There is a takeover movement fast gaining influence in development economics, a movement that demands that predictions about development outcomes be based on randomized controlled trials. The problem it takes up—of using evidence of efficacy from good studies to predict whether a policy will be effective if we implement it—is a general one, and affects us all. My discussion is the result of a long struggle to develop the right concepts to deal with the problem of warranting effectiveness predictions. Whether (...) I have it right or not, these are questions of vast social importance that philosophers of science can, and should, help answer. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

Explanations in the life sciences frequently involve presenting a model of the mechanism taken to be responsible for a given phenomenon. Such explanations depart in numerous ways from nomological explanations commonly presented in philosophy of science. This paper focuses on three sorts of differences. First, scientists who develop mechanistic explanations are not limited to linguistic representations and logical inference; they frequently employ diagrams to characterize mechanisms and simulations to reason about them. Thus, the epistemic resources for presenting mechanistic explanations are (...) considerably richer than those suggested by a nomological framework. Second, the fact that mechanisms involve organized systems of component parts and operations provides direction to both the discovery and testing of mechanistic explanations. Finally, models of mechanisms are developed for specific exemplars and are not represented in terms of universally quantified statements. Generalization involves investigating both the similarity of new exemplars to those already studied and the variations between them. (shrink)

Clinical trials and other forms of evaluation of medical treatment are held to give an objective assessment of the ‘clinical effectiveness’ of the medical treatments under evaluation. This kind of evaluation is central to the evidence-based medicine movement, as it provides a basis for the rational selection of treatment. The ethical status of randomised clinical trials is widely agreed to depend crucially upon the state of equipoise regarding which of two (or more) treatments is more (or most) effective in a (...) defined population. However, the meaning and nature of ‘clinical effectiveness’ are unclear. in this paper, I discuss the proposals to define clinical effectiveness as a relational property and as an intrinsic property, and the way effectiveness may supervene upon more fundamental physical properties of treatments. I discuss whether effectiveness is a single property or a family of properties; the types of outcome which can be explained by effectiveness properties; and the relationship between ‘objective’ and ‘preference’ outcomes. This paper suggests that while it may be possible to put clinical effectiveness on a proper metaphysical footing, in practice the language of clinical effectiveness is more properly a topic of the human sciences than of the natural sciences. (shrink)

Clinical trials and other forms of evaluation of medical treatment are held to give an objective assessment of the 'clinical effectiveness' of the medical treatments under evaluation. This kind of evaluation is central to the evidence-based medicine movement, as it provides a basis for the rational selection of treatment. The ethical status of randomised clinical trials is widely agreed to depend crucially upon the state of equipoise regarding which of two treatments is more effective in a defined population. However, the (...) meaning and nature of 'clinical effectiveness' are unclear. in this paper, I discuss the proposals to define clinical effectiveness as a relational property and as an intrinsic property, and the way effectiveness may supervene upon more fundamental physical properties of treatments. I discuss whether effectiveness is a single property or a family of properties; the types of outcome which can be explained by effectiveness properties; and the relationship between 'objective' and 'preference' outcomes. This paper suggests that while it may be possible to put clinical effectiveness on a proper metaphysical footing, in practice the language of clinical effectiveness is more properly a topic of the human sciences than of the natural sciences. (shrink)

In this paper I defend an etiological theory of biological functions (according to which the proper function of a trait is the effect for which it was selected by natural selection) against three objections which have been influential. I argue, contrary to Millikan, that it is wrong to base our defense of the theory on a rejection of conceptual analysis, for conceptual analysis does have an important role in philosophy of science. I also argue that biology requires a normative notion (...) of a "proper function", and that a normative notion is not ahistorical. (shrink)

I defend the historical definition of "function" originally given in my Language, Thought and Other Biological Categories (1984a). The definition was not offered in the spirit of conceptual analysis but is more akin to a theoretical definition of "function". A major theme is that nonhistorical analyses of "function" fail to deal adequately with items that are not capable of performing their functions.

According to historical theories of biological function, a trait's function is determined by natural selection in the past. I argue that, in addition to historical functions, ahistorical functions ought to be recognized. I propose a theory of biological function which accommodates both. The function of a trait is the way it contributes to fitness and fitness can only be determined relative to a selective regime. Therefore, the function of a trait can only be specified relative to a selective regime. Apart (...) from its desirable pluralism, only this view of relational function can support the function/accident and function/malfunction distinctions commonly thought to be part of the concept of function. Furthermore, only relational function correctly characterizes the explanatory consequences of function attributions in evolutionary biology. (shrink)

In psychiatry, pharmacological drugs play an important experimental role in attempts to identify the neurobiological causes of mental disorders. Besides being developed in applied contexts as potential treatments for patients with mental disorders, pharmacological drugs play a crucial role in research contexts as experimental instruments that facilitate the formulation and revision of neurobiological theories of psychopathology. This paper examines the various epistemic functions that pharmacological drugs serve in the discovery, refinement, testing, and elaboration of neurobiological theories of mental disorders. I (...) articulate this thesis with reference to the history of antipsychotic drugs and the evolution of the dopamine hypothesis of schizophrenia in the second half of the twentieth century. I argue that interventions with psychiatric patients through the medium of antipsychotic drugs provide researchers with information and evidence about the neurobiological causes of schizophrenia. This analysis highlights the importance of pharmacological drugs as research tools in the generation of psychiatric knowledge and the dynamic relationship between practical and theoretical contexts in psychiatry. (shrink)

I defend a radical interpretation of biological populations—what I call population pluralism—which holds that there are many ways that a particular grouping of individuals can be related such that the grouping satisfies the conditions necessary for those individuals to evolve together. More constraining accounts of biological populations face empirical counter-examples and conceptual difficulties. One of the most intuitive and frequently employed conditions, causal connectivity—itself beset with numerous difficulties—is best construed by considering the relevant causal relations as ‘thick’ causal concepts. I (...) argue that the fine-grained causal relations that could constitute membership in a biological population are huge in number and many are manifested by degree, and thus we can construe population membership as being defined by massively multidimensional constructs, the differences between which are largely arbitrary. I end by showing that positions in two recent debates in theoretical biology depend on a view of biological populations at odds with the pluralism defended here. 1 Introduction2 Biological Population, Broad and Narrow3 Difficulties with Narrow Biological Population Conditions3.1 Against the genealogical condition3.2 Against the conspecificity condition3.3 Against the proximity condition3.4 Against the typology condition4 Causal Connectivity5 Massively Multidimensional Population Constructs6 Population Uniqueness and Natural Selection6.1 Statisticalism and its discontents6.2 Price at what price?7 Conclusion. (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)

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

Accounts of the concepts of function and dysfunction have not adequately explained what factors determine the line between low‐normal function and dysfunction. I call the challenge of doing so the line‐drawing problem. Previous approaches emphasize facts involving the action of natural selection (Wakefield 1992a, 1999a, 1999b) or the statistical distribution of levels of functioning in the current population (Boorse 1977, 1997). I point out limitations of these two approaches and present a solution to the line‐drawing problem that builds on the (...) second one. (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)

Antidepressants, in particular newer agents, are among the most widely prescribed medications worldwide with annual sales of billions of dollars. The introduction of these agents in the market has passed through seemingly strict regulatory control. Over a thousand randomized trials have been conducted with antidepressants. Statistically significant benefits have been repeatedly demonstrated and the medical literature is flooded with several hundreds of.

This essay develops an account of health, the functional efficiency theory, which derives from Christopher Boorse's biostatistical theory. Like the BST, the functional efficiency theory is a nonevaluative view of health, but unlike the BST, it argues that the fundamental theoretical task is to distinguish levels of efficiency with which the parts and processes within organisms and within systems within organisms function. Which of these to label as healthy or pathological is of secondary importance. Because the statistical distributions that Boorse's (...) account relies on are distributions of functional efficiency, the functional efficiency theory arguably complements rather than challenges the BST. (shrink)

Over the past several decades, we devoted much energy to generating, reviewing and summarizing evidence. We have given far less attention to the issue of how to thoughtfully apply the evidence once we have it. That’s fine if all we care about is that our clinical decisions are evidence-based, but not so good if we also want them to be well-reasoned. Let us not forget that evidence based medicine (EBM) grew out of an interest in making medicine ‘rational’, with the (...) idea that rational clinical evaluations should be evidence-based. I agree with the uncontroversial statement that the best decision is supported, at least in part, by the best available evidence. Rationality, however, is constituted by reasoning, not evidence. Complete arguments are necessary for rational evaluations, arguments that begin with general evidence and end in a conclusion about a particular patient. In order to traverse these inferential gaps, medicine must address the issue of how to establish, as an intermediate premise, what the evidence has to say about the efficacy of an intervention for particular patients in a particular practice setting. (shrink)

How should we define ‘health’ and ‘disease’? There are three main positions in the literature. Naturalists desire value-free definitions based on scientific theories. Normativists believe that our uses of ‘health’ and ‘disease’ reflect value judgments. Hybrid theorists offer definitions containing both normativist and naturalist elements. This paper discusses the problems with these views and offers an alternative approach to the debate over ‘health’ and ‘disease’. Instead of trying to find the correct definitions of ‘health’ and ‘disease’ we should explicitly talk (...) about the considerations that are central in medical discussions, namely state descriptions and normative claims . This distinction avoids the problems facing the major approaches to defining ‘health’ and ‘disease’, and it more clearly captures what matters in medical discussions. (shrink)

A venerable tradition in the metaphysics of science commends ontological reduction: the practice of analysis of theoretical entities into further and further proper parts, with the understanding that the original entity is nothing but the sum of these. This tradition implicitly subscribes to the principle that all the real action of the universe (also referred to as its "causation") happens at the smallest scales-at the scale of microphysics. A vast majority of metaphysicians and philosophers of science, covering a wide swath (...) of the spectrum from reductionists to emergentists, defend this principle. It provides one pillar of the most prominent theory of science, to the effect that the sciences are organized in a hierarchy, according to the scales of measurement occupied by the phenomena they study. On this view, the fundamentality of a science is reckoned inversely to its position on that scale. This venerable tradition has been justly and vigorously countered-in physics, most notably: it is countered in quantum theory, in theories of radiation and superconduction, and most spectacularly in renormalization theories of the structure of matter. But these counters-and the profound revisions they prompt-lie just below the philosophical radar. This book illuminates these counters to the tradition principle, in order to assemble them in support of a vaster (and at its core Aristotelian) philosophical vision of sciences that are not organized within a hierarchy. In so doing, the book articulates the principle that the universe is active at absolutely all scales of measurement. This vision, as the book shows, is warranted by philosophical treatment of cardinal issues in the philosophy of science: fundamentality, causation, scientific innovation, dependence and independence, and the proprieties of explanation. (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)

Carl Craver investigates what we are doing when we sue neuroscience to explain what's going on in the brain.

The terms health, disease and illness are frequently used in clinical medicine. This has misled philosophers into believing that these concepts are important for clinical thinking and decision making. For instance, it is held that decisions about whether or not to treat someone or whether to relieve someone of moral responsibility depend on whether the person has a disease. In this paper it is argued that the crucial role of the disease concept is illusory. The health/disease distinction is irrelevant for (...) most decisions and represents a conceptual straightjacket. Sophisticated and mature clinical decision making requires that we free ourselves from the concept of disease. (shrink)

The terms "health", "disease" and "illness" are frequently used in clinical medicine. This has misled philosophers into believing that these concepts are important for clinical thinking and decision making. For instance, it is held that decisions about whether or not to treat someone or whether to relieve someone of moral responsibility depend on whether the person has a disease. In this paper it is argued that the crucial role of the 'disease' concept is illusory. The health/disease distinction is irrelevant for (...) most decisions and represents a conceptual straightjacket. Sophisticated and mature clinical decision making requires that we free ourselves from the concept of disease. (shrink)