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 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)

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)

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)

Explores some steps toward non-assimilative encounters in the "global village.".

There has been much interest in conspiracy theories (CTs) amongst philosophers in recent years. The aim of this paper will be to apply some of the philosophical research to issues in political theory. I will first provide an overview of some of the philosophical discussions about CTs. While acknowledging that particularism is currently the dominant position in the literature, I will contend that the ‘undue scepticism problem’, a modified version of an argument put forward by Brian Keeley, is an important (...) general objection to many CTs. This in turn leads to some substantial conclusions for liberal political philosophy, as the undue scepticism problem sets up a strong argument against non-liberal alternatives to liberal thought. I shall argue that we are justified in having far more doubt about the reliability of official sources in non-liberal societies, and it is legitimate to be more sceptical about claims designed to bolster non-liberal politics. Moreover, because scepticism is often more warranted in non-liberal societies, this may provide the possibility for the state to be stable, even if it is highly tyrannical or ineffective. These considerations are not intended to be decisive, but raise unresolved questions about the viability of non-liberal politics. (shrink)

Ethnic cleansing and other methods of political and social exclusion continue to thrive in our globalized world, complicating the idea that unity and diversity can exist in the same society. When we emphasize unity, we sacrifice heterogeneity, yet when we stress diversity, we create a plurality of individuals connected only by tenuous circumstance. As long as we remain tethered to these binaries, as long as we are unable to imagine the sort of society we want in an age of diversity, (...) we cannot achieve an enduring solution to conflicts that continue unabated despite our increasing proximity to one another. By envisioning the public as a multivoiced body, Fred Evans offers a solution to the dilemma of diversity. The multivoiced body is both one and many: heterogeneous voices that at once separate and bind themselves together through their continuous and creative interplay. By focusing on this traditionally undervalued or overlooked notion of voice, Evans shows how we can valorize simultaneously the solidarity, diversity, and richness of society. Moreover, recognition of society as a multivoiced body helps resists the pervasive countertendency to raise a chosen discourse to the level of "one true God," "pure race," or some other "oracle" that eliminates the dynamism of contesting voices. To support these views, Evans taps the major figures and themes of analytic and continental philosophy as well as modernist, postmodernist, postcolonial, and feminist thought. He also turns to sources outside of philosophy to address the implications of his views for justice, citizenship, democracy, and collective as well as individual rights. Through the seemingly simple conceit of a multivoiced body, Evans straddles both philosophy and political practice, confronting issues of subjectivity, language, communication, and identity. For anyone interested in moving toward a just society and politics, _The Multivoiced Body_ offers an innovative approach to the problems of human diversity and ethical plurality. (shrink)

Comparative political theory is at best an embryonic and marginalized endeavor. As practiced in most Western universities, the study of political theory generally involves a rehearsal of the canon of Western political thought from Plato to Marx. Only rarely are practitioners of political thought willing (and professionally encouraged) to transgress the canon and thereby the cultural boundaries of North America and Europe in the direction of genuine comparative investigation. Border Crossings presents an effort to remedy this situation, fully launching a (...) new era in political theory. Thirteen scholars from around the world examine the various political traditions of West, South, and East Asia and engage in a reflective cross-cultural discussion that belies the assumptions of an Asian "essence" and of an unbridgeable gulf between West and non-West. The denial of essential differences does not, however, amount to an endorsement of essential sameness. As viewed and as practiced by contributors to this ground-breaking volume, comparative political theorizing must steer a course between uniformity and radical separation--this is the path of "border crossings.". (shrink)

Ethnic cleansing and other methods of political and social exclusion continue to thrive in our globalized world, complicating the idea that unity and diversity can exist in the same society. When we emphasize unity, we sacrifice heterogeneity, yet when we stress diversity, we create a plurality of individuals connected only by tenuous circumstance. As long as we remain tethered to these binaries, as long as we are unable to imagine the sort of society we want in an age of diversity, (...) we cannot achieve an enduring solution to conflicts that continue unabated despite our increasing proximity to one another. By envisioning the public as a multivoiced body, Fred Evans offers a solution to the dilemma of diversity. The multivoiced body is both one and many: heterogeneous voices that at once separate and bind themselves together through their continuous and creative interplay. By focusing on this traditionally undervalued or overlooked notion of voice, Evans shows how we can valorize simultaneously the solidarity, diversity, and richness of society. Moreover, recognition of society as a multivoiced body helps resists the pervasive countertendency to raise a chosen discourse to the level of "one true God," "pure race," or some other "oracle" that eliminates the dynamism of contesting voices. To support these views, Evans taps the major figures and themes of analytic and continental philosophy as well as modernist, postmodernist, postcolonial, and feminist thought. He also turns to sources outside of philosophy to address the implications of his views for justice, citizenship, democracy, and collective as well as individual rights. Through the seemingly simple conceit of a multivoiced body, Evans straddles both philosophy and political practice, confronting issues of subjectivity, language, communication, and identity. For anyone interested in moving toward a just society and politics, _The Multivoiced Body_ offers an innovative approach to the problems of human diversity and ethical plurality. (shrink)