Philosophy of Medicine, Misc

Business models for biomedical research prescribe decentralization due to market selection pressures. I argue that decentralized biomedical research does not match four normative philosophical models of the role of values in science. Non-epistemic values affect the internal stages of for-profit biomedical science. Publication planning, effected by Contract Research Organizations, inhibits mechanisms for transformative criticism. The structure of contracted research precludes attribution of responsibility for foreseeable harm resulting from methodological choices. The effectiveness of business strategies leads to overrepresentation of profit values (...) versus the values of the general public. These disconnects in respect to the proper role of values in science results from structural issues ultimately linked to the distinct goals of business versus applied science, and so it seems likely that disconnects will also be found in other dimensions of attempts to combine business and science. The volume and integration in the publishing community of decentralized biomedical research imply that the entire community of biomedical research science cannot match the normative criteria of community-focused models of values in science. Several proposals for changing research funding structure might successfully relieve market pressures that drive decentralization. (shrink)

In some quarters within philosophy of medicine, more particularly in the phenomenological approaches, naturalism is looked upon with suspicion. This paper argues, first, that it is necessary to distinguish between two expressions of this attitude towards naturalism: phenomenological approaches to illness disagree with naturalism regarding various theoretical claims and they disapprove of naturalism on an ethical level. Second, this paper argues that both the disagreement with and the disapproval of naturalism are to a large extent confused. It then offers some (...) proposals to set up an agenda for future collaboration. (shrink)

Ill persons suffer from a variety of epistemically-inflected harms and wrongs. Many of these are interpretable as specific forms of what we dub pathocentric epistemic injustices, these being ones that target and track ill persons. We sketch the general forms of pathocentric testimonial and hermeneutical injustice, each of which are pervasive within the experiences of ill persons during their encounters in healthcare contexts and the social world. What’s epistemically unjust might not be only agents, communities and institutions, but the theoretical (...) conceptions of health that structure our responses to illness. Thus, we suggest that although such pathocentric epistemic injustices have a variety of interpersonal and structural causes, they are also sustained by a deeper naturalistic conception of the nature of illness. (shrink)

Modern health care relies extensively on the use of technologies for assessing and treating patients, so it is important to be certain that health care technologies perform their professed functions in an effective and safe manner. Philosophers of technology have developed methods to assign and evaluate the functions of technological products, the major elements of which are described in the ICE theory. This paper questions whether the standard of evidence advocated by the ICE theory is adequate for ascribing and assessing (...) technologies employed in health care. The paper proposes that the general problem with the standard of evidence embodied in the ICE theory is too permissive for assessing medical technologies, in that it does not take into account the relative benefit and harm of medical technologies in ensuring safe functional performance in patients. The paper illustrates how evidence-based medicine has demonstrated the value of clinical research methods, including observational studies, randomized and non-randomized clinical trials, and formal techniques, such as meta-analysis, to measure therapeutic effectiveness. I argue, therefore, that evidence from clinical research studies should take precedence over the testimonial evidence and other types of non-clinical evidence, in providing justification for health technologies. (shrink)

Evidence-based policy has support in many areas of government and in public affairs more generally. In this paper we outline what evidence-based policy is, then we discuss its strengths and weaknesses. In particular, we argue that it faces a serious challenge to provide a plausible, over-arching account of evidence. We contrast evidence-based policy with evidence-based medicine, especially the role of evidence in assessing the effectiveness of medicines. The evidence required for policy decisions does not easily lend itself to randomized controlled (...) trials, nor, for that matter, being listed in a single all-purpose hierarchy. (shrink)

In Unfit for the Future, Ingmar Persson and Julian Savulescu present a sophisticated argument in defense of the imperative of moral enhancement. They claim that without moral enhancement, the future of humanity is seriously compromised. The possibility of ultimate harm, caused by a dreadful terrorist attack or by a final unpreventable escalation of the present environmental crisis aggravated by the availability of cognitive enhancement, makes moral enhancement a top priority. It may be considered optimistic to think that our present moral (...) capabilities can be successfully improved by means of moral education, moral persuasion, and fear of punishment. So, without moral enhancement, drastic restrictions on human freedom would become the only alternative to prevent those dramatic potential outcomes. In this article, I will try to show that we still have reason to be less pessimistic and that Persson & Savulescu’s arguments are fortunately unconvincing. (shrink)

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

The theory stating that oxidative stress is at the root of several diseases is extremely popular. However, so far, no antioxidant is recommended or offered by healthcare systems neither approved as therapy by regulatory agencies that base their decisions on evidence-based medicine. This is simply because, so far, despite many preclinical and clinical studies indicating a beneficial effect of antioxidants in many disease conditions, randomised clinical trials have failed to provide the evidence of efficacy required for drug approval. In this (...) review, we discuss the levels of evidence required to claim causality in preclinical research on OS, the weakness of the oversimplification associated with OS theory of disease and the importance of the narrative in its popularity. Finally, from a more translational perspective, we discuss the reasons why antioxidants acting by scavenging reactive oxygen species might not only prevent their detrimental effects but also interfere with essential signalling roles. We propose that ROS have a complex metabolism and are generated by different enzymes at diverse sites and with different timing. Aggregating this plurality of systems in a single theory of disease may not be the best way to develop new drugs, and future research may need to focus on specific oxygen-toxifying pathways rather than on non-specific ROS scavengers. Finally, similarly to what is nowadays required for clinical trials, we recommend making unpublished data available in repositories, as this will allow big data approaches or meta-analyses without the blinders of the publication bias. (shrink)

Epidemiology is a science of disease which specifies rates . Evolution is a science of life which specifies changes . ‘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 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 are offered. (shrink)

With the UK government considering a ban on the prescription of homeopathic remedies on the NHS, John Worrall examines the rationale for such a proposal and suggests that the decision is not as simple as it might initially seem.

Randomised controlled trials (RCTs) are often seen as the 'gold standard' of evaluative research. However, whilst randomisation will ensure comparable groups, trials are still vulnerable to a range of biases that can undermine their internal validity. In this paper we describe a number of common threats to the internal validity of RCTs and methods of countering them. We highlight a number of examples from randomised trials in education and health care where problems of execution and analysis of the RCT has (...) undermined their internal validity. However, awareness of these potential biases can lead to careful planning to avoid or reduce their occurrence. If good quality randomised trials are to inform policy and practice in education then rigorous trials need to be designed that are the least susceptible to threats to their validity. (shrink)

This paper explores the reasons why the notion of 'evidence-based' practice has gained prominence in educational research. The ascendancy of 'evidence-based' practice is attributed to a crisis of legitimation in educational research. The paper offers a critical exegesis of a systematic review conducted under the auspices of the Effective Practice and Organisation of Care (EPOC) subgroup of the Cochrane Collaboration.

This paper argues that education should become more evidence-based. The distinction is made between using existing research and establishing high-quality educational research. The need for highquality systematic reviews and appraisals of educational research is clear. Evidence-based education is not a panacea, but is a set of principles and practices for enhancing educational policy and practice.

How is medical knowledge made? There have been radical changes in recent decades, through new methods such as consensus conferences, evidence-based medicine, translational medicine, and narrative medicine. Miriam Solomon explores their origins, aims, and epistemic strengths and weaknesses; and she offers a pluralistic approach for the future.

There is a vast literature on evidence-based practice in education. Both critics of and adherents to EBP seem to think of evidence largely as quantitative data, serving as a foundation from which practice could and should be derived; in Toulminian terms, evidence is treated solely as data/grounds. I argue in this paper that it is better in educational reasoning to view the function of evidence as backing of the warrant.

This thesis examines philosophical controversies surrounding the evaluation of medical treatments, with a focus on the evidential roles of randomised trials and mechanisms in Evidence-Based Medicine. Current 'best practice' usually involves excluding non-randomised trial evidence from systematic reviews in cases where randomised trials are available for inclusion in the reviews. The first paper challenges this practice and evaluates whether adding of evidence from non-randomised trials might improve the quality and precision of some systematic reviews. The second paper compares the alleged (...) methodological benefits of randomised trials over observational studies for investigating treatment benefits. It suggests that claims about the superiority of well-conducted randomised controlled trials over well-conducted observational studies are justified, especially when results from the two methods are contradictory. The third paper argues that postulating the unpredictability paradox in systematic reviews when no detectable empirical differences can be found requires further justification. The fourth paper examines the problem of absence causation in the context of explaining causal mechanisms and argues that a recent solution is incomplete and requires further justification. Solving the problem by describing absences as causes of 'mechanism failure' fails to take into account the effects of absences that lead to vacillating levels of mechanism functionality . The fifth paper criticises literature that has emphasised functioning versus 'broken' or 'non-functioning' mechanisms emphasising that many diseases result from increased or decreased mechanism function, rather than complete loss of function. Mechanistic explanations must account for differences in the effectiveness of performed functions, yet current philosophical mechanistic explanations do not achieve this. The last paper argues that the standard of evidence embodied in the ICE theory of technological function is too permissive for evaluating whether the proposed functions of medical technologies have been adequately assessed and correctly ascribed. It argues that high-quality evidence from clinical studies is necessary to justify functional ascriptions to health care technologies. (shrink)