A problematic view of peer review; the epistemic distance of medical humanities with medicine

Introduction

Interdisciplinarity is a trend in contemporary medical sciences. Medical humanities (MH) is an interdisciplinary field of inquiry that brings humanities (e.g. history, art, philosophy) together to address the theoretical issues in medicine [1, 2]. Although MH is a growing field worldwide there are still problems with its place in mainstream medicine. This letter aims to elaborate on this issue by explaining our recent experience performing an MH study and its rejection for publication. We use the comments of reviewers to point out epistemic distances between MH and medical specialties.

Interdisciplinary studies in medicine can be categorized into interdisciplinary fields and disciplines. Some interdisciplinarities have been turned into academic disciplines like bioethics. Critics of contemporary bioethics believe that it has lost its first critical enthusiasm [2]. On the contrary, some researchers believe that MH should not be turned into a discipline and remain a field to preserve its critical essence [2]. While we support the latter type, these fields face challenges in finding their place among others and a way to present their ideas.

Last year, we as scholars in the philosophy of medicine (PM) and MH, had a dialogue with some expert endocrinologists. Explaining their concerns in the diagnosis and treatment of thyroid disease we interestingly realized that they were talking about practical and real examples of what we had already investigated in PM as overdiagnosis and medicalization in its philosophical context. We decided to start an interdisciplinary study on the issue.

After reviewing the literature, we found that many studies addressed the issue, but none of them covered these terms as philosophical ones [3–5]. The research gap was bringing new philosophical insights into the literature of endocrinology. We were convinced that merging the technical and philosophical horizons in light of medicalization studies could be fruitful for the field. Medicalization studies is an interdisciplinary field concerned with conditions that previously were non-medical and are increasingly coming under medical observation and intervention [6].

After a collaborative investigation of literature in both endocrinology and PM we provided a manuscript titled “Tendency to Overtesting, overdiagnosis, and Overtreatment in Thyroid Diseases: A Philosophical Approach toward a Technical Issue” and submitted it to the journal “Diabetes and Metabolic Disorders” on October 26. 2024. On December 1st we received the decision letter from the editor-in-chief, followed by two hidden reviewers’ comments. In this letter, we analyze critical parts of their comments to show some misunderstandings of MH as an interdisciplinary field. The aim of this letter is neither to support our manuscript nor to criticize the journal due to the decision. Rather we use the reviewers’ comments to demonstrate a wider issue and invite scholars to consider it. Table 1 shows the categories of epistemic basic of reviewers and the epistemic distance between humanities and medicine that result in undervaluing such studies.

Table 1.

Epistemic distances between medicine and interdisciplinary studies on medical humanities

Epistemic distance category	Comments examples	Presumption of reviewers	Ignored aspects of interdisciplinarity/medical humanities
The Overgeneralization Of Quantitative Research Norms Over Non-quantitative Studies	“Incorporating quantitative data or statistics related to patient outcomes would provide stronger evidence for claims made.” “The introduction would benefit from including recent statistics or studies that highlight the prevalence of overtesting and overtreatment in thyroid diseases.”	Quantitative studies are more valuable than non-quantitative studies in any field.	Philosophical issues are not as measurable as scientific ones.
Overgeneralizations Of The Concept of Evidence	“Incorporating quantitative data or statistics related to patient outcomes would provide stronger evidence for claims made.” “The results section should include specific examples or case studies that illustrate the consequences of overtesting and overtreatment in thyroid diseases.”	Evidence is a super-value that is necessary for both medical and non-medical studies.	Arguments are more important than experimental evidence in medical humanities and the philosophy of medicine. Regardless of critiques of EBM itself, some medical scientists overgeneralize the concept of evidence to other spheres like ethics and philosophy
Overgeneralization Of Clinical Studies Methodology	“The methodology section lacks detail regarding the selection criteria for studies included in the analysis. Providing explicit inclusion/exclusion criteria would enhance transparency.”	Clinical methodologies like providing inclusion/exclusion criteria are necessary for any other studies.	The measures of reliability in philosophical reflections are different from clinical studies.
Haste For Application In Practice	“The abstract could be more impactful by emphasizing the most significant findings and their implications for clinical practice.” “Are the concerns raised in the article related to established practice guidelines or the routine practices of physicians?”	A theoretical reflection is valuable only if quickly applied in medical practice and clinical guidelines.	A philosophical reflection or hypothesis should be deeply perceived and cannot be applied as fast as clinical studies. The meaning of application includes but is not limited to coming into clinical guidelines. The concept of “application” is contextual and subjected to critical reflections and a single value-laden conception of application based on EBM cannot be overgeneralized into theoretical fields.
The Idea Of Self-sufficiency In Science And Medicine	“The article focuses on “thyroid diseases”. What justifies the use of diagnostic or therapeutic errors as examples of medicalization?” “ The definition of subclinical diseases not only in the thyroid diseases field but also in medicine is accused to evoke medicalization.“?”	Issues in medicine are all related to errors and can be fixed by doing science better. There are some downsides in medicine, but doing science better and preventing scientific errors are all we need to solve these issues.	Both intrinsic regulation and extrinsic philosophical reflection are needed for addressing issues in medicine.
Reduction Of All Theoretical Reflections To (bio)Ethics	“The discussion appropriately addresses ethical implications but could further explore how these issues affect patient autonomy and informed consent.”	All theoretical reflections on medicine are categorized under the medical ethics (bioethics) discipline.	Medical ethics is only an interdisciplinary discipline among others like medical humanities and the philosophy of medicine.

The overgeneralization of quantitative research norms over non-quantitative studies

In this category, the reviewers require quantitative and statistical evidence of support. The reviewer didn’t notice that philosophical issues are not as measurable as diseases to find their prevalence and provide statistics for them. Medicine has made its achievements in history by applying the quantitative approach. However, there are still fields of inquiry that remain non-quantitative. Non-quantitative studies such as MH and PM are justified with metrics other than statistical evidence. However, quantitative requirements in medical research are usually overgeneralized to theoretical fields like PM.

Overgeneralizations of the concept of evidence

In this category, the reviewer implicitly considers “evidence as a justifying component of a study. “Quantitative data or statistics” show that the evidence that the reviewer is valuing is experimental and statistical. Even with providing some arguments and locating the field in the sphere of PM, one reviewer implicitly stated that case studies are considered more justifying than philosophical arguments. This valuing has roots in the value-laden view of evidence in contemporary medicine.

Evidence-based medicine (EBM) as a dominant approach in contemporary medicine prioritizes the evidence over other determinants of medical sciences like mechanisms. Undoubtedly, evidence is a necessary component of medical research but EBM is under criticism regarding considering evidence as a super-value and neglecting other components of science. In this view it is not only justified to talk about “evidence-based philosophy”, it also is considered as the only acceptable way of doing philosophy and ethics.

Overgeneralization of clinical studies methodology

One of the reviewers requested inclusion/exclusion criteria for selecting the references. Seemingly no research in the interdisciplinary fields of medicine is safe from such criticism. While inclusion/exclusion criteria in choosing the participants are necessary for clinical studies to improve the reproducibility of results, it has been overgeneralized into all spheres of non-quantitative studies in medicine, and expecting them from a philosophical reflection shows a misunderstanding of the essence of PM. However, even with using such criteria, it is unknown why replication crisis is still a problem in medical sciences [7, 8].

Haste for application in practice

Reviewers questioned the application of these reflections in clinical practice and they are haste to apply these theoretical reflections to clinical guidelines and everyday practice. This may be rooted in a common perception of medical research in EBM that any study is valuable only if transcends the pyramid of evidence to systematic reviews, and meta-analysis, and finally enters the guidelines. Though PM and MH are not emancipated from clinical application, such reflections might come into the everyday practice of medicine in a different way from what proponents of EBM expect. A theoretical reflection cannot be integrated into medical practice unless it is well-perceived by PM scholars and medical practitioners.

The Idea of self-sufficiency in science and medicine

Although we did not use the word error anywhere the reviewer believes that medicalization is not a theoretical issue. Rather, we face some errors that can be fixed probably by better education of medical students, providing more comprehensive or explicit clinical guidelines, or by legal supervision. The way that they perceive these issues is under the idea of self-sufficiency in medicine. On the other hand, scholars in the fields of PM and MH believe that science itself cannot solve the issues raised by science and there is a need for theoretical reflections on those.

Reduction of all theoretical reflections to (bio)ethics

One reviewer criticized not including informed consent and autonomy while the manuscript was a bioethical one in her view. We have not used the word “informed consent” anywhere in the manuscript and we have used the word “autonomy” only once in its philosophical and not mere ethical meaning. Although we have addressed ethical issues we have not used the word informed consent as a technical word in bioethics because we consider our inquiry under the field of PM or at least philosophical bioethics. However since medical ethics is a dominant interdisciplinary discipline in medicine, other interdisciplinarities of medicine and humanities are overshadowed by it [2]. Moreover, as all medical researchers need approval from research ethics committees for their clinical research, their first image of the connection between medicine and humanities is usually medical ethics. Therefore other theoretical fields are reduced to medical ethics and usually requested to comply with the basic concepts and the language of bioethics.

Conclusion

While interdisciplinary fields are admired in medicine, when it comes to publishing in journals, there is little room for such reflections in scientific journals. Putting some super famous journals like the Lancet or rare special issues in highly professional journals apart, scientific journals are rarely welcome to philosophical hypotheses because they assume they are overly speculative, amalgams, or methodologically unclear. Furthermore, it is believed that they cannot attract other scientists enough to cite the article and improve the journal’s impact factor.

MH is usually reduced to statistics or ethics. Furthermore, the tradition of a scientific article review values quantification and refuses deep theoretical reflection or philosophical hypothesis. We believe that for more improvements in interdisciplinary studies, scientific journals can revisit their publication rules and request reviewers to pay more attention to the essence of such studies to prevent the overgeneralization of scientific values to theoretical and reflective studies and reduction of them to pre-existing ideas about interdisciplinarity in medicine.

We used this real-world experience not to support our previous manuscript, but to demonstrate a problem of interdisciplinary research and invite scholars from both MH and medical specialties to make dialogue regarding this issue.

Funding

None.

Data availability

Not applicable to this study.

Declarations

Ethical approval

Not applicable due to the essence of this letter.

Conflict of interest

The authors declare to have no conflict of interests.