Skip to main content

Advertisement

Log in

Preventive and curative medical interventions

  • Original Research
  • Published:
Synthese Aims and scope Submit manuscript

Abstract

Medical interventions that cure or prevent medical conditions are central to medicine; and thus, understanding them is central to our understanding of medicine. My purpose in this paper is to explore the conceptual foundations of medicine by providing a singular analysis of the concept of a ‘preventive or curative medical intervention’. Borrowing a general account of prevention from Phil Dowe, I provide an analysis of prevention, cure, risk reduction, and a preventive or curative intervention, before turning to preventive and curative medical interventions. The resulting counterfactual-mechanistic account holds that preventive and curative medical interventions reduce the probability of a medical condition in an actual population compared to their counterfactual omission, commonly by disrupting an etiological or constitutive mechanism for the condition.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. For recent philosophical work on concepts of cure, prevention, and risk reduction in medicine, see (Broadbent, 2019; Faust, 2013; Fuller, 2020; Krueger, 2017; Marcum, 2011; Stegenga, 2018).

  2. The problem afflicts counterfactual theories of causation in which the relata are events, including David Lewis’s early theory (Lewis, 1973), later modified to handle absences (Lewis, 2000).

  3. James Woodward (2021) critically discusses the experiments of Walsh and Sloman (2011) among other empirical psychology research, but with a focus on causation and causal judgments rather than prevention.

  4. Jonathan Schaffer (2001) argues that Dowe’s analysis of prevention is incompatible with Dowe’s own account of causation. Because I will ultimately bracket Dowe’s view of causal processes in Sect. 3, we won’t be concerned with the substance of Schaffer’s critique.

  5. For instance, we could understand the counterfactual in P2 through a non-backtracking miracle (Lewis, 1973) or an ideal intervention (Woodward, 2003). If the causal claim in the consequent of P2 is itself to be understood counterfactually, our solution must also make sense of nested counterfactual claims.

  6. Broadbent (2019) similarly argues that cure and prevention are part of the same goal in that they have the same result, the absence of the disease. The main difference is when the intervention is implemented.

  7. Elsewhere, I argue that medicine conceives of individual risks as something like a propensity; however, there are significant problems with inferring an individual risk as a patient-level propensity from a population risk as an aggregate propensity that is measured in an epidemiologic study (Fuller, 2020).

  8. Consequently, defining a preventive or curative intervention through risk reduction in a population makes no assumptions about how its effect is distributed among individuals, assumptions which typically are not supported by the results of a population comparison alone. INTERVENTION is thus well suited to interventions that are studied in a clinical trial or other epidemiologic study (as most contemporary medical interventions are).

  9. On conceptual issues related to ‘effectiveness’ of medical interventions, see Stegenga (2018). On the metaphysics of effectiveness, see Ashcroft (2002).

  10. In characterizing disease mechanisms, we may need to depart from Dowe’s (2000) account of a causal process, which involves transfers of conserved quantities. Woodward (2002) notes that biological mechanisms commonly include components engaged in ‘double prevention’ (Hall 2004) or ‘causation by disconnection’ (Schaffer 2000), in which A inhibits B, stopping B from inhibiting C. In these cases, there may be no transfer of a conserved quantity between A and C because A and C never come into physical contact, yet we may still want to say that A causes C. Rather than using conserved quantities, Woodward (2002) understands the causal interactions among the components of a mechanism according to his manipulability theory of causation (Woodward, 2003).

  11. A disease’s etiological mechanism includes the pathogenesis of the disease—the bodily process generating the disease—and can also be thought to include causes external to the body that initiate pathogenesis (Damman, 2020). The relationship between a disease and its constitutive mechanism is more variable, as we will see momentarily. Static diseases such as osteoarthritis that depend entirely on structural derangements may not have a constitutive mechanism.

  12. Steel (2008) articulates this intuitive idea as a ‘disruption principle’: “The disruption principle asserts that interventions on a cause make a difference to the probability of the effect if and only if there is an undisrupted mechanism running from the cause to the effect” (2008, p. 7), where a mechanism is the causal structure generating probability distributions involving such variables as the cause and the effect. Steel argues that the forward conditional (‘if’) is a consequence of the faithfulness condition, while the reverse conditional (‘only if’) is a consequence of the principle of the common cause. Steel further argues that the faithfulness condition is only sometimes reasonable in biological contexts, while the principle of the common cause is “on very firm ground” in biological contexts (p. 66). I cannot assess Steel’s argument here. But if Steel is right, then our assumption that there must be a mechanism running from our indirect etiological factor to the disease is “on very firm ground” because it amounts to the idea that a preventive intervention can prevent the disease only if there is a connecting mechanism.

  13. In contrast, Sara Moghaddam-Taaheri (2011) conceptualizes medical interventions as targeting the malfunctioning stage of a broken-normal mechanism in order to restore the mechanism’s normal physiological counterpart.

  14. Krueger (2017) objects to Stegenga’s account partly on the grounds that a curative intervention on this view may be less effective at preventing death than a non-curative intervention (e.g. antibiotics, which target the constitutive basis for cholera, may be less effective at preventing death from cholera compared to oral rehydration therapy, which does not target the constitutive basis). Krueger instead proposes that a curative intervention is “[a]n intervention that, on its own, is able to reduce patient mortality”, while noting that his definition is limited in its application (p. 233). However, Krueger’s objection and his definition are not compelling unless we require that a medical cure prevents death, which would fail to capture the paradigm case of a curative antibiotic for a typically benign infection like strep throat.

  15. It also suggests that one promising way to develop medical interventions is to research etiological and constitutive mechanisms for medical conditions and the ways that they can be disrupted.

  16. For example, analytic restrictions could be placed on the kinds of interventions that are ‘medical’ or on the kinds of etiologic factors that can be the target of ‘medical’ intervention.

  17. These inferences about preventive and curative interventions assume both that (i) the etiological mechanism’s parts are not all contained within the system (the body) exhibiting phenomenon D (the medical condition), and (ii) most or all of the constitutive mechanism’s parts are contained within the system. I cannot defend these assumptions here, but on this topic see (Craver, 2007; Kaiser & Krickel, 2017; Kastner & Andersen, 2018).

References

  • Aronowitz, R. (2015). Risky medicine: Our quest to cure fear and uncertainty. University of Chicago Press.

    Book  Google Scholar 

  • Ashcroft, R. (2002). What is clinical effectiveness? Studies in History and Philosophy of Biological and Biomedical Sciences, 33, 219–233.

    Article  Google Scholar 

  • Beebee, H. (2004). Causing and nothingness. In J. Collins, N. Hall, & L. A. Paul (Eds.), Causation and counterfactuals (pp. 291–308). MIT Press.

    Google Scholar 

  • Boorse, C. (1977). Health as a theoretical concept. Philosophy of Science, 44(4), 542–573.

    Article  Google Scholar 

  • Boorse, C. (2011). Concepts of health and disease. In D. M. Gabbay, P. Thagard, & J. Woods (Eds.), Handbook of the philosophy of science: Volume 16: Philosophy of medicine (pp. 13–64). Amsterdam: Elsevier.

    Google Scholar 

  • Boorse, C. (2016). Goals of medicine. In E. Giroux (Ed.), Naturalism in the philosophy of health: Issues and implications (pp. 145–178). Springer.

    Chapter  Google Scholar 

  • Borén, J., Chapman, M. J., Krauss, R. M., Packard, C. J., Bentzon, J. F., Binder, C. J., Daemen, M. J., Demer, L. L., Hegele, R. A., Nicholls, S. J., Nordestgaard, B. G., Watts, G. F., Bruckert, E., Fazio, S., Ference, B. A., Graham, I., Horton, J. D., Landmesser, U., Laufs, U., … Ginsberg, H. N. (2020). Low-density lipoproteins cause atherosclerotic cardiovascular disease: Pathophysiological, genetic, and therapeutic insights: A consensus statement from the European Atherosclerosis Society Consensus Panel. European Heart Journal, 41(24), 2313–2330.

    Article  Google Scholar 

  • Broadbent, A. (2019). Philosophy of medicine. Oxford University Press.

    Book  Google Scholar 

  • Chou, R., Dana, T., Blazina, I., Daeges, M., & Jeanne, T. L. (2016). Statins for prevention of cardiovascular disease in adults: Evidence report and systematic review for the US Preventive Services Task Force. JAMA, 316(19), 2008–2024.

    Article  Google Scholar 

  • Clarke, E. A. (1974). What is preventive medicine? Canadian Family Physician, 20(11), 65–68.

    Google Scholar 

  • Craver, C. F. (2007). Explaining the Brain: Mechanisms and the mosaic unity of neuroscience. Oxford University Press.

    Book  Google Scholar 

  • Damman, O. (2020). Etiological explanations. CRC Press.

    Book  Google Scholar 

  • Daniels, N. (2012). Treatment and prevention: What do we owe each other? In H. S. Faust & P. T. Menzel (Eds.), Prevention vs. treatment: What’s the right balance? (pp. 176–193). Oxford University Press.

    Google Scholar 

  • Defesche, J. C., Gidding, S. S., Harada-Shiba, M., Hegele, R. A., Santos, R. D., & Wierzbicki, A. S. (2017). Familial hypercholesterolaemia. Nature Reviews. Disease Primers, 3, 17093.

    Article  Google Scholar 

  • Dowe, P. (2000). Physical causation. Cambridge University Press.

    Book  Google Scholar 

  • Dowe, P. (2001). A counterfactual theory of prevention and “causation” by omission. Australasian Journal of Philosophy, 79(2), 216–226.

    Article  Google Scholar 

  • Faust, H. S. (2013). A cause without an effect? Primary prevention and causation. Journal of Medicine and Philosophy, 38(5), 539–558.

    Article  Google Scholar 

  • Faust, H. S., & Menzel, P. T. (Eds.). (2012). Prevention vs. treatment: What’s the right balance? Oxford University Press.

    Google Scholar 

  • Fuller, J. (2018). What are chronic diseases? Synthese, 195(7), 3197–3220.

    Article  Google Scholar 

  • Fuller, J. (2020). Epidemiological evidence: Use at your ‘own risk’? Philosophy of Science, 87(5), 1119–1129.

    Article  Google Scholar 

  • Fuller, J. (2021). Demarcating and judging medicine: Review of Broadbent’s “Philosophy of Medicine.” Philosophy of Science, 88(2), 370–376.

    Article  Google Scholar 

  • Fuller, J., & Flores, L. J. (2015). The Risk GP Model: The standard model of prediction in medicine. Studies in History and Philosophy of Biological and Biomedical Sciences, 54, 49–61.

    Article  Google Scholar 

  • Godlee, F. (2005). Preventive medicine makes us miserable. BMJ: British Medical Journal, 330, 7497.

    Google Scholar 

  • Greene, J. (2008). Prescribing by numbers: Drugs and the definition of disease. Johns Hopkins University Press.

    Google Scholar 

  • Hall, N. (2004). Two concepts of causation. In Collins, Hall, and Paul 2004 (pp. 225–276).

  • Hattersley, A. T., & Thorens, B. (2015). Type 2 diabetes, SGLT2 inhibitors, and glucose secretion. New England Journal of Medicine, 373(10), 974–976.

    Article  Google Scholar 

  • Hershenov, D. B. (2019). Pathocentric health care and a minimal internal morality of medicine. The Journal of Medicine and Philosophy, 45(1), 16–27.

    Article  Google Scholar 

  • Himes, R. H., Kersey, R. N., Heller-Bettinger, I., & Samson, F. E. (1976). Action of the vinca alkaloids vincristine, vinblastine, and desacetyl vinblastine amide on microtubules in vitro. Cancer Research, 36(10), 3798–3802.

    Google Scholar 

  • Hitchcock, C. (2007). Prevention, preemption, and the principle of sufficient reason. The Philosophical Review, 116(4), 495–532.

    Article  Google Scholar 

  • Illari, P. M., & Williamson, J. (2012). What is a mechanism? Thinking about mechanisms across the sciences. European Journal for Philosophy of Science, 2(1), 119–135.

    Article  Google Scholar 

  • John, S. D. (2014). Risk, contractualism, and Rose’s “prevention paradox.” Social Theory and Practice, 40(1), 28–50.

    Article  Google Scholar 

  • Kaiser, M. I., & Krickel, B. (2017). The metaphysics of constitutive mechanistic phenomena. The British Journal for the Philosophy of Science, 68(3), 745–779.

    Article  Google Scholar 

  • Kästner, L., & Andersen, L. M. (2018). Intervening into mechanisms: Prospects and challenges. Philosophy Compass, 13(11), e12546.

    Article  Google Scholar 

  • Krueger, J. (2015). Theoretical health and medical practice. Philosophy of Science, 82(3), 491–508.

    Article  Google Scholar 

  • Krueger, J. (2017). Ebola and the rhetoric of medicine: Supportive care and cure. In R. Bluhm (Ed.), Knowing and acting in medicine. Rowman & Littlefield International Ltd.

    Google Scholar 

  • Lewis, D. (1973). Causation. Journal of Philosophy, 70, 556–567.

    Article  Google Scholar 

  • Lewis, D. (2000). Causation as influence. Journal of Philosophy, 97(4), 182–197.

    Article  Google Scholar 

  • Marcum, J. A. (2011). Medical cure and progress: The case of type-1 diabetes. Perspectives in Biology and Medicine, 54(2), 176–188.

    Article  Google Scholar 

  • Michos, E. D., McEvoy, J. W., & Blumenthal, R. S. (2019). Lipid management for the prevention of atherosclerotic cardiovascular disease. New England Journal of Medicine, 381(16), 1557–1567.

    Article  Google Scholar 

  • Moghaddam-Taaheri, S. (2011). Understanding pathology in the context of physiological mechanisms: The practicality of a broken-normal view. Biology & Philosophy, 26(4), 603–611.

    Article  Google Scholar 

  • Olivier, D. (2017). The legitimacy of preventive medical advice: Is knowing enough? In R. Bluhm (Ed.), Knowing and Acting in Medicine. Rowman & Littlefield International Ltd.

    Google Scholar 

  • PDQ Pediatric Treatment Editorial Board. (2021). Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®): Health Professional Version. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US). Available from: https://www.ncbi.nlm.nih.gov/books/NBK65763/.

  • Reznek, L. (1987). The nature of disease. Routledge & Kegan Paul.

    Google Scholar 

  • Rothman, K. J., Greenland, S., & Lash, T. L. (Eds.). (2008). Modern epidemiology (3rd ed.). Lippincott Williams & Wilkins.

    Google Scholar 

  • Rose, G. 2008 (1992). The strategy of preventive medicine. Oxford Scholarship Online.

  • Salmon, W. C. (1984). Scientific explanation: Three basic conceptions. In PSA: Proceedings of the biennial meeting of the philosophy of science association 1984 (pp. 293–305).

  • Schaffer, J. (2000). Causation by disconnection. Philosophy of Science, 67(2), 285–300.

    Article  Google Scholar 

  • Schaffer, J. (2001). Phil Dowe, physical causation. The British Journal for the Philosophy of Science, 52(4), 809–813.

    Article  Google Scholar 

  • Steel, D. P. (2008). Across the boundaries: Extrapolation in biology and social science. Oxford University Press.

    Google Scholar 

  • Stegenga, J. (2018). Medical nihilism. Oxford University Press.

    Book  Google Scholar 

  • Sprenger, J., & Stegenga, J. (2017). Three arguments for absolute outcome measures. Philosophy of Science, 84(5), 840–852.

    Article  Google Scholar 

  • Tipper, D. J., & Strominger, J. L. (1965). Mechanism of action of penicillins: A proposal based on their structural similarity to acyl-D-alanyl-D-alanine. Proceedings of the National Academy of Sciences of the United States of America, 54(4), 1133–1141.

    Article  Google Scholar 

  • Valles, S. (2018). Philosophy of population health: Philosophy for a new public health era. Routledge.

    Book  Google Scholar 

  • Waks, A. G., & Winer, E. P. (2019). Breast cancer treatment: A review. JAMA, 321(3), 288–300.

    Article  Google Scholar 

  • Walsh, C. R., & Sloman, S. A. (2011). The meaning of cause and prevent: The role of causal mechanism. Mind & Language, 26(1), 21–52.

    Article  Google Scholar 

  • Wise, E. M., Jr., & Park, J. T. (1965). Penicillin: Its basic site of action as an inhibitor of a peptide cross-linking reaction in cell wall mucopeptide synthesis. Proceedings of the National Academy of Sciences of the United States of America, 54(1), 75–81.

    Article  Google Scholar 

  • Wolfrum, S., Jensen, K. S., & Liao, J. K. (2003). Endothelium-dependent effects of statins. Arteriosclerosis, Thrombosis, and Vascular Biology, 23(5), 729–736.

    Article  Google Scholar 

  • Woodward, J. (2002). What is a mechanism? A counterfactual account. Philosophy of Science, 69(S3), S366–S377.

    Article  Google Scholar 

  • Woodward, J. (2003). Making things happen: A theory of causal explanation. Oxford University Press.

    Google Scholar 

  • Woodward, J. (2021). Causation with a human face: Normative theory and descriptive psychology. Oxford University Press.

    Book  Google Scholar 

Download references

Acknowledgements

Thanks to the audience at the 2020 Conceptual and Methodological Aspects of Biomedical Research conference for helpful feedback and discussion of some of the ideas in this article. Thanks also to Olaf Dammann and to an anonymous reviewer for providing comments that helped improve the article.

Funding

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jonathan Fuller.

Ethics declarations

Conflict of interest

I have no conflicts of interest to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fuller, J. Preventive and curative medical interventions. Synthese 200, 61 (2022). https://doi.org/10.1007/s11229-022-03579-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11229-022-03579-0

Keywords

Navigation