This paper analyzes one dimension of the frequently alleged contradiction between treating medicine as a business and as a profession, namely the incompatibility between viewing the physician patient relationship in economic and moral terms. The paper explores the utilitarian foundations of economics and the deontological foundations of professional medical ethics as one source for the business/medicine conflict that influences beliefs about the proper understanding of the therapeutic relationship. It, then, focuses on the contrast and distinction between medicine as business and (...) profession by critically analyzing the classic economic view of the moral status of medicine articulated by Kenneth Arrow. The paper concludes with a discussion of some advantages associated with regarding medicine as a business. (shrink)

Recent philosophical attention to the language of disease has focused primarily on the question of its value-neutrality or non-neutrality. Proponents of the value-neutrality thesis symbolically combine political and other criticisms of medicine in an attack on what they see as value-infected uses of disease language. The present essay argues against two theses associated with this view: a methodological thesis which tends to divorce the analysis of disease language from the context of the practice of medicine and a substantive thesis which (...) holds that disease language is evaluatively neutral. In particular, the essay critically focuses on the value neutral position adopted by Christopher Boorse, which he terms a functional theory of disease. The argument concerns whether or not one can have value neutral description of disease states or whether disease language essentially involves values. (shrink)

This article isolates ten prepositions, which constitute the undercurrent paradigm of contemporary discourse of health disease and medicine. Discussion of the interrelationship between those prepositions leads to a systematic refutation of this paradigm. An alternative set is being forwarded. The key notions of the existing paradigm are that health is the natural condition of humankind and that disease is a deviance from that nature. Natural things are harmonious and healthy while human made artifacts are coercive interference with natural balance. It (...) is suggested that the current paradigm is influenced by the world of finances and by instrumental reason. The alternative model suggests that human nature cannot be delineated. Humans fashion their own selves and nature by artificial means, medicine among them. The article discusses the implications of the paradigm adapted in various scholarly and popular debates such as the use of sex hormones for contraception, the care of the elderly, holistic medicine and distributive justice in health care. Medicine is not an isolated or a privileged realm. There is no unique entitlement to health care. It is always part of a broader agenda of social values and institutions. A open view of human societies, values and practices as they are situated within concrete material conditions is the platform required for an integrative and creative discourse of health care. (shrink)

Living things are often plastic during their early development and are moulded by the environment. Many human fetuses have to adapt to a limited supply of nutrients, and in doing so they permanently change their physiology and metabolism. These programmed changes may be the origins of a number of diseases in later life, including coronary heart disease, stroke, diabetes and hypertension.

Ivan Illich, philosopher, historian, priest and social commentator died in Bremen, Germany on December 2, 2002. Illich was noted for his critique of the Church, education and medicine but his concepts dealt with more fundamental issues. This article reveals aspects of Illich, the man, and explores his ideas as they apply to the meaning of medicine and, in particular, the role of health care in contemporary society.

Despite its virtues, lay decision-making in medicine shares with professional decision-making a disturbing common feature, reflected both in formal policies prohibiting high-risk research and in informal policies favoring treatment decisions made when a crisis or change of status occurs, often late in a downhill course. By discouraging patient decision-making but requiring dedication to the patient's interests by those who make decisions on the patient's behalf, such practices tend to preclude altruistic choice on the part of the patient. This eclipse is (...) to be regretted not just because widescale altruism has the capacity to provide important social goods and correct injustices in distribution, but for intrinsic reasons as well. It is argued that preserving the possibility of altruism obliges patients – and future patients – to make decisions about dying and other medical matters in advance, thus avoiding that displacement of decision-making onto lay and professional second parties which results in altruism's eclipse. Keywords: altruism, medical decision-making, patient's interest, self-interest, autonomy, death and dying decisions, refusal of treatment, prolongation of life, allowing to die, high-risk research CiteULike Connotea Del.icio.us What's this? (shrink)

For the philosophy of medicine, there are two things of interest about the stoic account of moral norms, quite apart from whether the rest of stoic ethical theory is compelling. One is the stoic version of naturalism: its account of practical reasoning, its solution to the is/ought problem, and its contention that norms for creating, sustaining, or restoring human health are tantamount to moral norms. The other is the stoic account of human agency: its description of the intimate connections between (...) human health, rational agency, and moral norms. There is practical guidance to be gained from exploring those connections, whether or not one is ready to follow stoic moral theory all the way to its austere end. (shrink)

The field of spirituality and medicine has seen explosive growth in recent years, due in part to significant private support for the development of curricula in more than half of all U.S. medical schools, and for related residency training programs and research centers. While there is no single definition of "spirituality" in use across these initiatives, this article examines the definitions and learning objectives relevant to spirituality that are addressed in a 1999 report of the Medical School (...) Objectives Project (MSOP), with special attention to their ethical implications. It concludes with several "diagnostic" case studies of religious consciousness from the medical literature and in literary texts, again with attention to ethical concerns. (shrink)

Genomics has brought biology, medicine, agriculture, psychology, anthropology, and even philosophy to a new threshold. In this new context, the question about "what is human in humans" may end up being answered by geneticists, specialists of technoscience, and owners of biotech companies. The author defends, in this article, the idea that humanity is at risk in our age of genetic engineering, biotechnologies, and market-geared genetic research; he also argues that the values at the very core of our postgenomic era bring (...) to its peak the science-based ideology that has developed since the time of Galileo, Newton, Descartes, and Harvey; finally, it shows that the bioindustry has invented a new genomythology that goes against the scientific evidence produced by the research in human sciences in which life is interpreted as a language. (shrink)

E. Haavi Morreim's book, Holding Health Care Accountable , insightfully describes several features of the current crisis in malpractice in relation to the health care marketplace. In this essay, I delineate the key and eminently practical guide for reform that she lays out. I argue that her insights bring us to more fundamental aspects than immanent medical economy and accountability - aspects that are ignored at present. I describe the features of immanent economy and how they tend to cover over (...) epistemological and existential finitude in medicine, show how economy can in fact create new medical knowledge, and show that necessary error is a real feature of day-to-day medical practice. The current system, even with Morreim's reforms, remains at the level of immanent economy, but with modifications may point to the features of medicine that transcend medical knowledge and economy. The gifts of medicine cannot be reduced to the immanent medical economy, and any attempt to do so results in crisis. A health care that points to finitude and fallibility is one that points to the mystery of human existence and mortality. Any health care financing system that helps to delineate finitude - both epistemological and existential - is one that will give patients a new lease on living and dying. (shrink)

A perspective is developed for approaching affliction as a social fact. Disability and disease are considered as two ways in which we suffer a disjunction which arises from the need to take initiative with respect to the inexorable, whether that means the mark of disability or the unconquerability of disease.The story of affliction always raises and masks in certain respects the problem of suffering as the collective representation of our experience of subjectivity where that experience passes through the separateness of (...) being marked to the singularity of being without hope. (shrink)

The convergence of biomedical sciences with nanotechnology as well as ICT has created a new wave of biomedical technologies, resulting in visions of a ‘molecular medicine’. Since novel technologies tend to shift concepts of disease and health, this paper investigates how the emerging field of molecular medicine may shift the meaning of ‘disease’ as well as the boundary between health and disease. It gives a brief overview of the development towards and the often very speculative visions of molecular medicine. Subsequently (...) three views of disease often used in the philosophy of medicine are briefly discussed: the ontological or neo-ontological, the physiological and the normative/holistic concepts of disease. Against this background two tendencies in the field of molecular medicine are highlighted: (1) the use of a cascade model of disease and (2) the notion of disease as a deviation from an individual pattern of functioning. It becomes clear that molecular medicine pulls conceptualizations of disease and health in several, partly opposed directions. However, the resulting tensions may also offer opportunities to steer the future of medicine in more desirable directions. (shrink)

Generally, rational decision-making is conceived as arriving at a decision by a correct application of the rules of logic and statistics. If not, the conclusions are called biased. After an impressive series of experiments and tests carried out in the last few decades, the view arose that rationality is tough for all, skilled field experts not excluded. A new type of planner's counsellor is called for: the normative statistician, the expert in reasoning with uncertainty par excellence. To unravel this view, (...) the paper explores a specific practice of clinical decision-making, namely Evidence-Based Medicine. This practice is chosen, because it is very explicit about how to rationalize practice. The paper shows that whether a decision-making process is rational cannot be assessed without taking into account the environment in which the decisions have to be taken. To be more specific, the decision to call for new evidence should be rational too. This decision and the way in which this evidence is obtained are crucial to validate the base rates. Rationality should be model-based, which means that not only the isolated decision-making process should take a Bayesian updating process as its norm, but should also model the acquisition of evidence (priors and tests results) as a rational process. (shrink)

This essay argues that making a diagnosis in medicine is essentially a hermeneutic enterprise, one in which interpretation skills play a major part in understanding a disease. The clinical encounter is an event comprised of two voices; one is the voice of science which is grounded in empiricism, the other is that of human experience, which is grounded in story-telling and the interpretation of those stories.Using two voices, one from the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, which describes alcohol (...) abuse and alcohol dependence, and the other, that of Claire, a character in Edward Albee's play, A Delicate Balance, who is conversing with her brother-in-law, Tobias, I apply principles from Hans-Georg Gadamer's hermeneutics to the clinical diagnostic process. The essay will demonstrate that we overlook an enormous amount of information about alcoholism by an overreliance on objective data and that our hope for understanding alcoholics is in listening to their voices, and sharing the interpretation of their experiences with them. (shrink)

In this article I seek to say what it is for something to count as a neglected disease. I argue that neglect should be defined in terms of efforts at prevention, mitigation and cure, and not solely in terms of research dollars per disability-adjusted life-year. I further argue that the trend towards multifactorialism and risk factor thinking in modern epidemiology has lent credibility to the erroneous view that the primary problem with neglected diseases is a lack of research. A more (...) restrictive contrastive model of disease is endorsed as better suited to the definition of neglected disease. (shrink)

A less analytic and more wholistic approach to philosophy, described as best overall fit or seeing how things all hang together, is defended in recent works by John Rawls and Richard Rorty and can usefully be applied to problems in philosophy of medicine. Looking at sickness and its impact upon the person as a central problem for philosophy of medicine, this approach discourages a search for necessary and sufficient conditions for being sick, and instead encourages a listing of true and (...) interesting observations about sickness which reflect the convergence of a number of different viewpoints. Among the relevant viewpoints are other humanities disciplines besides philosophy and the social sciences. Literature, in particular, provides insights into the meaning and the uniqueness of episodes of sickness in a way that philosophers may otherwise fail to grasp. (shrink)

The question of the philosophical basis of medical science and medical practice is considered under three closely related themes: (i) the doctor-patient relationship, (ii) the structure of the medical-ethical discourse, and (iii) the problem of philosophical founding in relation to medical conduct. The doctor-patient relationship is regarded as a transformational relation. Acceptance of the illness of the patient, the construction of a complaint as a necessary condition — and not a description of an existing reality — as well as the (...) establishment of a common interest are determinants of that relation. They are related to the dominant form of science and thought in medicine, namely application. This is typical for the Standard Medical-Ethical Discussion (SMED), its scope and its rationality. The third issue leads to the thesis that this particular rationality is not a sufficient ground for considering the medical discourse to be founded in philosophy. (shrink)

This essay examines several recent philosophical attempts to define ‘disease’. Two prominent ones are considered in detail, an objective approach by Christopher Boorse and a normative approach by Caroline Whitbeck. Both are found to be inadequate for a variety of reasons, though Whitbeck's is superior because of her careful preliminary distinctions and because of its normative approach which is more nearly in accord with medical and lay usage. The paper concludes with a discussion of the nature of such efforts at (...) definition and suggests that their limitations are due both to the nature of our language and concepts in general, and to the nature of medicine in particular. It is the practical and changing character of medicine and its language that frustrates the efforts of philosophers to formulate such definitions. Keywords: disease, definition CiteULike Connotea Del.icio.us What's this? (shrink)

The ethical implications of the growth of for-profit health care institutions are complex. Two major moral criticisms of for-profit medicine are analyzed. The first claim is that for-profit health care institutions fail to fulfill their obligations to do their fair share in providing health care to the poor and so exacerbate the problem of access to health care. The second claim is that profit seeking in medicine will damage the physician-patient relationship, creating conflicts of interest that will diminish the quality (...) of care and erode patients' trust in their physicians and the public's trust in the medical profession. The authors conclude that while the continued expansion of for-profit health care may exacerbate in some respects problems of access, trust and conflicts of interest, it is a mistake to consider these problems as unique to for-profit health care; they are problems for not for-profit health care as well. Though these issues justify continuing moral concern, they do not at this time provide decisive grounds for substantially curbing or eliminating for-profit enterprise in health care. Keywords: for-profit medicine, competetion, access to health care, justice, patient-physician relationship CiteULike Connotea Del.icio.us What's this? (shrink)

The concept of predisposition in medicine is ancient, and the term diathesis was used to express it since the days of Hippocrates and, especially, of Galen.The concept of diathesis was enormously popular throughout the nineteenth century, despite the vagueness of its actual meaning. It was clarified only in the early years of the twentieth century (1902), when it was however losing its clinical relevance, by a replacement of the concept ofchemical individuality by A.E. Garrod, followed thirty years later by the (...) concept ofinborn factors in disease (1931). (shrink)

The often-emphasized tension between the singularity of the patient and technical–scientific reproducibility in medicine cannot be resolved without a discussion of the epistemological and methodological status of the human sciences. On the one hand, the rules concerning human action are analogous to the scientific laws of nature. They are de facto sufficiently stable to allow predictions and explanations similar to those of experimental sciences. From this point of view, it is only a trivial truth, but still a methodological irrelevancy, that (...) the patient and the doctor–patient relationship represent an ontologically irreproducible reality. On the other hand, however, one can never exclude that one can fail in the application of "laws" of the human sciences to the individual patient, for such laws are by no means wholly separated from a patient's personal-hermeneutic mediation, and can at any time be revoked by becoming aware of them. This requires a synergistic collaboration of clinical and statistical methods, and shows a methodologically relevant sense in which one cannot disregard the singularity of the patient. The reason for the crucial role of the patient's singularity in medicine is every individual patient's capacity to revoke, in principle, routines and quasi-automatisms, even though the personal mediation by the patient's consciousness de facto changes them in such a small degree that predictions and explanations modeled in experimental science remain possible. (shrink)

All the powerful influences exertedby the subjective-interpersonal dimension onthe organic or technical-functional dimensionof sickness and health do not make anintersubjective test concerning medicaltherapeutic results impossible. Theseinfluences are not arbitrary; on the contrary,they obey laws that are de facto sufficientlystable to allow predictions and explanationssimilar to those of experimental sciences.While, in this respect, the rules concerninghuman action are analogous to the scientificlaws of nature, they can at any time be revokedby becoming aware of them. Law-like andreproducible regularities in the sciences ofman (...) are by no means separated from a patient'spersonal-hermeneutic mediation. This makes itpossible for human beings to modify, improve orsometimes even entirely (or better almostentirely) suspend these psychological,sociological, ethnological, medical,regularities. For this reason the sciences ofman including medicine are under the obligationof constantly inspecting the continuingvalidity of the rules on which theirpredictions and explanations are based, namelyby indirect, statistical methods. Thisrequires a synergistic collaboration ofextra-clinical and clinical tests through whichmedicine can obtain a good level ofintersubjective testability. (shrink)

One of the most important developments in international medicine over the past two decades has been a turn to the market as a way of coping with rising costs and responding to calls for more freedom from government control. A full moral evaluation of the relationship of medicine and the market requires asking a wide range of questions bearing on the meaning and impact of market strategies on the economics of health care and on the clinical and public health outcomes (...) of those strategies. A number of the leading questions are presented and some provisional answers offered. (shrink)

The contributions that the philosophy of medicine can make to both the philosophy of science and the practice of science have been obscured in recent years by an overemphasis on personalities rather than critical themes. Two themes have dominated general discussion within contemporary philosophy of science: methodological essentialism and dynamic gradualism. These themes are defined and considered in light of Kenneth Schaffner's argument that theories in biomedicine have a structure and logic unlike that found in theories of the natural sciences. (...) Schaffner's arguments are suggestive but not definitive as a refutation of methodological essentialism. I argue that a primary reason for differences in the logic and structure of theories in biomedicine is not, as some philosophers have suggested, a product of ontological differences, but rather a product of the practical and pragmatic concerns of scientific theorizing in many areas of science, such as medicine. Keywords: philosophy of medicine, philosophy of science, logic of medicine, medical theory, methodological essentialism, dynamic gradualism CiteULike Connotea Del.icio.us What's this? (shrink)

Health, Disease, and Illness brings together a sterling list of classic and contemporary thinkers to examine the history, state, and future of ever-changing "concepts" in medicine.

This article provides an introduction to the articles in this theme issue. This collection examines epistemological, ontological, moral and political questions in medicine in light of the philosophical ideas of Charles Taylor. A synthesis of Taylor's relevant work is presented. Taylor has argued for a conception of the human sciences that regards human life as meaningful–deriving meaning from surrounding horizons of significance. An overview of the interdisciplinary articles in this issue is presented. This collection advances our thinking in the philosophy (...) of medicine as well as the philosophy of Charles Taylor. (shrink)

Randomized controlled trials (RCTs) are widely taken as the gold standard for establishing causal conclusions. Ideally conducted they ensure that the treatment ‘causes’ the outcome—in the experiment. But where else? This is the venerable question of external validity. I point out that the question comes in two importantly different forms: Is the specific causal conclusion warranted by the experiment true in a target situation? What will be the result of implementing the treatment there? This paper explains how the probabilistic theory (...) of causality implies that RCTs can establish causal conclusions and thereby provides an account of what exactly that causal conclusion is. Clarifying the exact form of the conclusion shows just what is necessary for it to hold in a new setting and also how much more is needed to see what the actual outcome would be there were the treatment implemented. (shrink)

What kinds of evidence reliably support predictions of effectiveness for health and social care interventions? There is increasing reliance, not only for health care policy and practice but also for more general social and economic policy deliberation, on evidence that comes from studies whose basic logic is that of JS Mill's method of difference. These include randomized controlled trials, case–control studies, cohort studies, and some uses of causal Bayes nets and counterfactual-licensing models like ones commonly developed in econometrics. The topic (...) of this paper is the 'external validity' of causal conclusions from these kinds of studies. We shall argue two claims. Claim, negative: external validity is the wrong idea; claim, positive: 'capacities' are almost always the right idea, if there is a right idea to be had. If we are right about these claims, it makes big problems for policy decisions. Many advice guides for grading policy predictions give top grades to a proposed policy if it has two good Mill's-method-of difference studies that support it. But if capacities are to serve as the conduit for support from a method-of-difference study to an effectiveness prediction, much more evidence, and much different in kind, is required. We will illustrate the complexities involved with the case of multisystemic therapy, an internationally adopted intervention to try to diminish antisocial behaviour in young people. (shrink)

This paper begins by examining the claim that the practice of medicine is essentially a moral endeavor. According to this view, all clinical practice has moral content, and each clinical situation has a moral dimension. I suggest that in order to recognize this moral dimension, clinicians must engage in an interpretive process, and that they must be able to interpret clinical data in ethical terms. However, clinicians often lack the ‘moral perception’ required to appreciate this moral dimension. I will argue (...) that physicians lack moral perception when the clinical data they are given do not offer sufficient opportunity for interpretation. This paper draws on the work of Merleau-Ponty to suggest that this loss of interpretation is, paradoxically, the result of the way that patients experience illness. This thesis may be productive, first, because it suggests opportunities to explore the process of moral perception. This thesis also suggests ways for ethicists and educators to enhance clinicians' perception of the ethical dimensions of clinical practice. Finally, the concept of moral perception, when grounded in the patient's experience of illness, creates a fruitful area of inquiry that warrants inclusion in what may someday be the philosophy of medicine's canon. (shrink)

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient (...) outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family. (shrink)

Beginning with a case vignette, this paper uses a semiotic approach to analyze several different kinds of understanding used in clinical medicine. By outlining semiotic structures, four distinct modes of understanding can be defined: (1) the representational mode, corresponding to scientific medicine; (2) the pragmatic mode, constituting the basic standpoint of medicine; (3) the hermeneutic mode, underlying the empathic, humanistic spirit of medicine; and (4) the ontologic mode, associated with both the ethical and ritual aspects of medicine. Clarifying the relationship (...) between these modes avoids common confusions in clinical situations. Although experienced clinicians intuitively use these different modes, they do not necessarily reflect upon them. They are instead mindful of them, and this unique multi-modal consciousness, I suggest, provides a model for integrating theory and practice. (shrink)

While ethicists have directed much attention to controversial biomedical issues--including euthanasia, abortion, and genetic engineering--they have largely ignored the less obvious, but more pervasive, everyday ethical problems faced by family physicians. Ethical Issues in Family Medicine addresses these problems, offering an ethics that reflects the distinctive features of family practice, and helping family physicians to appreciate the extent to which ethical issues influence their practice.

Drew Leder's Clinical Interpretation: The Hermeneutics of Medicine [1] is an essay which understates its case and thereby opens itself to misinterpretation. This response to Leder argues for a more thorough-going hermeneutic for both medicine and science. At the conceptual as well as the practical level, modern medicine and its scientific foundations are hermeneutic enterprises. The purpose of this essay is to argue that we should not back away from this more radical thesis. Embracing it will result in less alienation (...) of physicians from patients, and of physicians from the tasks of medicine. (shrink)

I will present here a personal point of view on the commitment of mathematicians in medicine. Starting from my personal experience, I will suggest generalisations including favourable signs and caveats to show how mathematicians can be welcome and helpful in medicine, both in a theoretical and in a practical way.

Trust relations in medicine are argued to be a requisite response to the special vulnerability of persons as patients. Even so, the problem of motivating trust remains a vital concern. On this score, it is argued that a strong motivation can be found in recognizing that professional self-interest actually entails cultivation of patient trust as a means to maintain professional self-governance. And while the initial move to restore trust must be provoked from such narrow concerns, the process of sustaining trust (...) will require educational initiatives aimed at restoring attitudes and skills suggestive of Percival's concept of empathic care. By including such initiatives, future waves of medical professionals are apt to sustain trust with deepened commitments to character, care, and trust as constitutive properties of their professional mission. (shrink)

The thesis of this paper is that because the significance of Western medicine lies in its ability to enhance the health of persons within a society, the practice of medicine is foremost an ethic and only thereafter a science. In support of the priority of an ethical perspective in medical practice, the paper explores the socio-cultural nature of knowledge, upon which science itself is constructed. Next, it draws from Levinas' philosophy, which illumines the problem of ontological and epistemological priority. Specifically, (...) it examines Levinas' rendering of the human face and of language, as they found the case for the priority of justice, or ethics. Finally, the paper offers the practice of narrative discourse as one solution that elevates the status of ethics within the institution of medicine and that has the potential to counteract the tendency in medical practice to employ a universalizing methodology based in science's power to control the human Other. (shrink)

This paper argues that modern society does not meet the problems posed by the experience of disease in a satisfactory way. It attempts to show this by examining the distinction between disease and plague. Disease is formulated as necesssarily involving the self in unforeseeable ways with what is other to itself: the challenge of disease is treated as the challenge of this involvement. On the other hand, plague as an abstract threat is that towards which the collective shows principled indifference. (...) The strength and the limits of this indifference are explored. Subsequent upon this, the paper examines the consequences of the loss of the distinction between disease and plague, particularly with respect to the implications of that loss for the treatment, management, and control of disease in modern society. (shrink)

Several recent publications have suggested that hermeneutics, the method of literary criticism, might prove to be useful in medicine. In this essay I consider this thesis with particular attention to the claim that medicine is hermeneutics all the way down. After examining an anti-positivist critique of positivist medicine and arguing that hermeneutic interpretation involves a more radical critique of modern medicine, I examine the supposed consequences of hermeneutical universalism:relativism, skepticism andantirealism which further evaluation reveals to be only potential consequences of (...) hermeneutics. A brief discussion ofphronesis and of the possible texts of medicine concludes the article. (shrink)

Herbert Fingarette [1] argues that alcoholism is not a disease and that the alleged alcoholic under certain circumstances has the power to control his or her drinking disorders. I shall analyze Fingarette's argument and show that his position rests on some logical and conceptual confusions.In analyzing Fingarette's argument for the self-control theory of drinking disorders I conclude that it is problematic for the following reasons: (1) his argument assumes that the identification of a single cause of alcoholism is a necessary (...) condition of its being a disease; (2) unless it is already assumed (a priori) that persons with drinking disorders possess freedom and self-control to the extent that Fingarette assumes they do, then such persons are likely to suffer from apathy or defeatism regarding their condition; (3) even if Fingarette is correct in his criticism of certain health care programs for those with drinking disorders, it does not follow from this that certain theories about the possible causes of such disorders are false; (4) Fingarette's claim that those with drinking disorders are morally responsible for their actions that result from their disorders is problematic, that is, unless it can be shown that such persons act freely; and (5) Fingarette attempts to support the self-control theory of alcoholism by refuting a straw man conception of the disease model of alcoholism. (shrink)

In his story entitled "Toenails," the surgeon Richard Selzer (1982) warns readers that total immersion in medicine is wrongheaded. Rather, to ensure their own health, doctors should discover other passions that permit them periodically to disconnect from medical practice. Selzer's surgeon character devotes his Wednesday afternoons to the public library, where he joins "a subculture of elderly men and women who gather … to read or sleep beneath the world's newspapers" (p. 69). Among these often eccentric personages is Neckerchief, an (...) arthritic man in his 80s who suffers from severe foot pain. His toenails, never trimmed because of his inability to reach them, have grown so long that they curve beneath his toes and .. (shrink)

, Lawrie Reznek argues that disease is not a natural kind term. I raise objections to Reznek's two central arguments for establishing that disease is not a natural kind. In criticizing his a priori, conceptual argument against naturalism, I argue that his conclusion rests on a weaker argument that appeals to the empirical diversity in the symptoms and manifestations of disease. I also raise questions about the account of natural kinds which Reznek utilizes and his point that conventions for classification (...) are excluded by there being natural kinds. Keywords: Disease, natural kind, value judgement CiteULike Connotea Del.icio.us What's this? (shrink)

In terms of Aristotle's intellectual virtues, the process of clinical reasoning and the discipline of clinical medicine are often construed as techne (art), as episteme (science), or as an amalgam or composite of techne and episteme. Although dimensions of process and discipline are appropriately described in these terms, I argue that phronesis (practical reasoning) provides the most compelling paradigm, particularly of the rationality of the physician's knowing and doing in the clinical encounter with the patient. I anchor this argument, moreover, (...) in Pellegrino's philosophy of medicine as a healing relationship, oriented to the end of a right and good healing action for the individual patient. (shrink)

We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% greater (...) than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy.Our most important criticism is Ioannidis’ basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found.We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary. (shrink)

Evidence - its nature and interpretation - is the key to many topical debates and concerns such as global warming, evolution, the search for weapons of mass destruction, DNA profiling, evidence-based medicine. In 2004 University College London launched a cross-disciplinary research programme "Evidence, Inference and Enquiry" to explore the question: "Can there be an integrated multidisciplinary science of evidence?" While this question was hotly contested and no clear final consensus emerged, much was learned on the journey. This book, based on (...) the closing conference of the programme held at the British Academy in December 2007, illustrates the complexity of the subject, with 17 chapters written from a diversity of perspectives including Archaeology, Computer Science, Economics, Education, Health, History, Law, Psychology, Philosophy and Statistics. General issues covered include principles and systems for handling complex evidence, evidence for policy-making, and human evidence-processing, as well as the very possibility of systematising the study of evidence. (shrink)

Despite increasing recognition of the ways in which ethical and social values play a role in science (Kitcher 2001; Longino 1990, 2002), scientists are often still reluctant to acknowledge or discuss ethical and social values at stake in their research. Even when research is closely connected to developing public policy, it is generally held that it should be empirical data, and not the values of scientists, that inform policy. According to this view, scientists need not, and should not, endorse non-epistemic (...) values related to their research, as doing so may bias their assessment of what the evidence is. As a result, debates over science-based policy tend to be construed solely as empirical discussions to be .. (shrink)

In this introductory paper, I try to give an overview of the concept of normativity in its philosophical history and its contemporary interpretations and uses in different fields. From philosophy of logic and mathematics to philosophy of language and mind, and to philosophy of medicine and care, normativity is found as a key concept pointing at the possibility of scientific and technical progress and improvement of human life in the interaction between the individual and his environment.

The notion of home is well known from our everyday experience, and plays a crucial role in all kinds of narratives about human life, but is hardly ever systematically dealt with in the philosophy of medicine and health care. This paper is based upon the intuitively positive connotation of the term “home.” By metaphorically describing the goal of palliative care as “the patient’s coming home,” it wants to contribute to a medical humanities approach of medicine. It is argued that this (...) metaphor can enrich our understanding of the goals of palliative care and its proper objectives. Four interpretations of “home” and “coming home” are explored: (1) one’s own house or homelike environment, (2) one’s own body, (3) the psychosocial environment, and (4) the spiritual dimension, in particular, the origin of human existence. Thinking in terms of coming home implies a normative point of view. It represents central human values and refers not only to the medical-technical and care aspects of health care, but also to the moral context. (shrink)

Medicine does not usually consider the human body from an aesthetic point of view. This article explores the notion of the lived body as aesthetic object in anthropological medicine, concentrating on the views of Buytendijk and Straus on human uprightness and gracefulness. It is argued that their insights constitute a counter-balance to the way the human body is predominantly approached in medicine and medical ethics. In particular, (1) the relationship between anthropological, aesthetic and ethical norms, (2) the possible danger of (...) a naturalistic fallacy, (3) the implications for the care of disabled people and (4) the intrinsic aesthetic quality of the human body are dealt with. (shrink)

This work brings together Philip van der Eijk's previously-published essays on the close connections that existed between medicine and philosophy throughout antiquity. Medical authors such as the Hippocratic writers, Diocles, Galen, Soranus and Caelius Aurelianus elaborated on philosophical methods such as causal explanation, definition and division and applied key concepts such as the notion of nature to their understanding of the human body. Similarly, philosophers such as Plato and Aristotle were highly valued for their contributions to medicine. This interaction was (...) particularly striking in the study of the human soul in its relation to the body, as illustrated by approaches to specific topics such as intellect, sleep and dreams, and diet and drugs. With a detailed introduction surveying the subject as a whole and a new essay on Aristotle's treatment of sleep, this wide-ranging and accessible collection is essential reading for the student of ancient philosophy and science. (shrink)

A number of philosophers of medicine have attempted to provide analyses of health and disease in which the role that values play in those concepts is restricted. There are three ways in which values can be restricted in the concepts of health and disease. They can be: (i) eliminated, (ii) tamed or (iii) corralled. These three approaches correspond, respectively, to the work of Boorse, Lennox, and Wakefield. The concern of each of these authors is that if unrestricted values are allowed (...) to infect our concepts of health and disease, then anything could be construed as healthy or diseased. They believe that, if at all possible, such a result should be avoided. Unfortunately, as I argue, this result is unavoidable and such attempts to limit values in these concepts are destined to fail. I argue for this position by showing how each of these three attempts to provide value-restricted analyses of health and disease fail as analyses of the concepts of health and disease and that they fail because of their attempts to restrict the role of values in their accounts. I also show how, despite their best efforts, each of these analyses are, themselves, value-driven and value-laden. This leads to the conclusion that values infect our concepts of health and disease at all levels. (shrink)

As historians of science increasingly turn to work on recent (post 1945) science, the historiographical and methodological problems associated with the history of contemporary science are debated with growing frequency and urgency. This book brings together authorities on the history, historiography and methodology of recent and contemporary science to review the problems facing historians of contemporary science, technology and medicine and to explore new ways forward. The chapters explore topics which will be of ever increasing interest to historians of postwar (...) science, including the difficulties of accessing and using secret archival material, the interactions between archivists, historians and scientists and the politics of evidence and historical accounts. (shrink)

Major Polish authors writing on the philosophy of medicine in the period under discussion are briefly presented, namely Tytus Chaubiski Wadysaw Biegaski, and Edmund Biernacki. General background of their work and possible influences are described. The views of the above authors on the meaning, scope and importance of the philosophy of medicine are outlined.

The purpose of this paper is to review the rising influence of commercialism in American medicine and to examine some of the consequences of this trend. Increased competition subverts physician collegiality, draws hospitals into for-profit ownership and behavior, and leads clinical investigators into secrecy and possibly into bias and abuse. Medicine faces a deprofessionalization evidenced in loss of control over the clinical setting and over self-regulation. Health care becomes a commodity relying on cultivation of desires instead of satisfaction of needs, (...) even as many basic needs go unmet. Patients become consumers empowered with lawsuits and the connection of medicine to the relief of suffering is attenuated. Medical encounters are increasingly impersonal, dominated by specialization, technology, and bureaucracy. Patients are losing their physician-advocates to new conflicts of interests, physicians are losing their impulse to charity, and trust in the doctor-patient relationship and in medicine generally is eroding. (shrink)

Medicine is unique in being a combination of natural science and human science in which both are essential. Therefore, in order to make sense of medical practice, we need to begin by drawing a clear distinction between the natural and the human sciences. In this paper, I try to bring the old distinction between the Geistes and Naturwissenschaften up to date by defending the essential difference between a realist explanatory theoretical study of nature including the body in which the scientist (...) discovers the causal properties of natural kinds and the interpretive understanding of human beings as embodied agents which, as Charles Taylor has convincingly argued, requires a hermeneutic account of self-interpreting human practices. (shrink)

From his earliest published work, Mental Illness and Personality (1954), to his last project, The History of Sexuality , Foucault was critical of the human sciences as a dubious and dangerous attempt to model a science of human beings on the natural sciences. He therefore preferred existential therapy, which did not attempt to give a causal account of human nature, but rather described the general structure of the human way of being and its possible distortions. Foucault focused his attack on (...) psychiatry, which claimed to have an explanation of normal and abnormal functioning of the personality modeled on medicine. Freud typified for him this deep mistake which he traced first to the Kantian understanding of human beings as transcendental/ empirical doubles which must think their own unthought, and then later to the gradually developing confessional practices which lead people in our culture to try unsuccessfully to put all their desires into words so as to conform to the norms of psychoanalysis which in turn are based on an account of sexuality as a cause of personality. Foucault proposed his genealogical account of how our culture arrived at this view of man as sexual being as a form of therapy which was to help us free ourselves from this restrictive self- interpretation. Keywords: normal, mental illness, sexuality, psychoanalysis CiteULike Connotea Del.icio.us What's this? (shrink)

This article reviews the strengths and limitations of five major paradigms of medical computer-assisted decision making (CADM): (1) clinical algorithms, (2) statistical analysis of collections of patient data, (3) mathematical models of physical processes, (4) decision analysis, and (5) symbolic reasoning or artificial intelligence (Al). No one technique is best for all applications, and there is recent promising work which combines two or more established techniques. We emphasize both the inherent power of symbolic reasoning and the promise of artificial intelligence (...) and the other techniques to complement each other. Keywords: Diagnosis, Computer Assisted Decision Making, Artificial Intelligence * Current address: Intelligenetics, 124 University Avenue, Palo Alto, CA. 94301, U.S.A. ** Dr. Shortliffe is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine and recipient of research career development award LM0048 from the National Library of Medicine. CiteULike Connotea Del.icio.us What's this? (shrink)

This paper defends an account of compassion and argues for the centrality of compassion to the proper practice of medicine. The argument proceeds by showing that failures of compassion can lead to poor medical treatment and disastrous outcomes. Several case studies are discussed, exemplifying the difference between compassionate and noncompassionate responses to patients seeking help. Arguments are offered in support of approaching reports of persistent pain with a trusting attitude, rather than distrust or skepticism. The article concludes by suggesting educational (...) improvements to encourage compassion. (shrink)

This essay is an array of several taxonomies of values which bear on medicine. The first is a rather low-level list of types of values, meant to be adequate to observational data collection about human valuing. It proceeds to a discussion of levels of valuing so that senses of higher and lower values are articulated. Next, it offers a consideration of intrinsic versus extrinsic and of fundamental versus domestic (or mediating, enabling) values, along with the notions of a practice and (...) virtues. Finally it offers an analysis of clusters of value types along the lines of personal values, social values and professional values acting as interlocking force fields affecting the judgments, reactions and decisions of persons working in health care. In addition to the anticipated elucidation contained in the dialectic, two conclusions are intended: (1) the topic of values in medicine is staggeringly complex, and (2) a medical career is in the best sense a tragic fate in that a noble calling is doomed to many failures because of an inability to reconcile conflicts of values as much as because techniques cannot accomplish everything. (shrink)

Medicine has traditionally been regarded as a rewarding career both financially and socially. How true, however, is that tradition in today's world of rising costs and decreasing revenues? The educational debt of the physician-in-training is steadily increasing, and currently does not affect specialty choice. As the cost of medical education continues to rise, the applicant pool begins to shrink, thereby possibly affecting the quality of future physicians. Once the physician has completed training however, the majority enjoy a positive return on (...) investment. Their incomes generally fail to remain ahead of inflation, and therefore, have remained within a narrow band of $40,000 in 1970 dollars. Finally, the demand for physician services cannot be attributed solely to either the consumer (patient) or to the supplier (physician). Rather, the demand for medical services appears to be a unique combination of the two. In conclusion, medicine still is an attractive career path, but the choices and consequences are becoming much more demanding. (shrink)

The pursuit of health is one of the most basic and prevalent concerns of humanity. In order to better attain and preserve health, a fundamental and unified description of the concept is required. Using Paul Tillich's ontological framework, I introduce a complete characterization of health and disease is that is useful to the philosophy of medicine and for health-care workers. Health cannot be understood merely as proper functioning of the physical body or of the separated levels of body, mind, and (...) soul. Rather, the multidimensional unity that is the essence of human life requires a new understanding of health as balanced self-integration within the multiple human dimensions. The ontological description of health and disease has concrete implications for how health-care workers should approach healing. It calls for a multidimensional approach to healing in which particular healing is needed and helpful if it considers the other realms of the human. It reveals the importance of accepting limited health as well as the value of faith understood as an ultimate concern because of its ability to wholly integrate the person. (shrink)

The phrase "personalized medicine" has a built-in positive spin. Simple genetic tests can sometimes predict whether a particular individual will have a positive response to a particular drug or, alternatively, suffer costly and debilitating side effects. But little attention has been given to some challenging issues of justice raised by personalized medicine. How should we determine who would have a just claim to access particular treatments, especially very expensive ones? How effective do those treatments need to be?If there were a (...) thick, bright line separating minimal responders from maximal responders, then we could allocate these treatments in a fair and cost-effective way. But there is no bright line. The .. (shrink)

The sociological dimension of science is studied using the discovery of the Wasserman reaction and its accidental application as a test for syphilis as a basis, ...

The problem of disease definition is related to theproblem of proving that a certain agent is thenecessary cause of a certain disease. Natural kindterms like rheumatoid arthritis and AIDS refer toessences which are discoverable rather thanpredeterminate. No statement about such diseases isa priori necessarily true. Because theories onnecessary causes involve natural kind semantics,Koch''s postulates cannot be used to falsify or verifysuch theories. Instead of proving that agent A is thenecessary cause of disease D, we include A in atheoretical definition of (...) D, take this to representthe real meaning of D, and discard thepretheoretical definition. This is illustrated byKoch''s own attempt to prove he had discovered thenecessary cause of tuberculosis. Methodologicalarguments about disease causation require a clear viewof our use of diagnostic terms. Medical lexicographersshould do more to provide such a view. (shrink)

Analyses of biological concepts of disease and social conceptions of health indicate that they are structurally interdependent. This in turn suggests the need for a bridge theory of illness. The main features of such a theory are an emphasis on the logical properties of value terms, close attention to the features of the experience of illness, and an analysis of this experience as action failure, drawing directly on the internal structure of action. The practical applications of this theory are outlined (...) for a number of problems in each of the three main practical areas, clinical work, teaching and research. In each case the resources of the theory suggest new models and generate new results. The full practical significance of the theory, however, is shown to consist in the way in which it ties together biological and social theories into an integrated picture of the conceptual structure of medicine as a whole. It is argued, finally, that practical efficiency of this kind is a test of theory not only in the philosophy of medicine but also in general philosophy. (shrink)

In addition to the neglect of philosophy by medicine, emphasized in a recent editorial in this journal, there has been an equally important neglect of medicine by philosophy. Philosophy stands to gain from medicine in three respects: in materials, the conceptual difficulties arising in the practice of medicine being key data for philosophical enquiry; in methods, these data, through their problematic character, being ideally suited to the technique of linguistic analysis; and in results, the practical requirements of medicine placing a (...) direct demand for progress on philosophical theory. The future of the relationship between philosophy and medicine depends on the development of a positive two-way trade between them. (shrink)

In these essays, Gadamer justifies the reasons for a philosophical interest in health and medicine, and a corresponding need for health practitioners to enter into a dialogue with philosophy.

Clarendon Later Ancient Philosophers -/- General Editors: Professor Jonathan Barnes, Balliol College, Oxford, and Professor A. A. Long, University of California, Berkeley -/- This series, which is modelled on the familiar Clarendon Aristotle and Clarendon Plato Series, is designed to encourage philosophers and students of philosophy to explore the fertile terrain of later ancient philosophy. The texts will range in date from the first century BC to the fifth century AD, and they will cover all the parts and all the (...) schools of philosophy. Each volume will contain a substantial introduction, an English translation, and a critical commentary on the philosophical claims and arguments of the text. The translations will aim primarily at accuracy and fidelity; but they will also be readable and accompanied by notes on textual problems that affect the philosophical interpretation. No knowledge of Greek or Latin will be assumed. -/- Galen's On the Therapeutic Method, written late in his life, represents the distillation in its most complete form of Galen's views on the nature, genesis, proper classification, and treatment of disease. It was one of the most widely read of all classical texts during the Middle Ages and the Renaissance, and formed the core of the medical curriculum until the seventeenth century. Although still deeply influential in the nineteenth century, it has been unjustly neglected in modern times. The work contains a fascinating collection of views on scientific terminology and taxonomy, the application of the logical methods of collection and division to science, the axiomatization of science, and the structure of causation. Consequently it is a key text in later Greek philosophy of science. -/- R. J. Hankinson provides here the first translation into any modern language of the first two books, together with an introduction and a philosophical commentary. (shrink)

In recent years, an increasing number of medical books and papers attempting to analyse the concepts of health and disease from the perspective of evolutionary biology have been published (Eaton etal., 1993; Ewald, 1993; Harrison, 1993; Nesse and Williams, 1995; Profet, 1991; Rose, 1991; Temple and Burkitt, 1994). This paper introduces the evolutionary approach to health and disease in an attempt to illuminate the premisses and the framework of Darwinian medicine. My primary aim is to analyse to what extent evolutionary (...) theory provides for a biological definition of the concept of disease. This analysis reveals some important differences between functional explanations in the field of evolutionary biology and functional explanations in the field of medicine. Moreover, I shall argue that the biological functions relevant to the health of an organism cannot be determined on the basis of evolutionary theory. Accordingly, it seems that Darwinian medicine does not provide for the definition of a biological concept of disease. Still,Darwinian medicine may suggest why we are susceptible to certain diseases; it might also prove a suggestive heuristic on the basis of which new hypotheses concerning relevant treatments of various diseases might be advanced. (shrink)

This essay examines historical and contemporary connections between Buddhist and medical traditions through a study of the Accomplishing Medicine ( sman sgrub ) practice and the Yuthok Heart Essence ( G.yu thog snying thig ) anthology. Accomplishing Medicine is an esoteric Buddhist yogic and contemplative exercise focused on several levels of “alchemical” transformation. The article will trace the acquisition of this practice from India by Tibetan medical figures and its assimilation into medical practice. It will propose that this alchemical practice (...) forms the central nexus of connection between Tibetan medicine and the Buddhist Nyingma tradition, and that this little-studied link is not a marginal feature of Tibetan medicine but rather one that has had a significant shaping factor on each tradition throughout history. (shrink)

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 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)

Causality in 19th and Early 20th Century Medicine 3 A Lakatosian Approach to the History of Medicine.