Medical nihilism is the view that we should have little confidence in the effectiveness of medical interventions. Jacob Stegenga argues persuasively that this is how we should see modern medicine, and suggests that medical research must be modified, clinical practice should be less aggressive, and regulatory standards should be enhanced.

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)

. Recent philosophers of science have not only revived the classical argument from inductive risk but extended it. I argue that some of the purported extensions do not fit cleanly within the schema of the original argument, and I discuss the problem of overdiagnosis of disease due to expanded disease definitions in order to show that there are some risks in the research process that are important and that very clearly fall outside of the domain of inductive risk. Finally, I (...) introduce the notion of epistemic risk in order to characterize such risks. (shrink)

Although it is now generally acknowledged that new biomedical technologies often produce new definitions and sometimes even new concepts of disease, this observation is rarely used in research that anticipates potential ethical issues in emerging technologies. This article argues that it is useful to start with an analysis of implied concepts of disease when anticipating ethical issues of biomedical technologies. It shows, moreover, that it is possible to do so at an early stage, i.e. when a technology is only just (...) emerging. The specific case analysed here is that of ‘molecular medicine’. This group of emerging technologies combines a ‘cascade model’ of disease processes with a ‘personal pattern’ model of bodily functioning. Whereas the ethical implications of the first are partly familiar from earlier—albeit controversial—forms of preventive and predictive medicine, those of the second are quite novel and potentially far-reaching. (shrink)

Douglas proposes a new ideal in which values serve an essential function throughout scientific inquiry, but where the role values play is constrained at key points, protecting the integrity and objectivity of science.

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

Even though the evidence‐based medicine movement (EBM) labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would respond to intervention. (...) I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of evidencebased medicine who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms. (shrink)

Proponents of the value ladenness of science rely primarily on arguments from underdetermination or inductive risk, which share the premise that we should only consider values where the evidence runs out or leaves uncertainty; they adopt a criterion of lexical priority of evidence over values. The motivation behind lexical priority is to avoid reaching conclusions on the basis of wishful thinking rather than good evidence. This is a real concern, however, that giving lexical priority to evidential considerations over values is (...) a mistake and unnecessary for avoiding the wishful thinking. Values have a deeper role to play in science. (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)

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)

Thomas S. Kuhn's classic book is now available with a new index.

Traits like simplicity and explanatory power have traditionally been treated as values internal to the sciences, constitutive rather than contextual. As such they are cognitive virtues. This essay contrasts a traditional set of such virtues with a set of alternative virtues drawn from feminist writings about the sciences. In certain theoretical contexts, the only reasons for preferring a traditional or an alternative virtue are socio-political. This undermines the notion that the traditional virtues can be considered purely cognitive.

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 question of the relationship of the making of value judgments in a typically ethical sense to the methods and procedures of science has been discussed in the literature at least to that point which e. e. cummings somewhere refers to as “The Mystical Moment of Dullness.” Nevertheless, albeit with some trepidation, I feel that something more may fruitfully be said on the subject.

Most recent philosophical thought about the scientific representation of the world has focused on dyadic relationships between language-like entities and the world, particularly the semantic relationships of reference and truth. Drawing inspiration from diverse sources, I argue that we should focus on the pragmatic activity of representing, so that the basic representational relationship has the form: Scientists use models to represent aspects of the world for specific purposes. Leaving aside the terms "law" and "theory," I distinguish principles, specific conditions, models, (...) hypotheses, and generalizations. I argue that scientists use designated similarities between models and aspects of the world to form both hypotheses and generalizations. (shrink)

Although epistemic values have become widely accepted as part of scientific reasoning, non-epistemic values have been largely relegated to the "external" parts of science (the selection of hypotheses, restrictions on methodologies, and the use of scientific technologies). I argue that because of inductive risk, or the risk of error, non-epistemic values are required in science wherever non-epistemic consequences of error should be considered. I use examples from dioxin studies to illustrate how non-epistemic consequences of error can and should be considered (...) in the internal stages of science: choice of methodology, characterization of data, and interpretation of results. (shrink)

In this essay, which was his presidential address to the Philosophy of Science Association, Ernan McMullin argued that the watershed between “classic” philosophy of science and the “new” philosophy of science can best be understood by analyzing the change in our perception of the role played by values in science. He begins with some general remarks about the nature of value, goes on to explore some of the historical sources for the claim that judgement in science is value‐laden, and concludes (...) by reflecting on the implications of this claim for traditional views of the objectivity of scientific knowledge‐claims. (shrink)

Critics of the ideal of value‐free science often assume that they must reject the distinction between epistemic and nonepistemic values. I argue that this assumption is mistaken and that the distinction can be used to clarify and defend the argument from inductive risk, which challenges the value‐free ideal. I develop the idea that the characteristic feature of epistemic values is that they promote, either intrinsically or extrinsically, the attainment of truths. This proposal is shown to answer common objections to the (...) distinction and provide a principled basis for separating legitimate from illegitimate influences of nonepistemic values in scientific inference. *Received June 2009; revised September 2009. †To contact the author, please write to: 503 S. Kedzie Hall, Michigan State University, East Lansing, MI 48824‐1032; e‐mail: [email protected]. (shrink)

A common complaint against the increasing privatization of research is that research that is conducted with the immediate purpose of producing applicable knowledge will not yield knowledge as valuable as that generated in more curiosity‐driven, academic settings. In this paper, I make this concern precise and reconstruct the rationale behind it. Subsequently, I examine the case of industry research on the giant magnetoresistance effect in the 1990s as a characteristic example of research undertaken under considerable pressure to produce applicable results. (...) The example permits one to arrive at a more optimistic assessment of the epistemic merits of private, application‐driven research. I attempt to specify the conditions that, in this case, advanced the production of interesting and reliable knowledge. (shrink)

The lack of public support for climate change policies and refusals to vaccinate children are just two alarming illustrations of the impacts of dissent about scientific claims. Dissent can lead to confusion, false beliefs, and widespread public doubt about highly justified scientific evidence. Even more dangerously, it has begun to corrode the very authority of scientific consensus and knowledge. Deployed aggressively and to political ends, some dissent can intimidate scientists, stymie research, and lead both the public and policymakers to oppose (...) important public policies firmly rooted in science. -/- To criticize dissent is, however, a fraught exercise. Skepticism and fearless debate are key to the scientific process, making it both vital and incredibly difficult to characterize and identify dissent that is problematic in its approach and consequences. Indeed, as de Melo-Martín and Intemann show, the criteria commonly proposed as means of identifying inappropriate dissent are flawed and the strategies generally recommended to tackle such dissent are not only ineffective but could even make the situation worse. -/- The Fight Against Doubt proposes that progress on this front can best be achieved by enhancing the trustworthiness of the scientific community and by being more realistic about the limits of science when it comes to policymaking. It shows that a richer understanding of the context in which science operates is needed to disarm problematic dissent and those who deploy it. This, the authors argue, is the best way forward, rather than diagnosing the many instances of wrong-headed dissent. (shrink)

"--Richard Grandy, Rice University "This is the first compelling diagnosis of what has gone awry in the raging 'science wars.

Evidence-Based Medicine (EBM) developed from the work of clinical epidemiologists at McMaster University and Oxford University in the 1970s and 1980s and self-consciously presented itself as a "new paradigm" called "evidence-based medicine" in the early 1990s. The techniques of the randomized controlled trial, systematic review and meta-analysis have produced an extensive and powerful body of research. They have also generated a critical literature that raises general concerns about its methods. This paper is a systematic review of the critical literature. It (...) finds the description of EBM as a Kuhnian paradigm helpful and worth taking further. Three kinds of criticism are evaluated in detail: criticisms of procedural aspects of EBM (especially from Cartwright, Worrall and Howick), data showing the greater than expected fallibility of EBM (Ioaanidis and others), and concerns that EBM is incomplete as a philosophy of science (Ashcroft and others). The paper recommends a more instrumental or pragmatic approach to EBM, in which any ranking of evidence is done by reference to the actual, rather than the theoretically expected, reliability of results. Emphasis on EBM has eclipsed other necessary research methods in medicine. With the recent emphasis on translational medicine, we are seeing a restoration of the recognition that clinical research requires an engagement with basic theory (e.g. physiological, genetic, biochemical) and a range of empirical techniques such as bedside observation, laboratory and animal studies. EBM works best when used in this context. (shrink)

Striving to boldly redirect the philosophy of science, this book by renowned philosopher Philip Kitcher examines the heated debate surrounding the role of science in shaping our lives. Kitcher explores the sharp divide between those who believe that the pursuit of scientific knowledge is always valuable and necessary--the purists--and those who believe that it invariably serves the interests of people in positions of power. In a daring turn, he rejects both perspectives, working out a more realistic image of the sciences--one (...) that allows for the possibility of scientific truth, but nonetheless permits social consensus to determine which avenues to investigate. He then proposes a democratic and deliberative framework for responsible scientists to follow. Controversial, powerful, yet engaging, this volume will appeal to a wide range of readers. Kitcher's nuanced analysis and authorititative conclusion will interest countless scientists as well as all readers of science--scholars and laypersons alike. (shrink)

When interests and preferences of researchers or their sponsors cause bias in experimental design, data interpretation or dissemination of research results, we normally think of it as an epistemic shortcoming. But as a result of the debate on science and values, the idea that all extra-scientific influences on research could be singled out and separated from pure science is now widely believed to be an illusion. I argue that nonetheless, there are cases in which research is rightfully regarded as epistemologically (...) deficient due to the influence of preferences on its outcomes. I present examples from biomedical research and offer an analysis in terms of social epistemology. (shrink)

In 2003, the pharmaceutical company Biovail received a spate of negative publicity around a program for its heart medication Cardizem LA. For a three-month period Biovail paid US doctors US$1000 (and their office managers US$150) for patient data when at least 11 of their patients renewed a prescription to Cardizem. Doctors who signed up for the trial but who did not keep 11 patients on the drug received US$250 for participation. According to Biovail, this was a research trial, meeting US (...) federal regulations for research trials – the consulting firm that had designed the trial had guaranteed that it would meet US criteria. The trial was expected to provide data that would help ‘in designing future clinical trial programs’, according to Biovail’s vice-president of finance. In addition, the results would eventually be published. However, the program was originally presented as a marketing campaign, and was being handled by Biovail’s sales department and sales force. According to ethicists who commented on the case, a US$1000 payment to doctors was unusually high for a post-marketing research trial, and a US$150 payment to office managers was thought to raise novel ethical conflicts. Cardizem is a drug intended for long-term use, so paying doctors to get patients started on a course of treatment could lead to substantial profits from these prescriptions. In line with this, immediate comments from professional ethicists and representatives of medical associations focused on questions about whether the Biovail campaign amounted to paying doctors to prescribe specific drugs. And that is a concern for the obvious reason that it has the potential to compromise doctors’ decisions about best care. Payments for prescriptions place doctors in ethically difficult situations: Peter Singer, a medical ethicist, says ‘There is clearly the potential for [physicians’] conflict of interest’ (Toronto Globe and Mail, 2003). Physicians’ decision-making is the most common locus of discussion in medical ethics.. (shrink)

Recent efforts to argue that nonepistemic values have a legitimate role to play in assessing scientific models, theories, and hypotheses typically either reject the distinction between epistemic and nonepistemic values or incorporate nonepistemic values only as a secondary consideration for resolving epistemic uncertainty. Given that scientific representations can legitimately be evaluated not only based on their fit with the world but also with respect to their fit with the needs of their users, we show in two case studies that nonepistemic (...) values can play a legitimate role as factors that override epistemic considerations in assessing scientific representations for practical purposes. (shrink)

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)

Richard Rudner famously argues that the communication of scientific advice to policy makers involves ethical value judgments. His argument has, however, been rightly criticized. This article revives Rudner’s conclusion, by strengthening both his lines of argument: we generalize his initial assumption regarding the form in which scientists must communicate their results and complete his ‘backup’ argument by appealing to the difference between private and public decisions. Our conclusion that science advisors must, for deep-seated pragmatic reasons, make value judgments is further (...) bolstered by reflections on how the scientific contribution to policy is far less straightforward than the Rudner-style model suggests. (shrink)

Traditionally, cognitive values have been thought of as a collective pool of considerations in science that frequently trade against each other. I argue here that a finer-grained account of the value of cognitive values can help reduce such tensions. I separate the values into groups, minimal epistemic criteria, pragmatic considerations, and genuine epistemic assurance, based in part on the distinction between values that describe theories per se and values that describe theory-evidence relationships. This allows us to clarify why these values (...) are central to science and what role they should play, while reducing the tensions among them. (shrink)

Claims that science should be more democratic than it is frequently arouse opposition. In this essay, I distinguish my own views about the democratization of science from the more ambitious theses defended by Paul Feyerabend. I argue that it is unlikely that the complexity of some scientific debates will allow for resolution according to the methodological principles of any formal confirmation theory, suggesting instead that major revolutions rest on conflicts of values. Yet these conflicts should not be dismissed as irresoluble.

A new, social epistemology of science that addresses practical as well as theoretical concerns.

How is medical knowledge made? There have been radical changes in recent decades, through new methods such as consensus conferences, evidence-based medicine, translational medicine, and narrative medicine. Miriam Solomon explores their origins, aims, and epistemic strengths and weaknesses; and she offers a pluralistic approach for the future.

In this book, Carl Cranor utilizes material from ethics, philosophy of law, epidemiology, tort law, regulatory law, and risk assessment to argue that the evidentiary standards for science used in the law to control toxics ought to be ...

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)

Claims that science should be more democratic than it is frequently arouse opposition. In this essay, I distinguish my own views about the democratization of science from the more ambitious theses defended by Paul Feyerabend. I argue that it is unlikely that the complexity of some scientific debates will allow for resolution according to the methodological principles of any formal confirmation theory, suggesting instead that major revolutions rest on conflicts of values. Yet these conflicts should not be dismissed as irresoluble.

Scrutinizes the fundamental myths that have guided the formulation of science policy for half a century myths that serve the professional and political interests of the scientific community, but often fail to advance the interests of society as a whole.

Kevin Elliott and Dan McKaughan argue that, in some cases, nonepistemic values provide legitimate reasons for scientists to accept an epistemically inferior option, a claim that they support with two case studies. This essay argues that Elliott and McKaughan have not shown that their case studies are indeed ones in which an epistemically inferior option was accepted. Specifically, their interpretation of these cases depends on problematic premises that it is epistemically better to wait for a slower-but-more-reliable method than to accept (...) the result of a quicker-but-less-reliable one and that a more detailed model is epistemically preferable to a simpler one. (shrink)