Medical Epistemology

In the first part of this paper, I will sketch the main features of traditional models of evidence, indicating idealizations in such models that I regard as doing more harm than good. I will then proceed to elaborate on an alternative model of evidence that is functionalist, complex, dynamic, and contextual, which I will call DYNAMIC EVIDENTIAL FUNCTIONALISM. I will demonstrate its application to an illuminating example of scientific inquiry, and defend it from some likely objections. In the second part, (...) I will use that alternative to solve a variety of classic and contemporary problems in the literature on scientific evidence having to do with the empirical basis of science and the use of evidence in public policy. (shrink)

Whipple disease is a rare, infectious, disease first described from a single case by Whipple in 1907. As well as characterising the clinical and pathological features of the condition, Whipple made two suggestions regarding its aetiology. These were either than the disease was caused by an infectious agent, or that it was of metabolic origin. As the disease is now thought to be caused by infection with the bacterium Tropheryma whipplei, historical reviews of the history of the disease typically mention (...) only the first of these suggestions. In this paper, we therefore revisit Whipple’s other theory. We argue that a diverse and often successful research programme was developed around this mechanism of disease causation which gave rise to many useful findings on the condition. In the later parts of this article, we then turn to discuss the surprising neglect of this period of Whipple disease research in the current literature, and conclude by offering a brief reconstruction of this early history suitable for use in a technical context. (shrink)

Were governments justified in imposing lockdowns to contain the spread of the COVID-19 pandemic? We argue that a convincing answer to this question is to date wanting, by critically analyzing the factual basis of a recent paper, “How Government Leaders Violated Their Epistemic Duties During the SARS-CoV-2 Crisis” (Winsberg et al. 2020). In their paper, Winsberg et al. argue that government leaders did not, at the beginning of the pandemic, meet the epistemic requirements necessitated to impose lockdowns. We focus on (...) Winsberg et al.’s contentions that knowledge about COVID-19 and resultant projections were inadequate; that epidemiologists were biased in their estimates of relevant figures; that there was insufficient evidence supporting the efficacy of lockdowns; and that lockdowns cause more harm than good. We argue that none of these claims are sufficiently supported by evidence, thus impairing their case against lockdowns, and leaving open the question of whether lockdowns were justified. (shrink)

The species of vitalism discussed here, to immediately rule out two possible misconceptions, is neither the feverish cosa mentale found in ruminations on ‘biopolitics’ and fascism – where it alternates quickly between being a form of evil and a form of resistance, with hardly any textual or conceptual material to discuss – nor the opaque, and less-known form in which it exists in the worlds of ‘Theory’ in the humanities, perhaps closely related to the cognate, ‘materiality’. Rather, vitalism here is (...) a malleable construct, often with a poisonous reputation, hovering in the realms of the philosophy of biology, the history of medicine, and the scientific background of the Radical Enlightenment. This is a more vital vitalism, or at least a more ‘biologistic’, ‘embodied’, medicalized vitalism. I first distinguish between what I would call ‘substantival’ and ‘functional’ forms of vitalism, as applied to the eighteenth century. Substantival vitalism presupposes the existence of something like a vital force which either plays a causal role in the natural world as studied by scientific means, or remains a kind of hovering, extra-causal entity. Functional vitalism tends to operate ‘post facto’, from the existence of living bodies to the desire to find explanatory models that will do justice to their uniquely ‘vital’ properties in a way that fully mechanistic models cannot. I discuss some representative figures of the Montpellier school as being functional rather than substantival vitalists. A second point concerns the reprisal of vitalism in ‘late modernity’; from Hans Driesch to Georges Canguilhem. I suggest that in addition to the substantival and functional varieties, we then encounter a third, more existential form of vitalism, articulated by Canguilhem, in which vitalism is a kind of attitude towards Life. All of this, I hope, argues for a form of vitalism which is neither tedious scientism nor dangerous political rhetoric of health and sickness; instead, a vitalism with its own discreet charm. (shrink)

Despite the conceptual problems in identifying the placebo effect, an increasing number of multidisciplinary inquiries rest on the assumption that there is a distinct class of effects, placebo effects. In this chapter, I argue against this assumption. I present cases and characterizations of the placebo effect as offered in the literature, and argue that the latter are subject to insurmountable problems. Moreover, I argue that identification of placebo effects as such is not useful for the three main purposes offered in (...) the literature. I then offer suggestions for why it may remain intuitive that some effects are placebo effects and close by noting the potential benefits of ultimately explaining away these intuitions. (shrink)

Bradford Hill (1965) highlighted nine aspects of the complex evidential situation a medical researcher faces when determining whether a causal relation exists between a disease and various conditions associated with it. These aspects are widely cited in the literature on epidemiological inference as justifying an inference to a causal claim, but the epistemological basis of the Hill aspects is not understood. We offer an explanatory coherentist interpretation, explicated by Thagard's ECHO model of explanatory coherence. The ECHO model captures the complexity (...) of epidemiological inference and provides a tractable model for inferring disease causation. We apply this model to three cases: the inference of a causal connection between the Zika virus and birth defects, the classic inference that smoking causes cancer, and John Snow’s inference about the cause of cholera. (shrink)

Advanced medical imaging, such as CT, fMRI and PET, has undergone enormous progress in recent years, both in accuracy and utilization. Such techniques often bring with them an illusion of immediacy, the idea that the body and its diseases can be directly inspected. In this paper we target this illusion and address the issue of the reliability of advanced imaging tests as knowledge procedures, taking positron emission tomography in oncology as paradigmatic case study. After individuating a suitable notion of reliability, (...) we argue that PET is a highly theory-laden and non-immediate knowledge procedure, in spite of the photographic-like quality of the images it delivers; the diagnostic conclusions based on the interpretation of PET images are population-dependent; PET images require interpretation, which is inherently observer-dependent and therefore variable. We conclude with a three-step methodological proposal for enhancing the reliability of advanced medical imaging. (shrink)

MALARIA, SCIENCE AND SOCIETY IN FERRARA FROM THE MIDDLE AGES TO THE NINETEENTH CENTURY -/- In this paper it is outlined the history of malaria in Ferrara and its suburbs, from ancient times up to the nineteenth century. It is considered the issue of malaria in Roman times, during the Middle Ages and the Renaissance, the discovery of quinine, the first scientific studies made at the University of Ferrara, the first analysis about the causes and the spread of the disease. (...) The conditions of backwardness of Ferrara society are considered, especially of the people living in the countryside, and the most common medical knowledge. Statistics about the spread of malaria after the unification of Italy are resumed. Problems of environmental recovery are taken into account. Scientific progresses due to positivism and to the doctors who faced the first anti-malarial campaigns, bringing their testimonies. The essay ends up with the reorganization of public health and places of health care in modern hospitals all over the province of Ferrara. (shrink)

MALARIA, SCIENCE AND SOCIETY IN FERRARA FROM THE MIDDLE AGES TO THE NINETEENTH CENTURY -/- In this paper it is outlined the history of malaria in Ferrara and its suburbs, from ancient times up to the nineteenth century. It is considered the issue of malaria in Roman times, during the Middle Ages and the Renaissance, the discovery of quinine, the first scientific studies made at the University of Ferrara, the first analysis about the causes and the spread of the disease. (...) The conditions of backwardness of Ferrara society are considered, especially of the people living in the countryside, and the most common medical knowledge. Statistics about the spread of malaria after the unification of Italy are resumed. Problems of environmental recovery are taken into account. Scientific progresses due to positivism and to the doctors who faced the first anti-malarial campaigns, bringing their testimonies. The essay ends up with the reorganization of public health and places of health care in modern hospitals all over the province of Ferrara. (shrink)

Medical scientists employ ‘quality assessment tools’ (QATs) to measure the quality of evidence from clinical studies, especially randomized controlled trials (RCTs). These tools are designed to take into account various methodological details of clinical studies, including randomization, blinding, and other features of studies deemed relevant to minimizing bias and error. There are now dozens available. The various QATs on offer differ widely from each other, and second-order empirical studies show that QATs have low inter-rater reliability and low inter-tool reliability. This (...) is an instance of a more general problem I call the underdetermination of evidential significance. Disagreements about the strength of a particular piece of evidence can be due to different—but in principle equally good—weightings of the fine-grained methodological features which constitute QATs. (shrink)

The purpose of this chapter is to describe what we see as several important new directions for philosophy of medicine. This recent work (i) takes existing discussions in important and promising new directions, (ii) identifies areas that have not received sufficient and deserved attention to date, and/or (iii) brings together philosophy of medicine with other areas of philosophy (including bioethics, philosophy of psychiatry, and social epistemology). To this end, the next part focuses on what we call the “epistemological turn” in (...) recent work in the philosophy of medicine; the third part addresses new developments in medical research that raise interesting questions for philosophy of medicine; the fourth part is a discussion of philosophical issues within the practice of diagnosis; the fifth part focuses on the recent developments in psychiatric classification and scientific and ethical issues therein, and the final part focuses on the objectivity of medical research. (shrink)

This book offers a philosophically-based, yet clinically-oriented perspective on current medical reasoning aiming at 1) identifying important forms of uncertainty permeating current clinical reasoning and practice 2) promoting the application of an abductive methodology in the health context in order to deal with those clinical uncertainties 3) bridging the gap between biomedical knowledge, clinical practice, and research and values in both clinical and philosophical literature. With a clear philosophical emphasis, the book investigates themes lying at the border between several disciplines, (...) such as medicine, nursing, logic, epistemology, and philosophy of science; but also ethics, epidemiology, and statistics. At the same time, it critically discusses and compares several professional approaches to clinical practice such as the one of medical doctors, nurses and other clinical practitioners, showing the need for developing a unified framework of reasoning, which merges methods and resources from many different clinical but also non-clinical disciplines. In particular, this book shows how to leverage nursing knowledge and practice, which has been considerably neglected so far, to further shape the interdisciplinary nature of clinical reasoning. Furthermore, a thorough philosophical investigation on the values involved in health care is provided, based on both the clinical and philosophical literature. The book concludes by proposing an integrative approach to health and disease going beyond the so-called “classical biomedical model of care”. (shrink)

"Correlation is not causation" is one of the mantras of the sciences—a cautionary warning especially to fields like epidemiology and pharmacology where the seduction of compelling correlations naturally leads to causal hypotheses. The standard view from the epistemology of causation is that to tell whether one correlated variable is causing the other, one needs to intervene on the system—the best sort of intervention being a trial that is both randomized and controlled. In this paper, we argue that some purely correlational (...) data contains information that allows us to draw causal inferences: statistical noise. Methods for extracting causal knowledge from noise provide us with an alternative to randomized controlled trials that allows us to reach causal conclusions from purely correlational data. (shrink)

This is the first book to explore the epistemology and ethics of advanced imaging tests, in order to improve the critical understanding of the nature of knowledge they provide and the practical consequences of their utilization in healthcare. Advanced medical imaging tests, such as PET and MRI, have gained center stage in medical research and in patients’ care. They also increasingly raise questions that pertain to philosophy: What is required to be an expert in reading images? How are standards for (...) interpretation to be fixed? Is there a problem of overutilization of such tests? How should uncertainty be communicated to patients? How to cope with incidental findings? This book is of interest and importance to scholars of philosophy of medicine at all levels, from undergraduates to researchers, to medical researchers and practitioners (radiologists and nuclear physicians) interested in a critical appraisal of the methodology of their discipline and in the ethical principles and consequences of their work. -/- . (shrink)

The paper investigates the epistemological and communicative competences the experts need to use and communicate evidence in the reasoning process leading to diagnosis. The diagnosis and diagnosis communication are presented as intertwined processes that should be jointly addressed in medical consultations, to empower patients’ compliance in illness management. The paper presents defeasible reasoning as specific to the diagnostic praxis, showing how this type of reasoning threatens effective diagnosis communication and entails that we should understand diagnostic evidence as defeasible as well. (...) It argues that metaphors might be effective communicative devices to let the patients understand the relevant defeasors in the diagnostic reasoning process, helping to improve effective diagnosis communication, and also encouraging a change in patients’ beliefs and attitudes on their own experience of illness and illness’ management. (shrink)

In recent years there has been an explosion of interest in Artificial Intelligence (AI) both in health care and academic philosophy. This has been due mainly to the rise of effective machine learning and deep learning algorithms, together with increases in data collection and processing power, which have made rapid progress in many areas. However, use of this technology has brought with it philosophical issues and practical problems, in particular, epistemic and ethical. In this paper the authors, with backgrounds in (...) philosophy, maternity care practice and clinical research, draw upon and extend a recent framework for shared decision-making (SDM) that identified a duty of care to the client's knowledge as a necessary condition for SDM. This duty entails the responsibility to acknowledge and overcome epistemic defeaters. This framework is applied to the use of AI in maternity care, in particular, the use of machine learning and deep learning technology to attempt to enhance electronic fetal monitoring (EFM). In doing so, various sub-kinds of epistemic defeater, namely, transparent, opaque, underdetermined, and inherited defeaters are taxonomized and discussed. The authors argue that, although effective current or future AI-enhanced EFM may impose an epistemic obligation on the part of clinicians to rely on such systems' predictions or diagnoses as input to SDM, such obligations may be overridden by inherited defeaters, caused by a form of algorithmic bias. The existence of inherited defeaters implies that the duty of care to the client's knowledge extends to any situation in which a clinician (or anyone else) is involved in producing training data for a system that will be used in SDM. Any future AI must be capable of assessing women individually, taking into account a wide range of factors including women's preferences, to provide a holistic range of evidence for clinical decision-making. (shrink)

How is scientific data used to represent phenomena and as evidence for claims about phenomena? In this paper, I propose that a specific type of claims – evidential claims – is involved in data practices to define and restrict the representational and evidential content of a dataset. I present an account of data practices in the epidemiology of the exposome based on the notion of evidential claims, which helps unpack the approaches, assumptions and warrants that connect different stages of research. (...) I identify three different strategies to generate different types of evidential claims in this case. The macro strategy, which individuates the dataset that serves as the initial evidential space for research. The micro strategy, which is used to generate evidential claims about the microscopic and individual component of target phenomena. The association strategy, that uses evidence from the other strategies to identify a dataset as representation of the different levels and relations of exposure and disease. Differentiating between these strategies sheds light on the multi-faceted landscape of biomedical research on environment and health; and the roles of data and evidence in the process of inquiry. (shrink)

The COVID-19 pandemic has demonstrated how different (even conflicting) interventions on nature can be scientifically justified: interventions can be deemed "effective" only in relation to specific target variables - in relation to variables the values of which we seek to control. Choosing the "right" target variables, in turn, depends on our values and pragmatic aims. This essay is based on a presentation given at the symposium "Multidisciplinary Perspectives on the COVID-19 Pandemic", organised at the Helsinki Collegium for Advanced Studies on (...) 16 June 2020. (shrink)

Requiring family authorization for apnea testing subtracts health professionals control over death determination, a procedure that has traditionally been considered a matter of clinical expertise alone. In this commentary, we first provide evidence showing that health professionals’ (HPs) disposition to act on death determination without family’s prior consent could be much lower than that referred to by Berkowitz and Garrett (2020). We hypothesize that HPs may have reservations about their own expertise as regards death, and may thus hesitate to impose (...) their views on patients’ families. We then address the theoretical question of clinical expertise in death determination by distinguishing judgments about facts (e.g., the presence or absence of spontaneous breathing) from interpretations given of these facts (i.e., their meaning for the vital status of an individual). We argue that, while clinicians may claim some expert authority on the former, they hold no particular authority on the latter. (shrink)

Within the evidence-based medicine construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians’ primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the “best” evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here (...) we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients. (shrink)

Shared decision‐making involves health professionals and patients/clients working together to achieve true person‐centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision‐making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion (...) between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision‐making for caesarean section. The team concluded that shared decision‐making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision‐making (defeaters) are disclosed. Informed consent is not shared decision‐making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision‐making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

Cancer research is experiencing ‘paradigm instability’, since there are two rival theories of carcinogenesis which confront themselves, namely the somatic mutation theory and the tissue organization field theory. Despite this theoretical uncertainty, a huge quantity of data is available thanks to the improvement of genome sequencing techniques. Some authors think that the development of new statistical tools will be able to overcome the lack of a shared theoretical perspective on cancer by amalgamating as many data as possible. We think instead (...) that a deeper understanding of cancer can be achieved by means of more theoretical work, rather than by merely accumulating more data. To support our thesis, we introduce the analytic view of theory development, which rests on the concept of plausibility, and make clear in what sense plausibility and probability are distinct concepts. Then, the concept of plausibility is used to point out the ineliminable role played by the epistemic subject in the development of statistical tools and in the process of theory assessment. We then move to address a central issue in cancer research, namely the relevance of computational tools developed by bioinformaticists to detect driver mutations in the debate between the two main rival theories of carcinogenesis. Finally, we briefly extend our considerations on the role that plausibility plays in evidence amalgamation from cancer research to the more general issue of the divergences between frequentists and Bayesians in the philosophy of medicine and statistics. We argue that taking into account plausibility-based considerations can lead to clarify some epistemological shortcomings that afflict both these perspectives. (shrink)

Philosophers of science and medicine now aspire to provide useful, socially relevant accounts of mechanism. Existing accounts have forged the path by attending to mechanisms in historical context, scientific practice, the special sciences, and policy. Yet, their primary focus has been on more proximate issues related to therapeutic effectiveness. To take the next step toward social relevance, we must investigate the challenges facing researchers, clinicians, and policy makers involving values and social context. Accordingly, we learn valuable lessons about the connections (...) between mechanistic processes and more fundamental reasons for medical interventions, particularly moral, ethical, religious, and political concerns about health, agency, and power. This paper uses debates over the controversial morning-after pill to gain insight into the deeper reasons for the production and use of mechanistic knowledge throughout biomedical research, clinical practice, and governmental regulation. To practice socially relevant philosophy of science, I argue that we need to account for mechanistic knowledge beyond immediate effectiveness, such as how it can also provide moral guidance, aid ethical categorization in the clinic, and function as a political instrument. Such insights have implications for medical epistemology, including the value-laden dimensions of mechanistic reasoning and the “epistemic friction” of values. Furthermore, there are broader impacts for teaching research ethics and understanding the role of science advisors as political advocates. (shrink)

The US Food and Drug Administration (FDA) is fraught with controversies over the role of values and politics in regulatory science, especially with drugs in the realm of reproductive health. Philosophers and science studies scholars have investigated the ways in which social context shapes medical knowledge through value judgments, and feminist scholars and activists have criticized sexism and injustice in reproductive medicine. Nonetheless, there has been no systematic study of values and gender norms in FDA drug regulation. I focus on (...) three questions about values in regulatory science. First, how have societal values and gender norms shaped the way that the FDA regulates drugs in the realm of reproductive health, specifically with drug labels? Second, what are the ethical, epistemic, and social consequences of these influences on regulation for women and other marginalized groups? Third, which societal values and gender norms ought to influence drug regulation about reproductive health, and how ought this happen? Integrating philosophical analysis with historical archival research and in-depth interviews, I conduct three case studies of drug labeling about reproductive health: (1) the “drug fact” about the mechanism of the morning-after pill; (2) the package inserts for patients about the health risks of oral contraceptives; and (3) the special physician labels made for prescribing drugs to pregnant women. I identify three challenges for the FDA and suggest ways to reduce the influence of sexist values and facilitate feminist alternatives. First, across these cases, I have found that there are many ways in which other concerns in reproductive medicine (such as zygotic life, fetal health, and population control) have devalued women’s health. Second, both knowledge and ignorance xvi about their reproductive health have contributed to women’s oppression, especially poor women and women of color. Finally, by avoiding the epistemic dimensions of ethics, powerful, mostly male parties in medicine (such as doctors, pharmaceutical companies, and religious institutions) have misused “informed consent,” “religious freedom,” and “paternalism” for unethical purposes. For improvement, I suggest extracting sexist values and gender norms from regulatory science that cause epistemic injustices, and I point to success stories for reforming sexism with feminism at the FDA. (shrink)

Brummett and Salter propose a useful and timely taxonomy of clinical ethics expertise (2019). As the field becomes further “professionalized” this taxonomy is important, and the core of it is right. It needs some refinement around the edges, however. In their conclusion, Brummett and Salter rightly point out that there is a significant difference between the ethicist whose recommendations are procedure- and process-heavy, consensus-driven, and dialogical and the authoritarian ethicist whose recommendations flow from “private moral views” (Brummett and Salter, 2019). (...) This admission doesn’t go far enough. Brummett and Salter’s taxonomy fails to capture the notion that offering recommendations whose normative force is moral is different in kind from recommendations whose normative force is non-moral, such as those recommendations that are free of moral content or justified by convention. The difference is in kind, not scale. I argue further that clinical ethics expertise, if possible, consists at least in offering recommendations whose normative force is moral. These two claims imply that the taxonomy fails to cut clinical ethics expertise at the joints: the ethicist who offers justified non-moral normative recommendations is a different kind of ethicist from the one who offers justified moral normative recommendations, yet both are categorized as clinical ethics experts. I finish by offering a refinement of the taxonomy that more precisely categorizes clinical ethicists. (shrink)

This book covers the overlap between informatics, computer science, philosophy of causation, and causal inference in epidemiology and population health research. Key concepts covered include how data are generated and interpreted, and how and why concepts in health informatics and the philosophy of science should be integrated in a systems-thinking approach. Furthermore, a formal epistemology for the health sciences and public health is suggested. -/- Causation in Population Health Informatics and Data Science provides a detailed guide of the latest thinking (...) on causal inference in population health informatics. It is therefore a critical resource for all informaticians and epidemiologists interested in the potential benefits of utilising a systems-based approach to causal inference in health informatics. (shrink)

Recently, there has been increasing interest in methodological aspects of advanced imaging, including the role of guidelines, recommendations, and experts’ consensus, the practice of self-referral, and the risk of diagnostic procedure overuse. In a recent Delphi study of the European Association for Nuclear Medicine (EANM), panelists were asked to give their opinion on 47 scientific questions about imaging in prostate cancer. Nine additional questions exploring the experts’ attitudes and opinions relating to the procedure of consensus building itself were also included. (...) The purpose was to provide insights into the mechanism of recommendation choice and consensus building as seen from the experts’ point of view. Results: Regarding the factors likely to influence the willingness to refer a patient for imaging, the most voted were incorporation into guidelines and data from scientific literature, while personal experience and personal relationship were chosen by a small minority. Regarding the recommendations more relevant to prescribe an imaging procedure, it resulted the incorporation into guidelines promoted by scientific societies (59% of votes); these guidelines also resulted the more trusted. With respect to patients’ preferences considered when prescribing an imaging procedure, the most voted was accuracy, resulted more important than easy access and time to access to the procedure. The majority of the experts expressed the opinion that there is a scarce use of imaging procedures in prostate cancer. With respect to the most relevant factor to build consensus, it resulted the transparency of the process (52% of votes), followed by multidisciplinarity of contributors. The main obstacle to incorporation of modern imaging procedures into guidelines resulted the lack of primary literature on clinical impact. Conclusions: Firstly, the panelists portray themselves as having Evidence-Based Medicine oriented and scientifically inclined attitudes and preferences. Secondly, guidelines and recommendations from scientific societies, especially clinical ones, are positively taken into account as factors influencing decisions, but panelists tend to consider their own appraisal of the scientific literature as more relevant. Thirdly, in respect of overuse, panelists do not think that advanced diagnostic procedures are overutilized in the specific case of Prostate Cancer, but rather they are underutilized. (shrink)

The modern concept of ideology was established by the liberal politician and philosopher Destutt de Tracy, with the objective of creating an all-embracing and general science of ideas, which followed the sensualist and empiricist trend initiated by Locke that culminated in the positivism of Comte. Natural selection and immunity are two key concepts in the history of biology that were strongly based on the Malthusian concept of struggle for existence. This concept wrongly assumed that population grew faster than the means (...) of existence. This “natural” law contained implicitly the idea that the poor and least gifted would not survive. This idea led to the progressive development of the concept of natural selection, whose definitive version was given by Darwin. Mechnikov took the concepts of struggle for existence and natural selection and conceived infectious diseases as a struggle between a host and its invader, the so-called phagocytosis theory. This theory created the necessity to possess mechanisms to discriminate between the own and the foreign, and led to the conception of the immune self. These concepts were not developed from ideas coming from perceptions or sensations, but from ideas coming from their values: individual interest, inevitable inequality, property, utility and profit. Values are ideals that constitute an ideological matrix which exerts a numinous activity and influence the development of our future actions. In consequence, science and its practice cannot avoid and ignore the values that drive them and impulse them towards certain directions. (shrink)

In this chapter I explicate and evaluate the concept of medical error. Unlike standard philosophical approaches to analyzing medical phenom- ena in the abstract, I instead address medical error specifi cally within the context of an embodied social world. I illustrate how, as a deeply contex- tual concept, medical error is inextricably tied to the social conditions— and concrete, powerful interests—of the particulars in which it is found. -/- I begin with an analysis that demonstrates the relational quality of medi- (...) cal error, as a functional, outcome-oriented concept, evaluating the origin and context of the term’s emergence, and connecting it to a similarly contextual concept, “standard of care.” I move on to note the concern- ing implications of medical error identifi cation and measurement when viewed through an intersectional standpoint. To do so, I discuss what intersectional approaches can help reveal about our contemporary social world of medicine and public health. Intersectional approaches, as I will explain, focus on how intersections of social identity can unmask social structures that negatively impact groups and individuals. It appears, as -/- I will suggest, that disparities in social goods (e.g., social standing, edu- cation, wealth) complicate our identification of medical error, itself, and compound concerns of equity and access to medical goods for those who have diminished expectations for health. (shrink)

Personalised medicine has been discussed as a medical paradigm shift that will improve health while reducing inefficiency and waste. At the same time, it raises new practical, regulatory, and ethical challenges. In this paper, we examine PM strategies epistemologically in order to develop capacities to address these challenges, focusing on a recently proposed strategy for developing patient-specific models from induced pluripotent stem cells so as to make individualised treatment predictions. We compare this strategy to two main PM strategies—stratified medicine and (...) computational models. Drawing on epistemological work in the philosophy of medicine, we explain why these two methods, while powerful, are neither truly personalised nor, epistemologically speaking, novel strategies. Both are forms of correlational black box. We then argue that the iPSC models would count as a new kind of black box. They would not rely entirely on mechanistic knowledge, and they would utilise correlational evidence in a different way from other strategies—a way that would enable personalised predictions. In arguing that the iPSC models would present a novel method of gaining evidence for clinical practice, we provide an epistemic analysis that can help to inform the practical, regulatory, and ethical challenges of developing an iPSC system. (shrink)

What constitutes clinical reasoning is a disputed subject regarding the processes underlying accurate diagnosis, the importance of patient‐specific versus population‐based data, and the relation between virtue and expertise in clinical practice. In this paper, I present a model of clinical reasoning that identifies and integrates the processes of diagnosis, prognosis, and therapeutic decision making. The model is based on the generalized empirical method of Bernard Lonergan, which approaches inquiry with equal attention to the subject who investigates and the object under (...) investigation. After identifying the structured operations of knowing and doing and relating these to a self‐correcting cycle of learning, I correlate levels of inquiry regarding what‐is‐going‐on and what‐to‐do to the practical and theoretical elements of clinical reasoning. I conclude that this model provides a methodical way to study questions regarding the operations of clinical reasoning as well as what constitute significant clinical data, clinical expertise, and virtuous health care practice. (shrink)

Medical explanations have often been thought on the model of biological ones and are frequently defined as mechanistic explanations of a biological dysfunction. In this paper, I argue that topological explanations, which have been described in ecology or in cognitive sciences, can also be found in medicine and I discuss the relationships between mechanistic and topological explanations in medicine, through the example of network medicine and medical genetics. Network medicine is a recent discipline that relies on the analysis of various (...) disease networks in order to find organizing principles in disease explanation. My aim is to show how topological explanations in network medicine can help solving the conceptual issues that pure mechanistic explanations of the genetics of disease are currently facing, namely the crisis of the concept of genetic disease, the progressive geneticization of diseases and the dissolution of the distinction between monogenic and polygenic diseases. However, I will also argue that topological explanations should not be considered as independent and radically different from mechanistic explanations for at least two reasons. First, in network medicine, topological explanations depend on and use mechanistic information. Second, they leave out some missing gaps in disease explanation that require, in turn, the development of new mechanistic explanations. Finally, I will insist on the specific contribution of topological explanations in medicine: they push us to develop an explanation of disease in general, instead of focusing on single explanations of individual diseases. This last point may have major consequences for biomedical research. (shrink)

The new field of meta-research investigates industry bias, publication bias, contradictions between studies, and other trends in medical research. I argue that its findings should be used as meta-evidence for evaluating therapies. ‘Meta-evidence’ is evidence about the support that direct ‘first-order evidence’ provides the hypothesis. I consider three objections to my proposal: the irrelevance objection, the screening-off objection, and the underdetermination objection. I argue that meta-research evidence works by rationally revising our confidence in first-order evidence and, consequently, in the hypothesis—typically, (...) downward. (shrink)

This paper summarizes the seminar AI in Medicine in Context: Hopes? Nightmares? that was held at the Centre for Ethics at the University of Toronto on October 17, 2017, with special guest assistant professor and neurosurgeon Dr. Sunit Das. The paper discusses the key points from Dr. Das' talk. Specifically, it discusses about Dr. Das' perspective on the ethical and moral issues that was experienced from applying artificial intelligence (AI) in law and how such issues can also arise when applying (...) AI to medicine, and concludes with a brief discussion on how such issues can be prevented. (shrink)

Contemporary reasoning about health is infused with the work products of experts, and expert reasoning about health itself is an active site for invention and design. Building on Toulmin’s largely undeveloped ideas on field-dependence, we argue that expert fields can develop new inference rules that, together with the backing they require, become accepted ways of drawing and defending conclusions. The new inference rules themselves function as warrants, and we introduce the term “warranting device” to refer to an assembly of the (...) rule plus whatever material, procedural, and institutional resources are required to assure its dependability. We present a case study on the Cochrane Review, a new method for synthesizing evidence across large numbers of scientific studies. After reviewing the evolution and current structure of the device, we discuss the distinctive kinds of critical questions that may be raised around Cochrane Reviews, both within the expert field and beyond. Although Toulmin’s theory of field-dependence is often criticized for its relativism, we find that, as a matter of practical fact, field-specific warrants do not enjoy immunity from external critique. On the contrary, they can be opened to evaluation and critique from any interested perspective. (shrink)

Gegenstand dieses Beitrags ist eine Auseinandersetzung mit der Wissenschaftlichkeit der Medizin. Den Leitfaden der Analyse bildet dabei ein jüngerer Ansatz in der analytischen Wissenschaftstheorie, wonach Systematizität als zentrales Kriterium von Wissenschaft anzusehen ist (Hoyningen-Huene 2013). Ich werde im Detail zeigen, dass die Medizin dieses mehrdimensionale Kriterium insgesamt erfüllt, dass aus der Wissenschaftlichkeit der Medizin aber gleichwohl normative Konsequenzen folgen, die beispielsweise zur Abgrenzung von der Homöopathie und einer kritischen Bewertung des biopsychosozialen Modells führen. Zudem resultieren der Anwendungscharakter der Medizin und (...) die zentrale Bedeutung des Arzt-Patienten-Verhältnisses nicht in einer Schwächung des Anspruchs der Medizin als Wissenschaft. (shrink)

Part of a symposium devoted to ‘Prediction, Understanding, and Medicine’, in which Alex Broadbent argues that the nature of medicine is determined by its competences, i.e., which things it can do well. He argues that, although medicine cannot cure well, it can do a good job of enabling people not only to understand states of the human organism and of what has caused them, but also to predict future states of it. From this Broadbent concludes that medicine is (at least (...) in part) essentially a practice of understanding and predicting, not curing. In reply to this bold position, I mount two major criticisms. First, I maintain that the reasons Broadbent gives for doubting that medicine can cure provide comparable reason for doubting that medicine can provide an understanding; roughly, the best explanation of why medicine cannot reliably cure is that we still lack much understanding of health and disease. Second, I object to the claim that a practice is medical only if it facilitates understanding and prediction. Although Broadbent has brought to light certain desirable purposes of medicine that are under-appreciated, my conclusion is that he has not yet provided enough reason to think that understanding and prediction are essential to it. Instead of supposing that medicine has an essence, in fact, I suggest that its nature is best understood in terms of a property cluster. (shrink)

The first part of a symposium devoted to Alex Broadbent's essay titled ‘Prediction, Understanding and Medicine’, this article notes the under-development of a variety of issues in the philosophy of medicine that transcend bioethics and the long-standing debates about the nature of health/illness and of evidence-based medicine. It also indicates the importance of drawing on non-Western, and particularly African, traditions in addressing these largely metaphysical and epistemological matters.

This is an epistemologically-driven history of the concept of evolution. Starting from its inception, this work will follow the development of this pregnant concept. However, in contradistinction to previous attempts, the objective will not be the identification of the different meanings it adopted through history, but conversely, it will let the concept to be unfolded, to be explicated and to express its own inner potentialities. The underlying thesis of the present work is, therefore, that the path that leads to the (...) development of the concept of evolution is the path that studies the possibilities of the evolution of concepts, and that the historical reconstruction of its conceptual trajectory will shed light into potential and unexploited possibilities. This methodology will provide useful tools and resources for future developments of the concept. For example, it will define the concept of transmutation as a different conceptual trajectory deviating from the one corresponding to evolution, at the onset of the 19th century. Moreover, epigenesis will not be the opposing concept to evolution, but only to simultaneous and instantaneous generation. It will demonstrate that every important system of epigenesis drew upon some kind of formative power to explain development. More importantly, it will show that the problem of preformation cannot be overlooked, and that some kind of virtual preformation must be considered in order to address the problems of generation and development. (shrink)

Assumptions about the epistemic ideal of objectivity, closely related to ontological assumptions about the nature of disease as pathophysiological abnormality, lead us into oversimplified ways of thinking about medical imaging. This is illustrated by current controversies in the early detection of cancer. Improvements in the technical quality of imaging failed to address the problem of overdiagnosis in breast cancer screening and exacerbate the problem in thyroid cancer diagnosis. Drawing on Douglas and on Daston and Galison, I distinguish 3 dimensions of (...) objectivity (accuracy, reliability, and precision) and demonstrate ways they may be at odds, as illustrated in the early detection of cancer. Guidelines for evaluating the efficacy of diagnostic imaging are insufficiently sensitive to this complexity. Improving imaging quality may raise epistemic issues, place disease definitions in question, and lead to overall harm or to changes in the distribution of harms and benefits among population subgroups. With a nod to Wittgenstein, I argue that we cannot take for granted that “an indistinct picture” is not “exactly what we need.” . (shrink)

In this paper, I argue that the concept of normality in medical research and clinical practice is inextricable from the concept of ambiguity. I make this argument in the context of Edmund Pellegrino's call for a renewed reflection on medicine’s basic concepts and by drawing on work in critical disability studies concerning Deafness and body integrity identity disorder. If medical practitioners and philosophers of medicine wish to improve their understanding of the meaning of medicine as well as its concrete practice, (...) I contend that they should take seriously the import and centrality of ambiguity for biomedicine. (shrink)

The paper will compare two methods used in the design of diagnostic strategies. The first one is a method that precises predictive value of diagnostic tests. The second one is based on the use of Bayes’ theorem. The main aim of this article is to identify the epistemological assumptions underlying both of these methods. For the purpose of this objective, example projects of one and multi-stage diagnostic strategy developed using both methods will be considered.

Population health has recently grown from a series of loosely connected critiques of twentieth-century public health and medicine into a theoretical framework with a corresponding field of research—population health science. Its approach is to promote the public’s health through improving everyday human life: affordable nutritious food, clean air, safe places where children can play, living wages, etc. It recognizes that addressing contemporary health challenges such as the prevalence of type 2 diabetes will take much more than good hospitals and public (...) health departments. -/- Blending philosophy of science/medicine, public health ethics and history, this book offers a framework that explains, analyses and largely endorses the features that define this relatively new field. Presenting a philosophical perspective, Valles helps to clarify what these features are and why they matter, including: searching for health’s “upstream” causes in social life, embracing a professional commitment to studying and ameliorating the staggering health inequities in and between populations; and reforming scientific practices to foster humility and respect among the many scientists and non- scientists who must work collaboratively to promote health. -/- Featuring illustrative case studies from around the globe at the end of all main chapters, this radical monograph is written to be accessible to all scholars and advanced students who have an interest in health—from public health students to professional philosophers. (shrink)

Designing and manufacturing medical devices for specific patients is becoming increasingly feasible with developments in 3D printing and 3D imaging software. This raises the question of how patient-specific devices can be evaluated, since our ‘gold standard’ method for evaluation, the randomised controlled trial, requires that an intervention is standardised across a number of individuals in an experimental group. I distinguish several senses of patient-specific device, and focus the discussion on understanding the problem of variations between instances of an intervention for (...) RCT evaluation. I argue that, despite initial appearances, it is theoretically possible to use RCTs to evaluate some patient-specific medical devices. However, the argument reveals significant difficulties for ensuring the validity of such trials, with implications for how we should think about methods of evidence gathering and regulatory approaches for these technologies. (shrink)

Inference to the Best Explanation is usually employed in the Scientific Realism debates. As far as particular scientific theories are concerned, its most ready usage seems to be that of a theory of confirmation. There are however more uses of IBE, namely as an epistemological theory of testimony and as a means of categorising and justifying the sources of evidence. In this paper, I will present, develop and exemplify IBE as a theory of the quality of evidence - taking examples (...) from medicine and showing that IBE can thereby provide the epistemological underpinning and justify the criteria of grading quality of mechanistic evidence that have been recently provided in the Clarke et al. paper on how evidence of medical mechanisms is to be construed alongside population studies. (shrink)

Over the past 25 years, several new “medicines” have come screeching onto health care’s various platforms, including narrative medicine, personalized medicine, precision medicine and person-centred medicine. Philosopher Miriam Solomon calls the first three of these movements different “ways of knowing” or “methods,” and argues that they are each a response to shortcomings of methods that came before them. They should also be understood as reactions to the current dominant model of medicine. In this article, I will describe our dominant model, (...) which I call “the new medical model.” I will argue that several towering problems in modern medicine can be traced to its philosophical foundations, which calls for philosophical analysis. (shrink)