“Inventing AIDS.” “Constructing cancers.” Relax; no bioterrorist mischief is implied. Like “Construction of nature,” “Social construction of illness,” “Social construction of scientific facts,” and many others, these are titles of scholarly books and projects in science, technology, and medicine studies. They express a fashion shared by doctrines loosely known under the rubric of postmodernism. It is recognizable by the frequent scare quotation marks around words such as truth, reality, scientific, and objectivity. The scare quotes convey the message that scientific knowledge (...) is so permeated by politics and cultural biases that it cannot be true and any claim to objectivity is illusory. (shrink)

From the sixties on it has become clear how the human physical condition could be influenced by human behavior. Although hypothesis were lacking to understand these connections, nursing research especially proved how systematically introduced patient behavior during illness and hospitalization could induce better recovery results and better prognosis for the patient.Information andattitude proved to be crucial elements in these processes of improved patient expectations. It took less than two decades to get to the insights we have in 1994. Recent research (...) shows the interlocking mechanisms of nervous and endocrine systems with the immune system as significantly being influenced by behavior and especially psychic and or psychosocial stress.This special issue of Theoretical Medicine briefly describes the historical development with contributions on the most recent state of the scientific art. These developments are emphasized by discussion on the clinical reality of the (breast) cancer patient and recent findings on the complexity of the prevalence of cancer in epidemiology. An attempt is made to consider practical consequences of the actual knowledge if applied to patient care. (shrink)

Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry of authority, power (...) and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care. Keywords: argumentation theory, informed consent, doctor-patient interaction, competency to consent, autonomy, medical paternalism. (shrink)

There has been a great deal of discussion, in this journal and others, about obstacles hindering the evolution of the philosophy of medicine. Such discussions presuppose that there is widespread agreement about what it is that constitutes the philosophy of medicine.Despite the fact that there is, and has been for decades, a great deal of literature, teaching and professional activity carried out explicitly in the name of the philosophy of medicine, this is not enough to establish that consensus exists as (...) to the definition of the field. And even if consensus can be obtained as to what constitutes the philosophy of medicine, this does not mean that it exists as a field. (shrink)

While classifications of mental disorders have existed for over one hundred years, it still remains unspecified what terms such as 'mental disorder', 'disease' and 'illness' might actually denote. While ontologies have been called in aid to address this shortfall since the GALEN project of the early 1990s, most attempts thus far have sought to provide a formal description of the structure of some pre-existing terminology or classification, rather than of the corresponding structures and processes on the side of the patient. (...) We here present a view of mental disease that is based on ontological realism and which follows the principles embodied in Basic Formal Ontology (BFO) and in the application of BFO in the Ontology of General Medical Science (OGMS). We analyzed statements about what counts as a mental disease provided (1) in the research agenda for the DSM-V, and (2) in Pies' model. The results were used to assess whether the representational units of BFO and OGMS were adequate as foundations for a formal representation of the entities in reality that these statements attempt to describe. We then analyzed the representational units specific to mental disease and provided corresponding definitions. Our key contributions lie in the identification of confusions and conflations in the existing terminology of mental disease and in providing what we believe is a framework for the sort of clear and unambiguous reference to entities on the side of the patient that is needed in order to avoid these confusions in the future. (shrink)

We performed a qualitative analysis of the Thesaurus in order to assess its conformity with principles of good practice in terminology and ontology design. We used both the on-line browsable version of the Thesaurus and its OWL-representation (version 04.08b, released on August 2, 2004), measuring each in light of the requirements put forward in relevant ISO terminology standards and in light of ontological principles advanced in the recent literature. Version 04.08b of the NCI Thesaurus suffers from the same broad range (...) of problems that have been observed in other biomedical terminologies. For its further development, we recommend the use of a more principled approach that allows the Thesaurus to be tested not just for internal consistency but also for its degree of correspondence to that part of reality which it is designed to represent. (shrink)

According to M. W. Service (1978), prior to Patrick Manson’s (1844–1922) discovery in 1877 that the mosquito Culex fatigans (Diptera: Culicidae) was the intermediate host of Bancroftian filariasis, the association of insects with disease and the nature of disease transmission was almost entirely speculation. As biographers P. H. Manson-Bahr and A. Alcock (1927) put it: “Manson’s investigations were thus the first convincing evidence that the vague beliefs traditional among many untutored races and countenanced from time to time by a few (...) sagacious medical men—beliefs that various specific diseases of the blood are disseminated by bloodsucking insects—were of good pathological report and worthy of further thought” .. (shrink)

In this paper, I offer one example of conceptual change. Specifically, I contend that the discovery that viruses could cause cancer represents an excellent example of branch jumping, one of Thagard’s nine forms of conceptual change. Prior to about 1960, cancer was generally regarded as a degenerative, chronic, non-infectious disease. Cancer causation was therefore usually held to be a gradual process of accumulating cellular damage, caused by relatively non-specific component causes, acting over long periods of time. Viral infections, on the (...) other hand, were generally understood to be acute processes, whereby single, specific and necessary causal agents acted alone to produce disease. However, during the 1960s and 1970s, a number of cancers were discovered to have an infectious aetiology. Of particular note were two—Burkitt’s lymphoma and cervical cancer—which I will discuss in detail later in this piece. Together, these discoveries led, in the short term, to a tentative aetiological reclassification of some types of cancer as infectious diseases and, in the longer term, to a full-blown reclassification of cancer as an aetiological disease branch in its own right. This process of reclassification forms the empirical basis for my concluding remarks on the influence of classification upon causation in medicine. Through this, I aim to demonstrate that conceptual change, far from being a purely abstract concern of the philosopher of science, is of substantial import to scientific practitioners. (shrink)

In this thesis, I give a metascientific account of causality in medicine. I begin with two historical cases of causal discovery. These are the discovery of the causation of Burkitt’s lymphoma by the Epstein-Barr virus, and of the various viral causes suggested for cervical cancer. These historical cases then support a philosophical discussion of causality in medicine. This begins with an introduction to the Russo- Williamson thesis (RWT), and discussion of a range of counter-arguments against it. Despite these, I argue (...) that the RWT is historically workable, given a small number of modifications. I then expand Russo and Williamson’s account. I first develop their suggestion that causal relationships in medicine require some kind of evidence of mechanism. I begin with a number of accounts of mechanisms and produce a range of consensus features of them. I then develop this consensus position by reference to the two historical case studies with an eye to their operational competence. In particular, I suggest that it is mechanistic models and their representations which we are concerned with in medicine, rather than the mechanism as it exists in the world. -/- I then employ these mechanistic models to give an account of the sorts of evidence used in formulating and evaluating causal claims. Again, I use the two human viral oncogenesis cases to give this account. I characterise and distinguish evidence of mechanism from evidence of difference-making, and relate this to mechanistic models. I then suggest the relationship between types of evidence presents us with a means of tackling the reference-class problem. This sets the scene for the final chapter. Here, I suggest the manner in which these two different classes of evidence become integrated is also reflected in the way that developing research programmes change as their associated causal claims develop. (shrink)

Periodic attacks of uncertain origin, where the clinical presentationresembles epilepsy but there is no evidence of a somatic disease, arecalled Pseudo-Epilepsy or Pseudo-Epileptic Attack Disorder (PEAD). PEADmay be called a `non-disease', i.e. a disorder on the fringes ofestablished disease patterns, because it lacks a rationalpathophysiological explanation. The first aim of this article is tocriticize the idea, common in medical science, that diseases are realentities which exist separately from the patient, waiting to bediscovered by the doctor. We argue that doctor and (...) patient construct adisease, and that the construction of the disease PEAD includes manynormative evaluations. The second aim is to provide insight into thesuffering of patients with PEAD. We focus on three aspects of thepatient, identity, autonomy and responsibility. We present somecharacteristic descriptions of (pseudo-)epileptic attacks by FjodorDostoevsky, Gustave Flaubert and Thomas Mann. We argue that diagnosingPEAD reduces a meaningful life event into an insignificant, thoughintriguing, medical phenomenon, and that the patient will not benefitfrom being diagnosed as having PEAD. (shrink)

In this paper I discuss a central objection against diseases being natural kinds—namely, that diseases are processes or transitions and hence they should not be conceptualized in the ‘substantish’ framework of natural kinds. I indicate that the objection hinges on conceiving disease kinds as phase kinds, in contrast to the non-phase, natural kinds of the exact sciences. I focus on somatic diseases and argue, via a representative comparison, that if disease kinds are phase kinds, then exact science kinds are phase (...) kinds as well. On the other hand, if exact science kinds are non-phase kinds, then disease kinds are non-phase kinds as well. This objection should thus be rejected, under a certain caveat, though. If natural kind membership has an influence over the diachronic identity of kind members, then it is possible, in principle, to draw the phase/non-phase distinction such that an ‘ontological gap’ lies between medical kinds and exact science kinds. I show further that this caveat is unavoidable even in relation to substantive universals and ‘essential’ properties—two controversial, strong features that were traditionally associated to natural kinds. (shrink)

In this paper, I focus on life-threatening medical conditions and argue that from the point of view of natural properties, induction(s), and participation in laws, at least some of the ill organisms dealt with in somatic medicine form natural kinds in the same sense in which the kinds in the exact sciences are thought of as natural. By way of comparing two ‘divisions of nature’, viz., a ‘classical’ exact science kind (gold) and a kind of disease (Graves disease), I show (...) that there is no justifiable ‘ontological gap’ between disease kinds and exact sciences kinds. We have instead a difference of degree. (shrink)

This paper examines today's received scientific medical model with respect to its ability to satisfy two conditions: (1) its explanatory adequacy relative to the full range of findings in the medical literature, including those indicating a correlation between psychosocial variables and disease susceptibility; and (2) the fit between its physicalist patient and disease concepts and what today's basic sciences, so-called sciences of complexity, tell us about the way matter, notably complex systems (e.g. patients), behave and the nature of scientific explanation. (...) I conclude that the received (biomedical) model falls short on both counts and to satisfy these conditions is to articulate a formal successor model. This successor must be guided by premises consistent with the findings and methods of today's basic sciences on which an applied science like medicine depends for its validity. Additionally, the successor model must be able to explain (and predict) the full range of clinical findings, both those that its predecessors explains and at least some of those that it does not. The aim of the paper is to identify such a model. (shrink)

The basic premise of today's scientific medicine is that the ‘book of man’ is written in the language of the biological sciences, ultimately molecular genetics and biochemistry. The patient is a complex biological organism and disease is a deviation from the norm of somatic parameters. At the same time, many major contemporary diseases are reported to have psychosocial and environmental components in their etiology. Hence the challenge: how can a medical model be both scientific and conceptually well-suited to today's disease (...) burden? I argue that certain contemporary "postmodern" sciences support alternative, non-reductionist (self-organizational) premises. So doing, they offer an infrastructure for a medical model at once scientific and responsive to the diseases at hand. Keywords: biomedicine (biological medicine), natural science paradigm, Cartesian dualism, self-organization, postmodern sciences, self-referentiality CiteULike Connotea Del.icio.us What's this? (shrink)

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase ‘‘quality of care’’ is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on its ability to improve (...) quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of ‘‘quality of care’’ are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, ‘‘quality of care,’’ in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that ‘‘quality of care’’ operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system. (shrink)

In Britain before 1911, the vast majority of the population provided medical care for themselves and had evolved a variety of schemes that checked the power of organized medicine and encouraged a steady improvement in standards. The evidence is that at the end of the nineteenth century about 5?6 percent of the population relied on the poor law, 10?15 percent on free care from charitable institutions, 75 percent on mutual aid, and the remainder paid fees to private doctors.

Taking the visual appeal of the ‘bell curve’ as an example, this paper discusses in how far the availability of quantitative approaches (here: statistics) that comes along with representational standards immediately affects qualitative concepts of scientific reasoning (here: normality). Within the realm of this paper I shall focus on the relationship between normality, as defined by scientific enterprise, and normativity, that result out of the very processes of standardisation itself. Two hypotheses are guiding this analysis: (1) normality, as it is (...) defined by the natural and the life sciences, must be regarded as an ontological, but epistemological important fiction and (2) standardised, canonical visualisations (such as the ‘bell curve’) impact on scientific thinking and reasoning to a significant degree. I restrict my analysis to the epistemological function of scientific representations of data: This means identifying key strategies of producing graphs and images in scientific practice. As a starting point, it is crucial to evaluate to what degree graphs and images could be seen as guiding scientific reasoning itself, for instance in attributing to them a certain epistemological function within a given field of research. (shrink)

Academic physicians and bioethicists are increasingly voicing objections to “drug rep” detailing. Leaders in academic medical centers are considering proposals to ban the small gifts of detailing within their walls. Such bans would be a mistake, as the small gifts are unlikely to act as bribes and do not create unacceptable conflicts of interest for physicians. Drug rep detailing does influence physician behavior, but this influence has not been shown to be harmful. Calls for a ban are premised on empirical (...) evidence for harm that is inconclusive at best, and emerging literature in economics suggests that detailing may well be socially beneficial. A preponderance of harm over benefit is not, however, the primary source of the animus against detailing, which stems from moral considerations that are independent of its social consequences. However, pharmaceutical advertising, including detailing, is a morally legitimate aspect of the world of medical practice that we in academic medicine ought to be preparing our trainees to encounter and properly sift. (shrink)

It is argued that medical science requires a classificatory system that (a) puts functions in the taxonomic center and (b) does justice ontologically to the difference between the processes which are the realizations of functions and the objects which are their bearers. We propose formulae for constructing such a system and describe some of its benefits. The arguments are general enough to be of interest to all the life sciences.

The paper discusses the evolving concept of causationin epidemiology and its potential interaction with logic and scientific philosophy. Causes arecontingent but the necessity which binds them totheir effects relies on contrary-to-fact conditionals,i.e. conditional statements whose antecedent is false.Chance instead of determinism plays a growing role inscience and, although rarely acknowledged yet, inepidemiology: causes are multiple and chancy; a priorevent causes a subsequent event if the probabilitydistribution of the subsequent event changesconditionally upon the probability of the prior event.

Many physicians assert that new cost-control mechanisms inappropriately interfere with clinical decision-making. They claim that high costs arise from poorly practiced medicine, and argue that effective utilization of resources is best promoted by advancing the scientific and ethical ideals of medicine. However, the claim is not warranted by empirical evidence. In this essay, I show how it rests upon aesthetic considerations associated with diagnostic elegance. I first consider scientific rationality generally. After a review of analytical empiricist and socio-historical approaches in (...) the philosophy of science, a form of Kant's aesthetic is used to explain how scientific discovery and justification are linked, and to show how meta-theoretical considerations associated with the goals and method of science work together with exemplars of practice. This analysis enables us to understand how the ideals of medicine as a science guide the initial patient history and physical exam in such a way that a parsimonious use of tests is indicated. Aesthetic considerations unite the basic scientific and ethical commitments of the modern medical paradigm and are central for rightly understanding clinical judgment. (shrink)

An explicit formal-ontological representation of entities existing at multiple levels of granularity is an urgent requirement for biomedical information processing. We discuss some fundamental principles which can form a basis for such a representation. We also comment on some of the implicit treatments of granularity in currently available ontologies and terminologies (GO, FMA, SNOMED CT).

We provide a methodology for the creation of ontological partitions in biomedicine and we test the methodology via an application to the phenomenon of blood pressure. An ontology of blood pressure must do justice to the complex networks of intersecting pathways in the organism by which blood pressure is regulated. To this end it must deal not only with the anatomical structures and physiological processes involved in such regulation but also with the relations between these at different levels of granularity. (...) For this purpose our ontology offers a variety of distinct partitions – of substances, processes and functions – and integrates these together within a single framework via transitive networks of part-whole and dependence relations among the entities in each of these categories. The paper concludes with a comparison of this methodology with the approaches of GOTM, KEGG, DIP and BIND and provides an outline of how the methodology is currently being applied in the field of biomedical database integration. (shrink)

The Unified Medical Language System and the Gene Ontology are among the most widely used terminology resources in the biomedical domain. However, when we evaluate them in the light of simple principles for wellconstructed ontologies we find a number of characteristic inadequacies. Employing the theory of granular partitions, a new approach to the understanding of ontologies and of the relationships ontologies bear to instances in reality, we provide an application of this theory in relation to an example drawn from the (...) context of the pathophysiology of hypertension. This exercise is designed to demonstrate how, by taking ontological principles into account we can create more realistic biomedical ontologies which will also bring advantages in terms of efficiency and robustness of associated software applications. (shrink)

The notion of competence in A Philosophical Basis of Medcial Practice presents a problem concerning the ontology of the body. This paper will maintain that an ontology of the body can only be based upon Cartesian grounds whereby the scientific knowable order is supposed to be identical to the natural order of things. Moral questions are not a part of this order and depend upon free will. Foucault has demonstrated that such a dualism between nature and morality cannot be warranted (...) for contemporary medical practice. Medical science does not derive its foundation from a natural order but from the order of knowing which is present in the body of knowledge (episteme). This body of knowledge is the significative cultural force in the way of looking at problems of disease, life and death. Thus in contemporary medical practice, concepts of morality and competence which are based on notions of free will, shall be discarded as non-sensical, even for the patient. (shrink)

According to the ‘fact-plus-value’ model of pathology propounded by K. W. M. Fulford, ‘disease’ is a value term that ought to reflect a ‘balance of values’ stemming from patients and doctors and other ‘stakeholders’ in medical nosology. In the present article I take issue with his linguistic-analytical arguments for why pathological status must be relative to such a kind of medico-ethical normativity. Fulford is right to point out that Boorse and other naturalists are compelled to utilize evaluative terminology when they (...) characterize the nature of diseases and biological dysfunctions. But the relevant ‘biofunctional judgements’ are no less factual and empirical for that. While it is indeed evaluative to say that biological dysfunctions involve failures to execute naturally selected functions, such judgments are not bound to entail anything about what is good or bad for us, and what should be treated or not. In the last part of the paper I ruminate briefly on the relationship between ‘biological evaluationism’, on my construal, and descriptions of ‘causal biology’. As I note in my conclusion, a strict bioevaluative concept of disease can be valid for every species on earth, and thus be of particular usefulness in general biological contexts. (shrink)

This paper argues that our modern concept of biological heredity was first clearly introduced in a theoretical and practical setting by the generation of French physicians that were active between 1810 and 1830. It describes how from a traditional focus on hereditary transmission of disease, influential French medical men like Esquirol, Fodéré, Piorry, Lévy, moved towards considering heredity a central concept for the conception of the human bodily frame, and its set of physical and moral dispositions. The notion of heredity (...) as a natural force, with a wide ranging capabilities of transmitting differentially both fundamental and accidental characters was generalized by that generation of physicians with the help of contemporary naturalists and physiologists. By 1830 the term hérédité was widespread, and it shared the explanatory and semantic qualities of traditional medical concepts like constitution and temperament. An analysis is given of the main developments that led to the conception of biological (including human) bodies as consisting of a layered, hierarchical organization of characters, differentially affected by the laws of conservation (Heredity) and change (Inneity, Variation). The mid-century work of the French physician Prosper Lucas, Traité Philosophique et Physiologique de L'Hérédité Naturelle, is shown to be the culmination of the efforts of several generations of French physicians towards having a feasible, complexly structured notion of how heredity works. (shrink)

These are the working notes of the workshop on Model-based and Qualitative Reasoning in Biomedicine, which was held during the European Conference on Artificial Intelligence in Medicine, AIME’03, on 19th October, 2003, in Protaras, Cyprus. The workshop brought together various researchers involved in the development and use of model-based and qualitative reasoning methods in tackling biomedical problems. Much of the biomedical knowledge is essentially model-based, as it is the understanding of the structure and function of biomedical systems that researchers wish (...) to achieve, and this is best done by developing models of these systems. In situations where it may not be appropriate or possible to use quantitative methods, researchers use qualitative approaches. Depending on the biomedical problem concerned, such descriptions may involve causal, temporal and spatial knowledge, possibly of an uncertain nature. Also in the medical management of disorders in patients, qualitative and model-based approaches are being used. For example, systems used for diagnosing disease rely on explicit models of normal or abnormal structure and behaviour (often referred to as ’first-principles models’) of the underlying disease process. Qualitative knowledge plays a role in the modelling of disease and treatment processes, including the handling of the uncertainty involved in these processes. Hence, there is little doubt that model-based and qualitative methods fit the biomedical domain really well. However, one of the problems with research in the biomedical field is that researchers applying model-based and qualitative-reasoning methods are often closely linked to their application field, such as, for example, cell biology or clinical medicine, and find it difficult to keep in contact with colleagues doing similar research, but working in a different biomedical application field. This is even more difficult if the techniques used are also different. For example, researchers involved in Bayesian network research and researchers using qualitative simulation methods hardly exchange views and ideas, despite the fact that their methods have in common that they emphasise representing qualitative biomedical knowledge. It was the aim of this workshop to bring together researchers along the entire spectrum of the biomedical field, from health-care research and clinical medicine to human biology, using a variety of methods and techniques, from (qualitative) Bayesian networks and symbolic machine learning, to qualitative simulation.. (shrink)

Medicine maintains a distinction between the medical symptom -- the patient''ssubjective experience and expression, and the privileged medical sign -- the objective findings observable by the doctor. Although the distinction is not consistently applied, it becomes clearly visible in the undefined, medically unexplained disorders of women patients. Potential impacts of genderized interaction on the interpretation of medical signs are addressed by re-reading the diagnostic process as a matter of social construction, where diagnosis results from human interpretation within a sociopolitical context. (...) The discussion is illustrated by a case story and empirical evidence of the gendering in the doctor-patient relationship. The theoretical analysis is supported by semiotic perspectives of bodily signs, feminist theory on experience, and Foucault''sideas about medical perception and gaze, and concludes that a medical diagnosis is seldom a biological fact, but the outcome of a process where biological, cultural and social elements are interwoven. Further deconstruction of the chain of signs from a feminist perspective, assigning validity to the voice of the woman patient, might broaden the understanding of women''shealth, illness and disease. (shrink)

Culver and Gert define ‘malady’ in their book Philosophy in Medicine . It is shown that this definition is sexist in its implication in that it either indirectly contributes to women's oppression or indirectly supports a policy that discriminates against women. This is because, on Culver and Gert's definition of ‘malady’, menopause, menstruation, and pregnancy become maladies. It is also argued that malady claims are normative in a way not recognized by Culver and Gert. Keywords: malady and/or disease, menopause, sexism, (...) definition, menstruation, pregnancy CiteULike Connotea Del.icio.us What's this? (shrink)

Contemporary medicine, it is argued here, employs reductive explanations, but at the same time resists wholesale reduction to ‘deeper’ biochemical and physical fields or theories. In its own reductive explanations, to be sure, medicine borrows causal concepts from other fields and so necessarily shares certain explanatory goals with those deeper fields. However, because medicine has additional, distinctive goals as well as a special subject matter and problems (it is a practical science), the field of medicine is ultimately irreducible.

Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, the (...) project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety. (shrink)

If a transformation in medicine occurs in the wake of the Human Genome Project, its likely focus will be prevention, a logical extension of the lessons of variation and individuality inherent in molecular genetics. The transformation of medicine will require a transformation in genetics education as well, focusing on the development of genetic literacy that allows patient and provider to collaborate as partners in health promotion and disease prevention. The components of genetic literacy include new views of genetics and of (...) disease, and attention to the nature of science, the principles of technology, and ethical, legal, and social implications of genetic medicine. (shrink)

A broad range of evidence regarding the functional organization of the vertebrate brain – spanning from comparative neurology to experimental psychology and neurophysiology to clinical data – is reviewed for its bearing on conceptions of the neural organization of consciousness. A novel principle relating target selection, action selection, and motivation to one another, as a means to optimize integration for action in real time, is introduced. With its help, the principal macrosystems of the vertebrate brain can be seen to form (...) a centralized functional design in which an upper brain stem system organized for conscious function performs a penultimate step in action control. This upper brain stem system retained a key role throughout the evolutionary process by which an expanding forebrain – culminating in the cerebral cortex of mammals – came to serve as a medium for the elaboration of conscious contents. This highly conserved upper brainstem system, which extends from the roof of the midbrain to the basal diencephalon, integrates the massively parallel and distributed information capacity of the cerebral hemispheres into the limited-capacity, sequential mode of operation required for coherent behavior. It maintains special connective relations with cortical territories implicated in attentional and conscious functions, but is not rendered nonfunctional in the absence of cortical input. This helps explain the purposive, goal-directed behavior exhibited by mammals after experimental decortication, as well as the evidence that children born without a cortex are conscious. Taken together these circumstances suggest that brainstem mechanisms are integral to the constitution of the conscious state, and that an adequate account of neural mechanisms of conscious function cannot be confined to the thalamocortical complex alone. (Published Online May 1 2007) Key Words: action selection; anencephaly; central decision making; consciousness; control architectures; hydranencephaly; macrosystems; motivation; target selection; zona incerta. (shrink)

It has been demonstrated that death certificates do not accurately record the actual cause of death in up to one-fourth of cases, as determined from subsequent autopsy findings. The purpose of this study was to explore the use of natural language autopsy data bases as an automated quality assurance mechanism. We translated the account of the major process leading to death, or the primary diagnosis, from all 45,564 narrative autopsy reports obtained at The Johns Hopkins Hospital between May 28, 1889, (...) and June 30, 1987, into the hierarchical system of Medical Subject Heading (MeSH) titles. We obtained a total of 125,772 MeSH title translations, 1,563 of them distinct (average 2.8 per case), ranging in frequency from 6,029 occurrences of LUNG to 1 occurrence apiece of 357 MeSH titles. The natural-language-to-MeSH translations showed expected trends over the past century: fewer infectious diseases; more cardiovascular and neoplastic disease among adults; and more respiratory diseases and congenital malformations in the pediatric age group. The greater availability of autopsy documents in electronic form should increase the value of this resource for quality assurance. (shrink)

In light of the human genome project, establishing the genetic aetiology of complex human diseases has become a research priority within Western medicine. However, in addition to the identification of disease genes, numerous research projects are also being undertaken to identify genes contributing to the development of human behavioural characteristics, such as cognitive ability and criminal tendency. The permissibility of this research is obviously controversial: will society benefit from this research, or will it adversely affect our conceptions of ourselves and (...) each other? When assessing the permissibility of this research, it is important to consider the nature and deterministic significance of behavioural genetic information. Whilst todate there has been much discussion and debate about the properties of genetic information per se and genetic determinism, this has not been applied to behavioural genetic research and its ethical implications. Therefore, this paper elucidates how behavioural genetic information can be distinguished from other types of genetic and non-genetic information and also synthesises the determinative significance of genetic factors for the development of human behavioural traits. Undertaking this analysis enables the ethical issues raised by this research to be debated in an appropriate context and indicates that separate policy considerations are warranted. (shrink)

The challenges posed by chronic illness have pointed out to epidemiologists the multifactorial complex nature of disease causality. This notion has been referred to as a web of causality. This web extends theoretically beyond risk markers. It includes determinants of emergence/non-emergence of disease. This web of determinants is a form of complex system. Due to its complexity, the determinants within such system are not linked to each others in a linear, predictable manner only. Predictability is possible only on a short-term (...) basis, and unpredictability sets in over the long run. Understanding such a system of determinants calls for articulation and testing of complex models which synthesize our knowledge of multiple determinants at many scales, both biological and otherwise. Given the complexity of this web and existing knowledge about the nonlinearity of such systems, the following question is posed: Can the challenge of studying causality be adequately addressed if emphasis continues to be placed on using tools and methods that are geared towards looking at such system from a linear paradigm? Or is it time to add to the epidemiologic research agenda the notion of nonlinearity and its relevant form of analytical approaches that are being tested in other disciplines? Furthermore, the question posed here applies as well to the study of determinants of health. Addressing determinants of heath adds further complexity to our task. (shrink)

A common worry about the genetic engineering of human beings is that it will reduce human genetic diversity, creating a biological monoculture that could not only increase our susceptibility to disease but also hasten the extinction of our species. Thus far, however, the evolutionary implications of human genetic modification remain largely unexplored. In this paper, I consider whether the widespread use of genetic engineering technology is likely to narrow the present range of genetic variation, and if so, whether this would (...) in fact lead to the evolutionary harms that some authors envision. By examining the nature of biological variation and its relation to population immunity and evolvability, I show that not only will genetic engineering have a negligible impact on human genetic diversity, but also that it will be more likely to ensure rather than undermine the health and longevity of the human species. (shrink)

Patients with persistent pain who lack adetectable underlying disease challenge thetheories supporting much of biomedicalbody-mind discourse. In this context,diagnostic labeling is as inherently vulnerableto the same pitfalls of uncertainty that besetany other interpretative endeavour. The endpoint is often no more than a name ratherthan the discovered essence of a pre-existentmedical condition. In 1990 a Committee of theAmerican College of Rheumatology (ACR)formulated the construct of Fibromyalgia in anattempt to rectify a situation of diagnosticconfusion faced by patients presenting withwidespread pain. It was (...) proposed thatFibromyalgia existed as a ``specific entity'',separable from but curiously able to co-existwith any other painful condition. Epistemological and semiotic analyses ofFibromyalgia have failed to find any sign,clinical or linguistic, which coulddifferentiate it from other diffusemusculoskeletal pain states. The construct ofFibromyalgia sought to define a discernablereality outside the play of language and topass it off as a natural phenomenon. However,because it has failed both clinically andsemiotically, the construct also fails the testof medical utility for the subject inpersistent pain. (shrink)

IntroductionThose in mental health-related consumer movements have made clear their demands for humane treatment and basic civil rights, an end to stigma and discrimination, and a chance to participate in their own recovery. But theorizing about the politics of recognition, 'recognition rights' and epistemic justice, suggests that they also have a stake in the broad cultural meanings associated with conceptions of mental health and illness.ResultsFirst person accounts of psychiatric diagnosis and mental health care (shown here to represent 'counter stories' to (...) the powerful 'master narrative' of biomedical psychiatry), offer indications about how experiences of mental disorder might be reframed and redefined as part of efforts to acknowledge and honor recognition rights and epistemic justice. However, the task of cultural semantics is one for the entire culture, not merely consumers. These new meanings must be negotiated. When they are not the result of negotiation, group-wrought definitions risk imposing a revision no less constraining than the mis-recognizing one it aims to replace. Contested realities make this a challenging task when it comes to cultural meanings about mental disorder. Examples from mental illness memoirs about two contested realities related to psychosis are examined here: the meaninglessness of symptoms, and the role of insight into illness. They show the magnitude of the challenge involved - for consumers, practitioners, and the general public - in the reconstruction of these new meanings and realities.ConclusionTo honor recognition rights and epistemic justice acknowledgement must be made of the heterogeneity of the effects of, and of responses to, psychiatric diagnosis and care, and the extent of the challenge of the reconstructive cultural semantics involved. (shrink)

I argued that a value-free account of our concept of <span class='Hi'>disease</span> cannot be given. Part of this argument consisted in showing that diseases as a class do not constitute a natural kind. To understand this, we need only see that we define and classify conditions into diseases and non-diseases not in terms of their causes but in terms of their effects. While no philosophical position is watertight, the arguments overwhelmingly favour the conclusion that diseases do not constitute a natural (...) kind. Keywords: <span class='Hi'>Disease</span>, natural kind, value-laden CiteULike Connotea Del.icio.us What's this? (shrink)

Public health involves the application of a wide variety of scientific and non-scientific disciplines to the very practical problems of improving population health and preventing disease. Public health has received surprisingly little attention from philosophers of science. In this chapter we consider some neglected but important philosophical aspects of the science of public health.

The integration of biomedical terminologies is indispensable to the process of information integration. When terminologies are linked merely through the alignment of their leaf terms, however, differences in context and ontological structure are ignored. Making use of the SNAP and SPAN ontologies, we show how three reference domain ontologies can be integrated at a higher level, through what we shall call the OBR framework (for: Ontology of Biomedical Reality). OBR is designed to facilitate inference across the boundaries of domain ontologies (...) in anatomy, physiology and pathology. (shrink)

The paper addresses the question of how different types of evidence ought to inform public health policy. By analysing case studies on obesity, the paper draws lessons about the different roles that different types of evidence play in setting up public health policies. More specifically, it is argued that evidence of difference-making supports considerations about ‘what works for whom in what circumstances’, and that evidence of mechanisms provides information about the ‘causal pathways’ to intervene upon.

The paper examines definitions of ‘cause’ in the epidemiological literature. Those definitions all describe causes as factors that make a difference to the distribution of disease or to individual health status. In the philosophical jargon, causes in epidemiology are difference-makers. Two claims are defended. First, it is argued that those definitions underpin an epistemology and a methodology that hinge upon the notion of variation, contra the dominant Humean paradigm according to which we infer causality from regularity. Second, despite the fact (...) that causes be defined in terms of ‘difference-making’, this cannot fixes the causal metaphysics. Causality in epidemiology ought to be interpreted according to the epistemic theory. In this approach relations are deemed causal depending on the evidence and on the available methods. Indeed, evidence to establish causal claims requires difference-making considerations; furthermore, those definitions of cause reflect the ‘variational’ epistemology and methodology of epidemiology. (shrink)

Tobacco, divine, rare superexcellent tobacco, which goes far beyond all panaceas, potable gold and philosopher's stones, a sovereign remedy to all diseases.Although most of the toxicity, including cancerogenicity, of tobacco is related to a mix of components other than nicotine present in cigarettes (U.S. Surgeon General 2010), it is indeed nicotine that causes addiction to smoking (Benowitz 2010; Russo et al. 2011).In 1988, the U.S. Surgeon General's Report concluded that cigarettes and other forms of tobacco are addictive as a result (...) of their nicotine content, and that the processes determining tobacco addiction "are similar to those that determine addiction to drugs such as heroin and cocaine." Previously, in .. (shrink)

Doctors and dentists have traditionally used antibiotic prophylaxis in certain patient groups in order to prevent infective endocarditis (IE). New guidelines, however, suggest that the risk to patients from using antibiotics is higher than the risk from IE. This paper analyses the relative risks of prescribing and not prescribing antibiotic prophylaxis against the background of Pascal’s Wager, the infamous assertion that it is better to believe in God regardless of evidence, because of the prospective benefits should He exist. Many doctors (...) seem to believe the parallel proposition that it is better to prescribe antibiotics, regardless of evidence, because of the prospective benefit conferred upon the patient. This has been called the “no lose philosophy” in medicine: better safe than sorry, even if the evidence inconveniently suggests that following this mantra is potentially more likely to result in sorry than safe. It transpires that, just as Pascal’s Wager fails to convince because of a lack of evidence to support it and the costs incurred by trying to believe, so the “belts and braces” approach of prescribing antibiotic prophylaxis is unjustifiable given the actual evidence of potential risk and benefit to the patient. Ultimately, there is no no-lose if your clinical decisions, like Pascal’s Wager, are based on faith rather than evidence. (shrink)

Rationale One's understanding of medical progress – what it is, how it is pursued and how it is assessed – may be deeply dependent on one's understanding of the metaphysics of medicine, and of diseases in particular. -/- Aims and Objectives In this paper I present a new account of the nature of diseases, neither realist nor constructivist, and describe what progress in medicine looks like if we understand diseases in this way. -/- Conclusions This new account, Constructive Realism, may (...) provide a better account of medicine than either realism or constructivism. (shrink)

The ontology of medicine—the question of whether disease entities are real or not—is an underdeveloped area of philosophical inquiry. This essay explains the primary question at issue in medical ontology, discusses why answering this question is important from both a philosophical and a practical perspective, and argues that the problem of medical ontology is unique, i.e., distinct, from the ontological problems raised by other sciences and therefore requires its own analysis.

We present an ontology of pain and of other pain-related phenomena, building on the definition of pain provided by the International Association for the Study of Pain (IASP). Our strategy is to identify an evolutionarily basic canonical pain phenomenon, involving unpleasant sensory and emotional experience based causally in localized tissue damage that is concordant with that experience. We then show how different variant cases of this canonical pain phenomenon can be distinguished, including pain that is elevated relative to peripheral trauma, (...) pain that is caused neuropathically (thus with no necessary peripheral stimulus), and pain reports arising through deception either of self or of others. We describe how our approach can answer some of the objections raised against the IASP definition, and sketch how it can be used to support more sophisticated discrimination of different types of pain resulting in improved data analysis that can help in advancing pain research. (shrink)

It is only by fixing on agreed meanings of terms in biomedical terminologies that we will be in a position to achieve that accumulation and integration of knowledge that is indispensable to progress at the frontiers of biomedicine. Standardly, the goal of fixing meanings is seen as being realized through the alignment of terms on what are called ‘concepts’. Part I addresses three versions of the concept-based approach – by Cimino, by Wüster, and by Campbell and associates – and surveys (...) some of the problems to which they give rise, all of which have to do with a failure to anchor the terms in terminologies to corresponding referents in reality. Part II outlines a new, realist solution to this anchorage problem, which sees terminology construction as being motivated by the goal of alignment not on concepts but on the universals (kinds, types) in reality and thereby also on the corresponding instances (individuals, tokens). We outline the realist approach, and show how on its basis we can provide a benchmark of correctness for terminologies which will at the same time allow a new type of integration of terminologies and electronic health records. We conclude by outlining ways in which the framework thus defined might be exploited for purposes of diagnostic decision-support. (shrink)

Ontology is a burgeoning field, involving researchers from the computer science, philosophy, data and software engineering, logic, linguistics, and terminology domains. Many ontology-related terms with precise meanings in one of these domains have different meanings in others. Our purpose here is to initiate a path towards disambiguation of such terms. We draw primarily on the literature of biomedical informatics, not least because the problems caused by unclear or ambiguous use of terms have been there most thoroughly addressed. We advance a (...) proposal resting on a distinction of three levels too often run together in biomedical ontology research: 1. the level of reality; 2. the level of cognitive representations of this reality; 3. the level of textual and graphical artifacts. We propose a reference terminology for ontology research and development that is designed to serve as common hub into which the several competing disciplinary terminologies can be mapped. We then justify our terminological choices through a critical treatment of the ‘concept orientation’ in biomedical terminology research. (shrink)

When does a human being begin to exist? We argue that it is possible, through a combination of biological fact and philosophical analysis, to provide a definitive answer to this question. We lay down a set of conditions for being a human being, and we determine when, in the course of normal fetal development, these conditions are first satisfied. Issues dealt with along the way include: modes of substance-formation, twinning, the nature of the intra-uterine environment, and the nature of the (...) relation between fetus and mother (connection, parthood, dependence). (shrink)

Current approaches to formal representation in biomedicine are characterized by their focus on either the static or the dynamic aspects of biological reality. We here outline a theory that combines both perspectives and at the same time tackles the by no means trivial issue of their coherent integration. Our position is that a good ontology must be capable of accounting for reality both synchronically (as it exists at a time) and diachronically (as it unfolds through time), but that these are (...) two quite different tasks, whose simultaneous realization is by no means trivial. The paper is structured as follows. We begin by laying out the methodological and philosophical background of our approach. We then summarize the structure and elements of the Basic Formal Ontology on which it rests, in particular the SNAP ontology of objects and the SPAN ontology of processes. Finally, we apply the general framework to the specific domain of biomedicine. (shrink)

Tumors, abscesses, cysts, scars, fractures are familiar types of what we shall call pathological continuant entities. The instances of such types exist always in or on anatomical structures, which thereby become transformed into pathological anatomical structures of corresponding types: a fractured tibia, a blistered thumb, a carcinomatous colon. In previous work on biomedical ontologies we showed how the provision of formal definitions for relations such as is_a, part_of and transformation_of can facilitate the integration of such ontologies in ways which have (...) the potential to support new kinds of automated reasoning. We here extend this approach to the treatment of pathologies, focusing especially on those pathological continuant entities which arise when organs become affected by carcinomas. (shrink)

The Foundational Model of Anatomy (FMA) is a map of the human body. Like maps of other sorts – including the map-like representations we find in familiar anatomical atlases – it is a representation of a certain portion of spatial reality as it exists at a certain (idealized) instant of time. But unlike other maps, the FMA comes in the form of a sophisticated ontology of its objectdomain, comprising some 1.5 million statements of anatomical relations among some 70,000 anatomical kinds. (...) It is further distinguished from other maps in that it represents not some specific portion of spatial reality (say: Leeds in 1996), but rather the generalized or idealized spatial reality associated with a generalized or idealized human being at some generalized or idealized instant of time. It will be our concern in what follows to outline the approach to ontology that is represented by the FMA and to argue that it can serve as the basis for a new type of anatomical information science. We also draw some implications for our understanding of spatial reasoning and spatial ontologies in general. (shrink)

This paper offers four arguments against a moral human right to health, two denying that the right exists and two denying that it would be very useful (even if it did exist). One of my sceptical arguments is familiar, while the other is not.The unfamiliar argument is an argument from the nature of health. Given a realistic view of health production, a dilemma arises for the human right to health. Either a state's moral duty to preserve the health of its (...) citizens is not justifiably aligned in relation to the causes of health or it does not correlate with the human right to health. It follows that no one holds a justified moral human right to health against the state.Education and herd immunity against infectious disease both illustrate this dilemma. In the former case, the state's moral duty correlates with the human right to health only if it demands too much from a cause of health; and in the latter, only if it demands nothing from a cause of health (that is, too little). (shrink)

Philosophers subscribing to particular principles of statistical inference and evidence need to be aware of the limitations and practical consequences of the statistical approach they endorse. The framework proposed (for statistical inference in the field of medicine) allows disparate statistical approaches to emerge in their appropriate context. My dissertation proposes a decision theoretic model, together with methodological guidelines, that provide important considerations for deciding on clinical trial conduct. These considerations do not amount to more stopping rules. Instead, they are principles (...) that address the complexity of interpreting and responding to interim data, based on a broad range of epistemic and ethical factors. While they are not stopping rules, they would assist a Data Monitoring Committee in judging its position with regard to necessary precautionary interpretation of interim data. By vindicating a framework that accommodates a wide range of approaches to statistical inference in one important setting (clinical trials), my results pose a serious challenge for any approach that advocates a single, universal principle of statistical inference. (shrink)

The schematic concept of levels of causal interaction is applied to the relation between genetics and biology. The strength of classical formal genetics lies in its power to proceed directly from observations on an external phenotype, to inferences concerning the nature and properties of the fundamental genetic factors. Its weakness comes from the fact that by short-circuiting the causal chain leading from genotype to phenotype, it creates a divorce between genetics and biology. It is argued that in order to reestablish (...) an articulation of genetics and the biology of whole organisms, it will be necessary to study in detail the entire causal chain leading from a difference in a genetic factor to a difference in a corresponding phenotypic character. This proposal is illustrated by a consideration of multifactorial diseases, which appear to be due to strong interactions between a moderate number of distinct loci; the frequency of abnormal alleles at any given locus may be surprisingly high. (shrink)

The idea that the immune system distinguishes between self and non-self was one of the central assumptions of immunology in the second half of 20th century. This idea influenced experimental design and data interpretation. However, in the face of new evidence there is a need for a new conceptual framework in immunology.

Poor quality medical care is sometimes attributed to physicians’ unwillingness to act on evidence about what works best. Evidence-based performance standards (EBPSs) are one response to this problem, and they are increasingly employed by health care regulators and payers. Evidence in this instance is judged according to the precepts of evidence-based medicine (EBM); it is probabilistic, and the randomized controlled trial (RCT) is the gold standard. This means that EBPSs suffer all the infirmities of EBM generally—well rehearsed problems with the (...) external validity of research findings as well as the inferential leap from study results in the aggregate to individual patient care. These theoretical weaknesses promise to have a practical impact on the care of patients. To avoid this, EBPSs should be understood as guidelines indicative of average effectiveness rather than standards to be applied in every case. (shrink)

My description of the cognitive processes involved in the discovery, development, and acceptance of the bacterial theory of ulcers might have left the impression that science is all in the mind (Thagard, forthcoming-b). But only part of the story of the bacterial theory of ulcers is psychological. This paper discusses the important role of physical interaction with the world by means of instruments and experiments, and the equally important role of social interactions among the medical researchers who developed the theory. (...) The main questions I want to answer are the following: 1. What instruments contributed to the development and acceptance of the new theory? 2. What kinds of experiments contributed to the development and acceptance of the new theory? 3. How did theorizing and experimentation interact in the development of new experiments and hypotheses? 4. How did social processes such as collaboration, communication, and consensus contribute to the development and widespread acceptance of the bacterial theory of ulcers? I conclude with a sketch of science as a complex system of interacting psychological, physical, and social processes. (shrink)

Modern medicine has produced many successful theories concerning the causes of diseases. For example, we know that tuberculosis is caused by the bacterium Mycobacterium tuberculosis, and that scurvy is caused by a deficiency of vitamin C. This chapter discusses the nature of medical theories from the perspective of the philosophy, history, and psychology of science. I will review prominent philosophical accounts of what constitutes a scientific theory, and develop a new account of medical theories as representations of mechanisms that explain (...) disease. An account of the nature of medical theories should illuminate many aspects of the development and application of medical knowledge. Most importantly, it should contribute to understanding of medical explanation, both at the general level of causes of diseases and at the individual level of diagnosis of particular cases of a disease. Medical researchers seek to explain the causes of diseases such as tuberculosis, while physicians seek to identify diseases that explain symptoms such as fever. A medical theory such as the bacterial theory of tuberculosis provides good explanations at both the general and individual levels. The primary aim of this chapter is to show how these explanations work. A secondary aim is to show how an account of medical theories can shed light on other aspects of medical research and practice, including the nature of medical discovery, the process of evaluation of competing medical theories, and the ways in which effective treatments of disease depend on the development of good mechanistic theories about diseases. (shrink)

Biology is the study of life, psychology is the study of mind, and medicine is the investigation of the causes and treatments of disease. This chapter describes how the central concepts of life, mind, and disease have undergone fundamental changes in the past 150 years or so. There has been a progression from theological, to qualitative, to mechanistic explanations of the nature of life, mind and disease. This progression has involved both theoretical change, as new theories with greater explanatory power (...) replaced older ones, and emotional change as the new theories brought reorientation of attitudes toward the nature of life, mind, and disease. After a brief comparison of theological, qualitative, and mechanistic explanations, I will describe how shifts from one kind of explanation to another have carried with them dramatic kinds of conceptual change in the key concepts in the life sciences. Three generalizations follow about the nature of conceptual change in the history of science: there has been a shift from conceptualizations in terms of simple properties to ones in terms of complex relations; conceptual change is theory change; and conceptual change is often emotional as well as cognitive. The contention that historical development proceeds in three stages originated with the nineteenth-century French philosophers, Auguste Comte, who claimed that November 9, 2006 human intellectual development progresses from a theological to a “metaphysical” stage to a “positive” (scientific) stage (Comte, 1988). The stages I have in mind are different from Comte’s, so let me say what they involve. By the theological stage I mean systems of thought in which the primary explanatory entities are supernatural ones beyond the reach of science, such as gods, devils, angels, spirits, and souls. For example, the concept of fire was initially theological, as in the Greek myth of Prometheus receiving fire from the gods.. (shrink)

Epidemiology relies upon a broad interpretation of determinism. This paper discusses analogies with the evolution of the concept of cause in physics, and analyzes the classical nine criteria proposed by Sir Austin Bradford Hill for causal assessment. Such criteria fall into the categories of enumerative induction, eliminative induction, deduction and analogy. All of these four categories are necessary for causal assessment and there is no natural hierarchy among them, although a deductive analysis of the study design is preliminary to any (...) assessment. (shrink)

Systems involving many interacting variables are at the heart of the natural and social sciences. Causal language is pervasive in the analysis of such systems, especially when insight into their behavior is translated into policy decisions. This is exemplified by economics, but to an increasing extent also by biology, due to the advent of sophisticated tools to identify the genetic basis of many diseases. It is argued here that a regularity notion of causality can only be meaningfully defined for systems (...) with linear interactions among their variables. For the vastly more important class of nonlinear systems, no such notion is likely to exist. This thesis is developed with examples of dynamical systems taken mostly from mathematical biology. It is discussed with particular reference to the problem of causal inference in complex genetic systems, systems for which often only statistical characterizations exist. (shrink)

The thought that diseases form natural kinds tends not to sit well with the essentialist treatment of natural kinds. The essentialist’s candidates for the essences of diseases—etiological properties—rarely satisfy the essentialist’s requirement that they be necessary and sufficient for membership within the kind. Consequently philosophers of medicine have tended to back away from treating diseases as natural kinds. However, this retreat was too hasty: there are good reasons for thinking that diseases form natural kinds. The problem lies with the essentialist (...) treatment of natural kinds, and not with treating disease as forming natural kinds. A similar revolution has taken place within the species debate, where the notion of natural kind has been ‘taken back’ from the essentialist. Borrowing the revised treatment of natural kinds from the philosophers of species and modifying it slightly, I offer a proposed treatment of disease kinds in terms of homeostatic property clusters. (shrink)

Epidemiology is a science of disease which specifies rates (illness prevalences, incidences, distributions, etc.). Evolution is a science of life which specifies changes (gene frequencies, generations, forms, function, etc.). Evolutionary Epidemiology is a synthesis of these two sciences which combines the empirical power of classical methods in genetical epidemiology with the interpretive capacities of neo-darwinian evolutionary genetics. In particular, prevalence rates of genetical diseases are important data points when reformulated for the purpose of analysis in terms of their evolutionary frequencies. (...) Traits which exceedprevalences beyond the rates of mutation (in Hardy-Weinberg calculations) or evidence unusualrange of phenotypic reaction are of special interest. This is because traits which did not confer advantages in the environment of evolutionary adaptation cannot accede, through natural selection, to anything but low rates of genomic prevalence.Evolutionary epidemiology is, in all of medicine, of particular promise in ongoing efforts to better understand psychopathology. Many complexities of phenotypic adjustment arise when new developmental demands are placed on an old genome. The new and complex biosocial ecology of human mass society now evokes different phenotypes than those in the prehistorical ecology to which the genome is structurally and functionally better adapted. Some of these new phenotypes are darwinian failures. In this paper, the theoretical implications of evolutionary epidemiology are extended and some tentative points of clinical application (particularly to psychiatry) are offered. (shrink)

The materialist approach to the body is often, if not always understood in ‘mechanistic’ terms, as the view in which the properties unique to organic, living embodied agents are reduced to or described in terms of properties that characterize matter as a whole, which allow of mechanistic explanation. Indeed, from Hobbes and Descartes in the 17th century to the popularity of automata such as Vaucanson’s in the 18th century, this vision of things would seem to be correct. In this paper (...) I aim to correct this inaccurate vision of materialism. On the contrary, the materialist project on closer consideration reveals itself to be, significantly if not exclusively, (a) a body of theories specifically focused on the contribution that ‘biology’ or rather ‘natural history’ and physiology make to metaphysical debates, (b) much more intimately connected to what we now call ‘vitalism’ (a case in point is the presence of Théophile de Bordeu, a prominent Montpellier physician and theorist of vitalism, as a fictional character and spokesman of materialism, in Diderot’s novel D’Alembert’s Dream), and ultimately (c) an anti-mechanistic doctrine which focuses on the unique properties of organic beings. To establish this revised vision of materialism I examine philosophical texts such as La Mettrie’s Man a Machine and Diderot’s D’Alembert’s Dream; medical entries in the Encyclopédie by physicians such as Ménuret and Fouquet; and clandestine combinations of all such sources (Fontenelle, Gaultier and others). (shrink)

The presence of philosophy, amidst other humanities,within the body of medical education seems to raise no doubt nowadays. There are, however, some questions of a general nature to be discussed regarding the aforementioned fact. Three of them are of the greatest importance: (1) What image of medicine prevails in modern Western societies? (2)What ideals of medical professionals are commonly shared in these societies? (3) What is the intellectual background of the students of medico-related faculties? The real purposes and goals ascribed (...) to philosophy as a part of medical curricula, as well as methods of teaching philosophy depend on the answers given to these questions. An option to be presented here is influenced by the experience of teaching philosophy to students of medical faculties at the Jagiellonian University in Krakw. This approach is deliberately posed against mainstream medical education that is usually based on an unquestioned belief in the power of biomedical sciences. Such a model cannot, however,pretend to be a universal one to be implemented allover the world. In any case, it is the only thing a philosopher can do to improve the quality of a physician-patient encounter in facing a disease. (shrink)

It was in the course of one particular clinical encounter that I came to realize the power of narrative, especially for expressing clinically presented ethical matters. In Husserlian terms, the mode of evidence proper to the unique and the singular is the very indirection that is the genius of story-telling. Moreover, the clinical consultant is unavoidably changed by his or her clinical involvement. The individuals whose situation is at issue have their own stories that need telling. Clinical ethics is in (...) this sense a way of helping patients, families, and, yes, health providers to discover and give voice to those stories. In this way, clinical ethics is an evoking of meaning. Kierkegaard understood this well: Indirect communication is the language for the unique and the otherwise inexpressible. (shrink)

In various documents the view emerges that contemporary biotechnosciences are currently experiencing a scientific revolution: a massive increase of pace, scale and scope. A significant part of the research endeavours involved in this scientific upheaval is devoted to understanding and, if possible, ameliorating humankind: from our genomes up to our bodies and brains. New developments in contemporary technosciences, such as synthetic biology and other genomics and “post-genomics” fields, tend to blur the distinctions between prevention, therapy and enhancement. An important dimension (...) of this development is “biomimesis”: i.e. the tendency of novel technologies and materials to mimic or plagiarize nature on a molecular and microscopic level in order to optimise prospects for the embedding of technological artefacts in natural systems such as human bodies and brains. In this paper, these developments are read and assessed from a psychoanalytical perspective. Three key concepts from psychoanalysis are used to come to terms with what is happening in research laboratories today. After assessing the general profile of the current revolution in this manner, I will focus on a particular case study, a line of research that may serve as exemplification of the vicissitudes of contemporary technosciences, namely viral biomaterials. Viral life forms can be genetically modified (their genomes can be rewritten) in such a manner that they may be inserted in human bodies in order to produce substances at specific sites such as hormones (testosterone), neurotransmitters (dopamine), enzymes (insulin) or bone and muscle tissue. Notably, certain target groups such as top athletes, soldiers or patients suffering from degenerative diseases may become the pioneers serving as research subjects for novel applications. The same technologies can be used for various purposes ranging from therapy up to prevention and enhancement. (shrink)