Are the small and indolent cancers found in abundance in cancer screening normal variations, risk factors, or disease? Naturalists in philosophy of medicine turn to pathophysiological findings to decide such questions objectively. To understand the role of pathophysiological findings in disease definition, we must understand how they mislead in diagnostic reasoning. Participants on all sides of the definition of disease debate attempt to secure objectivity via reductionism. These reductivist routes to objectivity are inconsistent with the Bayesian nature of clinical reasoning; (...) when they appeal to the sciences, they are inconsistent with what philosophy of biology tells us about its natural kinds. Proposals that we narrow the scope of our claims in the disease definition debates are useful, but paradigms can still distort our reasoning in particular cases, even when we are self-conscious about their status. (shrink)

A common object found within medical museums is the developmental series: an arrangement of embryos depicting the transformation of an unremarkable blob into an anatomically organized and recognizable organism. The developmental series depicts a normative process, one where bodies emerge in reliable sequential stages to reveal anatomically perfect beings. Yet a century before the developmental series would become a visual model of embryological development, the very process of development itself was discerned through the comparative study of preserved human fetuses—specifically, those (...) deemed “monstrous” or characterized as “malformations.” This article examines how anatomically diverse fetal bodies were reformulated from singular curiosities into alternative developmental pathways whose characteristics testified to the laws of nature and to the primordial, physical relationship between humans and other species. In early nineteenth century Amsterdam, the father-son team of physicians Gerard and Willem Vrolik built up an internationally renowned anatomical museum famous especially for Willem’s collection of fetal malformations. Physical preparations of fetal malformations play a central role in Willem’s monumental handbook on developmental embryology: comparing human embryos against one another and the embryos of other species, Willem plots out a sequence of embryological development in which a body’s form marks its place within the ever-unfolding natural order. In conversation with the literature on model organisms, this article explores how the “monstrous” gets standardized and, in doing so, contributes to the scientific production of a normative physiological process. (shrink)

Some of Catherine Malabou’s recent work has developed her conception of plasticity (originally deployed in a reading of Hegelian Aufhebung ) in relation to neuroscience. This development clarifies and advances her attempt to bring contemporary theory into dialogue with the natural sciences, while indirectly indicating her engagement with the French tradition in philosophy of science and philosophy of medicine, especially the work of Georges Canguilhem. I argue that we can see her development of plasticity as an answer to some specific (...) shortcomings in Canguilhem’s conception of organic or biological normativity as advanced in The Normal and the Pathological . Such a view of plasticity shows its potential to provide the basis for a powerful critical engagement with contemporary conceptions of selfhood, self-transformation, subjectivation, and the general theory of norms. (shrink)

Discussing the workings of technology in care as aesthetic rather than as ethical or epistemological interventions focusses on how technologies engage in and change relations between those involved. Such an aesthetic study opens up a repertoire to address values that are abundant in care, but are as yet hardly theorized. Kamphof studies the problem that sensor technology reveals things about the elderly patients without the patients being aware of this. I suggest improvement of these relations may be considered in aesthetic (...) terms, for instance by developing the affective quality of people’s technological relationships. (shrink)

This paper proposes an ethical reflection on personalized medicine and more precisely on the diagnostic technology underlying it, including nanochips. Our approach is inspired by a combination of two philosophical frames of reference: first, John Dewey’s distinction between intuitive valuation and reflexive evaluation, second, John Rawls’ reflective equilibrium. We aim at what we call a ‘reflexive equilibrium’, a mutual adjustment between on the one hand, the intuitive beliefs scientists have about the ethics of the technologies they work on (‘valuations’ in (...) Dewey’s vocabulary) and, on the other hand, the reflexive ethical assessment of these technologies (‘evaluations’). Our goal, in this paper, is to provide the first step of this process through a philosophical analysis of some valuations on individualized medicine. In order to apprehend the ethical values shaping the development of biochips, we present and analyze qualitative interviews with scientists involved in the conception and the development of biochips involving nanotechnologies. We then propose a critical assessment of the role of ethics in these scientific practices. Last, we suggest two distinct and complementary ways to solve some of the issues brought to light by the interviews, without aiming at any dogmatic or “ready-made” answer. The first of these perspectives gives a central role to the capability individuals could achieve through personalized medicine; the second approach analyses the ethical disruptions entailed by personalized medicine with a special focus on care. (shrink)

This contribution intends to explore patients’ lived experience, with a focus on the temporal dimension. On the basis of a qualitative study that led me to interview persons with Parkinson’s disease, caregivers, and medical professionals, I develop an empirical and philosophical investigation of the temporalities surrounding the implementation of deep brain stimulation in Greece. I raise the issue of access to DBS medical care, and show how distinct temporalities are implied when the patients face such a matter: that of linear (...) time, linked with the medical discourse, the bureaucratic time linked to administrative and financial hurdles in the implementation and maintenance of DBS, and the technological time of the body/technology fusion. I consider initially the impact of technology and health care settings on the lived experience of patients and the enactment of multiple bodies which are interrelated with the social world. I then expand my analysis in order to show that this experience cannot be a solipsistic one, or specific to one physician/patient relationship. It is fully socially shaped. (shrink)

This paper considers proposals for developing ‘co-productive’ medical partnerships, within the UK National Health Service (NHS), concentrating in particular on the potential problem involved in combining professional and lay conceptions of health. Much of the literature that advocates the introduction of co-productive healthcare partnerships assumes that medical professionals and patients share, or can easily come to share, a common set of beliefs about what is valuable with regard to health interventions and outcomes. However, a substantial literature documents the contestability of (...) the concept of health, particular across professional and lay divides. We suggest that this potential disagreement ought to be taken seriously, and suggest that the prospect of a co-productive NHS in which patients and professionals act in partnership is threatened by the existence of unresolved epistemic differences. We suggest that part of the solution may lie in re-framing this potential disagreement in the terms provided by Engel’s bio-psycho-social account of health, and demonstrate how support for this account can be grounded upon a critical realist foundation. What we call a ‘stratified conception of health’ reveals the potential complementarity between health beliefs which may have at first seemed to be essentially contradictory. We consider some of the practical implications this idea has for conceiving and creating co-productive medical partnerships. (shrink)

This paper addresses the remarkable longevity of the idea of vitalism in the biological sciences and beyond. If there is to be a renewed vitalism today, however, we need to ask – on what kind of original conception of life should it be based? This paper argues that recent invocations of a generalized, processual variety of vitalism in the social sciences and humanities above all, however exciting in their scope, miss much of the basic originality – and interest – of (...) the vitalist perspective itself. The paper argues that any renewed spirit of vitalism in the contemporary era would have to base itself on the normativity of the living organism rather than on any generalized conceptions of process or becoming. In the terms of the paper, such a vitalism would have to be concrete and ‘disciplinary’ rather than processual or generalized. Such a vitalism would also need to accommodate, crucially, the pathic aspects of life – pathology, sickness, error; in short everything that makes us, as living beings, potentially weak, without power, at a loss. Sources for such a pathic vitalism might be found above all in the work of Georges Canguilhem – and Friedrich Nietzsche – rather than primarily in Bergson, Whitehead or Deleuze. (shrink)

Who is speaking in the history of social thought? The question of the authentic voice of social thought is typically posed in terms that tend to be either ambitiously theoretical or carefully methodological. Thus histories of social thought frequently offer either a résumé of general ideas about society (say from Montesquieu to Parsons) or a survey which gets bogged down in a rather tedious, nit-picking debate about empirical methodology. This paper is something of a preview of a pro jected attempt (...) on the part of the authors to capture the voice of social thought in rather different terms. Our three theses are: (1) that those who speak 'in the name of society' have just as frequently been doctors and bureaucrats as opposed to 'social philosophers' or professional sociologists; correlatively, (2) that the creative voice of social thought has more often been technical, problem-centred and tied up with par ticular rationalities of government as opposed to being either exclu sively theoretical or merely responsive to 'objective problems' in society; and, (3) that if sociology today struggles for a voice in which to speak this may be in some part due to the ways in which the past history of social thought has typically been conceived. (shrink)

Placebos are commonly defined as ineffective treatments. They are treatments that lack a known mechanism linking their properties to the properties of the condition on which treatment aims to intervene. Given this, the fact that placebos can have substantial therapeutic effects looks puzzling. The puzzle, we argue, arises from the relationship placebos present between culturally meaningful entities, our intentional relationship to the environment and bodily effects. How can a mere attitude toward a treatment result in appropriate bodily changes? We argue (...) that an ‘enactive’ conception of cognition accommodates and renders intelligible the phenomenon of placebo effects. Enactivism depicts an organism’s adaptive bodily processes, its intentional directedness, and the meaningful properties of its environment as co-emergent aspects of a single dynamic system. In doing so it provides an account of the interrelations between mind, body and world that demystifies placebo effects. (shrink)

The contentious topic of female circumcision brings together medical science, women’s health activism, media, and national and international policy-making in pursuit of the common goal of eradicating such practices. Referring to these diverse and heterogeneous practices as ‘female genital mutilation’ (FGM), eradicators have then condemned them as ‘barbaric’ and medically harmful to female bodies and sexuality. In presuming that bodies can be separated from their cultural contexts, the anti-FGM discourse not only replicates a nature/culture dualism that has been roundly questioned (...) by feminists in science studies and cultural studies, but has also perpetuated a colonialist assumption by universalizing a particular western image of a ‘normal’ body and sexuality in its quest to liberate women and girls. I use my own story as a circumcised woman to highlight the entanglements of body and culture as presented in these feminist theories of female bodies. (shrink)

This article begins with the question, is mind prefigured in life? Andreas Webber and Francisco Varela argue that the autopoietic model in combination with Jonas's theory of metabolism provide a more robust model than Kant's account of natural teleology in the third critique, and thus it is able to make a claim to, at least, a pre-figuration of human freedom. I argue that Freud's illustration of the death drive via the analogy of the cell in Beyond the Pleasure Principle provides (...) a valuable counter-example to Jonas's conception of metabolism and exposes the type of metaphysical assumptions that the Kantian project was so averse to. My intention here is not to reify either Jonas or Freud's claims on the determinative nature of natural causation; rather it is to argue that each exists as valuable heuristic tools. Any causal determinative judgment on the nature of natural teleology must be exercised with nothing less than a Kantian level of caution as the implication of placing the value of the coherence of our conceptual structures over the actual mechanical processes of the natural world confronts us with the direct risk of misrecognition on a massive scale. (shrink)

The article focuses on the impact of the concept of self-care on persons who are understood as incapable of self-care due to their physical and/or mental ‘incapacity’. The article challenges the idea of this health care concept as empowerment and highlights the difficulties for persons who do not fit into this concept. To exemplify this, the self-care concept is discussed with regard to persons with Alzheimer’s disease (AD). In the case of persons with AD, self-care is interpreted in many different (...) ways—depending on the point of view, for instance as an affected person or a carer. To prevent a marginalisation of the growing group of elderly persons with dementia, the article argues that concepts such as those of personhood, wellbeing, autonomy, rationality and normality have to be re-thought with regard to an increasingly ageing population. Taking into account that AD as a socio-medical construct has to be understood in the context of power relations, the article focuses on the mutual influence between the concepts of self-care and of AD and its possible impact on governing dementia and AD in particular. Michel Foucault’s considerations on ‘technologies of the self’ provide the basis for the discussion of the self-care concept within existing societal power relations. (shrink)

The importance given by historian and philosopher of science Georges Canguilhem to the role of practice, techniques, and experimentation in concept-formation was largely overlooked by commentators. After placing Canguilhem’s contributions within the larger history of historical epistemology in France, and clarifying his views regarding this expression, I re-evaluate the relation between concepts and experimental practices in Canguilhem’s philosophy of science. Drawing on his early writings on the relations between science and technology in the 1930s, on the Essai sur quelques problèmes (...) concernant le normal et le pathologique , and on La formation du concept de réflexe aux XVIIe et XVIIIe siècles , I argue that the formation and rectification of concepts in Canguilhem’s sense are intrinsically bound with the experimental, material, technical, and cultural contexts in which concepts are operationalized. (shrink)

The historiography of race is usually framed by two discontinuities: the invention of race by European naturalists and anthropologists, marked by Carl Linnaeus’s Systema naturae and the demise of racial typologies after World War II in favor of population-based studies of human diversity. This framing serves a similar function as the quotation marks that almost invariably surround the term. “Race” is placed outside of rational discourse as a residue of outdated essentialist and hierarchical thinking. I will throw doubt on this (...) underlying assumption, not in order to re-legitimate race but in order to understand better why race has been, and continues to be, such a politically powerful and explosive concept. (shrink)

The tendency to idealise artificial intelligence as independent from human manipulators, combined with the growing ontological entanglement of humans and digital machines, has created an “anthrobotic” horizon, in which data analytics, statistics and probabilities throw our agential power into question. How can we avoid the consequences of a reified definition of intelligence as universal operation becoming imposed upon our destinies? It is here argued that the fantasised autonomy of automated intelligence presents a contradistinctive opportunity for philosophical consciousness to understand itself (...) anew as holistic and co-creative, beyond the recent “analytic” moment of the history of philosophy. Here we introduce the concept of “crealectic intelligence”, a meta-analytic and meta-dialectic aspect of consciousness. Intelligent behaviour may consist in distinguishing discrete familiar parts or reproducible functions in the midst of noise via an analytic process of segmentation; intelligence may also manifest itself in the constitution of larger wholes and dynamic unities through a dialectic process of association or assemblage. But, by contrast, crealectic intelligence co-creates realities in the image of an ideal or truth, taking into account the desiring agent imbued with a sense of possibility, in a relationship not only with the Real but also with the creative sublime or “Creal”. (shrink)

The practice of terminating a pregnancy following the diagnosis of a fetal abnormality raises questions about notions of bodily normality and the ways these shape ethical decision-making. This is particularly the case with terminations done on the basis of ostensibly minor morphological anomalies, such as cleft lip and isolated malformations of the limbs or digits. In this paper, I examine a recent case of selective termination after a morphology ultrasound scan revealed the fetus to be missing a hand . Using (...) the work of Georges Canguilhem, I show that a person with acheiria could be considered normal. Further, I show that this case reveals a kind of “undecidability” in the significance of fetal sex/gender and disability in termination. From this, I consider the conceptual interaction of disability with sex/gender, to argue that the ethics of disability termination are not as distinct from those of sex/gender selection as is commonly supposed. (shrink)

Psychedelic-assisted Psychotherapy combines the use of psychedelic compounds, such as psilocybin, with psychotherapy. PAP has shown some promise as a novel treatment for Major Depressive Disorder, and empirical research suggests that its efficacy turns on the altered states induced by psychedelic compounds. In this paper we draw on the literature of phenomenology to explain the therapeutic potential of psychedelic experiences. Svenaeus characterises mental illness as a form of suffering that entails three distinct but related experiences of alienation or “unhomelike being-in-the-world”: (...) illness suffering, which relates to embodiment; existential suffering, which relates to self-narratives, and political suffering, which relates to social relationships. Ratcliffe further characterises the experience of MDD in phenomenological terms as a loss of pre-intentional possibility that manifests as excessive noematic feeling in the experience of embodiment, restrictive narratives in the construction of self, and disconnectedness in experience of the social world. We contend that PAP ameliorates the suffering associated with MDD by inducing and consolidating a state of broadened pre-intentional possibility—one that entails sudden, profound and enduring changes in embodiment, self-narratives, and social experience. We argue further that this phenomenological account is consistent with a bio-psycho-social model of mental health and illness, and we frame it as an argument supporting the plausibility of recent claims about treatment success. This helps to justify ongoing future empirical research in this setting. (shrink)

Social theorists in recent years have concerned themselves with the matter of the kind and intensity of people’s everyday reflective capacities. In this respect, Bourdieu has mostly been found wanting. This article seeks to counter this sentiment with recourse to an ‘anti-mechanistic’ reading of Bourdieu’s theory of practice. It begins by arguing that in imposing a strict delineation between consciousness and habitus, Bourdieu and his critics alike at times unwittingly conflate habitus and mechanistic habit, at once vaunting conscious deliberation and (...) neglecting the non-habitual acts that habitus makes possible. Next it turns to the treatment, within the mechanistic reading, of the notion of the ‘social world’. The argument is that in this reading the social world is reified and rendered the mere background or setting for social practices rather than the product of those practices. Without recognition of this latter quality, the social world becomes hypostatized and exists outside of time. The secondary aim, then, is to argue for a thoroughgoing temporal relation to social reality in Bourdieu’s theory. (shrink)

Phenomenology has contributed to healthcare by providing resources for understanding the lived experience of the patient and their situation. But within a burgeoning literature on the characteristic features of illness, there has not yet been an account appropriate to describe congenital illnesses: conditions which are present from birth and cause suffering or medical threat to their bearers. Congenital illness sits uncomfortably with standard accounts in phenomenology of illness, in which concepts such as loss, doubt, alienation and unhomelikeness presuppose prior health. (...) These accounts reflect, in different ways, Maurice Merleau-Ponty’s assumption that the ways of living of the ill contain allusions to fundamental, healthy functions. The originality of congenital illness complicates this assumption and demands its own original phenomenology. In this paper, I sketch my personal experience living with a single-ventricle heart condition. While some of this story may reflect my own idiosyncratic experience, I hope that much of it will resonate with the congenital illness experience. I argue that the phenomenological literature on illness, grounded in the notion of loss, does not describe the congenital illness experience. I show how a number of other patient-centred theories of health and illness which have been influential on phenomenology can and cannot elucidate congenital illness. In particular, I consider Georges Canguilhem’s account of the normal and the pathological; debates in disability; and the notion of illness as biographical disruption. I show that congenital illness results in the preadmission of its patients to a paradoxical logic of medical palliation, one product of which is existential maturity. (shrink)

In this article, I critically analyze the anthropological foundation of the bioethics of philosopher Jean-François Malherbe, particularly as presented in his book, Pour une Éthique de la Médecine. Malherbe argues that such practices as organ donation and transplants, assisted reproduction, resuscitation, and other uses of biotechnologies in contemporary medicine are unethical because they go against essential human nature. Furthermore, he uses this position as a basis to prescribe public policy and institutional practice. In contrast, I argue not only that ‘human (...) nature’ is much more malleable and adaptive to changes in technology and society than Malherbe allows, but also that his criticisms of medicine and technoscientific development overstep the bounds of the social function of philosophical ethics, which is to inform and clarify public debate. Public policy and institutional practice is thus best left to the democratic political process under the parameters of the just rule of law. (shrink)

Public health advocates, government agencies, and commercial organizations increasingly use nutritional science to guide food choice and diet as a way of promoting health, preventing disease, or marketing products. We argue that in many instances such references to nutritional science can be characterized as nutritional scientism. We examine three manifestations of nutritional scientism: the simplification of complex science to increase the persuasiveness of dietary guidance, superficial and honorific references to science in order to justify cultural or ideological views about food (...) and health, and the presumption that nutrition is the primary value of food. This paper examines these forms of nutritional scientism in the context of biopolitics to address bioethical concerns related to the misuse of scientific evidence to make claims regarding the effect of diet on health. We argue that nutritional scientism has ethical implications for individual responsibility and freedom, concerning iatrogenic harm, and for well-being. (shrink)

At once historical and philosophical, Michel Foucault used his genealogical method to expose the contingent conditions constituting the institutions, sciences and practices of the present. His analyses of the asylum, clinic, prison and sexuality revealed the historical, political and epistemological forces that make up certain types of subjects, sciences and sites of control. Although noting the originality of his work, a number of early critics questioned the normative framework of Foucault's method. Nancy Fraser argued that Foucault's genealogical method was ‘normatively (...) confused’ as it implied political critique yet claimed to be value-neutral. Jürgen Habermas and Charles Taylor also questioned the normative basis of Foucault's appeals to critique, arguing it was self-refuting as Foucault left no room for the subject to escape power. Although a debate among these scholars was planned for the mid-1980s, Foucault's death in 1984 meant this could not occur. A number of edited volumes sought to fabricate a debate, with defenders of Foucault excavating his published monographs to construct responses to his critics. While the monographs remain the central texts of Foucault's oeuvre, over the past decade his Collège de France lectures have been published and translated into English. This article offers a schematic survey of the influence of the Collège de France lectures in recasting different points in the debates over normativity, critique and resistance. (shrink)

We defend a view of the distinction between the normal and the pathological according to which that distinction has an objective, biological component. We accept that there is a normative component to the concept of disease, especially as applied to human beings. Nevertheless, an organism cannot be in a pathological state unless something has gone wrong for that organism from a purely biological point of view. Biology, we argue, recognises two sources of biological normativity, which jointly generate four “ways of (...) going wrong” from a biological perspective. These findings show why previous attempts to provide objective criteria for pathology have fallen short: Biological science recognizes a broader range of ways in which living things can do better or worse than has previously been recognized in the philosophy of medicine. (shrink)

The paper treats several ontological questions about certain nineteenth-century and contemporary medical and scientific conceptualizations of hereditary relation. In particular, it considers the account of mid-nineteenth century psychiatric thought given by Foucault in Psychiatric Power: Lectures at the Collège de France, 1973–1974 and Abnormal: Lectures at the Collège de France, 1974–1975 . There, Foucault argues that a fantastical conceptual prop, the ‘metabody,’ as he terms it, was implicitly supposed by that period’s psychiatric medicine as a putative ground for psychiatric pathology. (...) After presenting the heart of Foucault’s thought on the ‘metabody,’ the paper investigates the possibility that a contemporary version of a ‘metabody’ may operate today as a conceptual analog of the nineteenth-century psychiatric theory and practice that Foucault began to expose in the texts examined here. It speculates that we might identify a contemporary genetic version of a ‘metabody’ in a particular current conception of the gene as replicator, an item marked by an ambiguous temporal ontology. (shrink)

This paper falls under the rubric of the sociology of knowledge, which bridges the gap between phenomenological philosophy and the human sciences. It presents an empirical investigation of the communicative construction of psychotherapeutic reality. I examine therapeutic talk and psychotherapists' reconstructions of the transition from state socialism in Germany in 1989. In both instances I show how psychotherapists' commonly shared interpretative conventions and rules of reasoning produce typical accounts. The first part of the paper shows how certain interpretative conventions and (...) rules of reasoning organize therapeutic talk and interaction in general. The second part focuses on how the interpretative conventions typical of therapy also inform psychotherapists' interpretations of the transition from state socialism. (shrink)

Definitions of health in terms of some kind of balance form a category of their own within the sphere of health definition. Such definitions have their roots in the beginnings of scientific medicine, and popular versions are common among lay people. It has even been claimed that balance is fundamental to health for all species. Several present-day definitions of health in terms of balance are presented here. Particular attention is given to the call for a definition of health applicable to (...) both humans and animals within the One Health approach, involving human medicine, veterinary medicine and ecology. Definitions in terms of balance have been suggested but none has been thoroughly analysed with regard to its suitability. There are therefore three concerns in this paper. The first is to introduce versions of the category of balance, as a first step towards a nomenclature of health definitions. The second is to analyse the claim made recently that balance is a universal criterion of health in all species including humans. The third is to ascertain whether any of the versions discussed is suited to the One Health approach. (shrink)

Conceptual analysis of health and disease is portrayed as consisting in the confrontation of a set of criteria—a “definition”—with a set of cases, called instances of either “health” or “ disease.” Apart from logical counter-arguments, there is no other way to refute an opponent’s definition than by providing counter-cases. As resorting to intensional stipulation is not forbidden, several contenders can therefore be deemed to have succeeded. This implies that conceptual analysis alone is not likely to decide between naturalism and normativism. (...) An alternative to this approach would be to examine whether the concept of disease can be naturalized. (shrink)

The paper discusses two recent approaches to schizophrenia, a phenomenological and a neuroscientific approach, illustrating how new directions in philosophy and cognitive science can elaborate accounts of psychopathologies of the self. It is argued that the notion of the minimal and bodily self underlying these approaches is still limited since it downplays the relevance of social interactions and relations for the formation of a coherent sense of self. These approaches also illustrate that we still lack an account of how 1st (...) and 3rd person observations can fruitfully go together in an embodied account of disorders of the self. Two concepts from enactive cognitive science are introduced, the notions of autonomy and sense-making. Based on these, a new proposal for an enactive approach to psychopathologies of the self is outlined that integrates 1st and 3rd person perspectives, while strongly emphasising the role of social interactions in the formation of self. It is shown how the enactive framework might serve as a basis for an alternative understanding of disorders of the self such as schizophrenia, as a particular form of socially constituted self-organisation. (shrink)

Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM , the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological challenges (...) of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility. (shrink)

Next SectionThe current focus on early intervention trials in Alzheimer's disease research raises particular ethical issues. These arise out of problems of validating study results and translating them into general practice for one thing and out of unwanted effects of an uncertain diagnosis for diagnosed people for another. The first addresses the demands of scientific research compared to those of medical practice, questioning how the medical value of clinical trials is evaluated. The second relates the scientific and medical value of (...) early intervention trials to the normative value of an uncertain diagnosis. Are people who are diagnosed with a potential early form of AD in clinical studies patients proper—although they would not have been diagnosed with the given “disease” in non-research-oriented medical settings? The very problem of framing this question in terms of diagnostic misconceptions connects conceptual with ethical issues of research into preclinical stages of neurodegenerative diseases. (shrink)

Whether “information” exists in biology, and in what sense, has been a topic of much recent discussion. I explore Shannon, Dretskean, and teleosemantic theories, and analyze whether or not they are able to give a successful naturalistic account of information—specifically accounts of meaning and error—in biological systems. I argue that the Shannon and Dretskean theories are unable to account for either, but that the teleosemantic theory is able to account for meaning. However, I argue that it is unable to account (...) for error. Thus I conclude that while talk of informational meaning is justifiable within a naturalistic framework, talk of informational error is not, and must be used in a metaphorical sense only. (shrink)

Seeking a scientific basis for understanding and treating mental illness, and inspired by the work of Ivan Pavlov, American physiologists, psychiatrists and psychologists in the 1920s turned to nonhuman animals. This paper examines how new constructs such as “experimental neurosis” emerged as tools to enable psychiatric comparison across species. From 1923 to 1962, the Cornell “Behavior Farm” was a leading interdisciplinary research center pioneering novel techniques to experimentally study nonhuman psychopathology. Led by the psychobiologist Howard Liddell, work at the Behavior (...) Farm formed part of an ambitious program to develop new preventative and therapeutic techniques and bring psychiatry into closer relations with physiology and medicine. At the heart of Liddell’s activities were a range of nonhuman animals, including pigs, sheep, goats and dogs, each serving as a proxy for human patients. We examine how Pavlov’s conceptualization of ‘experimental neurosis’ was used by Liddell to facilitate comparison across species and communication between researchers and clinicians. Our close reading of his experimental system demonstrates how unexpected animal behaviors and emotions were transformed into experimental virtues. However, to successfully translate such behaviors from the animal laboratory into the field of human psychopathology, Liddell increasingly reached beyond, and, in effect, redefined, the Pavlovian method to make it compatible and compliant with an ethological approach to the animal laboratory. We show how the resultant Behavior Farm served as a productive “hybrid” place, containing elements of experiment and observation, laboratory and field. It was through the building of close and more naturalistic relationships with animals over extended periods of time, both normal and pathological, and within and outside of the experimental space, that Liddell could understand, manage, and make useful the myriad behavioral complexities that emerged from the life histories of experimental animals, the researchers who worked with them, and their shared relationships to the wider physical and social environments. (shrink)

Germund Hesslow has argued that concepts of health and disease serve no important scientific, clinical, or ethical function. However, this conclusion depends upon the particular concept of disease he espouses; namely, on Boorse's functional notion. The fact/value split embodied in the functional notion of disease leads to a sharp split between the science of medicine and bioethics, making the philosophy of medicine irrelevant for both. By placing this disease concept in the broader context of medical history, I shall show that (...) it does capture an essential part of modern medical ideology. However, it is also a self-contradictory notion. By making explicit the value desiderata of medical nosologies, a reconfiguration of the relation between medicine, bioethics, and the philosophy of medicine is initiated. This, in turn, will involve a recovery of the caring dimensions of medicine, and thus a more humane practice. (shrink)

The traditional contrast between naturalist and normativist disease concepts fails to capture the most salient features of the health concepts debate. By using health concepts as a window on background notions of medical science and ethics, I show how Christopher Boorse (an influential naturalist) and Lennart Nordenfelt (an influential normativist) actually share deep assumptions about the character of medicine. Their disease concepts attempt, in different ways, to shore up the same medical model. For both, health concepts function like demarcation criteria (...) in the philosophy of science: they mark off the jurisdiction of medical science, and protect it from an inappropriate intrusion of socioeconomic factors, which threaten the integrity of modern medicine. These views are challenged by new developments in healthcare such as managed care and total quality review. To frame the health concepts debate in a way that better captures the issues integral to these new developments, I advance a new way of reading the distinction between weak and strong normativists. Strong normativists are skeptical of the demarcation project, think facts and values cannot be disentangled, and hold that socioeconomic conditions unavoidably influence how pathology is understood. The new health concepts debate should be framed as one between weak and strong normativists, and it concerns how we should respond to the current developments in health care. (shrink)

What clinicians, biomedical scientists, and other health care professionals know as individuals or as groups and how they come to know and use knowledge are central concerns of medical epistemology. Activities associated with knowledge production and use are called epistemic practices. Such practices are considered in biomedical and clinical literatures, social sciences of medicine, philosophy of science and philosophy of medicine, and also in other nonmedical literatures. A host of different kinds of knowledge claims have been identified, each with different (...) uses and logics of justification. A general framework is needed to situate these diverse contributions in medical epistemology, so we can see how they fit together. But developing such a framework turns out to be quite tricky. In this survey, three possible frameworks are considered along with the difficulties associated with each of them. The essay concludes with a fourth framework, which considers any epistemology as part of a practice that is oriented toward overcoming errors that emerge in antecedently given practices where knowledge is developed and used. As medicine indirectly advances health by directly mitigating disease, so epistemology indirectly advances knowledge by directly mitigating error. (shrink)

“We have to be willing to consider stimulants as an option because we are not correcting students' disadvantages in other, more traditional ways,” writes Ray (2016), pointing out how limited and in...

Though the authors of this commentary have deep felt doubts about the fruitfulness of Björkman and Hansson’s analysis of bodily rights, they do not doubt their capacity to develop both creative and provocative thoughtsIt is always welcoming to be confronted with thoughts that, even though one wholeheartedly disagrees with them, have the effect of stimulating one’s own reflections on matters, which without such confrontations, would have been less distinct, less critical—and we would gladly admit, less polemical. Thus it is thanks (...) to Barbro Björkman and Sven Ove Hansson’s article, “Bodily rights and property rights”, that we have been able to set our present course into these murky waters. The issue they want to address is by no means of a kind that lends itself easily to theoretical speculation. This has, perhaps, as much to do with the inherent intricacy of the issue itself as with the controversy it has managed to arouse. The issue is: is it possible to have ownership over one’s own body—that is, is it appropriate to treat the body and its components as property? What are the implications of conceptualising the body and its parts in terms of property? Should one, as a general rule, be able to sell and buy human biological material? If so, who should be allowed to buy and sell it? Does the sale or donation of one’s own bodily parts imply a transfer of ownership rights to the buyer or receiver, or is it rather that ownership of human bodily parts can only be acquired after the material has been, say, manipulated in a laboratory?Contrary to Björkman and Hansson, who see “the primary normative issue” to be “what combination of rights a person should have to a particular item of biological material”, we believe that their decision to construe …. (shrink)

The relationship of man himself to his environment is an inseparable part of ecology; for he also is an organism and other organisms are a part of his environment. Ecology, therefore, broadly conceived and rightly understood, instead of being an academic science merely, out of touch with humanistic interests, is really that part of every other biological science which brings it into immediate relation to human kind. The proper place of humans in ecological study has been a recurring issue for (...) ecology. Of course humans are part of Nature writ large, but are they part of the ecologist's nature? The question bothered biologists even before the discipline of ecology was firmly institutionalized.... (shrink)

In this article I discuss the problem of embodied subjectivity, viewed from the perspective of spatiality. The questions I address arise from my ethnographic study on chronic pain. My main argument is that, in contrast to philosophical understanding of space as an a priori, or as a container, space and spatiality are shaped and reshaped through the body in pain. What characterizes most patients' experiences of space is movement. This can be understood through Merleau-Ponty's phenomenological theory of the lived body (...) but needs in addition a cultural contextualization. Because of biomedical thinking, in Western settings chronic pain is liminal. It does not fit the biomedical categories of disease or space. This profoundly shapes patients' understanding of their subjectivity as homeless, and their experience of spatiality as estranged and exiled. (shrink)

Overdiagnosis and disease are related concepts. Widened conceptions of disease increase overdiagnosis and vice versa. This is partly because there is a close and complex relationship between disease and overdiagnosis. In order to address the problems with overdiagnosis, we may benefit from a closer understanding this relationship. Accordingly, the objective of this article is to elucidate the relationship between disease and overdiagnosis. To do so, the article starts with scrutinizing how overdiagnosis can explain the expansion of the concept of disease. (...) Then it investigates how definitions of disease address various challenges of overdiagnosis. The article specifically investigates recent attempts to clarify the relationship between the concepts of disease and overdiagnosis. Several shortcomings are identified and lead to a closer analysis of overdiagnosis in the diagnostic process. Contrary to recent contributions to the field, it is argued that cases of overdiagnosis are not cases of disease. They are non-verified labelling of disease. It is revealed how overdiagnosis establishes an unwarranted link between indicative phenomena, such as polyps or cell changes, and harm, and thereby generates a link to disease. One implication of this study is that we should stop attributing disease language to indicative phenomena. That is, we should stop calling it “cancer screening” when we are actually searching for polyps. Another implications is that we should strive for scientific progress in differentiating phenomena that are of negative value to us from those that are not. In overdiagnosis we diagnose something that is not disease: it is over-diagnosis. (shrink)

Obesity has generated significant worries amongst health policy makers and has obtained increased attention in health care. Obesity is unanimously defined as a disease in the health care and health policy literature. However, there are pragmatic and not principled reasons for this. This warrants an analysis of obesity according to standard conceptions of disease in the literature of philosophy of medicine. According to theories and definitions of disease referring to internal processes, obesity is not a disease. Obesity undoubtedly can result (...) in disease, making it a risk factor for disease, but not a disease per se. According to several social conceptions of disease, however, obesity clearly is a disease. Obesity can conflict with aesthetic, moral, or other social norms. Making obesity a “social disease” may very well be a wise health policy, assuring and improving population health, especially if we address the social determinants of obesity, such as the food supply and marketing system. However, applying biomedical solutions to social problems may also have severe side effects. It can result in medicalization and enhance stigmatization and discrimination of persons based on appearance or behavior. Approaching social problems with biomedical means may also serve commercial and professionals’ interests more than the health and welfare of individuals; it may make quick fix medical solutions halt more sustainable structural solutions. This urges health insurers, health care professionals, and health policy makers to be cautious. Especially if we want to help and respect persons that we classify and treat as obese. (shrink)

In his influential theory of health Nordenfelt bases the concepts of health and illness on the notions of ability and disability. A premise for this is that ability and disability provide a more promising, adequate, and useful basis than well-being and suffering. Nordenfelt uses coma and manic episodes as paradigm cases to show that this is so. Do these paradigm cases (and thus the premise) hold? What consequences does it have for the theory of health and illness if it they (...) do not? These are the key questions in this article, which first presents the relationship between pain and disability in Nordenfelt’s theory and the paradigm cases he uses to argue for the primacy of disability over pain. Then, Nordenfelt’s concepts of illness are outlined, highlighting its presumptions and arguments. The main point is that if you do not have an action-theoretical perspective, it is not obvious that disability is the core concept for illness. The compelling effect of the paradigm cases presupposes that you see ability as the primary issue. To those who do not share this presumption, people in coma may not be ill. There are alternative well founded arguments for the primacy of first person experiences for the concept of illness. Hence, we need better arguments for the primacy of disability over first person experiences in illness, or first-person experience should be more primarily included in the concept of illness. (shrink)

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease (...) as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization. (shrink)