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)

An astonishing volume and diversity of evidence is available for many hypotheses in the biomedical and social sciences. Some of this evidence—usually from randomized controlled trials (RCTs)—is amalgamated by meta-analysis. Despite the ongoing debate regarding whether or not RCTs are the ‘gold-standard’ of evidence, it is usually meta-analysis which is considered the best source of evidence: meta-analysis is thought by many to be the platinum standard of evidence. However, I argue that meta-analysis falls far short of that standard. Different meta-analyses (...) of the same evidence can reach contradictory conclusions. Meta-analysis fails to provide objective grounds for intersubjective assessments of hypotheses because numerous decisions must be made when performing a meta-analysis which allow wide latitude for subjective idiosyncrasies to influence its outcome. I end by suggesting that an older tradition of evidence in medicine—the plurality of reasoning strategies appealed to by the epidemiologist Sir Bradford Hill—is a superior strategy for assessing a large volume and diversity of evidence. (shrink)

Debates about the ethics and effects of placebos and whether ‘placebos’ in clinical trials of complex treatments such as acupuncture are adequate rage. Yet there is currently no widely accepted definition of the ‘placebo’. A definition of the placebo is likely to inform these controversies. Grünbaum’s characterization of placebos and placebo effects has been touted by some authors as the best attempt thus far, but has not won widespread acceptance largely because Grünbaum failed to specify what he means by a (...) therapeutic theory and because he does not stipulate a special role for expectation effects. Grünbaum claims that placebos are treatments whose ‘characteristic features’ do not have therapeutic effects on the target disorder. I show that with four modifications, Grünbaum’s definition provides a defensible account of placebos for the purpose of constructing placebo controls within clinical trials. The modifications I introduce are: adding a special role for expectations, insisting that placebo controls control for all and only the effects of the incidental treatment features, relativizing the definition of placebos to patients, and introducing harmful interventions and nocebos to the definitional scheme. I also provide guidance for classifying treatment features as characteristic or incidental. (shrink)

The standard philosophical definition of placebos offered by Grünbaum is incompatible with Cartwright’s conception of randomized clinical trials. I offer a modified account of placebos that respects this role and clarifies why many current medical trials fail to warrant the conclusions they are typically seen as yielding. I then consider recent changes to guidelines for reporting medical trials and show that pessimism over parsing out the cause of “unblinding” is premature. Specifically, using a trial of antidepressants, I show how more (...) sophisticated statistical analyses can parse out the source of such effects and serve as an alternative to placebo control. (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)

Causal claims in biomedical contexts are ubiquitous albeit they are not always made explicit. This paper addresses the question of what causal claims mean in the context of disease. It is argued that in medical contexts causality ought to be interpreted according to the epistemic theory. The epistemic theory offers an alternative to traditional accounts that cash out causation either in terms of “difference-making” relations or in terms of mechanisms. According to the epistemic approach, causal claims tell us about which (...) inferences (e.g., diagnoses and prognoses) are appropriate, rather than about the presence of some physical causal relation analogous to distance or gravitational attraction. It is shown that the epistemic theory has important consequences for medical practice, in particular with regard to evidence-based causal assessment. (shrink)

Some Key Controversies in the Philosophy of Science Larry Laudan. the mouths of my realist, relativist, and positivist. (By contrast, there is at least one person who hews to the line I have my prag- matist defending.) But I have gone to some  ...

This paper examines the state of the field of “science and values”—particularly regarding the implications of the thesis of transient underdetermination for the ideal of value-free science, or what I call the “ideal of epistemic purity.” I do this by discussing some of the main arguments in the literature, both for and against the ideal. I examine a preliminary argument from transient underdetermination against the ideal of epistemic purity, and I discuss two different formulations of an objection to this argument—an (...) objection that requires the strict separation of the epistemic from the practical. A secondary aim of the paper is to suggest some future directions for the field, one of which is to replace the vocabulary of values that is often employed in the literature with a more precise one. (shrink)

This is an important book precisely because there is none other quite like it.

This chapter explores the idea that causal inference is warranted if and only if the mechanism underlying the inferred causal association is identified. This mechanistic stance is discernible in the epidemiological literature, and in the strategies adopted by epidemiologists seeking to establish causal hypotheses. But the exact opposite methodology is also discernible, the black box stance, which asserts that epidemiologists can and should make causal inferences on the basis of their evidence, without worrying about the mechanisms that might underlie their (...) hypotheses. I argue that the mechanistic stance is indeed a bad methodology for causal inference. However, I detach and defend a mechanistic interpretation of causal generalisations in epidemiology as existence claims about underlying mechanisms. (shrink)

Imre Lakatos' philosophical and scientific papers are published here in two volumes. Volume I brings together his very influential but scattered papers on the philosophy of the physical sciences, and includes one important unpublished essay on the effect of Newton's scientific achievement. Volume II presents his work on the philosophy of mathematics (much of it unpublished), together with some critical essays on contemporary philosophers of science and some famous polemical writings on political and educational issues. Imre Lakatos had an influence (...) out of all proportion to the length of his philosophical career. This collection exhibits and confirms the originality, range and the essential unity of his work. It demonstrates too the force and spirit he brought to every issue with which he engaged, from his most abstract mathematical work to his passionate 'Letter to the director of the LSE'. Lakatos' ideas are now the focus of widespread and increasing interest, and these volumes should make possible for the first time their study as a whole and their proper assessment. (shrink)

Knowledge in a Social World offers a philosophy for the information age. Alvin Goldman explores new frontiers by creating a thoroughgoing social epistemology, moving beyond the traditional focus on solitary knowers. Against the tides of postmodernism and social constructionism Goldman defends the integrity of truth and shows how to promote it by well-designed forms of social interaction. From science to education, from law to democracy, he shows why and how public institutions should seek knowledge-enhancing practices. The result is a bold, (...) timely, and systematic treatment of the philosophical foundations of an information society. (shrink)

During the last three decades, reflections on the growth of scientific knowledge have inspired historians, sociologists, and some philosophers to contend that scientific objectivity is a myth. In this book, Kitcher attempts to resurrect the notions of objectivity and progress in science by identifying both the limitations of idealized treatments of growth of knowledge and the overreactions to philosophical idealizations. Recognizing that science is done not by logically omniscient subjects working in isolation, but by people with a variety of personal (...) and social interests, who cooperate and compete with one another, he argues that, nonetheless, we may conceive the growth of science as a process in which both our vision of nature and our ways of learning more about nature improve. Offering a detailed picture of the advancement of science, he sets a new agenda for the philosophy of science and for other "science studies" disciplines. (shrink)

We argue that the health sciences make causal claims on the basis of evidence both of physical mechanisms, and of probabilistic dependencies. Consequently, an analysis of causality solely in terms of physical mechanisms or solely in terms of probabilistic relationships, does not do justice to the causal claims of these sciences. Yet there seems to be a single relation of cause in these sciences - pluralism about causality will not do either. Instead, we maintain, the health sciences require a theory (...) of causality that unifies its mechanistic and probabilistic aspects. We argue that the epistemic theory of causality provides the required unification. (shrink)

‘The problem with simulations is that they are doomed to succeed.’ So runs a common criticism of simulations—that they can be used to ‘prove’ anything and are thus of little or no scientific value. While this particular objection represents a minority view, especially among those who work with simulations in a scientific context, it raises a difficult question: what standards should we use to differentiate a simulation that fails from one that succeeds? In this paper we build on a structural (...) analysis of simulation developed in previous work to provide an evaluative account of the variety of ways in which simulations do fail. We expand the structural analysis in terms of the relationship between a simulation and its real-world target emphasizing the important role of aspects intended to correspond and also those specifically intended not to correspond to reality. The result is an outline both of the ways in which simulations can fail and the scientific importance of those various forms of failure. (shrink)

Helen Longino seeks to break the current deadlock in the ongoing wars between philosophers of science and sociologists of science--academic battles founded on disagreement about the role of social forces in constructing scientific knowledge. While many philosophers of science downplay social forces, claiming that scientific knowledge is best considered as a product of cognitive processes, sociologists tend to argue that numerous noncognitive factors influence what scientists learn, how they package it, and how readily it is accepted. Underlying this disagreement, however, (...) is a common assumption that social forces are a source of bias and irrationality. Longino challenges this assumption, arguing that social interaction actually assists us in securing firm, rationally based knowledge. This important insight allows her to develop a durable and novel account of scientific knowledge that integrates the social and cognitive. Longino begins with a detailed discussion of a wide range of contemporary thinkers who write on scientific knowledge, clarifying the philosophical points at issue. She then critically analyzes the dichotomous understanding of the rational and the social that characterizes both sides of the science studies stalemate and the social account that she sees as necessary for an epistemology of science that includes the full spectrum of cognitive processes. Throughout, her account is responsive both to the normative uses of the term knowledge and to the social conditions in which scientific knowledge is produced. Building on ideas first advanced in her influential book Science as Social Knowledge, Longino brings her account into dialogue with current work in social epistemology and science studies and shows how her critical social approach can help solve a variety of stubborn problems. While the book focuses on epistemological concerns related to the sociality of inquiry, Longino also takes up its implications for scientific pluralism. The social approach, she concludes, best allows us to retain a meaningful concept of knowledge in the face of theoretical plurality and uncertainty. (shrink)

Evidence-based medicine (EBM) makes use of explicit procedures for grading evidence for causal claims. Normally, these procedures categorise evidence of correlation produced by statistical trials as better evidence for a causal claim than evidence of mechanisms produced by other methods. We argue, in contrast, that evidence of mechanisms needs to be viewed as complementary to, rather than inferior to, evidence of correlation. In this paper we first set out the case for treating evidence of mechanisms alongside evidence of correlation in (...) explicit protocols for evaluating evidence. Next we provide case studies which exemplify the ways in which evidence of mechanisms complements evidence of correlation in practice. Finally, we put forward some general considerations as to how the two sorts of evidence can be more closely integrated by EBM. (shrink)

The philosophy of evidence-based medicine -- What is EBM? -- What is good evidence for a clinical decision? -- Ruling out plausible rival hypotheses and confounding factors : a method -- Resolving the paradox of effectiveness : when do observational studies offer the same degree of evidential support as randomized trials? -- Questioning double blinding as a universal methodological virtue of clinical trials : resolving the Philip's paradox -- Placebo controls : problematic and misleading baseline measures of effectiveness -- Questioning (...) the methodological superiority of "placebo" over "active" controlled trials -- Examining the paradox that traditional roles for mechanistic reasoning and expert -- Judgment have been up-ended by EBM -- A qualified defence of the EBM stance on mechanistic reasoning -- Knowledge that versus knowledge how : situating the EBM position on expert clinical judgment -- Moving EBM forward. (shrink)

A feminist primer for philosophers of science -- The legacy of twentieth century philosophy of science -- What feminist science studies can offer -- Challenges from every direction -- The prospects of twenty-first century philosophy of science.

Advocates of the self-corrective thesis argue that scientific method will refute false theories and find closer approximations to the truth in the long run. I discuss a contemporary interpretation of this thesis in terms of frequentist statistics in the context of the behavioral sciences. First, I identify experimental replications and systematic aggregation of evidence (meta-analysis) as the self-corrective mechanism. Then, I present a computer simulation study of scientific communities that implement this mechanism to argue that frequentist statistics may converge upon (...) a correct estimate or not depending on the social structure of the community that uses it. Based on this study, I argue that methodological explanations of the “replicability crisis” in psychology are limited and propose an alternative explanation in terms of biases. Finally, I conclude suggesting that scientific self-correction should be understood as an interaction effect between inference methods and social structures. (shrink)

There are some philosophical questions that can be answered without attention to the social context in which evidence is produced and distributed.ing away from social context is an excellent way to ignore messy details and lay bare the underlying structure of the limits of inference. Idealization is entirely appropriate when one is essentially asking: In the best of all possible worlds, what am I entitled to infer? Yet, philosophers’ concerns often go beyond this domain. As an example I examine the (...) debate on mechanistic evidence and then reevaluate a canonical case study in this debate. I show that for the assessment of actual evidence, produced in a world that is far from ideal, omission of the social aspects of medical epistemology leads philosophers to draw the wrong lessons from cases they take as paradigmatic cases for their views. I close by arguing that social epistemology provides an avenue to incorporate these complications and provides the necessary framework to understand medical evidence. (shrink)

Industry is a major source of funding for scientific research. There is also a growing concern for how it corrupts researchers faced with conflicts of interest. As such, the debate has focused on whether researchers have maintained their integrity. In this article we draw on both the history of medicine and formal modeling to argue that given methodological diversity and a merit-based system, industry funding can bias a community without corrupting any particular individual. We close by considering a policy solution (...) that may seem to promote unbiased inquiry but that actually exacerbates the problem without additional restrictions. (shrink)

For evidence-based practice and policy, randomised controlled trials (RCTs) are the current gold standard. But exactly why? We know that RCTs do not, without a series of strong assumptions, warrant predictions about what happens in practice. But just what are these assumptions? I maintain that, from a philosophical stance, answers to both questions are obscured because we don't attend to what causal claims say. Causal claims entering evidence-based medicine at different points say different things and, I would suggest, failure to (...) attend to these differences makes much current guidance about evidence for medical and social policy misleading. (shrink)

In this paper I offer an anti-Humean critique to Williamson and Russo’s approach to medical mechanisms. I focus on one of the specific claims made by Williamson and Russo, namely the claim that micro-structural ‘mechanisms’ provide evidence for the stability across populations of causal relationships ascertained at the (macro-) level of (test) populations. This claim is grounded in the epistemic account of causality developed by Williamson, an account which—while not relying exclusively on mechanistic evidence for justifying causal judgements—appeals nevertheless to (...) mechanisms, and rejects their anti-Humean interpretation in terms of capacities, powers, potencies, etc. By using (and expanding on) Cartwright’s basic critique against Humean mechanisms, I suggest that, in order to move beyond the level of plausibility, Williamson and Russo’s position is in need of a clarification as to the occurent reading of the components, functioning and interferences of mechanisms. Relatedly, as concerns Williamson’s epistemic account of causation, I argue that this account is in need of a more straightforward answer as to what truth-makers its causal claims should have. (shrink)