This article critically analyses the concept of evidence in evidence‐based policy, arguing that there is a key problem: there is no existing practicable theory of evidence, one which is philosophically‐grounded and yet applicable for evidence‐based policy. The article critically considers both philosophical accounts of evidence and practical treatments of evidence in evidence‐based policy. It argues that both fail in different ways to provide a theory of evidence that is adequate for evidence‐based policy. The article contributes to the debate about how (...) evidence can and should be used to reduce contingency in science and in policy based on science. (shrink)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: -/- The main aim of this review will be to assess the effects of changing practitioner empathy or patient expectations for all conditions. The main objective is to conduct a systematic review of randomised trials where the intervention involves manipulating either (a) practitioner empathy or (b) patient expectations, or (c) both.

In August 2011, a group of medical doctors, ethicists, academic and medical physicists were asked to debate and reach consensus on the potential need for randomised control trials to test charged particle radiation therapy for treating tumours. The outcome of the meeting was a paper recently published in the Journal of Medical Ethics entitled “Position statement on ethics, equipoise and research on charged particle therapy” by Sheehan et al. However 6 of the 30 meeting participants withdrew from authorship of the (...) ‘position statement’ because their views were not adequately represented. The ‘position statement’ did not state our reasons for withdrawing from the statement, which is a considerable omission. We had two principal objections: the case for the benefits to patients and society of randomized trials to test CPRT was not adequately represented, and the complexities and potential harms of CPRT were not clearly stated. In this response we explain and justify our objections. Patients, doctors and policymakers seeking to make independent judgments about whether equipoise exists for the relative benefits of CPRT should therefore read this document alongside the ‘position’ statement. (shrink)

The philosophy of evidence-based medicine -- What is EBM? -- What is good evidence for a clinical decision? -- Ruling out plausible rival hypotheses and confounding factors : a method -- Resolving the paradox of effectiveness : when do observational studies offer the same degree of evidential support as randomized trials? -- Questioning double blinding as a universal methodological virtue of clinical trials : resolving the Philip's paradox -- Placebo controls : problematic and misleading baseline measures of effectiveness -- Questioning (...) the methodological superiority of "placebo" over "active" controlled trials -- Examining the paradox that traditional roles for mechanistic reasoning and expert -- Judgment have been up-ended by EBM -- A qualified defence of the EBM stance on mechanistic reasoning -- Knowledge that versus knowledge how : situating the EBM position on expert clinical judgment -- Moving EBM forward. (shrink)

Philosophers of science have insisted that evidence of underlying mechanisms is required to support claims about the effects of medical interventions. Yet evidence about mechanisms does not feature on dominant evidence-based medicine “hierarchies.” After arguing that only inferences from mechanisms (“mechanistic reasoning”)—not mechanisms themselves—count as evidence, I argue for a middle ground. Mechanistic reasoning is not required to establish causation when we have high-quality controlled studies; moreover, mechanistic reasoning is more problematic than has been assumed. Yet where the problems can (...) be overcome, mechanistic reasoning can and should be used as evidence. (shrink)

Debates about the ethics and effects of placebos and whether ‘placebos’ in clinical trials of complex treatments such as acupuncture are adequate rage. Yet there is currently no widely accepted definition of the ‘placebo’. A definition of the placebo is likely to inform these controversies. Grünbaum’s characterization of placebos and placebo effects has been touted by some authors as the best attempt thus far, but has not won widespread acceptance largely because Grünbaum failed to specify what he means by a (...) therapeutic theory and because he does not stipulate a special role for expectation effects. Grünbaum claims that placebos are treatments whose ‘characteristic features’ do not have therapeutic effects on the target disorder. I show that with four modifications, Grünbaum’s definition provides a defensible account of placebos for the purpose of constructing placebo controls within clinical trials. The modifications I introduce are: adding a special role for expectations, insisting that placebo controls control for all and only the effects of the incidental treatment features, relativizing the definition of placebos to patients, and introducing harmful interventions and nocebos to the definitional scheme. I also provide guidance for classifying treatment features as characteristic or incidental. (shrink)

Proponents of evidence-based medicine and some philosophers of science seem to agree that knowledge of mechanisms can help solve the problem of applying results of controlled studies to target populations (‘the problem of extrapolation’). We describe the problem of extrapolation, characterize mechanisms, and outline how mechanistic knowledge might be used to solve the problem. Our main thesis is that there are four often overlooked problems with using mechanistic knowledge to solve the problem of extrapolation. First, our understanding of mechanisms is (...) often (and arguably, likely to remain) incomplete. Secondly, knowledge of mechanisms is not always applicable outside the tightly controlled laboratory conditions in which it is gained. Thirdly, mechanisms can behave paradoxically. Fourthly, as Daniel Steel points out, using mechanistic knowledge faces the problem of the ‘extrapolator’s circle’. At the same time, when the problems with mechanistic knowledge have been addressed, such knowledge can and should be used to mitigate (nothing can entirely solve) the problem of extrapolation. (shrink)

A resilient issue in research ethics is whether and when a placebo-controlled trial is justified if it deprives research subjects of a recognized treatment. The clinicians' moral duty to provide the best available care seems to require the use of ‘active’ controlled trials that use an established treatment as a control whenever such a therapy is available. In another regard, ACTs are supposedly methodologically inferior to PCTs. Hence, the moral duty of the clinical researcher to use the best methods will (...) favor PCTs. In this target article, I analyze the three reasons for believing that ACTs are inferior to PCTs namely: 1) ACTs lack ‘assay sensitivity’; 2) ACTs do not measure absolute effect size; and 3) ACTs require more participants; and I contend that none are acceptable. Consequently the tension between clinical and research ethics dissolves: the moral duty of the clinician to avoid PCTs is unopposed by methodological considerations. (shrink)

Unlike its friendly cousin the placebo effect, the nocebo effect (the effect of expecting a negative outcome) has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo interventions are not necessarily nocebo effects; they could have arisen due to natural history. Meanwhile, ethical informed consent (in clinical trials and clinical practice) has centred almost exclusively on the need to inform patients about (...) intervention risks with patients to preserve their autonomy. Researchers have failed to consider the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining (ethical) informed consent and communicating intervention risks with patients. (shrink)

Objectives -/- Surveys in various countries suggest 17% to 80% of doctors prescribe ‘placebos’ in routine practice, but prevalence of placebo use in UK primary care is unknown. Methods -/- We administered a web-based questionnaire to a representative sample of UK general practitioners. Following surveys conducted in other countries we divided placebos into ‘pure’ and ‘impure’. ‘Impure’ placebos are interventions with clear efficacy for certain conditions but are prescribed for ailments where their efficacy is unknown, such as antibiotics for suspected (...) viral infections. ‘Pure’ placebos are interventions such as sugar pills or saline injections without direct pharmacologically active ingredients for the condition being treated. We initiated the survey in April 2012. Two reminders were sent and electronic data collection closed after 4 weeks. Results -/- We surveyed 1715 general practitioners and 783 (46%) completed our questionnaire. Our respondents were similar to those of all registered UK doctors suggesting our results are generalizable. 12% (95% CI 10 to 15) of respondents used pure placebos while 97% (95% CI 96 to 98) used impure placebos at least once in their career. 1% of respondents used pure placebos, and 77% (95% CI 74 to 79) used impure placebos at least once per week. Most (66% for pure, 84% for impure) respondents stated placebos were ethical in some circumstances. Conclusion and implications -/- Placebo use is common in primary care but questions remain about their benefits, harms, costs, and whether they can be delivered ethically. Further research is required to investigate ethically acceptable and cost-effective placebo interventions. (shrink)

Unlike its friendly cousin the placebo effect, the nocebo effect has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo interventions are not necessarily nocebo effects; they could have arisen due to natural history. Meanwhile, ethical informed consent has centred almost exclusively on the need to inform patients about intervention risks with patients to preserve their autonomy. Researchers have failed to consider (...) the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining informed consent and communicating intervention risks with patients. There are no data in this work. (shrink)

AI, in the form of artificial carers, provides a possible solution to the problem of a growing elderly population Yet, concerns remain that artificial carers ( such as care-or chat-bots) could not emphathize with patients to the extent that humans can. Utilising the concept of empathy perception,we propose a Turing-type test that could check whether artificial carers could do many of the menial tasks human carers currently undertake, and in the process, free up more time for doctors to offer empathy. (...) -/- . (shrink)

Rationale and objectives: Medical humanities are becoming increasingly recognized as positively impacting medical education and medical practice. However, the extent of medical humanities teaching in medical schools is largely unknown. We reviewed medical school curricula in Canada, the UK and the US. We also explored the relationship between medical school ranking and the inclusion of medical humanities in the curricula. -/- Methods: We searched the curriculum websites of all accredited medical schools in Canada, the UK and the US to check (...) which medical humanities topics were taught, and whether they were mandatory or optional. We then noted rankings both by Times Higher Education and U.S. News and World Report and calculated the average rank. We formally explored whether there was an association between average medical school ranking and medical humanities offerings using Spearman's correlation and inverse variance weighting meta-analysis. -/- Results: We identified 18 accredited medical school programmes in Canada, 41 in the UK, and 154 in the US. Of these, nine (56%) in Canada, 34 (73%) in the UK and 124 (80%) in the US offered at least one medical humanity that was not ethics. The most common medical humanities were medical humanities (unspecified), history, and literature (Canada); sociology and social medicine, medical humanities (unspecified), and art (UK); and medical humanities (unspecified), literature and history (US). Higher ranked medical schools appeared less likely to offer medical humanities. -/- Conclusions: The extent and content of medical humanities offerings at accredited medical schools in Canada, the UK and the US varies, and there appears to be an inverse relationship between medical school quality and medical humanities offerings. Our analysis was limited by the data provided on the Universities' websites. Given the potential for medical humanities to improve medical education and medical practice, opportunities to reduce this variation should be exploited. (shrink)

The American Journal of Bioethics, Volume 12, Issue 3, Page 33-34, March 2012.

The revised Declaration of Helsinki allows placebo-controlled trials to be used even when there is an established therapy, provided there are adequate ‘methodological’ reasons for doing so. This seems to violate the principle of beneficence: where there is an established therapy, physicians treating patients with a placebo are withholding a known effective therapy. Because of this problem, we hypothesised that clinical researchers may be unwilling to risk violating the principle of beneficence and employ placebo-controlled trials in cases where there is (...) an established therapy. In this paper, we began to investigate this hypothesis. After summarising the arguments for and against using placebo controls in clinical practice, we exploredthe extent to which placebo-controlled trials are used in cases where there is an established therapy. To do this, we conducted as systematic search for all placebo-controlled trials published in 2015 in the five highest impact general medical journals. We identified 70 placebo-controlled trials. Of these, 66 were for indications where there was no established effective therapy. Only four used a placebo control in spite of there being an available effective therapy. The infrequent use of placebo controlled trials where established therapy exists highlights a seeming discrepancy between what the Declaration of Helsinki allows and what clinical investigators believe to be ethically acceptable. The evidence presented in this paper suggests that the Declaration of Helsinki be reconsidered, and perhaps revised, in light of actual practice. (shrink)

Since its introduction just over two decades ago, evidence-based medicine (EBM) has come to dominate medical practice, teaching, and policy. There are a growing number of textbooks, journals, and websites dedicated to EBM research, teaching, and evidence dissemination. EBM was most recently defined as a method that integrates best research evidence with clinical expertise and patient values and circumstances in the treatment of patients. There have been debates throughout the early 21st century about what counts as good research evidence between (...) EBM proponents and philosophical critics and even within the EBM community itself. Similar controversy arises about the relative worth of patient values and clinical expertise (and how these can be integrated). EBM has also evolved in ways that have come under scrutiny. Specifically, policymakers have used EBM research methodology to increase the relative importance of clinical guidelines that some clinicians have argued are tyrannical. Philosophers have addressed all of these controversies, and with very few exceptions have been critical of EBM. In addition most philosophical attention has been on the epistemic role of Randomization and evidence hierarchies, with relatively little attention being paid to the role of Diagnosis, expertise, patient values, and Systematic Reviews within EBM. (shrink)

Introduction Current treatments for pain have limited benefits and worrying side effects. Some studies suggest that pain is reduced when clinicians deliver positive messages. However, the effects of positive messages are heterogeneous and have not been subject to meta-analysis. We aimed to estimate the efficacy of positive messages for pain reduction. -/- Methods We included randomized trials of the effects of positive messages in a subset of the studies included in a recent systematic review of context factors for treating pain. (...) Several electronic databases were searched. Reference lists of relevant studies were also searched. Two authors independently undertook study selection, data extraction, risk of bias assessment, and analyses. Our primary outcome measures were differences in patient- or observer-reported pain between groups who were given positive messages and those who were not. -/- Results Of the 16 randomized trials (1703 patients) that met the inclusion criteria, 12 trials had sufficient data for meta-analysis. The pooled standardized effect size was −0.31 (95% confidence interval [CI] −0.61 to −0.01, p = 0.04, I2 = 82%). The effect size remained positive but not statistically significant after we excluded studies considered to have a high risk of bias (standard effect size −0.17, 95% CI −0.54 to 0.19, P = 0.36, I2 = 84%). -/- Conclusion Care of patients with chronic or acute pain may be enhanced when clinicians deliver positive messages about possible clinical outcomes. However, we have identified several limitations of the present study that suggest caution when interpreting the results. We recommend further high-quality studies to confirm (or falsify) our result. -/- FUNDING -/- Alexander Mebius research has been funded through the ERC grant "Philosophy of Pharmacology: Safety, Statistical Standards, and Evidence Amalgamation" (GA: 639276). (shrink)

A resilient issue in research ethics is whether and when a placebo-controlled trial is justified if it deprives research subjects of a recognized treatment. The clinicians' moral duty to provide the best available care seems to require the use of ‘active’ controlled trials that use an established treatment as a control whenever such a therapy is available. In another regard, ACTs are supposedly methodologically inferior to PCTs. Hence, the moral duty of the clinical researcher to use the best methods will (...) favor PCTs. In this target article, I analyze the three reasons for believing that ACTs are inferior to PCTs namely: 1) ACTs lack ‘assay sensitivity’; 2) ACTs do not measure absolute effect size; and 3) ACTs require more participants; and I contend that none are acceptable. Consequently the tension between clinical and research ethics dissolves: the moral duty of the clinician to avoid PCTs is unopposed by methodological considerations. (shrink)

Five reasons why teaching medical humanities in medical schools improves student performance, enhances wellbeing, and ameliorates patient outcomes.

The feature of being ‘double blind’, where neither patients nor physicians are aware of who receives the experimental treatment, is universally trumpeted as being a virtue of clinical trials. The rationale for this view is unobjectionable: double blinding rules out the potential confounding influences of patient and physician beliefs. Nonetheless, viewing successfully double blind trials as necessarily superior leads to the paradox that very effective experimental treatments will not be supportable by best (double-blind) evidence. It seems strange that an account (...) of evidence should make a priori judgments that certain claims can never be supported by ‘best evidence’. So far as treatments with large effects go, the claim that they are effective is highly testable and intuitively they should receive greater support from the evidence. In this paper I argue that the two potential confounders ruled out by double blinding are often not actual confounders outside placebo controlled trials of treatments with mild effects and that have subjective outcome measures. (shrink)

What happens when someone acts? A familiar answer goes like this. There is something that the agent wants, and there is an action that he believes conducive to its attainment. His desire for the end, and his belief in the action as a means, justify taking the action, and they jointly cause an intention to take it, which in turn causes the corresponding movements of the agent's body. I think that the standard story is flawed in several respects. The flaw (...) that will concern me in this paper is that the story fails to include an agent-or, more precisely, fails to cast the agent in his proper role. (shrink)

Providing an original and systematic treatment of foundational issues in philosophy of religion, J. L. Schellenberg's new book addresses the structure of..

Abstract I argue that meaning in life is importantly influenced by bioloical ties. More specifically, I maintain that knowing one's relatives and especially one's parents provides a kind of self-knowledge that is of irreplaceable value in the life-task of identity formation. These claims lead me to the conclusion that it is immoral to create children with the intention that they be alienated from their bioloical relatives?for example, by donor conception.

Retributive theories of punishment argue that punishing a criminal for a crime she committed is sufficient reason for a justified and morally permissible punishment. But what about when the state gets lucky in its decision to punish? I argue that retributive theories of punishment are subject to “Gettier” style cases from epistemology. Such cases demonstrate that the state needs more than to just get lucky, and as these retributive theories of punishment stand, there is no anti-luck condition. I’ll argue that (...) Gettier-style cases demonstrate an impermissible instance of punishment, even though they meet the conditions of retributive theories of punishment. Retributive theories are, therefore, too weak. The safety condition from epistemology provides the anti-luck condition needed for permissible punishment. I argue that two forms of retributivism, rights-forfeiture and what I call standard retributivism, are both subject to Gettier-style cases. Unlike the literature on standards of proof, this paper argues that safety is a condition on punishment itself, i.e., in all nearby possible worlds, the accuser must correctly accuse the convicted for the crime they actually committed. (shrink)

J.L. Schellenberg offers a path to a new kind of religious outlook. Reflection on our early stage in the evolutionary process leads to skepticism about religion, but also offers a new answer to the problem of faith and reason, and the possibility of a new, evolutionary form of religion.

Supervaluationism is often described as the most popular semantic treatment of indeterminacy. There’s little consensus, however, about how to fill out the bare-bones idea to include a characterization of logical consequence. The paper explores one methodology for choosing between the logics: pick a logic thatnorms beliefas classical consequence is standardly thought to do. The main focus of the paper considers a variant of standard supervaluational, on which we can characterizedegrees of determinacy. It applies the methodology above to focus ondegree logic. (...) This is developed first in a basic, single-premise case; and then extended to the multipremise case, and to allowdegreesof consequence. The metatheoretic properties of degree logic are set out. On the positive side, the logic is supraclassical—all classical valid sequents are degree logic valid. Strikingly, metarules such as cut and conjunction introduction fail. (shrink)

Evidence-based medicine has always required integration of patient values with ‘best’ clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored.

Hailed by the Bulletin of the American Mathematical Society as "undoubtedly a major addition to the literature of mathematical logic," this volume examines the essential topics and theorems of mathematical reasoning. No background in logic is assumed, and the examples are chosen from a variety of mathematical fields. Starting with an introduction to symbolic logic, the first eight chapters develop logic through the restricted predicate calculus. Topics include the statement calculus, the use of names, an axiomatic treatment of the statement (...) calculus, descriptions, and equality. Succeeding chapters explore abstract set theory—with examinations of class membership as well as relations and functions—cardinal and ordinal arithmetic, and the axiom of choice. An invaluable reference book for all mathematicians, this text is suitable for advanced undergraduates and graduate students. Numerous exercises make it particularly appropriate for classroom use. (shrink)

Ultimism and the aims of human immaturity -- Faith without details, or how to practice skeptical religion -- Simple faith and the complexities of tradition -- The structure of faith justification -- How skeptical faith is true to reason -- Anselm's idea -- Leibniz's ambition -- Paley's wonder -- Pascal's wager -- Kant's postulate -- James's will -- Faith is positively justified : the many modes of religious vision.

It's an achievement of the last couple of decades that people who work in linguistic semantics and people who work in the philosophy of language have arrived at a friendly, de facto agreement as to their respective job descriptions. The terms of this agreement are that the semanticists do the work and the philosophers do the worrying. The semanticists try to construct actual theories of meaning (or truth theories, or model theories, or whatever) for one or another kind of expression (...) in one or another natural language; for example, they try to figure out how the temperature could be rising compatibly with the substitutivity of identicals. The philosophers, by contrast, keep an eye on the large, foundational issues, such as: what's the relation between sense and denotation; what's the relation between thought and language; whether translation is determinate; and whether life is like a fountain. Every now and then the philosophers and the semanticists are supposed to get together and compare notes on their respective progress. Or lack thereof. (shrink)

This paper offers an alternate explanation of cases from the doxastic wronging literature. These cases violate what I call the degree of inquiry right—a novel account of zetetic obligations to inquire when interests are at stake. The degree of inquiry right is a moral right against other epistemic agents to inquire to a certain threshold when a belief undermines one’s interests. Thus, the agents are sometimes obligated to leave inquiry open. I argue that we have relevant interests in reputation, relationships, (...) and the well-being of our social groups. These interests generate obligations against others to “do their homework” before closing inquiry. This alternate account makes better sense of puzzles that accounts of doxastic wronging fall prey to. (shrink)

The aim of this paper is to elaborate on the phenomenological approach to expertise as proposed by Dreyfus and Dreyfus and to give an account of the extent to which their approach may contribute to a better understanding of how athletes may use their cognitive capacities during high-level skill execution. Dreyfus and Dreyfus's non-representational view of experience-based expertise implies that, given enough relevant experience, the skill learner, when expert, will respond intuitively to immediate situations with no recourse to deliberate actions (...) or mental representations. The paper will subsequently outline some implications and consequences of such an approach and will also examine to what extent Dreyfus and Dreyfus's skill model is capable to resist different attacks that have been made against their view, and in particular regarding the practical application of their approach to the skill domain of competitive sport. (shrink)

Prologue: Toward a new Enlightenment -- From bounded to relational being -- Bounded being -- In the beginning is the relationship -- The relational self -- The body as relationship : emotion, pleasure and pain -- Relational being in everyday life -- Multi-being and the adventure of everyday life -- Bonds, barricades, and beyond -- Relational being in practice -- Knowledge as co-creation -- Education in a relational key -- Therapy as relational recovery -- Organizing : the precarious balance -- (...) From the moral to the sacred -- Beyond moral pluralism -- All our relations, approaching the sacred -- Epilogue: The coming of relational consciousness. (shrink)

The phenomenon of ambivalence is an important one for any philosophy of action. Despite this importance, there is a lack of a fully satisfactory analysis of the phenomenon. Although many contemporary philosophers recognize the phenomenon, and address topics related to it, only Harry Frankfurt has given the phenomenon full treatment in the context of action theory – providing an analysis of how it relates to the structure and freedom of the will. In this paper, I develop objections to Frankfurt's account, (...) all revolving around the charge that his account contains a serious ambiguity between willing and identifying. With such objections in place, I then develop an analysis that avoids the difficulties and ambiguities that Frankfurt's analysis is prey to. I briefly distinguish ambivalence from other types of internal conflict. This paper aims to offer conceptual clarification on the phenomenon of ambivalence, which will then allow for discussions about the normative merits and demerits of ambivalence, the effects of ambivalence on autonomous action, and methods of resolution of ambivalence. (shrink)

According to the cognitive model of psychopathology, maladaptive beliefs about oneself, others, and the world are the main factors contributing to the development and persistence of various forms of mental suffering. Therefore, the key therapeutic process of Cognitive Behavioral Therapy (CBT)—a therapeutic approach rooted in the cognitive model—is cognitive restructuring, i.e., a process of revision of such maladaptive beliefs. In this paper, I examine the philosophical assumptions underlying CBT and offer theoretical reasons to think that the effectiveness of belief revision (...) in psychotherapy is very limited. This is the case, I argue, because the cognitive model wrongly assumes that our body of beliefs is unified, while it is in fact fragmented. (shrink)

Every soul has an unconscious knowledge of the ultimate truth of things, a premise long taught by all great spiritual teachers, East and West, regularly experienced by those who follow the spiritual path. In the quest to help reestablish that universal connection, editor J. Douglas Kenyon has culled from the pages of Atlantis rising magazine this compilation of concise and well-illustrated articles by world-class researchers and theoreticians."--Back cover.