1 Can clinical medicine, criticized as it is, answer for its theory, or for the doctrines that guide it? The last decades have witnessed the organization of tensions (scientific medicine or medical humanism, biomedicine or bio-psycho-social medicine) which exhibit a kind of to-and-fro around the art/science opposition – a debate which has never found definitive outcome. Looking at medicine from the outside, we can deplore the fact that its epistemology is insufficient, or at least flawed. Body-machine and lived body, diseases and patients, objective knowledge and incorporated tacit knowledge, facts and values, power of direction and power of service or agency, intellectual virtues and moral virtues –all of the threads that make up the fabric of practice seem stretched between two opposite poles. But rather than verifying whether or not it satisfies certain criteria, I will attempt to explain –from clinical practice – its latent epistemology. If medicine is in crisis, it must discover and rediscover its specific normativity, lest it resign itself to its planned obsolescence (the fiction of a medicine without doctors). Without claiming to describe and discuss here all the heterogeneity of knowledge and faculties necessary for practice, nor the multiple reasons which lead to the discrediting of clinical practice, I will limit myself to indicating two crucial points which organize their mutual divergence: on the one hand, medical rationality, whose plurality of modes can be admitted without difficulty,  comes up against an obstacle that seems insurmountable (designated as subjectivity in Canguilhem,  or the “true nature of the body” in Lacan,  to cite only the two authors who have pushed the issue at stake the furthest); on the other hand, the commendable desire to dry up as much as possible the multiple sources of uncertainty that weaken medical practice,  failing to recognize their irreducible nature, serves to aggravate the problem to be solved (i.e. how to be more effecient?) by remedies that have become poisons.  These two directions have metaphysical extensions (what ontology for the recipient of the medical action: any singularity or not, an individuated substance, a quasi-unum between body and soul?) and managerial and political consequences that will not be discussed here.  On the other hand, we would like to argue that the epistemology that is suitable for medical clinic must take into account the real object of practice, because –and this is the thesis supported – the clinic is the most adequate “science” of this object. It will first be necessary to situate the critical context in which these questions arise today, then to present some salient features of the clinic.
2 Perhaps it is appropriate to warn the reader of the precariousness of what we are affirming. By electing practice as the hard rock of medicine, we are, as a practitioner, in the front row, but immediately suspect. Immersion impedes the position of the disinterested spectator—the only one who can correctly report the action in progress. Worse still, if for philosophy, “all good material must be foreign”, a doctor should not risk exploring philosophically the material that is most familiar to them: when they commit themselves, denounces Canguilhem, to “certain pseudo-philosophical literature […] medicine and philosophy rarely find their account”. We will simply suggest that the situated perspective offers advantages that the disinterested spectator does not have: where would they stand anyway? The clinic does not admit third parties into its laboratory: it only has protagonists, fully immersed in the characterized situation. As with any practice, its public nature does not prevent certain aspects from being perceptible only to those who are fully engaged in it, and therefore less threatened with scholastic illusions to state what is stumbling. Finally, being interested in it means that the subjectivity of the doctor is also at stake.
The Coordinates of the Problem
3 The question of its epistemology has long been discussed in a restricted circle outside of medicine. That the clinic still presents itself today as an epistemological curiosity is attested by the profusion of contradictory theses. The debate has lingered at length on the opposition between art and science, which has never found a definitive solution, since medicine illustrates precisely some of the conceptual defects of this paradigmatic opposition.  For lack of having thwarted it correctly, the EBM (Evidence-Based Medicine) movement has had no difficulty in establishing its supremacy in training and discourses of legitimation.  The old dispute seemed obsolete: there is no medicine worthy of its name that is not based on proven facts. Today, the so-called personalized medicine  on the one hand, and artificial intelligence on the other, would contribute to “making obsolete” an outdated “artisanal” medicine. The very term clinic seems to indicate – as some self-appointed scholars would have us believe –a practice on the verge of extinction, supplanted by professionalism and its range of skills, or by the mantra of “P4 medicine” (personalized, preventive, predictive and participatory). Asked to answer for the validity of the knowledge it uses, to clarify the identity of its recipient (this or that molecular receptor, or the anyone averaged by big data?) and its purpose (cure or care, normalize or emancipate?), hoped for and contested because of the power it has acquired over our lives, medicine is still seeking its compass, and the epistemological question never ceases to have to be put back to work, because what could satisfy the least demanding satisfies no one. Many have come to terms with the distinction between the science of disease and the art of caring for the sick, which has sometimes been transformed into a division of labor between technicians of the objective failures of the body machine and warmly compassionate “humanists”. The former will take care of the translation between the laboratory of fundamental sciences and the patient’s bed; the latter will take care of maintaining the sanitary cordon that protects them from the flourishing alternative medicines. Some call “personalization” a cellular or molecular stratification, others “person-centered” care, a bio-psycho-social trinity. But the organic idiotypy unveiled by science is not the indivisible totality of the individual grasped as an organism (in relation to its environment) which is the relevant biological level. And since the lived experience of illness, whether as decline, devaluation or suffering, “must be held to be one of the components of the illness itself”,  it is artificial and fallacious to extract the objectivity of illness from the very notion of illness. The “science of diseases”, if it is satisfied with biological objectivity, thus misses its object completely. This failure takes on a maximum relief “at the nebulous frontier of somatic medicine and psychosomatic medicine”,  a zone whose population is constantly growing. For its part, patient-centered medicine is taking up what an old alternative to the “biomedical”  model inaugurated. But to establish its legitimacy, it must provide evidence, submit to the EBM process, and therefore smooth out, if possible, variations in practices in order to be able to define standards of guaranteed quality. This is why this current takes a reductionist approach to assessing its relevance: multiple psychological assessment scales and social vulnerability scores for patients, empathy scores for doctors, coding of specific behaviors and fragments of speech in recorded consultations, etc. The aim is then to correlate these measures with the degree of patient satisfaction and compliance with the treatment so that their usefulness is evidence-based.  “Person-centered medicine” also misses its own object, since it evacuates what cannot be measured. 
4 Finally, the same statement is made. As the medicalization of our lives continues to grow, when our lifestyles manifest themselves as physical or mental illnesses that doctors can name without being able to treat them because they are at the crossroads of multiple causes, it will be said that these illnesses fall outside the scope of medicine. And the practical conclusion takes various forms, but it comes down to this: as the demand for meaning is projected outside the power and competence of medicine, or even sent back to a mysterious related discipline,  there has been a demand since the beginning at least of clinical experimentation  to “reintroduce humanism” which would have been lost, to make it as important an element as science, in order to bring about a “new synthesis”, which is an essential condition for the doctor and medicine to still accomplish their secular function.  But what is this function, if not to have to respond to a demand?
5 The epistemology that is appropriate to the medical clinic must take into account the real object of practice, because it is the most adequate “science” of this object. In her inaugural lecture at the Collège de France, Anne Fagot-Largeault echoed Feinstein’s words: “it is not by being less scientific that we will be more human, it is by being more and differently scientific”.  For my part, to be differently scientific is, for example, to take literally Canguilhem’s assertion that medicine is “the science of the limits of the powers that the other sciences claim to confer upon it” , and to consider the reality of the gap that will never cease to separate the available data (whatever the extent of the disciplinary knowledge that is mobilized to shed light on a situation) and the solution to be determined for a given patient. This hiatus is common to all practices: it is one that separates the rules from their application in a contingent situation.  It is also to admit that, if science “has no meaning because it does not answer the only question that matters to us, that of knowing what we should do and how we should live” , medicine is the place where, on the occasion of illness, the doctor is asked the question of knowing what we should do and how we should live. When they are called upon to help with their knowledge, they are supposed to have a knowledge that “speaks” to a subject that is not just anybody about an object that is not just anything. 
6 Incorporating algorithmic assistance (or psychological assessments and functional imaging, genomics, and an anthropological perspective) into a diagnostic or therapeutic approach does not replace the need for keen observation of sometimes tenuous clues in order to be able to feed reasoning with correct premises, nor does it replace the need for experience acquired through assiduous practice to gauge the degree of plausibility that these clues confer on the hypotheses, and even less does it replace the need for imaginative power to find one’s way around chaotic, disordered situations.
The Clinic as Laboratory
7 Consider this statement, posed as an axiom but which remains a conjecture: the clinic is the laboratory of medicine. In the subjective sense of the genitive (of medicine), the clinic designates the framework of its practice, i.e. the place where its originary and original essence (having to respond to a request) acquires its greatest visibility. An experience takes place there, that is to say, to varying degrees, research, an encounter, tests, analyses, teaching, and therapy. It can be rightly argued that the clinic is experimental, in the Bernardian sense of the term, and that the requisites of a scientific medicine for Bernard bear a striking resemblance to the criteria of the tekhnè of Aristotle’s Metaphysics. 
8 But the clinic is also the laboratory of medicine in the objective sense of the genitive, that is to say, the privileged place of its elaboration and production. From laboratory, the clinic also takes its character of labor, which requires attention and assiduity. Medicine produced clinically – in the laboratory of the clinic –will only be distinct from medicine produced by other means, if it breaks the mooring at its originary moment, which is the patient’s request. Thus, randomized therapeutic trial, artificial intelligence, precision medicine, the use of biotechnologies, can be welcomed as so many outgrowths of the clinic that sometimes increase certain capacities to act… clinically, as long as they are not sacralized but profaned, that is to say, restored to clinical use,  instead of being considered as competing medicines that would impose their own grammar, and therefore different language games. 
9 The signifier laboratory thus summons experience to a central place: the lived experience of a speaker with a suffering body motivates an addressed request –the clinic is the place of this address; the doctor’s experience confers on them a certain address in the response; patient and doctor inaugurate an objective and subjective experience that takes the form of an experiment. The clinic is also experimental in the sense that what takes place there is not entirely predictable: the attempt is a trial, and the laboratory is the place of its elaboration. 
The Salient Features of the Clinic
Body, Request, Knowledge
11 From the beginning, its field has been that of a response to the request of the ailing.  Affirming this secular anchoring provides it with a solid architectonics, insensitive to the turbulence of fashions that constantly demand its updating. What are its most salient features? What is going on there? The medical clinic is a specific way of tying together three “elementary” threads that are mutually implicated: body, demand, knowledge. Bodies are observed, scrutinized, auscultated; requests are made, calling for an answer, soliciting knowledge. This simplicity of exposition calls for some precisions.
12 The clinic confronts the body insofar as it is alive, that is to say exposed to, and actualizing, illness, suffering, aging, death, but also pleasure and jouissance: caught in a libidinal economy, the body obeys laws other than those of physiology. Suffering and illness motivate a request, sometimes reduced to a cry, which establishes a minimal sociality as a backdrop to the experience: the call to the other,  which we sense summons recognition and love below and beyond a concrete response. Therefore, what the patient asks for is an integral part of the clinical investigation to be carried out. To address a request, even to satisfy a vital need, supposes another person who brings together two traits: their aptitude to satisfy it, and their willingness to do so. If the request questions what one expects from the other, answering it raises the question of what one wants for the other. Nevertheless, to answer as well as possible calls for the development of a knowledge which doubles the ethical aim with a practical efficiency. The aim of science remains subordinated to therapy, that is to say, a beneficial power that operates on the body, inevitably nourished by a doctrine, unless we admit, going against Canguilhem, that there exists a science of health. What some people might wish in medicine, that is to say, to deal only with pure organisms, situated only in the register of the need for care that knowledge of the functioning of the body would allow to satisfy, does not correspond to the usual reality. The knowledge of biology excludes an essential part of bodily life, which the practicing physician must (in the pre-moral sense of the modal verb “must” ) integrate, not out of “humanism” or politeness, but quite simply because it is part of the reality of the clinical situation. This is particularly significant to the point of occupying almost the entire scene, when we find ourselves in the extremely frequent situation where the complaint does not correspond to any lesion referent. For lack of adequate epistemological support, doctor and patient often prefer to remain “deaf to the request rather than to hear the cry, the scream, that it conceals” . But the doctor has no choice but to include among the parameters of the relevant situation, considerations that are generally neglected, even though they are an integral part of the enigma to be solved: the patient does not tell everything, they make decisions contrary to their health, they can let themselves be sick, they attribute a strange meaning to the occurrence of their illness, they do not necessarily take the prescribed medication, they can lack confidence and grant it to an impostor, they arouse emotions and feelings that disrupt the objectivity of the doctor, etc.
13 The reader will have guessed it: each of the three elementary threads is steeped in language. There is no living human body without language – both the faculty possessed and the condition of possibility.  The clinic deals with living bodies that have language, with speakers who have (and are not) a body. Therefore, medical semiology is not only a semiotics of a special kind, but also a semantics and a hermeneutics. Bodies touch and words are exchanged: the specific technique is always weighted with an aesthetics and an erotics. Language allows the communication of one’s needs, but also the expression of desire and the quest for recognition which are intertwined in the request and often cause knowledge to stumble. The narrative puts in a certain order a heterogeneous mixture of reality, fantasies, memories, desires, and all of this gives shape to the situation as the doctor becomes aware of it. Language subjectifies the speaker (as the inauguration of a subject who uses speech and discourse to “represent” themselves, as they call upon the other to observe them ) but also conditions the repertoire in which the lived experience is transmitted. The clinic, concerned with the denotative function of language, obliges itself, in order to retain what refers to the referential of the morbid fact, to a listening that also hears what refers to the referential of a lived experience, and what is not referential. As it is not always possible to distinguish between what is “simple” communication of the felt phenomena (as if the word here only served as a channel that adds nothing of its own), and what is speech as an expression of subjectivity, the properly medical listening must remain flexible, navigating between the multiple valences of the traces-indices, the multiple lives of the body, and the varied registers of speech.
14 Such is the starting point of the clinic: a symptomatic entanglement, the symptom of the patient in the broad sense of a sickly synthesis, of a singular entanglement between body, request and knowledge. This entanglement is contingent, and unique in its kind, but would not be analyzable without the regular arrangements in the nature of bodies, and the rules of grammar. It is this knotting that makes a case (casus case, what falls before us and that we cannot ignore) for the doctor who finds themselves required to unravel the skein or challenged to do so.
Two Fundamental Operations
15 The clinic then carries out two logically successive operations: the diagnosis and the determination of a therapy. We limit ourselves to indicating the essential characteristics for our purpose.
16 The diagnostic operation is the critical analysis, the unraveling, of the symptomatic complexion, under the time constraint of the vital emergency or the pressure exerted by the request. It is a prerequisite for the therapeutic decision, and its accuracy is therefore crucial for the patient’s future; the operation is arduous because it comes up against multiple obstacles in order to extract from the contingent situation the elements that will serve as material for the premises of the reasoning, which has been studied from all angles.  In fact, diagnosis is like a heterogeneous mental process: there are a dozen different epistemic practices! 
17 On the other hand, the materiality of what needs to be organized is less studied. The diagnostic operation is based on an indexical practice.  The medical sign is deciphered within a multitude of bodily marks, but the majority of the clues integrated into the premises of the diagnostic reasoning are fragments of speech. Anamnesis is the most valuable tool for developing a hypothesis. The selection of relevant clues involves interpreting traces that may be insignificant to the layman, marginal data, garbage or trivial details. The traces are attributed a variable valence, from that which is neglected to that which allows a solid deduction, passing through all the degrees of plausibility. The collection of traces is always stretched between the perceptual and the conceptual, which weighs down the meanings of an interpretative theory, which is particularly delicate when it comes to separating the organic from the functional, but in all cases an effort must be made to articulate the patient’s testimony as evidence and the other forms of evidence obtained. It is not just a question of associating material evidence and elements of discourse in a reasoning: the patient reads (deciphers and interprets) their own traces, and there may be hesitation or disagreement about their valence. In order to discern what falls within the variants of normality and what joins the canon of pathological forms, the doctor also makes an inventory of “places”: what concerns the body as a whole, the major physiological functions, the effects of the medications taken, the evolving course of the symptoms. The conflict with the scientific paradigm that has discredited this indexical practice is thus badly posed: it is only once the traces have been transformed into signs that the rules of logic and the application of the classical or probabilistic scientific method can come into play. What we tend to forget is that the quality of this investigation conditions the validity of the subsequent reasoning, which has much in common with a rhetorical approach. Indeed, the doctor must persuade themselves to act and persuade the patient that the proposals made are well-founded. What is expected from the diagnosis is not the truth, but sufficient likelihood to be convinced to act.
18 The determination of a therapy is, in a way, the dénouement of the diagnostic operation of disentangling in view of a new knotting: the common aim (of the doctor and the patient) of the medical act, the ultimate aim of the practice, is for the patient to be able to reconnect with their health, that is to say, with their own normativity. But what matters to us here is not so much its result as its determination, from which we expect a maximum degree of reliability. However, therapeutics remains a conjecture, i.e. a supposition based (and not gratuitous) on probabilities (and not an a priori certainty) and which is not controlled by the facts. Thus, the association between a genetic variation and the response to a given drug remains probabilistic.  The fact that will ultimately validate or invalidate the supposition is still to come: it is the result obtained in such and such a patient, after a prescription, that is equivalent to testing the diagnostic hypothesis for the individual case. However, even in the most ordinary situations, this retains a part of the unknown. This is why Canguilhem’s statement remains valid: “to treat is always to experiment” . The two reasons put forward also remain valid: the individual character of therapeutic action does not lend itself well to a mathematical type of knowledge; and the doctor cannot say in advance where the limit, which varies from one patient to another, will be between the harmful, the innocent, or the beneficial. And it is for the same reasons that practical reasoning in the sense of Aristotle  is more adequate than the simple application of the general rule to the case that we thought we had identified, with all due respect to all those who no longer prescribe anything that has not been the subject of “recommendations”.
Concluding Propositions for an Epistemology of Medicine
19 If the medical clinic appears then as a productive technique of diverse remediations which produce objective bodily effects, these remediations are so many unravelings/ravelings which do not necessarily leave a visible trace, in particular when they pass speech: praxis, poièsis and épistémè constitute the rabbit-duck picture of a tekhnè in a broader sense, built on aesthetics (aisthèsis) nourishing an empirical experience (empeiria).
20 What the laboratory of the clinic teaches us is that every situation encountered deserves a thorough examination, that is to say, it deserves to be elevated to the level of a case, an enigma to be unraveled in view of therapy. Everything necessary for the two operations of the clinic (natural sciences, biotechnologies, information technologies, human and social sciences, etc.) is admissible by right: medical practice mobilizes a heterogeneous set of knowledge and faculties in order to find solutions to the concrete problems of the people who ask for them. But all of this auxiliary equipment does not remove the uncertainty inherent in the determination of a conjecture (diagnosis and therapy). For life itself is uncertain. Medical practice is confronted with the stumbling blocks of reality, which also disorient everyone in their own existence.
21 This clinic is individual because each patient carries out a pathological individuation that is proper to them. When we say that they carry it out, we do not only mean that the subject keeps a margin of maneuver, that the field of possibilities is not restricted to the average destiny of their category, in short that their future is partly their business, but also that the determinations that do not depend on their choices, their freedom, their will, are also individuated and actualized in a singular way (if it is by returning to the pre-individual common that certain too heavy pathological individuations find some relief, it is that the individuation is never definitively fixed).
22 Aisthesis, empeiria, praxis, phronèsis: the heart of medical practice finally appears infratechnical. This delicate and fragile dimension has been forgotten, but isn’t it the appropriate method to make the junction between the biological sciences and the treatment of the individual? Medical judgment is the intermediary between sensations and science –or rather their alloy, which is paradoxical only because of the lack of knowledge of what a practice really is. Thus, if making use of aisthèsis (but also of emotions or empathy) allows us to know the patient better, this use will be a full-fledged component of tekhnè, and not a simple accessory that only the general duty of humanity would impose on an impersonal but self-sufficient technique. Attention to subjectivity is no less technical, as psychoanalysis shows.
23 The widespread scientistic wish hopes for the day when the vague and the fragile will be expelled from medicine. But the study of the laboratory that is the clinic reveals the normative power of tinkering, as the very conditions of an exercise that succeeds only by finely adapting to its object. It is a question of taking care of it, of perfecting it, of bringing it to its highest degree of relevance.  Canguilhem considered that medicine has reached the point where its rationality is accomplished “in the recognition of its limits, understood not as the failure of an ambition that has given so much proof of its legitimacy, but as the obligation to change its register” . We have tried to show that it was not so much a question of changing registers as of realizing the interweaving of a plurality of registers
G. Khushf. “A framework for understanding medical epistemologies”. Journal of Medicine and Philosophy, 2013, 38, 461-486.
G. Canguilhem. “Puissance et limites de la rationalité en médecine (1978)”. Études d’histoire et de philosophie des sciences concernant le vivant et la vie. Paris: Vrin, 7th edition, 1994, p. 392-412.
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Id., “Menaces sur la phronésis : l’impact de la nouvelle gouvernance hospitalière sur la pratique médicale”. C. Lefève, F. Thoreau, A. Zimmer (eds.), Les Humanités médicales – L’engagement des sciences humaines et sociales en médecine. Paris: Doin, 2020, p. 61-69.
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J. Gayon, “Épistémologie de la médecine”. Dominique Lecourt (ed), Dictionnaire de la pensée médicale. Paris: PUF, “Quadrige”, 2004, p. 430-439.
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One of the founding references is the article by G. L. Engel. “The need for a new medical model: a challenge for biomedicine”. Science, 1977, 196, p. 129-136.
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My position therefore goes so far as to say that it is not up to the clinic to adapt to P4 medicine, but that the latter will only be medicine if it complies with the rules of the clinic.
J.-C. Weber. “Expérience, expertise, experimentation”. In Eurocos, Humanisme et santé. Du malade passif au patient expert !. Paris: Éditions de santé, p. 173-185.
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Hilflosigkeit and Nebenmensch in the language of Freud, who discovers there the secret motive of all morality, as indeed Levinas does with other theoretical coordinates.
G. Canguilhem. “La santé : concept vulgaire et question philosophique”. Id., Écrits sur la médecine, op.cit, p. 52.
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G. Khushf. “A framework for understanding medical epistemologies”, art. cit.
C. Ginzburg. “Signes, traces, pistes. Racines d’un paradigme de l’indice”. Le Débat, 1980, 6, p. 3-44.
X. Guchet. La Médecine personnalisée…, op.cit.
G. Canguilhem. “Thérapeutique, expérimentation, responsabilité”, art.cit., p.389.
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J.-C. Weber. “Prendre soin de sa technè”. Le Coq-héron, 2011/3. Vol. 206, p. 33-47.
G. Canguilhem. “Puissance et limites de la rationalité en médecine”, art.cit., p. 408.