Philosophy of Medicine, Miscellaneous

This article argues that actor-network theory, as an alternative to critical theory, has lost its critical impetus when examining commodification in healthcare. The paper claims that the reason for this, is the way in which actor-network theory’s anti-essentialist ontology seems to black box 'intentionality' and ethics of human agency as contingent interests. The purpose of this paper was to open the normative black box of commodification, and compare how Marxism, Habermas and ANT can deal with commodification and ethics in healthcare. (...) Moreover, a new account of 'intentionality' in critical thinking was elaborated. Using Strawson's analysis of 'reactive attitudes and resentment,' the ethical implications of commodification in health care were examined as an assessment of intentions. Synthesizing critical theory with the relational materialism of actor-network theory, this article advances a new approach that seeks to bridge interdisciplinary boundaries, and guide actor-network theory in a critical and humanist direction. Providing new theoretical insights on commodification and 'intentionality' in health care. (shrink)

It is unknown to what extent medical researchers generalize study findings beyond their samples when their sample size, sample diversity, or knowledge of conditions that support external validity do not warrant it. It is also unknown to what extent medical researchers describe their results with precise quantifications or unquantified generalizations, i.e., generics, that can obscure variations between individuals. We therefore systematically reviewed all prospective studies (n = 533) published in the top four highest ranking medical journals, Lancet, New England Journal (...) of Medicine (NEJM), Journal of the American Medical Association (JAMA), and the British Medical Journal (BMJ), from January 2022 to May 2023. We additionally reviewed all NEJM Journal Watch clinical research summaries (n = 143) published during the same time. Of all research articles reporting prospective studies, 52.5% included generalizations beyond specific national study populations, with the numbers of articles with generics varying significantly between journals (JAMA = 12%; Lancet = 77%) (p < 0.001, V = 0.48). There was no evidence that articles containing broader generalizations or generics were correlated with larger or more nationally diverse samples. Moreover, only 10.2% of articles with generalizations beyond specific national populations reported external validity strengthening factors that could potentially support such extrapolations. There was no evidence that original research articles and NEJM Journal Watch summaries intended for practitioners differed in their use of broad generalizations, including generics. Finally, from the journal with the highest citation impact, articles containing broader conclusions were correlated with more citations. Since there was no evidence that studies with generalizations beyond specific national study populations or with generics were associated with larger, more nationally diverse samples, or with reports of population similarity that may permit extensions of conclusions, our findings suggest that the generalizations in many articles were insufficiently supported. Caution against overly broad generalizations in medical research is warranted. (shrink)

O direito à morte digna é majoritariamente ignorado pelo ordenamento brasileiro. Essa invisibilidade do processo de finitude e suas consequências são tema deste estudo, que objetiva realizar um levanta-mento exploratório para identificar pontos relevantes que devem ser desenvolvidos para garantir um processo de finitude digno. Foram analisadas 50 publicações, mediante levantamento online e físico de obras publicadas até março de 2023. Os estudos analisados expressam preocupação com dilemas éticos do cuidar do ser humano em finitude, mas não analisam formas existentes (...) de tutela da finitude nem quais searas ainda são carentes de normatização para dar eficácia a esse cuidado. Espera-se que esta pesquisa contribua para fortalecer o olhar crítico ao tema, considerando as atuais tutelas da fini-tude, os limites legais do Estado e os potenciais passos futuros para fazer avançar os estudos aplicados à atualização prática do ordenamento brasileiro. (shrink)

Neste livro reunimos alguns dos trabalhos apresentados no GT Filosofia, História e Sociologia da Ciência e da Tecnologia, durante o XIX Encontro Nacional da ANPOF, realizado em Goiânia, de 10 a 14 de outubro de 2022. Agradecemos aos autores e às autoras que contribuíram com seus textos para a realização deste projeto. Esperamos que os leitores e as leitoras aproveitem o rico material filosófico presente neste livro.

In this paper, we illustrate some serious difficulties involved in conveying information about uncertain risks and securing informed consent for risky interventions in a clinical setting. We argue that in order to secure informed consent for a medical intervention, physicians often need to do more than report a bare, numerical probability value. When probabilities are given, securing informed consent generally requires communicating how probability expressions are to be interpreted and communicating something about the quality and quantity of the evidence for (...) the probabilities reported. Patients may also require guidance on how probability claims may or may not be relevant to their decisions, and physicians should be ready to help patients understand these issues. (shrink)

The paper offers the concept of reversing the medical humanities. In agreement with the call from Kristeva et al. to recognise the bidirectionality of the medical humanities, I propose moving beyond debates of attitude and aptitude in the application and engagement (either friendly or critical) of humanities to/in medicine, by considering a reversal of the directions of epistemic movement (a reversal of the flow of knowledge). I situate my proposal within existing articulations of the field found in the medical humanities (...) meta-literature, pointing to a gap in the current terrain. I then develop the proposal by unfolding three reasons why we might gain something from exploring a reversed knowledge flow. First, a reversed knowledge flow seems to be an inherent—but still to be articulated—possibility in medical humanities and thus provides an opportunity for more knowledge. Second, the current unidirectionality of the field is founded on an inconsistency in the depiction of the connection between medicine and humanities, which risks creating the very divide that medical humanities set out to bridge. Practising a reversal may help avoid this divide. And third, a reversal might help rebalance the internal epistemic power, so as to motivate less external scepticism and in turn displace more external epistemic power towards medical humanities. I end the paper with a remark on precursors for a reversal, and ideas for where to go from here. (shrink)

This study clarifies the need for a renewed account of the body in physiotherapy to fill sizable gaps between physiotherapeutical theory and practice. Physiotherapists are trained to approach bodily functioning from an objectivist perspective; however, their therapeutic interactions with patients are not limited to the provision of natural-scientific explanations. Physiotherapists’ practice corresponds well to theorisation of the body as the bearer of original bodily intentionality, as outlined by Merleau-Ponty and elaborated upon by enactivists. We clarify how physiotherapeutical practice corroborates Merleau-Ponty’s (...) critical arguments against objectivist interpretations of the body; particularly, his analyses demonstrate that norms of optimal corporeal functioning are highly individual and variable in time and thus do not directly depend on generic physiological structures. In practice, objectively measurable physical deviations rarely correspond to specific subjective difficulties and, similarly, patients’ reflective insights into their own motor deficiencies do not necessarily produce meaningful motor improvements. Physiotherapeutical procedures can be understood neither as mechanical manipulations of patients’ machine-like bodies by experts nor as a process of such manipulation by way of instructing patients’ explicit conscious awareness. Rather, physiotherapeutical practice and theory can benefit from the philosophical interpretation of motor disorders as modifications of bodily intentionality. Consequently, motor performances addressed in physiotherapy are interpreted as relational features of a living organism coupled with its environment, and motor disorders are approached as failures to optimally manage the motor requirements of a given situation owing to a relative loss of the capacity to structure one’s relation with their environment through motor action. Building on this, we argue that the process of physiotherapy is most effective when understood as a bodily interaction to guide patients towards discovering better ways of grasping a situation as meaningful through bodily postures and movements. (shrink)

ABSTRACT Francis Bacon and René Descartes have traditionally been presented as leaders of opposed philosophical currents. However, more and more studies show important continuities between their philosophies. This article explores one of them: their perspectives on medicine. The dominion over nature and the instinct for self-preservation are the central elements of the theoretical framework within which they inserted their assessments of medicine. Medicine is valued as the most outstanding discipline for its benefits for the care of the human being. Departing (...) from this start-point, one finds further coincidences about the status, practice, and reform of medicine. (shrink)

In this article I propose to reframe debates about ideals of emotion in medicine, abandoning the current binary setup of this debate as one between ‘clinical detachment’ and empathy. Inspired by observations from my own field work and drawing on Sky Gross’ anthropological work on rituals of practice as well as Henri Lefebvre’s notion of rhythm, I propose that the normative drive of clinical practice can be better understood through the notion of attunement. In this framework individual types of emotions (...) are not, as such, appropriate or inappropriate, but are evaluated depending on their synchronicity with the specific rhythms of the practice. To set up this proposal, I show how typical arguments about emotions in medicine—what I call emotion-entity focused frameworks—are insufficient. I then draw on ethnographic observations from two orthopaedic departments and interviews with medical practitioners to show (1) how clinical practice is driven by rhythmicity, shaped in the case of orthopaedic surgery by a clinical aim of efficient, controlled intervention, and (2) how clinicians continuously refer to this drive and the flow of rhythms when evaluating inappropriate or problematic emotion. I argue that the use of a rhythm framework rather than ideals of detachment or empathy allows for a sensitivity to the complexity and situation-dependent elements of emotional ideals in clinical practice; and I end by proposing the term ‘attuned concern’—which stresses the importance of regulation and adjustment to circumstances rather than of maintaining a constant distance/involvement—as a more fitting alternative to ‘clinical detachment’. (shrink)

A minimal essentialism (‘intrinsic biological essentialism’) about natural kinds is required to explain the projectability of human science terms. Human classifications that yield robust and ampliative projectable inferences refer to biological kinds. I articulate this argument with reference to an intrinsic essentialist account of HPC kinds. This account implies that human sciences (e.g., medicine, psychiatry) that aim to formulate predictive kind categories should classify biological kinds. Issues concerning psychiatric classification and pluralism are examined.

In this paper we focus on some new normativist positions and compare them with traditional ones. In so doing, we claim that if normative judgments are involved in determining whether a condition is a disease only in the sense identified by new normativisms, then disease is normative only in a weak sense, which must be distinguished from the strong sense advocated by traditional normativisms. Specifically, we argue that weak and strong normativity are different to the point that one ‘normativist’ label (...) ceases to be appropriate for the whole range of positions. If values and norms are not explicit components of the concept of disease, but only intervene in other explanatory roles, then the concept of disease is no more value-laden than many other scientific concepts, or even any other scientific concept. We call the newly identified position “value-conscious naturalism” about disease, and point to some of its theoretical and practical advantages. (shrink)

The term ‘heat’ originates from the Old English word hǣtu, a word of Germanic origin; related to the Dutch ‘hitte’ and German ‘Hitze’. Today, we distinguish three different meanings of the word ‘heat’. First, ‘heat’ is understood in colloquial English as ‘hotness’. There are, in addition, two scientific meanings of ‘heat’. ‘Heat’ can have the meaning of the portion of energy that changes with a change of temperature. And finally, ‘heat’ can have the meaning of the transfer of thermal energy (...) from a hotter to a colder system or body. By contrast, for the Ancients and Scholastics, ‘heat’ was a manifest, real quality of bodies and there was an ontological distinction between biological or innate heat (which was regarded as an innate principle of life for warm-blooded animals) and the physical manifest heat of external objects, which is potentially harmful. During the late Renaissance period, however, both views changed fundamentally and evolved - via the application of physical and mechanical analogies - into the foundations for today’s unified mechanistic theory of heat. (shrink)

One of the Belmont Report’s most important contributions was the clear and serviceable distinction it drew between standard medical practice and biomedical research. A less well-known achievement of the Report was its conceptualization of innovative practice, a type of medical practice that is often mistaken for research because it is new, untested, or experimental. Although the discussion of innovative practice in Belmont is brief and somewhat cryptic, this does not reflect the significant progress its authors made in understanding innovative practice (...) and the distinctive ethical issues it raises. This article explores the history and broader context of Belmont’s conception of innovative practice, its strengths and weaknesses, and its contemporary relevance for scholars working in bioethics and health policy. While this conception of innovative practice deserves our attention, it is inherently limited in some important ways. (shrink)

The mantra that "the best way to predict the future is to invent it" (attributed to the computer scientist Alan Kay) exemplifies some of the expectations from the technical and innovative sides of biomedical research at present. However, for technical advancements to make real impacts both on patient health and genuine scientific understanding, quite a number of lingering challenges facing the entire spectrum from protein biology all the way to randomized controlled trials should start to be overcome. The proposal in (...) this chapter is that philosophy is essential in this process. By reviewing select examples from the history of science and philosophy, disciplines which were indistinguishable until the mid-nineteenth century, I argue that progress toward the many impasses in biomedicine can be achieved by emphasizing theoretical work (in the true sense of the word 'theory') as a vital foundation for experimental biology. Furthermore, a philosophical biology program that could provide a framework for theoretical investigations is outlined. (shrink)

How have and how might philosophers contribute to linking disability and activism in these peri-COVID-19 times, especially in forms of public engagement that go beyond podcasted talks and articles aimed at a public audience? How do we harness philosophical thinking to contribute positively to those living with disability whose vulnerabilities are heightened by this pandemic and the ableism highlighted by collective responses to it?

In ontological terms, what can we learn from the current state of the art in Epidemiology? Applying the Quinean criterion of ontological commitment, we can learn that there are several fundamental entities for the theory to work. One is a virus type entity, in which the (in)famous Coronavirus is a particular case. In metaphysical terms, this entity can, in principle, be understood in several ways. One of those ways, apparently, and perhaps intuitively, is the notion of object. Applying the metametaphysical (...) method of Unavailable Metaphysical Stories, we found that Epidemiology is incompatible with an object metaphysics. (shrink)

Cancer research is experiencing ‘paradigm instability’, since there are two rival theories of carcinogenesis which confront themselves, namely the somatic mutation theory and the tissue organization field theory. Despite this theoretical uncertainty, a huge quantity of data is available thanks to the improvement of genome sequencing techniques. Some authors think that the development of new statistical tools will be able to overcome the lack of a shared theoretical perspective on cancer by amalgamating as many data as possible. We think instead (...) that a deeper understanding of cancer can be achieved by means of more theoretical work, rather than by merely accumulating more data. To support our thesis, we introduce the analytic view of theory development, which rests on the concept of plausibility, and make clear in what sense plausibility and probability are distinct concepts. Then, the concept of plausibility is used to point out the ineliminable role played by the epistemic subject in the development of statistical tools and in the process of theory assessment. We then move to address a central issue in cancer research, namely the relevance of computational tools developed by bioinformaticists to detect driver mutations in the debate between the two main rival theories of carcinogenesis. Finally, we briefly extend our considerations on the role that plausibility plays in evidence amalgamation from cancer research to the more general issue of the divergences between frequentists and Bayesians in the philosophy of medicine and statistics. We argue that taking into account plausibility-based considerations can lead to clarify some epistemological shortcomings that afflict both these perspectives. (shrink)

We raise a problem of applicability of RCTs to validate nuclear diagnostic imaging tests. In spite of the wide application of PET and other similar techniques that use radiopharmaceuticals for diagnostic purposes, RCT-based evidence on their validity is sparse. We claim that this is due to a general conceptual problem that we call Prevalence of Treatment, which arises in connection with designing RCTs for testing any diagnostic procedure in the present context of medical research, and is particularly apparent in this (...) case. We also identify three practical reasons why RCTs do not qualify as the best option for PET validation, which have to do with specific characteristics of nuclear diagnostic imaging, and of radiopharmaceuticals. The paper is meant to contribute both to the philosophical discussion on the EBM hierarchy of evidence, and on the specific debate on radiopharmaceuticals in nuclear medicine. (shrink)

Evidence-based medicine (EBM) calls for medical practitioners to “integrate” our best available evidence into clinical practice. A significant amount of the literature on EBM takes this integration to be unproblematic, focusing on questions like how to interpret evidence and engage with patient values, rather than critically looking at how these features of EBM can be implemented together. Other authors have also commented on this gap in the literature, for example, identifying the lack of clarity about how patient preferences and evidence (...) from trials is supposed to be integrated in practice. In this paper, I look at this issue from an epistemological perspective, (looking at how different types of knowledge in EBM can be used to make sounds judgements). In particular, I introduce an epistemological issue for this integration problem, which I call the epistemic integration problem. This is essentially the problem of how we can use information that is both general (eg, about a population sample) and descriptive (eg, about what expected outcomes are) to reach clinical judgements that are individualized (applying to a particular patient) and normative (about what is best for their health). (shrink)

The modern concept of ideology was established by the liberal politician and philosopher Destutt de Tracy, with the objective of creating an all-embracing and general science of ideas, which followed the sensualist and empiricist trend initiated by Locke that culminated in the positivism of Comte. Natural selection and immunity are two key concepts in the history of biology that were strongly based on the Malthusian concept of struggle for existence. This concept wrongly assumed that population grew faster than the means (...) of existence. This “natural” law contained implicitly the idea that the poor and least gifted would not survive. This idea led to the progressive development of the concept of natural selection, whose definitive version was given by Darwin. Mechnikov took the concepts of struggle for existence and natural selection and conceived infectious diseases as a struggle between a host and its invader, the so-called phagocytosis theory. This theory created the necessity to possess mechanisms to discriminate between the own and the foreign, and led to the conception of the immune self. These concepts were not developed from ideas coming from perceptions or sensations, but from ideas coming from their values: individual interest, inevitable inequality, property, utility and profit. Values are ideals that constitute an ideological matrix which exerts a numinous activity and influence the development of our future actions. In consequence, science and its practice cannot avoid and ignore the values that drive them and impulse them towards certain directions. (shrink)

In this article, I will reconstruct the monocausal model and argue that modern 'multifactorial diseases' are not monocausal by definition. 'Multifactorial diseases' are instead defined according to a constitutive disease model. On closer analysis, infectious diseases are also defined using the constitutive model rather than the monocausal model. As a result, our classification models alone cannot explain why infectious diseases have a universal etiology while chronic and noncommunicable diseases lack one. The explanation is instead provided by the nineteenth-century germ theorists.

Some ‘naturalist’ accounts of disease employ a biostatistical account of dysfunction, whilst others use a ‘selected effect’ account. Several recent authors have argued that the biostatistical account offers the best hope for a naturalist account of disease. We show that the selected effect account survives the criticisms levelled by these authors relatively unscathed, and has significant advantages over the BST. Moreover, unlike the BST, it has a strong theoretical rationale and can provide substantive reasons to decide difficult cases. This is (...) illustrated by showing how life-history theory clarifies the status of so-called diseases of old age. The selected effect account of function deserves a more prominent place in the philosophy of medicine than it currently occupies. _1_ Introduction _2_ Biostatistical and Selected Effect Accounts of Function _3_ Objections to the Selected Effect Account _3.1_ Boorse _3.2_ Kingma _3.3_ Hausman _3.4_ Murphy and Woolfolk _4_ Problems for the Biostatistical Account _4.1_ Schwartz _5_ Analysis versus Explication _6_ Explicating Dysfunction: Life History Theory and Senescence _7_ Conclusion. (shrink)

The first part of a symposium devoted to Alex Broadbent's essay titled ‘Prediction, Understanding and Medicine’, this article notes the under-development of a variety of issues in the philosophy of medicine that transcend bioethics and the long-standing debates about the nature of health/illness and of evidence-based medicine. It also indicates the importance of drawing on non-Western, and particularly African, traditions in addressing these largely metaphysical and epistemological matters.

Dominant views about the nature of health and disease in bioethics and the philosophy of medicine have presumed the existence of a fixed, stable, individual organism as the bearer of health and disease states, and as such, the appropriate target of medical therapy and ethical concern. However, recent developments in microbial biology, neuroscience, the philosophy of cognitive science, and social and personality psychology (Ickes...

This is an epistemologically-driven history of the concept of evolution. Starting from its inception, this work will follow the development of this pregnant concept. However, in contradistinction to previous attempts, the objective will not be the identification of the different meanings it adopted through history, but conversely, it will let the concept to be unfolded, to be explicated and to express its own inner potentialities. The underlying thesis of the present work is, therefore, that the path that leads to the (...) development of the concept of evolution is the path that studies the possibilities of the evolution of concepts, and that the historical reconstruction of its conceptual trajectory will shed light into potential and unexploited possibilities. This methodology will provide useful tools and resources for future developments of the concept. For example, it will define the concept of transmutation as a different conceptual trajectory deviating from the one corresponding to evolution, at the onset of the 19th century. Moreover, epigenesis will not be the opposing concept to evolution, but only to simultaneous and instantaneous generation. It will demonstrate that every important system of epigenesis drew upon some kind of formative power to explain development. More importantly, it will show that the problem of preformation cannot be overlooked, and that some kind of virtual preformation must be considered in order to address the problems of generation and development. (shrink)

This paper begins the last instalment of a six-part project correlating the key aspects of Kant’s architectonic conception of philosophy with a special version of the Chinese Book of Changes that I call the “Compound Yijing”, which arranges the 64 hexagrams (gua) into both fourfold and threefold sets. I begin by briefly summarizing the foregoing articles: although Kant and the Yijing employ different types of architectonic reasoning, the two systems can both be described in terms of three “levels” of elements. (...) Starting at an unnumbered level devoid of any element (the tao or thing in itself), the system proceeds by elaborating a key fourfold distinction (or “quaternity”) on the first level, a twelvefold distinction on the second level, and twelve quaternities (grouped in four quadrants, each with a set of three quaternities) on the third level. Each set of three quaternities (i.e., each quadrant) on the third level corresponds to one of the four “faculties” of the university, as elaborated in Kant’s book, The Conflict of the Faculties. Previous papers have examined the correlations between three key quaternities that Kant defends in relation to each of three faculties (philosophy, theology, and law) and the 12 gua that correspond to that faculty in the Compound Yijing. The final step is to explore the fourth quaternity on the third level, the 12 gua corresponding to the medical faculty. The “idea of reason” in Kant’s metaphysics that guides this wing of the comparative analysis is freedom, and the ultimate purpose of this faculty of the university is to train doctors to care for people’s physical well-being, as free agents imbedded in nature. But this paper will focus only on the four gua that correspond to four basic concepts in Kant’s theory of medicine. The two quaternities in the “yin-yang” (medical) quadrant of the Compound Yijing that will be skipped here are as follows. First, Kant’s account of the idea of freedom itself, which gives rise to the area of traditional metaphysics known as rational cosmology, comes in the first Critique’s Dialectic, in the section on the Antinomy of Reason (CPR A405-567/B432- 595). There he examines four irresolvable issues: whether the world has a beginning in time; whether composite substances consist of simple parts; whether a causality of freedom operates in the natural world; and whether an absolutely necessary being exists. Later I will argue that these correspond to the quaternity consisting of gua 15, 22, 36, and 52. (shrink)

In this paper, I argue that the concept of normality in medical research and clinical practice is inextricable from the concept of ambiguity. I make this argument in the context of Edmund Pellegrino's call for a renewed reflection on medicine’s basic concepts and by drawing on work in critical disability studies concerning Deafness and body integrity identity disorder. If medical practitioners and philosophers of medicine wish to improve their understanding of the meaning of medicine as well as its concrete practice, (...) I contend that they should take seriously the import and centrality of ambiguity for biomedicine. (shrink)

A background assumption of this paper is that the repertoire of inference schemes available to humanity is not fixed, but subject to change as new schemes are invented or refined and as old ones are obsolesced or abandoned. This is particularly visible in areas like health and environmental sciences, where enormous societal investment has been made in finding ways to reach more dependable conclusions. Computational modeling of argumentation, at least for the discourse in expert fields, will require the possibility of (...) modeling change in a stock of schemes that may be applied to generate conclusions from data. We examine Randomized Clinical Trial, an inference scheme established within medical science in the mid-20th Century, and show that its successful defense by means of practical reasoning allowed for its black-boxing as an inference scheme that generates (and warrants belief in) conclusions about the effects of medical treatments. Modeling the use of a scheme is well-understood; here we focus on modeling how the scheme comes to be established so that it is available for use. (shrink)

As it emerged from philosophical analyses and cognitive research, most concepts exhibit typicality effects, and resist to the efforts of defining them in terms of necessary and sufficient conditions. This holds also in the case of many medical concepts. This is a problem for the design of computer science ontologies, since knowledge representation formalisms commonly adopted in this field (such as, in the first place, the Web Ontology Language - OWL) do not allow for the representation of concepts in terms (...) of typical traits. The need of representing concepts in terms of typical traits concerns almost every domain of real world knowledge, including medical domains. In particular, in this article we take into account the domain of mental disorders, starting from the DSM-5 descriptions of some specific disorders. We favour a hybrid approach to concept representation, in which ontology oriented formalisms are combined to a geometric representation of knowledge based on conceptual space. As a preliminary step to apply our proposal to mental disorder concepts, we started to develop an OWL ontology of the schizophrenia spectrum, which is as close as possible to the DSM-5 descriptions. (shrink)

This article analyses the phenomenon of epistemic injustice within contemporary healthcare. We begin by detailing the persistent complaints patients make about their testimonial frustration and hermeneutical marginalization, and the negative impact this has on their care. We offer an epistemic analysis of this problem using Miranda Fricker's account of epistemic injustice. We detail two types of epistemic injustice, testimonial and hermeneutical, and identify the negative stereotypes and structural features of modern healthcare practices that generate them. We claim that these stereotypes (...) and structural features render ill persons especially vulnerable to these two types of epistemic injustice. We end by proposing five avenues for further work on epistemic injustice in healthcare. (shrink)

Harms of medical interventions are systematically underestimated in clinical research. Numerous factors—conceptual, methodological, and social—contribute to this underestimation. I articulate the depth of such underestimation by describing these factors at the various stages of clinical research. Before any evidence is gathered, the ways harms are operationalized in clinical research contributes to their underestimation. Medical interventions are first tested in phase 1 ‘first in human’ trials, but evidence from these trials is rarely published, despite the fact that such trials provide the (...) foundation for assessing the harm profile of medical interventions. If a medical intervention is deemed safe in a phase 1 trial, it is tested in larger phase 2 and 3 clinical trials. One way to think about the problem of underestimating harms is in terms of the statistical ‘power’ of a clinical trial—the ability of a trial to detect a difference of a certain effect size between the experimental group and the control group. Power is normally thought to be pertinent to detecting benefits of medical interventions. It is important, though, to distinguish between the ability of a trial to detect benefits and the ability of a trial to detect harms. I refer to the former as power-B and the latter as power-H. I identify several factors that maximize power-B by sacrificing powerH in phase 3 clinical trials. If a medical intervention is approved for general use, it is evaluated by phase 4 post-market surveillance. Phase 4 surveillance of harms further contributes to underestimating the harm profile of medical interventions. At every stage of clinical research the hunt for harms is shrouded in secrecy, which further contributes to the underestimation of the harm profiles of medical interventions. (shrink)

The purpose of this chapter is to describe what we see as several important new directions for philosophy of medicine. This recent work (i) takes existing discussions in important and promising new directions, (ii) identifies areas that have not received sufficient and deserved attention to date, and/or (iii) brings together philosophy of medicine with other areas of philosophy (including bioethics, philosophy of psychiatry, and social epistemology). To this end, the next part focuses on what we call the “epistemological turn” in (...) recent work in the philosophy of medicine; the third part addresses new developments in medical research that raise interesting questions for philosophy of medicine; the fourth part is a discussion of philosophical issues within the practice of diagnosis; the fifth part focuses on the recent developments in psychiatric classification and scientific and ethical issues therein, and the final part focuses on the objectivity of medical research. (shrink)

This chapter has two aims. The first aim is to compare and contrast three different conceptual-explanatory models for thinking about mental illness with an eye towards identifying the assumptions upon which each model is based, and exploring the model’s advantages and limitations in clinical contexts. Major Depressive Disorder is used as an example to illustrate these points. The second aim is to address the question of what conceptual-theoretical framework for thinking about mental illness is most likely to facilitate the discovery (...) of causes and treatments of mental illness in research contexts. To this end, the National Institute of Mental Health’s Research Domain Criteria (RDoC) Project is briefly considered. (shrink)

With the ascent of modern epidemiology in the Twentieth Century came a new standard model of prediction in public health and clinical medicine. In this article, we describe the structure of the model. The standard model uses epidemiological measures-most commonly, risk measures-to predict outcomes (prognosis) and effect sizes (treatment) in a patient population that can then be transformed into probabilities for individual patients. In the first step, a risk measure in a study population is generalized or extrapolated to a target (...) population. In the second step, the risk measure is particularized or transformed to yield probabilistic information relevant to a patient from the target population. Hence, we call the approach the Risk Generalization-Particularization (Risk GP) Model. There are serious problems at both stages, especially with the extent to which the required assumptions will hold and the extent to which we have evidence for the assumptions. Given that there are other models of prediction that use different assumptions, we should not inflexibly commit ourselves to one standard model. Instead, model pluralism should be standard in medical prediction. (shrink)

The fascinating Journey of the Renaissance Medicine.

Un viaggio nell'arte medica del Rinascimento.

What makes a high-quality biomarker experiment? The success of personalized medicine hinges on the answer to this question. In this paper, I argue that judgment about the quality of biomarker experiments is mediated by the problem of theoretical underdetermination. That is, the network of biological and pathophysiological theories motivating a biomarker experiment is sufficiently complicated that it often frustrates valid interpretation of the experimental results. Drawing on a case-study in biomarker diagnostic development from neurooncology, I argue that this problem of (...) underdetermination can be overcome with greater coordination across the biomarker research trajectory. I then sketch an account for how coordination across a research trajectory can be evaluated. I ultimate conclude that what makes a high-quality biomarker experiment must be judged by the epistemic contribution it makes to this coordinated research effort. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

Measuring the effectiveness of medical interventions faces three epistemological challenges: the choice of good measuring instruments, the use of appropriate analytic measures, and the use of a reliable method of extrapolating measures from an experimental context to a more general context. In practice each of these challenges contributes to overestimating the effectiveness of medical interventions. These challenges suggest the need for corrective normative principles. The instruments employed in clinical research should measure patient-relevant and disease-specific parameters, and should not be sensitive (...) to parameters that are only indirectly relevant. Effectiveness always should be measured and reported in absolute terms (using measures such as 'absolute risk reduction'), and only sometimes should effectiveness also be measured and reported in relative terms (using measures such as 'relative risk reduction')-employment of relative measures promotes an informal fallacy akin to the base-rate fallacy, which can be exploited to exaggerate claims of effectiveness. Finally, extrapolating from research settings to clinical settings should more rigorously take into account possible ways in which the intervention in question can fail to be effective in a target population. (shrink)

To be effective, a medical intervention must improve one's health by targeting a disease. The concept of disease, though, is controversial. Among the leading accounts of disease-naturalism, normativism, hybridism, and eliminativism-I defend a version of hybridism. A hybrid account of disease holds that for a state to be a disease that state must both (i) have a constitutive causal basis and (ii) cause harm. The dual requirement of hybridism entails that a medical intervention, to be deemed effective, must target either (...) the constitutive causal basis of a disease or the harms caused by the disease (or ideally both). This provides a theoretical underpinning to the two principle aims of medical treatment: care and cure. (shrink)

Georges Canguilhem is known to have regretted, with some pathos, that Life no longer serves as an orienting question in our scientific activity. He also frequently insisted on a kind of uniqueness of organisms and/or living bodies – their inherent normativity, their value-production and overall their inherent difference from mere machines. In addition, Canguilhem acknowledged a major debt to the German neurologist-theoretician Kurt Goldstein, author most famously of The Structure of the Organism in 1934; along with Merleau-Ponty, Canguilhem was the (...) main figure who introduced the work of Goldstein and his ‘phenomenology of embodiment’ into France. In this paper I inquire if we should view Canguilhem and Goldstein as ‘biochauvinists’, that is, as thinkers who consider that there is something inherently unique about biological entities as such, and if so, of what sort. (shrink)

Canguilhem is known to have regretted, with some pathos, that Life no longer serves as an orienting question in our scientific activity. He also frequently insisted on a kind of uniqueness of organisms and/or living bodies – their inherent normativity, their value-production and overall their inherent difference from mere machines. In addition, Canguilhem acknowledged a major debt to the German neurologist-theoretician Kurt Goldstein, author most famously of The Structure of the Organism in 1934; along with Merleau-Ponty, Canguilhem was the main (...) figure who introduced the work of Goldstein and his ‘phenomenology of embodiment’ into France. In this paper I inquire if we should view Canguilhem and Goldstein as ‘biochauvinists’, that is, as thinkers who consider that there is something inherently unique about biological entities as such, and if so, of what sort. (shrink)

In Clough’s reply paper to me (http://wp.me/p1Bfg0-1aN), she laments how feminist calls for diversity within scientific communities are inadvertently sidelined by our shared feminist empiricist prescriptions. She offers a novel justification for diversity within epistemic communities and challenges me to accept this addendum to my prior prescriptions for biomedical research communities (Goldenberg 2013) on the grounds that they are consistent with the epistemic commitments that I already endorse. In this response, I evaluate and accept her challenge.

Research on the human microbiome has gen- erated a staggering amount of sequence data, revealing variation in microbial diversity at the community, species (or phylotype), and genomic levels. In order to make this complexity more manageable and easier to interpret, new units—the metagenome, core microbiome, and entero- type—have been introduced in the scientific literature. Here, I argue that analytical tools and exploratory statisti- cal methods, coupled with a translational imperative, are the primary drivers of this new ontology. By reducing the (...) dimensionality of variation in the human microbiome, these new units render it more tractable and easier to interpret, and hence serve an important heuristic role. Nonetheless, there are several reasons to be cautious about these new categories prematurely ‘‘hardening’’ into natural units: a lack of constraints on what can be sequenced metagenomically, freedom of choice in taxonomic level in defining a ‘‘core microbiome,’’ typological framing of some of the concepts, and possible reification of statistical constructs. Finally, lessons from the Human Genome Project have led to a translational imperative: a drive to derive results from the exploration of microbiome variation that can help to articulate the emerging paradigm of per- sonalized genomic medicine (PGM). There is a tension between the typologizing inherent in much of this research and the personal in PGM. (shrink)

Evidence hierarchies are widely used to assess evidence in systematic reviews of medical studies. I give several arguments against the use of evidence hierarchies. The problems with evidence hierarchies are numerous, and include methodological shortcomings, philosophical problems, and formal constraints. I argue that medical science should not employ evidence hierarchies, including even the latest and most-sophisticated of such hierarchies.