get a serious reply, meaning one that actually answers the question. The organizers have asked me to talk about medical epistemology and EBM. The former is just the study of, or inquiry into, the nature and basis of medical knowledge. So my rst nave question is, of course, what is EBM? You might at least expect me to know this, having been invited here as a so-called expert speaker, but I would challenge the conference organizers to nd anything I have written or said in which I claimed to know what EBM is. The thing I nd odd and to the nave enquirer this really is quite remarkably odd is that its keenest defenders dont seem to be very clear on this either. They are absolutely clear that it is a wonderful and important thing, of great and even revolutionary signicance. The literature is littered with claims to the effect that EBM is a movement, a paradigm, a philosophy, an approach to practice and all manner of technical-sounding terms, whose use would suggest to the uninitiated that the authors knew what the thing was on whose behalf they were making such claims. (Some of us have tried to catalogue these various claims and qualiers and inquire as to their meaning and justication [24] only to be met with dismissive responses [5] or more often no response whatsoever.) Yet while authors are certain that EBM is on to something exciting [6], is unquestionably the right approach to follow in medicine, wherever and whenever possible [7] and even that anyone in medicine today who does not believe it is in the wrong business [8] they readily admit (in the same articles and chapters which make these claims) that there is no agreed denition of EBM [57], no shared account of its methodology among its exponents [5,7], no systematic account of its proper relationship to practice nor even any evidence that it produces substantive benets [59].
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What is yet more curious (again, to those unfamiliar with the mores of EBM discourse) is that the greatest enthusiasts for EBM write as though the question of what it is doesnt really matter as though only a very unexciting person with far too much time on his hands would think to ask [6]. The most crass contributors actually celebrate the multiplicity of incompatible denitions and accounts of EBM, treating this as evidence that EBM has evolved so much and so rapidly, treating the wide circulation of the phrase EBM as proof of the success of the concept [5,6]. They say things like: Our search for the best denition led to the conclusion that there are too many denitions, so what the heck, heres our own [6] before proceeding to add another apparently ad hoc denition for others to nd in subsequent searches. (Is this their idea of contributing to the body of research? Would you put such people in charge of your shopping list, let alone your health? I noticed you already had far too many cabbages so I thought, what the heck, and got you another one.) Ever since Sackett et al. stipulated what became the most cited denition of EBM as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients [10] it has been standard practice for EBM authors to dene their position in strictly platitudinous terms. What is more, their sense of the absurdity of criticizing EBM and sometimes their outrage that anyone dares to do so [11] is based not on any evidence for the superiority of their approach over any considered alternative (for as noted they admit no such evidence exists) but rather, it appears, on the implicit belief that EBM requires no evidence presumably because its reasonableness is self-evident? This is why, I take it, they can live with so many different denitions: one platitude is as good as another. Whether we talk about using current best evidence, a systematic approach to the acquisition, appraisal and application of research evidence to guide healthcare decisions [6] or using quantitative information, in concert with all other forms of knowledge, sensibly, in a clinical context [11] it is hard for anyone seriously to disagree with whatever is being proposed. We may not be entirely sure what it is that is being proposed, but the language in which the proposal is couched reassures us that, whatever it is, it must be very reasonable. How many people would like important decisions about their health to be made in terms of unsystematic approaches and the silly use of quantitative information? Denitions can only really be incompatible if they have substantive implications: the more semantically empty they are, the more they function like alternative slogans to promote a brand name so maybe EBM is less like an academic thesis or practical proposal and more like a brand name, associated with a range of products and publications, as well as career and funding opportunities for its exponents [12,13]. Denitions and accounts of its content may change, but so long as the brand EBM continues to attract interest and funding, EBM incorporated remains a sustainable enterprise, supporting new and updated manuals, training days, seminars and workshops . . . across the globe [6] even if all that most of these events achieve is the articulation of the just plain obvious (the superiority of good over bad evidence, the systematic over the unsystematic and the sensible over the silly use of quantitative information) to participants whose attendance was secured by the need to put something down on their CVs to indicate staff development, plus a department heads promise to pay expenses.
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Consider this, from a recent EBM publication [6]. Berating philosophers (the term initially placed in scare quotes, as though the authors cant decide whether their target is real philosophers or people pretending to be philosophers) for questioning the epistemological foundations of EBM, the authors retort: We are sure the intellectual ruminations would be fascinating if only we could understand them. The debate is for philosophers, not busy healthcare practitioners. For now, all we want to say is this: if youre overwhelmed by the literature in healthcare, then it doesnt matter if youre a doctor, dentist, nurse, midwife or therapist, EBM is for you! [6]. In other words: you are far too busy to think about the meaning and justication of the claims we invite you to accept, so just accept them! Corroboration of the brand name account of EBM: the attempt to establish unthinking, habitual brand loyalty? So is that the answer to my nave question: What is EBM? Its a brand name, a very successful marketing strategy? This would explain the equation of the mass circulation of the phrase with the success of the concept in the work of enthusiasts, and the existence of a vast literature in defence of what appears to be a platitude. Defenders of EBM would no doubt want to reject this characterization. In that case, they really ought to explain and justify the intellectual substance of their position. The onus surely is on defenders of EBM to do this, not those who question or criticize EBM. Which of the denitions and qualiers do they want to defend? Do they still want to claim that EBM is a scientic paradigm, throwing out allusions to Kuhns work on scientic revolutions [5,7,14], or will they now admit that this particular theft of philosophical terminology serves no explanatory purpose and represents sheer intellectual affectation [4,15]? If EBM is a philosophy then in what sense? If its a position or theory then what are its key claims? If its a movement then what, precisely, are its goals? It obviously will not do to respond: Lets leave the debate to philosophers. This book is for healthcare practitioners. We say it again if you are drowning in medical literature, EBM is for you! [6]. It was not philosophers who generated a massive literature on EBM, peppered with pilfered technical terms and thrust under the noses of practitioners. Instead of patronizing the punters you fear might drown in the tide of texts just like your own, try explaining in non-vacuous terms what you are claiming, and if you really dont understand an expression then dont cite it as the essence of your approach.

False dichotomies and the very idea of an evidence hierarchy

In the early days, there did seem to be something substantial differentiating EBMs approach to medical knowledge and practice from alternative possible positions. At least, to ignorant observers like me, EBMs distinctiveness lay in its commitment to a gold standard, the idea that randomized controlled trails and their systematic analysis (meta-analyses, systematic reviews, pooled analyses and so on) generated best evidence and such things as expert opinion, intuition, pathological principles, clinical experience and tacit knowledge were either poor evidence or not really evidence at all [14,16]. The implications of somethings not being best evidence also seemed clear: it should be deemphasized in clinical practice, and practice should be remodelled according to the new paradigm [14].

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The serious problems with this view were swiftly articulated by critics [1719] and at this stage EBM started to evolve in the way I have just described. While typically failing to respond directly to criticisms, EBM protagonists began to react to criticism by producing new accounts of what EBM is and isnt [10]. The accounts functioned to discredit critics by implying the problems they found with earlier forms of EBM were based on a simplistic reading of its claims, which did not have the substantive implications critics had inferred and objected to.1 It became acceptable to talk of integrating aspects of traditional medicine into the new paradigm, even to the point of giving them a place in a hierarchy of evidence [20]. Obviously, systematic research in the form of randomized controlled trails and methods of their analysis would be positioned at the top of the hierarchy, but many other factors relevant to clinical decision making, including intuition, theories, personal experience and professional judgement, could have a place in the hierarchy, albeit a more lowly one than the best evidence [21]. There have been many different evidence hierarchies in the short history of EBM.2 So it is not 100% clear how this particular intellectual device solves the problems associated with there being many different denitions of EBM. Substituting different hierarchies for different denitions still leaves us with a lot of people agreeing that something called EBM is exciting, important, unquestionably right and all the rest, but still not agreeing on precisely what it is. Somewhat ironically, given the overtly antiphilosophical tone of some of the EBM literature I have cited, it would seem that the substantive agreement among its exponents concerns not specic features of the hierarchy but rather an underlying philosophical point, viz. the very idea that it makes sense to grade or classify generic types of evidence, as a way of understanding medical knowledge and its proper application to practice, such that certain kinds of evidence can be inherently best, a gold standard. Why do I call this a philosophical point? Commitment to the idea of an evidence hierarchy is not commitment to a specic scientic claim or theory, but to a particular way of thinking about science, evidence and practice [21]. As noted, EBM protagonists have never envisaged EBM itself being subjected to scientic testing [1416]. If its a theory or thesis of any sort, or if it is something else (e.g. a method or practice) that somehow embodies a thesis, then its a thesis about science, its nature and proper relationship to clinical practice. It represents a reframing of the debate about good practice: it aims to affect the conceptual framework in terms of which we discuss and evaluate practice [21]. In particular, it embodies an ideal of the good practitioner as one whose decisions rely as little as possible on sources that can be regarded as subjective and personal, and whose practices are instead determined (as far as realistically possible in an imperfect world) by sources that are objective and impersonal. So scientic research aimed at producing generalizable conclusions is always best evidence, to be privileged whenever possible over less objective sorts, even
1

The problem, of course, with responding to criticism of any substantive claim by watering it down is that you risk losing the semantic content that made it sound like an interesting thing to say in the rst place. Do this too much and you really will be left with nothing but a brand name. 2 See below as a portion of intellectual history, sixteen years is not very long. [2]

though, in real life it will often be necessary to appeal to sources lower down the hierarchy. In the later forms of EBM, such subjective factors as context-specic information, ones own experiences, the tacit awareness that one builds up of an area of practice by regular engagement, the intuitions one develops in the process of building that awareness and other aspects of what used to be called professional judgement (now more typically referred to as opinion) are acknowledged to have a role precisely because, unfortunately, it is not always realistic to deduce implications for practice directly from systematic research. But the more real-world decision making approximates to this objective, scientic ideal the better: it stands to reason that we need more science not less [9]. To explain the origins of this position in terms of the history of ideas, and ultimately to explain what I think is wrong with it, Im going to use an illustration from a famous TV series for no better reason than that it amused me for a while, and that you might just recognize it, because the latest spin-off lm of the series is currently showing in the country hosting these lectures. The series is The X-Files, whose central characters were Special Agents Fox Mulder and Dana Scully of the FBI. Scully had a scientic background at least one scene in every episode depicted Scully wearing a white coat to reinforce her scientic credentials while Mulder was, by all generally accepted standards, patently insane. Nonetheless, within the context of the series, Mulder found his insanity repeatedly vindicated by the insanity of his world. One episode opens with a pregnant woman lying next to her partner in bed, then suddenly we see her apparently waking up, but in circumstances so bizarre that most of us, as mundane post-medieval realists, would immediately assume that she was dreaming or hallucinating: she is giving birth, but her baby is being delivered by a devil. Hes a proper devil, with huge horns, a cloven hoof, rubbery red skin and a long swishy tail at the back, and inexplicable plumes of ame shoot out from behind him, perhaps suggesting some hellish digestion problem. Then suddenly we see her wake up again, only now she is no longer pregnant, her bedroom is as it was, no obvious signs of re damage and no sign of either her partner or the baby. Mulder and Scully investigate. Scullys methods are, as ever, stereotypically scientic. The husband has disappeared with the child and based on the experiences the woman describes, Scully initiates tests to determine whether or not she has been drugged. Learning that hubby had some clinical training raises the possibility for Scully that he, for reasons yet unknown, decided to drug his wife, deliver and make off with the child. Mulder, meanwhile, learns that the husband is of Romanian origin and regards this fact as extremely signicant. He promptly begins consulting a database cataloguing Romanian myths concerning his key search terms: devils/demons, newborns and abduction. There follows a wonderful scene where the investigators share their conclusions in a mobile phone conversation. Scully is in the lab, decked out in her authentic scientic researchers white coat, but has to report that she has found no conclusive evidence of any substance in the womans body that might have caused her experiences. Mulder then presents his own ndings. He is sitting in a parked car holding a photograph of the husband, on which he is casually sketching a pair of horns, presumably to see how well they t. This, in all seriousness, is the ensuing exchange.
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MULDER: This has all the hallmarks. Its a text-book case of demonic foetal harvesting. SCULLY: Whats your supposition, Mulder? Surely you are not suggesting this man is the devil? MULDER: Im not supposing or suggesting anything. The evidence speaks for itself. Whats the moral of this story? Well, rst of all, the evidence never speaks for itself in the way that Mulder implies. Some things may strike us as just plain obvious, but they only strike us as anything because of our own intellectual activity. The evidence is not out there awaiting discovery any more than the correct categorization of the problem is just out there. Once we have arrived at both a characterization of the problem and the relevant evidence, we may, of course, be able (sometimes) to deduce the answer, but only if we have framed the right question. Observation is something humans do, and it is something they do in the context of doing all sorts of other things, including questioning, categorizing and theorizing. Part of the fun of The X-les was Mulders incongruous approach to investigation, which often meticulously aped the form of scientic research, while readily embracing theories of an extravagantly unscientic or antiscientic nature. No matter how systematic Mulders search of the Romanian demons database, no defender of EBM would commend his approach as scientic, and not because it just so happens that we have a dearth of systematic research into the existence of demons. Anyone proposing such research would not be taken seriously by any credible scientic community, because considerations of theory, judgements about which sources to trust and the choice of underlying framework for an investigation are not externally but internally related to our conception of science: that is to say, part of what we mean by a scientic attitude implies an intuitive disposition to adopt certain types of framework and not others,3 and you dont need to have made a particularly thorough study of the history of ideas to work out why. My earlier use of the term post-medieval realist was a deliberate clue: scientic methods develop and thrive only in the context of world-views that tend not to include demonic foetal harvesting within the category of things that might really happen.4 All of our thinking takes place against the background of some sort of conceptual map [22] or framework, some picture of the world and our place within it. When confronted with background assumptions as different to our own as Agent Mulders this is
3

In contrast to wearing a white coat, which is externally related to our concept of a scientist. 4 I realise that I may have come across as peddling a simplistic version of intellectual history at this point, suggesting that science begins in the modern era, when arguably many of the ancients practiced science. My point is that a pre-Socratic scientist qualies for this label, in part, because he abandons accounts of phenomena we would regard as superstitious. The medieval scientist who, in his spare time, tied people to stakes for being possessed by demons may be regarded as betraying or abandoning science, and the very fact that such an accusation is meaningful suggests that we know what it is for certain theories to be unscientic or anti-scientic. Note, this is not a matter of the undoubted wickedness of tying the possessed to stakes. Animal and even human vivisection may be practiced scientically and still be wicked. The point concerns the assumed theoretical framework. (So, my practice of saluting magpies to ward off bad luck is not wicked, but it is unscientic.)

particularly obvious, but more subtle differences can be harder to detect. The kind of nave and insistent questioning that (as noted in my opening comments) characterizes philosophical methodology leads naturally to the excavation of underlying assumptions [22]. If I ask you why a particular conclusion just follows from a particular observation, and listen carefully to your answer, then I can learn something about the normative structures that underlie your thinking. If we reect, seriously, on why certain claims strike us as too obvious to deny, then we can bring our own background assumptions out into the open not necessarily to reject them, but at least to enable us to understand ourselves better and to locate our current thinking in relation to the broader history of ideas that has brought us to where we are now [23]. The sense of perspective that this can bring is palpably absent from much of the EBM debate, where authors seem so caught up in the currently fashionable status of EBM that they write as though it requires no further defence: having come of age it is here to stay [57]. Sixteen years is a long time in any one persons life, but it really is not a very long period of intellectual history [2]. (The demons, unfortunately, lasted a lot longer.) The key point for the moment is that underlying frameworks broad ways of seeing the world tend to be thought of as a denitive part of the subject matter of philosophy, as philosophical positions, simply because they tend to be what lies at the end of any serious line of philosophical enquiry [22]. What, then, is the framework underlying the thinking of EBMs advocates? As we have seen, such contributors frequently shun philosophical dialogue, apparently convinced that their own fundamental assumptions dont even require spelling out, let alone subjecting to critical scrutiny [27,17,18]. Even so, their statements provide ample scope for philosophical analysis. We have seen that EBM discourse is characterized by a series of semantic oppositions between the objective and subjective, the impersonal and the personal, the generalizable and the context-specic, the explicit and the implicit. Protagonists treat it as obvious that evidence from systematic research is inherently better provides a stronger, more valid warrant [9] for clinical decision making than other possible warrants for decisions, because it is the most objective, scientic and rational basis that a course of action can have. Other types of warrant for decisions are less valid because they are more subjective or personal and therefore less objective. In short, a conceptual map is assumed which depicts objectivity, rationality and science as alternatives to thinking that is subjective and personal: these categories are treated as oppositions, mutually exclusive, on either side of an absolute dividing line [21]. The EBM protagonist Ken Goodman puts this point in terms of his own favourite science ction example, illustrating the nature of the dichotomy with reference to the characters of Mr Spock and Dr McCoy from the TV series Star Trek [9]. Spock is interested only in science and logic: he collects evidence then only believes in whatever follows deductively (as a matter of strict logical entailment) from the evidence. Imaginative leaps, hunches, personal experience, intuition, ad hoc theorizing and tacit understanding have no place in his approach to forming beliefs and decisions. McCoy, in contrast, relies on all of these things, and as a consequence is portrayed as the more human, but (as though this just follows) the less rational and objective of the two. As a Star Trek enthusiast, Goodman is no doubt well aware that databases on the

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series record Dr McCoys most celebrated line as: Its worse than that, hes dead, Jim! so he no doubt takes it as read that, when our lives depend on it, we would all rather be treated by Mr Spock. These assumptions reect the position in philosophy known as logical positivism [24]. It is not a theory inspired by any issue that the EBM salesmen considered earlier would deem relevant to busy health professionals [6]. Its a theory about meaning which, as it happens, developed and grew in popularity in part as a response to the archetypal academic philosophy problem scepticism about the external world. My comments on this issue will have to be sketchy, but hopefully not too sketchy to make any sense. The problem of radical scepticism doubt about our grounds for belief in the very existence of the real world nds its most memorable expression in the work of Descartes, who entertained the possibility that all of his experiences were illusory, then set about trying to refute this possibility so as to provide a sound foundation for all future epistemology [25]. Descartes argued that without a solution to this basic problem (how to demonstrate that experience per se is not illusory) all claims to knowledge are put in question, awaiting rational justication. This lack of rational foundations affects our beliefs in science, in everyday life, indeed in any area of human thought and endeavour. Unfortunately, while many found his articulation of the problem extremely persuasive, fewer readers found his proposed solution persuasive. So the legacy Descartes bequeathed to modern epistemology was not the rm foundation he promised but a crisis of justication. This crisis inspired some radical solutions, including appeal to various epistemic criteria of reality [26]. The nature of such solutions is that they dene reality in terms of certain specic methods for discovering facts [26]. So, by denition, scepticism is refuted with reference to those facts discoverable by the relevant methods: if certain conclusions are demonstrable via certain methods then it is strictly nonsense (i.e. it is meaningless or self-contradictory) to doubt their truth or the reality of the facts discovered. The price paid for such solutions, of course, is the abandonment of all features of reality not discoverable by the specied methods to irredeemable scepticism, or even to question the meaningfulness of their claim to be real at all [21]. The logical positivist equates of the meaning of a claim with its method of (empirical) verication [27] giving rise to (stipulated) denitions of objectivity and reality, as concerning exclusively that which is discoverable via the methods of repeatable controlled experiments. This, supposedly, rescues empirical science from scepticism, but the disastrous consequences of this philosophy for ethics [2629], social science [21,28] and even theoretical physics [26,28,30] were documented long before the development of EBM. Logical positivism is, nonetheless, the epistemological parent of EBM [21]. EBM gets its intellectual character from this parent, in particular its disposition to privilege experimental data and statistical methods of reasoning as the basis for objective conclusions, over all other forms of human reasoning, its automatic scepticism towards beliefs founded on personal experience (however extensive), intuition and judgement (however well explained and defended) and all theories not directly deduced from the evidence. We have already examined the aws in this character. The different aspects of human reasoning it attempts to divide are internally related to each other in the project of living and prac-

ticing well. Personal judgement is not a form of low-grade evidence but the activity and rational obligation of each responsible individual, who attempts to balance all the different concerns and demands, to evaluate competing claims and warrants for decisions in the diverse and often unique situations she or he faces [31,32]. It is by no means clear that there can be, or should be, any general theory telling us how to do this well, which sources of information are, generically, better in any situation individuals might face or which factors should hold sway in any nal decision [22]. The exponents of virtue ethics have for centuries argued that the search for general formulae to tell us how to live and practice well is an intellectual dead end, that all we can hope to do as theorists is nd ways to assist practitioners in developing the sorts of dispositions (or virtues) that will help them cope with a complex and unpredictable world. This is a more humble role for theory and research than the role of leading practice, and I think that an approach of this sort is what is needed in current medical epistemology.

Conclusion
To sum up, Ive argued that the only non-platitudinous feature of EBM thinking is an underlying philosophy or philosophical attitude, and that attitude is wrong. The very idea of a conceptual division between the objective and personal judgement does too much violence to human reasoning to be philosophically sustainable. Reasoning, scientic investigation and experiment are human practices, the activities of persons. Strip away the human elements of reasoning and you have not rational, evidence-based decisions but rather no rational basis for distinguishing good from bad evidence. Far from de-emphasizing personal judgement, or relegating it to a lower form of evidence than supposedly impersonal sources, we need an approach to medical epistemology that places the concept of judgement at the centre, and treats the (primarily moral) project of how to cultivate good judgement as its central concern [22,28]. I would actually argue that this is what is needed in general epistemology, so this is perhaps an occasion when applying philosophy to an area like medicine can teach us something about the core concerns of stereotypically academic philosophy. I have argued elsewhere [22] that the best way to respond to scepticism is to look at the role of reasoning in the living of a full human life scepticism is an attitude that requires justication, and what is more, it is an attitude that will be justied in some contexts, in relation to specic claims and situations, and not in others. This is why the sort of radical scepticism envisaged by modern philosophers from Descartes onwards never strikes people as an intellectual attitude they could seriously adopt for it has no role in the living of a coherent and meaningful life. In medical epistemology the focus needs to shift away from the (spurious) pragmatic project of reshaping practice in accord with an assumed and intellectually unsustainable rational ideal, to the more properly philosophical project of assisting practitioners in developing their own rationally defensible conceptions of good practice and the intellectual basis of their activities. The current problems for medical epistemology are the heritage of broader problems in the history of epistemology, and if considering one area can motivate us to address another then so much the better for both.
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