Dunja Dreesens

94 Means-to-ends reasoning Find ways to reach a goal This type of reasoning asks the question what ways are there to reach a certain wanted outcome and which of those ways would be the more efficient? Often used in clinical consultations to make sure that something happens whatever the circumstances. The inference remains uncertain but less so by using multiple means that will lead to the same outcome (238). Logic of care (Mol) Taking care while the uncertain future unfolds In The Logic of Care, Annemarie Mol (225) suggests that healthcare is more like a ‘practice’ than it is about making choices. This approach puts emphasis on the importance of taking good care for the patient and the prevention of neglect. Inferring is a process that unfolds over time, while addressing many factors on the way. Non-analytical reasoning (Gigerenzer, Stolper) Using intuition Non-analytical reasoning such as heuristics and gut feelings (combination of heuristics and emotions (239)) used to make inferences. These types of reasoning are considered fast, intuitive and automatic thought processes. Gigerenzer showed that non-analytical reasoning can in certain environments outperform analytical reasoning in psychological, biological, sociological and economic inference tasks (240). * Types of reasoning are not exclusive and may overlap. They appear promising yet challenges remain. First, findings from ethnography question whether structured frameworks really influence or reflect guideline development processes (241, 242). In an ethnographic study of guideline development meetings, Moreira showed that guideline developers formulate guidance by combining different “repertoires of evaluation , organised around four different epistemic criteria: robustness, usability, acceptability and adequacy” (241). Importantly, such criteria are deployed at each stage of evidence appraisal: usability, acceptability and adequacy are integral to evidence assessment, rather than being easily categorised as either ‘judgements’ or ‘additional considerations’ as current evidence to decision frameworks suggest (232). Acknowledging the importance of these epistemic skills in evidence appraisal become much more important when it is understood that recommendations nearly always draw on different types of knowledge. Second, bringing knowledge together is not just a process of integrating, triangulation and finding a single answer. Knowledge from many sources is often conflicting, and indeed the exploration of opposing ideas is often very important. In social sciences, methods for evidence synthesis of other kinds of data have been developed and assessed in research (243) and in practice guideline development (223), but these have not yet been adopted routinely in healthcare guideline development. A process of integration is not just a technical, simple mechanistic process. Guideline development is a human, social process involving relevant stakeholders in discussion, debate and judgement. Therefore, the guideline development processes also rely on a balanced and representative guideline committee that functions well (244). Finally, integrating many types of knowledge is not a process in which anything goes. Some integration processes are likely to be better than others. Guideline development needs to be transparent and consistent so that reality, be it physical or social, can limit the inferences and recommendations made. We need a range of integration approaches depending on our understanding of what is true and Chapter 5