This volume covers a wide range of conceptual, epistemological and methodological issues in the philosophy of science raised by reflection upon medical science and practice.

This paper critically examines a particular strategy for resolving the central ethical dilemma associated with randomized clinical trials — the “community equipoise” strategy . The dilemma is that RCTs appear to violate a physician's duty to choose that therapy which there is most reason to believe is in the patient's best interest, randomizing patients even once evidence begins to favor one treatment. The community equipoise strategy involves the suggestion that our judgment that neither treatment is to be preferred is to (...) be assessed according to a community rather than an individual standard. Thus, though a physician may personally believe that there is some reason to prefer one treatment, patients can legitimately be randomized if there remains disagreement in the community of medical professionals. Rationales in favor of this conception include the following: medical knowledge is best understood as residing in the community, the judgments of others count as evidence, and so should change one's own opinion, subjects would not be better off outside the trial, and the point of any trial is the resolution of dispute in the medical community. I critically examine these rationales and argue that they are insufficient. Amongst the problems are tensions between various of these underlying rationales, and important ambiguities in just what the CE criterion is to amount to. Finally, I argue that even if use of CE was justified, it would not justify carrying out RCTs anywhere near long enough to discharge our duty to gain reliable knowledge on which to base safe and effective medical practice. Hence, we need some different justification for carrying out RCTs. (shrink)

Recognizing that all traits are the result of an interaction between genes and environment, I offer a set of criteria for nevertheless making sense of our practice of singling out certain traits as genetic ones, in effect making a distinction between causes and mere conditions. The central criterion is that a trait is genetic if it is genetic differences that make the differences in that trait variable in a given population. A second criterion requires that genetic traits be individuated in (...) a way that matches what some genetic factors cause specifically. Clarifying our causal and classificatory language here can help us to avoid confusions of both theoretical and practical significance. (shrink)

The central dilemma concerning randomized clinical trials (RCTs) arises out of some simple facts about causal methodology (RCTs are the best way to generate the reliable causal knowledge necessary for optimally-informed action) and a prima facie plausible principle concerning how physicians should treat their patients (always do what it is most reasonable to believe will be best for the patient). A number of arguments related to this in the literature are considered. Attempts to avoid the dilemma fail. Appeals to informed (...) consent and mechanisms for minimizing the resulting harm are important for policy, but informed consent is problematic and mechanisms for minimization of harm do not address the dilemma. Appeals to some sort of contract model of justification are promising and illuminating. Keywords: randomized clinical trials, ethics CiteULike Connotea Del.icio.us What's this? (shrink)

This paper critically examines a particular strategy for resolving the central ethical dilemma associated with randomized clinical trials (RCTs) — the “community equipoise” strategy (CE). The dilemma is that RCTs appear to violate a physician's duty to choose that therapy which there is most reason to believe is in the patient's best interest, randomizing patients even once evidence begins to favor one treatment. The community equipoise strategy involves the suggestion that our judgment that neither treatment is to be preferred (that (...) there obtains a state of “equipoise”) is to be assessed according to a community rather than an individual standard. Thus, though a physician may personally believe that there is some reason to prefer one treatment, patients can legitimately be randomized if there remains disagreement in the community of medical professionals. Rationales in favor of this conception include the following: (i) medical knowledge is best understood as residing in the community, (ii) the judgments of others count as evidence, and so should change one's own opinion, (iii) subjects would not be better off outside the trial, and (iv) the point of any trial is the resolution of dispute in the medical community. I critically examine these rationales and argue that they are insufficient. Amongst the problems are tensions between various of these underlying rationales, and important ambiguities in just what the CE criterion is to amount to. Finally, I argue that even if use of CE was justified, it would not justify carrying out RCTs anywhere near long enough to discharge our duty to gain reliable knowledge on which to base safe and effective medical practice. Hence, we need some different justification for carrying out RCTs. (shrink)

In this article, I review and expand upon arguments showing that Freedman's so-called "clinical equipoise" criterion cannot serve as an appropriate guide and justification for the moral legitimacy of carrying out randomized clinical trials. At the same time, I try to explain why this approach has been given so much credence despite compelling arguments against it, including the fact that Freedman's original discussion framed the issues in a misleading way, making certain things invisible: Clinical equipoise is conflated with community equipoise, (...) and several versions of each are also conflated. But a misleading impression is given that, rather than distinct criteria being arbitrarily conflated, a puzzle is solved and a number of features unified. Various issues are pushed under the rug, hiding flaws of the "clinical equipoise" approach and thus deceiving us into thinking that we have a solution when we do not. Particularly significant is the ignoring of the crucial distinction between the individual patient decision and the policy decision. (shrink)

It is often claimed that a clinical investigator may ethically participate (e.g., enroll patients) in a trial only if she is in equipoise (if she has no way to ground a preference for one arm of the study). But this is a serious problem, for as data accumulate, it can be expected that there will be a discernible trend favoring one of the treatments prior to the point where we achieve the trial's objective. In this paper, I critically evaluate Benjamin (...) Freedman's 'clinical equipoise' solution to this dilemma. I argue that Freedman actually puts forth at least two distinct contrasts - one in terms of community vs. individual equipoise, and another concerning clinical vs. theoretical equipoise - and that neither of them resolves the dilemma. I then make a proposal for a more adequate account of how to think about the circumstances under which entering subjects in trials would be justified - a 'sliding-scale equipoise' that arises out of a discussion of patients' values. (shrink)

The units of selection problem is an issue within evolutionary theory (or the philosophy thereof) and concerns the question of what units or objects are acted upon by natural selection -- for example, whether these are genes, organisms or groups of organisms. One of the central theses of Elliot Sober’s recent book, The Nature of Selection, is that the philosophical problem of what it means for something to be a unit of selection is to be understood by applying the correct (...) account of what it is in general for a factor to be a cause in a population.The account of population-causation that Sober utilizes for this purpose comes from the recent literature on probabilistic causality. This account requires that for C to cause E in a population, a unanimity condition must be satisfied: C must raise the probability of E in each causal context. (shrink)

The public attitude to animal use in Australia and New Zealandcan be inferred from survey results and political activity. The publicis concerned about the rights of animals as far as any uses causing painare concerned, but takes a more utilitarian view of the taking of lifewhere no suffering is involved. Many of the participants in two recentANZCCART conferences fall short in their knowledge of and attitudetoward these concerns. Animal welfare legislation and standards need tobe reformed so that painful animal use (...) is eliminated, even if economicgrowth suffers as a result. (shrink)

This paper examines some criticisms that have been made of two standard genetic methodologies: heritability and path analysis. I conclude that the criticisms should be taken seriously, concerning both the accuracy of heritability measures and their significance. In light of the fact that such studies remain prominent in the literature, I consider what possible rationale they can retain consistent with these criticisms. In particular, I consider (1) a role in the identification of high-risk individuals and (2) a heuristic role in (...) the planning of research strategy. (shrink)

This paper is a preliminary exploration concerning how the ethics of research on human subjects may differ when we move from the well-discussed context of research on therapies to the less-discussed context of research on enhancements. A number of differences are described. There are some features that make such research more morally problematic in certain ways, but some of the features may actually ameliorate some of the moral tensions that exist in human subjects research. It is hoped that this analysis (...) will aid and encourage discussion of the topic that could help guide those who intend to carry out such this research. (shrink)

With both the cost and quality of health care under scrutiny, many in the health care industry have turned to outcomes research and practice guidelines for answers. But many physicians have resisted, claiming their clinical judgment is a better guide. Both camps may be right.

: As clinicians, researchers, bioethicists, and members of society, we face a number of moral dilemmas concerning randomized clinical trials. How we manage the starting and stopping of such trials—how we conceptualize what evidence is sufficient for these decisions—has implications for both our obligations to trial participants and for the nature and security of the resultant medical knowledge. One view of how this is to be done, "clinical equipoise," recently has been given an extended defense by Paul Miller and Charles (...) Weijer in their article "Rehabilitating Equipoise." The present paper critiques this position and Miller and Weijer's defense of it. I argue that their attempted rehabilitation fails. Their analysis suffers from a number of confusions, as well as a failure to make crucial distinctions, adequately to clarify key concepts, or to think through exactly what needs to be established to justify their claim. We are left with little reason to uphold the clinical equipoise criterion. (shrink)

Sober argues that the units of selection problem in evolutionary biology is to be understood and solved by applying the general analysis of what it means for C to cause E in a population. The account he utilizes is the unanimity account, according to which C causes E in a population when C raises the probability of E in each causal context. I argue that he does not succeed here, both because the unanimity account is not well grounded in the (...) general case, and because there are important differences between cases of population causation which do involve selection and those which do not. (shrink)

We are pleased to once again present to the readers of Theoretical Medicine and Bioethics papers from the Philosophy of Medicine Roundtable. Previous issues have followed the 3rd and 4th Roundtables, and the current issue presents a selection from the more than 20 papers presented at the 5th Philosophy of Medicine Roundtable, which took place in New York, at Columbia University, in November 2013. Like its predecessors, held in Birmingham, AL, Rotterdam, and San Sebastian, this Roundtable attracted speakers from around (...) the world. It also featured keynote presentations from Rita Charon of Columbia University and Ross Upshur of the University of Toronto.It may seem somewhat odd to feature a special issue on philosophy of medicine in a journal that effectively has philosophy of medicine in its title. However, a review of the contents of this journal and similar ones, such as the Journal of Medicine and Philosophy, will quickly reveal such an issue’s purpose. The dominant content of these j .. (shrink)

During the last few years two major volumes have been published, both greatly revised versions of earlier Gifford Lectures: Charles Taylor’s A Secular Age ( 2007 ) and Raimon Panikkar’s The Rhythm of Being ( 2010 ). The two volumes are similar in some respects and very dissimilar in others. Both thinkers complain about the glaring blemishes of the modern, especially the contemporary age; both deplore above all a certain deficit of religiosity. The two authors differ, however, both in (...) the details of their diagnosis and in their proposed remedies. Taylor views the modern age—styled as “secular age”—as marked by a slide into secular agnosticism, into “exclusive humanism”, and above all into an “immanent frame” excluding theistic “transcendence”. Although sharing the concern about “loss of meaning”, Panikkar does not find its source in the abandonment of (mono)theistic transcendence; on the contrary, both radical transcendence and agnostic immanence are responsible for the deficit of genuine faith. For him, recovery of faith requires an acknowledgment of our being in the world, as part of the “rhythm of being” happening in a holistic or “cosmotheandric” mode. In classical Indian terminology, while Taylor’s emphasis on the transcendence-immanence tension reflects ultimately a dualistic perspective (dvaita), Panikkar’s holistic notion of the rhythm of being captures the core of Advaita Vendanta. (shrink)

Recently, Fred Gifford attempted to explicate the meaning of the term genetic as applied to phenotypic traits. He takes as his primary goal the explication of how the term is used and tries to avoid conclusions about how it should be used. He proposes two independent criteria (DF and PI) which together capture much of what biologists mean when they describe traits as genetic. Although Gifford's approach is extremely insightful in many ways, I argue that his analysis (...) is not sufficiently critical concerning the adequacy of common usage.In particular, while DF is a perfectly legitimate and useful measure of heritability in populations, it is not necessarily a genetic one and should not be labeled as such. PI on the other hand, although very intuitive, depends on an extremely problematic distinction between causes and mere conditions (e.g., genes and epigenetic factors). Both criteria will be highly relative and both, via what I term the new problem of genetics, will inspire contradictory analyses based on the same data. (shrink)

: The authors respond to objections Fred Gifford has raised against their paper "Rehabilitating Equipoise." They situate this exchange in the wider context of recent debate over equipoise, highlighting substantial points of agreement between themselves and Gifford. The authors offer a brief restatement of "Rehabilitating Equipoise" in which they amplify some of its core arguments. They then assess Gifford's objections. Finding each to be unfounded, they argue that there is no justification for "pulling the plug" on (...) clinical equipoise. (shrink)

This collection of essays by eminent philosopher Fred Dretske brings together work on the theory of knowledge and philosophy of mind spanning thirty years. The two areas combine to lay the groundwork for a naturalistic philosophy of mind. The fifteen essays focus on perception, knowledge, and consciousness. Together, they show the interconnectedness of Dretske's work in epistemology and his more contemporary ideas on philosophy of mind, shedding light on the links which can be made between the two. The first (...) section of the book argues the point that knowledge consists of beliefs with the right objective connection to facts; two essays discuss this conception of knowledge's implications for naturalism. The next section articulates a view of perception, attempting to distinguish conceptual states from phenomenal states. A naturalized philosophy of mind, and thus a naturalized epistemology, is articulated in the third section. This collection will be a valuable resource for a wide range of philosophers and their students, and will also be of interest to cognitive scientists, psychologists, and philosophers of biology. (shrink)

This paper proposes a third meditation-category—automatic self-transcending— to extend the dichotomy of focused attention and open monitoring proposed by Lutz. Automaticself-transcending includes techniques designed to transcend their own activity. This contrasts with focused attention, which keeps attention focused on an object; and open monitoring, which keeps attention involved in the monitoring process. Each category was assigned EEG bands, based on reported brain patterns during mental tasks, and meditations were categorized based on their reported EEG. Focused attention, characterized by beta/gamma activity, (...) included meditations from Tibetan Buddhist, Buddhist, and Chinese traditions. Open monitoring, characterized by theta activity, included meditations from Buddhist, Chinese, and Vedic traditions. Automaticself-transcending, characterized by alpha1 activity, included meditations from Vedic and Chinese traditions. Between categories, the included meditations differed in focus, subject/object relation, and procedures. These findings shed light on the common mistake of averaging meditations together to determine mechanisms or clinical effects. (shrink)

Fred Feldman's fascinating new book sets out to defend hedonism as a theory about the Good Life. He tries to show that, when carefully and charitably interpreted, certain forms of hedonism yield plausible evaluations of human lives. Feldman begins by explaining the question about the Good Life. As he understands it, the question is not about the morally good life or about the beneficial life. Rather, the question concerns the general features of the life that is good in itself (...) for the one who lives it. Hedonism says (roughly) that the Good Life is the pleasant life. After showing that received formulations of hedonism are often confused or incoherent, Feldman presents a simple, clear, coherent form of sensory hedonism that provides a starting point for discussion. He then presents a catalogue of classic objections to hedonism, coming from sources as diverse as Plato, Aristotle, Brentano, Ross, Moore, Rawls, Kagan, Nozick, Brandt, and others. One of Feldman's central themes is that there is an important distinction between the forms of hedonism that emphasize sensory pleasure and those that emphasize attitudinal pleasure. Feldman formulates several kinds of hedonism based on the idea that attitudinal pleasure is the Good. He claims that attitudinal forms of hedonism - which have often been ignored in the literature -- are worthy of more careful attention. Another main theme of the book is the plasticity of hedonism. Hedonism comes in many forms. Attitudinal hedonism is especially receptive to variations and modifications. Feldman illustrates this plasticity by formulating several variants of attitudinal hedonism and showing how they evade some of the objections. He also shows how it is possible to develop forms of hedonism that are equivalent to the allegedly anti-hedonistic theory of G. E. Moore and the Aristotelian theory according to which the Good Life is the life of virtue, or flourishing. He also formulates hedonisms relevantly like the ones defended by Aristippus and Mill. Feldman argues that a carefully developed form of attitudinal hedonism is not refuted by objections concerning 'the shape of a life'. He also defends the claim that all of the alleged forms of hedonism discussed in the book genuinely deserve to be called 'hedonism'. Finally, after dealing with the last of the objections, he gives a sketch of his hedonistic vision of the Good Life. (shrink)

"Taken as a trilogy, _consent not to be a single being_ is a monumental accomplishment: a brilliant theoretical intervention that might be best described as a powerful case for blackness as a category of analysis."—Brent Hayes Edwards, author of _Epistrophies: Jazz and the Literary Imagination_ In _The Universal Machine_—the concluding volume to his landmark trilogy _consent not to be a single being_—Fred Moten presents a suite of three essays on Emmanuel Levinas, Hannah Arendt, and Frantz Fanon in which he (...) explores questions of freedom, capture, and selfhood. In trademark style, Moten considers these thinkers alongside artists and musicians such as William Kentridge and Curtis Mayfield while interrogating the relation between blackness and phenomenology. Whether using Levinas's idea of escape in unintended ways, examining Arendt's antiblackness through Mayfield's virtuosic falsetto and Anthony Braxton's musical language, or showing how Fanon's form of phenomenology enables black social life, Moten formulates blackness as a way of being in the world that evades regulation. Throughout _The Universal Machine_—and the trilogy as a whole—Moten's theorizations of blackness will have a lasting and profound impact. (shrink)

"Taken as a trilogy, _consent not to be a single being_ is a monumental accomplishment: a brilliant theoretical intervention that might be best described as a powerful case for blackness as a category of analysis."—Brent Hayes Edwards, author of _Epistrophies: Jazz and the Literary Imagination_ In _Stolen Life_—the second volume in his landmark trilogy _consent not to be a single being_—Fred Moten undertakes an expansive exploration of blackness as it relates to black life and the collective refusal of social (...) death. The essays resist categorization, moving from Moten's opening meditation on Kant, Olaudah Equiano, and the conditions of black thought through discussions of academic freedom, writing and pedagogy, non-neurotypicality, and uncritical notions of freedom. Moten also models black study as a form of social life through an engagement with Fanon, Hartman, and Spillers and plumbs the distinction between blackness and black people in readings of Du Bois and Nahum Chandler. The force and creativity of Moten's criticism resonate throughout, reminding us not only of his importance as a thinker, but of the continued necessity of interrogating blackness as a form of sociality. (shrink)

Philosophical interest in situated cognition has been focused most intensely on the claim that human cognitive processes extend from the brain into the tools humans use. As we see it, this radical hypothesis is sustained by two kinds of mistakes, confusing coupling relations with constitutive relations and an inattention to the mark of the cognitive. Here we wish to draw attention to these mistakes and show just how pervasive they are. That is, for all that the radical philosophers have said, (...) the mind is still in the head. (shrink)

The paper provides close commentary on an important but generally neglected passage in "Prior Analytics" B.21 where, in the course of solving a logical puzzle concerning our knowledge of universal statements, Aristotle offers his only explicit treatment of the Platonic doctrine of Recollection. I show how Aristotle defends his solution to the "Paradox of Knowing Universals", as we might call it, and why he introduces Recollection into his discussion of the puzzle. The reading I develop undermines the traditional view of (...) the passage and lends fresh insight into Aristotle's conception of Plato's particular version of innatism; more specifically, when understood as I recommend, the passage strongly suggests that, on Aristotle's view, Plato's theory of Recollection is specifically designed to explain our apprehension of universal truths. The reading I propose also enables us to see how the allegedly non-standard use of the technical term ἐπαγω³ή in B.21 can be understood in a perfectly straightforward fashion to refer to an inductive inference from singular statements to the universal truth they exemplify. Owing to this last point in particular, the paper carries serious consequences for our understanding of the purported doublet in the problematic opening chapter to the "Posterior Analytics" where Aristotle offers his only explicit attempt to solve Meno's Paradox. (shrink)