Evolutionary medicine (EM) is an emerging field of medical studies that uses evolutionary theory to explain the ultimate causes of health and disease. The field’s main objective is to reconceptualize bodily vulnerabilities and pathophysiologies as evolutionary tradeoffs—many the result of an evolutionary mismatch between our ancient genome and modern lifestyle. This conceptual shift allows EM to describe health and disease in terms of adaptive functions and to prescribe treatments that best complement our evolved bodies. The goal is to “transform the (...) way patients and doctors see disease” (Nesse and Williams 1994, p. 245) in order to harness a renewed “feeling for the organism as a product of natural selection” .. (shrink)

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)

This article presents a distinct sense of ‘mechanism’, which I call the functional sense of mechanism. According to this sense, mechanisms serve functions, and this fact places substantive restrictions on the kinds of system activities ‘for which’ there can be a mechanism. On this view, there are no mechanisms for pathology; pathologies result from disrupting mechanisms for functions. Second, on this sense, natural selection is probably not a mechanism for evolution because it does not serve a function. After distinguishing this (...) sense fromsimilar explications of ‘mechanism’, I argue that it is ubiquitous in biology and has valuable epistemic benefits. (shrink)

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

Two decades ago, the eminent evolutionary biologist George C. Williams and his physician coauthor, Randolph Nesse, formulated the evolutionary medicine research program. Williams and Nesse explicitly made adaptationism a core component of the new program, which has served to undermine the program ever since, distorting its practitioners’ perceptions of evidentiary burdens and in extreme cases has served to warp practitioner’s understandings of the relationship between evolutionary benefits/detriments and medical ones. I show that the Williams and Nesse program more particularly embraces (...) the panselectionist variety of adaptationism (the empirical assumption that non-adaptive evolutionary processes are causally unimportant compared to natural selection), and argue that this has harmed the field. Panselectionism serves to conceal the enormous evidentiary hurdles that evolutionary medicine hypotheses face, making them appear stronger than they are. I use two examples of evolutionary medicine texts, on neonatal jaundice and on asthma, to show that some evolutionary medicine practitioners have allowed their fervent panselectionism to directly shape their recommendations for clinical practice. I argue that this escalation of panselectionism’s influence is inappropriate under Williams’ and Nesse original stated standards, despite being inspired by their program. I also show that the examples’ conflation of clinical and evolutionary considerations is inappropriate even under Christopher Boorse’s controversial evolution-rooted concepts of disease and health. (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)

Mechanisms are a way of explaining how biological phenomena work rather than why single elements of biological systems are there. However, mechanisms are usually described as physiological entities, and little or no attention is paid to malfunction as an independent theoretical concept. On the other hand, malfunction is the main focus of interest of applied sciences such as medicine. In this paper I argue that malfunctions are parts of pathological mechanisms, which should be considered separate theoretical entities, conceptually having a (...) priority over physiological sequences. While pathological mechanisms can be described in terms of a Cummins-like mechanistic explanation, they show some unnoticed peculiarities when compared to physiological ones. Some features of pathological mechanisms are considered, such as outcome variability, ambivalence and dependence on a range. (shrink)

Human beings have the unique ability to view the world in a detached way: We can think about the world in terms that transcend our own experience or interest, and consider the world from a vantage point that is, in Nagel's words, "nowhere in particular". At the same time, each of us is a particular person in a particular place, each with his own "personal" view of the world, a view that we can recognize as just one aspect of the (...) whole. How do we reconcile these two standpoints--intellectually, morally, and practically? To what extent are they irreconcilable and to what extent can they be integrated? Thomas Nagel's ambitious and lively book tackles this fundamental issue, arguing that our divided nature is the root of a whole range of philosophical problems, touching, as it does, every aspect of human life. He deals with its manifestations in such fields of philosophy as: the mind-body problem, personal identity, knowledge and skepticism, thought and reality, free will, ethics, the relation between moral and other values, the meaning of life, and death. Excessive objectification has been a malady of recent analytic philosophy, claims Nagel, it has led to implausible forms of reductionism in the philosophy of mind and elsewhere. The solution is not to inhibit the objectifying impulse, but to insist that it learn to live alongside the internal perspectives that cannot be either discarded or objectified. Reconciliation between the two standpoints, in the end, is not always possible. (shrink)

In this article, I argue that distinguishing ‘evolutionary’ from ‘Darwinian’ medicine will help us assess the variety of roles that evolutionary explanations can play in a number of medical contexts. Because the boundaries of evolutionary and Darwinian medicine overlap to some extent, however, they are best described as distinct ‘research traditions’ rather than as competing paradigms. But while evolu- tionary medicine does not stand out as a new scientific field of its own, Darwinian medicine is united by a number of (...) distinctive theoretical and methodological claims. For example, evolutionary medicine and Darwinian medicine can be distinguished with respect to the styles of evolutionary explanations they employ. While the former primarily involves ‘forward looking’ explanations, the latter depends mostly on ‘backward looking’ explanations. A forward looking explanation tries to predict the effects of ongoing evolutionary processes on human health and disease in contem- porary environments (e.g., hospitals). In contrast, a backward looking explanation typically applies evolutionary principles from the vantage point of humans’ distant biological past in order to assess present states of health and disease. Both approaches, however, are concerned with the prevention and control of human diseases. In con- clusion, I raise some concerns about the claim that ‘nothing in medicine makes sense except in the light of evolution’. (shrink)

The topic of disease mechanisms is of clinical importance, as our understanding of such mechanisms plays an important role in how we approach devising treatments for disease. In this paper, I critique an argument made by Mauro Nervi, in which he asserts that pathology is often better viewed in the context of distinct theoretical mechanisms. I use this critique as a starting point to argue that viewing pathology as a broken-normal, malfunctioning mechanism is more therapeutically practical and more relevant to (...) clinical drug design, than creating a theoretical separation of pathology from physiology. (shrink)

Neurosis can be interpreted as a methodological condition which any aim-pursuing entity can suffer from. If such an entity pursues a problematic aim B, represents to itself that it is pursuing a different aim C, and as a result fails to solve the problems associated with B which, if solved, would lead to the pursuit of aim A, then the entity may be said to be "rationalistically neurotic". Natural science is neurotic in this sense in so far as a basic (...) aim of science is represented to be to improve knowledge of factual truth as such (aim C), when actually the aim of science is to improve knowledge of explanatory truth (aim B). Science does not suffer too much from this neurosis, but philosophy of science does. Much more serious is the rationalistic neurosis of the social sciences, and of academic inquiry more generally. Freeing social science and academic inquiry from neurosis would have far reaching, beneficial, intellectual, institutional and cultural consequences. (shrink)

The concept of mechanism is analyzed in terms of entities and activities, organized such that they are productive of regular changes. Examples show how mechanisms work in neurobiology and molecular biology. Thinking in terms of mechanisms provides a new framework for addressing many traditional philosophical issues: causality, laws, explanation, reduction, and scientific change.

Scientism is a philosophy which purports to define what the world ‘really is’. It adopts what the philosopher Thomas Nagel called ‘an epistemological criterion of reality’, defining what is real as that which can be discovered by certain quite specific methods of investigation. As a consequence all features of experience not revealed by those methods are deemed ‘subjective’ in a way that suggests they are either not real, or lie beyond the scope of meaningful rational inquiry. This devalues capacities that (...) (we argue) are in fact essential components of good reasoning and virtuous practice. Ultimately, the implications of scientism for statements of value undermine value-judgements essential for science itself to have a sound basis. Scientism has implications, therefore, for ontology, epistemology and also for which claims we can assert as objective truths about the world. Adopting scientism as a world view will have consequences for reasoning and decision-making in clinical and other contexts. We analyse the implications of this approach and conclude that we need to reject scientism if we are to avoid stifling virtuous practice and to develop richer conceptions of human reasoning. (shrink)

In Studying Human Behavior, Helen E. Longino enters into the complexities of human behavioral research, a domain still dominated by the age-old debate of “nature versus nurture.” Rather than supporting one side or another or attempting..

Proponents of evidence-based medicine and some philosophers of science seem to agree that knowledge of mechanisms can help solve the problem of applying results of controlled studies to target populations (‘the problem of extrapolation’). We describe the problem of extrapolation, characterize mechanisms, and outline how mechanistic knowledge might be used to solve the problem. Our main thesis is that there are four often overlooked problems with using mechanistic knowledge to solve the problem of extrapolation. First, our understanding of mechanisms is (...) often (and arguably, likely to remain) incomplete. Secondly, knowledge of mechanisms is not always applicable outside the tightly controlled laboratory conditions in which it is gained. Thirdly, mechanisms can behave paradoxically. Fourthly, as Daniel Steel points out, using mechanistic knowledge faces the problem of the ‘extrapolator’s circle’. At the same time, when the problems with mechanistic knowledge have been addressed, such knowledge can and should be used to mitigate (nothing can entirely solve) the problem of extrapolation. (shrink)

This chapter contains sections titled: Introduction The Once Received View (ORV) Criticisms of the ORV The “Model Model” of Scientific Theories Mechanisms: Investigating Nonformal Patterns in Scientific Theories Conclusion.

These are exciting times for the defenders of Person-Centred Medicine(PCM). A recent editorial of the International Journal of Person-Centred medicine celebrates the new interest policy-makers are taking in PCM, but worries that: ‘the nomenclature of “person-centred medicine” risks the accusation that such a term represents a further rhetorical addition to the already rhetorically overburdened nature of health services.’ The worries are indeed justified. Practitioners struggling to do their jobs in the resource-constrained environments of contemporary health services may well react cynically (...) to the latest linguistic innovation, especially if it seems, like its predecessors, to combine the blindingly obvious with the ‘revolutionary’. With reference to the case studies of ‘quality theory’ in management studies and Evidence-based medicine, the paper argues that initially promising ideas are compromised when required to meet the agendas of policy-makers looking for a quick fix to what are in fact deep, structural problems in the delivery of health services. We must resist such moves if we are to preserve the intellectual and moral integrity of PCM as a critical perspective on medical practice, and to develop ideas that are actually helpful to practitioners and the users of health services. (shrink)

Chapter 1 Who this book is for and who it is not for1 There are already too many books offering solutions to the problems of the health service. ...

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)

Experimental methods and conceptual confusion : philosophy, science, and what emotions really are -- To 'make our voices resonate' or 'to be silent'? : shame as fundamental ontology -- Emotion, cognition, and world -- Shame and world.

Neurosis can be interpreted as a methodological condition which any aim-pursuing entity can suffer from. If such an entity pursues a problematic aim B, represents to itself that it is pursuing a different aim C, and as a result fails to solve the problems associated with B which, if solved, would lead to the pursuit of aim A, then the entity may be said to be "rationalistically neurotic". Natural science is neurotic in this sense in so far as a basic (...) aim of science is represented to be to improve knowledge of factual truth as such, when actually the aim of science is to improve knowledge of explanatory truth. Science does not suffer too much from this neurosis, but philosophy of science does. Much more serious is the rationalistic neurosis of the social sciences, and of academic inquiry more generally. Freeing social science and academic inquiry from neurosis would have far reaching, beneficial, intellectual, institutional and cultural consequences. (shrink)

Case methods of reasoning are persuasive, but we need to address problems of bias in order to use them to reach morally justifiable conclusions. A bias is an unwarranted inclination or a special perspective that disposes us to mistaken or one-sided judgments. The potential for bias arises at each stage of a case method of reasoning including in describing, framing, selecting and comparing of cases and paradigms. A problem of bias occurs because to identify the relevant features for such purposes, (...) we must use general views about what is relevant; but some of our general views are biased, both in the sense of being unwarranted inclinations and in the sense that they are one of many viable perspectives. This reliance upon general views to determine relevancy creates additional difficulties for defenders who maintain that case methods of moral reasoning are not only useful, but more basic, reliable or prior to other forms of moral reasoning. If we cannot identify the case's relevant features and issues independently of our general views or biases, we need further explanation about why a case method or casuistry should be viewed as prior to or more basic or reliable than other forms of moral reasoning. Problems of bias also arise for other methods of reasoning. In medical science, case reviews are regarded as an unreliable way to form generalizations, and methods such as clinical trials are used to address bias. (shrink)